Antisecretory Therapy Research Articles

Artificial intelligence automates and augments baseline impedance measurements from pH-impedance studies in gastroesophageal reflux disease

Artificial intelligence (AI) has potential to streamline interpretation of pH-impedance studies. In this exploratory observational cohort study, we determined feasibility of automated AI extraction of baseline impedance (AIBI) and evaluated clinical value of novel AI metrics. pH-impedance data from a convenience sample of symptomatic patients studied off (n = 117, 53.1 ± 1.2years, 66% F) and on (n = 93, 53.8 ± 1.3years, 74% F) anti-secretory therapy and from asymptomatic volunteers (n = 115, 29.3 ± 0.8years, 47% F) were uploaded into dedicated prototypical AI software designed to automatically extract AIBI. Acid exposure time (AET) and manually extracted mean nocturnal baseline impedance (MNBI) were compared to corresponding total, upright, and recumbent AIBI and upright:recumbent AIBI ratio. AI metrics were compared to AET and MNBI in predicting ≥ 50% symptom improvement in GERD patients. Recumbent, but not upright AIBI, correlated with MNBI. Upright:recumbent AIBI ratio was higher when AET > 6% (median 1.18, IQR 1.0-1.5), compared to < 4% (0.95, IQR 0.84-1.1), 4-6% (0.89, IQR 0.72-0.98), and controls (0.93, IQR 0.80-1.09, p ≤ 0.04). While MNBI, total AIBI, and the AIBI ratio off PPI were significantly different between those with and without symptom improvement (p < 0.05 for each comparison), only AIBI ratio segregated management responders from other cohorts. On ROC analysis, off therapy AIBI ratio outperformed AET in predicting GERD symptom improvement when AET was > 6% (AUC 0.766 vs. 0.606) and 4-6% (AUC 0.563 vs. 0.516) and outperformed MNBI overall (AUC 0.661 vs. 0.313). BI calculation can be automated using AI. Novel AI metrics show potential in predicting GERD treatment outcome.

An integrated approach to treatment of patients with complicated forms of gastroesophageal reflux disease

Aim. To justify the appropriateness of applying the integrated algorithm of treatment, including the sequential application of conservative antireflux treatment and antireflux surgery, in patients with complicated forms of gastroesophageal reflux disease.&#x0D; Methods. The main group of the study included 554 patients with complicated forms of gastroesophageal reflux disease (erosive esophagitis in 301, peptic stricture in 36, Barrett's esophagus in 90 and a combination of several complications in 127 patients), and the control group included 229 patients with uncomplicated gastroesophageal reflux disease and indications for surgical treatment. At the diagnostic stage, fiberoptic esophagogastroduodenoscopy with chromoendoscopy using a double dye staining technique (Lugol and methylene blue) and biopsies of areas suspicious for metaplasia, as well as a barium contrast multi-positional radiographic examination of the esophagus and gastroesophageal junction were used. At the treatment stage, both groups received conservative antireflux treatment lasting 48 weeks, comprising lifestyle regulation, diet, antisecretory drug therapy (proton pump inhibitors omeprazole or rabeprazole 20 mg orally twice a day, antispasmodic agent domperidone 20 mg orally 3 times a day or itopride 50 mg orally 3 times a day), followed by either laparotomic or laparoscopic antireflux surgery. In the main group, antireflux surgery was supplemented with endoscopic argon plasma coagulation during the postoperative period in the patients with Barrett's esophagus and esophageal bougienage under endoscopic control during the pre- and postoperative period in the patients with a peptic stricture.&#x0D; Results. The frequency of intraoperative [6.3% (95% CI 1.45.8%), p=0.0462] and early postoperative complications [41.5% (95% CI 37.445.7%), p=0.0011] in the main group were statistically significantly higher than in the control group. There was no clinically important difference. Frequency of late postoperative complications in the main group [5.4% (95% CI 3.77.6%)] did not have statistically significant differences from the control (p=0.1239). The integrated algorithm of treatment has proven to be safe with provision for the need to develop measures to reduce the overall incidence of early postoperative complications. Excellent and satisfactory immediate treatment results were achieved in 91.7% (95% CI 89.193.9%), and excellent and satisfactory long-term results were achieved in 91.3% (95% CI 88.793.5%) patients of the main group, and were statistically significantly worse than in the control group, p=0.0008 and p=0.0021 for the immediate and long-term results, respectively. The difference was attributable to the extremely high efficiency of the treatment algorithm in the control group and had no clinical significance.&#x0D; Conclusion. The use of the integrated algorithm of treatment based on the implementation of antireflux surgery is appropriate in all patients with complicated forms of gastroesophageal reflux disease.

