Gastric emptying in patients with gastroesophageal reflux

Gastric myoelectrical activity and its relationship to the development of nausea and vomiting after intensive chemotherapy and autologous stem cell transplantation

OBJECTIVES

Gastric motor dysfunction may be responsible, in some patients, for the nausea and emesis that occur after high-dose chemotherapy (HDT) and autologous stem cell transplantation (SCT). Because gastric myoelectrical abnormalities may result in nausea and vomiting in other contexts, we sought to define the prevalence of these abnormalities and their relationship to the development of nausea and vomiting in patients undergoing autologous HDT and SCT, and to determine whether electrogastrography (EGG) could serve to detect gastric motor dysfunction in this population.

METHODS

We prospectively studied patients with a variety of malignancies who received standard transplantation doses of chemotherapeutic agents and antiemetics. Gastric emptying scintigraphy was performed before HDT. Gastric myoelectrical activity was assessed before HDT and on days 0, 7, 14, 21, and 28 from SCT using cutaneous EGG electrodes and a portable EGG recorder, and was analyzed by means of a dedicated software program after removal of motion artifact. Symptom assessment was obtained daily from initiation of HDT to 28 days after SCT.

RESULTS

A total of 25 patients were studied: 13 women and 12 men, with a median age of 50 yr (range = 32-65 yr). Before HDT, gastric emptying scintigraphy was normal in all patients (median T(1/2) of 50 min [range = 22-75 min]) and only one patient had mild nausea and anorexia. Nausea, emesis, and anorexia occurred in all patients, peaked in severity at day +7 from SCT and, with the exception of anorexia, had returned toward baseline levels by day +28. Fasting dysrhythmias were present in 63% of the studies at baseline. Serial EGG recordings revealed significant slowing of the dominant frequency with a consequent decrease in tachygastria and increase in normogastria and bradygastria as the symptoms peaked in severity with a subsequent return to baseline values at the study's end. The only clinical variable that was predictive of symptom severity was gender. Women had a higher risk of developing anorexia (score > or = 2) at day +14 compared to men (odds ratio = 11.2; 95% CI = 1.7-76.9; p = 0.01).

CONCLUSIONS

Baseline abnormalities in gastric myoelectrical activity occur frequently in patients who undergo HDT and autologous SCT despite normal gastric emptying scintigraphy and an absence of symptoms. Although slowing of the dominant frequency was seen as symptoms worsened, we failed to identify any EGG parameter at baseline that could predict the severity of nausea, vomiting or anorexia after transplantation.

Effect of cisapride on gastric emptying in patients with gastro-oesophageal reflux disease

To investigate the effect of cisapride in gastro-oesophageal reflux disease (GERD), gastric emptying time, measured using scintigraphy, and reflux symptoms were compared before and after cisapride therapy in 30 patients with endoscopically proven GERD. Gastric emptying time was also measured in 20 age-matched controls. Patients with GERD were treated with 30 mg cisapride orally three times daily for 7 days. Gastric emptying time was significantly reduced following cisapride therapy in 28 of these patients (71.6 +/- 18.1 min versus 57.9 +/- 13.9 min), although it was still longer than the gastric emptying time of the control group (i.e. 46.2 +/- 8.1 min). In addition, cisapride relieved heartburn, which is a representative symptom of GERD. These findings suggest that cisapride may be useful in treating reflux symptoms and oesophagitis in patients with GERD.

Impact of delayed gastric emptying on the outcome of antireflux surgery

OBJECTIVE

To study the effect of Nissen fundoplication on the pattern of gastric emptying and intragastric distribution of symptoms in patients with normal and delayed gastric emptying before surgery, especially in those with delayed emptying before surgery.

SUMMARY BACKGROUND DATA

Gastroesophageal reflux disease is associated with delayed gastric emptying and dyspeptic symptoms in approximately 40% of the patients. After Nissen fundoplication, dyspeptic symptoms are also not uncommon.

METHODS

Thirty-six patients (26 men, 10 women, mean age 43.1) were studied before and 3 months after Nissen fundoplication. Gastric emptying (dual-isotope, expressed in lag phase, emptying rate, T50, and intragastric distribution) was not included in the decision for surgery. Reflux-related and dyspeptic symptoms were scored before and at 3, 6, and 12 months after surgery.

RESULTS

Twenty-six patients had normal and 10 had delayed gastric emptying before surgery. Nissen fundoplication on average enhanced gastric emptying for solids in both subgroups by a combination of a decrease in mean lag phase, emptying rate, and T50. The preoperative difference in intragastric distribution between patients with and without delayed gastric emptying was abolished by fundoplication. Patients with normal gastric emptying before surgery showed an increase in early postprandial satiety; in those with delayed emptying, this was not observed. A correlation was found between preoperative T50 for liquid gastric emptying and postoperative nausea at 3 months in patients with normal gastric emptying. In patients with delayed emptying, preoperative correlations between lag phase for liquids and nausea respectively early satiety were significant, as well as for T50 for liquids and vomiting.

CONCLUSIONS

Nissen fundoplication equalizes the preoperative difference in intragastric distribution and accelerates gastric emptying without an effect on symptoms in patients with preexisting delayed gastric emptying, but with an increase in early satiety in patients with normal gastric emptying. Delayed gastric emptying is not a contraindication for antireflux surgery.

Helicobacter pylori and symptomatic relapse of gastro-oesophageal reflux disease: a randomised controlled trial

BACKGROUND

There is little information on the effects of Helicobacter pylori eradication in patients with a primary diagnosis of gastro-oesophageal reflux disease (GORD). Our aim was to investigate the effect of H pylori eradication in this group of patients.

METHODS

We did a double-blind, randomised, placebo-controlled study in 70 patients with GORD. We assigned individuals to three groups. All patients received lansoprazole 30 mg twice daily for 10 days, followed by 30 mg once daily for 8 weeks. Patients infected with H pylori received either antibiotics (clarithromycin 500 mg and amoxicillin 1000 mg twice daily) or placebo for the first 10 days. Controls were patients not infected with H pylori. Patients were followed up for 6 months at 2-week intervals for GORD symptoms. At the end of the study we repeated endoscopy and oesophageal and gastric 24 h-pH monitoring.

FINDINGS

58 of 70 patients completed our study. At the end of the study 16 of these patients were H pylori-positive (14 placebo and two eradication failures), 13 were negative because of successful H pylori eradication, and 29 were controls. H pylori-positive patients relapsed earlier (54 days) than did those in whom H pylori was eradicated (100 days) (p=0.046). The H pylori-negative control group relapsed after the longest period (110 days). However, time to relapse was also affected by oesophagitis grade (no oesophagitis 127 days, grade III or IV oesophagitis 18 days). When results were corrected for the affect of oesophagitis grade, H pylori-positive patients relapsed earlier (p=0.086) than H pylori-eradiated patients and controls (p=0.001).

INTERPRETATION

H pylori infection positively affects the relapse rate of GORD. Eradication of H pylori could, therefore, help to prolong disease-free interval in patients with GORD.

Hiatal hernia size is the dominant determinant of esophagitis presence and severity in gastroesophageal reflux disease

OBJECTIVE

Although reflux esophagitis is a multifactorial disease, the relative importance of these pathogenetic factors has not been clearly established. In this study, regression analysis was used to model the major determinants of esophagitis in patients with symptomatic gastroesophageal reflux disease (GERD).

METHODS

Sixty-six GERD patients and 16 asymptomatic controls were evaluated. All patients underwent upper endoscopy, esophageal manometry, and 24-h pH monitoring. Esophagrams were performed in 38 of the GERD patients and all controls. Stepwise regression was performed using esophagitis severity as the dependent variable. Logistic regression was performed grouping subjects as controls, nonerosive GERD, or erosive esophagitis.

