Stretta: A valuable endoscopic treatment modality for gastroesophageal reflux disease

One potential option for the management of refractory gastro-esophageal reflux disease (GERD) is the delivery of radiofrequency energy to the gastro-esophageal junction (Stretta). This endoscopic therapy is safe, effective, durable, and repeatable if necessary and serves an unmet need for many GERD sufferers. Stretta could be effective in decreasing esophageal sensitivity to acid and in decreasing the gastro-esophageal junction compliance, which in turn contributes to symptomatic benefit by decreasing refluxate volume. Therefore, Stretta may serve as an endoscopic pain modulator and should be considered in patients with refractory symptoms despite proton pump inhibitors, as well as in patients with functional heartburn.

Impedance-high resolution manometry analysis of patients with nonerosive reflux disease

BACKGROUND & AIMS

Transient lower esophageal sphincter relaxations (TLESRs) contribute to episodes of reflux. Few studies have assessed the frequencies or compositions of TLESRs and reflux episodes in patients with reflux disease. We used combined high-resolution manometry and impedance monitoring to analyze reflux episodes and esophageal motility in these patients, compared with those of healthy individuals.

METHODS

We evaluated the frequency of TLESRs and the relationship between the reflux pattern and esophageal pressures during TLESRs in 14 patients with nonerosive reflux disease (NERD) and 11 controls. Study participants underwent combined high-resolution manometry and impedance monitoring before and 60 minutes after a solid and liquid meal. The diagnosis of NERD was confirmed by a 24-hour pH impedance test.

RESULTS

The frequency of TLESRs did not differ between patients with NERD and controls. In patients with NERD, TLESRs were associated more often with reflux episodes than in controls (93% ± 6% vs 66% ± 19%; P < .05). Patients with NERD had a higher percentage of pure liquid reflux episodes (33% ± 15% vs 10% ± 2%; P < .05), whereas controls had a higher percentage of mixed reflux episodes (45% ± 16% vs 67% ± 17% in patients with NERD; P < .05). Patients with NERD also had a higher percentage of reflux (liquid and mixed) associated with common cavities (74% ± 18% vs 50% ± 20% in controls; P < .05).

CONCLUSIONS

In contrast to previous studies, we found that TLESRs are associated more often with reflux in patients with NERD than control subjects; this association increases when only liquid and mixed refluxes are considered. These findings indicate that factors involved in the occurrence of reflux in patients with NERD during TLESRs are different from those in healthy subjects.

[Gastroesophageal reflux disease and connective tissue dysplasia in aspect of premorbid and comorbid disorders]

AIM

To investigate the phenotypic and visceral signs of connective tissue dysplasia (CTD) and comorbid diseases of the digestive system in gastroesophageal reflux disease (GERD) patients with different types of esophageal reflux as the predictors of its variants.

MATERIAL AND METHODS

In 124 patients with GERD the clinical features, phenotypic and visceral signs of undifferentiated CTD were studied in details.

RESULTS

In 82.0% of patients with GERD associated with gastroesophageal type of reflux (GER) phenotypic and especially visceral signs of STD were detected, mainly in the form of cardiochalasia and hiatal hernia. In patients with duodenogastroesophageal reflux symptoms (DGER) the signs of STD were marked in 42.0% of cases, mostly in the form of biliary tract structure abnormalities. The risk of GERD associated with prevalence of GER, was 11.9 times higher in the presence of diagnostically meaningful combination of 6 or more signs of STD than in patients with DGER. Realization of predictor options in GER occurs in the preference of sharp, acidic foods, spices, taking medications that reduce lower esophageal sphincter tone. GERD, associated with DGER, is formed in patients with family history of diseases of the biliary tract and in the preference of food rich of calories.

CONCLUSION

Study of STD symptoms as predictors of structural development of GERD and its variants is prospective to predict disease, choice of profession and eating behavior, primarily in young adults.

Effect of electrical stimulation of the lower esophageal sphincter using endoscopically implanted temporary stimulation leads in patients with reflux disease

BACKGROUND

Electrical stimulation therapy (EST) has been shown to increase lower esophageal sphincter (LES) pressure in animals; however, data on the effect of EST on LES pressure in patients with gastroesophageal reflux disease (GERD) are lacking.

OBJECTIVE

The aim of our study was to investigate the effect of EST on LES pressure and esophageal function in patients with GERD.

METHODS

Patients with a diagnosis of GERD responsive to proton pump inhibitors (PPIs), increased esophageal acid on 24-h pH monitoring off GERD medications, basal LES pressure >5 mmHg, hernia <2 cm and esophagitis <LA grade B were included. A temporary pacemaker lead was placed endoscopically in the LES by creating a 3 cm submucosal tunnel, secured to the esophagus using endoscopic clips along the body of the lead and exteriorized nasally. EST was delivered 6-12 h post-implant per protocol using (i) short-pulse 200 μs, 20 Hz, and (ii) intermediate-pulse 3 ms, 20 Hz, each for 20 min at varying amplitudes. High-resolution manometry was performed pre-, during and post-EST. Symptoms of heartburn, chest or abdominal pain and dysphagia pre-, during and post-stimulation and 7 days post-procedure were recorded. Continuous cardiac monitoring was performed during and after the EST to evaluate any effect of EST on cardiac rhythm.

RESULTS

Six male patients (mean age 34.6 years) underwent successful endoscopic lead implantation; the first patient had premature lead dislodgement and did not undergo EST. The remaining five patients underwent successful EST. All patients had a significant increase in LES pressure with all sessions of EST. There was no effect on swallow-induced LES relaxation, And there were no EST-related adverse symptoms or any cardiac rhythm abnormalities.

CONCLUSIONS

In patients with GERD, short-term EST delivered using electrodes endoscopically implanted in the LES results in a significant increase in LES pressure without affecting patients' swallow function or causing any adverse symptoms or cardiac rhythm disturbances. EST may offer a novel therapy to patients with GERD.

Evidence for oesophageal and anorectal involvement in very early systemic sclerosis (VEDOSS): report from a single VEDOSS/EUSTAR centre

BACKGROUND

The oesophagus is the first gastrointestinal (GI) tract involved in systemic sclerosis (SSc), followed by the anorectum.

OBJECTIVE

Evaluation of oesophageal and anorectal involvement and their correlations in patients with very early diagnosis of SSc (VEDOSS).

PATIENTS AND METHODS

59 patients with VEDOSS, evaluated with oesophageal and anorectal manometry and investigated with lung function tests and chest HRCT. Demographic data, oesophageal and anorectal symptoms, Raynaud's phenomenon, autoantibodies, videocapillaroscopy patterns, puffy fingers and digital ulcers were recorded for all patients.

RESULTS

In 4 patients oesophageal manometry and in 17 patients anorectal manometry was not performed because of scarce tolerance. Oesophageal peristalsis was absent in 14 patients; its pressure and speed were significantly lower in 41 patients (p<0.001 and p=0.005, respectively). The maximum pressure and mean pressure (Pmax and Pm) of lower oesophageal sphincter were significantly lower (p=0.012 and p=0.024, respectively). Patients with a diffusing capacity of the lung for carbon monoxide<80% presented a hypotonic lower oesophageal sphincter (p=0.008) and an abnormal peristalsis (p<0.001); patients with a diffusing capacity of the lung for carbon monoxide>80% showed only an abnormal peristalsis (<0.001). The anal resting pressure (ARP) at 4.3 cm and 2 cm from anal edge and the anal canal Pm were significantly decreased (p<0.001 and p=0.010, respectively). The maximum voluntary contraction was significantly abnormal in its Pmax and Pm (p=0.017 and p=0.005) and in its duration (p=0.001). In patients with a positive HRCT, the ARP and the canal Pmax and Pm were significantly lower; patients with negative HRCT presented only an abnormal ARP.

CONCLUSIONS

In patients with VEDOSS, oesophageal and anorectal disorders are frequently detected, showing that very early SSc is characterised by GI involvement.

Irritable bowel syndrome and organic diseases: A comparative analysis of esophageal motility

AIM: To assess the esophageal motility in patients with irritable bowel syndrome (IBS) and to compare those with patients with autoimmune disorders.

