Background: Pediatric-onset Crohn's disease (CD) may represent a more severe form of disease. The aim of this study was to describe long-term outcome and identify associated risk factors of complicated behavior in a large population-based pediatric-onset CD cohort. Patients and methods: Cases included all patients recorded in the EPIMAD registry diagnosed with definite or probable CD between January 1988 and December 2004, under the age of 17 years at the time of diagnosis, with at least two years of follow-up. Results: Five hundred and thirty-five patients were included. Median follow-up was 11.1 years[IQR, 7.3-15.0]. At the end of follow-up, 8% (n = 44) of patients had pure ileal disease (L1), 8% (n = 44) had pure colonic disease (L2), and 83% (n = 439) had ileocolonic disease (L3). L4 disease and perianal disease were observed in 42% (n = 227) and 16% (n = 85) of patients, respectively. At the end of follow-up, 58% (n = 308) of patients presented complicated disease behavior (B2, 39% and B3, 19%), and 42% (n = 163) of patients with inflammatory behavior at diagnosis had evolved to complicated behavior. During followup, 86% of patients (n = 466) received at least one course of corticosteroids, 67% (n = 357) of patients had been exposed to immunosuppressants and 35% (n = 187) of patients received at least one anti-TNF agent. Forty-three percent (n = 230) of patients underwent at least one intestinal resection. The overall mortality rate was 0.93% and the SMR was 1.6[0.5-3.8] (p = 0.20). Five cancers were reported with a crude cancer incidence rate of 1.1% and an SIR of 3.3[1.2-7.0] (p = 0.01). In a multivariate Cox model, ileal (HR, 1.87 [1.09-3.21], p = 0.022) or ileocolonic (HR, 1.54[1.01-2.34], p = 0.042) and perianal lesions at diagnosis (HR, 1.81[1.13-2.89], p = 0.013) were significantly associated with complicated behavior. Conclusion: About 80% of patients with pediatric-onset CD presented extensive ileocolonic disease during follow-up. The majority of patients evolved to complicated behavior. Surgery, cancer and mortality were observed in 43%, 0.9% and 0.9% of patients, respectively. (c) 2018 Editrice Gastroenterologica Italiana S. r. l. Published by Elsevier Ltd. All rights reserved.

BACKGROUND:Radiofrequency (RF) energy delivery is an endoscopic procedure developed for the treatment of gastro-oesophageal reflux disease.AIM:To compare RF and a proton pump inhibitor strategy (PPI) in PPI-dependent patients by carrying out a prospective, randomized trial.METHODS:Patients with PPI-dependent typical reflux symptoms were randomly allocated to either RF or PPI regimen alone. The primary endpoint, evaluated at 6-month, was defined as the possibility for the patient to stop or to decrease PPI use to <50% of the effective dose required at baseline.RESULTS:In the RF group, 18/20 patients stopped (n = 3) or decreased (n = 15) PPI use as compared to eight of 16 in the PPI group (P = 0.01). None of the control patients could stop PPI. Health-related quality of life scores were not different between groups. No significant change in oesophageal acid exposure (OAE) was noted between baseline and 6-months after RF. No severe complication was reported.CONCLUSIONS:Radiofrequency energy delivery is a safe and effective therapeutic option, allowing reduction in or discontinuation of PPI therapy in patients with PPI-dependent symptoms, without loss of quality of life. However, in a majority of patients, PPI therapy cannot be completely stopped. The efficacy of RF does not seem to be related to a decrease in OAE.

Introduction: Le RGO est une affection fréquente qui peut retentir lourdement sur la qualité de vie des patients. Chez les malades dépendant d'un traitement par inhibiteurs de pompe à proton (IPP), le recours à la chirurgie représente une alternative possible, mais qui comporte une morbidité non négligeable. La radiofréquence (RF) selon la méthode STRETTA est une modalité endoscopique consistant à administrer un courant de haute fréquence dans la région cardiale. Le but de cette étude prospective randomisée ouverte était de comparer l'efficacité de la RF à la prise d'IPP seule chez des patients atteints de RGO.

