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The operative mortality and morbidity of laparoscopic fundoplication are lower than for the open procedure. Questions have been raised regarding its long-term durability. One hundred seventy-one patients who had undergone laparoscopic Nissen fundoplication at least 5 years previously answered a questionnaire. During this period, 291 patients underwent a laparoscopic Nissen fundoplication. Surveillance data were available for 171 patients at a mean of 6.4 years after surgery. Overall, 96.5% were satisfied and 3.5% were not satisfied with the result of the procedure. Persistent symptoms included abdominal bloating (20.5%), diarrhea (12.3%), regurgitation (6.4%), heartburn (5.8%) and chest pain (4.1%); 27.5% reported dysphagia, and 7% had required dilatation. Fourteen percent were on continuous proton pump inhibitor therapy, but 79% of these patients were treated for vague abdominal or chest symptoms unrelated to reflux, which calls into question the indications for this therapy. Ninety-three percent of all patients were satisfied with their decision to have surgery. The overall well-being score increased significantly from 2.2 +/- 1.6 before surgery to 8.8 +/- 2 (P > 0.0001) at more than 5 years after surgery. Twenty-one percent had undergone additional diagnostic procedures after surgery such as endoscopy and/or barium swallow. Laparoscopic Nissen fundoplication is an excellent long-term treatment for gastroesophageal reflux disease with persistent success for more than 5 years. Some patients have continuing symptoms and remain on therapy, but more than 90% of all patients undergoing laparoscopic Nissen fundoplication remain satisfied with their decision to have surgery. These results are at least as good as those achieved with open fundoplication and prove the long-term worth of this procedure.
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PMID:Five- to eight-year outcome of the first laparoscopic Nissen fundoplications. 1198 29

Cholelithiasis and gastroesophageal reflux are both very common diseases that may occur simultaneously. Management of asymptomatic gallstones is still controversial. Because severe complications due to gallstones may occur incidental cholecystectomy during nonrelated abdominal surgery may be offered to patients with coexisting gallbladder disease. The aim of this study was to assess the clinical outcome of patients after laparoscopic fundoplication and incidental cholecystectomy for cholelithiasis compared with the outcome of patients after fundoplication alone. We conducted a retrospective chart review and prospective analysis using a questionnaire of the clinical outcome of patients who underwent laparoscopic fundoplication and incidental cholecystectomy from June 1991 to January 2000 in comparison with sex- and age-matched patients who had antireflux surgery alone. Sixty-seven (6.3%) of 1065 patients had a laparoscopic cholecystectomy at the time of laparoscopic antireflux surgery; 101 (75%) of 134 answered the questionnaire. The mean follow-up time was 4.6 years. Laparoscopic cholecystectomy did not influence surgical morbidity or mortality. Postoperative symptom score (1-10) did not show a statistically significant difference regarding bloating, diarrhea, abdominal pain, nausea, vomiting, biliary problems, jaundice, pancreatitis, dysphagia for liquids and solid, heartburn, regurgitation, and chest pain when the two groups were compared. We conclude that incidental cholecystectomy during laparoscopic antireflux surgery is safe and does not appear to influence the clinical outcome of the antireflux procedure.
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PMID:Incidental cholecystectomy during laparoscopic antireflux surgery. 1213 45

In general terms, all patients who undergo a laparoscopic fundoplication procedure should have objective evidence of gastroesophageal reflux. However, occasionally patients without objective evidence of reflux disease are referred for surgery. This study assessed the outcome of a highly selected group of patients who underwent laparoscopic fundoplication without objective evidence of reflux at either preoperative endoscopy or pH monitoring. Data from all patients undergoing laparoscopic fundoplication in our department over a 9-year period from December 1991 to January 2001 were collected prospectively. From a total of 1,003 patients, a subgroup of 15 patients was identified who had no evidence of ulcerative oesophagitis at endoscopy or abnormal reflux on 24-h pH monitoring. Eight of these patients had typical symptoms of reflux (four had predominantly heartburn, four had predominantly volume regurgitation) and seven patients had atypical symptoms such as cough, bloating, chest pain, or sore throat. All patients had tried medication for acid suppression before surgery, with five gaining little or no benefit. The mean acid exposure time was 2% (range 0.1-3.6%). A correlation between typical symptoms and reflux events of over 50% was noted in three patients. All patients underwent laparoscopic fundoplication, with one conversion to an open procedure. Mean patient satisfaction score (0-10 linear score) was 8.7 at 3 months and 1 year postoperatively. Three patients failed to improve following surgery. These three all had atypical symptoms, a symptom correlation of less than 50% with acid reflux on pH monitoring, and two of the three had a poor response to medication. All other patients benefited symptomatically from surgery. We concluded that the absence of objective evidence of reflux should not always preclude patients from a laparoscopic fundoplication. Carefully selected patients with typical reflux symptoms can have a good outcome. However, patients who do not have typical symptoms and who respond poorly to acid suppression are not likely to benefit from surgery.
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PMID:Laparoscopic fundoplication for patients with symptoms but no objective evidence of gastroesophageal reflux. 1247 78