RESULTS

Hiatal hernia size, lower esophageal sphincter pressure, esophageal acid exposure, and number of reflux episodes >5 min significantly correlated with esophagitis severity. Stepwise regression identified hiatal hernia size (p = 0.0001) and lower esophageal sphincter pressure (p = 0.0024) as significant predictors of esophagitis. Logistic regression also identified hiatal hernia size (chi2 = 17.07, p < 0.0001) and lower esophageal sphincter pressure (chi2 = 5.97, p = 0.0146) as significant predictors of erosive esophagitis.

CONCLUSION

Esophagitis severity is best predicted by hiatal hernia size and lower esophageal sphincter pressure. Of these, hiatal hernia size is the strongest predictor.

Pathogenesis of gastroesophageal reflux and Barrett esophagus

Barrett esophagus is a metaplastic condition that affects the lower esophagus and is a complication of gastroesophageal reflux disease (GERD). Under normal circumstances, the reflux of gastric contents into the esophagus is prevented by a complex barrier at the esophagogastric junction. Dysfunction of the lower esophageal sphincter and the presence of a hiatal hernia lead to failure of this barrier. Esophageal mucosal damage results from the chronic exposure of the esophageal mucosa to gastroduodenal contents and the lack of an effective mucosal defense. This article is an overview of the dysfunction of the esophagogastric junction that leads to GERD. The role of the contents of the reflux and that of Helicobacter pylori infection in the pathogenesis of Barrett esophagus are also summarized.

Fundal gastritis as a potential cause of reflux oesophagitis

The transient lower oesophageal sphincter relaxations which allow reflux may be due to altered afferent pathways from the fundus. We aimed to determine whether fundal inflammation is the underlying cause. Two endoscopic biopsies were taken from each of the gastric antrum and fundus in 25 asymptomatic controls with a normal endoscopy (median age 54 range 13-83 years), and 33 patients with erosive oesophagitis (median age 52, 11-78 years). No patient had taken acid suppression therapy or antibiotics for at least 1 month. Sections were stained with haematoxylin and eosin and Giemsa stain and examined in a blinded fashion by one pathologist for the presence of gastritis (Sydney classification) and Helicobacter pylori. Chronic gastritis was common in both groups, but was usually mild. In Helicobacter pylori-negative subjects, there was significantly less chronic gastritis in the antrum and the fundus in oesophagitis patients than in controls (p < 0.05). When present, gastric atrophy was usually antral and mild in severity. There was no difference in the incidence of gastric atrophy in patients with oesophagitis compared with controls (24% compared with 40%; p > 0.05). Chronic gastritis is not more common in patients with oesophagitis, and is unlikely to play a part in the pathogenesis of this disease.

Pathogenesis of gastroesophageal reflux and Barrett esophagus

Barrett esophagus is a metaplastic condition that affects the lower esophagus and is a complication of gastroesophageal reflux disease (GERD). Under normal circumstances, the reflux of gastric contents into the esophagus is prevented by a complex barrier at the esophagogastric junction. Dysfunction of the lower esophageal sphincter and the presence of a hiatal hernia lead to failure of this barrier. Esophageal mucosal damage results from the chronic exposure of the esophageal mucosa to gastroduodenal contents and the lack of an effective mucosal defense. This article is an overview of the dysfunction of the esophagogastric junction that leads to GERD. The role of the contents of the reflux and that of Helicobacter pylori infection in the pathogenesis of Barrett esophagus are also summarized.

Role of hiatus hernia and gastric mucosal atrophy in the development of reflux esophagitis in the elderly

BACKGROUND AND AIMS

The pathogenetic mechanism responsible for the increased prevalence of reflux esophagitis in the elderly remains controversial. The aim of this study was to determine if an increased occurrence of hiatus hernia (HH) and/or a lower rate of gastric mucosal atrophy (GMA) are the main causes of the increased prevalence of reflux esophagitis in elderly patients.

METHODS

The prevalence of HH, GMA, and reflux esophagitis was investigated by reviewing the endoscopic films of 2788 consecutive patients examined during a 3-year period.

RESULTS

The prevalence of esophagitis in males was higher than in females (11.6% vs 7.6%, P< 0.0005). The prevalence of reflux esophagitis and HH was found to increase with age in females, but not in male patients. The prevalence of reflux esophagitis in hernia-positive patients also increased with age in women, but not in men. Age, male gender, presence of HH, and closed-type of GMA were significant risk factors for the prevalence of esophagitis (P=0.0001, 0.0229, <0.0001, <0.0001, respectively). In addition, the risk ratios of HH and low-grade GMA for reflux esophagitis increased with age, and this tendency was higher in female patients than in males.

CONCLUSIONS

Aging, male gender, HH and closed-type GMA are most likely the risk factors of endoscopically proven reflux esophagitis in Japanese patients.

Clinical correlations in infants in the neonatal intensive care unit with varying severity of gastroesophageal reflux

BACKGROUND

Gastroesophageal reflux (GER) is frequently a benign condition in infancy with spontaneous resolution. In the neonatal intensive care unit (NICU), however, it can add to neonatal morbidity if not adequately diagnosed and treated. The objective of the current study was to analyze factors associated with GER in infants in the NICU and correlate them with the severity of the disease.

METHODS

All infants in the NICU (n = 150; born November 1994 through April 1999) who were evaluated by a five-channel pH study to rule out GER were included in the study. Infants were grouped as normal, with a reflux index (RI) of less than 6 (n = 66); mild, with RI of 6 to 14 (n = 42); and severe, with RI of more than 14 (n = 42). Maternal and neonatal data were obtained. Clinical GER was defined as the presence of feeding problems (significant gastric residue or emesis) and medical improvement with antireflux measures and medications.

RESULTS

There was no difference in birth weight, gestational age; incidence of patent ductus arteriosus, intraventricular hemorrhage, necrotizing enterocolitis, or chronic lung disease; and treatment with aminophylline or caffeine among the groups. Infants with mild and severe GER (RI 6-14 and >14) had significantly more clinical GER than the normal group (P = 0.0001). Additionally, infants with RI more than 14 had significantly more respiratory distress syndrome, lower hematocrits at the time of study and longer length of stay than those with no or mild GER (P = 0.02).

CONCLUSION

Infants with severe GER had lower hematocrits despite receiving more blood transfusions and iron therapy. Infants with severe GER also had prolonged hospital stays. Early diagnosis and aggressive management of GER may decrease neonatal morbidity and result in earlier discharge from the NICU.

Bile reflux and oesophagitis

Duodenal contents, and especially bile acids and trypsin, are noxious to the oesophageal mucosa, their damaging potential depending on pH. Various methodologies have been used to measure duodenogastric or duodenogastro-oesophageal reflux, all of them having technical limitations. Controversy exists as to the extent of duodenogastric reflux in GORD. Reflux of both acid and duodenal contents into the oesophagus increases with worsening of oesophagitis. Experimental data suggest that bile acids and trypsin are noxious to the oesophageal mucosa and that their damaging potential depends on pH. The injurious concentrations are, however, higher than those usually observed in the human oesophagus. Direct measurement of bile acids and trypsin is difficult and various methodologies have been used to measure duodenogastric or duodenogastro-oesophageal reflux, all of them having technical limitations. Whereas available data as to the extent of duodenogastric reflux in gastro-oesophageal reflux disease (GORD) are controversial, most observations show that reflux of both acid and duodenal contents into the oesophagus increases with worsening of oesophagitis. Furthermore, acid and duodenal contents occur simultaneously in most reflux episodes. In this issue of the journal, Marshall et al. report that exposure of the gastric fundus to duodenal contents as assessed by bilirubin monitoring is similar in GORD patients with varying degrees of oesophageal mucosal injury and in healthy controls.

