Esophageal function in patients with angina-type chest pain and normal coronary angiograms.

Ten per cent of patients with angina pectoris have normal coronary arteries and cardiac function and, despite this reassurance, continue to have chest pain. Since pain of cardiac or esophageal origin is clinically difficult to differentiate, 50 patients with severe chest pain, normal cardiac function, and normal coronary arteriography with ergotamine provocation were evaluated with a symptomatic questionnaire and esophageal function test. On 24-hour esophageal pH monitoring, 23 patients had abnormal reflux, and 27 were normal. There was no difference in the incidence and severity of chest pain, esophageal symptoms, or medication taken between refluxers and nonrefluxers. Ten refluxers and ten nonrefluxers had chest pain on exercise electrocardiography. Thirteen refluxers documented chest pain during the pH monitoring period, and in 12 it coincided with a reflux episode. Fifteen nonrefluxers documented chest pain during the monitoring period, and in only one did it coincide with a reflux episode. Of the 23 refluxers, 12 were treated with medical therapy and 11 by a surgical antireflux procedure, and all followed for two to three years. Ten (91%) of the 11 surgically treated patients are totally free of chest pain compared with five (42%) of the 12 medically treated patients. All 12 patients who had chest pain coincide with a documented reflux episode responded positively to antireflux therapy, eight surgical and four medical. It is concluded that 46% of patients complaining of angina pectoris with normal cardiac function and coronary arteriography have gastroesophageal reflux as a possible etiology. Seventy-three per cent of these patients have total abolition of chest pain by either surgical or medical antireflux therapy. Patients whose experience of chest pain coincided with a documented reflux episode on 24-hour esophageal pH monitoring had a 100% response to medical or surgical therapy. Overall, surgical therapy gave better results (91%) but was associated with an 18% temporary morbidity. Objective evaluation of reflux status and its correlation to the symptom of chest pain by 24-hour pH monitoring allows for selective therapy in these difficult to manage patients.     

Alkaline reflux gastritis. Late results on a controlled trial of diagnosis and treatment.

In 1977, a controlled, prospective trial was initiated to test the hypothesis that excessive enterogastric (EG) reflux was responsible for a unique postgastrectomy syndrome, "alkaline reflux gastritis." Late (42 +/- 3 months) follow-up on all treated patients (N = 14; Rx = 45 cm Roux Y limb) is reported. The following parameters were assessed in symptomatic (N = 11 nonrefluxers, 15 refluxers) and asymptomatic postgastrectomy patients (N = 9): CCK-stimulated scintographically determined EG reflux (EGRI %), intragastric (IG) concentration of bile acids (BA, mM), net bile acid reflux/hr (microM), maximum acid output (mEq/hr), intragastric pH, gastric emptying of 99Tc-labeled solids (T 1/2; minutes), gastritis score (GS = 0-15), and specific symptomotology. A significant linear relationship was noted between intragastric BA concentration and the severity of histologic gastritis in the residual gastric pouch. As a group, excessive refluxers demonstrated significantly greater IG BA concentration, net BA reflux/hour, and EGRI than did either nonrefluxers or controls. Gastritis score in this group was also greater, intragastric pH higher, and maximal acid output (MAO) lower. Gastric emptying was not different between groups. Following Roux (N = 14), reflux was eliminated early and late, pH fell, MAO increased, and gastritis improved. Early marked delays in emptying occurred but normalized late and were rarely a clinical problem. Early symptomatic results were pain eliminated in 14/14, nausea in 8/14, vomiting 11/14, bilious vomiting in 14/14. Complications were one marginal ulcer (no vagotomy), two severe delays in emptying (simultaneous Roux + vagotomy). Late symptomatic results were recurrent or persistent pain in 4/14, nausea in 7/14, vomiting in 5/14. Bilious vomiting remains eliminated.     

Gastroesophageal reflux and pulmonary aspiration: incidence, functional abnormality, and results of surgical therapy.

