Is EGJOO a Purely Manometric Diagnosis?

The diagnosis of esophagogastric outlet obstruction (EGJOO) includes a heterogenous group of disorders with a wide variation in clinical course ranging from spontaneous resolution to achalasia. EGJOO can be subdivided into primary EGJOO or secondary EGJOO in which structural, infiltrative, or medication-related causes can be implicated. Recently, research studies have focused on further phenotyping of patients with EGJOO using provocative testing during high resolution esophageal manometry (HRM) as well as non-manometric adjuvant testing. We will review the various modalities used for diagnosis and assessment of EGJOO as well as the available treatments.

Under Pressure: Right Heart Catheterization and Provocative Testing for Diagnosing Pulmonary Hypertension

Pulmonary hypertension (PH) is a heterogenous disorder involving multiple pathophysiological processes that ultimately affect the vasculature within the lungs. Right heart catheterization (RHC) continues to be the benchmark for diagnosing PH. The use of provocation techniques during RHC can help sub-characterize the type of PH and thus assist in developing appropriate treatment strategies for the management of each PH subtype. This review examines proven and novel approaches for evaluating the pulmonary vasculature during RHC and aspires to provide an accurate, clinically relevant framework for using RHC to diagnose and manage PH. Further improvement in standardized protocols will help optimize the application of RHC in patients with PH.

“Non-classical” indication for provocative testing of growth hormone: a retrospective cohort study in adult patients under replacement therapy

Background: Adult growth hormone deficiency (GHD) is considered a rare condition. Current guidelines state that GH provocative test is indicated in patients affected by organic hypothalamic/pituitary disease or with history of head injury, irradiation, hemorrhage or hypothalamic disease with multiple pituitary deficiencies. Nevertheless, clinical picture related to GHD may be subtle. Objective: We have retrospectively evaluated the indication to GHRH+arginine test in our monocentric cohort of patients treated with hrGH in order to assess whether other conditions had been considered as a rationale for provocative testing. Methods: 96 patients (51 females and 45 males), aged 19-67 years were included. The GHRH+arginine test had been performed in 29 patients with organic hypothalamic/pituitary disease and in 4 patients for Childhood onset-GHD (Co-GHD). In other patients the diagnosis was suspected for “non classical” reasons in clinical picture suspected for GHD. Results: Classical indications included previously known primary empty sella (n=15), pituitary surgery (n=14), pituitary cyst (n=1), non-secreting pituitary tumors (n=3) but more than half patients (57.3%) had been studied for “non classical” indications: metabolic syndrome (n=25), asthenia (n=13), heart failure (n=4), osteoporosis (n=6), unexplained hypoglycaemia (n=1) and infertility (n=6). The latter represented a significant percentage in the male subgroup under 45 ys. IGF-1 levels were lower than 50th percentile in 63% of patients. Finally, among non-classical reasons organic pituitary disease was discovered in 22 patients. Conclusions: Idiopathic GHD may be unrecognized due to its subtle manifestations and that an extended use of dynamic GH test may reveal such condition. A potential field of investigation could be to identify subsets of patients with clinical conditions caused or worsened by underlying unrecognized GHD.