Oesophageal transit, disintegration and gastric emptying of a film-coated risedronate placebo tablet in gastro-oesophageal reflux disease and normal control subjects

BACKGROUND

Risedronate sodium is a pyridinyl bisphosphonate, proven effective for the treatment and prevention of postmenopausal osteoporosis and glucocorticoid-induced osteoporosis and Paget's disease of the bone.

AIM

To compare the oesophageal transit, disintegration and gastric emptying of the commercial film-coated risedronate tablet in subjects with gastro-oesophageal reflux disease (GERD) and normal control subjects.

METHODS

A total of 30 subjects, 15 patients with GERD and 15 age- and sex-matched, normal control subjects, participated in a single-centre, open-label, comparative gamma scintigraphy study. The GERD subjects had active erosive oesophagitis within 4 weeks prior to dosing.

RESULTS

The mean oesophageal transit (GERD, 4.4 s; controls, 3.1 s), mean disintegration (GERD, 21.8 min; controls, 19.2 min) and mean gastric emptying (GERD, 15.9 min; controls, 15.0 min) were similar in the two subject groups. The oesophageal transit is rapid and given the rapid disintegration and gastric emptying, oesophageal contact occurring via reflux of risedronate was unlikely since most, if not all, of the dosage form exited from the stomach within 30 min.

CONCLUSIONS

The oval shape and film-coating on the commercial risedronate tablet promotes rapid oesophageal transit and minimizes oesophageal contact, even in the high-risk GERD population.

The effects of tegaserod (HTF 919) on oesophageal acid exposure in gastro-oesophageal reflux disease

BACKGROUND

Tegaserod (HTF 919), a 5-HT4 receptor partial agonist, has prokinetic effects that might be useful in decreasing acid reflux in gastro-oesophageal reflux disease (GERD).

METHODS

To investigate the potential clinical utility of tegaserod in GERD, a five-period crossover study (balanced Latin square) was designed to evaluate the efficacy of 4 b.d. doses of tegaserod vs. placebo. Four-hour manometry (1 h fasting and 3 h postprandial) with continuous recording of lower oesophageal sphincter pressure and distal oesophageal pH, was performed at the end of each 2-week treatment period in 19 patients with mild-to-moderate GERD. Recordings were scored for mean lower oesophageal sphincter pressure, number of transient lower oesophageal sphincter relaxations, and distal oesophageal acid exposure.

RESULTS

Tegaserod (1 mg/day and 4 mg/day) caused a more than 50% decrease in acid exposure in the postprandial period in patients with abnormal acid exposure, although only the 1 mg/day tegaserod treatment elicited statistically significant decreasing (P < 0.05) for the entire treatment group (percentage time for which pH < 4: placebo=13%; 1 mg/day dose=5%; 4 mg/day dose=8%). A decreased number of reflux episodes was demonstrated with both the 1 mg/day and 4 mg/day tegaserod doses. There was no apparent effect on mean lower oesophageal sphincter pressure, whilst transient lower oesophageal sphincter relaxations frequency decreased in the 1-2.5 h post-dose.

CONCLUSIONS

Tegaserod in a dose of 1 mg/day causes a significant decrease in postprandial oesophageal acid exposure. The reduction in oesophageal acid exposure with tegaserod treatment may result from enhanced oesophageal acid clearance, improved gastric emptying, and/or reduced transient lower oesophageal sphincter relaxations.

Diagnosis of reflux disease

There are numerous tests for which a diagnostic value in the context of gastro-oesophageal reflux disease has been claimed. Some of these tests (e.g. the acid perfusion test) have become obsolete after the advent of 24-hour oesophageal pH monitoring. With the latter test not only can excessive reflux be identified, but also, and more importantly, a temporal relationship can be demonstrated between a patient's symptoms and reflux episodes. Radiographical examination of the oesophagus has largely been replaced by endoscopy, although the use of the former test is still indicated in certain circumstances (e.g. in the differentiation of sliding from para-oesophageal hiatus hernia). In clinical practice, the so-called proton pump inhibitor test has gained considerable popularity. Despite several studies on the specificity and sensitivity of this test, its value has not yet been established with sufficient accuracy. Conventional manometric evaluation of lower oesophageal sphincter pressure has been over-emphasized as a diagnostic test in gastro-oesophageal reflux disease.

Helicobacter pylori infection and gastro-oesophageal reflux disease: coincidence or association?

Concerning the relationship between Helicobacter pylori infection and gastro-oesophageal reflux disease (GORD), the debate is ongoing whether the infection confers protection, is harmful or whether both entities are independent. Epidemiological evidence is given for an increased prevalence of GORD and a decreased prevalence of H. pylori infection in the western world. The assumpton derived from it is that H. pylori protects from GORD. Pathophysiological aspects need to consider the type and expression of gastritis which is associated with varying changes of gastric function. Depending on the type of gastritis, acid secretion may either increase or decrease and thereby impact on acid exposure of the oesophagus. Other changes related to the role of H. pylori in pathophysiology of GORD are still hypothetical. Clinical data are controversial whether or not GORD increases after H. pylori eradication. Prospective studies including characterization of strains and gastric physiology will clarify this issue. An accelerated induction of gastric mucosal atrophy in patients on long-term proton pump inhibitors is reported in most available studies. An increase of inflammatory activity in fundic and corpus mucosa is a consistent phenomenon. Therefore, in the authors' opinion, eradication appears advisable.

Anti-reflux surgery in the laparoscopic era

The introduction of laparoscopic anti-reflux surgery has led to a renewed interest in the operative treatment of gastro-oesophageal reflux disease (GORD). Three groups of patients can be identified who are particularly suited to laparoscopic anti-reflux surgery. Failure to respond to medical treatment has been historically the main determinant for those referred for anti-reflux surgery. With the availability of modern anti-secretory drugs most patients with chronic GORD can control their symptoms adequately by these means. Even effective medical therapy, however, is not without problems. In many patients rapid and consistent relapse of symptoms and oesophagitis occurs on cessation of therapy. Some of these patients do not want to be reliant on a form of medication that has yet to firmly establish its record for safety over many years of continued use. A second readily identifiable group of patients are those who are often described as 'volume refluxers'. They are bothered by persistent fluid regurgitation despite adequate control of their heartburn with acid suppressive drugs. Third there are those individuals who develop oesophageal strictures and those with Barrett's oesophagus and concomitant reflux symptoms and also those with respiratory complications associated with presumed aspiration of gastric juice into the pharynx and into the respiratory tree. The low morbidity associated with laparoscopic surgery that has been achieved in the best modern series means that the pendulum may swing back to surgery and therefore it is even more important that the right operation (fundoplication) is done for the right patient. Failure to create an adequate crural repair behind the wrap is associated with a risk of early post-operative para-oesophageal herniation and proximal wrap migration. The question of tailored anti-reflux surgery based on the pre-operative motor function of the body of the oesophagus is widely applied, although the scientific basis for these selective approaches is rather weak. Partial fundoplication seems to be associated with very low rates of dysphagia and of gas bloat. Assessment of the post-operative result should ideally be done by an independent observer and should consider not only traditional outcome measures but also the impact of surgery on the quality of the patient's life. Investigations on the cost effectiveness of these surgical therapeutic strategies suggest important benefits of surgery, which should be incorporated into the clinical decision process when assessing different long-term management alternatives for patients with chronic GORD.