The incidence of aspiration, the causative esophageal pathophysiology, and the results of surgical therapy were evaluated in 100 patients with abnormal gastroesophageal reflux documented by 24-hour esophageal pH monitoring. Based on historical evidence, 48 patients were suspected to be aspirators. Eight patients had documented episodes of aspiration (drop on esophagela pH, followed by acid taste in mouth and onset of cough or wheezing spell) during the monitoring period. Nine patients were considered to be potential aspirators because they presented oral acid regurgitation without development of pulmonary symptoms. In five patients a primary respiratory disorder (PRD) induced gastroesophageal reflux. The remaining 78 patients had abnormal reflux without aspiartion or regurgitation. Aspirators had a 75% incidence of esophageal motor abnormality on manometry, and the clearance of refluxed acid was significantly delayed in the supine position. A history of heartburn and endoscopic evidence of esophagitis were present in only half of the patients who were documented aspirators. Potential aspirators were spared from aspiration by rapid esophageal clearance of refluxed acid unaffected by changes in body position. Patients with a PRD had higher distal esophageal segment (DES) pressure and normal esophageal motility with minimal esophagitis. Nonaspirators significantly improved their clearance while in the supine position, emphasizing the protective effect of esophageal peristalsis against aspiration. An antireflux procedure in five aspirators raised the DES pressure significantly and returned the reflux status to normal by 24-hour pH-monitoring standards. The incidence of aspiration appears to be less than that suspected by history and is due to a motor disorder that interferes with the ability of the esophagus to clear reflex acid. Abnormal pulmonary symptoms can induce or result from gastroesophageal reflux and, when the latter occurs, an antireflex procedure stops both reflux and aspiration.     

Evaluation of the nissen antireflux procedure by esophageal manometry and twenty-four hour pH monitoring

Fifteen normal volunteers without symptoms of gastroesophageal reflux and sixteen patients with symptoms of gastroesophageal reflux unresponsive to medical management and having endoscopic esophagitis had esophageal manometry and twenty-four hour pH monitoring of the distal esophagus. The symptomatic patients underwent a Nissen antireflux procedure and were restudied at four months. After surgery, patients had less reflux, a higher sphincteric pressure, and an equal amount of sphincter within the abdomen as did asymptomatic control subjects.     

Relationship between symptom response and oesophageal acid exposure after medical and surgical treatment for gastro-oesophageal reflux disease

BACKGROUND: The relationship between symptom severity and objective evidence of gastro-oesophageal reflux disease (GORD) after medical and surgical treatment has recently been questioned. This study aimed to compare the symptomatic and physiological response (as measured by pHmetry) to the treatment of GORD by proton pump inhibitors (PPIs) and by laparoscopic antireflux surgery, and to examine the relationship between the patient's subjective and objective response to treatment of GORD. METHODS: Seventy patients underwent 24-h oesophageal pH measurement and DeMeester symptom assessment (for heartburn and regurgitation, grade 0-3) while off medical treatment, while taking PPIs and after laparoscopic fundoplication. RESULTS: The median percentage total time with oesophageal pH < 4 off treatment, during medical treatment and after fundoplication was 9.5, 4.3 and 0.5 per cent respectively. After medical treatment 30 patients became asymptomatic although 18 of these still had pathological reflux on pH testing. Of the 19 patients who remained symptomatic after surgery only two had pathological acid reflux. CONCLUSION: The symptomatic response of patients to either PPIs or antireflux surgery is a poor indicator of successful treatment in terms of reduced lower oesophageal acid exposure. A high proportion of patients whose symptoms are improved by PPIs still have pathological levels of acid reflux. Conversely, most patients who complain of reflux symptoms after antireflux surgery have no evidence of residual reflux on pHmetry.     

Patterns of gastroesophageal reflux in health and disease.

