The Effect of Jejunal Meal Feeding on Gastroesophageal Reflux

Background: Postprandial gastric distention is frequently associated with transient lower esophageal sphincter relaxation and gastroesophageal reflux (GER). Since the role of nutrient perfusion into the jejunum in inducing GER is not well understood, we studied the effect of jejunal feeding on GER through a percutaneous gastrojejunal tube in patients with and without reflux esophagitis. Methods: Nine stroke patients with reflux esophagitis were fed through a percutaneous gastrojejunal tube with either a liquid meal (2 kcal/2 ml/min) or saline for 2 h randomly on 2 separate days. An esophageal pH probe was placed 5 cm above the gastroesophageal junction to detect acid reflux. Six stroke patients without esophagitis were enrolled as controls. Results: In both the patients with esophagitis and the controls, esophageal acid exposure (15.3% (4.9%-28.2%) versus 2.7% (0.0%-10.8%), P = 0.003; 5.9% (0.5%-6.7%) versus 0.0% (0.0%-1.5%), P = 0.01) and events of acid reflux (5 (1-16) versus 2 (0-8), P = 0.02; 12 (3-17) versus 1 (0-4), P = 0.02) were significantly greater during jejunal meal feeding than during saline infusion. Furthermore, in the reflux patients, but not in the controls, acid clearance time was also greater during jejunal meal feeding than during saline infusion (2.9 min (0.5-9.6 min) versus 0.7 min (0.0-4.3 min), P = 0.04). Conclusions: We therefore conclude that jejunal nutrient infusion without gastric distention can induce GER in both patients with reflux esophagitis and controls. This implies that GER induced by jejununal nutrients may in part explain the incapability of jejunal tube feeding to prevent gastropulmonary aspiration in patients at risk.     

Can percutaneous endoscopic jejunostomy prevent gastroesophageal reflux in patients with preexisting esophagitis?

OBJECTIVE: Percutaneous endoscopic jejunostomy has been used for preventing pulmonary aspiration arising from gastric contents by concomitant jejunal feeding and gastric decompression in susceptible patients. Our objective was to evaluate gastroesophageal reflux in patients with percutaneous endoscopic jejunostomy tube feeding. METHODS: Eight cerebrovascular accident patients with percutaneous endoscopic jejunostomy tube placement caused by reflux esophagitis with hematemesis, food regurgitation or vomiting, and/or recurrent aspiration pneumonia were tested for gastroesophageal reflux using 24-h esophageal pH monitoring during continuous jejunal liquid meal or saline infusion with concomitant gastric decompression. Twenty-four hour pH monitoring was also performed during intragastric feeding on a different day. RESULTS: During the liquid meal feeding period, percutaneous endoscopic jejunostomy feeding reduced esophageal acid exposure 46% [12.9% (4.9-28.2%) versus 24.0% (19.0-40.6%), p = 0.01], compared to intragastric feeding. However, in the period of the jejunal tube infusion, esophageal acid exposure was significantly lower during saline infusion than during meal infusion [3.2 (0.0%-10.8%) versus 12.9% (4.9-28.2%), p = 0.008]. CONCLUSION: Percutaneous endoscopic jejunostomy feeding reduced but did not eliminate gastroesophageal reflux, compared to intragastric feeding in patients with severe gastroesophageal reflux. However, gastroesophageal reflux during percutaneous jejunal feeding was associated with meal infusion. This might, in part, explain the failure of percutaneous endoscopic jejunostomy tube placement to prevent pulmonary aspiration.     

酸袋在反流性食管炎中作用的研究

目的 探讨酸袋在反流性食管炎中的作用.方法 应用胃食管反流病问卷(RDQ量表)和胃镜检查确诊15名健康者和24例反流性食管炎患者.使用4通道食管测压系统确定受试者下食管括约肌(LES)位置,将单通道pH电极置于LES远端下方1 cm处监测空腹pH值o.5 h,给予标准餐后继续监测pH值2 h,然后将探针移至LES近端上方5 cm处行24 h动态pH临测.结果 16例反流性食管炎患者(66.67%)与10名健康者(10/15)存在酸袋.反流性食管炎组较健康组酸袋出现时间早[11.00(4.25～17.00)min比30.00(15.50～54.25)min,P＜0.05]、平均pH值低[1.84(1.59～2.19)比2.32(1.96～2.71),P＜0.05].而餐前胃食管连接部平均pH值及酸袋持续时间差异无统计学意义.结论 反流性食管炎患者有异常食管酸反流,且酸袋出现时间早、平均pH值低,其食管黏膜损伤可能与此有关.     