METHODS: 15 patients with IBS, 22 with systemic lupus erythematosus (SLE) and 19 with systemic sclerosis (SSc) were prospectively selected from a total of 115 patients at a single university centre and esophageal motility was analysed using standard manometry (Mui Scientific PIP-4-8SS). All patients underwent esophago-gastro-duodenoscopy before entering the study so that only patients with normal endoscopic findings were included in the current study. All patients underwent a complete physical, blood biochemistry and urinary examination. The grade of dysphagia was determined for each patient in accordance to the intensity and frequency of the presented esophageal symptoms. Furthermore, disease activity scores (SLEDAI and modified Rodnan score) were obtained for patients with autoimmune diseases. Outcome parameter: A correlation coefficient was calculated between amplitudes, velocity and duration of the peristaltic waves throughout esophagus and patients’ dysphagia for all three groups.

RESULTS: There was no statistical difference in the standard blood biochemistry and urinary analysis in all three groups. Patients with IBS showed similar pathologic dysphagia scores compared to patients with SLE and SSc. The mean value of dysphagia score was in IBS group 7.3, in SLE group 6.73 and in SSc group 7.56 with a P-value > 0.05. However, the manometric patterns were different. IBS patients showed during esophageal manometry peristaltic amplitudes at the proximal part of esophagus greater than 60 mmHg in 46% of the patients, which was significant higher in comparison to the SLE (11.8%) and SSc-Group (0%, P = 0.003). Furthermore, IBS patients showed lower mean resting pressure of the distal esophagus sphincter (Lower esophageal sphincter, 22 mmHg) when compared with SLE (28 mmHg, P = 0.037) and SSc (26 mmHg, P = 0.052). 23.5% of patients with SLE showed amplitudes greater as 160 mmHg in the distal esophagus (IBS and SSc: 0%) whereas 29.4% amplitudes greater as 100 mmHg in the middle one (IBS: 16.7%, SSc: 5.9% respectively, P = 0.006). Patients with SSc demonstrated, as expected, in almost half of the cases reduced peristalsis or even aperistalsis in the lower two thirds of the esophagus. SSc patients demonstrated a negative correlation coefficient between dysphagia score, amplitude and velocity of peristaltic activity at middle and lower esophagus [r = -0.6, P < 0.05].

CONCLUSION: IBS patients have comparable dysphagia-scores as patients with autoimmune disorders. The different manometric patterns might allow differentiating esophageal symptoms based on IBS from other organic diseases.

Medium and long-term outcomes after pneumatic dilation or laparoscopic Heller myotomy for achalasia: a meta-analysis

Recent randomized studies comparing outcomes after pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) for the treatment of achalasia are conflicting and limited to short-term follow-up. Our meta-analysis compared the long-term durability of these approaches, with the hypothesis that LHM offers superior long-term remission compared with PD. We identified 36 studies published between 2001 and 2011 with at least 5 years of follow-up. Those studies describing PD included 3211 patients (mean age, 49.8 y). For PD, the mean 5-year remission rate was 61.9% and the mean 10-year remission rate was 47.9%. Overall, 1526 patients (mean age, 46.3 y) were treated with LHM; 83% received a fundoplication. In contrast, the mean 5- and 10-year remission rates after LHM were 76.1% and 79.6%, respectively. Finally, the perforation rate for LHM was twice that of PD (4.8% vs. 2.4%; P<0.05). We conclude that despite a higher frequency of perforation, LHM affords greater long-term durability.

Diaphragm valves reduce gastroesophageal reflux following cardiomyotomy for patients with achalasia

BACKGROUND

This study was designed to investigate the effect of a novel surgical method on cardia sphincter function and complication rates after Heller's cardiomyotomy for patients with achalasia.

METHODS

Forty-eight patients (19 males, mean age 34.0 +/- 10.5 years, range, 12-58) were included in this study. A spindle diaphragm valve was used in the surgery to rebuild the cardiac sphincter function. The efficacy of the surgery was determined by clinical assessment of symptoms and lower esophageal sphincter pressure (LESP) measurements. Barium meal examination was also used to evaluate the efficacy.

RESULTS

The mean LESP before surgery was 41.3 +/- 11.6 mmHg. It was reduced to 16.8 +/- 3.7 mmHg and 17.5 +/- 2.5 mmHg 3 and 12 months after surgery (P < 0.01). All patients were free of symptoms such as swallow difficulties or acid reflux during the follow up. However, barium swallow examination showed that 1 patient had mild reflux after the surgery. Clinical symptom scores on swallow difficulties/obstruction was reduced from 2.5 +/- 0.65 before surgery to 0.06 +/- 0.24 12 months after the surgery (P < 0.01).

CONCLUSION

A spindle diaphragm valve used with Heller's cardiomyotomy was associated with a very low incidence of post-surgical complications, such as gastroesophageal reflux. This technique may be used in treating all patients with achalasia.

Functional importance of laparoscopic sleeve gastrectomy for the lower esophageal sphincter in patients with morbid obesity

BACKGROUND

Obesity is characterized by excess body fat measured in body mass index (BMI), which is the weight in kilograms (kg) divided by the height in square meters [m(2)]. In the Northern Hemisphere, the prevalence of overweight has increased by up to 34%. This situation is associated with high incidence of comorbidities such as gastroesophageal reflux disease. Bariatric surgery is the only effective treatment for severe obesity, resulting in amelioration of obesity comorbidities. Data on LES competence following sleeve gastrectomy (SG), one of the several bariatric procedures, are conflicting.

METHODS

In a prospective study, we enrolled 37 patients and divided them into two subgroups in order to evaluate lower esophageal sphincter pressure (LESP) and esophageal motility before and after laparoscopic sleeve gastrectomy (LSG) by means of stationary esophageal manometry. A study collective also underwent a gastroscopy. Participants (20) were healthy controls who volunteered.

RESULTS

Preoperative median BMI in group I (control) differed statistically significantly (p < 0.0001) as compared to groups II and III (22 vs. 50.5 or 47.5 kg/m², respectively). After LSG, the BMI of groups II and III decreased to 39.5 and 45 kg/m², respectively. Postoperatively, LESP increased significantly, namely, from preoperative 8.4 to 21.2 mmHg in group II and from 11 to 24 mmHg (p < 0.0001) in group III. Tubular esophageal motility profits from LSG. As expected, the gastroscopy findings ranged from cardiac insufficiency, esophagitis and hiatal hernia to gastric ulcer.

CONCLUSION

LSG significantly increased lower esophageal pressure independent of weight loss after LSG and may protect obese patients from gastroesophageal reflux.

[Peculiarities of gastroesophageal reflux disease in patients with type 2 diabetes mellitus]

The problem of coupling of gastroesopahgeal reflux disease (GERD) and type 2 diabetes mellitus (DM2) remains to be elucidated. The relevant data are contradictory, but certain authors believe that GERD may sometimes be regarded as a complication of DM2. The possible pathogenetic mechanisms include diabetic nephropathy (leading to motor dysfunction of the upper digestive tract and dysregulation of the tone of the lower sphincter) and diabetic gastropathy (delayed gastric evacuation and disturbed motor and tonic functions of the upper gastrointestinal tract are additional preconditions for the development of pathologic gastroesophageal reflux). 78 patients with DM2 were divided into 2 groups depending on duration of the disease (below and above 7 years). The control group was comprised of 40 subjects with normal glucose tolerance. The presence and severity (frequency of erosive oesophageal lesions) of GERD were directly related to the duration of DM2. Other factors with which GERD is associated include insulin requirements and diabetic neuropathy. Patients with DM2 more frequently than controls suffer asymptomatic GERD resulting from visceral neuropathy. Patients with long-standing DM2 need examination of the upper digestive tract by instrumental methods (oesophagogastroduodenoscopy, 24hr potentiometry) even in the absence of continuous complaints of heartburn, acid regurgitation, and other typical manifestations of GERD for the early recognition of the disease and timely prescription of antireflux therapy.

In vitro effects of famotidine and ranitidine on lower esophageal sphincter tone in rats

BACKGROUND/AIMS

The aim of this study was to investigate the effects of the H2 receptor antagonists famotidine and ranitidine on lower esophageal sphincter pressure in the rat isolated lower esophageal sphincter preparation contracted with carbachol.