Straight leg raise metrics on high‐resolution manometry associate with esophageal reflux burden

Straight leg raise (SLR) is a provocative maneuver that assesses esophagogastric junction (EGJ) barrier function during high-resolution manometry (HRM). We evaluated the value of SLR in symptomatic reflux patients undergoing ambulatory reflux monitoring. Adult patients being evaluated for reflux symptoms with esophageal physiologic testing off antisecretory therapy over a 12month period were studied. Demographics, clinical presentation, HRM studies, and reflux monitoring studies were analyzed. Intra-abdominal and intra-esophageal pressures were extracted at baseline and during SLR from HRM studies. Acid exposure time (AET) was derived from reflux monitoring studies, and EGJ morphology and tone from HRM studies. SLR pressure metrics predicting abnormal AET were evaluated. Of 122 patients, 70 (57.4%) had ≥50% peak intra-abdominal pressure increase during SLR (58.0±1.4years, 75.7% female). Peak intra-esophageal pressure gradient between baseline and SLR predicted pathologic AET when ≥100% (AUC 0.78, sensitivity 71%, specificity 75%, P<.001), seen in 60.7% with AET>6%, but only 23.7% with AET<4% (P=.01). Peak intra-esophageal pressure gradient ≥100% was most discriminative in identifying abnormal acid burden in type 1 EGJ morphology (P=.005) but trended toward significance in type 2 and type 3 morphology (P=.1). Normal and abnormal EGJ contractile integral did not associate with peak intra-esophageal pressure gradient either collectively or when subdivided by EGJ morphology (P≥.2). Analysis of intra-esophageal pressure gradients during SLR, a simple HRM maneuver, may augment evaluation of symptomatic GERD, and provide adjunctive evidence supporting GERD.

Esophageal contractile segment impedance from high-resolution impedance manometry correlates with mean nocturnal baseline impedance and acid exposure time from 24-hour pH-impedance monitoring.

Esophageal baseline impedance (BI) acquired during esophageal contraction (contractile segment impedance [CSI]) is proposed to improve BI accuracy in gastroesophageal reflux disease (GERD). We evaluated associations between CSI and conventional and novel GERD metrics. We analyzed high-resolution impedance manometry (HRIM) and ambulatory pH-impedance studies from 51 patients (58.6 ± 1.5years; 26% F) with GERD symptoms studied off antisecretory therapy. Patients with achalasia or absent contractility were excluded. CSI (averaged across 10 swallows) and BI-HRIM (from the resting landmark phase) were acquired from the distal impedance sensors (distal sensor and 5cm above the lower esophageal sphincter). Acid exposure time (AET) and mean nocturnal baseline impedance (MNBI) were calculated. Associations between CSI, BI-HRIM, MNBI, and AET were evaluated using correlation (Pearson) and receiver operating characteristic (ROC) analysis. Presenting symptoms included heartburn (67%), regurgitation (12%), cough (12%), and chest pain (10%). CSI-distal and CSI-5 each correlated with BI-HRIM, AET, and distal MNBI. Associations with AET were numerically stronger for CSI-distal (r = -0.46) and BI-HRIM-distal (r = -0.44) than CSI-5 (r = -0.33), BI-HRIM-5 (r = -0.28), or distal MNBI (r < -0.36). When compared to AET <4%, patients with AET >6% had significantly lower CSI-distal and BI-HRIM-distal values but not CSI-5, BI-HRIM-5, or MNBI. ROC areas under the curve for AET >6% were numerically higher for CSI-distal (0.81) than BI-HRIM-distal (0.77), distal MNBI (0.68-0.75), CSI-5 (0.68), or BI-HRIM-5 (0.68). CSI from HRIM studies inversely correlates with pathologic AET and has potential to augment the evaluation of GERD.

