Update in Gastroenterology

Update in Gastroenterology

Norton J. Greenberger, MD

From Brigham and Women's Hospital, Boston, Massachusetts.

2002-2003 Series: Update Sessions from ACP–ASIM's 2002 Annual Session

David A. Cramer, MD, and Paul T. Kefalides, MD, Co-Editors

This Update summarizes important advances reported in the past 2 years on the management of digestive disorders. I discuss clinical problems that practicing internists commonly encounter and cover new developments in areas frequently discussed in the gastroenterology literature. I have divided the Update into sections on gastroesophageal reflux disease, Helicobacter pylori infection, infectious diarrhea, colorectal cancer screening, gastrointestinal bleeding, and inflammatory bowel disease.

Gastroesophageal Reflux Disease

Gastric Acid Pocket Bathes Gastroesophageal Junction

The following study of the pathophysiology of the gastroesophageal junction explains in part why the junction is so susceptible to injury and why symptoms of acid injury occur after a meal when food buffers gastric acid.

FletcherJ,
WirzA,
YoungJ,
et al.

Unbuffered highly acidic gastric juice exists at the gastroesophageal junction after a mealGastroenterology2001121775-83

Fletcher J, Wirz A, Young J, et al. Unbuffered highly acidic gastric juice exists at the gastroesophageal junction after a meal. Gastroenterology. 2001; 121:775-83. [PMID: 11606490]

Fletcher and colleagues measured the pH of esophageal refluxate in the stomach during a fast and after a meal. They hoped to identify the location of unbuffered acid in relationship to the gastroesophageal squamocolumnar junction, and they hypothesized that acidic gastric juice can separate and form layers over ingested gastric contents in a pocket.

In the 40 dyspeptic patients studied, the squamocolumnar junction was marked with radiopaque endoscopic clips. Dual gastric and esophageal pH tracings were recorded with an electrode pulled through the upper gastrointestinal tract. The authors found that after a meal, highly acidic, unbuffered gastric juice extended from the cardia across the gastroesophageal squamocolumnar junction to a distance 1.8 cm into the distal esophagus. The median pH was 1.6, compared with a pH of 4.7 in the body of the stomach (P < 0.001). This acidic layer may be a key factor in the high prevalence of disease at this site.

Dysmotility Was Associated with More Severe Reflux

As gastroesophageal reflux disease (GERD) increases in prevalence, more patients are contemplating surgical therapies. Patients have fundoplication as a definitive treatment for gastroesophageal reflux, as an alternative to long-term …

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