Only one multicenter prospective study has been published so far on the feasibility of endoscopic suturing for the treatment of GERD. A new multicenter prospective study on efficacy and safety of the procedure was conducted. Patients (pts) and methods: Inclusion criteria were: age>18y, symptomatic GERD (GERD-HRQL>20 without treatment), continuous and effective PPI therapy for more than 3 months, absence of hiatal hernia, Barrett's or achalasia, body mass index < 40. During the 2 months prior the procedure, GERD-HRQL score, esophageal 24h pHmetry and manometry were obtained once PPI were stopped for 10 days. 2 or 4 sutures (Endocynch, Bard) were performed on a vertical axis, the upper at the level of the Z line. Follow-up consisted in: questionnaire at 1,3,6 and 12 months (mo), pHmetry, manometry and gastroscopy at 3 mo, gastroscopy at 1 year. Results: 60 pts (mean age: 49, 20 females) were included. A mean of 2.7 sutures per pt was used. Side-effects rapidly resolutive were: retrosternal pain (15%) and dysphagia (18%). The percentage of pts without PPI is 75% at 1 mo, 67% at 3 mo, 53% at 6 mo and 50% at 12 mo. The percentage of pts still with PPI but at lower doses is 19% at 1 mo, 25% at 3 mo, 28% at 6 mo and 33% at 12 mo. GERD-HRQL decreased at 1, 3, 6 and 12 mo (p<0.05). Only one pt had surgery during the follow-up period. Lower esophagus sphincter pressure was unchanged at 3 mo. pH<4 time was reduced from 11.2 to 9.2% at 3 months (p<0.05). At gastroscopy, all initial sutures were in place in 48% of pts, and at least one suture has disappeared in 52% of cases (including 4% of pts without any more suture). Conclusion: This study demonstrates the safety of this suturing system for the treatment of GERD and its efficacy to reduce the need for PPI treatment. However, gastroscopy and results observed at 1 year suggest that long term persisting effects are uncertain.

Our aim was to compare the results of the analysis of postprandial duodenojejunal motor patterns provided by a conventional computer-aided analysis with those provided by the new nonlinear mathematical method borrowed from 'chaos theory for determining how nonlinear analysis can improve fed motor pattern analysis and detect organization of postprandial contractions. Ten patients who had been explored for an idiopathic gastroparesis, and 20 healthy volunteers underwent duodenojejunal manometric recording for 3 h after a 750 kcal meal. Computer-aided analysis on each half-hour of the postprandial recording period calculated the number of waves (NW) and the area under the curve (AUC). Pressure signals were concurrently described by phase portraits obtained by plotting each pressure value at time t with the pressure value at time t + 1 s. The shape and amplitude of phase portraits were visually analysed and the relative area covered (RAC) by the phase portraits was calculated. With conventional analysis, NW and AUC were maximal during the first post-meal hour then decreased with time both in healthy volunteers and gastroparetic patients. With this analysis, the only difference between patients and controls was a lower NW (P < 0.02) in patients, observed only in the duodenum. Phase portraits analysis demonstrated lower RAC, a different distribution of RAC and more regular phase portraits in patients than in controls. Phase portraits outlined the heterogeneity of the patient group contrasting with the homogeneity of the control group when no subgroup was demonstrated by conventional analysis. We therefore conclude that the study of post prandial duodenojejunal motor behaviour could be improved by nonlinear dynamic analysis.

Although delayed gastric emptying of hquids or solids may be one of the mechanisms that increases the volume of gastric contents available for reflux into the esophagus, investigations of this possible relationship have yielded conflicting results.

Twenty-eight patients with chronic idiopathic dyspepsia defined by the presence of chronic unexplained symptoms suggestive of gastric stasis and directly related to food ingestion were included in this prospective study. Gastric emptying of the liquid and solid phases of a meal was quantified by a dual-isotope method, and symptoms were evaluated by a diary and a visual analog scale. Delay in gastric emptying was evidenced in 59% of the dyspeptic patients; it occurred with liquids in more cases than solids. Quantitative and qualitative evaluation of symptoms was of no practical value in predicting the presence of objective stasis. The dyspeptic patients were included in a double- blind randomized controlled trial of cisapride, a new gastrokinetic drug devoid of central antiemetic effects. After six weeks of cisapride treatment, all patients with initially abnormal gastric emptying rates for liquids, and all but one for solids returned to normal ranges, and significant differences between cisapride and placebo groups were observed for half emptying times of both solids (136±16 min vs 227 ±32 min; P<0.02) and liquids (61±4 min vs 132±37 min; P<0.01). Cisapride also significantly improved dyspeptic symptom scores at weeks 3 and 6 of treatment as compared to those measured before treatment. Nevertheless, the decrease in global diary score was significantly higher than that seen with placebo at week 3 (−16±6 vs −1±9; P<0.05), but not at week 6 (−18±5 vs −10±8). The symptomatic effect of cisapride at week 3 was significantly more pronounced in patients with abnormal initial gastric emptying than in those with normal gastric emptying (−30±7vs −4±6; P<0.02).These results underline the importance of objective evaluation of gastric emptying in the detection of patients with gastric stasis who exhibited the best symptomatic response to cisapride.