Optimization of impedance-measured reflux events in GORD utilizing acid exposure time

BackgroundCombining impedance with pH monitoring improves the detection and characterization of gastro-oesophageal reflux (GOR), yet the two modalities frequently differ in GOR quantification. Ambulatory 24-h pH-impedance monitoring often reveals more significant oesophageal acid exposure than impedance-measured reflux activity in patients with symptomatic gastro-oesophageal reflux disease (GORD). The purpose of this study is to elucidate the discrepancies between these modalities by assessing the predictive accuracy of impedance compared to acid exposure standards.MethodsA single-institution, retrospective review of sequential 24-h pH-impedance results of 72 patients with symptomatic GOR off anti-secretory therapy was conducted. Reflux events measured by impedance were stratified by patient position and compared to oesophageal acid exposure time (AET). Oesophageal AET limits for GORD detection were utilized as gold standards to generate serial receiver operator characteristics (ROC) curves to assess the sensitivity and specificity of current impedance GORD detection limits and identify optimized impedance standards based on area under the curve (AUC) analysis.ResultsMean total AET time was 10.5% (± 9.9%), and 63.8% of patients had elevated AET. By impedance, median GOR frequency was 43 (IQR 21–68), and 22.2% exceeded conventional GOR frequency limits of normal. ROC curve analysis revealed the current impedance standard of > 73 GOR events has a sensitivity of 32.6% and specificity of 96.5% (AUC 0.74) for GORD detection. By AUC analysis, an impedance threshold of > 41 GOR events is optimal for GORD detection (sensitivity 69.6%, specificity 80.7%, AUC 0.83).ConclusionConventional impedance standards for abnormal GOR frequency are weakly sensitive for the detection of GORD, providing a possible explanation to discrepancies in AET and impedance interpretation. Lowering impedance-measured GOR frequency limits to > 41 optimizes sensitivity and specificity while increasing congruence between pH and impedance metrics.

Sa1252 PROSPECTIVE EVALUATION OF SYMPTOM CORRELATION FOR GASTROESOPHAGEAL REFLUX DISEASE BY AMBULATORY WIRELESS PH MONITORING AFTER PER-ORAL ENDOSCOPIC MYOTOMY

Ambulatory pH monitoring following POEM is reportedly abnormal in up to 60% of patients. There are limited data regarding correlation of patient reported symptoms with reflux episodes during these studies after POEM. To evaluate the relationship of patient reported typical and atypical GERD symptoms to objective reflux episodes by ambulatory pH monitoring after POEM. From a prospective database, consecutive patients who underwent POEM for esophageal motility disorders at our hospital were identified. High resolution impedance manometry (HRM) and Eckardt scores (ES) were recorded at baseline. At 6 months after POEM, HRM, ES and 48-hour ambulatory wireless pH testing (Bravo, Medtronic, Minneapolis, MN) off antisecretory therapy were obtained. Symptoms experienced during pH testing were recorded. A positive pH study was defined as pH <4 in >5.3% of time on day 1 alone, day 2 alone or total test duration. A symptom index (SI) score (percentage of a GERD-related symptom that correlates with a pH event <4) and symptom sensitivity index (SSI) (percentage of test duration events with pH <4 that are associated with symptoms) were calculated. Symptom-reflux correlation was defined as SI ≥50% or SSI ≥ 10%. 208 consecutive patients underwent POEM between 2015 and 10/2019. The study population included 93 patients (52 ± 17 yrs.; 53M) who underwent follow-up testing 6 months after POEM. The most common indication for POEM was type 1 (18%), type 2 achalasia (58%) and EGJOO (13%). At 6 month follow-up, there were significant decreases in mean ES (1.3 ± 1.9 vs. 7.7 ± 1.9) and mean IRP (8.7 ± 6.4 mmHg vs. 29.6 ± 15.3 mmHg, both p<0.001). A positive pH test was present in 70/93 (75%). The frequency of reported symptoms and their correlation with events during pH testing are recorded in Table 1. At least one symptom was reported by 58/93 (62%), the most frequent of which were cough (29%), heartburn (27%), and chest pain (27%). All reported symptoms had an SI <50% and SSI<10%. For all 3096 reported symptoms, SSI was 9.9%. There was no difference in the frequency of any reported symptom in patients with and without a positive pH study (Table 2). In this series, 75% of post-POEM patients evaluated had abnormal wireless pH testing. Both typical and atypical symptoms of GERD after POEM showed poor correlation with abnormal acid exposure and occurred with equal frequency among those with and without abnormal pH testing. Objective testing rather than patient reported symptoms are required to diagnose, treat and prevent potential complications from post–POEM GERDView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Endoscopic reversal of Roux-en-Y anatomy for the treatment of recurrent marginal ulceration.

