Maximal acid output and oesophagitis in hiatus hernia

Role of gastric acid in the aetiology of dyspeptic disease and dyspepsia

The main diseases associated with dyspepsia are peptic ulcer disease, gastro-oesophageal reflux disease and non-ulcer dyspepsia. Increased gastric acid secretion is a characteristic of most duodenal ulcer patients and of a small minority of non-ulcer dyspepsia and gastro-oesophageal reflux disease patients. Although acid secretion is normal in most gastro-oesophageal reflux disease patients, the condition is mainly the result of excess exposure of the distal oesophagus to acid refluxing from the stomach. Increased mucosal sensitivity to acid is involved in the aetiology of dyspeptic symptoms in the majority of patients with peptic ulcer disease and gastro-oesophageal reflux disease, and in a minority of non-ulcer dyspepsia subjects. Gastric acid, therefore, plays an important role in both the aetiology of dyspeptic diseases and in the aetiology of dyspeptic symptoms.

A critical analysis, with appropriate controls, of gastric acid and pepsin secretion in clinical esophagitis

Because esophagitis is a presumed "acid-peptic" disease, fasting gastric contents (volume and acid and pepsin concentrations) and basal and pentagastrin-stimulated acid and pepsin outputs were studied in 155 patients with endoscopically defined (and graded 1-4) esophagitis and 508 control patients without esophagitis. Basal pepsin and maximal acid and pepsin outputs were lower in the patients with esophagitis than in those without esophagitis. In further analysis, the patients were subdivided into three categories, duodenal ulcer, nonulcer with no disease other than esophagitis, and postgastric surgery, because these categories affect gastric secretion independently of esophageal disease and in the rank order given. Each category was subdivided by sex, because men secreted more than women. Within each category there was no systematic difference in fasting, basal, or maximal gastric acid or pepsin secretion between patients with and patients without esophagitis. Severity of esophagitis was not related to any secretion parameters. Hiatal hernia was present in 50% of patients with esophagitis vs. 15% of controls without the condition (P less than 0.01); however, this did not independently influence the gastric secretion findings. Lower esophageal sphincter pressure was also measured in 62 of the patients, 31 with and 31 without esophagitis. Below 10 mm Hg (incompetent sphincter), 9 of 10 patients had esophagitis but accounted for only less than 30% of the patients with esophagitis, whereas none of 11 patients with basal acid output of less than 0.1 mEq/h and lower esophageal sphincter pressure of greater than 10 mm Hg had esophagitis. Because neither the composition of gastric juice nor basal or stimulated gastric acid or pepsin output could be correlated to the presence or severity of esophagitis, factors other than amount or composition of gastric juice per se must be responsible for susceptibility to esophagitis.

The interpretation of oesophageal pH monitoring data

Continuous monitoring of oesophageal pH is regarded as the gold standard for all reflux investigations. However, since gastro-oesophageal reflux is considered a normal phenomenon which occurs to a certain extent in each individual, the distinction between "normal" and "abnormal" is not always obvious and is not possible to achieve with a single test. Moreover, data depend on technical hardware such as recording devices and electrodes together with such patient characteristics as age, position, activity, and medication. Although much literature on pH monitoring has appeared recently, many investigations have failed to take into account the basic principles that are of major importance for any biomedical test such as reproducibility, sample reliability, and indications. There is a need to standardize the technique in order to compare studies performed in different centres, provided the technique is reproducible.

Gastric secretion and reflux pattern in reflux oesophagitis before and during ranitidine treatment

Ranitidine (150 mg X 2) and placebo were given to 42 patients with reflux oesophagitis for 8 weeks by the double-blind crossover technique. Gastric secretion tests and 24-h pH monitoring at two different oesophageal levels were performed before and during the treatment periods. Gastric hypersecretion was present in 76%. Ninety-seven per cent had reflux for more than 1% of 24 h, and 67% for more than 4.2%. Ranitidine reduced basal and stimulated gastric acid output and secretion rates (p less than 0.001), total reflux time to the lower level (p less than 0.05), and number of reflux episodes to the upper and lower levels of the oesophagus in the supine position. Basal, maximal, and peak acid output, gastric secretion rates, number of reflux episodes, and total reflux time at the upper oesophageal level in the supine position were significantly more reduced in symptomatic responders than in non-responders. No correlation was found between ranitidine-induced reduction of gastric secretion and length of oesophageal reflux time.

The association of oesophagitis with disease in the stomach and duodenum

The records of all upper digestive endoscopies performed in one year in the Clinical Measurement Department of a teaching hospital serving a population of 250 000 were reviewed; 25% of patients had oesophagitis, which was usually associated with other significant findings such as peptic ulcer and gastroduodenal erosions. Only about 1 in 6 patients with oesophagitis had an endoscopically identified hiatus hernia. Oesophagitis was associated with gastric acid hypersecretion in both men and women.

Gastric acid secretion, oesophageal acid reflux, and oesophagitis in patients with symptomatic gastro-oesophageal reflux

Forty-seven patients with symptomatic gastro-oesophageal reflux were evaluated on the basis of symptoms, endoscopy, extended 18-h pH-monitoring of the lower oesophagus, and the pentagastrin test. The patients' acid secretion capacity did not correlate with symptoms or duration of acid reflux, but men with endoscopic oesophagitis had significantly higher BAO and MAO values than men without oesophagitis. In women this correlation was not found. The higher MAO values (in meq/h) in men than in women were abolished when the MAO was expressed as meq/h/FFB (fat-free body mass). The MAO values in all the men or all the women were not higher than the values obtained from a normal Finnish population. Both men and women with endoscopic oesophagitis had a significantly longer duration of oesophageal acid reflux than men and women with normal mucosa.

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 pattern of bile salt reflux and acid secretion in sliding hiatal hernia

The role played by gastric fluid refluxed from the stomach into the oesophagus of patients with symutomatic sliding hiatal hernia has been evaluated in terms of gastric bile salt concentration and acid secretion rates. Patients with a peptic stricture had a higher basal acid output than control subjects. Approximately half of both hiatal hernia groups studied had periods of increased total bile salt concentrations either while fasting or following a test meal, This would indicate abnormal pyloric function in these patients. The quantitative examination of total and individual bile salts in solution in gastric juice suggests that a combination of gastric acid pepsin and bile may be a major, factor in the pathogenesis of the clinical responses to gastrooesophageal reflux. Neither total nor individual bile salt concentrations found in gastric juice helped to differentiate between the specific types of response seen in symptomatic sliding hiatal hernia.