Twenty-four pH monitoring the distal esophagus quantitates gastroesophageal reflux in a near physiologic setting by measuring the frequency and duration of acid exposure to the esophageal mucosa. Fifteen asymptomatic volunteers were studies with 24-hour pH and esophageal manometry. The normal cardia was more competent supine than in the upright position. Physiologic reflux was unaffected by age, rarely occurred during slumber, and was the rule after alimentation. One hundred symptomatic pateitns with an abnormal 24-hour pH record (2 S.D. above the mean of controls) could be divided into three patterns of pathological reflux: those who refluxed only in the upright position (9), only in the supine position (37), and in both positions (54). Upright differed from supine refluxers by excessive aerophagia causing reflux episodes by repetitive belching. Compared to controls, they had excessive post-prandial reflux, lower DES pressure, and less DES exposed to the positive pressure of the abdomen. Supine differed from upright refluxers by having a higher incidence of esophagitis and an inability to clear the esophagus of acid after a supine reflux episode. Compared to controls, they had only a lower DES pressure. Combined refluxers had a higher incidence of esophagitis than supine refluxers. Stricture (15%) was seen only in this group. They were similar to supine refluxers in their inability to clear a supine reflux episode. Compared to controls, they had a lower DES pressure and less DES exposed to the positive pressure of the abdomen. Forty of the 100 patients had an antireflux procedure (4 upright, 8 supine, 28 combined). The most severe postoperative flatus and abdominal distention was seen in the upright refluxers. It is concluded that minimal reflux is physiological. Patients with pathological reflux all have lower DES pressure. Patients with upright reflux have less of their DES exposed to the positive pressure environment of the abdomen. Patients with supine reflux have an inability to clear the esophagus of reflux acid and are prone to develop esophagitis. Patients with both upright and supine reflux have the most severe disease and are at risk in developing strictures. In patients with only upright reflux, aerophagia and delayed gastric emptying may be an important etiological factor.     

Recurrent Heartburn after Laparoscopic Fundoplication is Not Always Recurrent Reflux

Introduction A small cohort of patients present after antireflux surgery complaining of recurrent heartburn. Many of these patients have been empirically recommenced on proton pump inhibitors. Objective The aim of this study was to determine whether patients with symptoms that suggest recurrent reflux had objective evidence of reflux, and to determine predictors of recurrent reflux. Methods We identified all patients from an existing database who had undergone pH monitoring for “recurrent heartburn” after fundoplication. These patients were then cross-referenced to another database, which recorded the outcomes for patients who had undergone a laparoscopic fundoplication. Patients complaining of dysphagia or other problems without heartburn were excluded from analysis. Results Seventy-six patients were identified who met the inclusion criteria. Fifty-six (74%) of these had a normal 24-h pH study. Thirty-five patients (63%) with a normal pH study were on medication for heartburn at the time of referral. Three factors were found to be associated with an abnormal 24-h pH study: a partial fundoplication (P = 0.039), onset of symptoms 6 months or more after surgery (P < 0.001), and a good symptom response when antireflux medication was recommenced (P = 0.015). Conclusions Not all patients complaining of recurrent heartburn after fundoplication have evidence of abnormal reflux. Objective evidence of abnormal esophageal acid exposure should be confirmed before recommencing antireflux medication. Presented at the 10th World Congress of the International Society for Diseases of the Esophagus (ISDE), Adelaide Convention Center, South Australia, Australia, February 24, 2006     

Gastroesophageal reflux disease: symptoms versus pH monitoring results.

