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A careful history can localize gastrointestinal motility disorders and suggest appropriate diagnostic tests. Dysphagia, odynophagia, heartburn and reflux have esophageal origins. The same symptoms occur in achalasia, a classic motor disorder of the lower esophageal sphincter, which can be diagnosed by barium swallow, endoscopy and esophageal motility studies. Nausea, vomiting, anorexia, bloating and abdominal pain are symptoms of motor disorders of the stomach and small intestine. When these symptoms are accompanied by unexplained right upper quadrant pain, elevated liver enzyme levels and unexplained recurrent pancreatitis, the diagnosis of impaired biliary motility is suggested. Colorectal motility disorders may present as abdominal pain, diarrhea, constipation and/or fecal incontinence. If symptoms do not resolve with dietary changes and appropriate medications and the anatomy is normal on lower gastrointestinal studies, colorectal motility studies may be indicated.
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PMID:Gastrointestinal motility disorders. 859 65

Our objective was to monitor serum and urine biochemical changes after oral sodium phosphate cleansing in a prospectively designed study. The study subjects were seven healthy, asymptomatic adults. Sodium phosphate 45 ml diluted in 45 ml water was given orally at baseline and 12 hr later. Calcium, ionized calcium, phosphorus, sodium, potassium, creatinine, and PTH were analyzed at 2, 4, 6, 9, 12, 14, 16, 18, 21 and 24 hr after the first challenge. Urinary calcium, phosphorus, sodium, potassium, and cyclic AMP were analyzed at baseline and every 2 hr after oral sodium phosphate. Blood pressure, pulse, and respiratory rate were recorded every 2 hr and symptom questionnaires using visual analog scales were completed. A marked rise in phosphorus (peak range 3.6-12.4 mg/dl, P < 0.001) and falls in calcium (P < 0.001) and ionized calcium (P < 0.001) were seen. Rises seen in PTH and urinary cAMP confirmed the physiologic significance of the biochemical effect. There were no significant changes in other serum and urine laboratory or clinical assessments. Reported significant symptoms included bloating, cramps, abdominal pain, and nausea. Significant hypocalcemia and hyperphosphatemia after oral sodium phosphate raises concern about its use in normal individuals. Oral sodium phosphate should not be administered in patients with cardiopulmonary, renal, or hepatic disease.
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PMID:Biochemical effects of oral sodium phosphate. 867 96

From 1990 through 1993, we treated 36 patients with recurrent typical biliary colic but who showed no ultrasonic evidence of cholelithiasis by laparoscopic cholecystectomy. Associated symptoms included nausea (75%), bloating (56%), fatty-food intolerance (53%), vomiting (17%), weight loss (31%), bowel irregularity (28%), reflux or dyspepsia (25%), and fever (17%). Diagnostic evaluation included ultrasound (100%), upper gastrointestinal series (36%), oral cholecystogram (14%), computed tomographic scan (39%), endoscopic retrograde cholangiopancreatography (17%), upper gastrointestinal endoscopy (14%), and hepatobiliary scan (92%). Quantitative hepatobiliary scans in 33 patients revealed a low gallbladder ejection fraction (EF) of less than 35% in 29 patients (88%; mean EF = 9%), and 13 patients experienced reproducible pain after cholecystokinin provocation. All patients underwent attempted laparoscopic cholecystectomy; one case of unsuspected acute acalculous cholecystitis was converted to open laparotomy because of unclear anatomy. Gross and histological examination of the gallbladders revealed chronic inflammation (83%), cholesterolosis (31%), cholesterol crystals or small stones (17%), acute inflammation (8%), polyps (6%), and normal histology (6%); however, blind retrospective scoring of gallbladders revealed significant chronic inflammation in only 38%. In the 2 to 40 months (mean, 14 months) since operation, there have been no deaths (97% follow-up). Laparoscopic cholecystectomy relieved pain in 93% of patients with a low preoperative EF compared with 75% of patients with a normal EF (nonsignificant p value). Persistent abdominal or gastrointestinal complaints included flatulence (31%), loose stools or fecal urgency (29%), belching (29%), indigestion (20%), nausea (11%), and "typical" gallbladder pain (9%). We conclude that many patients with symptoms of biliary colic and scintigraphic evidence of biliary dyskinesia have histologic findings of chronic cholecystitis. Although laparoscopic cholecystectomy usually eliminates biliary colic, persistent nonbiliary complaints are frequent.
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PMID:Chronic acalculous cholecystitis: laparoscopic treatment. 868 Jun 33