MATERIALS AND METHODS

Lower esophageal sphincter tissues of eight rats for each group were placed in a standard organ bath. After contraction with carbachol, freshly prepared famotidine and ranitidine were added directly to the tissue bath in cumulatively increasing concentrations. Activities were recorded on an online computer using the software BSL PRO v 3.7, which also analyzed the data.

RESULTS

Ranitidine caused a small statistically insignificant relaxation in the contracted lower esophageal sphincter at the two applied concentrations. Although 1.5 x 10⁻⁵ M famotidine did not cause a significant relaxation in lower esophageal sphincter tone, this value for 4.5 x 10⁻⁵ M famotidine was 9.33%, and the relaxation was significant when compared with controls (p<0.05).

CONCLUSIONS

Neither famotidine nor ranitidine caused any direct significant change in lower esophageal sphincter tone in the therapeutic dose range applied to the organ bath. However, the higher dose of famotidine caused a significant relaxation in the lower esophageal sphincter tone. Further in vivo human studies may affect the usage of these drugs during gastroesophageal reflux disease treatment.

Overweight is a risk factor for both erosive and non-erosive reflux disease

INTRODUCTION

Studies have reported that the association between overweight and erosive oesophagitis is very strong, whilst seeming less consistent with non-erosive reflux disease.

AIM

We have hypothesized that this difference may be due to the heterogeneity of endoscopy-negative population.

METHODS

We studied 81 patients with erosive oesophagitis, 48 controls and 295 endoscopy-negative patients classified by impedance-pH-testing as: (1) pH-POS (abnormal acid exposure); (2) hypersensitive oesophagus (normal acid exposure/SAP+); (3) functional heartburn (normal acid exposure/SAP-). Body mass index was also calculated.

RESULTS

Mean body mass index was significantly higher (p<0.05) in erosive oesophagitis than in endoscopy-negative patients as a whole and controls [27 (18-40) vs. 25 (16-48) vs. 23 (16-34)]. However, the separation of endoscopy-negative patients showed that mean body mass index was higher (p<0.05) in those with increased acid exposure time [26 (18-45)] than in hypersensitive oesophagus [24 (16-48)]. The former subgroup was similar to erosive oesophagitis, whilst the latter one to both functional heartburn [23 (16-34)] and controls (p=ns). Increased body mass index represented a risk factor for erosive oesophagitis (odds ratio 1.4; 95% confidence interval, 1.2-1.6) and non-erosive reflux disease pH-POS subgroup (odds ratio 1.35; 95% confidence interval, 1.2-1.5).

CONCLUSION

Our study shows that overweight represents an important risk factor for erosive oesophagitis and pH-POS non-erosive reflux disease and not for hypersensitive oesophagus and functional heartburn. This provides an explanation for the previously reported lesser role of this variable in non-erosive reflux disease population.

[Electroacupuncture at "Zusanli"(ST 36) can inhibit frequencies of transient lower esophageal sphincter relaxation induced by gastric distention in cats]

OBJECTIVE

To observe the influence of electroacupuncture (EA) of "Zusanli" (ST 36) and ST 36 + "Neiguan" (PC 6) on gastric distention induced transient lower esophageal sphincter relaxation (TLESR) in cats.

METHODS

Forty cats were randomly divided into model (gastric distension) group, EA-ST 36 group, EA-PC 6 group, EA-ST 36 + PC 6 group, EA-non-acupoint group, EA-ST 36 + saline (2 mL i.v.) group, EA-ST 36 + L-arginine (precusor of nitric oxide, 200 mg/kg i.v.) group, and EA-ST 36+Tacrine (cholinesterase inhibitor, 5.6 mg/kg i. p.) group, with 5 cats being in each group. TLESR model was established by extending the stomach with an air balloon. EA (2 Hz/100 Hz, 3-4 mA) was applied to bilateral ST 36, PC 6 and ST 36 + PC 6 and non-acupoint (exterior-superior site of the hip) while gastric distension. L-Arginine was given 10 min before EA, and Tacrine was given 30 min before EA. The frequency of TLESR and lower esophageal sphincter pressure (LESP) were recorded by using a perfused sleeve assembly.

RESULTS

Compared with the model group, the frequency of TLESR in 60 min as well as the percentage of common cavity during TLESR were significantly decreased in the EA-ST 36, EA-PC 6, EA-ST 36 + PC 6, EA-ST 36 + saline groups (P < 0.05). Compared with the EA-ST 36 + saline group, the frequency of TLESR in 60 min was up-regulated significantly in the EA-ST 36 + Tacrine group (P < 0.01) rather than in the EA-ST 36 + L-Arginine group, suggesting a reduction of the efficacy of EA-ST 36 by cholinergic suppression (not by nitric oxide). No significant differences were found among the EA-ST 36, EA-PC 6 and EA-ST 36 + PC 6 groups in the frequency of TLESR and the percentage of common cavity (P > 0.05). In comparison with the baseline level, LESP was increased significantly only in the EA-ST 36 group (P < 0.05).

CONCLUSION

EA at ST 36 can reduce both the frequency of TLESR and the percentage of common cavity during TLESR in gastric distension cats, which may be mediated by cholinergic pathway.

Improvement in reflux gastroesophagitis in a patient with spinal muscular atrophy after surgical correction of kyphoscoliosis: a case report

BACKGROUND

Scoliosis, a three-dimensional deformity, has secondary effects on the gastrointestinal system. Reflux gastroesophagitis with hiatus hernia in patients with scoliosis is difficult to manage. We present a patient in whom primary correction of a spinal deformity was associated with resolution of symptoms of reflux.

CASE DESCRIPTION

A 15-year-old girl with severe thoracolumbar kyphoscoliosis visited our scoliosis research institute complaining of back pain, positional imbalance, intermittent respiratory tract infections, and gastrointestinal discomfort such as pain, dysphagia, and heartburn for several years. On preoperative CT, her abdominal organs were in a deviant position, and esophagogastroduodenoscopy revealed severe reflux gastroesophagitis, Los Angeles classification (LA) Grade D, and a sliding hiatus hernia. After kyphoscoliosis correction, the patient's truncal balance and pain improved. Postoperatively, the patient reported abdominal pain and dysphagia that gradually subsided after 3 weeks. At 1 year, the patient had no abdominal complaints secondary to reflux gastroesophagitis, and episodes of recurrent respiratory tract infections were substantially reduced. Postoperative evaluation showed the reflux gastroesophagitis had improved to LA Grade A. Postoperative CT showed the abdominal cavity had expanded and the abdominal organs were more centered.

LITERATURE REVIEW

The association between scoliosis and reflux gastroesophagitis is well documented. However, the secondary effects of scoliosis correction on gastrointestinal symptoms caused by reflux gastroesophagitis have not been investigated in detail.

PURPOSE AND CLINICAL RELEVANCE

This patient illustrates the relationship between spinal deformity and gastrointestinal symptoms. Postural balance correction resulted in the alleviation of reflux gastroesophagitis symptoms secondary to hiatus hernia.

BPC 157 therapy to detriment sphincters failure-esophagitis-pancreatitis in rat and acute pancreatitis patients low sphincters pressure

Possibly, acute esophagitis and pancreatitis cause each other, and we focused on sphincteric failure as the common causative key able to induce either esophagitis and acute pancreatitis or both of them, and thereby investigate the presence of a common therapy nominator. This may be an anti-ulcer pentadecapeptide BPC 157 (tested for inflammatory bowel disease, wound treatment) affecting esophagitis, lower esophageal and pyloric sphincters failure and acute pancreatitis (10 μg/kg, 10 ng/kg intraperitoneally or in drinking water). The esophagitis-sphincter failure procedure (i.e., insertion of the tubes into the sphincters, lower esophageal and pyloric) and acute pancreatitis procedure (i.e., bile duct ligation) were combined in rats. Esophageal manometry was done in acute pancreatitis patients. In rats acute pancreatitis procedure produced also esophagitis and both sphincter failure, decreased pressure 24 h post-surgery. Furthermore, bile duct ligation alone immediately declines the pressure in both sphincters. Vice versa, the esophagitis-sphincter failure procedure alone produced acute pancreatitis. What's more, these lesions (esophagitis, sphincter failure, acute pancreatitis when combined) aggravate each other (tubes into sphincters and ligated bile duct). Counteraction occurred by BPC 157 therapies. In acute pancreatitis patients lower pressure at rest was in both esophageal sphincters in acute pancreatitis patients. We conclude that BPC 157 could cure esophagitis/sphincter/acute pancreatitis healing failure.

