Oesophageal reflux tests, manometry, endoscopy, biopsy, and radiology in healthy subjects

Radiologic Diagnosis of Gastro-Oesophageal Reflux

It has been proposed that the high density of ordinary barium suspensions may complicate the radiologic diagnosis of gastro-oesophageal reflux. For this reason P-contrast was developed (Ferring AB); a contrast medium with the same density as water (1 g/cm3). A comparison of P-contrast and barium (Mixobar Ventrikel 400 mg/ml) was performed in 82 patients. All patients were examined with both contrast media and the findings were compared with those at reflux test at manometry, endoscopy and 24-hour pH monitoring. Another 40 patients and 15 symptom-free controls were examined with two different amounts of barium, 100 ml and 200 ml, to study if the radiologic diagnosis of reflux varied with the volume of contrast medium administered. P-contrast was found to have no advantages over barium for the diagnosis of gastro-oesophageal reflux. The outcome of the radiologic examination was not influenced by the different volumes of barium used.

Radiologic Diagnosis of Gastro-Oesophageal Reflux

In 149 patients, a standardized radiologic method for the detection of gastro-oesophageal reflux was applied and compared with the results obtained at endoscopy and by a manometric reflux test. Radiologic reflux was recorded in 53 patients, of whom 25 had reflux without abdominal compression and 51 with compression. At least one of the other two types of examination disclosed pathologic conditions in all but 2 of 53 patients. Oesophagitis was significantly more severe among the patients with reflux observed at radiography. The presence of hiatal incompetence with reflux only to the hiatal hernia but not to the oesophagus was not a strong indicator of gastro-oesophageal reflux disease. Hiatal hernia was present in a significantly larger number of the patients with reflux at radiography than in those without reflux. Increased width of the hiatus gave stronger evidence for reflux disease than in patients with a normal hiatus. Thus, the width of the hiatus also had a bearing on the diagnosis of gastro-oesophageal reflux disease.

Radiologic Diagnosis of Gastro-Oesophageal Reflux by Means of Graded Abdominal Compression

The aim of the study was to ascertain whether abdominal compression by a standardized technique increases the reliability of the radiologic diagnosis of gastro-oesophageal reflux. Eightyeight patients were examined by means of a manometric reflux test, 24-hour measurements of pH and endoscopy. The radiologic examination was performed with and without graded abdominal compression, the patient at the same time turning from side to side. When abdominal compression was included the result of the radiologic examination was positive in 31 patients. In the absence of abdominal compression reflux was detected in 11 of these patients. In one patient reflux was detected only without compression. All these 31 patients had one more test positive and in 27 at least 2 more tests were positive. Another 21 patients had reflux disease as indicated by at least 2 of the 3 other tests. The compression technique seems to yield no false positive responses, and proved to be significantly more reliable than examinations without compression.

Globus jugularis and dysphagia in patients with hiatus hernia

The aim of the article was to study if there is any relationship between globus sensation in the jugular fossa (GJ), intermittent esophageal dysphagia (IED), and the presence of a hiatus hernia, and if GJ can be relieved after hiatus hernia repair. 167 patients with a hiatus hernia (Group A) and 61 other patients with hiatus hernia and gastroesophageal reflux disease who were surgically treated with Nissen fundoplication (Group B), filled in a symptom questionnaire on GJ and IED. GJ was found in 66% and IED in 68% of patients in group A. In group B, 49% had GJ and 64% IED before surgery. At surgical follow-up 16% (P < 0.005) and 43% (P < 0.05) had GJ and IED, respectively. The combination of GJ and IED was found in 28% of IED patients before operation and in 31% at surgical follow-up. The high frequency of GJ in patients with hiatus hernia and the significant relief of GJ after hiatus hernia repair imply that GJ most likely is a referred sensation from the esophagus. IED and GJ are two parallel phenomena in patients with hiatus hernia, but do not seem to have any causal relationship.

