Epigastric Discomfort Research Articles

Ginkgo Biloba extract for angina pectoris: a systematic review.

To evaluate the efficacy and safety of Ginkgo Biloba extract for patients with angina pectoris according to the available evidence. Electronic databases were searched for all of the randomized controlled trials (RCTs) of angina pectoris treatments with Ginkgo Biloba extract, either alone or combined with routine Western medicine (RWM), and controlled by untreated, placebo, Chinese patent medicine, or RWM treatment. The RCTs were retrieved from the following electronic databases: PubMed/MEDLINE, ProQuest Health and Medical Complete, Springer, Elsevier, and ProQuest Dissertations and Theses, Wanfang Data, China National Knowledge Infrastructure (CNKI), VIP database, China Biology Medicine (CBM), Chinese Medical Citation Index (CMCI), from the earliest database records to December 2012. No language restriction was applied. Study selection, data extraction, quality assessment, and data analyses were conducted according to the Cochrane standards. RevMan 5.1.0 provided by Cochrane Collaboration The data were analysed by using. A total of 23 RCTs (involving 2,529 patients) were included and the methodological quality was evaluated as generally low. Ginkgo Biloba extract with RWM was more effective in angina relief and electrocardiogram improvement than RWM alone. Reported adverse events included epigastric discomfort, nausea, gastrointestinal reaction, and bitter taste. Ginkgo Biloba extract may have beneficial effects on patients with angina pectoris, although the low quality of existing trials makes it difficult to draw a satisfactory conclusion. More rigorous, high quality clinical trials are needed to provide conclusive evidence.

Feocromocitoma-Paraganglioma: revisión de tema

El feocromocitoma es una enfermedad poco frecuente, correspondiente a un tumor derivado de las células cromafines, originado en la médula de la glándula suprarrenal. Cuando este tumor se origina en los paraganglios el término correcto es paraganglioma. Las manifestaciones clínicas son variables y secundarias a la masa tumoral o a la producción exagerada de catecolaminas. Los síntomas originados por el crecimiento de la masa tumoral incluyen dolor abdominal, malestar epigástrico, obstrucción de estructuras cercanas como la vía biliar y los uréteres, y, cuando está localizado en otros sitios como el mediastino, disnea. Los síntomas secundarios a la hiperproducción de catecolaminas son diaforesis, palpitaciones, cefalea, crisis hipertensivas, hipertensión sostenida, constipación, náuseas, vómito y, en la forma más exagerada, crisis catecolaminérgicas. El diagnóstico se realiza mediante la medición de metanefrinas libres en orina de 24 horas o en plasma, y como alternativa se puede realizar medición de catecolaminas en orina de 24 horas. La medición de ácido vanilmandélico es poco sensible, lo mismo que la medición de catecolaminas en plasma, la cual no es recomendada. El tratamiento de esta enfermedad es quirúrgico. En aquellos pacientes con feocromocitoma maligno o paraganglioma se puede realizar una estrategia de observación activa y en quienes tengan progresión de la enfermedad el uso de quimioterapia o, según el grado de compromiso, el uso de metayodobencilguanidina marcada con yodo-131 es la terapia de elección. El uso de terapia molecular diana utilizando inhibidores de tirosina quinasa es un área de investigación activa.

Is intraoperative cholangiography necessary during laparoscopic cholecystectomy for cholelithiasis?

To determine the efficacy and safety benefits of performing intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) to treat symptomatic cholelithiasis. Patients admitted to the Minimally Invasive Surgery Center of Tianjin Nankai Hospital between January 2012 and January 2014 for management of symptomatic cholelithiasis were recruited for this prospective randomized trial. Study enrollment was offered to patients with clinical presentation of biliary colic symptoms, radiological findings suggestive of gallstones, and normal serum biochemistry results. Study participants were randomized to receive either routine LC treatment or LC+IOC treatment. The routine LC procedure was carried out using the standard four-port technique; the LC+IOC procedure was carried out with the addition of meglumine diatrizoate (1:1 dilution with normal saline) injection via a catheter introduced through a small incision in the cystic duct made by laparoscopic scissors. Operative data and postoperative outcomes, including operative time, retained common bile duct (CBD) stones, CBD injury, other complications and length of hospital stay, were recorded for comparative analysis. Inter-group differences were statistically assessed by the χ2 test (categorical variables) and Fisher's exact test (binary variables), with the threshold for statistical significance set at P<0.05. A total of 371 patients were enrolled in the trial (late-adolescent to adult, age range: 16-70 years), with 185 assigned to the routine LC group and 186 to the LC+IOC group. The two treatment groups were similar in age, sex, body mass index, duration of symptomology, number and size of gallstones, and clinical symptoms. The two treatment groups also showed no significant differences in the rates of successful LC (98.38% vs 97.85%), CBD stone retainment (0.54% vs 0.00%), CBD injury (0.54% vs 0.53%) and other complications (2.16% vs 2.15%), as well as in duration of hospital stay (5.10±1.41 d vs 4.99±1.53 d). However, the LC+IOC treatment group showed significantly longer mean operative time (routine LC group: 43.00±4.15 min vs 52.86±4.47 min, P<0.01). There were no cases of fatal complications in either group. At the one-year follow-up assessment, one patient in the routine LC group reported experiencing diarrhea for three months after the LC and one patient in the LC+IOC group reported on-going intermittent epigastric discomfort, but radiological examination provided no abnormal findings. IOC addition to the routine LC treatment of symptomatic cholelithiasis does not improve rates of CBD stone retainment or bile duct injury but lengthens operative time.