OBJECTIVES: The reason why some patients with gastroesophageal reflux disease (GERD) have symptoms of upper aerodigestive system irritation, while others mainly have gastroenterologic symptoms, is not well established. This retrospective case series study was designed to examine the existence of a correlation between symptoms and reflux characteristics, based on data obtained from esophageal pH monitoring. METHODS: The study population consisted of 139 patients; 97 patients presented with laryngopharyngeal symptoms of GERD, including unexplained hoarseness, throat clearing, chronic cough, laryngospasm, globus, throat pain, and 42 patients presented with gastroenterologic symptoms, including heartburn and regurgitation. The results of 24-hour, double-channel ambulatory esophageal pH monitoring were analyzed comparing 2 symptom groups. The incidence of abnormal acid reflux at the upper and lower esophageal segments and the effects of upright and supine positions on reflux parameters were evaluated. RESULTS: The incidence of laryngopharyngeal reflux was significantly higher in the laryngopharyngeal symptom group than in the other (52% versus 38%). The patients with laryngopharyngeal reflux from both groups showed no significant differences in terms of number of acid reflux episodes, percentage of times pH was 4, and esophageal acid clearance. Upright and supine parameters did not show significant differences between the patient groups. Upright acid reflux episodes were, however, common in both groups at the lower esophageal and laryngopharyngeal segments. CONCLUSION: Recent studies suggesting that otolaryngologic patients commonly show upright, daytime reflux with normal esophageal clearance and that typical GERD patients commonly have supine, nocturnal reflux with prolonged esophageal clearance are not supported by this study. This study indicates that acid reflux parameters and positional changes are not sufficient to explain why patients with GERD experience different symptoms. The regional symptoms of GERD may be attributed to the impairment of epithelial resistance, motor activity, and buffering systems for the esophageal antireflux barrier.     

Objective analysis of gastroesophageal reflux after laparoscopic heller myotomy: An anti-reflux procedure is required

Background Controversy exists over the necessity of performing a concurrent antireflux procedure with a Heller myotomy. We therefore sought to objectively analyze gastroesophageal reflux following laparoscopic Heller myotomy where an antireflux procedure was not performed.Methods A prospective database of 66 cases of laparoscopic Heller myotomy performed between November 1996 and June 2002 was reviewed. Previous, concurrent, or subsequent fundoplication was performed in 12 patients; therefore 54 patients without antireflux procedures were available for analysis. Follow-up included symptomatic assessment in 50 patients (93%). Heartburn was assessed on a four-point scale with clinical significance defined as >2 episodes/week. Objective testing, including endoscopy, esophagogram, manometry, and 24-h pH monitoring, was offered to all patients. Objective evidence of reflux was defined as the composite endpoint of positive 24-h pH monitoring or esophagitis on endoscopy.Results Significant heartburn was reported in 15 of 50 patients (30%). Positive 24-h pH recordings were seen in 11 of 22 patients tested while esophagitis was seen in 13 of 21 patients tested, resulting in objective evidence of reflux in 18 of 30 patients tested (60%). Of these 18 patients, seven did not have significant heartburn. All 12 patients without objective reflux did not have significant heartburn. Therefore, of the 30 patients with objective testing, seven (23%) had objective reflux without subjective heartburn (silent reflux).Conclusion Objective analysis reveals an unacceptable rate of gastroesophageal reflux in laparoscopic Heller myotomy without an antireflux procedure. We therefore recommend performing a concurrent antireflux procedure.     