Hoarseness and misdirected swallowing in patients with hiatal hernia

The purpose of this study was to elucidate whether misdirected swallowing is an extra-laryngeal cause of hoarseness and investigate whether the prevalence of misdirected swallowing and hoarseness in patients with hiatal hernias differ from those with and without pathological gastroesophageal reflux (GER). One hundred and ninety eight patients with hiatal hernias diagnosed via esophageal manometry and pH-reflux test and 262 subjects in the general population who did not have a hiatal hernia at endoscopy, filled in a questionnaire about symptoms on hoarseness, misdirected swallowing, and heartburn. Hoarseness (35%), misdirected swallowing to the larynx (MSL; 35%), misdirected swallowing to the nose (MSN; 22%) and heartburn (85%) were significantly more common in patients with hiatal hernia than in controls (13, 5, 1, and 6%, respectively, P<0.001). MSL and MSN in the patient group were significantly interrelated (P<0.0001). Hoarseness and MSL were not significantly associated (P<0.076). Hoarseness and MSL were as common in the hernia group with normal GER, as in the group with pathological GER. There is a predisposition for hoarseness and MSL in patients with hiatal hernias, but the cause-and-effect relationship is unclear. Hoarseness does not seem to be caused by pathological GER.

An evidence-based, Latin-American consensus on gastro-oesophageal reflux disease

In recognition of the high prevalence of gastro-oesophageal reflux disease (GORD) and its importance in Latin America, the InterAmerican Association of Gastroenterology and the InterAmerican Society of Digestive Endoscopy organized a Latin-American Consensus on GORD in Cancun, Mexico in September 2004. The main objectives of the consensus meeting were to provide evidence-based guidance with respect to the diagnosis and treatment of GORD, relevant to all countries in the region. The methodology, results and recommendations of the consensus are described in detail.

Twenty-four-hour esophageal pH monitoring in children and adolescents with chronic and/or recurrent rhinosinusitis

Gastroesophageal reflux (GER) disorder was studied in children and adolescents with chronic and/or recurrent rhinosinusitis not associated with bronchial asthma. Ten children with a clinical and radiological diagnosis of chronic and/or recurrent rhinosinusitis, consecutively attended at the Pediatric Otolaryngology Outpatient Clinic, Federal University of São Paulo, were evaluated. Prolonged esophageal pH monitoring was used to investigate GER disorder. The mean age of the ten patients evaluated (eight males) was 7.4 +/- 2.4 years. Two patients presented vomiting as a clinical manifestation and one patient presented retrosternal pain with a burning sensation. Twenty-four-hour esophageal pH monitoring was performed using the Sandhill apparatus. An antimony probe electrode was placed in the lower third of the esophagus, confirmed by fluoroscopy and later by a chest X-ray. The parameters analyzed by esophageal pH monitoring included: total percent time of the presence of acid esophageal pH, i.e., pH below 4 (<4.2%); total number of acid episodes (<50 episodes); number of reflux episodes longer than 5 min (3 or less), and duration of the longest reflux episode (<9.2 min). One patient (1/10, 10%) presented a 24-h esophageal pH profile compatible with GER disorder. This data suggest that an association between chronic rhinosinusitis not associated with bronchial asthma and GER disorder may exist in children and adolescents, especially in those with compatible GER disorder symptoms. In these cases, 24-h esophageal pH monitoring should be performed before indicating surgery, since the present data suggest that 10% of chronic rhinosinusitis surgeries can be eliminated.

Hoarseness and misdirected swallowing before and after antireflux surgery

CONCLUSION

Patients with hiatus hernia can be relieved from H, MSL and MSN by hiatus hernia repair.

OBJECTIVE

It has been hypothesized that respiratory symptoms in patients with gastro-oesophageal reflux disease (GORD) may, in some cases, be due to misdirected swallowing as a consequence of defective opening of the upper oesophageal sphincter. The aim of this study was to investigate whether patients with hiatus hernia are relieved from symptoms of misdirected swallowing to the larynx (MSL) and nose (MSN), as well as hoarseness (H), as a result of hiatus hernia repair.

MATERIAL AND METHODS

A questionnaire concerning symptoms of H, MSL and MSN was administered to 90 patients under investigation for hiatus hernia repair before and after surgery.