Characteristics and frequency of transient relaxations of the lower esophageal sphincter in patients with reflux esophagitis

Electromyogram of the submental muscles, esophageal manometry, and pH studies were simultaneously performed in an unselected group of 12 patients with subjective and objective evidence of gastroesophageal reflux (GER) disease to determine the frequency of transient relaxation of the lower esophageal sphincter (LES) and mechanisms of GER. Findings from these patients were compared with data from 10 asymptomatic healthy volunteers. Recordings were obtained for 1 h in the fasting state and 3 h after a standard 850-kcal meal. Transient relaxation of the LES was the only mechanism of acid reflux in normal subjects and accounted for 73.0% of the episodes of acid reflux in patients with GER disease. In both normal subjects and patients with GER, a large number of transient relaxations were associated at their onset with an attenuated submental EMG complex, a small pharyngeal contraction, and an esophageal contraction. The incidences of these associated events were similar in the two study populations. The frequency of transient relaxation of the LES in patients with GER was identical to that of controls. The frequency did not differ even in 9 patients with GER disease who had endoscopic esophagitis. Thirty-six percent of transient relaxations in the normal subjects were accompanied by pH evidence of reflux, but in the GER patients with endoscopic esophagitis 65% of the transient LES relaxations resulted in a reflux event. Acid reflux at the moment of deep inspiration was the second most common mechanism of GER in our patients. Four patients who demonstrated this mechanism had hiatal hernias and more severe esophagitis than the rest of the group. Our findings confirm that transient relaxation of the LES is the major mechanism of GER in patients with reflux esophagitis. However, the similar frequency of this relaxation in GER patients and in healthy asymptomatic subjects suggests that factors other than transient LES relaxation play an important role in the pathogenesis of GER disease.     

小儿非心源性胸痛与胃食管反流的关系

目的了解小儿非心源性胸痛(NCCP)与胃食管反流(GER)的关系,探讨食管pH值监测在小儿NCCP诊断中的意义。方法对36例(病例组)诊断为NCCP并排除呼吸系统和胸部肌肉骨骼病变患儿进行24 h食管pH值监测,其中20例行胃镜检查。根据食管炎诊断标准,诊断为食管炎(食管炎组)11例,非食管炎(非食管炎组)9例。结果病例组24 h食管pH值<4、反流≥5 min、最长反流时间、酸性反流指数、Boix-Ochoa评分分别为(60±7)次、(2．44±0．74)次、(12．4±2．8)min、6．72±1．39、(24．6±3．9)分,对照组分别为(33±4)次、(0．35±0．11)次、(4．3±0．9) min、1．25±0．19、(7．7±0．9)分,两组比较差异有统计学意义(t分别=3．44、2．79、2．73、3．89、4．24, P均<0．01);以Boix-Ochoa评分>11．99为病理性GER诊断标准,病例组GER阳性为58．3％(21／36)。20例经胃镜检查的患者中诊断为食管炎为55．0％(11／20),其中GER阳性为81．8％(9／11);诊断为非食管炎为45．0％(9／20),其中GER阳性者为33．3％(3／9)。食管炎组反流≥5 min、酸性反流指数分别为(5．8±2．0)次、12．5±3．5,非食管炎组分别为(0．9±0．5)次、3．4±1．4,两组比较差异有统计学意义(Z分别=-2．400、-2．545,P均<0．05);食管炎组24 h食管pH值<4、最长反流时间、Boix-Ochoa评分分别为(73±11)次、(26±7)min、(41±10)分,非食管炎组分别为(34±11)次、(4±3)min、(14±5)分,两组比较差异有统计学意义(Z值分别为-2．926、-2．675、-2．584,P均<0．01)。结论GER是小儿NCCP的重要原因,食管pH值监测有助于小儿NCCP的病因诊断,并能指导治疗。     