High-resolution manometric characteristics help differentiate types of distal esophageal obstruction in patients with peristalsis

BACKGROUND

High-resolution manometry (HRM) can identify obstructive motor features at the esophagogastric junction and abnormalities in esophageal bolus transit. We sought to determine if HRM patterns can differentiate functional from organic mechanical lower esophageal sphincter (LES) obstruction.

METHODS

Segmental characteristics of peristalsis were examined using HRM in symptomatic subjects with elevated postdeglutitive residual pressure gradients across the LES (≥5mmHg). Sixteen consecutive patients with non-achalasic mechanical fixed obstruction were compared with 13 patients with elevated pressure gradients yet no mechanical obstruction and 14 asymptomatic controls. Pressure volumes were determined in mmHg cm s for peristaltic segments defined on HRM Clouse plots using an on-screen pressure volume measurement tool.

KEY RESULTS

Residual pressure gradients were similarly elevated in both patient groups. A visually conspicuous and distinctive shift in the proportionate pressure strengths of the second and third peristaltic segments was apparent across groups. Whereas the ratios of peak pressures and pressure volumes between second and third segments approached 1 in controls (0.92, 0.98), pressures shifted to the second segment in mechanical obstruction (peak pressure ratio: 1.2±0.4; pressure volume ratio: 1.8±0.9) and to the third segment in functional obstruction (peak ratio: 0.7±0.2; volume ratio: 0.5±0.2; P<0.02 for any comparison of either group with controls). A threshold volume ratio of 1.0 correctly segregated 93% of obstruction (P<0.0001); visual pattern inspection was equally effective.

CONCLUSIONS & INFERENCES

When elevated residual pressure gradients are present in non-achalasic patients, topographic characteristics of peristalsis can differentiate fixed mechanical obstruction from functional obstruction.

4-aminobutyrate aminotransferase (ABAT): genetic and pharmacological evidence for an involvement in gastro esophageal reflux disease

Gastro-esophageal reflux disease (GERD) is partly caused by genetic factors. The underlying susceptibility genes are currently unknown, with the exception of COL3A1. We used three independent GERD patient cohorts to identify GERD susceptibility genes. Thirty-six families, demonstrating dominant transmission of GERD were subjected to whole genome microsatellite genotyping and linkage analysis. Five linked regions were identified. Two families shared a linked region (LOD 3.9 and 2.0) on chromosome 16. We used two additional independent GERD patient cohorts, one consisting of 219 trios (affected child with parents) and the other an adult GERD case control cohort consisting of 256 cases and 485 controls, to validate individual genes in the linked region through association analysis. Sixty six single nucleotide polymorphism (SNP) markers distributed over the nine genes present in the linked region were genotyped in the independent GERD trio cohort. Transmission disequilibrium test analysis followed by multiple testing adjustments revealed a significant genetic association for one SNP located in an intron of the gene 4-aminobutyrate aminotransferase (ABAT) (P(adj) = 0.027). This association did not replicate in the adult case-control cohort, possibly due to the differences in ethnicity between the cohorts. Finally, using the selective ABAT inhibitor vigabatrin (γ-vinyl GABA) in a dog study, we were able to show a reduction of transient lower esophageal sphincter relaxations (TLESRs) by 57.3 ± 11.4 % (p = 0.007) and the reflux events from 3.1 ± 0.4 to 0.8 ± 0.4 (p = 0.007). Our results demonstrate the direct involvement of ABAT in pathways affecting lower esophageal sphincter (LES) control and identifies ABAT as a genetic risk factor for GERD.

Day-to-day discrepancy in Bravo pH monitoring is related to the degree of deterioration of the lower esophageal sphincter and severity of reflux disease

BACKGROUND

The Bravo capsule allows monitoring of esophageal acid exposure over a two-day period. Experience has shown that 24-32% of patients will have abnormal esophageal acid exposure detected on only one of the 2 days monitored. This variation has been explained by the effect of endoscopy and sedation. The aim of this study was to assess the day-to-day discrepancy following transnasal placement of the Bravo capsule without endoscopy or sedation and to determine factors related to this variability.

METHODS

Bravo pH monitoring was performed by transnasal placement of the capsule in 310 patients. Patients were divided into groups based on the composite pH score: both days normal, both days abnormal and only one of the 2 days abnormal. Lower esophageal sphincter (LES) characteristics were compared between groups.

RESULTS

Of the 310 patients evaluated, 60 (19%) showed a discrepancy between the 2 days. A total of 127 patients had a normal pH score on both days and 123 had an abnormal pH score on both days. Of the 60 patients with a discrepancy, 27 were abnormal the first day and 33 (55%) were abnormal the second day. Patients with abnormal esophageal acid exposure on both days had higher degrees of esophageal acid exposure and were more likely to have a defective LES compared to those with an abnormal score on only one day (35 vs. 83%, p=0.027).

CONCLUSION

Patients with a discrepancy between days of Bravo pH monitoring have lower esophageal acid exposure. Variability between the 2 days represents early deterioration of the gastroesophageal barrier and indicates less advanced reflux disease.

Achalasia of the oesophagus in infancy: a case report

BACKGROUND

Achalasia characteristically causes dismotility of the lower oesophageal sphincter and defective peristalsis of the body of the oesophagus, in response to the act of swallowing, as a result of ganglionic cells degeneration. The resultant oesophageal dilatation leads to food stasis and may cause oesophagitis and tracheobronchial aspiration. Achalasia is a rare occurrence in the paediatric age group and even more extremely rare in the neonate and young infant. Urgent radiologic evaluation of the underlying cause of persistent on-going vomiting in an infant is mandatory.

OBJECTIVE

To emphasize the role of upper gastrointestinal imaging in infants with persistent on-going vomiting, severe dehydration and malnutrition through case illustration of a 9-month-old infant seen in a private medical outfit in Lagos.

METHODS

Dilute barium oesophagogram, pre- and postoperatively, was performed in a 9-month-old infant and illustrative images were presented. Literature materials on achalasia of the oesophagus were reviewed and juxtaposed with findings in the illustrated case for discussion.

RESULTS

Only 3 to 4 percent of achalasia is reported to occur in the paediatric age group with average duration of 28 months from onset of symptoms to diagnosis. Persistent vomiting and failure to thrive are common. Pneumatic dilatations and surgical myotomy are recommended treatment methods.

CONCLUSION

Urgent upper gastrointestinal contrast study is appropriate in infants with suspected achalasia for successful management.

Effects of mosapride on esophageal functions and gastroesophageal reflux

BACKGROUND AND AIM

A substantial number of patients with gastroesophageal reflux disease show symptomatic resistance to high-dose proton pump inhibitors. In those cases, prokinetics are possible candidates for treatment. The aim of the present study was to determine whether mosapride, a prokinetic agent, stimulates esophageal functions, and prevents acidic and non-acidic gastroesophageal reflux.

METHODS

Normal volunteers (nine and 13 for two experiments, respectively) were enrolled. Salivary secretion, esophageal peristaltic contractions, and resting lower esophageal sphincter pressure with and without mosapride administration were recorded using a cross-over protocol. Post-prandial acidic and non-acidic reflux levels were also recorded.

RESULTS

Mosapride at a standard dose of 15 mg/day did not stimulate salivary secretion or any esophageal motor functions. It also failed to prevent acidic and non-acidic post-prandial gastroesophageal reflux.

CONCLUSIONS

Mosapride at 15 mg/day, a standard dose in Japan, did not change the esophageal motility and salivary secretion in healthy volunteers. Future study on a larger number of individuals with higher dose of mosapride is worthwhile.

