Interaction of gastroesophageal reflux and esophageal motility. Evaluation by ambulatory 24-hour manometry and pH-metry

Reflux Laryngitis: Correlation between the Symptoms Findings and Indirect Laryngoscopy

Introduction The indirect laryngoscopy has an important role in the characterization of reflux laryngitis. Although many findings are nonspecific, some strongly suggest that the inflammation is the cause of reflux.

Objective The aim of this study was to evaluate the correlation between reflux symptoms and the findings of indirect laryngoscopy.

Methods We evaluated 27 patients with symptoms of pharyngolaryngeal reflux disease.

Results Laryngoscopy demonstrated in all patients the presence of hypertrophy of the posterior commissure and laryngeal edema. The most frequent symptoms were the presence of dry cough and foreign body sensation.

Conclusion There was a correlation between the findings at laryngoscopy and symptoms of reflux.

Proton pump inhibitor influence on reflux in Barrett's oesophagus

OBJECTIVES

It is important to identify factors responsible for the development of Barrett's oesophagus (BO). The effect of proton pump inhibitors (PPIs) on oesophageal clearance of both acid and alkaline reflux in these patients is uncertain and studies comparing BO patients and healthy controls (HCs) have not been performed earlier.

METHODS

Two groups of patients were studied: 18 HCs and 12 BO patients. Oesophageal motility, acid reflux and duodenogastro-oesophageal reflux (DGOR) were measured using a three-pressure transducer catheter with an antimony pH tip, connected to a sodium ion selective electrode. All patients were studied both on and off PPIs.

RESULTS

Without PPI therapy, BO patients had significantly more upright and supine acid reflux and upright DGOR compared with HCs. During acid reflux, HC demonstrated more peristalsis than BO [HC, % peristalsis=64 (9), BO=53 (8), P<0.01], but this was not seen during DGOR. [HC, % peristalsis=68 (14), BO=56 (11)]. In Barrett's patients, DGOR was significantly reduced with PPIs [off PPI, % upright DGOR=61 (17), on PPIs=19 (15), P<0.01], and no oesophageal motility differences were seen compared with results without PPIs.

CONCLUSION

HCs demonstrate better oesophageal motility compared with BO patients to prevent acid and alkaline reflux. When acid reflux occurred, HCs had better coordinated motility to remove it. This increased coordination did not occur during DGOR, suggesting different stimulation mechanisms. PPI reduced DGOR in BO patients, without any change in oesophageal motility.

Esophageal smooth muscle reactivity is impaired in chronic reflux esophagitis by both receptor- and nonreceptor-mediated mechanisms

AIM

Esophagitis is associated with an impaired esophageal peristalsis. A few studies have been aimed at understanding the pathophysiology of abnormal peristaltic activity. The mechanism of impaired esophageal smooth muscle reactivity in the chronic gastroesophageal reflux (GER) model is investigated in vitro for the first time.

MATERIALS AND METHODS

The chronic GER rat model was created by partial gastric outlet obstruction. The histopathological findings related to esophagitis were evaluated. Smooth muscle strips of the tunica muscularis mucosa of esophagus were studied in standard organ chambers. Carbachol- and KCl-induced contractile responses and serotonin- and papaverine- induced relaxant responses in both reflux and sham-operated control groups were determined.

RESULTS

Histopathologically, chronic reflux esophagitis was observed in all specimens of the reflux group. Contractile (carbachol- and KCl-induced) smooth muscle responses were significantly decreased in the reflux group. When compared to control group, relaxant response of smooth muscle to serotonin was also significantly decreased in the reflux group. However, there was no difference in papaverine-induced relaxant responses between 2 groups.

CONCLUSIONS

Our study describes the effects of chronic GER on rat esophageal smooth muscle contractility in vitro. We found that both receptor- (carbachol, serotonin) and nonreceptor-mediated (KCl) esophageal smooth muscle reactivity were impaired in chronic reflux esophagitis. These changes may correspond to the functional motor abnormalities of the esophagus seen in patients with chronic reflux esophagitis.

Comparative study of salivary pH and volume in adults with chronic laryngopharyngitis by gastroesophageal reflux disease before and after treatment

INTRODUCTION

Gastroesophageal Reflux Disease (GERD) is the most prevalent digestive disease of the modern society and has been associated with abnormalities in the larynx and pharynx (LPR). Nonetheless, little is known about the mechanisms involved in this atypical form of the disease. Contradictory clinical data suggest a defense deficit at this segment. Saliva with its organic and inorganic components is responsible for the homeostasis of the oral mucosa and the digestive tract. Salivary pH and volume abnormalities have been linked to laryngopharyngeal symptoms of GERD and LPR. In a recent study we demonstrated significant salivary pH reduction in patients with LPR. Another study found correlation between reduced salivary pH and volume directly related to esophageal pH-metry results.

AIM

To evaluate salivary pH and volume before and after clinical treatment of LPR.

MATERIAL AND METHOD

Twenty-three adults with LPR had total fasting saliva tested before and after a 12-week course of oral proton pump inhibitor.

RESULTS

A statistically significant difference was found in salivary pH before and after treatment with increase of pH values after control of the disease (p<0.001). Salivary volumes of treated patients were also significantly higher than in pre-treated patients (p=0.009).

DISCUSSION

These findings suggest that salivary pH and volume are influenced by the presence of gastroesophageal contents and that salivary pH monitoring can potentially become a cost-effective method for diagnosing and controlling LPR.

