Augmented histamine test in the treatment of symptomatic hiatal hernia

Rationale for high-dose H2-receptor blockade in the treatment of gastro-oesophageal reflux disease

Chronic gastro-oesophageal reflux disease is a common clinical problem. The underlying pathophysiology is considered to be acid injury to the oesophageal mucosa secondary to reflux of gastric contents across an incompetent lower oesophageal sphincter. Evidence suggests that gastro-oesophageal reflux disease is primarily a motility disorder, possibly the combined effect of decreased lower oesophageal sphincter pressure, abnormal oesophageal peristalsis, and, perhaps, delayed gastric emptying. The rationale for the use of acid-suppressing drugs in chronic gastro-oesophageal reflux disease is based on control of the known destructive role of acid and pepsin. Recent evidence indicates, however, that standard doses of H2-receptor blockers are often inadequate to control gastric acid-induced injury in many patients with chronic reflux. Long-term maintenance therapy with standard doses of these drugs has proved unsuccessful in approximately 50% of patients. More recent studies show that greater symptom relief and improved healing can be achieved with the use of larger doses of H2-receptor antagonists. This has been shown particularly with ranitidine at a dosage of 300 mg four times daily.

Gastric acid secretion in patients with symptomatic hiatus hernia and effect of a modified Belsey MK IV repair on gastric acid secretion

Fasting, basal, and pentagastrin-stimulated (6 microgram/kg body weight) gastric acid secretion was assessed in 53 patients with radiologically verified sliding hiatus hernia without stricture formation. There was no difference in the acid secretory variables between patients with heartburn and those with heartburn and pain. A study of the acid secretory variables in 34 patients before and 3 months after a modified Belsey MK IV repair for symptomatic hiatus hernia showed that after the repair the pH of basal secretion had risen, and that the volume of basal secretion as well as basal and peak acid output had been reduced. These changes must probably be ascribed to an unintentional vagotomy during the operation. It is concluded that in the evaluation of a surgically established barrier against gastro-oesophageal reflux in terms of oesophageal pH, changes in gastric acid secretion should be taken into consideration.

The response of the lower oesophageal sphincter to maximal doses of pentagastrin

Measurements of the lower oesophageal sphincter pressure and gastric secretion were made in patients with dyspepsia but no reflux and in patients with a hiatus hernia and reflux in response to a near maximal dose of pentagastrin. Patients with hiatus hernia had lower resting sphincter pressures than those with dyspepsia. The magnitude of the pressure rise following pentagastrin was related to the resting tone of the sphincter. However, in terms of percentage increase over resting sphincteric pressure, patients with dyspepsia and patients with a hiatus hernia had similar response.

Simplified management of reflux esophagitis with stricture

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