Comparing 3-hour pH monitoring in esophagus with 24-hour pH monitoring to diagnose GERD

BACKGROUND/AIMS

Ambulatory pH monitoring is an invasive method and it would bring some discomfort for patients to wear the probe for prolonged periods. A short time pH monitoring may be more acceptable with high compliance. Our aim is to determine whether analyzing a 3-hour (prandial and postprandial) period from an ambulatory 24-hour pH monitoring in esophagus would be as sensitive as the routine test.

METHODOLOGY

Patients had been called for esophageal manometry and ambulatory 24-hour pH monitoring. 3-hour data were analyzed from the standard ambulatory 24-hour pH recording. GERD was confirmed if pH was less than 4.0 for more than 4% of 24 hours, the data were then reanalyzed by determining the percent time of pH < 4.0 during a 3-hour period. Kappa test and Mc-nemar test were used in the study.

RESULTS

Two hundred twenty-one patients met the entrance criterion. The 3-hour test had a sensitivity of 86% when compared to the 24-hour test and a specificity of 84%. Kappa test and Mc-nemar test verified the two monitor periods were considerable consistency.

CONCLUSION

3-hour analysis is sensitive and specific test for demonstrating GERD. By using this test, patients can suffer less discomfort and appear enhanced compliance.

Manometric changes of the lower esophageal sphincter after sleeve gastrectomy in obese patients

INTRODUCTION

Laparoscopic sleeve gastrectomy has been accepted as an option for surgical treatment of obesity. After surgery, some patients present reflux symptoms associated with endoscopic esophagitis, therefore PPI's treatment must be indicated.

PURPOSE

This study aims to evaluate the manometric characteristic of the lower esophageal sphincter (LES) before and after sleeve gastrectomy

MATERIAL AND METHOD

This prospective study includes 20 patients submitted to esophageal manometry in order to determine the resting pressure, and total and abdominal LES length before and after the sleeve gastrectomy. Statistical variations on the LESP were validated according to Student's "t" test.

RESULTS

Seventeen female and three male patients were included, with a mean age of 37.6 +/- 12.6 years. All patients reduced their body weight, from an initial BMI of 38.3 kg/m(2) to 28.2 kg/m(2) 6 months after surgery. No postoperative complications were observed in these patients. Preoperative mean LESP was 14.2 +/- 5.8 mmHg. Postoperative manometry decreased in 17/20 (85%), with a mean value of 11.2 +/- 5.7 mmHg (p = 0.01). Seven of them presented LESP <12 mmHg and ten patients <6 mmHg after the operation. Furthermore, the abdominal length and total length of the high pressure zone at the esophagogastric junction were affected.

CONCLUSION

A sleeve gastrectomy produces an important decrease in LES pressure, which can in turn cause the appearance of reflux symptoms and esophagitis after the operation due to a partial resection of the sling fibers during the gastrectomy.

Transient lower oesophageal sphincter relaxation in achalasia: everything but LOS relaxation

In conducting clinical high-resolution oesophageal pressure topography (HROPT) studies we observed that after subjects sat upright between series of supine and upright test swallows, they frequently had a transient lower oesophageal sphincter relaxation (TLOSR). When achalasia patients were studied in the same protocol, they exhibited a similar HROPT event leading to the hypothesis that achalasics had incomplete TLOSRs. We reviewed clinical HROPT studies of 94 consecutive non-achalasics and 25 achalasics. Studies were analyzed for a TLOSR-like event during the study and, when observed, that TLOSR-like event was characterized for the degree and duration of distal oesophageal shortening, the degree of LOS relaxation, associated crural diaphragm (CD) inhibition, oesophageal pressurization and upper oesophageal sphincter (UOS) relaxation. About 64/94 (68%) non-achalasics and 15/24 (63%) of achalasics had a pressure topography event after the posture change characterized by a prolonged period of distal oesophageal shortening and/or LOS relaxation. Events among the non-achalasics and achalasics were similar in terms of magnitude and duration of shortening and all were associated with CD inhibition. Similar proportions had associated non-deglutitive UOS relaxations. The only consistent differences were the absence of associated LOS relaxation and the absence of HROPT evidence of reflux among the achalasics leading us to conclude that their events were incomplete TLOSRs. Achalasic patients exhibit a selective defect in the TLOSR response suggesting preservation of all sensory, central and efferent aspects of the requisite neural substrate with the notable exception of LOS relaxation, a function of inhibitory (nitrergic) myenteric plexus neurons.

[Side effects of caffeine]

Caffeine is one of the most commonly ingested alkaloids worldwide. It is present in coffee, tea, soft and energy drinks, chocolate, etc. Currently published data has been stressed that the metyloxantine consumption increases the risk of coronary heart disease, arterial hypertension, arterial stiffness, and an elevation of cholesterol and homocysteine plasma concentration. The acute high consumption may also modulate insulin sensitivity and glucose blood level. However, the long-term consumption reduces the incidence of the type 2 diabetes mellitus. When administered in high doses the substance may cause various side effects, related to abnormal stimulation of the central nervous system, decrease tonus of the lower esophageal sphincter, as well as increase risk of miscarriage and intrauterine growth retardation. The final manifestation of side reactions is dependent on the genotype, especially polymorphisms of genes associated with caffeine metabolism, i.e., cytochrome P450-CYP1A2 and catechol-O-methyltransferase (COMT).

Long-term outcomes of laparoscopic Heller myotomy for achalasia

BACKGROUND

Short-term outcomes of laparoscopic Heller myotomy (LHM) for achalasia have been excellent, although the long-term durability of this operation remains to be established. The aim of this study was to evaluate the long-term outcomes of LHM.

METHODS

A single-institution review of patients undergoing LHM between 1992 and 2003 with > or =5 years follow-up. Failure was defined as symptom recurrence requiring reoperation. Univariate and multiple regression analysis were performed to identify preoperative variables predictive of long-term success.

RESULTS

A total of 46 patients underwent LHM with Toupet (n = 42) or Dor (n = 4) fundoplication. At a mean follow-up of 6.4 years, 37 (80%) patients remained free from failure. Mean time to symptom recurrence in those failing LHM was 21.3 months (range, 0.5-77). Causes of failure included nonfunctioning end-stage esophagus (n = 4), fibrotic narrowing at the gastroesophageal junction (n = 4), and tight wrap (n = 1). Univariate analysis identified high preoperative lower esophageal sphincter pressure (LESP), no prior therapy, short duration of symptoms, and absence of sigmoidal esophagus as predictors of long-term success (P < or = .044 each). High LESP remained the only predictor of long-term durability in multiple regression analysis (P = .043). Reoperations included redo myotomy (n = 2), esophagectomy (n = 6), or both (n = 1). At final follow-up, 44 (96%) patients reported significant symptom improvement compared with pre-LHM severity.

CONCLUSION

LHM is associated with an 80% long-term success rate. Successful LHM may be predicted by high LESP, no prior therapy, short symptom duration, or absence of sigmoidal esophagus. In this series, failures of LHM underwent reoperation (redo myotomy or esophagectomy) with good results.

[Novel aspects in the pathogenesis of gastroesophageal reflux disease]

In addition to lower esophageal sphincter (LES) relaxations and decreased LES tone, increased intra-abdominal pressure can also play role in the pathogenesis of gastroesophageal reflux disease (GERD),.

AIM

To analyze the correlation between occupation-related increased intra-abdominal pressure or straining (experienced for years) and the prevalence of GERD symptoms.

METHODS

Reflux symptoms were analyzed through a questionnaire among professional singers, wind players and glassblowers in comparison with controls.

RESULTS

Heartburn, regurgitation and hoarseness were significantly more frequent among professional singers than in controls (P<0.001). Among wind players heartburn (P<0.05) and regurgitation (P<0.01), among glassblowers regurgitation (P<0.01) were significantly more frequent in comparison with control subjects. Reflux symptoms correlated significantly with the duration of professional activity (P<0.05).

CONCLUSIONS

Results suggest that reflux symptoms are more frequent among subjects with occupation-related increased intra-abdominal pressure. GERD seems to be a work-related disease in this aspect.

Esophageal motor function in Familial Mediterranean Fever: a prospective evaluation of motility in 31 patients

BACKGROUND

The aims of this study were to evaluate esophageal motor function in patients with Familial Mediterranean Fever (FMF) who had upper gastrointestinal symptoms and to compare esophageal motor function between FMF patients who developed amyloidosis and patients without amyloidosis.