Outcomes of laparoscopic antireflux procedures

BACKGROUND: Laparoscopy has increased the number of patients undergoing operative correction of gastroesophageal reflux disease (GERD). Symptom improvement has been most commonly reported as the means to assess operative outcome. We compared symptomatic outcome to postoperative pH testing at short-term follow-up to determine the accuracy of clinical assessment at predicting whether acid exposure would be normal or abnormal. METHODS: Of 640 patients who had antireflux surgery between 1993 and 1999, 228 (36%) agreed to repeat manometry and 24-hour pH monitoring 8 to 12 weeks postoperatively and are the subject of this study. Symptom resolution was assumed if the frequency was less than once per week. Normal acid exposure consisted of a distal esophageal pH below 4 less than 4% of the time and a DeMeester composite score less than 14.7. Accuracy of symptom scoring was calculated using acid exposure as the standard.RESULTS: The primary symptom was improved in 93% of the 228 patients. Acid exposure was reduced from a preoperative DeMeester score of 71 to 16 (P <0.05). Eighty percent of patients had normalization of acid exposure postoperatively. Heartburn was the only symptom to have a significant correlation with acid exposure in the postoperative period (P <0.05). Heartburn resolved in 181 patients, 168 of whom had normal acid exposure (true negative). Thirty-eight patients without symptoms had abnormal acid exposure (false negative). Nine patients had persistent heartburn with abnormal acid exposure (true positive) whereas 13 patients had persistent heartburn with normal acid exposure (false positive). Thus, the positive predictive value of heartburn was 43%, the negative predictive value was 82%, and the overall accuracy was 78%. CONCLUSIONS: Operative treatment improves both the symptoms of GERD and the degree of acid exposure as measured by pH monitoring. The most accurate symptom for predicting acid exposure in the postoperative period is heartburn. Although the absence of heartburn postopertively is fairly reliable at predicting normal acid exposure on pH testing, the presence of heartburn warrants postoperative pH monitoring, as more than half of these patients will have normal acid exposure.     

Duodenogastric reflux and reflux esophagitis

Twenty-seven patients with gastroesophageal reflux were prospectively investigated to define the role of duodenogastric reflux in the development of reflux esophagitis. Duodenogastric reflux was detected and quantified by pH monitoring of the gastric environment 5 cm distal to the distal esophageal sphincter. Alkaline duodenogastric reflux was identified by the occurrence of spontaneous, intense gastric alkalinization during fasting periods. Patients with reflux with esophagitis were distinguished from those without esophagitis by having fewer of these episodes and, consequently, more acid stomachs than had patients without esophagitis. As previously shown, refluxers with esophagitis also had more frequent acid gastroesophageal reflux and prolonged gastric emptying. These findings suggest that refluxers with esophagitis have a functional gastropyloric disturbance resulting in delayed gastric emptying, decreased frequency of alkaline duodenogastric reflux episodes, and more frequent acid gastroesophageal reflux than do refluxers without esophagitis.     

Specificity and sensitivity of objective diagnosis of gastroesophageal reflux disease

To evaluate the diagnostic value of different tests for gastroesophageal reflux disease, a test population was constructed from 45 patients with symptoms of heartburn and regurgitation with or without esophagitis and 45 healthy subjects, who never experienced heartburn, regurgitation, or swallowing discomfort. The test population underwent esophagoscopy, standard acid reflux test, 24-hour pH monitoring, and manometry of the lower esophageal sphincter. Sensitivity, specificity, positive predictive value, negative predictive value, and the accuracy of the tests and test combinations were calculated. Esophagoscopy had a sensitivity of 62%, that is, only 62% of patients with the disease have evidence of mucosal damage on endoscopy. Manometric measurements of the lower esophageal sphincter had a sensitivity of 84%, a specificity of 89%, and an accuracy of 87%. Twenty-four hour esophageal pH monitoring had a sensitivity, specificity, and accuracy of 96%. The results show that 24-hour pH monitoring can detect gastroesophageal reflux disease with an accuracy of 96% by measuring an increase in esophageal acid exposure. Manometry of the lower esophageal sphincter can detect a mechanically deficient sphincter as a cause of the disease with an accuracy of 87%. The test combination of 24-hour monitoring and motility studies can select patients with an accuracy of 91% who have an increase in esophageal exposure to gastric juice because of a deficient cardia. Antireflux surgery is designed to reduce esophageal exposure to gastric juice in patients with a deficient sphincter by creating a mechanical antireflux mechanism at the cardia. Therefore it is necessary to determine the mechanical status of the sphincter with manometry before surgery in such patients. Thus the indications for antireflux surgery are (1) uncontrolled symptoms of increased esophageal exposure to gastric juice; (2) a documented increase in esophageal exposure to gastric juice by 24-hour pH monitoring; and (3) a mechanically defective sphincter on motility with a pressure of 6 mm Hg or less, an overall length of 2 cm or less, and an abdominal length of 1 cm or less.     