Marginal ulceration is one of the most common adverse events after Roux-en-Y gastric bypass (RYGB). The incidence rate of marginal ulcer may be as high as 7%.1-3 Antisecretory therapy is the first-line treatment. However, more than one-third of patients undergo surgical revision for intractable ulcers.4,5 The surgical outcome is excellent overall, except for smokers.5,6 Smokers with intractable marginal ulcer pose an extreme management challenge to clinicians. In this video (Video 1, available online at www.VideoGIE.org), we describe an active-smoker patient with recurrent and intractable marginal ulcer despite multiple surgical revisions and use of maximal medical therapy who was successfully treated with endoscopic reversal of RYGB.

Perforation of anastomotic peptic ulcer following pancreaticoduodenectomy: a report of three cases

BackgroundPerforation of a marginal peptic ulcer after pancreaticoduodenectomy (PD) can lead to severe conditions, although its clinical features have not been well reported. In this article, we present three cases of marginal peptic ulcer perforation after PD that we experienced in our institute and attempt to clarify its appropriate treatment and prevention.Case presentationMarginal ulcer perforation confirmed with computed tomography and/or surgical exploration occurred in 3 (1.8%) of 163 consecutive patients who underwent PD (including 160 patients who underwent a total or subtotal stomach-preserving procedure) at our institution. The three patients (one man and two women) had a median age of 77 (65–79) years. Two of these patients had a medical history of duodenal peptic ulcer. All three patients had biliary neoplasms. Two of the patients underwent subtotal stomach-preserving PD with antro-jejunal anastomosis, and the other patient underwent pylorus-preserving PD with duodenal jejunostomy. The perforation occurred with a sudden and severe onset of abdominal pain 34, 94, and 1204 days, respectively, after the PDs. At the time of the perforation, all of the patients had been withdrawn from postoperative prophylactic antipeptic ulcer agents, with the cessation periods ranging from 12 to 1008 days. In addition, all the patients were in fasting conditions for 1 to 13 days just before the perforation. Surgical treatment with direct suturing of the perforated ulcer was performed for two patients, while conservative therapy was performed for one patient. Their primary treatment courses were satisfactory. Chronic antisecretory agent therapy was prescribed for 562, 271, and 2370 days, respectively, from marginal ulcer perforation, and no ulcer recurrence was noted in any of the patients.ConclusionsLack of antisecretory therapy and fasting were considered an essential cause of marginal peptic ulcer perforation after PD. In addition, unlike the native duodenum, the jejunal limb used for reconstruction to a preserved stomach may be at increased risk of ulceration. Chronic permanent administration of antisecretory agents and fasting avoidance are desirable for patients who have undergone stomach-preserving PD to prevent marginal ulcer perforation.