The aim of this study was to compare symptomatic outcomes after laparoscopic antireflux surgery in patients with upright vs. supine reflux. A prospective database was used to assess postoperative clinical outcomes in relation to positional patterns of reflux in 117 patients. Supine reflux was present in 31%, upright in 24%, and the remaining 44% had bipositional reflux. Preoperatively there were no differences in the frequency of typical or atypical symptoms between groups. At a mean follow-up of 18 +/- 11 months postoperatively, there were marked differences in symptoms between groups. Patients with upright reflux noted significantly more heartburn, chest pain, odynophagia, and bloating postoperatively when compared to patients with supine and bipositional reflux (P < 0.05). According to visual analog scales, patients with upright reflux expressed less satisfaction with operative results, ascribing more symptoms to the esophagus and stomach, when compared to those with supine reflux (P < 0.05). Although all patients reported improvement, the extent of the relief from preoperative symptoms was less in patients with upright reflux (P < 0.05). When asked if, in retrospect, they favored operative therapy, the patients with upright reflux were less enthusiastic (P < 0.05). Although antireflux surgery eliminates reflux in nearly all patients, postoperative symptomatic outcome is related to the preoperative pattern of reflux. Although all patients showed symptomatic improvement, the extent of that improvement was significantly less in patients with upright reflux. These patients should be carefully counseled preoperatively regarding expected symptomatic outcomes.
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PMID:Patients with upright reflux have less favorable postoperative outcomes after laparoscopic antireflux surgery than those with supine reflux. 1250 20

The purpose of this study was to compare the quality of life (QOL) and functional results of 42 patients undergoing primary (60%) and 23 patients undergoing redo (40%) transthoracic paraesophageal hernia repairs. All patients had a floppy Nissen or Belsey anti-reflux repair with or without a Collis gastroplasty. Morbidity occurred in 12% of patients and was similar between groups (P=1.0). Overall QOL scores were not different between groups. Patients undergoing initial repair were found to have significantly higher QOL scores related to their GERD symptoms (P=0.02). Postoperative GERD symptom scores were not significantly different between groups for heartburn, regurgitation, epigastric/chest pain, or cough. Redo patients had more bloating (P=0.02) and dysphagia (P=0.04). Overall, total GERD scores were higher in the redo group compared to the initial group indicating worse GERD-related dysfunction in the redo group (15.8+/-3.8 vs. 6.3+/-1.6, P=0.03). Functional and QOL analysis of transthoracic paraesophageal hernia repairs indicates that redo procedures are associated with a higher incidence of specific gastrointestinal symptoms and worse GERD-related QOL when compared to initial procedures. These differences, while statistically significant, have limited clinical relevance as the overall QOL was not different between groups and low GERD symptom scores were found in both groups.
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PMID:Quality of life following primary vs. redo transthoracic paraesophageal hernia repairs. 1800 23

A 70-yr-old woman complained of left sided chest pain and non-bilious vomiting for four days after taking a gastric bloating agent for an upper gastrointestinal study. The chest radiography revealed gastric air-fluid levels and bowel loops in the left thoracic cavity. An emergency thoracotomy was performed. The abdominal organs (stomach, spleen, splenic flexure of the colon) were in the left thorax and the entire left hemidiaphragm was absent. There were no diaphragmatic remnants visible for reconstruction of the left diaphragm. We provided warm saline irrigation and performed a left lower lobe adhesiotomy. Thirteen days after surgery, the chest radiography showed improvement in the herniation but mild haziness remained at the left lower lung field. Here we present the oldest case of congenital diaphragmatic agenesis presenting with transient gastric volvulus and diaphragmatic hernia.
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PMID:Congenital hemidiaphragmatic agenesis presenting as reversible mesenteroaxial gastric volvulus and diaphragmatic hernia: a case report. 1954 20