Gastroesophageal reflux disease and Barrett's esophagus

GERD has emerged as an important medical issue by virtue not only of its high prevalence, but also by the concern that it may predispose to adenocarcinoma of the esophagus. It generally is classified into erosive and nonerosive forms. Nonerosive GERD tends to remain as such in most patients, and treatment is based on symptom relief. In contrast, erosive GERD mandates aggressive lifelong treatment based on its inevitable relapse without appropriate treatment. Two excellent therapies are available for GERD. Proton-pump inhibitors are highly efficacious and have an excellent long-term (> 10 years) safety profile. Laparoscopic fundoplication offers a new and easier method of delivering a standard reliable procedure also with excellent long-term efficacy. The occurrence of Barrett's esophagus among reflux patients has emerged as an important problem mostly because of the rapidly rising incidence of adenocarcinoma of the esophagus in the population. All patients with long-standing reflux symptoms should be screened for Barrett's and subsequently followed regularly with surveillance endoscopy if Barrett's is detected. Although there are no data to show that aggressive medical or surgical treatment alters the malignant potential of this disease, patients need lifelong therapy.

Pharmacologic strategies for treating gastroesophageal reflux disease

OBJECTIVE

This paper presents a synopsis of the pathophysiology of gastroesophageal reflux disease (GERD) and the efficacy, safety, and cost of the agents commonly used in its treatment.

BACKGROUND

Symptomatic relief of GERD can be obtained with lifestyle changes (avoidance of factors that may exacerbate symptoms, such as overeating and use of alcohol and tobacco) and use of over-the-counter medications such as antacids or histamine-2 (H2)-receptor antagonists. When these measures are unsuccessful, treatment with prescription-strength medications is required to prevent complications, such as Barrett's esophagus or esophageal adenocarcinoma.

METHODS

Current guidelines for the management of GERD were identified through a MEDLINE search of the English-language literature from January 1995 through December 1999 and a search of the bibliographies of identified articles.

CONCLUSION

Patients who do not respond to initial therapy should be managed with prescription-strength H2-receptor antagonists. Endoscopy should be considered for patients with atypical or refractory symptoms. Patients with a confirmed diagnosis of refractory GERD, severe esophagitis, Barrett's esophagus, or peptic stricture should be treated with and maintained on a proton-pump inhibitor.

Gastric myoelectric activity in older adults treated with cisapride for gastro-oesophageal reflux disease

BACKGROUND

The incidence of both gastro-oesophageal reflux disease (GERD) and upper gastrointestinal motility disorders appears to increase with age. However, there is a dearth of data concerning the utility of a prokinetic agent such as cisapride in the treatment of older adults with symptomatic GERD.

AIM

To investigate the incidence of electrogastrographic abnormalities in older adults with and without GERD symptoms, as well as the effect of cisapride therapy on symptoms of GERD and electrogastrographic responses.

METHODS

We report on 18 older adults with symptomatic GERD and 10 older adult controls (mean ages 71 and 75 years, respectively). Subjects underwent electrogastrographic evaluation pre- and postprandially under baseline conditions and after 1 month of treatment with 10 mg q.d.s. of cisapride.

RESULTS

Heartburn frequency and postprandial fullness were both significantly (P < 0. 05) reduced after cisapride treatment. Acid contact time was not significantly changed. The percentage of 2-4 cpm activity in the electrogastrographic analysis was significantly (P < 0.05) increased with cisapride treatment, and the instability coefficient was significantly (P < 0.05) diminished with cisapride treatment.

CONCLUSIONS

Enhanced gastric functioning and reduction in heartburn suggest that cisapride is efficacious in the treatment of older adults with symptomatic GERD, and that gastric dysrhythmias and postprandial fullness are resolved with cisapride treatment.

Prospective study of the effect of laparoscopic hemifundoplication on motor and sensory function of the proximal stomach

BACKGROUND

Some 30 per cent of patients develop dyspeptic symptoms following antireflux surgery. These symptoms may result from alterations in the motor and sensory function of the proximal stomach.

METHODS

Proximal gastric motor and sensory function was studied with an electronic barostat in 12 patients with reflux who underwent laparoscopic hemifundoplication. In addition, 24-h pHmetry, gastric emptying (scintigraphy) and vagus nerve integrity (pancreatic polypeptide response to hypo-glycaemia) were assessed. Fifteen healthy volunteers served as controls.

RESULTS

Laparoscopic hemifundoplication significantly decreased total acid exposure time (P < 0.05). Vagus nerve function remained intact in all but one patient. The mean(s.e.m.) lag phase for emptying of solids was significantly shorter after operation than before (15(3) versus 21(3) min; P < 0.05). Proximal gastric compliance was not significantly different before and after fundoplication. However, mean(s.e.m.) postprandial relaxation was significantly reduced (P < 0.05) after hemifundoplication compared with the value before operation (3341(1105) versus 12 763(3616) ml over 90 min) and in controls (14 567(2358) ml over 90 min). Postprandial fullness was significantly increased after hemi-fundoplication (P < 0.05). Postprandial gastric relaxation correlated with the lag phase for emptying of solids (r = 0.55, P < 0.02).

CONCLUSION

After hemifundoplication, proximal gastric compliance is not altered but postprandial relaxation is impaired and associated with sensations of fullness and shorter duration of the lag phase for emptying of solids.

Standardization of a simplified scintigraphic methodology for the assessment of gastric emptying in a multicenter setting

OBJECTIVE

Scintigraphy remains the gold standard to study gastric emptying. The technique is onerous and normal values vary between centers. Standardized protocols, although desirable, are not presently available. We validated a simplified scintigraphic protocol in a multicenter setting.

METHODS

In 69 healthy volunteers from seven Canadian institutions, gastric emptying of a standard meal (99mTc-labeled beef liver) was assessed by scintigraphy every 10 min for 1 h, then every 20 min for the next 2 h. Gastric retention was fitted to a power exponential model, Prop(t) = (-(kappat)beta) with Prop(t) = proportion of retention at time t, either using all 13 time intervals (conventional technique) or using measurements at 0, 1, 2, and 3 h (simplified technique).

RESULTS

The power exponential model yielded identical emptying curves and T 1/2 values with both techniques. Gastric emptying was more rapid in men than in women < 35 yr (p<0.01) and in younger than in older men (p<0.005). Gastric emptying was slower in women from Québec than in women from Ontario (p<0.04). Gastric retention was similar at 1, 2, and 3 h among the seven centers. Gastric emptying of a beef liver meal was slower than that of a low fat egg substitute (p<0.03).

CONCLUSIONS

A simpler scintigraphic approach, using four rather than 13 samples, provides results comparable to those of the conventional technique. This simpler approach provides an economical, yet accurate, alternative to the techniques presently used and is applicable to a multicenter setting.

Prokinetic activity of nizatidine: implications for the management of patients with gastroesophageal reflux disease

Gastroesophageal reflux is a common condition caused mainly by motility disorders of the upper gastrointestinal tract. The most effective therapy combines acid suppression with a promotility agent. Nizatidine is a well-tolerated and effective histamine-2 (H2)-receptor antagonist used to suppress gastric acid secretion. Animal and human studies have conclusively demonstrated that nizatidine also has prokinetic activity comparable to that of cisapride, and its effect is evident <1 hour after administration of doses commonly used in clinical practice. This prokinetic activity occurs through noncompetitive inhibition of acetylcholine; this inhibition approximates the inhibition caused by neostigmine. Nizatidine appears to possess a prokinetic mechanism that may be helpful in treating patients with gastroesophageal reflux.

Effect of sumatriptan, a 5HT1 agonist, on the frequency of transient lower esophageal sphincter relaxations and gastroesophageal reflux in healthy subjects

OBJECTIVE

Meals increase the rate of transient lower esophageal sphincter (LES) relaxations, in part by gastric distension. The 5HT1 agonist sumatriptan reduces fasting fundic tone, prolongs the meal-induced fundic relaxation, and delays gastric emptying. We therefore hypothesized that sumatriptan might have a significant effect on the rate of postprandial transient LES relaxations and gastroesophageal reflux. We aimed to study the effect of sumatriptan on postprandial transient LES relaxations and reflux in healthy subjects.