Gastroesophageal scintigraphy to assess the severity of gastroesophageal reflux disease.

Thirty-six (36) patients with symptomatic gastroesophageal reflux were studied. Symptoms of heartburn, regurgitation and dysphagia were scored as to their severity and compared to quantitative tests of gastroesophageal reflux. Patients were studied with the acid reflux test, fiberoptic endoscopy, esophageal mucosal biopsy with a pinch forceps, esophageal manometry and radioisotopic gastroesophageal scintigraphy. Symptoms were scored according to an arbitrary grading system as mild, moderate, or severe. There were significant correlations between symptoms scores and both the degree of endoscopic esophagitis and the gastroesophageal reflux indices as measured by the radioisotopic scintiscan, but not with the degree of histologic esophagitis or lower esophageal sphincter pressure. Review of the findings suggests the following profile for patients who might require antireflux surgery: severe symptoms, presence of endoscopic esophagitis; resting lower esophageal sphincter pressure below 10 mmHg; and gastroesophageal reflux index above 10%.     

Absence of gastroesophageal reflux disease in a majority of patients taking acid suppression medications after Nissen fundoplication

Recent studies have shown that many patients use acid suppression medications after antireflux surgery. The aim of this study was to determine the frequency of gastroesophageal reflux disease in a cohort of surgically treated patients with postoperative symptoms and a high prevalence of acid suppression medication use. The study group consisted of 86 patients who had symptoms following Nissen fundoplication that were sufficient to merit evaluation with 24-hour distal esophageal pH monitoring. All completed a detailed symptom questionnaire. The mean postoperative follow-up period was 28 months (median 18 months). Thirty-seven patients (43%) were taking acid suppression medications after fundoplication. Only 23% (20 of 86) of all the patients and only 24% (9 of 37) of those taking acid suppression medications had abnormal esophageal acid exposure on the 24-hour pH study. Heartburn and regurgitation were the only symptoms that were significantly associated with an abnormal pH study. Endoscopic assessment of the fundoplication was the most significant factor associated with an abnormal pH study. Multivariable logistic regression analysis showed that patients with a disrupted, abnormally positioned fundoplication had a 52.6 times increased risk of abnormal esophageal acid exposure. Most patients who use acid suppression medications after antireflux surgery do not have abnormal esophageal acid exposure, and the use of these medications is thus often inappropriate. Because of the limited predictive power of symptoms, objective evidence of reflux disease should be obtained before prescribing acid suppression medication for patients who have undergone antireflux surgery. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Ga., May 20–23, 2001.     

Laparoscopic antireflux surgery and its effect on cough in patients with gastroesophageal reflux disease

In addition to heartburn and regurgitation, cough is a frequent nonspecific complaint of patients with gastroesophageal reflux disease. The incidence of alternative etiologies for patients with chronic cough who are undergoing antireflux surgery is not known. To determine this, and the response of chronic cough to fundoplication, we performed a retrospective review of 129 patients with proven gastroesophageal reflux referred for surgical therapy. Chronic cough was present in 37 (29%) preoperatively. No differences were found in age, sex, or preoperative manometric findings between those with and without chronic cough. Patients with cough had a higher number of lower esophageal reflux events on preoperative 24-hour pH testing, and were more likely to have persistent dysphagia after surgery. Fifty-nine percent of patients with cough had an alternative etiology for cough, compared to 36% of those without cough. Of the common alternative etiologies, only a history of postnasal drip occurred more frequently in those with cough. Complete resolution of cough occurred in 24 patients (64%), with another 10 (27%) reporting significant improvement. The average cough score improved significantly regardless of which coexisting etiology the patients may have had. Additionally, heartburn and regurgitation were improved in 94% of all patients. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Ga., May 20–23, 2001 (oral presentation).     