METHODS

31 FMF patients with dyspeptic symptoms and 31 healthy age-matched individuals were included in the study. Endoscopic examination and esophageal motility testing were performed.

RESULTS

Esophageal motor abnormalities were detected in 25.8% (8/31) of these patients [incomplete Lower esophageal sphincter (LES) relaxation: n=4, esophageal hypomotility: n=2, and hypotensive LES: n=2]. Median LES relaxation (%) (min-max) was significantly lower in patients with FMF compared to control group 94% (54-100) vs. 98% (80-100), p=0.019 respectively). However, mean LES pressure (mmHg) (19.5+/-8.9 vs. 19.7+/-5.6, p=0.813), duration of LES relaxation (s) (7.9+/-1.7 vs. 8.7+/-1.7, p=0.068), contraction amplitude of esophageal body (mmHg) (60.4+/-23.3 vs. 58.2+/-19.7, p=0.691) and median (min-max) peak velocity (s) [3.1(-1.43-50.3) vs. 3.1 (0.9-8.7), p=0.435] were similar in patients with FMF compared to control group. There were no significant differences with regard to LES pressure, LES relaxation, LES relaxation duration, contraction amplitude (mmHg) and peak velocity (sc) among patients with FMF and amyloidosis, amyloidosis negative FMF patients and healthy controls.

CONCLUSIONS

Abnormal esophageal manometric findings can be observed at least in a subgroup of patients with FMF regardless of amyloid status. Investigation of esophageal motor function in patients with FMF who exhibit unexplained upper gastrointestinal symptoms between attacks may be a helpful tool in order to delineate esophageal motor dysfunction.

Effect of Straining on the Lower Esophageal Sphincter: Identification of the “Straining-Esophageal Reflex” and Its Role in Gastroesophageal Competence Mechanism

The lower esophagus is intra-abdominal and exposed to intra-abdominal pressure (IAP) variations that may lead to gastroesophageal reflux (GER). We investigated the hypothesis that the lower esophageal sphincter (LES) undergoes phasic contraction on IAP increase, with a resulting inhibition of the stress GER. The study comprised 17 subjects (age 42.3 +/- 8.7 SD yr, 10 men, 7 women) who were scheduled for surgical repair of abdominal hernia. The patients had no swallowing problems. The electromyographic (EMG) activity of the LES and pressure within the LES were recorded at rest and during increased IAP (coughing, straining). The recording was repeated after LES anesthetization or saline infiltration. The LES EMG at rest showed regular slow waves (SWs), superimposed on or followed by random action potentials (APs). Coughing or straining induced increase of the SWs parameters and also of the APs; although the increase with straining was less than with coughing, the difference was insignificant. Coughing or straining increased the LES pressure significantly (p < .05, p < .05, respectively). Ten minutes after LES anesthetization, coughing or straining did not produce significant LES EMG or pressure changes, while saline infiltration of LES caused LES response similar to preinjection. Thus, coughing and straining effected an increase of the LES EMG activity and pressure, an action presumably mediated through a reflex that we call the "straining-esophageal reflex." This reflex seems to be evoked during increased intra-abdominal pressure and to effect LES contraction, thus, sharing with other factors in prevention of gastroesophageal reflux.

Terminating motor events for TLESR are influenced by the presence and distribution of refluxate

Transient lower esophageal sphincter relaxation (TLESR) is frequently associated with reflux events and terminates with a primary or secondary peristaltic wave. However, it is unclear whether the presence and properties of the refluxate affect TLESR-termination events. The aims of this study were to determine the pattern of terminating esophageal motor activity after TLESR in healthy subjects and factors affecting the type of terminating motor event. Fifteen healthy subjects (7 men, age 18-56) were studied. High-resolution manometry and impedance/pH monitoring were performed simultaneously in supine position for 2 h after subjects took a 1,000-kcal meal (Awake Study). This procedure was repeated during the night under polysomnographic recording for 6-8 h after consuming a 1,000-kcal meal (Sleep Study). We categorized three types of TLESR-terminating motor events, primary peristalsis (PP), full secondary contraction (FSC), which propagated the entire esophagus, and partial secondary contractions (PSC), which started distal to the upper esophageal sphincter. Overall, 289 TLESR events were found. The percentages of TLESR events terminated by PP, FSC, and PSC were 22%, 14%, and 64%, respectively. TLESR events terminated by PP were less likely to be accompanied by reflux events. TLESR events terminated by FSC were significantly more likely to have evidence for proximal esophageal reflux and esophago-pharyngeal reflux. Findings were similar in awake and sleep states. We concluded that, in healthy recumbent subjects, the most common TLESR-termination event is a secondary contraction, rather than PP. Presence and distribution of the refluxate is a major influence on the type of terminating contraction.

A novel endoesophageal magnetic device to prevent gastroesophageal reflux

BACKGROUND

Endoscopic methods to prevent gastroesophageal reflux (GER) show scarce effectiveness and may narrow the esophageal lumen more or less stiffly, sometimes impairing bolus transit and leading to dysphagia. The aim of this study was to demonstrate the possibility of reinforcing lower esophageal sphincter (LES) tone by implanting endoluminally a magnetic device.

MATERIALS AND METHODS

The device consists of two small magnetic plaques to be implanted in the submucosa close to LES with opposite polarities facing so that they attract one other, closing the esophageal lumen. The magnets were implanted by means of a special endoluminal device in five esophageal-gastric ex vivo specimens taken from swine. Variation in endoluminal pressure at the LES level was measured by means of slow pull-through of a thin side-hole manometric catheter in each specimen, before and after insertion of the magnets.

RESULTS

The new high-pressure zone exhibited a length of about 2 cm and a pressure of 14.2+/-1.27 mmHg [mean +/- standard deviation (SD)], significantly (p<0.001) higher than that measured before insertion of the magnetic valve (1.5+/-0.26 mmHg).

CONCLUSIONS

The present research demonstrates that it is possible to create at the LES level a dynamic closure of a value considered sufficient to prevent GER, by implanting in the esophageal submucosa of anatomical specimens a magnetic device by means of a special endoluminal probe. Once effectiveness and tolerability of magnets covered by a biocompatible sheath have been demonstrated in vivo, this device could become a simple and effective nonsurgical solution to GER.

Clinical, radiological, and manometric profile in 145 patients with untreated achalasia

BACKGROUND

Esophageal achalasia is characterized by the absence of esophageal peristalsis and by a dysfunctional lower esophageal sphincter (LES). Descriptions of clinical, radiological, and manometric findings in patients with achalasia usually have been based on small numbers of patients. This study was designed to determine in patients with untreated achalasia: (1) clinical presentation; (2) how often a diagnosis of gastroesophageal reflux disease (GERD) was erroneously made based on the presence of heartburn; (3) manometric profile; (4) relationship between chest pain and the manometric finding of vigorous achalasia.

METHODS

Between 1990 and 2004, a diagnosis of esophageal achalasia was established in 145 patients. None of them had been previously treated (no previous endoscopic or surgical treatment). We evaluated the demographic and clinical characteristics, as well as the results of the endoscopy, barium swallow, esophageal manometry, and ambulatory pH monitoring. We also compared the clinical and the manometric profile of patients with classic and patients with vigorous achalasia.

RESULTS

Most patients with untreated achalasia had dysphagia (94%). Regurgitation was present in 76% and heartburn in 52%. Chest pain (41%) and weight loss (35%) were less common. Acid-suppressing medications had been prescribed to 65 patients (45%) who complained of heartburn on the assumption that GERD was present. The LES was hypertensive in 43% of patients only. There was no significant difference in the prevalence, severity, and duration of chest pain in patients with classic and with vigorous achalasia.

CONCLUSIONS

These results show that in patients with untreated achalasia: (1) dysphagia was the most frequent complaint, but regurgitation and heartburn were frequently present; (2) a diagnosis of GERD based on the presence of heartburn was highly unreliable; (3) the LES was hypertensive in less than half of patients; and (4) the prevalence, severity, and duration of chest pain did not correlate with the manometric finding of vigorous achalasia.