METHODS

Esophageal manometry and pH monitoring were performed in 13 healthy volunteers for 30 min before and 90 min after a semiliquid meal (790 kcal). Sumatriptan 6 mg subcutaneous (s.c.) or s.c. placebo were administered on separate days 30 min after the meal.

RESULTS

Sumatriptan significantly increased postprandial LES pressure from 11.0 +/- 1.2 mm Hg to 17.6 +/- 1.2 mm Hg (p < 0.05). However, reflux events were not diminished. In the contrary, reflux was more frequent after sumatriptan than after placebo (3 [1.5-4.5]/30 min vs 2 [0-3]/30 min, p < 0.05). Transient LES relaxations were more frequent after sumatriptan, particularly in the second 30-min period after drug administration (3 [2.5-5]/30 min vs 2 [1.5-2]/30 min, p < 0.05).

CONCLUSIONS

Sumatriptan prevents the natural decay in rate of transient LES relaxations that occurs after a meal and favors the occurrence of gastroesophageal reflux despite increasing LES pressure. The sustained postprandial high rate of transient LES relaxations after sumatriptan may be a consequence of a prolonged fundus relaxation and retention of meal in the proximal stomach.

Motor and sensory function of the proximal stomach in reflux disease and after laparoscopic Nissen fundoplication

OBJECTIVE

After Nissen fundoplication, dyspeptic symptoms such as fullness and early satiety develop in >30% of patients. These symptoms may result from alterations in proximal gastric motor and sensory function.

METHODS

We have evaluated proximal gastric motor and sensory function using an electronic barostat in 12 patients after successful laparoscopic Nissen fundoplications (median follow-up; 12 months). Twelve age- and gender-matched patients with severe gastroesophageal reflux disease (GERD) and 12 healthy volunteers served as controls. Studies were performed in the fasting state and after meal ingestion. Gastric emptying tests were performed in all patients. Vagus nerve integrity was measured by the response of pancreatic polypeptide (PP) to insulin hypoglycemia.

RESULTS

Minimal distending pressure and proximal gastric compliance were not significantly different between post-Nissen patients, GERD patients, and healthy controls. Postprandial relaxation of the stomach, however, was significantly (p < 0.05) reduced post-Nissen (267 +/- 34 ml), compared with controls (400 +/- 30 ml) and GERD (448 +/- 30 ml). Postprandial relaxation was significantly (p < 0.01) prolonged in GERD patients. Postprandial relaxation of the stomach correlated with gastric emptying of solids (r = 0.62; p = 0.01). Gastric emptying of solids became significantly (p < 0.05) faster after fundoplication. Postprandial fullness was significantly (p < 0.05) increased in the operated patients.

CONCLUSIONS

Post-Nissen patients have a significantly reduced postprandial gastric relaxation and significantly accelerated gastric emptying, which may explain postoperative dyspeptic symptoms. The abnormalities result from fundoplication and not from vagus nerve injury or reflux per se, because in reflux patients gastric relaxation and gastric emptying are prolonged.

Effects of promethazine on porcine gastroduodenal function: a sonographic study

This sonographic study was aimed at examining the effect of sedation with promethazine (1.5 mg x kg(-1)), on gastroduodenal function in neonatal piglets. On 3 consecutive days, observations of gastroduodenal motility during the first 3 postprandial h were made in 13 animals (3 to 5 days old; 7 sleeping naturally and 6 sedated 2 h prior to feeding). Promethazine significantly reduced both the closures per min of the terminal part of the pyloric antrum and pyloric canal and the percentage of gastric contractions that were followed by closure of the terminal pyloric antrum and canal. Such actions of promethazine on motility of the gastroduodenal junction could lead to a delay in gastric emptying of ingesta with a consequent increased risk of reflux of gastric contents into the esophagus. Because gastroesophageal reflux has been associated with the pathogenesis of sudden infant death syndrome (SIDS), care should be taken if promethazine is to be used as a sedative in neonates.

Prevalence of impaired gastric emptying of solids in systemic sclerosis: diagnostic and therapeutic implications

The aims of this study were to evaluate the gastric emptying of solids in patients with progressive systemic sclerosis, correlate the esophageal motility abnormalities with their gastric emptying status, delineate the symptoms suggestive of abnormal gastric emptying, and assess the effect of metoclopramide in patients with abnormally slow gastric emptying. Twenty patients underwent esophageal motility evaluation and gastric emptying studies with a radiolabeled solid meal. Gastric emptying was also measured in 13 healthy volunteers. Four patients in whom esophageal motility was normal also had an accompanying normal rate of gastric emptying. In 16 patients with abnormal esophageal motility, mean gastric emptying was significantly delayed as compared with that in normal subjects (67.4% vs 49.8% retention of isotope at 2 hours, P < .05). Ten patients had absolute criteria for slow gastric emptying (>+2 SD). However, only postprandial bloating and early satiety were symptoms that accurately predicted slow radionuclide emptying. In four of these patients in whom gastric emptying was slow, 10 mg intramuscular metoclopramide significantly (P < .05 vs baseline) accelerated the gastric emptying of the same test meal. We conclude that (1) gastric emptying of solids was delayed in approximately two thirds of patients with abnormal esophageal motility, whereas it was normal in patients with normal esophageal motor function; (2) metoclopramide significantly accelerated this slow gastric emptying; and (3) delayed gastric emptying contributes to the severity of the gastroesophageal reflux frequently present in patients with progressive systemic sclerosis, and promotility agents offer a valuable therapeutic approach.

Mechanisms of gastro-oesophageal reflux in the lateral decubitus positions

Gastro-oesophageal reflux is more common in the right than in the left lateral position but the reasons why are not well understood. We have therefore studied the mechanisms underlying reflux in the lateral decubitus positions in patients with reflux disease. Fifteen patients with symptomatic reflux and excessive oesophageal acid exposure were studied (nine male, age 25-63 years). Each was intubated with a perfused manometric assembly, incorporating a Dent sleeve, and a pH probe. Following a 30-min basal period, a 400-kCal meal was infused into the stomach and patients were studied for 60 min in each lateral position. Following infusion of the meal, lower oesophageal sphincter (LOS) pressure fell and transient LOS relaxation (TLOSR) frequency increased. Acid reflux episodes were more common in the postprandial period (fasting 0 (0-6) h, first postprandial hour 1 (0-9) h, P = 0.0002, second postprandial hour 1 (0-22) h, P = 0.02) and occurred more than twice as often in the right lateral position (right 3 (0-22) h, left 0 (0-10) h, P = 0.01). However, TLOSRs, swallow-related relaxations and low basal LOS pressures were equally common in both lateral positions. In patients with reflux disease, postprandial reflux is twice as common in the right lateral position. This does not relate to differences in gastro-oesophageal junctional pressure, suggesting that other aspects of barrier function or differences in the intragastric distribution of chyme may be important.

Gastroesophageal reflux in children

Gastroesophageal reflux (GER) is a common disorder in infants and children with a high rate of spontaneous resolution. Some children, however, will continue to have problems and progress from functional GER to pathogenic GER. In children with functional GER, diagnostic testing and pharmacologic treatment is unnecessary. In more involved cases, there are a number of tests available that help to quantify and qualify the extent of disease. Treatment begins with conservative measures and progresses to acid neutralization/supression and medications to enhance motility. Should medical management fail to control the consequences of reflux disease, surgical intervention is warranted.