Nonpropulsive Esophageal Contractions and Gastroesophageal Reflux

Nonpropulsive esophageal contractions radiologically described as tertiary contractions or "corkscrew" esophagus suggest the presence of an underlying motility disorder and may lead to impaired acid clearance. The goals of this study were to determine the prevalence and role of gastroesophageal reflux (GER) in patients with tertiary contractions. Thirty-five consecutive patients with spontaneous, repetitive, nonpropulsive esophageal contractions noted on esophagography were studied with endoscopy, infusion esophageal manometry, and 24-h ambulatory pH monitoring. All patients had esophageal symptoms, mainly dysphagia, heartburn, and chest pain, but only three were found to have esophagitis by endoscopy and biopsy. Nineteen patients had repetitive, nonlumen-obliterating, nonperistaltic (tertiary) contractions, six had corkscrew esophagus, and 10 had forceful, lumen-obliterating simultaneous contractions (rosary bead esophagus). Twenty patients (58%) had GER by pH criteria with mean values: % time pH less than 4, 40.9; %upright pH less than 4, 41; %supine pH less than 4, 44.3%; number of episodes with greater than 5 min of pH less than 4, 12. Esophageal motility revealed "nutcracker" esophagus in eight, low LESP in two, and nonspecific esophageal motility disorder in 10. Symptoms or severity of nonperistaltic contractions did not correlate with GER. Radiologically demonstrable free reflux or the presence of heartburn did not predict GER. We conclude that 1) GER occurs in up to 58% of patients with nonpropulsive (tertiary) esophageal contractions on esophagography, and may play a role in the induction of abnormal peristaltic activity of the esophageal body; 2) GER is usually not associated with endoscopic evidence of esophagitis or characteristic symptoms, and is recognized by 24-h pH monitoring. We speculate that detection and treatment of GER may improve the symptomatic management of patients with nonpropulsive esophageal contractions.     

Healing of severe reflux esophagitis with PPI does not improve esophageal dysmotility

Esophageal dysmotility is frequently associated with gastroesophageal reflux disease (GERD). The aim of this study was to investigate the relationship between the severity of reflux esophagitis and esophageal dysmotility and evaluate the effect of prolonged treatment with proton pump inhibitor (lansoprazole 30 mg/day) on esophageal motility in patients with severe reflux esophagitis associated with esophageal motility disorder. Twelve healthy subjects (HS) and 100 patients with reflux disease were involved in the study consisting of two parts: (i) comparison of esophageal motility in HS and patients with non-eroseive reflux disease (NERD), mild esophagitis and severe esophagitis; (ii) effect of 3-6 months lansoprazole therapy on esophageal motility in 23 patients with severe esophagitis, pathologic acid reflux and esophageal peristaltic dysfunction. Results included the following. (i) Esophageal dysmotility was noted in both patients with NERD and erosive GERD. (ii) Severe esophagitis was associated with severe esophageal dysmotility. (iii) Healing of severe esophagitis did not improve esophageal dysmotility. The resting lower esophageal sphincter pressure was 3.9 mmHg (range 1.7-20) before treatment and 4.8 mmHg (range 1.2-18.3) after esophagitis healing (P = 0.23, vs. before treatment), the amplitude of distal esophageal contraction was 28.8 mmHg (range 10.9-80.6) before treatment and 33.3 mmHg (range 10.0-72.5) after esophagitis healing (P = 0.59, vs. before treatment) and the frequency of failed peristalsis was 70% (range 0-100%) before treatment and 70% (range 0-100%) after esophagitis healing (P = 0.78, vs. before treatment). Both esophageal motility disorders and acid reflux play important roles in the mechanism of GERD, especially in severe esophagitis. Esophageal dysmotility is not secondary to acid reflux and esophagitis; it should be a primary motility disorder.     