Functional Dyspepsia: An Unresolved Issue

Functional dyspepsia (FD) is one of the commonest medical problems which affect the quality of life. Due to its global presentation variety of symptoms recorded, therefore no global consensus developed. The recorded symptoms of functional dyspepsia are nonspecific and the pathophysiology is diverse. The role of genetics in the susceptibility of FD is still not well established. The last Rome III criteria defined the FD as symptoms of epigastric pain or discomfort, early satiety and postprandial fullness with in the last three months with symptoms not less than six months. Patient cannot have any evidence of structural disease and predominant Gastro esophageal reflux symptoms. Failure to respond to ‘test and treat approach’ is also categorize as FD. A universally effective treatment for functional dyspepsia remains elusive. The purpose of this paper is to highlight the details in perspective of functional dyspepsia.

First Masquerading as Gallstones, Pulmonary Hypertension Mimics PE

Patients presenting to emergency and urgent care centers with calf pain after long and short-haul flights are a common presentation throughout Europe. Patients fitting an epidemiological risk profile for cholelithiasis and presenting with right upper quadrant abdominal pain can also be a common presentation fitting of a specific patient profile. However, pulmonary hypertension can present in a nuanced and possible missed chronic and acute presentation. The patient case we present profiles a mildly obese 54-year-old Caucasian woman and recent holiday maker with unilateral calf pain and shortness of breath after traveling on a long-haul flight with tertiary symptoms of indigestion and epigastric discomfort indicative of gastroenteritis. This case highlights the required diligence for emergency physicians to maintain a high index of suspicion and broad differential diagnosis in the undifferentiated patient with seemingly common or classic presentations. We find that a serendipitous definitive diagnosis is made by following a systematic and organized approach.

L-ARGININE AND ARTERIAL HYPERTENSION: ANTIHYPERTENSIVE AND METABOLIC EFFECTS

Resume. The effectiveness of antihypertensive treatment remains at a low level despite of numerous antihypertensives. Nitric oxide (NO) plays an important role in the pathogenesis of arterial hypertension (AH). It is synthesized from L-arginine in the presence of endothelial NOsynthase but the practical use of the above mentioned amino acid in the treatment of AH remains uncertain. In this study a total of 80 adult patients (men and women in equivalent amounts) with AH II stage were recruited. The whole group of patients was divided into 2 subgroups according to the prescribed antihypertensive pharmacotherapy: 1 st subgroup (n=40) used Valsartan 0.08 g per os once a day in the morning + Amlodipinum 0.005 g per os once a day in the evening; 2 nd subgroup (n=40) in addition to the above mentioned medicines used L-arginine 1.0 g three times a day before meal. To estimate the efficacy of treatment and its metabolic effects were evaluated the following parameters: systolic and diastolic blood pressure, glucose, total cholesterol, high- and low- density lipoproteins, triglycerides. The period of clinical observation was 30 days. All patients had different neurological complaints, such as: anxiety, headache, loss of concentration, insomnia, dizziness, fatigue. At the end of clinical observation their quantity and expressiveness decreased, especially in the 2 nd group. One patient even required lower dose of L-arginine (2.0 g/day) because of the significant daytime sleepiness. After the correction of pharmacotherapy this complaint disappeared. In 5 patients the use of L-arginine before meal caused gastrointestinal disorders, such as nausea, flatulence and epigastric discomfort. That is why they began to use this medicine during or after meal. Such change in the treatment didn’t reduce the effectiveness of Larginine. In 30 days the levels of systolic and diastolic blood pressure decreased, especially in the 2 nd group of comparison (p<0.05). The effectiveness of antihypertensive therapy in the 1 st group was