RESULTS

Before surgery, MSL occurred in 30% of patients, MSN in 30% and H in 25%. These symptoms were significantly interrelated (p <0.008). After antireflux surgery, all symptoms were significantly reduced (p <0.001). Symptom reduction was not related to the weight of the patients.

Effects of anti-reflux surgery on chronic cough and asthma in patients with gastro-oesophageal reflux disease

This two-group prospective study evaluated the effect of anti-reflux surgery (fundoplication) on 24 patients with severe gastro-oesophageal reflux disease (GORD) and concomitant asthma (n=13) or chronic cough (n=11). Twenty-four hour oesophageal pH monitoring and lung function tests (FEV1, FVC) were done before and within 1 year after anti-reflux surgery. A diary was kept by the patient during the 4-week period prior to surgery and during 4-week periods 6 and 12 months postoperatively, with daily monitoring of peak expiratory flow rate, respiratory and reflux symptoms and medication. In non-asthmatic patients, coughing was reduced by 47% and 80% during the day and night, respectively, 12 months after surgery (P < 0.01). Concomitant hoarseness and expectoration were also significantly reduced (P<0.05). No effect on lung function was seen. In patients with asthma, small, non-significant reductions in asthma symptom scores and consumption of rescue medication were seen. Twenty-two patients were completely free from their GORD symptoms after surgery. In conclusion, anti-reflux surgery in patients with GORD had a more favourable effect on concomitant cough than concomitant asthma.

Prospective study of symptoms and gastro-oesophageal reflux 10 years after posterior partial fundoplication

BACKGROUND

This was a prospective study of symptoms, and short-term and long-term reflux competence after partial fundoplication.

METHODS

Some 101 patients were operated consecutively with posterior partial (270 degrees ) fundoplication. Indications for surgery were reflux disease without erosive oesophagitis in 25 patients, moderate oesophagitis in 43, severe oesophagitis in 25 and paraoesophageal hernia in eight. Symptom score, manometry and pH tests were performed before operation, 6 months after operation and after 6-14 years.

RESULTS

All patients (n = 101) were free from heartburn and regurgitation at early follow-up. There was evidence of clinical recurrence at late follow-up (n = 87) in two of 22 patients without oesophagitis before operation, two of 39 with moderate oesophagitis before operation and three of 19 patients with severe oesophagitis before operation; 92 per cent had good reflux control at late follow-up.

CONCLUSION

Posterior partial fundoplication shows excellent reflux control at early follow-up. Ten years later fewer than 10 per cent of patients have recurrence, which is more common in patients who had severe oesophagitis before operation.

Gastroesophageal reflux in healthy subjects. Significance of endoscopic findings, histology, age, and sex

BACKGROUND

Our aim was to evaluate which specific factors are of importance for the gastroesophageal reflux seen in presumably healthy subjects.

METHODS

We investigated 57 healthy, asymptomatic volunteers with computer-aided medical history interrogation, endoscopy, biopsy specimens from the distal esophagus, manometry, and 24-h ambulatory pH-monitoring.

RESULTS

Eight subjects (14%) claimed intermittent reflux symptoms at the computer interview, but they did not have more acid reflux at pH-monitoring than asymptomatic volunteers. Thirteen subjects (23%) had abnormalities at endoscopy, 3 of whom had an erosion in the distal esophagus, and 12 had hiatus hernia. Subjects with hiatus hernia had increased acid reflux at 24-h pH-monitoring compared with those without hernia. If subjects with hernia were excluded, the degree of acid reflux was similar in all age groups. Men had more acid reflux than women, and these differences persisted if subjects with hernia were excluded. There was no correlation of histologic signs of esophagitis in the distal esophagus, lower esophageal sphincter pressure, smoking habit, or body mass index with reflux of acid to the esophagus.

CONCLUSION

Hiatus hernia is a common finding in healthy subjects, and it predisposes to gastroesophageal acid reflux. Histologic abnormalities are poorly related to acid reflux in healthy volunteers. We found increased acid reflux in healthy men compared with women, but larger studies are needed to confirm these findings. Symptom evaluation is not sufficient to exclude significant gastroesophageal reflux in healthy volunteers, and we suggest that the possibility of esophageal abnormalities should be excluded by endoscopy in comparative studies of gastroesophageal reflux disease.

