Digestive diseases and sciences
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Comparative Study
Comparison of effects of upright versus supine body position and liquid versus solid bolus on esophageal pressures in normal humans.
New studies monitoring ambulatory esophageal pressures during food ingestion often compare results to normal values obtained from supine liquid swallows. We compared distal esophageal peristaltic and lower esophageal sphincter (LES) pressures in 15 normal subjects during six liquid swallows in the upright and supine positions, and six solid (small marshmallow) swallows in upright position. LES pressures were significantly (P less than 0.05) higher supine than upright but no differences were noted in LES pressure, relaxation, and duration of relaxation between upright solid and liquid swallows. ⋯ Atypical wave forms, defined as nontransmitted, simultaneous, and simultaneous/repetitive, increased in the upright position compared to supine (P less than 0.01), and during solid vs liquid swallows (P less than 0.05). These results indicate that body position substantially affects normal distal esophageal peristalsis and LES pressure and that "abnormal" wave forms occur more frequently during swallowing solids than liquids in the upright position. Conclusions regarding "abnormal" motility over prolonged periods and during food ingestion in patients should be tempered by these findings.
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Over a seven-year period, 138 patients with portal hypertension presented on 223 occasions with endoscopically proven acute variceal hemorrhage. Hemorrhage ceased spontaneously on 92 occasions (41%). On 126 occasions (57%) passage of the four-lumen modification of the Sengstaken-Blakemore tube was required, and hemorrhage was successfully controlled in 98%. ⋯ There were 28 complications attributed to the use of tamponade in 186 episodes of hemorrhage (15%). On 12 occasions these complications proved fatal (6.4%). In four further patients failure of tamponade to control hemorrhage was fatal.
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Hemoglobin-heme is variably converted to porphyrin during enterocolic transit. This intestinal converted fraction, as measured by HemoQuant, was elevated as a predictor of the occult bleeding site in 152 patients with discrete lesions. The intestinal converted fraction, expressed as the percentage of total fecal hemoglobin, was similar with upper gastrointestinal and proximal colon lesions. ⋯ Unfortunately, large within-site variation caused considerable overlap between sites. We conclude that the intestinal converted fraction is influenced by the site and amount of bleeding. However, its clinical utility is compromised by substantial individual differences in luminal hemoglobin metabolism.
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The efficacy and complications of esophageal tamponade as the first procedure in the routine management of acute variceal hemorrhage were evaluated in 151 consecutive bleeding episodes treated at a specialized unit. The Sengstaken-Blakemore tube was employed in the 118 cases in which emergency endoscopy demonstrated bleeding esophageal varices, and the Linton-Nachlas balloon in the 33 cases with bleeding from gastric varices. Hemostasis lasting at least 24 hr was obtained in 91.5% of cases treated with the Sengstaken-Blakemore balloon and in 88% of those treated with the Linton-Nachlas balloon. ⋯ The only severe complication noted in these 151 episodes of bleeding treated by tamponade was pulmonary aspiration, which was detected in 10% of cases. This complication was related to the presence and degree of encephalopathy (P less than 0.001) and was prevented by orotracheal intubation prior to tamponade. These results indicate that balloon tamponade continues to be a reliable and valuable method to arrest bleeding from esophagogastric varices.
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Comparative Study
Cysteamine-induced inhibition of mucosal and pancreatic alkaline secretion in rat duodenum.
To determine the effect of cysteamine on the alkaline secretion by the duodenal epithelium, pancreas, and Brunner's glands in relation to the pathogenesis of duodenal ulceration, the alkaline secretion by various types of duodenal loops was comparatively studied. The results obtained were as follows: (1) Cysteamine significantly reduced both mucosal and pancreatobiliary alkaline secretion in the proximal duodenum of rats. (2) The ratio of contribution of pancreatobiliary alkaline secretion to total neutralization of acid in the proximal duodenum was 55.9% under continuous perfusion. (3) There was no significant difference between the amounts of alkali per unit volume of the proximal and distal duodenal loops. (4) The alkaline substance secreted by the proximal duodenal mucosa was confirmed to be the bicarbonate. From these findings, it has been concluded that the impairment of bicarbonate secretion by the mucosal epithelium of proximal duodenum, not by Brunner's glands, plays a causative role in cysteamine-induced duodenal ulceration.