Safety of compound Qinghuang powder in patients with myelodysplastic syndromes

Objective To evaluate the safety of compound Qinghuang powder for myelodysplastic syndromes（MDS）. Methods A total of108 patients with MDSwere collected, 60 patients were treated with Qinghuang powder（Qinghuang powder group）and 48 with compound Qinghuang powder（compound Qinghuang group）. The treatment time of 3 months was as one course, and all the patients were treated for more than one course. The patients who developed adverse reactions in the Qinghuang powder group changed to receive compound Qinghuang powder. The adverse reactions were recorded during the treatment. Results The overall incidence of adverse reactions in the compound Qinghuang powder group was significantly lower than that in the Qinghuang powder group（18.75% vs. 41.7%; χ^26.492, P〈0.05）. None in the compound Qinghuang powder group and 3 patients in the compound Qinghuang powder group developed moderate to severe adverse reactions. The incidences of various adverse reactions in the compound Qinghuang powder group were lower than those in the Qinghuang powder group, especially, lower limb swelling （4.17%vs. 25%;χ^29.205, P〈0.05） epigastric discomfort（18.75% vs. 41.67%; χ^26.492, P〈0.05）. Twenty patients who developed adverse reactions in the Qinghuang powder group changed to receive compound Qinghuang powder. Among them, 5 patients （25%） maintained adverse reactions. The various adverse reactions after changing to compound Qinghuang powder were decreased, especially, facial swelling （10% vs. 30%; χ^22.50, P〈0.05）, leg swelling （5%vs. 45%;χ^28.533, 〈0.05）, and abdominal pain and diarrhea（10%vs. 30%;χ^22.50, P〈0.05）. No patient developed liver or kidney dysfunction after the treatment with Qinghuang powder or Compound Qinghuang powder. Conclusion Compound Qinghuang powder is safer than Qinghuang powder in the treatment of MDS. Key words: Myelodysplastic Syndromes; Qinghuang powder; Realgar; Arsenic; Traditional Chinese Drug adverse reaction

EUS of Pancreatic Neuroendocrine Tumors: A Single Center Experience

Introduction: Pancreatic neuroendocrine tumors (PETs) are rare neoplasms that account for 1-2% of pancreatic tumors and can have malignant potential.EUS-FNA has been shown to be effective in both diagnosis and localization of PETs. Methods: A retrospective study of all (18) patients at our tertiary care center with histologically confirmed PET. The main outcome measurements were clinical features of PETs and utility of EUS-FNA for the diagnosis of PETs. Results: Thirteen patients underwent EUS;10 had confirmed histopathology, however the other 3 required surgical pathology for confirmation. Of all 18 patients,15 (83%) had nonfunctional PETs. These 15 did not present with diarrhea, peptic ulcers, or hypoglycemia. Two of 3 functional tumors were smaller than the average for our patient population,with no predilection for a specific location within the pancreas. All 3 functional tumors were in women, with ages varying between 39 and 63. The size of lesions ranged from 3 mm to 83 mm with the average lesion being 27.55 mm.The average nonfunctional lesion was 28.75 mm(range 10-83),while the average functional lesion was 21.75 mm (range 3-59). Epigastric discomfort was the presenting symptom in all 3; only 6(33%) of all 18 patients presented without symptoms and incidentally found masses on imaging. Two of the 3 functional PETs underwent Whipple procedures,while the third,a gastrinoma,underwent distal pancreatectomy. All other cases are either pending or not surgical candidates. Conclusion: EUS-FNA is a very useful tool in evaluating PETs from a sensitivity and preoperative localization standpoint. The low morbidity/mortality associated with a relatively noninvasive procedure allows for localization and better characterization of the lesions, with added benefit of sampling for early potential histological diagnosis. Although our data pool was small,we were not able to appreciate a link between size of tumor and symptoms on presentation. The functional tumors that were documented were all in women of varying ages, and mortality was no different between functional and nonfunctional PETs. While older studies suggested functional tumors to be more common, our study found that nonfunctional tumors are more common, which is in line with more recent data from similar studies with more patients; this is thought to be due to more incidental tumor findings from more widespread imaging and advancing resolution. Considering EUS-FNA as a key component of the preoperative localization workup should be further supported by our study and similar studies before it. Our study showed that functional tumors tend to be smaller on average compared to nonfunctional PETs, and would benefit from EUS-FNA for diagnostic yield due to demonstrated high sensitivity, specificity, and positive predictive value in the setting of PETs.