Laparoscopic management of gastroesophageal reflux disease

This monograph provides a review of the contemporary surgical management of gastroesophageal reflux disease (GERD), drawing primarily on the experience at Emory University Hospital. We emphasize the importance of precise anatomic and physiologic preoperative evaluation to confirm the diagnosis of GERD, and stress technical aspects of laparoscopic fundoplication that have improved outcomes.

Computerized thermistor technique for indirect studies of esophageal blood flow

The aim of this study was to elaborate on a computerized microthermistor technique for indirect measurement of esophageal blood flow and to investigate if any changes in circulation could be found in patients who are provoked by esophageal acid perfusion of their acid-sensitive mucosa. A thermistor was mounted in a plastic catheter and placed in the esophagus 11 cm above the lower esophageal sphincter. The signal from the thermistor was transmitted to a personal computer. A 15 degrees C water bolus was injected into the catheter in order to cool the esophageal wall at the catheter side hole 1 cm above the thermistor. The reliability of the thermistor test was examined by repeating it in 29 patients. No statistical difference between the two test occasions was found. Twenty-five patients were provoked with an acid perfusion test, 14 of whom had a positive reaction with heartburn. Patients with a positive acid perfusion test had a shorter rewarming time before as well as after provocation than patients with a negative acid perfusion test. It is concluded that this thermistor technique is well suited for measuring intraluminal rewarming rate as an indirect sign of changes in esophageal blood flow. Furthermore, the results indicate that blood supply of the esophageal wall is increased in patients with a positive acid perfusion test.

Variations in esophageal oxygen tension measured with intraluminal antimony electrodes

Monocrystalline antimony electrodes (crystallographically oriented monocrystalline antimony; COMA) are known to be sensitive to oxygen and to pH. Accordingly, it has been shown that COMA electrodes can be used for the measurement of tissue oxygen tension provided the pH remains constant or is accounted for by the simultaneous use of a glass electrode. In this study the combination of a COMA together with a glass electrode was evaluated for measurement of esophageal oxygen tension in 5 patients. The COMA electrodes showed a mean value of 2.1 pH units higher than the glass electrodes, corresponding to a pO2 level in the esophagus of 10 kPa. As the more protracted oxygen effect on the COMA electrodes was easily recognized, especially in levels of the pH above 7.8 units, they were used for indirect evaluation of intraluminal oxygen tension in the esophagus in a further 57 patients, monitored over 24 h for gastroesophageal reflux disease. The intraluminal pO2 decreased in the supine position and with increase in age. An increase in pO2 was seen after eating and during reflux periods. The changes in pO2 are interpreted as being secondary to blood flow alterations in the esophagus.

Simultaneous two level oesophageal pH monitoring in healthy controls and patients with oesophagitis: comparison between two positions

For oesophageal pH monitoring, the pH probe is usually positioned 5 cm above the lower oesophageal sphincter (LOS). This is by convention, and has not been compared with other positions in its ability to discriminate between physiological and abnormal acid reflux. Using simultaneous two level 24 hour pH monitoring (5 and 10 cm above manometrically determined LOS) in 31 controls and 51 patients with reflux oesophagitis, the significance of the precise position of the probe in the oesophagus was examined. Secondly, this study compared the discrimination between the two groups achieved at the two levels. Patients had greater acid exposure than controls at both levels. In controls, acid exposure was greater at distal than at the proximal level except the supine acid exposure, which was similar at both levels. In patients, acid exposure was greater at the distal level for all variables (median % of total time pH < 4 = 11.7 v 7.6; p = 0.001). There was excellent correlation between the two levels for all variables in controls (r = 0.883, 0.935, 0.813, and p < 0.001 for percentage of time pH < 4 for total, supine, and upright times) as well as in patients (r = 0.848, 0.848, 0.779, and p < 0.001). On discriminant and receiver operating characteristic analysis, pH threshold 4 seemed as good as or better than other pH thresholds in discriminating between controls and patients. The percentage of total time pH below 4 seemed to discriminate as well or better than other variables at both levels. The distal level (5 cm above LOS) provided slightly better discrimination than proximal level (10 cm) (percentage of subjects correctly classified=81.7 v 75.6). The critical factor for the reliability of the test is not the precise position of the pH probe relative to the LOS, but that the same position is consistently used in patients and controls.

pH monitoring: the gold standard in detection of gastrointestinal reflux disease?