Esophageal achalasia--manometric patterns

Achalasia is a primary esophageal motility disorder involving the body of the esophagus and lower esophageal sphincter. Esophageal manometry is the gold standard to diagnose achalasia. Two cardinal features are encountered in achalasia: incomplete LES relaxation and absent peristalsis in the lower esophagus. In a group of 94 patients with dysphagia we looked for the manometric changes, trying to identify clinical and manometric particularities of the cases with achalasia. 35 cases had manometric changes compatible with the diagnostic of achalasia. A number of 41 patients had other esophageal motility disorders and 8 patients had normal esophageal manometry. The majority of patients (80%) had an increase basal pressure in the lower esophageal sphincter (LES) and the rest of them had a normal pressure of the LES. Absence of the lower esophageal sphincter relaxation or incomplete relaxation was observed in all cases. Aperistalsis was found in 33 patients (94.3%) and 2 patients (5.7%) presented hyperperistaltism of the tubular esophagus. We followed the manometric changes pre and post treatment in 10 cases, all having similar manometric modifications, before and after treatment; only the basal pressure of the lower esophageal sphincter was modified after treatment.

Novel treatments of GERD: focus on the lower esophageal sphincter

Up to 50% of patients with gastroesophageal reflux disease (GERD) still suffer from GERD symptoms despite proton pump inhibitor (PPI) therapy, indicating a need for new treatments. The lower esophageal sphincter (LES) plays a crucial role in maintaining the mechanical barrier necessary for prevention of gastric reflux. Transient LES relaxation (TLESR) is an important factor behind the occurrence of reflux, and preclinical studies have identified a number of targets for pharmacologic modification of TLESR. However, only gamma-aminobutyric acid (GABA) type B receptor (GABA(B)) agonists and metabotropic glutamate receptor 5 (mGluR5) modulators have shown positive proof of concept in the clinical setting. The mGluR5 negative allosteric modulator ADX10059 improved symptoms in GERD patients, but was associated with central side effects such as dizziness. Baclofen, a GABA(B) receptor agonist, reduces the incidence of TLESR and improves GERD symptoms in both adult and pediatric GERD patients. However, the utility of baclofen is similarly limited by poor tolerability and recent research has focused on the development of GABA(B) receptor agonists with improved tolerability. XP19986, a prodrug of R-baclofen, reduced the number of reflux episodes in a dose-ranging study and was similarly tolerated to placebo. AZD3355 and AZD9343 are GABA(B) receptor agonists with limited central nervous system activity that have been shown in preclinical studies to reduce the incidence of TLESR and decrease esophageal acid exposure; data from clinical studies of these agents in GERD patients are awaited with interest. Agents that target TLESR activity may therefore offer a promising new add-on treatment for patients who suffer from GERD symptoms despite PPI therapy.

New insights in the neural regulation of the lower oesophageal sphincter

Gastro-oesophageal reflux disease (GORD) is caused by disordered control of the gastro-oesophageal reflux barrier, comprised internally of the lower oesophageal sphincter (LOS) and externally the crural diaphragm (CD). Both relax briefly to allow bolus passage during oesophageal peristalsis. Brief relaxation also occurs prior to gastro-oesophageal reflux, known as transient LOS relaxation (TLOSR), normally allowing venting of gas. TLOSRs also account for up to 90% of acid reflux episodes. The development of GORD therefore depends upon the rate of TLOSR and the physical and chemical nature of refluxate. We established an animal model of reflux in ferrets, in which similar patterns of TLOSR are seen to humans. TLOSRs are mediated via a vago-vagal pathway initiated by tension receptors in the gastric musculature. They have central terminals in the brainstem which provide input to a central program generator. The program has 3 simultaneous outputs: 1. brief activation of vagal motor neurones to the LOS, which activate inhibitory enteric motorneurones, leading to smooth muscle relaxation: 2. suppression of oesophageal peristalsis: 3. suppression of motor output to the CD. We have investigated several aspects of the TLOSR pathway in ferrets, and determined that the optimal site for therapeutic pharmacological intervention is at gastric vagal tension receptor endings. Their responses to distension are potently inhibited by gamma-aminobutyric acid type B (GABAB) receptor agonists and metabotropic glutamate type 5 receptor (mGluR5) antagonists. These effects translate to inhibition of TLOSR and reflux in animal models and humans. Clinical studies indicate both types of drug may have potential in the treatment of GORD.

[Correlation between clinical symptoms and radiologic findings before and after pneumatic balloon dilatation for achalasia]

BACKGROUND/AIMS

We investigated the risk factors for short-term recurrence and analyzed the correlation between subjective clinical symtoms and objective radiological findings in patients with achalasia undergoing pneumatic balloon dilatation.

METHODS

Twenty patients who were treated by pneumatic balloon dilatation were enrolled. We compared prospectively various indices before and after the treatment as follows: 1) Eckardt symptom score and dysphagia grade, 2) The ratio of the maximal width in mid-esophageal lumen to the minimal width in distal esophagus around lower esophageal sphincter, and 3) the percentage of maximum activity retained in the esophagus at 30 seconds and T in esophageal scan two days after the treatment.

RESULTS

1) Clinical indices and radiologic indices significantly improved after pneumatic dilatation. 2) There was no significant correlation between the clinical indices and the radiologic indices before and after the treatment. 3) The difference percentage of clinical indices did not show significant correlation with the difference percentage of the radiologic indices. 4) Compared to the group above 20% in the difference percentage of 30 second residual fraction, the one below 20% had a four-fold risk in short-term recurrence.

CONCLUSIONS

Clinical symptoms and radiologic indices significantly improve after pneumatic dilatation but have no significant correlation to each other. The group below 20% in the difference percentage of 30 second residual fraction has a high risk of recurrence and may need careful examination and early repeated pneumatic dilation.

Nonerosive reflux disease: a pathophysiologic perspective

Nonerosive reflux disease (NERD) is the most common phenotype of gastroesophageal reflux disease. By definition, patients with NERD have typical reflux symptoms caused by the intraesophageal reflux of gastric contents but have no visible esophageal mucosal injury. This is in contrast to patients with reflux esophagitis, also known as erosive reflux disease, and Barrett's esophagus, who have obvious esophageal mucosal injury on endoscopy. Only 50% of patients with NERD have pathologic esophageal acid contact time (ACT) as detected on 24-hour pH monitoring (ie, NERD-positive). NERD patients with physiologic esophageal ACT and good temporal correlation of symptoms with reflux events (symptom index > 50% or symptom-association probability > 95%) are considered to have esophageal hypersensitivity (ie, NERD-negative). Finally, patients with physiologic esophageal ACT but poor symptom-reflux correlation are now considered to have functional heartburn and not NERD. NERD-positive patients have motor dysfunction and acidic reflux abnormalities that are similar to patients with reflux esophagitis and Barrett's esophagus, whereas NERD-negative patients have minimal abnormalities that are not much different than healthy controls. The histopathologic feature most indicative of NERD is the presence of dilated intercellular spaces within squamous epithelium, an ultrastructural abnormality readily identified on transmission electron microscopy and on light microscopy.

New esophageal function testing (impedance, Bravo pH monitoring, and high-resolution manometry): clinical relevance

Esophageal testing aims to quantify gastroesophageal reflux or characterize esophageal motility. Reflux monitoring traditionally has been based on the detection of acidic reflux by a transnasal catheter that measures esophageal pH. Recently there have been two major developments in this field: the wireless Bravo pH capsule (Medtronic, Inc., Minneapolis, MN), which allows catheter-free monitoring, and impedance-pH measurement, a catheter-based technique that enables detection of acidic and nonacidic reflux. The assessment of esophageal motility has relied on conventional manometry for many years. Two new procedures also recently became available to assess esophageal motility: high-resolution manometry, which uses many closely spaced pressure sensors and provides spatiotemporal plots of esophageal pressure changes, and impedance manometry, a test that directly measures bolus transit and provides conventional manometric data. The advantages, disadvantages, and clinical importance of these new esophageal tests are discussed in this review.

[Functional changes in the cardioesophageal region following laparoscopic fundoplication]

Functional changes of antireflux mechanisms after laparoscopic fundpolication.

AIM

To examine manometry and pH-study in evaluation of the changes in measurable features of antireflux mechanisms after fundoplication for gastro-oesophageal reflux disease.