Estudo comparativo do pH e do volume salivar em indivíduos com laringofaringite crônica por doença do refluxo gastroesofágica antes e após o tratamento

INTRODUÇÃO: A Doença do Refluxo Gastroesofágico (DRGE) é a doença digestiva mais prevalente da atualidade e, recentemente, tem sido implicada em uma gama de alterações do seguimento laringofaríngeo (RLF). No entanto, pouco se sabe dos mecanismos fisiopatológicos destas manifestações supraesofágicas da DRGE. Os achados clínicos contraditórios e recentes pesquisas sugerem haver deficiências na capacidade de defesa deste seguimento. Uma das principais responsáveis pela homeostase da mucosa oral e do trato digestivo é a saliva com seu conteúdo orgânico e inorgânico. Tanto alterações do pH quanto do volume salivar já foram correlacionados com os sintomas e sinais sugestivos da DRGE e RLF. Estudo recente de nossa autoria demonstra diminuição estatisticamente significante do pH salivar de indivíduos com RLF quando comparado a controles sem a doença. Outro estudo constatou correlação entre a redução do volume X pH da saliva em indivíduos com DRGE, estando esta redução diretamente relacionada aos níveis de pH esofágico constatados durante pH-metria esofágica de 24 horas. OBJETIVOS: Avaliar como se comportam o pH e volume da saliva em um mesmo indivíduo com DRGE e RLF antes e após o tratamento clínico. MATERIAL E MÉTODO: Vinte e três pacientes com RLF tiveram o pH e volume da saliva total testados antes e após receberem tratamento com droga bloqueadora de bomba de prótons durante 12 semanas. RESULTADOS: Houve uma diferença estatisticamente significante (p<0,001) entre o pH da saliva antes e após o tratamento, estando este maior após o controle clínico da doença. O volume de saliva no paciente tratado foi significativamente maior do que no paciente pré-tratamento (p=0.009). DISCUSSÃO: Os achados sugerem que o pH salivar é influenciado pela presença de refluxo gastroduodenal à região laringofaríngea. Caso estudos futuros com populações maiores realmente comprovem esta correlação, poderemos cogitar a possibilidade de usar a mensuração do pH salivar, que é feita de forma rápida e não invasiva, como um meio de diagnosticar e avaliar o comportamento e controle do Refluxo Laringofaríngeo.

Prolonged monitoring of esophageal motor function in healthy children

OBJECTIVE

To describe diurnal variations of esophageal motor function in children using combined ambulatory 24-hour esophageal manometry and continuous intraluminal pH measurement (MP24).

METHODS

Medical records of all patients referred for the performance of MP24 from 1995 to 2002 at a tertiary care center were reviewed. Patients were selected retrospectively for this study using the following inclusion criteria: (1) no dysphagia, (2) normal upper gastrointestinal barium radiograph, (3) normal esophagogastroduodenoscopy and biopsies, (4) normal stationary esophageal manometry, (5) normal esophageal pH probe, and (6) no gastrointestinal pathology appearing after long-term follow-up. Data from the MP24 of these children were retrospectively analyzed for differences between meal, upright, and supine periods using nonparametric univariate analysis.

RESULTS

One hundred twenty-three children had MP24 during the study period. Eleven met the criteria for normality and were included. Their mean age was 12.4 +/- 1.5 years. The number of contractions/minute in the upper, middle, and lower esophageal body differed significantly during meals and in the upright and supine periods (P < 0.01). A significant increase in motor activity occurred during meals (P < 0.01). There was less motor activity observed in the supine position than in the upright position (P < 0.01). There were significant differences in effective (P < 0.05) and total propagated peristalsis among the meal, upright, and supine periods (P < 0.01), with the largest percentage of propagated contractions observed during meals.

CONCLUSION

This study provides the first information on prolonged esophageal motor activity in pediatric patients without esophageal disease. MP24 in children demonstrates significant diurnal variations in esophageal motor function that is similar to the findings in studies of healthy adults.

Gastroesophageal reflux disease in patients with columnar-lined esophagus

Columnar-lined esophagus or Barrett's esophagus is closely associated with gastroesophageal reflux disease. Animal and human studies have shown not only acid but duodenogastroesophageal reflux acting in synergy with acid causes the most esophageal injury. Patients with Barrett's esophagus manifest typical and atypical symptoms of reflux. Ten percent to 25%, however, have clinically silent reflux. Early diagnosis is essential for this disease as it is a risk factor for the development of adenocarcinoma of the esophagus.

The role of esophageal motility in gastroesophageal reflux disease: technique and clinical results of ambulatory 24-hour mano/-pH-metry

The interplay between esophageal motility and gastroesophageal reflux (GER) was investigated with a new ambulatory system of 24-h monitoring of intraesophageal pressures and pH (MP24). The technique allows for simultaneous digital recordings and off-line data analysis. Both computer-aided and visual analyses were used, and algorithms for intercorrelation of mano- and pH-metry were developed. In a group of normal volunteers the physiological response of esophageal motility on GER was defined. In unselected patients suffering from GER disease, the esophageal motility prior to and during GER events were analyzed. In healthy people, most GER episodes occurred spontaneously and were cleared from the distal esophagus by peristaltic contractions. In GER patients, reflux episodes were often preceded by irregular contractions; during GER, esophageal motility was less often peristaltic compared with controls. Therefore, we conclude that MP24 gives relevant information in GER disease which might help in selecting patients for medical or surgical therapy.