Diagnosis and Treatment of Peptic Ulcer in Adults (Clinical Guidelines of the Russian Gastroenterological Association, Russian Society of Colorectal Surgeons and the Russian Endoscopic Society)

Aim . These clinical recommendations present up-to-date methods for the diagnosis and treatment of peptic ulcer. The recommendations are intended for gastroenterologists and general practitioners. General provisions. Peptic ulcer (PU) represents a chronic relapsing disease occurring with alternating periods of exacerbation and remission. The main manifestation of the disease is the formation of a defect (ulcer) in the wall of the stomach and duodenum. Most cases of peptic ulcer are pathogenetically associated with the infection of H. pylori . PU can be an independent disease or represent symptomatic ulcers of the stomach and duodenum (medicinal, as a result of stress or endocrine pathologies, associated with chronic diseases of internal organs). In the absence of contraindications, esophagogastroduodenoscopy is recommended for all patients with suspected ulcer with the purpose of confirming the diagnosis. In order to determine indications for eradication therapy, all ulcer patients should be tested for the presence of H. pylori using a 13 C-breath test or a stool antigen test. In the case of simultaneous endoscopy, rapid urease test can be used. For the prevention of subsequent relapses of ulcer, all PU patients with confirmed H. pylori should undergo eradication therapy. In addition, in order to achieve ulcer healing, 4–6 week antisecretory therapy with proton pump inhibitors is recommended. Clinical recommendations contain criteria for assessing the quality of medical care, an algorithm of the doctor’s actions, as well as information for patients. Conclusions . These clinical recommendations present modern ideas about the etiology and pathogenesis of peptic ulcer disease, its clinical manifestations, methods of laboratory and instrumental diagnostics and basic approaches to conservative and surgical treatment.

A125 ABNORMAL REFLUX IS UNCOMMON IN PATIENTS PRESENTING WITH ISOLATED OROPHARYNGEAL SYMPTOMS

Abstract Background Gastroesophageal reflux disease (GERD) is often implicated as a potential etiology for various oropharyngeal (OP) symptoms. Although ambulatory reflux monitoring has been recommended by professional societies for the assessment of OP symptoms, it is unclear if objective measures of acid exposure in the esophagus correlate with the presence of these OP symptoms. Aims The aim of this study is to determine the prevalence of abnormal 24-hour pH monitoring in patients presenting with various OP symptoms in our motility unit. Methods A retrospective chart review was performed on all patients referred for 24-hour pH monitoring for the evaluation of OP symptoms to the open-access Clinical Motility Unit at the University Health Network between January 1, 2008 and June 1, 2019. Seven symptom categories were examined including cough, globus, throat discomfort, voice change, dental erosion, altered taste, and sensation of phlegm in the throat. The results of the 24-hour pH monitoring were collected. A test was considered abnormal if while off anti-secretory therapy the overall acid exposure (pH &amp;lt; 4) in the distal esophagus was greater than 4.2% of the total time or if while on anti-secretory therapy the overall acid exposure in the esophagus was greater than 1.2% of the time. Descriptive statistics were performed to analyze the data. Results 384 patients were included in the final analysis. 167 patients (43.5%) presented with cough, 63 (16.4%) with globus, 86 (22.4%) with throat discomfort, 19 (5.9%) with voice changes, 13 (3.4%) with dental erosion, 17 (4.4%) with altered taste and 19 (4.9%) with sensation of phlegm in the throat. Overall, 19.5% of patients presenting with oropharyngeal symptoms had abnormal 24-hour pH monitoring. Abnormal 24-hr pH monitoring was present in 24.6% of those with cough, 15.9% of those with globus, 16.3% of those with throat discomfort, 21.1% of those with voice changes, 23.1% of those with dental erosion, 5.9% of those with altered taste and 10.5% of those with sensation of phlegm in the throat. Conclusions This study demonstrates that only a small proportion of patients with OP symptoms have abnormal gastroesophageal acid reflux based on objective 24-hour pH monitoring. Given these findings, future studies to examine the factors that predict having abnormal 24-hour pH monitoring in patients presenting with OP symptoms will help guide resource management of motility testing to determine which patients would benefit most from this type of evaluation. Funding Agencies None