Gastroesophageal reflux disease during pregnancy

Pregnant patients with symptomatic GERD should be managed aggressively with lifestyle modification and dietary changes. Antacids and antacids/alginic acids combination or sucralfate should be considered first-line medical therapy. If symptoms are not adequately relieved or complications develop, treatment with cimetidine or ranitidine should be considered; these H2 receptor antagonists are preferred during pregnancy. Nizatidine cannot be recommended. Proton-pump inhibitors should be used with caution because little human experience is available. Despite this caveat, both proton-pump inhibitors are likely to be safe during pregnancy.

Helicobacter pylori infection, reflux esophagitis, and atrophic gastritis: an unexplored triangle

OBJECTIVE

H. pylori causes chronic gastritis, which may progress to peptic ulcer, gastric atrophy, or gastric cancer. However, little is known about the role of H. pylori infection in reflux esophagitis and the relationship between reflux esophagitis and atrophic gastritis needs to be clarified. We sought to identify the possible interrelationships among Helicobacter pylori infection, reflux esophagitis, and atrophic gastritis, to signal areas in which researchers should consider focusing their attention.

METHODS

A broad-based Medline search was performed to identify all related publications addressing H. pylori infection, atrophic gastritis, gastroesophageal reflux disease (GERD), secretion of gastric acid, and gastric motility published between 1966 and July 1997.

RESULTS

Whereas some studies have shown no significant association between H. pylori infection and reflux esophagitis, others have observed that the prevalence of H. pylori infection was lower in patients with GERD, implying a protective role. Eradication of H. pylori leads to occurrence of reflux esophagitis in some cases, but the mechanisms inducing posteradication reflux esophagitis are unknown. H. pylori infection may lead to atrophic gastritis (and hence hypochlorhydia) through both bacterial and host factors, although gastric atrophy and subsequent intestinal metaplasia are hostile to H. pylori because of hypochlorhydria. Although it has been reported that long-term proton pump inhibitor therapy for refractory reflux esophagitis may induce or enhance the development of gastric atrophy in H. pylori-infected patients, this relationship has been disputed.

CONCLUSIONS

H. pylori infection may be negatively associated with reflux esophagitis, but this requires confirmation. Research then needs to focus on whether this is explained through motility- or acid-related mechanisms. The potential costs of maintenance antireflux therapy may need to be taken into account when evaluating the cost effectiveness of anti-H. pylori therapy.

Laparoscopic gastric antroplasty in children with delayed gastric emptying and gastroesophageal reflux

BACKGROUND/PURPOSE

A significant number of children (50%) with gastroesophageal reflux (GER) have delayed gastric emptying (DGE). Although controversial, many pediatric surgeons use a gastric outlet procedure in conjunction with fundoplication for gastroesophageal reflux in these patients. This paper describes the technique and clinical outcome of 61 patients undergoing a laparoscopic gastric antroplasty at the time of the laparoscopic fundoplication.

METHODS

The charts of 61 patients who underwent laparoscopic gastric antroplasty in conjunction with laparoscopic fundoplication between May 26, 1992 and October 17, 1996 were reviewed retrospectively. All patients had a documented DGE confirmed by a liquid isotope meal being retained in the stomach. After completion of the fundoplication, a laparoscopic antroplasty was performed by incising a 2 to 3.5-cm linear incision in the pylorus and distal gastric antrum. The seromuscular wall was divided to the level of the mucosa allowing the mucosa to bulge through the defect. The wound was closed transversely using interrupted 2-0 silk sutures.

RESULTS

Four of the 61 patients underwent conversion to open antroplasty for technical reasons. The remaining 57 patients recovered uneventfully from the laparoscopic antroplasty with clinical resolution of both GER and DGE. Two of 57 patients had intermittent episodes of retching and were unable to tolerate large bolus feedings because of dumping. They were treated by dividing the feedings into two smaller portions. These symptoms cleared within 6 months. The remaining 55 patients have tolerated feedings well. Evaluation of the gastric emptying was performed randomly in selected patients with documented improvement of the emptying after antroplasty. An evisceration of omentum through the umbilical incision developed in one patient on the third postoperative day.

CONCLUSIONS

Patients with delayed gastric emptying who need fundoplication can be treated with laparoscopic gastric antroplasty in conjunction with laparoscopic fundoplication. Laparoscopic antroplasty appears to be clinically efficacious in improving delayed gastric emptying.

Gastroesophageal reflux after distal gastrectomy: possible significance of the angle of His

OBJECTIVE

We investigated whether the angle of His influences gastroesophageal reflux after distal gastrectomy.

METHODS

Thirty-eight patients having distal gastrectomy and 10 controls underwent upper gastroesophageal fluoroscopy to measure the angle of His, and gastroesophageal reflux was assessed by scintigraphy. The association between scintigraphic reflux and the angle of His was then evaluated.

RESULTS

In distal gastrectomy patients with and without reflux symptoms, the angle was 108.82 +/- 21.88 degrees and 96.07 +/- 13.25 degrees, respectively; it was 74.14 +/- 10.85 degrees in the controls. The angle was significantly larger in the patients than in the controls (p < 0.01). In addition, the angle in the symptomatic gastrectomy group tended to be larger than in the asymptomatic group. The angle was also significantly larger in patients with a scintigraphic reflux index > or =6% than in those with an index <6% (p < 0.05).

CONCLUSIONS

These findings suggest that the angle of His plays a role in reflux after distal gastrectomy and that the severity of reflux may be estimated by measuring this angle.

Is a gastric drainage procedure necessary at the time of antireflux surgery?

BACKGROUND

Gastroesophageal reflux is part of a generalized foregut motility disorder, which may also include delayed gastric emptying. With persistence of gastroesophageal reflux, or the presence of complications, including recurrent aspiration syndrome and esophageal stricture formation, surgical correction may be indicated. It is uncertain whether a procedure to resolve delayed gastric emptying is indicated at this time as well.

METHODS

Sixty-seven children with proven gastroesophageal reflux had preoperative gastric emptying assessed using 99Technetium-Sn-colloid labelled milk. Delayed gastric emptying was defined as a gastric residual activity of more than 40% at 2 hours after feeding. The antireflux operation was a partial anterior fundoplication. Postoperative milk scans assessed the effect of surgery on gastric emptying.

RESULTS

Gastric emptying at 2 hours improved overall from a median of 22% before surgery to 17% after surgery. In 17 patients delayed gastric emptying was identified before surgery; in 15 of those it returned to within normal limits after surgery. In 50 children with normal gastric emptying before surgery (gastric residual activity at 2 hours 16%), 14 (28%) showed delayed gastric emptying in the postoperative scan.

CONCLUSIONS

Delayed gastric emptying is common in children who undergo surgery for gastroesophageal reflux disease. A partial anterior fundoplication antireflux operation improves gastric emptying to within normal limits in the majority (88%) in this group, rendering a synchronous gastric drainage procedure unnecessary.

Delayed gastric emptying affects outcome of Nissen fundoplication in neurologically impaired children

BACKGROUND

Nissen fundoplication (NF) has a relatively high failure rate in neurologically impaired children with gastroesophageal reflux (GER). In 1990 we began to use routine technetium 99m sulfur colloid emptying scans and pyloroplasty with NF for delayed gastric emptying (DGE) in our neurologically impaired patients. The aim of this study was to determine the influence of DGE and pyloroplasty on the outcome of NF in neurologically impaired children.

METHODS

One hundred neurologically impaired children underwent NF by a single surgeon between August 1986 and July 1995. Beginning in January 1990 emptying scans were routinely obtained, and patients with DGE underwent pyloroplasty with NF. Outcome analysis was performed for recurrence/wrap failure and other parameters. Mean follow-up was 5.8 years, with a minimum of 18 months.