METHODS

Laparoscopic Nissen-Rossetti fundoplications with hiatorhaphy were performed in patients with gastroesophageal reflux disease. Preoperative and postoperative manometry and pH-study were compared in set of twenty satisfied orjerated without any complaints after surgery who agreed with preoperative and postoperative examinations.

RESULTS

Higher length of lower esophageal sphincter following antireflux fundoplication (P = 0.0003), increased tone of lower esophageal sphincter with antireflux fundoplication (P = 0.0001) and lower value of pH-study after fundoplication (P = 0.0001) were observed.

CONCLUSION

Postoperative manometry and pH-study effectively evaluated gastro-oesophageal reflux changes following fundoplication for gastro-oesophageal reflux disease.

Evidence for the ''paradox'' association between hypertensive lower esophageal sphincter and gastroesophageal reflux disease

There are several studies suggesting the paradoxical simultaneous presence of hypertensive lower oesophageal sphincter and gastroesophageal reflux disease. We present a case of a 22-year-old male patient who was examined in our outpatient clinic with oesophageal food bolus impaction during a meal, severe chest pain and drooling. Manometry revealed a hypertensive lower esophageal sphincter pressure (resting pressure 35 mmHg) and pHmetry revealed a DeMeester score > 14.72 (43.27). Six months after therapy with lansoprazole, manometry revealed a normal lower oesophageal sphincter (resting pressure 14 mmHg) and the DeMeester score was < 14.72 (5.89). The patient is now asymptomatic. This report is the only published case which exhibits the normalization of lower oesophageal pressure 6 months after gastroesophageal reflux disease management with lansoprazole, thus proving and establishing the above ''paradox''.

Infant apnea and gastroesophageal reflux: a critical review and framework for further investigation

Gastroesophageal reflux and apnea of prematurity are both common occurrences in premature infants. However, a causal relationship between the two remains controversial. Strong physiologic evidence indicates that a variety of protective reflex responses may elicit laryngeal adduction and apnea. Although a potential link between gastroesophageal reflux and apnea may exist through this pathway, clinical studies can be cited to either support or refute such a link in premature infants. The majority of gastroesophageal reflux episodes do not appear to be related to apnea. In a specific subset of events, a causal relationship may exist. Whether this is related to the character of the reflux episode or to a predisposition in a subpopulation of infants is unclear. This review presents the evidence for and against an association between gastroesophageal reflux and apnea, discusses techniques used in their evaluation, and identifies approaches for future investigation.

Esophageal motility differences among aged patients with achalasia: a Taiwan report

BACKGROUND AND AIM

There are limited reports on esophageal motility pressures in aged patients with achalasia and these are inconclusive. The aim of the present retrospective study was to understand the changes of esophageal motility in aged achalasia patients among the Taiwan population.

METHODS

Manometric studies of 49 patients with achalasia had been performed through January 1998 to June 2005. The findings of lower esophageal sphincter (LES) basal and residual pressures and esophageal body contraction amplitudes were calculated and compared between the older and younger patient groups at different age cut-offs.

RESULTS

Higher basal LES pressure increased significantly from the cut-off age of 65 years (i.e. patients over 65 had significantly higher basal LES pressure than younger patients: 37.0 +/- 4.19 mmHg vs 30.0 +/- 1.32 mmHg, P = 0.045). With patients > or =70 years old, it was more obvious (46.0 +/- 3.7 mmHg vs 29.6 +/- 1.2 mmHg, P = 0.001). Beginning at the cut-off age of 55, the LES residual pressure was significantly higher in older patients than those who were younger (14.0 +/- 11.06 mmHg vs 11.1 +/- 0.6 mmHg, P = 0.017). LES residual pressure is more significant in the older groups. A linear correlation between age and residual LES pressures (r = 0.383) was found. No differences were found in esophageal contraction pressure.

CONCLUSIONS

Older achalasia patients in Taiwan have higher basal LES pressures, with a linear correlation between age and residual LES pressures. Age has no influence on esophageal contraction pressure.

The effect of gastric overfilling on the pharyngo-esophageal and lower esophageal sphincter: a possible factor in restricting food intake

BACKGROUND

How afferent activity in the gut achieves the required ingestion control has not been established. The authors hypothesized that gastric overdistension effects an increase in pharyngo-esophageal and lower esophageal sphincter activity aimed at inhibiting ingestion.

MATERIAL/METHODS

The study comprised 16 mongrel dogs. Under anesthesia, one balloon-tipped catheter was placed in the stomach, another within the lower esophageal sphincter (LES), and a third within the pharyngo-esophageal sphincter (PES). The gastric balloon was filled with H(2)O in increments of 10 ml and LES and PES pressures were recorded. The test was repeated after individual gastric, LES, and PES anesthetization.

RESULTS

Gastric balloon filling with more than 20 ml of H(2)O showed progressively increasing LES pressure up to 110-120 ml of gastric filling, beyond which the pressure exhibited no further increase upon incrementally increased gastric filling volume. PES pressure increased only with a gastric filling volume exceeding 100-110 ml and continued to increase with increasing gastric filling. Gastric filling as above while the stomach, LES, and PES were separately anesthetized produced no LES or PES pressure response.

CONCLUSIONS

LES and PES appear to contract on gastric filling; PES responds only to excess gastric filling. It seems that LES and PES response to gastric filling is mediated through a reflex which the authors call the "gastro-esophagopharyngeal reflex" (GEPR). Changes in the evoked response would indicate a defect in the reflex pathway. GEPR might thus serve as an investigative tool in the diagnosis of gastroesophageal disorders, although further studies are required.

Failed antireflux surgery: results after reoperation

BACKGROUND

Since laparoscopy has become a common surgical approach for antireflux surgery, little is known regarding reoperation for failed antireflux surgery.

METHODS

Records of all patients who underwent reoperation without esophageal resection for symptoms of recurrent gastroesophageal reflux disease or hiatal hernia between July 1, 1995 and April 1, 2004 were reviewed. There were 126 patients. Two patients declined research participation. The remaining 124 patients (71 women and 53 men) formed the basis for this study. Median age was 53 years (range, 19 to 83 years). The initial operation was a laparoscopic antireflux procedure in 76 patients (61.3%) and an open repair in 48 (38.7%). A single previous operation had been done in 100 patients, two operations in 20, and three operations in 4. The median interval between the most recent reoperation and the previous operation was 28 months. All patients were symptomatic. The surgical approach was a thoracotomy in 83 patients, laparotomy in 36, laparoscopy in 4, and thoracoabdominal in 1. A Nissen fundoplication was performed in 86 patients (69.4%), Belsey fundoplication in 31(25.0%), and others in 7.

RESULTS

There were no operative deaths. Complications occurred in 27 patients (21.7%). Median hospitalization was 6 days (range, 5 to 58 days). Follow-up ranged from 10 days to 10 years (median, 9.7 months). Improvement was observed in 114 patients (91.9%). Functional results were classified as excellent in 69 patients (55.6%), good in 19 (15.4%), fair in 26 (20.9%), and poor in 10 (8.1%). No single operative approach was functionally superior.

CONCLUSIONS

We conclude that reoperation for failed antireflux surgery is safe and effective. Results of reoperation were not affected by the type of reoperation or whether the previous approach was laparoscopic or open.

Gastrooesophageal reflux disease

Gastrooesophageal reflux disease, GERD, is a common problem which is expensive to diagnose and treat. The disease is increasing in prevalence in the Western world with important risk factors being obesity and the eradication of Helicobacter pylori. Increasing research points to transient LES relaxation and spatial separation of the diaphragm and LES (hiatal hernia in chest) being the critical mechanisms of acid reflux. Heartburn and acid regurgitation are classic symptoms of GERD, but their sensitivity is poor. Ambulatory oesophageal pH testing is the most sensitive test for GERD, while endoscopy is the most specific test. Medical treatment with PPIs has revolutionized the treatment of GERD and its complications, but long-term side effects do exist. Laparoscopic antireflux surgery and PPIs have similar efficacy in the few available long-term trials. Currently, endoscopic treatments for GERD should not be a clinical alternative outside of research trials. New drug therapies should be directed at modulating transient LES relaxation.