Gastroesophageal reflux disease (GERD) is one of the most frequent benign diseases of the gastrointestinal tract and in some cases the diagnosis may be very difficult. There are many diagnostic procedures but none of them could prove or definitely exclude the disease. The 24-h pH-monitoring is the "gold standard" for detection of gastroesophageal reflux and in many patients the reflux correlates with the GERD. The evaluation of a diagnostic method has to be done in a similar manner to the evaluation of therapeutic study (phase 1 to phase 4). For the definition of the "gold standard" for detection of a special diagnosis (e.g., the gastresophageal reflux disease), the results of phase 3 studies for different methods had to be compared. The method with the best values for sensitivity and specificity is yet to be discovered. Until now, pH monitoring has been the gold standard for the diagnosis of GERD. However, there are many problems connected with using this method in clinical practice.

Alkaline oesophageal reflux--an artefact due to oxygen corrosion of antimony pH electrodes

Antimony electrodes are widely used for gastro-oesophageal pH monitoring. They are also sensitive to oxygen, however, especially at low PO2 levels, which are known to shift recorded values in the alkaline direction. This study, which compares antimony and glass electrodes for oesophageal pH monitoring in six adults, shows that values recorded by antimony electrodes are 2.1 +/- 0.8 pH units (mean +/- SD) higher than by glass electrodes (p < 0.001; n = 7642). A further 52 patients with suspected gastro-oesophageal reflux were investigated by 24-h pH monitoring by means of antimony electrodes. In these patients the oesophageal pH was higher than 8.0 for 7% of the time (range, 0-60%). The alkaline periods recorded with antimony electrodes were all protracted in time, smoothly increasing from a neutral pH, and did not correspond to a sudden increase in pH, which would be expected if alkaline reflux had occurred. It is concluded that high pH values obtained by antimony electrodes are due to the oxygen sensitivity of the electrodes. The diagnosis of alkaline reflux seems to be valid only when pH monitoring is performed with glass electrodes or when values obtained with antimony electrodes are adjusted for the influence of the oxygen tension in the oesophagus.

Oesophageal speech after laryngectomy: a study of possible influencing factors

52 patients with laryngeal carcinoma were studied before and after laryngectomy with regard to what factors might influence the development of oesophageal speech. The investigations consisted of oesophageal manometry, a follow-up interview and a review of surgical approaches and radiotherapy. 43% of the patients achieved socially acceptable oesophageal speech, 22% were able to speak single words, and 35% had no oesophageal speech at all. 61% had post-operative dysphagia. Age was the only factor which significantly correlated to intelligible speech. The intraoesophageal pressure during oesophageal phonation exceeded in all cases the low PO-HPZ pressure after operation. The extension of surgery and radiation field, severity of dysphagia, alcohol and smoking habits, and mental condition did not differ between the 3 groups of oesophageal speech. It was concluded that the rather complicated process of acquiring oesophageal speech is much more dependent on learning ability which decreases with age than on various kinds of motor dysfunction after laryngectomy.