Crohn’s Disease: How Sure is Sure?

Introduction: Endoscopy with biopsy has been the gold standard for diagnosis of Crohn’s disease. A 33-year-old male presented with mid epigastric discomfort and constipation. Miralax and protonix was initiated. Over the ensuing 6 weeks, his symptoms of abdominal pain and bloating worsened. He lost 15 pounds, and had night sweats, early satiety, and abdominal tenderness. A CT scan of the abdomen showed abnormally thickened proximal ileal loops consistent with Crohn’s disease, and prednisone was started. He returned within days with worsening abdominal pain. Urgent colonoscopy with ileal visualization showed no significant abnormalities. Steroids were continued. CT enterography showed a segment of small bowel within the mid abdomen extending right to left with diffuse wall thickening as well as cystic implants within the omentum and adenopathy at the mesenteric root. Eventually, he experienced worse abdominal pain, fever, and vomiting. CT showed intra-peritoneal air consistent with a perforated hollow viscous. Emergent laparotomy with biopsy of peritoneal implants confirmed the diagnosis of intermediate grade follicular center cell lymphoma. Bowel perforation in GI lymphomas is seen in approximately 9% of intestinal lymphoma cases, half of which occur after initiation of chemotherapy. Clinical entities that mimic intestinal lymphoma include Crohn’s disease, carcinomatosis, carcinoid tumors, and ischemic injury. Bowel perforation in GI lymphomas is seen in approximately 9% of intestinal lymphoma cases, half of which occur after initiation of chemotherapy. Clinical entities that mimic intestinal lymphoma include Crohn’s disease, carcinomatosis, carcinoid tumors, and ischemic injury. Clues in this case that Crohn’s disease was not the right diagnosis was the rapid progression of disease, night sweats, weight loss, and absence of diarrhea. CT enterography showed progression of disease uncharacteristic of Crohn’s disease. Radiographs often depict abnormalities in patients with inflammatory bowel disease (IBD). However, a false positive rate of 16-20% with the low positive predictive value of a normal radiograph (62%) make radiography a poor diagnostic test. The empiric use of steroids in this patient may have not only increased the risk of bowel perforation, but was likely the cause for inconclusive histopathology on colonoscopic biopsy. This serves to reinforce that it is still crucial to have a biopsy-proven diagnosis of Crohn’s disease prior to initiation of steroids.Figure 1

A Case Report: Gastric Foreign Bodies of 14 Batteries

Case Report: A 25-year-old female patient was admitted for committing suicide by swallowing 14 batteries 1 hour before admission. She was complaining of epigastric discomfort and referred for a CT scan, which confirmed foreign bodies of high density inside the stomach. Gastroscopy was performed to remove the foreign bodies of batteries. Batteries were revealed after aspirating the food bolus in stomach. Rat-tooth forcep failed to grap the batteries firmly due to the smooth surface of batteries. A snare was then used to remove the batteries. Proper skill was to snare on one end of batteries and keeping them parallel to the longitudinal axis of gastric and esophageal tract before pulling them. All the 14 batteries were taken out successfully without complications. Foreign bodies of batteries should be removed as soon as possible due to the toxicity. In this case, snare was proven to be the most appropriate tool to remove the cylindrical foreign bodies. The critical tip of the procedure is to snare on one end of the cylindrical foreign bodies and keep them parallell to the longitudinal axis of gastric and esophageal tract.Figure 1Figure 2

Watch It Grow: Esophageal Impaction With Chia Seeds

Introduction: A 39-year-old male with asthma and seasonal allergies presented with the acute onset of persistent, severe dysphagia. The patient had a long history of intermittent dysphagia to solids which had worsened over the preceding 2 weeks. Twelve hours before presentation, he swallowed a tablespoon of dry chia seeds followed by a glass of water. He immediately experienced epigastric discomfort and was unable manage his oral secretions. Glucagon did not relieve his symptoms. Emergent EGD showed complete distal esophageal obstruction with a gel of hydrated chia seeds. Attempts at traversing or advancing the bolus using an adult diagnostic upper endoscope were unsuccessful. Removal of the seeds using a Roth net and grasping forceps was also unsuccessful due to a semi-solid consistency. A neonatal gastroscope was advanced past the obstruction revealing a stricture at the GE junction. The neonatal gastroscope was then used to push small amounts of the chia seed gel into the stomach until the impaction was relieved. The patient was started on twice daily PPI, and a liquid diet was recommended until repeat endoscopy was performed. Chia seeds (Salvia hispanica) are small (2mm x 1.5mm), oval seeds native to Mexico and Guatemala. They have been used for food, medicine, and paint since Aztec civilization. They were initially introduced to the U.S. by terracotta “pets” on which the seeds would grow. Over the last 5 years, their use as a food product has been growing in popularity due to high protein, omega-3 fatty acid, and fiber content. Chia seeds are marketed to improve cardiovascular health, promote weight loss, and improve glycemic control. When added to liquid, dry chia seeds immediately begin to form a hydrogel capsule absorbing up to 27 times their weight in water. In the stomach, this process contributes to a feeling of satiety. In our patient, an underlying esophageal stricture resulted in the formation of a hydrogel in his esophagus causing complete esophageal obstruction. This is the first report of esophageal food impaction with chia seeds. With the increasing popularity of chia seeds, patients with a history of dysphagia or esophageal strictures should be cautioned about their use, especially in their dry form.Figure 1