Current aspects of surgical treatment of gastro-esophageal reflux disease

Gastroesophageal reflux disease (GERD) is characterized by abnormal reflux of gastric content into the esophagus, pharynx, respiratory tract and oral cavity. In recent years, there has been a significant increase of the incidence of this disease, that significantly aggravates quality of life of the population. The 'gold standard' for treating GERD is anti-secretory therapy with proton pump inhibitors (PPIs). However, up to 40% of patients are unresponsive to PPIs even after dose adjustment. Advantages and disadvantages of modern surgical approaches for this pathology are reviewed. Laparoscopic fundoplication including Nissen (360°), Toupet (270°) and Dor procedures (180°) is the most common anti-reflux operation. In addition, new alternative surgical options are also discussed. For example, these are minimally invasive methods such as LINX reflux control system, electrical stimulation of the lower esophageal sphincter and transoral incisionless fundoplication (TIF). These methods are less aggressive and have less side effects. A comparative assessment of modern methods of surgical treatment of GERD is made.

Erosive and ulcerative lesions of gastrointestinal tract in patients with burns

To analyze the incidence of erosive and ulcerative lesions of gastrointestinal tract in patients with burns, including those complicated by gastrointestinal bleeding, depending on severity of injury, complications of burn disease and treatment features. Medical records of 1833 patients were reviewed. We have retrospectively analyzed symptoms of disease and incidence of gastrointestinal bleeding depending on treatment strategy in patients with identified erosive and ulcerative lesions of gastrointestinal tract. Risk of gastrointestinal erosions and ulcers, including those complicated by gastrointestinal bleeding, correlates with area and depth of burn damage, especially in patients with thermo-inhalation injury and infectious complications of burn disease. Proton pump inhibitors intake in patients with burns of up to 50% of body surface area (BSA) and deep lesions up to 40% of BSA is followed by less incidence of gastrointestinal bleeding compared to H2-histamine receptor blockers. At the same time, severe burns of more than 50% of BSA ensure high risk of gastrointestinal bleeding regardless antisecretory therapy. Endoscopy upon admission is recommended in all patients with burns ≥30% of BSA or deep lesions ≥20% of BSA, as well as severe thermo-inhalation injury. This approach ensures timely diagnosis of gastrointestinal lesions and their adequate treatment.

Fundic gland polyp prevalence according to Helicobacter pylori infection status.

The prevalence of fundic gland polyp (FGP) occurrence has not been clarified in individuals with Helicobacter pylori infection post-eradicated status. This study was performed to examine the relationship between FGP prevalence and H. pylori infection status. We enrolled 3400 subjects (2185 male subjects and 1215 female subjects; mean age 54.7 ± 9.5 years) with known H. pylori infection status and who underwent an upper gastrointestinal endoscopy examination as part of an annual check-up. Subjects without and with H. pylori infection numbered 1617 and 239, respectively, while 1544 had a post-eradication status. The presence of FGP and degree of gastric mucosal atrophy were determined in each subject using an endoscopic method. Endoscopy findings showed FGPs in 1029 (30.3%) of all subjects. The prevalence ratio of FGP positivity in H. pylori-negative, H. pylori-positive, and post-eradicated subjects was 51.9%, 1.7%, and 12.0%, respectively. Multiple logistic regression analysis revealed that female gender, older age, milder gastric mucosal atrophy, and anti-secretory therapy were significant risk factors for FGP occurrence. As compared with H. pylori-positive subjects, the odds ratios for H. pylori-negative and post-eradication status were 48.3 and 6.6, respectively (P < 0.001). In the post-eradication status subjects, longer duration following bacterial eradication was a significant risk factor for occurrence of FGPs. The risk of FGP occurrence in individuals who have undergone H. pylori eradication treatment is lower as compared with those who have never been infected. However, that risk increases over time following eradication.

Gastroenteropancreatic neuroendocrine tumors

Neuroendocrine neoplasms (NEN) are increasingly diagnosed tumors with great clinical and prognostic heterogeneity. One of the peculiarities of NEN is the presence of a clinical hormone syndrome in about 30 % of cases. Somatostatin receptor imaging plays an important role in the diagnosis of spreading and in the planning of therapy. NEN patients should be co-supervised by specialized centers and if possible treated as part of studies. In the case of NEN with no or only circumscribed metastases, complete resection in curative intention is generally the highest therapeutic goal. Small neuroendocrine tumors (NET) G1 of the stomach, duodenum and rectum can be curatively endoscopically resected. In the case of a metastatic, non-curative disease, an antiproliferative therapy with the aim of growth control takes place. In patients with functionally active tumors, an antisecretory or symptomatic therapy is used to control the hormone syndrome. The treatment of metastatic NET is often multimodal and must be established by an experienced interdisciplinary team. The prognosis of NEN is mainly determined by the stage at the time of diagnosis, tumor differentiation, grading and localization of the primary tumor.