RESULTS

DGE was found in 35 (65%) of the 54 children who had emptying scans. All 11 children with normal scans had successful NF without recurrent reflux (100%). Forty (93%) of 43 children who underwent pyloroplasty and NF had successful outcomes. Thirty-eight children underwent NF without evaluation of gastric emptying with success in 30 of them (78.9%). Overall success improved from 34 (83%) of 41 in the first half of the study, when 3 (7%) of 41 children underwent emptying scans, to 55 (93%) of 59 in the second half, when 51 (86%) of 59 of the children underwent emptying scans.

CONCLUSIONS

DGE is common in neurologically impaired children with GER. NF in children with normal gastric emptying has a high probability of success. Pyloroplasty improves the outcome of NF in children with DGE. Neurologically impaired children should be evaluated for DGE before operation for GER.

Changes in gastric emptying in early postnatal life

OBJECTIVE

To study the pattern of gastric emptying in very premature infants and to determine whether there are changes with postnatal age and the ability to tolerate feedings.

METHODS

Sequential ultrasound measurements of the gastric antral cross-sectional area were obtained in 32 infants (mean gestational age, 26 +/- 1 weeks) before and after feeding for 2 hours. Studies were carried out after initiation of feedings, when full feedings were received, and at 32 weeks. Infants classified as feeding intolerant (n = 9) were also studied when feedings were restarted. Gastric emptying was assessed by the time taken for antral cross-sectional area to reach maximal value and to decrease to half the maximal increment (half-antral clearance).

RESULTS

Delayed antral distention was observed at the time of the initial study in both feeding-tolerant (8 of 23) and feeding-intolerant (8 of 9) infants; however, there were significant differences in times for maximal antral distention (p < 0.002) and half-antral clearance (p < 0.006) between the feeding-tolerant and feeding-intolerant infants. By the time of full feedings, the feeding-intolerant infants showed immediate gastric emptying but still had a longer half-antral clearance time (p < 0.01). By 32 weeks, all infants had immediate antral distention and a more mature curvilinear pattern of gastric emptying.

CONCLUSIONS

Knowledge of these different patterns of gastric emptying in very premature infants may lead to the development of more rational feeding strategies.

Pattern of gastric emptying in patients with systemic sclerosis

Gastric emptying studies, using an indigenously prepared radiolabeled solid food marker in the form of Indian bread called Chapati, were performed on 13 patients with systemic sclerosis. Six patients had limited cutaneous disease and seven had diffuse cutaneous disease. Earlier, the procedure was standardized in 30 healthy volunteers. Seven of the 13 (54%) patients (five with diffuse and two with limited cutaneous disease) had delayed gastric emptying. Most of these patients had gastric symptoms. This pattern of gastric emptying may be clinically significant, particularly in patients with diffuse cutaneous disease.

The epidemiology of functional gastrointestinal disorders in North America

This article has summarized the epidemiology of several disorders commonly seen in a gastroenterologist's practice. The emphasis has been on population-based data because many people with these disorders never seek health care, and psychological features have been shown to be strongly associated with health care-seeking behavior. Each of these disorders is common in the community; in fact, the majority of the population experiences intermittent gastrointestinal symptoms. In general, the national surveys sponsored by the U.S. Public Health Service have been shown to underestimate the prevalence of these conditions. In part, this is due to the fact that subjects are asked to report diagnoses rather than symptoms, and current coding schemes do not provide specific codes for each of the functional gastrointestinal disorders. Still, these studies have demonstrated the large number of physician visits and overall costs attributable to these disorders. A number of surveys of more limited populations have been done to assess the prevalence of these disorders. Rates have varied because of the definitions used and the degree to which organic diagnoses are excluded. These studies have been helpful in demonstrating the burden of illness in the community. Age and gender differences in the community have been much less marked than those identified in clinic-based studies, thus highlighting the importance of population-based research. Future studies need to focus on the incidence and natural history of these disorders. Studies of incidence cases can best evaluate the role of etiologic factors, whereas studies of prevalent cases are best for assessing the burden of disease in the community. Understanding the natural history of these disorders is important in determining the efficacy of future therapeutic interventions. The fact that these disorders represent 50% of visits to a gastroenterologist practice highlights the importance of these disorders and the potential contribution of gastrointestinal dysmotility in clinical practice.

Gastroesophageal reflux in childhood

Gastroesophageal reflux (GER) is one of the most frequent symptomatic clinical disorders affecting the gastrointestinal tract of infants and children. During the past 2 decades, GER has been recognized more frequently because of an increased awareness of the condition and also because of the more sophisticated diagnostic techniques that have been developed for both identifying and quantifying the disorder. Gastroesophageal fundoplication is currently one of the three most common major operations performed on infants and children by pediatric surgeons in the United States. Normal gastroesophageal function is a complex mechanism that depends on effective esophageal motility, timely relaxation and contractility of the lower esophageal sphincter, the mean intraluminal pressure in the stomach, the effectiveness of contractility in emptying of the stomach, and the ease of gastric outflow. More than one of these factors are often abnormal in the same child with symptomatic GER. In addition, in patients with GER disease, and particularly in those patients with neurologic disorders, there appears to be a high prevalence of autonomic neuropathy in which esophagogastric transit and gastric emptying are frequently delayed, producing a somewhat complex foregut motility disorder. GER has a different course and prognosis depending on the age of onset. The incompetent lower esophageal sphincter mechanism present in most newborn infants combined with the increased intraabdominal pressure from crying or straining commonly becomes much less frequent as a cause of vomiting after the age of 4 months. Chalasia and rumination of infancy are self-limited and should be carefully separated from symptomatic GER, which requires treatment. The most frequent complications of recurrent GER in childhood are failure to thrive as a result of caloric deprivation and recurrent bronchitis or pneumonia caused by repeated pulmonary aspiration of gastric fluid. Children with GER disease commonly have more refluxing episodes when in the supine position, particularly during sleep. The reflux of acid into the mid or upper esophagus may stimulate vagal reflexes and produce reflex laryngospasm, bronchospasm, or both, which may accentuate the symptoms of asthma. Reflux may also be a cause of obstructive apnea in infants and possibly a cause of recurrent stridor, acute hypoxia, and even the sudden infant death syndrome. Premature infants with respiratory distress syndrome have a high incidence of GER. Esophagitis and severe dental carries are common manifestations of GER in childhood. Barrett's columnar mucosal changes in the lower esophagus are not infrequent in adolescent children with chronic GER, particularly when Heliobacter pylori is present in the gastric mucosa. Associated disorders include esophageal dysmotility, which has been recognized in approximately one third of children with severe GER. Symptomatic GER is estimated to occur in 30% to 80% of infants who have undergone repair of esophageal atresia malformations. Neurologically impaired children are at high risk for having symptomatic GER, particularly if nasogastric or gastrostomy feedings are necessary. Delayed gastric emptying (DGE) has been documented with increasing frequency in infants and children who have symptoms of GER, particularly those with neurologic disorders. DGE may also be a cause of gas bloat, gagging, and breakdown or slippage of a well-constructed gastroesophageal fundoplication. The most helpful test for diagnosing and quantifying GER in childhood is the 24-hour esophageal pH monitoring study. Miniaturized probes that are small enough to use easily in the newborn infant are available. This study is 100% accurate in diagnosing reflux when the esophageal pH is less than 4.0 for more than 5% of the total monitored time.

Is motility impaired in the entire upper gastrointestinal tract in patients with gastro-oesophageal reflux disease?

BACKGROUND

Although the pathogenesis of gastro-oesophageal reflux disease is multifactorial, abnormal function of the lower oesophageal sphincter has been established, and in some cases motility defects in the oesophageal body has been described. In some patients with gastro-oesophageal reflux disease delayed gastric emptying has also been observed.