Because no contraceptive agent is perfect, patients must weigh the benefits and risks of the contraceptive method they decide to initiate and continue. Individual decision making and provider-client communication interact in complex ways to determine contraceptive behavior. Use of the contraceptive injectable depot medroxyprogesterone acetate (DMPA) should be preceded by counseling which individualizes its risks and benefits, answers all questions (asked and unasked), and develops a longterm plan to minimize side effects. Counseling should cover the contraceptive and noncontraceptive benefits of DMPA; specific side effects such as bleeding changes, weight changes, and fertility changes; the mechanisms of action; and ways to avoid acquiring sexually transmitted diseases. When evaluating and managing side effects, a differential diagnosis independent of DMPA must be considered first (especially for postcoital bleeding and headache). A pregnancy test should be offered in the first month of amenorrhea, after which no treatment is necessary. Ovulation resumption after use may be spontaneous or may be induced with menotropin therapy. Spotting and breakthrough bleeding may be handled by counseling or by a short course of high-dosage ibuprofen or of low-dose estrogen supplementation. Counseling may help women manage weight gain through caloric reduction and an increase in exercise. Acne which occurs soon after adoption of the method may be managed pharmacologically. Increased intake of dietary fiber and fluids may ameliorate the symptoms of abdominal bloating, and temporary nausea can be treated with antacids. Recent research has shown that depression does not increase with DMPA use, although the contraceptive is sometimes implicated in mood changes. Breast tenderness decreases with prolonged DMPA usage and can be managed with proper support garments and a reduction in other causative agents such as caffeine. Women who experience an increase in varicose veins should wear support hose and elevate their legs when possible. Women with symptoms of hypoestrogenic side effects should undergo a serum estradiol level test and appropriate replacement therapy. DMPA can be used immediately postpartum even in breast-feeding women. Women with amenorrhea should be tested for pregnancy before initiating DMPA or reinitiating use at an interval longer than 11-13 weeks. No adverse side effects have been found if pregnancy does occur.
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PMID:Counseling issues and management of side effects for women using depot medroxyprogesterone acetate contraception. 872 1

Gastroparesis is delayed gastric emptying of either solids or liquids, which occurs in the absence of mechanical obstruction. Although associated with many diseases, the most frequent cause of gastroparesis is diabetes mellitus. It is estimated that up to 50% of diabetic patients may have this problem. Symptoms of gastroparesis include postprandial nausea, epigastric pain/burning, bloating, early satiety, excessive eructation, anorexia and vomiting. The vomiting associated with gastroparesis often has the following two features: (1) emesis of undigested foods ingested more than four hours previous; and (2) emesis of undigested foods in the middle of the night or in the morning prior to eating breakfast. It is important to recognize and treat gastroparesis not only to decrease symptoms but also to prevent bezoar formation and nutritional deficiencies as well as to improve glycemic control in brittle diabetics. The purpose of this article is to review the physiology of gastric emptying and to use this information to understand the pharmacological therapies for this debilitating problem.
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PMID:Gastroparesis: current management. 878 40