소양인체질병증 임상진료지침: 음허오열병

Abstract Clinical Practice Guideline for Soyangin Disease of Sasang Constitutional Medicine: Yin-Deficit Diurnal-Heat (Eumheo-oyeol) symptomatology Jun-Sang Yu, Eui-Ju Lee * Dept. of Sasang Constitutional Medicine, College of Korean Medicine, Sangji University, Seoul, Korea * Dept. of Sasang Constitutional Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Korea ObjectivesThis research was carried out to establish the clinical practice guideline(CPG) for Yin-Deficit Diurnal-Heat (Eumheo-oyeol) symptomatology of Soyangin disease.Methods Dongeuisusebowon(sinchuk edition) and several kinds of literatures including journal articles concerning this symptomatology of Soyangin disease were collected and classified. Sasang constitutional specialists’ conference washeld to make an agreement on the conflicting issues as well. Consensus was drawn as a result of the conference.Results & Conclusions3 papers were selected as an inclusion and exclusion criteria for the relevant articles to Yin-Deficit Diurnal-Heat(Eumheo-oyeol) symptomatology of Soyangin disease. Yin-Deficit Diurnal-Heat (Eumheo-oyeol) symptomatology consists of two aspects : Yin-Deficit Diurnal-Heat (Eumheo-oyeol) severe pattern and Yin-Deficit Diurnal-Heat (Eumheo-oyeol) critical pattern. In Yin-Deficit Diurnal-Heat (Eumheo-oyeol) severe pattern contains 1 disease, namely, Clear Yang Depletion of Large Intestine (Daejang-cheongyang Moson) pattern (Lower wasting-thirst (Haso) pattern). In Yin-Deficit Diurnal-Heat (Eumheo-oyeol) critical pattern contains 2 diseases, Yin-Deficit Diurnal-Heat (Eumheo-oyeol) pattern and Yin-DeficitDiurnal-Heat (Eumheo-oyeol) advanced pattern. Yin-Deficit Diurnal-Heat (Eumheo-oyeol) symptomatology has several kinds of symptoms like dry mouth, disliking to drink much water, diurnal body fever, coldness on the back and nausea as well as body fever, chest discomfort, constipation or dry stool as a common symptoms of Interior Heat disease. Clear Yang Depletion of Large Intestine(Daejang-cheongyang Moson) pattern (Lower wasting-thirst (Haso) pattern) has above mentioned symptoms and much urine/ turbid urine, thin thigh and knee joints and twinge of joint pain over the body. Yin-Deficit Diurnal-Heat(Eumheo-oyeol) pattern has symptoms like indigestion and epigastric discomfort, abdominal pain and vomiting in addition. Yin-Deficit Diurnal-Heat (Eumheo-oyeol) advanced pattern has symptoms like hematemesis as well.Key Words: Sasang Constitutional Medicine, Clinical Practice Guideline, Soyangin, Yin-Deficit Diurnal-Heat (Eumheo-oyeol) symptomatology

A Phase I Open-Label Study to Evaluate the Safety and Tolerability of Medi4736, an Anti-Programmed Cell Death-Ligand 1(Pd-L1) Antibody, in Combination with Tremelimumab in Patients with Advanced Non-Small Cell Lung Cancer (Nsclc)