Although abdominal complaints are frequent in both acute and chronic alcoholism, little is known of the effect of ingestion of ethanol with a meal on the function of the upper digestive tract. We have studied the effects of oral ethanol (1 g/kg body wt) taken with food on (1) the gastric emptying rate of a solid-liquid meal as measured by a dual radioisotope technique in six normal subjects; and (2) the gastric response (emptying and secretion), biliopancreatic secretions, and duodenal nutrient absorption after an homogenized meal, as evaluated by a gastroduodenal intubation-marker perfusion technique on seven healthy volunteers. In the latter experiments, radioimmunoassays of gastrin, secretin, cholecystokinin, pancreatic polypeptide, motilin, somatostatin, gastric inhibitory polypeptide, and vasoactive intestinal polypeptide were performed serially. As compared with the control experiment, alcohol induced the following effects: (1) marked delay of gastric emptying of solids, smaller slowing effect on gastric emptying of the liquid phase of the solid-liquid meal and of the homogenized meal; (2) no significant change in gastric acid secretion; (3) no change in the overall postprandial pancreatic enzyme outputs, but a delay of lipase secretion; (4) no change in the early bile salt postprandial output, but a reduced bile salt secretion from the second postprandial hour onwards; (5) no significant change in carbohydrate and lipid duodenal absorption; and (6) a significantly greater postcibal gastrin release. The mechanisms for these effects of alcohol on upper digestive tract function remain to be clarified.

We have measured, by an intubation method, gastric evacuation and gastrointestinal absorption of alcohol ingested with a meal in seven healthy nonalcoholic subjects. A homogenized meal containing [14C]PEG and ethanol (1 g/kg body wt) was given intragastrically while saline containing [57CO]vitamin B12 was perfused into the duodenum. Of the ingested alcohol, 39.4±4.1% was absorbed through the stomach wall during the first postprandial hour and 73.2±4.2% during the total postcibal period, whereas only 24±3% was absorbed during the same time in the duodenum. Thus alcohol ingested with a meal is mainly and rapidly absorbed in the stomach; the contribution of the small intestine below the angle of Treitz to alcohol absorption is negligible.

Caloric regulation of gastric emptying was mainly assessed with artificial liquid meals. We thus studied the effects of glucidic and lipidic caloric loads on gastric emptying of a solid-liquid meal (400 ml; 480 kcal), measured by an isotopic technique. Sixteen healthy subjects were separated in 3 groups; solutions of identical volume (400 ml) were added to the meal: water in group I (N = 6), glucose polymers (Caloreen; 400 kcal) in group II (N = 5), and triglycerides (Intralipide; 400 kcal) in group III (N = 5). Gastric emptying was dramatically slower in groups II and III than in group I, whatever the parameter considered. The magnitude of this caloric brake was identical for the 2 caloric loads tested and concerned both phases of the meal. Therefore, 3 h after the end of the meal, intragastric percentages of ingested liquids were 50 +/- 4 in group II, 52 +/- 5 in group III, vs 14 +/- 1 p. 100 in group I (p less than 0.001); for solids these percentages were 56 +/- 6 and 68 +/- 2 vs 11 +/- 3 p. 100 (p less than 0.001). In all groups, emptying of solids was slower than that of liquids, but the kinetics of this discrimination was modified by the increase of caloric load. The pyloric output of calories, estimated for the 3 h of the study was close to 2 kcal/min for the 3 groups studied. Thus, the 2 fold increase of the caloric concentration in groups II and III as compared to group I, did not modify the delivery rate of energy to small bowel.(ABSTRACT TRUNCATED AT 250 WORDS)

Symptoms suggesting gastroparesis in patients without gastric outlet obstruction are very common but their relation to an objective delay of gastric emptying has been poorly investigated. A dual isotopic technique was used to evaluate patients with non-obstructive dyspepsia (idiopathic and secondary) (part 1) and to assess the effects of a new gastrokinetic agent: cisapride, on gastric emptying in such patients (part 2). Sixty patients with postprandial dyspeptic symptoms (vomiting, nausea, gastric bloating or full feeling) and without lesions at upper endoscopy were studied. They were distributed into three groups: idiopathic dyspepsia (n = 31), postvagotomy dyspepsia (n = 16) and dyspepsia secondary to medical disorders (n = 13). All patients ingested the same ordinary meal; 99mTc sulphur colloid tagged egg white was the solid phase marker and 111In chloride was the liquid phase marker. In part 1, evaluation of gastric emptying in the first 50 patients shows a delay of gastric emptying rate of solids and liquids as compared with controls. Striking differences separate the three groups of patients, however, percentages of delayed gastric emptying rate of solids and or liquids averaged 90% in postvagotomy or secondary dyspepsia groups whereas it was 44% in idiopathic dyspepsia group. Moreover, liquid emptying rate was often the only one impaired in idiopathic dyspepsia, and in 12 of the 27 patients of this group the faster emptying rate of liquids as compared with that of solids (always found in normal subjects), could not be evidenced. In part 2, 10 patients entered a double blind cross over study of cisapride (8 mg intravenously). A significant increase of solid (p<0.01) and liquid (p<0.05) emptying rates was found in patients with initial gastric emptying delay. This study emphasises the importance of an objective evaluation of gastric emptying in the presence of symptoms of gastric stasis and suggests that specific local acting therapy may be useful in patients with identified abnormal gastric emptying.