Helicobacter pylori-like organisms (Hp) and polymorphonuclear leucocytes (PMNs) in 2614 gastroduodenal biopsies from 602 patients with dyspepsia, in Al Ain, United Arab Emirates, between October 1990 and October 1992, were histologically graded to determine the prevalence of Hp gastritis and their utilization in the evaluation of treatment efficacy in these patients. Symptoms of functional dyspepsia included, in order of frequency, abdominal pain or discomfort, flatulence, burning sensation, regurgitation, fullness, nausea, vomiting, bloating and belching. The biopsies were paraffin embedded, sectioned and stained with hematoxylin and eosin (H and E) to grade the inflammation. In addition to H and E, several special stains including modified Giemsa (MG), Wharthin-Starry silver and cold Ziehl-Neelsen stains were utilized to clearly identify Hp organisms. Giemsa method was found to be superior to other special stains in visualizing the Hp organisms in paraffin sections, and was utilized in every case. Two immunohistochemical markers for B cells (CD20) and T cells (CD45RO) were utilized for labeling lymphocytes infiltrating the lamina propria of the gastroduodenal biopsies in formalin-fixed paraffin-embedded sections. H and E and MG stained sections were utilized to count PMNs and Hp, and were graded 0, 1, 2, and 3, corresponding to none, mild, moderate, and severe grades of the Sydney system for classification of gastritis, respectively. Of the total initial 2318 endoscopic biopsies, 98.8% of the patients had suitable biopsies for histologic evaluation. Unsuitable biopsies were recovered from patients with gastric carcinoma. Inflammation was seen in 98.5% of 595 patients with suitable biopsies. In 74.5% of these patients the inflammation was active; 37.5, 32.5 and 4.5% had mild, moderate and severe active inflammation, respectively. In the remaining 24% of the 595 patients, the gastritis was chronic without activity or atrophic changes. As many as 73.6% of the patients with suitable biopsies were Hp positive; 39.8, 29.1 and 4.7% had grades 1, 2 and 3 Hp, respectively. Intestinal metaplasia was found in 28.9% of the 602 patients, and was seen more often in Hp positive than Hp negative patients (34.5 vs 14%, P < 0.005, for d.f. = 1; chi 2 = 10.35). Of the Hp positive patients, 172 and 46 patients attended the first and second follow-up endoscopy visits, respectively. The triple treatment was composed of one dose of tinidazole (2gm), doxycycline, 200 mg initial dose and 100 mg daily for two weeks, and bismuth subcitrate (Gist-Brocades nv, Delft, The Netherlands), 2 tablets twice daily for 4 weeks. After triple drug treatment, eradication of Hp was accomplished, histologically, in 38.4 and 45.7% of the patients on first and second follow-up visits, respectively. Thus, the Sydney system-based grading scale provides an objective histological evaluation of Hp gastritis for accurate prevalence studies, and may prove to be of value in estimating treatment efficacy.
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PMID:Grading Helicobacter pylori gastritis in dyspeptic patients. 881 77

A prospective, randomized three-arm trial is presented of 150 consecutive patients attending for double-contrast barium enema (BE). This compares 'Picolax' (a combined stimulant and osmotic agent), 'Picolax' following a 3 day low-residue diet and 'Kleen-Prep' (a polyethylene-glycol osmotic agent). Faecal clearance, mucosal coating and colon fluid were scored in four colonic segments by two radiologists working independently and blinded to the preparation used. Analyses of an elderly subgroup and of side effects was performed. Low-residue diet conferred no benefit to Picolax preparation, which was satisfactory (ability to exclude 5 mm polyps) in 80% of patients. Kleen-Prep failed to achieve adequate preparation in 46%, due to excess fluid and poor mucosal coating. Kleen-Prep caused more patient nausea, abdominal bloating and pain than Picolax. Patients 70 years and older had similar results. Low-residue diet need not be used in addition to Picolax. Kleen-Prep as a single agent is not recommended for BE preparation.
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PMID:Barium enema preparation: a study of low-residue diet, "Picolax' and 'Kleen-Prep'. 882 25