ABSTRACT Aim: Programmed cell death-1 (PD-1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) are inhibitory regulators of T cell activation. MEDI4736 (M) is a human IgG1 mAb, engineered to prevent ADCC activity, that blocks PD-L1 binding to PD-1 and CD-80. Tremelimumab (T) is a human IgG2 monoclonal antibody directed against CTLA-4. M + T in NSCLC may have greater antitumor activity compared with each agent alone. Methods: A Phase 1 study (NCT02000947) is evaluating the safety/tolerability, pharmacokinetics, immunogenicity and antitumor activity of M + T in patients (pts) with NSCLC. The study has dose-escalation phase and dose-expansion phase (immunotherapy-naive and -pretreated cohorts). The study will assess pharmacokinetic, pharmacodynamic parameters, including serum/tissue PDL1, immune cell phenotypes and cytokine profiling. Pharmacogenomic analysis of blood/tumor samples may be performed to examine gene expression patterns at baseline versus changes in response to treatment. Results: As of April 23, 2014, 12 pts were treated: 3 pts each in Cohort 1a (3 mg/kg M + 1 mg/kg T), Cohort 2a (10 mg/kg M + 1 mg/kg T); Cohort 3a (15 mg/kg M + 1 mg/kg T), Cohort 3b (10 mg/kg M + 3 mg/kg T). Pts had 2–5 lines of prior therapy (Median = 3). ECOG PS ranged from 0–1. The most frequent drug-related AEs (reported in ≥ 2 pts) included increased amylase, abdominal pain, arthralgia, colitis, diarrhea, epigastric discomfort, fatigue and nausea. ≥Grade (Gr) 3 drug-related AEs: 2 pts with Gr 3 (Cohort 2a: increased AST/ALT, 3b: diarrhea/colitis), 1 pt with Gr 4 (Cohort 3a: increased amylase), and 1 pt with Gr 5 (Cohort 2a: myasthenia gravis resulting in respiratory failure). Drug-related AEs leading to treatment discontinuation: 2 pts (Cohort 2a: increased ALT, myasthenia gravis, 3b: colitis). On first assessment at 8 weeks for 12 subjects: 2 unconfirmed PRs, 3 additional pts with tumor shrinkage not meeting PR, and 5 pts (Cohort 1a: 3; Cohort 3b: 2) with PD. 10 pts remain on study. Conclusions: The current safety profile and early anti-tumor activity of M + T supports continued clinical assessment. Disclosure: S.J. Antonia: Honoraria from BMS and MedImmune/Astra Zeneca for work related to designing, implementing, and analyzing various clinical trials. MedImmune considers the research funding received for the conduct of a MedImmune-sponsored study as conflict of interest; S. Goldberg: I have received research funding from MedImmune and AstraZeneca. MedImmune considers the research funding received for the conduct of a MedImmune-sponsored study as conflict of interest; A. Balmanoukian: Research/clinical trials funded by MedImmune. I have also agreed to be a speaker for Boehringer Ingelheim Pharmaceuticals. MedImmune considers the research funding received for the conduct of a MedImmune-sponsored study as conflict of interest; R. Narwal: Employee of Medimmune and owns stock/stock options in AstraZeneca; P.B. Robbins: Employee of Medimmune and owns stock/stock options in AstraZeneca; G. D'angelo: Employed by MedImmune. I currently hold stock ownership of AstraZeneca; A. Blake-Haskins: Employee of Medimmune and owns stock/stock options in AstraZeneca; J.J. Karakunnel: Employee of Medimmune and owns stock/stock options in AstraZeneca; N. Rizvi: I receive consulting income from Medimmune, Roche, Merck and BMS. MedImmune considers the research funding received for the conduct of a MedImmune-sponsored study as conflict of interest.

Treatment of functional dyspepsia and gastroparesis.

Functional dyspepsia (FD) and gastroparesis (GP) are the two most prevalent gastric neuromuscular disorders. These disorders are frequently confused, have more similarities than differences, and can be thought of as two ends of a continuous spectrum of gastric neuromuscular disorders (Fig. 1). FD is currently defined by the Rome III criteria; it is now subdivided into a pain-predominant subtype (epigastric pain syndrome) and a meal-associated subtype (post-prandial distress syndrome). GP is defined by symptoms in conjunction with delayed gastric emptying in the absence of mechanical obstruction. Symptoms for both FD and GP are similar and include epigastric pain or discomfort, early satiety, bloating, and post-prandial nausea. Vomiting can occur with either diagnosis; it is typically more common in GP. A patient suspected of having either FD or GP should undergo upper endoscopy. In suspected FD, upper endoscopy is required to exclude an alternative organic cause for the patient's symptoms; however, most (70 %) patients with dyspeptic symptoms will have FD rather than an organic disorder. In suspected GP, upper endoscopy is required to rule out a mechanical obstruction. A 4-hour solid-phase gastric emptying scan is recommended to confirm the diagnosis of GP; its utility is unclear in patients with FD, as it may not change treatment. Once the diagnosis of FD or GP is made, treatment should focus on the predominant symptom. This is especially true in patients with GP, as accelerating gastric emptying with the use of prokinetics may not necessarily translate into an improvement in symptoms. Unfortunately, no medication is currently approved for the treatment of FD and, thus, technically, all treatment options remain off-label, including medications for visceral pain (e.g., tricyclic antidepressants) and nausea. This review focuses on treatment options for FD and GP with an emphasis on new advances in the field over the last several years.

