Esophageal manometry provides a detailed evaluation of esophageal contractility and, therefore, represents the reference method for diagnosis of esophageal motility disorders. Significance and ...clinical relevance have been further increased by implementation of high-resolution esophageal manometry (HRM), which reveals the functional anatomy of the esophagus in a visually-intuitive manner. The current 3 rd version of the international Chicago Classification (CC v3.0) gives standardized recommendations on performance and interpretation of HRM and serves as the basis for much of this expert consensus document. However, CC v3.0 gives only limited information with regards to the function of the lower and upper esophageal sphincters, the use of adjunctive tests including solid test meals and long-term ambulatory HRM measurements. In this expert consensus, we describe how to perform and interpret HRM on the basis of the CC v3.0 with additional recommendations based on the results of recent, high-quality clinical studies concerning the use of this technology to assess the causes of esophageal symptoms in a variety of clinical scenarios.
Malnutrition is a common feature of terminal chronic liver disease. In Great Britain earlier studies revealed a widespread use of inappropriate dietary management for example, protein restriction in ...patients with liver cirrhosis (LC). Therefore, it was the aim of this study to evaluate the current dietary recommendations for patients with LC, recommended by gastroenterologists in Germany.
Anonymous questionnaires were sent to 576 members of the Bavarian Society of Gastroenterology. Information was requested on the dietary management and on the diagnostic assessment of nutritional status of all patients with LC seen in the past 12 months. Further questions were included concerning knowledge of recent guidelines on enteral nutrition (EN) in LC, use of an adequate EN and estimated prevalence of malnutrition.
Forty-four percent of all questionnaires were returned within 4 weeks; of those 94% were fully completed and appropriate for further analysis. Fifty-six percent respondents stated that they were familiar with guidelines concerning EN in patients with LC and 92% believed that evidence-based recommendations are both important and relevant for everyday practice. Only 23% of the respondents gave a correct estimate of the prevalence of protein-calorie malnutrition in patients with chronic liver disease. The majority underestimated the correct amount of energy and protein intake that is recommended by the European Society for Parenteral and Enteral Nutrition guidelines on EN for patients with LC. Only 42% respondents recommended a protein-rich diet whereas most of the respondents under or overestimated the required daily energy (55%) and protein intake (58%). As simple bedside methods such as the subjective global assessment or anthropometry are considered adequate to identify malnutrition in LC, these methods were familiar only to 24 and 55% of the respondents, respectively. Forty-one percent, however, believed that an evaluation of the body mass index represents the best diagnostic tool to detect malnourished patients although body mass index may be misleading in cirrhotics with tense ascites.
The dietary management of German cirrhotic patients should be improved, especially concerning the required daily energy and protein intake. Simple bedside methods for the diagnosis of malnutrition are widely unknown. In general, malnutrition in LC clearly represents a widely underestimated problem even in a highly specialized sample of medical practitioners in digestive and hepatological diseases. At the same time the number of nutrition support teams in German speaking countries are very low. A higher number of multidisciplinary teams including dietitians, psychologists and physical activity supervisors caring for undernourished patients might be an important step for an improvement towards correct management of malnutrition in LC.
Irritable bowel syndrome is characterized by chronic abdominal symptoms and irregular bowel movements without any cause than can be revealed by routine diagnostic assessment. In recent years, its ...pathophysiology has come to be much better understood, and new therapeutic approaches have been developed. These advances were taken into consideration and assessed for their relevance to clinical practice in the framework of a new interdisciplinary S3 guideline.
A systematic search of the literature retrieved a total 5573 articles, from which 243 were selected on the basis of criteria relating to their form and content, individually assessed, and summarized in evidence tables. The recommendations formulated in this way were discussed in a Delphi procedure and a consensus conference, then accordingly modified and finalized.
Variable symptom constellations are caused by disturbances of gastrointestinal regulation at multiple levels. The diagnosis of irritable bowel syndrome requires both chronic bowel symptoms that interfere with everyday life and the exclusion of relevant differential diagnoses. Its treatment is based on general therapeutic principles, dietary recommendations, psychological components, and symptomatic medication. Bulking agents, laxatives, spasmolytics, loperamide, and probiotic agents are recommended (with variable recommendation strengths), as are--for selected patients--antidepressants, 5-HT4 agonists, 5-HT3 antagonists, and topical antibiotics.
The first German S3 guideline on irritable bowel syndrome translates up-to-date scientific knowledge as represented in current publications into concrete recommendations for diagnosis and treatment in clinical practice. In the future, it is likely that further causative pathophysiological mechanisms will be discovered; this should lead, in turn, to the development of new, causally directed treatments, which will supplement or replace the traditional, purely symptomatic treatments that are still in use today.
Malfunctions of enteric neurons are believed to play an important role in the pathophysiology of irritable bowel syndrome (IBS). Our aim was to investigate whether neuronal activity in biopsies from ...IBS patients is altered in comparison to healthy controls (HC).
Activity of human submucous neurons in response to electrical nerve stimulation and local application of nicotine or a mixture of histamine, serotonin, tryptase, and TNF-α (IBS-cocktail) was recorded in biopsies from 17 HC and 35 IBS patients with the calcium-sensitive-dye Fluo-4 AM. The concentrations of the mediators resembeled those found in biopsy supernatants or blood. Neuronal activity in guinea-pig submucous neurons was studied with the voltage-sensitive-dye di-8-ANEPPS.
Activity in submucous ganglia in response to nicotine or electrical nerve stimulation was not different between HC and IBS patients (P = 0.097 or P = 0.448). However, the neuronal response after application of the IBS-cocktail was significantly decreased (P = 0.039) independent of whether diarrhea (n = 12), constipation (n = 5) or bloating (n = 5) was the predominant symptom. In agreement with this we found that responses of submucous ganglia conditioned by overnight incubation with IBS mucosal biopsy supernatant to spritz application of this supernatant was significantly reduced (P = 0.019) when compared to incubation with HC supernatant.
We demonstrated for the first time reduced neuronal responses in mucosal IBS biopsies to an IBS mediator cocktail. While excitability to classical stimuli of enteric neurons was comparable to HC, the activation by the IBS-cocktail was decreased. This was very likely due to desensitization to mediators constantly released by mucosal and immune cells in the gut wall of IBS patients.
Nonhepatic cancer risk of cirrhotic patients seems to be increased. Major surgery and chemotherapy in cirrhosis are associated with increased mortality and morbidity, which limits treatment.
The aims ...of this study were analysis of (a) prevalence, (b) outcome after treatment, (c) of survival rate and (d) predictors of survival in a cirrhotic population.
The study population was assembled retrospectively from a database of hospitalized patients (n=354). The Kaplan-Meier method was used to calculate the survival rate, and Cox regression analysis was performed to identify prognostic parameters.
Altogether, 84 neoplasms in 70 patients were observed. A total of 54 were nonhepatic (15.3%) mainly colorectal carcinoma, prostate cancer and tobacco-related neoplasms. TNM stage was the best prognostic parameter (p<0.0001). Low bilirubin (p=0.01), normal albumin (p=0.005) and absence of ascites (p<0.0001) were also related significantly to longer survival. The rate of postinterventional death after specific treatment was high. A proportion of patients received no specific therapy due to reduced physical performance, even in cases of limited disease.
Our data confirm the increased risk of cirrhotic patients for developing nonhepatic cancer. Advanced TNM stage was associated with reduced long-term survival. Scoring systems, such as Child's classification and Model of Elevated Liver Disease (MELD) score, were suitable parameters to predict mortality. Oncological management in patients with cirrhosis must be on an individual basis, independent from TNM classification.
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