Bronchial asthma and acid reflux into the distal and proximal oesophagus

The prevalence of pathological gastro-oesophageal reflux in children and adolescents with asthma was studied by 24 hour two level oesophageal pH monitoring in 42 subjects aged 9-20 years with moderate or severe bronchial asthma. The importance of oesophagobronchial nerve reflexes and of aspiration of gastric acid as triggers in asthma was assessed by studying whether episodes of reflux into the distal and into the proximal oesophagus were followed by asthma attacks. Twenty-one subjects (50%) had a pathological total reflux time in the distal oesophagus and six (16%) in the proximal oesophagus. Nine patients had pathological gastro-oesophageal reflux into the distal oesophagus together with symptoms of asthma during the day on which the recording took place. In three of them the episodes of asthma symptoms were significantly correlated with preceding episodes of reflux into the distal oesophagus, and in one subject to reflux into the proximal oesophagus. We conclude that pathological gastro-oesophageal reflux is common in children and adolescents with asthma, but it seems to provoke symptoms of asthma in only a few. Symptoms of asthma were more often elicited by exposure of the distal oesophagus to gastric acid, possibly by a vagal reflex, than by aspiration of gastric juice.

Esophageal acid perfusion, airway function, and symptoms in asthmatic patients with marked bronchial hyperreactivity

It is believed that GER can trigger asthma by the stimulation of acid-sensitive receptors in the esophagus. The aim of this study was to determine whether esophageal acid stimulation in asthmatic patients can provoke clinically detectable bronchospasm and if a possible response is correlated to bronchial reactivity. Eight patients with chronic asthma and GER disease were investigated on three occasions with a histamine challenge test followed by acid provocation of the esophagus. Assessment of bronchial function was made by FEV1, chest auscultation, and respiratory symptoms. While symptoms and signs of bronchoconstriction induced by esophageal acid stimulation were not detected clinically on any occasion, there was a significant correlation between histamine reactivity and the subclinical bronchospasm following acid provocation. It is concluded that esophageal acid stimulation during daytime in the majority of asthmatic patients is not a strong and immediate trigger of asthma.

Effects of ranitidine treatment on patients with asthma and a history of gastro-oesophageal reflux: a double blind crossover study

Forty eight patients with moderate to severe asthma were enrolled in a double blind crossover study designed to evaluate the effects of ranitidine treatment, 150 mg twice daily for four weeks, on gastro-oesophageal reflux, asthma control, and bronchial reactivity. All 48 had a history of reflux symptoms and 27 had in addition reflux associated respiratory symptoms. Thirty two patients had objective evidence of acid reflux on 24 hour pH monitoring (pH of less than 4 for more than 1% of the 24 hours) and 27 patients had a positive result in the acid perfusion test. Reflux symptoms were significantly improved after ranitidine treatment. Ranitidine treatment was associated with modest improvements in nocturnal asthma and daily use of inhaled bronchodilator drugs but there was no significant change in bronchial reactivity, lung function, peak flow, or the number of eosinophils in the blood. Comparisons between the effect of ranitidine treatment on asthma control were performed between patients with and without a history of reflux associated respiratory symptoms, with and without a positive result in the acid perfusion test, and with and without objective evidence of gastro-oesophageal reflux. A history of reflux associated respiratory symptoms was the only factor that predicted an improvement in asthma control after ranitidine treatment. These results indicate that antireflux treatment will produce only small improvements in asthma control in asthmatic patients with a history of gastro-oesophageal reflux.

Can mild bronchospasm reduce gastroesophageal reflux?

During attacks of asthma, changes in the transdiaphragmatic pressure gradient may impair the antireflux barrier and provoke gastroesophageal reflux (GER). If GER triggers asthma and asthma causes GER, a vicious circle could arise with an increase in the severity of asthma symptoms. The aim of this investigation was to determine whether postprandial reflux in asthmatics with GER disease is increased during histamine-induced bronchospasm and also if theophylline increases GER during provoked episodes of bronchospasm. Ten patients with chronic asthma and pathologic GER were challenged with either histamine or saline in randomized order with and without their regular dose of oral slow-release theophylline. FEV1 was recorded at regular intervals during the hour of provocation, and acid reflux (pH less than 4) was monitored by antimony pH electrodes in the esophagus. GER was not more pronounced during the provoked bronchospasm period irrespective of theophylline treatment or not. It seems unlikely that mild bronchospasm provokes reflux in patients with asthma and GER. It would appear that mild bronchospasm is rather protective against gastroesophageal reflux.