Global prevalence of, and risk factors for, uninvestigated dyspepsia: a meta-analysis

ObjectivesMany cross-sectional surveys have reported the prevalence of uninvestigated dyspepsia, but there has been no recent systematic review of data from all studies to determine its global prevalence and risk...

Breast cancer metastasis to the stomach confirmed using gastroscopy: A case report.

Breast cancer metastasis to the stomach is relatively rare. Unlike infiltrating ductal carcinoma, invasive lobular carcinoma (ILC) has a high tendency to metastasize to the stomach. The present study reports a case of a 53-year-old female who had undergone a modified radical mastectomy of the left breast for ILC eight years previously and presented at the clinic seeking treatment for epigastric discomfort from sour regurgitation and belching that had persisted for one month. Gastroscopy revealed multiple apophysis lesions in the stomach, which were diagnosed as metastatic tumors to the stomach. The diagnosis was further established using histological and immunohistochemical analyses for gross cystic disease fluid protein-15, cytokeratin (CK) 7 and CK20. The patient was treated with systemic chemotherapy without surgery. During the treatment, two gastroscopy procedures revealed that the apophysis lesions in the gastric body had narrowed significantly. Few cases of breast cancer metastasizing to the stomach have been reported, particularly those that have been confirmed using gastroscopy. The present study reports a case of breast cancer metastasis to the stomach to raise awareness of the condition.

Observational study of the effects of dabigatran on gastrointestinal symptoms in patients with non-valvular atrial fibrillation

BackgroundDyspepsia (including upper abdominal pain, abdominal pain, abdominal discomfort, epigastric discomfort, and dyspepsia) is a symptom that is carefully monitored during dabigatran treatment. However, detailed information on dyspepsia, including onset, duration, severity, and use of drug treatment, has not yet been established in Japanese patients. MethodsWe conducted a multi-center, prospective, open-label, randomized, and parallel-group-comparison observational study of 309 patients with non-valvular atrial fibrillation who had been newly prescribed dabigatran at 19 institutes in Japan. Gastrointestinal adverse events were evaluated using the Global Overall Severity (GOS) scale self-reports to describe symptoms and to assess frequency and severity of symptoms (Part 1). Thereafter, patients with a GOS score ≥3 were randomized to receive a 4-week course of a proton pump inhibitor, an H2-receptor antagonist or a gastric mucosal protective drug (Part 2). ResultsThe incidence of dyspepsia symptoms due to dabigatran was 17.2% (53/309, 95% confidence interval 13.1–21.8%), with 77% of events occurring within 10 days of initiation. Five patients discontinued the study because of dyspepsia. At the end of the observation period, the mean GOS score of those reporting dyspepsia was 3.5±1.7, with 11.3% (35/309) reporting a score ≥3. Substantial differences in the incidence of dyspepsia were observed between the study institutes (0–41%). In the multivariate regression analysis, no significant factor was found to affect incidence or severity of dyspepsia. The majority (83–100%) reported that symptoms improved with treatment (GOS score ≤2), and there was no significant difference between the three different treatment groups. ConclusionsThe reported symptoms of dyspepsia were generally mild, but were moderate in approximately 10% of patients. Proton pump inhibitors, H2-receptor antagonists, and rebamipide seemed to be equally effective in relieving dabigatran-related dyspepsia (umin-CTR UMIN000007579).