Current advances in the treatment of gastroesophageal reflux disease: a focus on esophageal protection

Gastroesophageal reflux disease (GERD) is characterized by high morbidity and a significant decrease in the quality of life of patients, and is a major risk factor for esophageal adenocarcinoma. Nowadays, antisecretory therapy with proton pump inhibitors (PPI) is the "gold standard" of conservative treatment of GERD, but in some cases this therapy is unsuccessful. According to various studies, the prevalence of refractory GERD can reach 30-40%. The latest scientific data in the field of genetics and pathophysiology of GERD demonstrate that a disruption of the barrier function of the esophageal mucosa and an increase of its permeability can be the leading causes of refractoriness. Thus, the optimal therapy for patients with GERD should not only suppress the secretion of hydrochloric acid, but also restore the barrier function of the mucous membrane, providing an esophagoprotective effect. To achieve these goals, Alfasoxx was developed, which consists of a mixture of low molecular weight hyaluronic acid and low molecular weight chondroitin sulfate dissolved in a bioadhesive carrier (poloxamer 407). The clinical efficacy of this product has been confirmed by three prospective, randomized, placebo - controlled trials. Alfasoxx has a healing and restorative effect towards the esophageal epithelium and due to high ability for bioadhesion provides long - term protection of the mucous membrane of the esophagus. Combination therapy for GERD with the use of PPI and an esophagoprotector offers new perspectives for the treatment of patients with GERD.

Влияние приверженности антисекреторной терапии на риск развития гастропатии, индуцированной приёмом нестероидных противовоспалительных средств

Влияние приверженности антисекреторной терапии на риск развития гастропатии, индуцированной приёмом нестероидных противовоспалительных средств

The role of parenteral nutrition in patients with malignant bowel obstruction.

The role of parenteral nutrition in the treatment of malignant bowel obstruction is underestimated since palliative literature mainly focuses on gastric aspiration, nothing per os and antisecretory therapy. The purpose of this review is the appraisal of the literature with a focus on the potential contribution of parenteral nutrition. Literature included in a recent meta-analysis and in a Cochrane review on parenteral nutrition in malignant bowel obstruction and updated through PUBMED until March 2019 has been reviewed. Prompt withholding of food intake, nasogastric aspiration and then the use of antisecretory agents represent the milestones of treatment which are applied to all patients with malignant bowel obstruction. After this initial approach, excluding few surgical patients and those defined as imminently dying, there is a heterogeneous group of patients achieving a benefit in a few days but with a prompt recurrence of symptoms as they attempt to reassume some food intake. Parenteral nutrition in hospital or at home addresses to these patients provided their life expectancy is likely to depend on progressive nutritional deterioration due to the prolonged starvation more than on the tumour spread. These patients on home parenteral nutrition can survive a few months with some indefinite benefit on quality of life whereas untreated patients have a survival of few weeks. Parenteral nutrition should be considered in selected patients who benefit from standard palliative treatment of malignant obstruction and are obliged to maintain a total bowel rest for weeks or months.

The Utility of Esophageal Motility Testing in Gastroesophageal Reflux Disease (GERD).