Evaluation of gastroesophageal reflux disease

Patients with gastroesophageal reflux disease (GERD) may present with a variety of symptoms, including heartburn, regurgitation, dysphagia, chronic cough, laryngitis, or even asthma. Therefore, the clinical presentation of GERD varies among individuals and conversely symptoms not always correspond to the presence of actual reflux. For that reason, the diagnosis poses certain challenges to the physician. To overcome these challenges, a thorough clinical examination followed by objective functional testing could improve diagnostic accuracy. In addition, a proper evaluation of patients with GERD can help in identifying those who will likely benefit the most from an antireflux procedure. The diagnostic work-up of these patients should include: symptomatic evaluation, upper endoscopy, barium swallow, high-resolution manometry, and ambulatory pH monitoring. Once a proper diagnosis of GERD is achieved, antireflux surgery is an excellent option for patients with partial control of symptoms with medication, for patients who do not want to be on long-term medical treatment (compliance/cost), or when complications of medical treatment occur.     

Laparoscopic fundoplication for symptomatic but physiologic gastroesophageal reflux

Esophageal pH monitoring identifies some patients who have physiologic amounts of esophageal acid exposure but have a strong correlation between symptoms of esophageal reflux events. These patients with symptomatic physiologic reflux probably have enhanced sensory perception of reflux events and may be difficult to control with acid-suppressive therapy. Little is known about the role of fundoplication in such patients. Patients with no endoscopic evidence of gastroesophageal reflux disease and a normal 24-hour pH composite score (<22.4 in our laboratory), but a symptom index (SI = number of symptoms with pH <4/total number of symptoms) greater than 50% were offered laparoscopic fundoplication if acid-suppressive therapy was unsatisfactory. This group comprised 18 (4%) of 459 patients undergoing fundoplication at our institution. Heartburn, dysphagia, and reflux symptoms were scored on a scale of 0 to 10 with patients on and off medicine preoperatively, and at a mean of 7.2 months (range 1 to 32 months) postoperatively. The 18 patients with symptomatic physiologic reflux (6 males and 12 females) had heartburn as a major complaint. Preoperative response to proton pump inhibitors for heartburn was 72% and for all symptoms was 60%. The group had a mean pH composite score of 14 (range 4 to 22). The symptom used to calculate the symptom index was heartburn in 12 patients, regurgitation in three, chest pain in two, and cough in one. An average of 18 symptoms (range 2 to 56) were recorded. The mean symptom index was 82 % (range 50% to 100%). A Nissen fundoplication was performed in nine patients and a Toupet fundoplication in nine. Surgery was successful (>90%) in alleviating reflux symptoms in 14 patients and partially successful (>75%) in three of the remaining four patients. Gas bloat and dysphagia were seen in one patient each. Fundoplication is effective at relieving reflux symptoms in carefully selected patients with symptomatic physiologic reflux, with minimal side effects. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24, 200O (poster presentation).     

Computerized 24-hour ambulatory esophageal pH monitoring and esophagogastroduodenoscopy in the reflux patient. A comparative study.

Ambulatory 24-hour esophageal pH monitoring and esophagogastroduodenoscopy were performed in 72 patients with symptoms suggestive of gastroesophageal reflux. Additionally, 22 asymptomatic healthy volunteers underwent pH monitoring. In patients with classic reflux symptoms and endoscopic esophagitis, a mean of 5.41 minutes/hour of reflux below pH 4 was found compared to 0.70 minutes/hour in controls (p less than 0.0001). The mean number and duration of reflux events in this group were 1.51 events/hour and 4.0 minutes/event, compared with 0.31 events/hour and 2.26 minutes/event in volunteers (p less than 0.001, p less than 0.01). A new system for ambulatory esophageal pH monitoring is presented using a pH-sensitive radiotelemetry pill or a pH probe and computerized methods for ambulatory data collection, analysis, and storage. An overall sensitivity of 76% was obtained with a 91% selectivity for detection of acid reflux in 51 patients having classic symptoms of gastroesophageal reflux. Ambulatory pH monitoring was positive for acid reflux in seven of 11 patients with normal endoscopic findings. Conversely, eight of 12 patients with normal pH monitoring had endoscopic esophagitis. In 19 patients presenting with atypical symptoms or previous gastric surgery, endoscopic findings were normal in 15. Nine of these 15 were identified as acid refluxers by pH monitoring. A combined approach using both pH monitoring and endoscopy is warranted for maximal detection and quantification of disease. A clear clinical role for pH monitoring is seen in the early diagnosis of acid reflux, particularly in patients having normal endoscopic findings with nonspecific gastrointestinal complaints or previous gastric operations.     