Sclerotherapy as a palliative treatment for spontaneous huge biloma

A 91-year-old man with a history of surgically cured nasal cancer and coronary artery disease presented to our emergency department (ED) due to epigastric discomfort and poor appetite lasting for 1 day. He denied any prior trauma, intra-abdominal surgery, or choledocholithiasis. There was no dizziness or exertional dyspnea, but icteric sclera was present. Laboratory testing revealed hyperbilirubinemia (3.67 mg/dl). An abdominal computed tomography (CT scan) showed one huge hepatic cystic lesion with biliary obstruction (Fig. 1a). The surgeon deemed surgical cystectomy or fenestration unsuitable owing to his advanced age and cardiac comorbidity. CT-guided pigtail insertion was done with bile-like fluid aspirated, but no bile duct connection was found. The diagnosis of biloma was favored. After 2 days of drainage, we instilled 70 ml povidone iodine solution into the cyst cavity for sclerotherapy. A non-contrast CT 1 week later showed significant shrinkage of the biloma (Fig. 1b). He was discharged uneventfully after jaundice subsided, with progressive biloma shrinkage during the follow-up months. Bilomas are localized encapsulated pseudotumors consisting of bile juice accumulation, mostly within the hepatic parenchyma and rarely in the peritoneum or abdominal wall [1]. Bilomas result from traumatic injury of intraor extra-hepatic bile duct, or a complication of hepatobiliary procedures (mostly within 6 months). Nontraumatic and non-iatrogenic ones are termed ‘‘spontaneous bilomas’’, as in this patient [2]. Typical presentations are upper abdominal pain, but obstructive jaundice is rather rare, since bilomas commonly harbor connections with bile ducts. The exact mechanism of spontaneous biloma formation is unclear, but spasm of the sphincter of Oddi or biliary diverticuli rupture has been purported as a plausible mechanism [3]. Small bilomas are usually asymptomatic and regress spontaneously within weeks. Large and symptomatic bilomas are often managed with surgical or percutaneous drainage [4]. We have not found any reports concerning sclerotherapy for biloma for those patients unfit for surgery, but it would be a safe alternative option.

Focused echocardiogram by emergency physicians (EP) in resuscitation room of Accident and Emergency (A&amp;E) Department

Results Patient A, elderly lady with lung cancer presented with progressive dyspnoea, desaturation, and low blood pressure. Bedside echo showed dilated right ventricle and McConnell sign. Diagnosis of pulmonary embolism was confirmed by CTPA. She was given thrombolytic in A&E with hemodynamic improvement. Patient B, 55 year old man presented with vomiting, diarrhoea, hypotension and tachycardia. Bedside echo showed severely depressed myocardial contractility. Provisional diagnosis of myocarditis was made, which proved to be the eventual diagnosis. Patient C, 49 year-old lady presented with epigastric discomfort and desaturation. Bedside echo showed right atrial (RA) mass. CT in A&E showed large anterior mediastinal mass with invasion into RA. The diagnosis was later confirmed to be spindle cell carcinoma with RA invasion. Patient D, 63 year-old man presented with dizziness and breathlessness. Clinically he was in profound shock, with pale appearance and cold extremities. BP was not recordable and blood gas showed severe lactic acidosis with pH 6.9. Bedside echo showed a large circumferential pericardial effusion with collapsed right chambers and plethoric IVC. Emergency pericardiocentesis was done with dramatic improvement in hemodynamic status. CT thorax showed a right lung tumour abutting the pericardium.

Unusual mucoepidermoid carcinoma of the liver misdiagnosed as squamous cell carcinoma by intraoperative histological examination

As rare condition, mucoepidermoid carcinoma may occur in liver although its etiology and pathogenesis is still unclear. We report here a case of intrahepatic mucoepidermoid carcinoma misdiagnosed as cholangiocarcinoma and squamous cell carcinoma by preoperative radiologic and intraoperative histological examinations, respectively. A 60-year-old woman presented with a 1-month history of progressive jaundice, epigastric discomfort, and weight loss with slightly increased carbohydrate antigen 19-9 (CA19-9). Computed tomography (CT) showed a large tumor, 8.0 cm in diameter, in the left lobe of the liver. A preliminary diagnosis of a cholangiocarcinoma of the liver was made. In the intraoperative histological examination, a diagnosis of squamous cell carcinoma was made based on predominantly invasive epidermoid cells with abundant keratinization and absence of mucin-producing cell component. However, postoperative histological diagnosis of the lesion was mucoepidermiod carcinoma of liver by thoroughly microscopical inspection and the presence of mucin-producing cells confirmed by Alcian blue staining. Despite surgical excision and chemotherapy, the tumor showed very aggressive malignancy with tumor recurrence. The patient died shortly afterward, surviving 6 months after surgery. Due to its rarity and distinct morphological features, mucoepidermoid carcinoma might be erroneously interpreted as squamous cell carcinoma by those who were not familiar with this condition in unusual locations. Therefore, removal of sufficient tissue from different portions of the lesion is essential for the surgeons and pathologists to make a precise diagnosis in the intraoperative histological examination.Virtual slideThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/4956311271136060