Here, we discuss how esophageal motor testing plays important roles in patients with suspected gastroesophageal reflux disease (GERD). In addition to guiding appropriate placement of catheters for ambulatory reflux monitoring, esophageal high-resolution manometry (HRM) rules out confounding diagnoses, such as achalasia spectrum disorders, that can present with symptoms similar to that of GERD, but are managed very differently. HRM performed with impedance in the post-prandial setting (PP-HRIM) can assess for rumination syndrome or supragastric belching, which should be directed towards behavioral interventions. The recent GERD Classification of Motor Function recommends a hierarchical approach, focusing on (1) the esophagogastric junction (EGJ), (2) the esophageal body, and (3) esophageal contraction reserve, which can be assessed with provocative maneuvers at HRM, such as multiple rapid swallows (MRS). This approach can inform the appropriate tailoring of antireflux surgery. Novel esophageal motility metrics, such as the EGJ-contractile integral from HRM, or post-reflux swallow-induced peristaltic wave indices from 24-h pH-impedance monitoring, may also assist with GERD diagnosis. Assessment of esophageal motor function can contribute in a significant manner to the care of patients with suspected GERD, particularly when esophageal symptoms do not improve with antisecretory therapy, and/or when surgical or endoscopic antireflux therapies are under consideration.

RIVAROXABAN SAFETY DURING DEEP VEIN THROMBOSIS TREATMENT IN PATIIENTS WITH RELATED DAMAGES OF STOMACH AND DUODENUM

The aimof this study was to assess the risk of use of rivaroxaban, which was associated with gastro-duodenal bleeding in patients with deep venous thrombosis.Methods: an analysis of anticoagulant treatment in 683 patients with deep venous phlebothrombosis. All the patients underwent fiberoptic gastroduodenoscopic procedure prior to the anticoagulant treatment. When erosive-ulcerative lesions were detected, the patients received antisecretory therapy with proton pump inhibitors along with anticoagulant therapy.Results: EGD did not show any only stomach pathology only in 10.7 percent of patients at the time of admission. A symptom-free pathology that became a diagnostic finding was identified in 53.1 percent of patients. Fiberoptic gastroduodenoscopy showed completed bleeding or bleeding that was stopped using endoscopic balloon tamponade with achievement of stable hemostasis in 12.9 patients. 59.1 percent of patients received anti-coagulant therapy with rivaroxaban (Xarelto®). In the presented series of patients with acute deep vein thrombosis, the use of rivopoxaban appeared a safe therapeutic option not only in patients with erosive-ulcerative lesions in the gastroduodenal system, but also in those with endoscopic signs of stopped bleeding (on the top of already administered antisecretory therapy with proton pump inhibitors).

Somatostatin Analogues in the Treatment of Neuroendocrine Tumors: Past, Present and Future.

In recent decades, the incidence of neuroendocrine tumors (NETs) has steadily increased. Due to the slow-growing nature of these tumors and the lack of early symptoms, most cases are diagnosed at advanced stages, when curative treatment options are no longer available. Prognosis and survival of patients with NETs are determined by the location of the primary lesion, biochemical functional status, differentiation, initial staging, and response to treatment. Somatostatin analogue (SSA) therapy has been a mainstay of antisecretory therapy in functioning neuroendocrine tumors, which cause various clinical symptoms depending on hormonal hypersecretion. Beyond symptomatic management, recent research demonstrates that SSAs exert antiproliferative effects and inhibit tumor growth via the somatostatin receptor 2 (SSTR2). Both the PROMID (placebo-controlled, prospective, randomized study in patients with metastatic neuroendocrine midgut tumors) and the CLARINET (controlled study of lanreotide antiproliferative response in neuroendocrine tumors) trial showed a statistically significant prolongation of time to progression/progression-free survival (TTP/PFS) upon SSA treatment, compared to placebo. Moreover, the combination of SSA with peptide receptor radionuclide therapy (PRRT) in small intestinal NETs has proven efficacy in the phase 3 neuroendocrine tumours therapy (NETTER 1) trial. PRRT is currently being tested for enteropancreatic NETs versus everolimus in the COMPETE trial, and the potential of SSTR-antagonists in PRRT is now being evaluated in early phase I/II clinical trials. This review provides a synopsis on the pharmacological development of SSAs and their use as antisecretory drugs. Moreover, this review highlights the clinical evidence of SSAs in monotherapy, and in combination with other treatment modalities, as applied to the antiproliferative management of neuroendocrine tumors with special attention to recent high-quality phase III trials.