METHODS

Oesophageal and gastric motor function, as evaluated by use of scintigraphy and manometry, were studied concomitantly in 105 patients with chronic, gastro-oesophageal reflux disease before and after antireflux surgery. In a subgroup of these patients (n = 29) similar data were retrieved also at 2.7 years after antireflux surgery.

RESULTS

Impaired oesophageal motor function expressed as delayed transit of a labelled bolus was closely associated with motor dysfunction also recorded in the stomach as determined by delayed emptying of labelled solid food items. A similar relationship was found when oesophageal motor dysfunction was characterized as the frequency of failed primary peristalses after water swallows during manometry. When the 105 patients were studied half a year after an antireflux operation, noncorrelation between oesophageal and gastric motor function could be recorded.

CONCLUSIONS

These data further substantiate the view that gastro-oesophageal reflux disease is associated with a disturbed motor function within the entire upper gastrointestinal tract.

Pathological esophageal acidification and pneumatic dilitation in achalasic patients. Too much or not enough?

Endoscopy, esophageal manometry and pH monitoring, gastric emptying test, and heartburn quantification on a visual analog scale were performed in 22 achalasic patients in order to clarify which events are associated with pathological esophageal acidification after successful LES dilatation. Five patients presented pathological acidification. Dilatation reduced LES tone from 38.3 +/- 4.2 to 14.6 +/- 1.1 mm Hg (mean +/- SEM); there was, however, no difference between nonrefluxers and refluxers (14.8 +/- 1.2 vs 13.8 +/- 2.5 mm Hg). The emptying time in achalasic patients was delayed compared to controls (315.9 +/- 20.9 min vs 209 +/- 10.4) due to prolonged lag-phase and reduced slope of the antral section-time curve, but, again, there was no difference between refluxers and nonrefluxers. The acid clearance was delayed in refluxers compared to nonrefluxers (15.9 +/- 4.5 vs 2.5 +/- 1.8 min, P<0.05). Two refluxers presented grade 1 esophagitis; one of them developed an esophageal ulcer. The heartburn score was the same in refluxers and nonrefluxers. Pathological acidification after pneumatic dilatation is associated with persistent problems in esophageal emptying rather than with excessive sphincter divulsion.

Pathophysiology in gastroesophageal reflux disease: the surgeon's view

Symptoms of gastroesophageal reflux are common in the general population. Pathophysiological factors of importance include esophageal and gastric motility, hiatal hernia, acid secretion as well as anatomical and hormonal factors. In the eye of the surgeon several of the most important factors for severe reflux can be corrected surgically. These include lower esophageal sphincter pressure, esophageal intra-abdominal length and hiatal hernia. The result of surgery is dependent on whether the patient has symptoms related to gastroesophageal reflux or not. It is important that disease history symptoms and pathophysiological findings at investigations match. We have found that not all physiological investigations have to be pathological. Symptomatic response to profound acid inhibition is essential, however, and patients not responding to a high dosage of proton-pump inhibitors should be reconsidered.

Effect of hiatal hernia on esophageal manometry and pH-metry in gastroesophageal reflux disease

An increased frequency of reflux events and a prolonged acid clearance have been shown in gastroesophageal reflux (GER) patients with a hiatal hernia as compared to those without. The objective of the present study was to further investigate esophageal motility and patterns of reflux in GER patients, in relation to the presence or absence of hiatal hernia. Esophageal manometry and ambulatory 24-hr esophageal pH-metry were used in 42 patients with GER and 18 controls. Eighteen of the patients were considered to have a nonreducing hiatal hernia on endoscopy. Hiatal hernia patients showed a higher extent of reflux (total composite score, P = 0.016; total reflux time, P = 0.008, reflux time in supine position, P = 0.024; reflux time in upright position, P = 0.008), a lower frequency of reflux events (P = 0.005), a more severe esophagitis on endoscopy (P < 0.01) and a lower amplitude of peristalsis at 5 cm proximal to LES (P = 0.0009) as compared to patients without hiatal hernia. The amplitude of peristalsis at the distal esophagus was inversely related to the extent of reflux (P = 0.024). Acid clearance was also significantly prolonged in the hernia subgroup (P = 0.011). Although LES resting pressure did not differ significantly between the two subgroups of patients, it was inversely related to the extent of reflux in the patients with hiatal hernia (P = 0.0005). It is concluded, that GER patients with hiatal hernia present with an increased amount of reflux and more severe esophagitis, which results in more severely impaired esophageal peristalsis as compared to patients without hernia. Prolonged acid clearance and impaired esophageal emptying observed in patients with hiatal hernia could be the result of both the presence of the hernia itself and the reduced peristaltic activity of the esophagus.

Delayed gastric emptying and Helicobacter pylori infection in patients with chronic renal failure

Forty patients with chronic renal failure (CRF) were enrolled in this study. Twelve of the 40 patients had upper gastrointestinal symptoms or signs (GI Sx). Twenty of the 40 patients had been receiving regular haemodialysis (HD) for at least 1 year prior to the study. Radionuclide-labelled solid meals were used to calculate gastric emptying times (GETs). The carbon-14 urea breath test (14C4-UBT) was used to diagnose Helicobacter pylori (HP) infection. Among the 40 patients, 35 (88%) had an abnormal GET and 22 (55%) had a positive 14C-UBT for HP infection. There were no statistically significant differences in the incidence of abnormal GET among patients with HP infection and patients without HP infection. There were also no significant differences in the incidence of HP infection among patients with abnormal and normal GETs. In addition, the incidences of abnormal GET in patients with and without upper GI Sx were 83% and 89% respectively. The incidences of HP infection in patients with and without upper GI Sx were 58% and 54%, respectively. The incidences of abnormal GET in HD and non-HD patients were 95% and 80%, respectively. The incidences of HP infection in HD and non-HD patients were 45% and 65%, respectively. The differences in the incidences of abnormal GET and HP infection among HD and non-HD patients, as well as among patients with and without upper GI Sx, were not statistically significant.

Intervening in GERD: the phases of management

The discomforts and histologic changes of gastroesophageal reflux disease call for a stepped approach consisting of four phases: lifestyle modification, initiation of pharmacologic therapy, intensification of drug therapy, and in some cases antireflux surgery. Decisions are guided by symptom patterns, which serve to suggest the predominant pathophysiologic mechanisms.

Effect of fundoplication on the gastric emptying of liquids

To evaluate the effect of fundoplication on the gastric emptying (GE) of liquids, the authors studied 96 male Wistar rats divided into three main groups: group E (early postoperative), formed by 32 rats that received physiological saline as a test meal and whose gastric emptying was evaluated 8 days after surgery; group L (late postoperative), which received the same test meal but was evaluated 29 days after surgery; and group G (glucose), which received 5% glucose in water and was studied 8 days after surgery. Each group was subdivided in two subgroups of 16 animals: in one (atropine), the animals received intravenous (I.V.) atropine sulfate (0.3 mg/100 mg rat weight) 60 minutes before GE test; the other subgroup (controls) received I.V. physiological saline. In both subgroups 8 animals had been submitted to fundoplication and 8 to sham operation. Every test meal, containing 6 mg% red phenol, was infused by gravity through a metallic catheter. Gastric retention was determined by measuring the concentration of the marker in the liquid recovered from the stomach 10 minutes after infusion. In the animals of group E, fundoplication increased the gastric emptying of physiological saline, both in the control and the atropine subgroups. In the L group, gastric retention values were similar in fundoplication and sham-operated rats, suggesting an adaptation of the stomach to the fundoplication. In the G group, fundoplication enhanced GE among the control animals, but not among those receiving I.V. atropine sulfate. These results support the importance of gastric emptying studies in every patient to be submitted to fundoplication.