Abnormalities in gastrointestinal motility have been reported in a substantial proportion of patients with functional dyspepsia, supporting the use of prokinetic drugs for treatment of dyspeptic symptoms. To evaluate efficacy and safety of levosulpiride in short-term treatment, 1298 patients were enrolled in a double-blind multicentric study carried out in 45 Italian Gastroenterology Departments. Patients were randomly assigned to either levosulpiride (25 mg tid), domperidone (10 mg tid), metoclopramide (10 mg tid) or placebo (1 tablet tid) for 4 weeks. Patients were selected on the basis of: a) occurrence in the last 4 weeks of at least 5/10 selected symptoms (anorexia, nausea, vomiting, upper abdominal pain, postprandial bloating, abdominal fullness, early satiety, belching, heartburn, regurgitation), severity of which should reach/exceed a total score of 8, as assessed by a specific scale ranging from 0 (absent) to 3 (severe); b) normal results of routine biochemical, ultrasound and endoscopic examinations. In addition, each patient subjectively evaluated efficacy of treatment by a visual analogue scale. Significant improvement was recorded for all symptoms at days 10 and 28 in all groups (p < 0.001), but levosulpiride was significantly (p < 0.01) superior to domperidone, metoclopramide and placebo both in the overall clinical improvement scale as well as in a subgroup of symptoms (postprandial bloating, epigastric pain, heartburn). Active treatments and placebo were comparable as far as concerns occurrence of side-effects (12-20%) including galactorrhoea, breast tenderness and menstrual changes.
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PMID:Levosulpiride in functional dyspepsia: a multicentric, double-blind, controlled trial. 889 46

Disorders of stomach function refer to neuromuscular abnormalities of gastric motility that involve the fundus, corpus, antrum, pylorus, and antroduodenal coordination. Symptoms related to disorders of stomach function are commonly meal-related; "dyspepsia" symptoms of epigastric fullness; or bloating, discomfort, and nausea in the postprandial period. Early satiety and prolonged stomach fullness are often present, and in severe cases the patient may vomit undigested food. Neuromuscular disorders of stomach function should not be considered until structural and metabolic diseases that may also cause these nonspecific symptoms are excluded. A thorough history, routine laboratory studies, ultrasound of the gallbladder and pancreas, and upper endoscopy will exclude the majority of diseases that may cause dyspepsia symptoms. Disorders of gastric neuromuscular function may be detected by solid-phase gastric emptying studies which detect gastroparesis and by electrogastrography which detects abnormalities of gastric myoelectrical activity termed gastric dysrhythmias. Invasive tests to determine abnormalities in gastric motility include intraluminal pressure and gastric tone/compliance recordings. Treatment approaches are limited at the present time and include dietary counseling and gastroprokinetic agents such as metoclopromide, cisapride, and erythromycin. Increased understanding of the pathophysiology of disorders of gastric neuromuscular function will lead to an improved and more rational armamentarium for the treatment of symptoms related to functional disorders of the stomach.
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PMID:Functional disorders of the stomach. 890 32

Cyclospora cayetanensis, a coccidian parasite, is a new cause of prolonged diarrhea. It has been most recently associated with ingestion of contaminated fruit. Although infection with C. cayetanensis is considered rare, the exact prevalence in Canada is unknown. Transmission is thought to occur through contaminated food and water. The incubation period varies from days to weeks. Patients present with nausea, vomiting, anorexia, bloating, abdominal cramping, increased gas and watery diarrhea. The illness may last up to 6 weeks and may respond to treatment with trimethoprim-sulfamethoxazole. C. cayetanensis is differentiated from other coccidians by its sporulation characteristics and its autofluorescence. To obtain a positive result of a laboratory test for the organism, a modified Ziehl-Neelsen acid-fast stain is recommended. Proper laboratory handling of specimens is facilitated by inclusion of clinical information on requisition forms.
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PMID:Cyclosporiasis: a new cause of diarrhea. 891 Dec 96


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