Symptoms are a poor indicator of reflux status after fundoplication for gastroesophageal reflux disease: role of esophageal functions tests

BACKGROUND: If a patient develops foregut symptoms after a fundoplication, it is assumed that the operation has failed, and acid-reducing medications are often prescribed. Esophageal function tests (manometry and pH monitoring) are seldom performed early in the management of these patients. HYPOTHESIS: In patients who are symptomatic after fundoplication for gastroesophageal reflux disease, a symptom-based diagnosis is not accurate, and esophageal function tests should be performed routinely before starting acid-reducing medications. DESIGN: Prospective study. SETTING: University hospital.Patients and METHODS: One hundred twenty-four patients who developed foregut symptoms after laparoscopic fundoplication (average, 17 months postoperatively) underwent esophageal manometry and pH monitoring. Sixty-two patients (50%) were taking acid-reducing medications. MAIN OUTCOME MEASURES: Postoperative symptoms, use of antireflux medications, grade of esophagitis, esophageal motility, and DeMeester scores. RESULTS: Seventy-six (61%) of the 124 patients had normal esophageal acid exposure, while the acid exposure was abnormal in 48 patients (39%). Only 20 (32%) of the 62 patients who were taking acid-reducing medications had reflux postoperatively. Regurgitation was the only symptom that predicted abnormal reflux. CONCLUSIONS: These results show that (1) symptoms were due to reflux in 39% of patients only; (2) with the exception of regurgitation, symptoms were an unreliable index of the presence of reflux; and (3) 68% of patients who were taking acid-reducing medications postoperatively had a normal reflux status. Esophageal function tests should be performed early in the evaluation of patients after fundoplication to avoid improper and costly medical therapy.     

Interaction of lower esophageal sphincter pressure and length of sphincter in the abdomen as determinants of gastroesophageal competence

This study defines the components of distal esophageal sphincter function which predict gastroesophageal competence and examines the mechanisms by which three antireflux procedures restore competence to the cardia. In a prospective study, the reflux status of 391 patients was determined by 24 hour pH monitoring. Distal esophageal sphincter pressure and length of sphincter exposed to the positive pressure environment of the abdomen was measured by esophageal infusion manometry. Similar pre- and postoperative studies were performed in 45 patients who were randomized to three equal groups for the Hill, Belsey and Nissen antireflux procedures.Two hundred sixty-seven (68 percent) of the 391 patients had a positive 24 hour pH test. Competence of the cardia was related to pressure in the distal esophageal sphincter, to the length of sphincter in the abdomen and to an interaction between both (all p < 0.05). Thus, competence of the cardia requires an adequate pressure and length of sphincter in the abdomen. In determining competence, the pressure and length effects are not additive, but have an interacting relationship.Sphincter pressure and abdominal length are independently corrected by surgery. Restoration of competence requires increases in both. The gastric fundic wrap best augments distal esophageal sphincter pressure by application of normal functioning smooth muscle to the lower esophagus. Sphincter dynamics are normal after a wrap as the gastric fundus and distal esophageal sphincter share the functions of synchronous contraction and simultaneous relaxation on deglutition.