The diagnostic value of computerized short-term oesophageal pH-monitoring in suspected gastro-oesophageal reflux

In 109 consecutive patients suspected of having gastro-oesophageal reflux (GOR) a 3.5-h pH-monitoring in the oesophagus was performed during the daytime. The data were stored in a portable recording system, and three different variables (mean pH, mean acid clearance rate, and number of spikes) were calculated. Compared with a combined endoscopic-histologic score for the diagnosis of oesophagitis, assumed to be due to GOR, the 3.5-h pH-monitoring had a sensitivity of 85% and a specificity of 81%. The data suggest that the short-term pH-monitoring is almost as accurate as the traditional 24-h pH-monitoring and more convenient both for the patient and the gastroenterologic unit.

24-hour oesophageal two-level pH monitoring in healthy children and adolescents

Two-level pH recording in the oesophagus was performed for 24 h in 28 healthy schoolchildren between 9.3 and 17.3 years of age, to obtain reference values for reflux studies. The pH probes were placed 5 and 15 cm above the lower oesophageal sphincter by means of the manometric technique. A standardized acid-free diet was given on the day of recording. A drop in pH to 4.0 or below was regarded as reflux. The normal upper limit of total reflux time was 1.0% at the lower oesophageal level. Mean reflux time was about three times shorter at the upper level than at the lower, which indicates the importance of exact positioning of the pH probe.

Influence of theophylline on gastro-oesophageal reflux and asthma

The aim of the study was to determine whether gastro-oesophageal (GO)-reflux was increased by normal maintenance doses of theophylline, and if so, whether this was detrimental to lung function in asthmatic patients with symptoms of reflux. In 25 patients with moderate or severe bronchial asthma and a history of respiratory symptoms aggravated by reflux, two consecutive oesophageal 24-h pH recordings were made, one with and the other without their ordinary dose of slow release theophylline. The theophylline treatment caused a significant increase in total reflux time and reflux symptoms but did not worsen the asthma. Patients with subtherapeutic serum levels showed significant improvement in lung function and those with therapeutic serum levels did not. It is concluded that theophylline, in view of its potential to exacerbate GO-reflux, should be used with caution as maintenance therapy in asthmatic patients with GO-reflux.

Esophageal body motor disturbances in gastroesophageal reflux and the effects of fundoplication

Thirty-seven patients with gastroesophageal reflux disease (GERD) were included in an esophageal manometry study before and six months after fundoplication. The motility pattern of the body of the esophagus in the patient group was compared with that of 15 healthy controls. No differences in swallowing amplitudes were found between patients with different degrees of esophagitis or between GERD patients and controls. Peristaltic activity was slightly impaired in patients with endoscopic esophagitis compared with controls. No correlation was found between dysphagia and chest pain symptoms on the one hand and on peristaltic pattern and swallowing amplitudes on the other. It was concluded that conventional esophageal manometry has little to contribute to the investigation of symptoms such as non-burning chest pain and dysphagia in GERD. Effective anti-reflux surgery eliminates these symptoms with little influence on the esophageal motility pattern.

Oesophagitis, signs of reflux, and gastric acid secretion in patients with symptoms of gastro-oesophageal reflux disease

In a study comprising 100 patients referred to a surgical clinic with symptoms suggestive of gastro-oesophageal reflux disease the value of different diagnostic procedures was investigated. Positive acid perfusion and 24-h pH tests were the commonest findings. Forty-nine per cent showed a normal oesophageal mucosa or diffuse oesophagitis at endoscopy. The severity of heartburn and regurgitation did not differ between patients with normal oesophageal mucosa and oesophagitis of various severities. The severity of macroscopic oesophagitis was significantly correlated to the total reflux time, the presence of reflux or a hiatal hernia at radiology, an open cardia or reflux at endoscopy, pressure transmission or reflux and low lower oesophageal sphincter pressure at manometry. Gastric hypersecretion was found in 66% of the patients. Gastric acid secretion was not correlated to the severity of oesophagitis or to the findings at 24-h pH test. In patients with severe oesophagitis the sensitivity for radiologic, manometric, and endoscopic signs of incompetence of the gastro-oesophageal junction was 94%.