Weight loss is a recognized alarm symptom for organic gastrointestinal (GI) disease, yet the association between obesity and specific GI symptoms remains poorly described. A meta-analysis was conducted to determine which GI symptoms predominate among obese individuals. A search of the literature using the databases MEDLINE, EMBASE PubMed and Current Contents (1950 - November 2011) was conducted. All studies assessing GI symptoms and increasing body mass index (BMI)/obesity were included. English and non-English articles were searched. A random effect model of the studies was undertaken. Overall, significant associations between GI symptoms and increasing BMI were found for upper abdominal pain (odds ratio [OR] = 2.65, 95% confidence interval [CI]: 1.23-5.72), gastroesophageal reflux (OR = 1.89, 95% CI: 1.70-2.09), diarrhoea (OR = 1.45, 95% CI: 1.26-1.64), chest pain/heartburn (OR = 1.74, 95% CI: 1.49-2.04), vomiting (OR = 1.76, 95% CI: 1.28-2.41), retching (OR = 1.33, 95% CI: 1.01-1.74) and incomplete evacuation (OR = 1.32, 95% CI: 1.03-1.71). However, no significant associations were found for all abdominal pain, lower abdominal pain, bloating, constipation/hard stools, fecal incontinence, nausea and anal blockage. Several key GI symptoms are associated with increasing BMI and obesity. In addition, there were a number of other GI symptoms that had no relationship with obesity. A greater knowledge of the GI symptoms associated with obesity along with the physiology will be important in the clinical management of these patients.
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PMID:Gastrointestinal symptoms and obesity: a meta-analysis. 2218 20

The classic symptoms of irritable bowel syndrome (IBS) are abdominal pain, bloating and some form of bowel dysfunction. The pain is typically colicky in nature and can occur at any site although most commonly it is on the left side. The abdomen feels flat in the morning and then gradually becomes more bloated as the day progresses reaching a peak by late afternoon or evening. It then subsides again over night. Traditionally IBS is divided into diarrhoea, constipation or alternating subtypes. IBS patients frequently complain of one or more non-colonic symptoms, these include constant lethargy, low backache, nausea, bladder symptoms suggestive of an irritable bladder, chest pain and dyspareunia in women. The traditional view that IBS is a largely psychological condition is no longer tenable. Rectal bleeding, a family history of malignancy and a short history in IBS should always be treated with suspicion. Both pain and bowel dysfunction are often made worse by eating. It is recommended that a coeliac screening test is undertaken to rule out this condition. Other routine tests should include inflammatory markers such as CRP or ESR. Calprotectin is a marker for leukocytes in the stools and detects gastrointestinal inflammation. A negative test almost certainly rules out inflammatory bowel disease, especially in conjunction with a normal CRP. Fermentable carbohydrates can have a detrimental effect on IBS and this has led to the introduction of the low FODMAP diet.
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PMID:Managing irritable bowel syndrome in primary care. 2645 14

Patients with functional gastrointestinal disorders (FGIDs) often experience distress, reduced quality of life, a perceived lack of validation, and an unsatisfactory experience with health care providers. A health care provider can provide the patient with a framework in which to understand and legitimize their symptoms, remove self-doubt or blame, and identify factors that contribute to symptoms that the patient can influence or control. This framework is implemented with the consideration of important factors that impact FGIDs, such as gender, age, society, and the patient's perspective. Although the majority of FGIDs, including globus, rumination syndrome, IBS, bloating, constipation, functional abdominal pain, sphincter of Oddi dyskinesia, pelvic floor dysfunction, and extra-intestinal manifestations, are more prevalent in women than men, functional chest pain, dyspepsia, vomiting, and anorectal pain do not appear to vary by gender. Studies suggest sex differences in somatic but not visceral pain perception, motility, and central processing of visceral pain; although further research is required in autonomic nervous system dysfunction, genetics and immunologic/microbiome. Gender differences in response to psychological treatments, antidepressants, fiber, probiotics, and anticholinergics have not been adequately studied. However, a greater clinical response to 5-HT3 antagonists but not 5-HT4 agonists has been reported in women compared with men.
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PMID:Age, Gender and Women's Health and the Patient. 2714 22

The prevalence of non-cardiac chest pain (NCCP) ranges from 13-33%. A majority of those presenting with a chief complaint of chest pain are found to have a diagnosis of NCCP. Aerodigestive diseases are a cause of NCCP, and billions of dollars are spent annually on the treatment of NCCP. Furthermore, NCCP can cause significant psychological stress. NCCP is commonly diagnosed when patients have chest pain despite a normal cardiac evaluation. The leading cause of NCCP is gastro-oesophageal reflux disease (GORD). GORD should be suspected in patients who report a history of acid regurgitation, cough, dysphagia, and bloating. Another common cause of NCCP is obstructive airway disease (OAD). A thorough history and review of the symptoms should be performed for those with suspected NCCP, especially because of the contributing end organs. It is known that environmental exposures can commonly cause GORD and OAD; however, NCCP has not been fully explored in the context of environmental exposure. Patients with a history of exposure to particulate matter can develop environmental-exposure-associated GORD and coexisting OAD. This narrative review aims to provide a practical overview of NCCP, its causes, their relation to environmental exposure, and associated biomarkers. The authors used a PubMed search that spanned 2003-2018 to accomplish this. Additionally, this review provides a broad overview of biomarkers of GORD-associated NCCP and OAD-associated NCCP due to environmental exposure.
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PMID:Non-Cardiac Chest Pain: A Review of Environmental Exposure-Associated Comorbidities and Biomarkers. 3077 67


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