Ambulatory Esophageal pH Recording in Gastroesophageal Reflux: Relevance to the Development of Esophagitis

In a group of 60 patients with symptomatic gastroesophageal reflux (GER), we carried out upper gastrointestinal (GI) endoscopy and 24-h ambulatory esophageal pH monitoring to assess the relationship between acid reflux and esophagitis. The results of 24-h pH measurement were compared with those of 15 asymptomatic control subjects who were studied with ambulatory 24-h esophageal pH monitoring only. Thirty-two patients (53.3%) had a normal esophagus macroscopically, and 28 patients (46.7%) had some degree of esophagitis. There was no significant difference between the two groups with and without esophagitis, regarding male:female ratio, age, and duration of symptoms. The group with esophagitis was more symptomatic (p less than 0.001) than the group without, and differed significantly in relation to all pH variables, i.e., number of GER episodes per hour, duration of mucosal exposure to acid (pH less than 4), and number of GER episodes requiring more than 5 min to clear per hour for the upright, supine, and 24-h periods, compared with the control group (p less than 0.001) and the group without esophagitis (p less than 0.001). In the group with esophagitis, comparison of the above pH variables in the upright and supine periods showed significantly higher values in the upright than in the supine period for the total number of reflux episodes per hour (p less than 0.001) and the number of episodes greater than 5 min/h (p less than 0.05). We conclude that the presence of esophagitis is related to both frequency and duration of GER episodes. Our findings also stress the importance of daytime acid exposure in the pathogenesis of esophagitis.     

Mechanisms of Acid Gastroesophageal Reflux in the Japanese Population

In contrast to Western countries, reflux esophagitis is considered to be less common in the Orient, including Japan. Transient LES relaxation (TLESR) is a major mechanism of gastroesophageal reflux (GER); however, there are no data on the mechanisms of GER in Japanese people. In addition, it is unclear whether or not the rate of TLESRs, in the sitting position, is higher in reflux esophagitis patients than in healthy subjects. The aim of this study is to determine the mechanisms of acid reflux and the rate of TLESRs, and to compare the rate of acid reflux during TLESRs between healthy volunteers and patients with reflux esophagitis in Japan. Preprandial and postprandial esophageal manometry and pH monitoring were performed in the sitting position in ten healthy volunteers and ten patients with reflux esophagitis of Los Angeles grade C. The energy level of the meal was 692 kcal and consisted of 33% fat. In healthy volunteers, 100% (median) of the acid reflux episodes occurred during TLESRs compared with 55.0% in patients with esophagitis. The remaining reflux episodes in the esophagitis patients were related to straining (12.8%) and absent basal LES pressure (19.5%). The rate of TLESRs in patients with esophagitis was 4.7 h⁻¹ (3.3–5.7) [median, (interquartile range)] and did not vary significantly from that in healthy volunteers [5.0 h⁻¹ (4.3–6.3)] 3 h postprandially. The rate of acid reflux during TLESRs in patients with esophagitis (42.7%, median) 3 h postprandially was significantly higher than in healthy volunteers (9.2%). In Japan, the mechanisms of GER in both groups are similar to those reported in Western countries. The rate of acid reflux during TLESRs in patients with reflux esophagitis is significantly higher than in healthy volunteers; however, compared to rates reported in Western countries these rates are very low for both groups.     

Gastric emptying in infants with gastroesophageal reflux. Ultrasound evaluation before and after cisapride administration.

The present study aimed to evaluate gastric emptying in children with gastroesophageal reflux (GER) by means of real-time ultrasonography, on the basis of measurements of the cross-sectional area of the gastric antrum. Twelve children with GER were studied (seven males, five females; age range, 3-13 months) and compared with 12 normal control children (six males, six females; age range, 3-13 months). The diagnosis of GER was confirmed by 24-h esophageal pH-monitoring. The GER patients had a significantly greater antral area than the controls at 90, 105, and 120 min after eating a standard meal (cow's milk formula, 300 ml/m2 body surface area); in addition, final gastric emptying time was significantly greater in the patients than in the controls (145 +/- 36.9 versus 78.7 +/- 19.3 min; p less than 0.0025). After 8 weeks of treatment with cisapride (0.3 ml/kg, three times a day) 24-h esophageal pH-monitoring and ultrasonography studies were repeated in the patients. The total percentage reflux time was significantly lower (p less than 0.038), and ultrasonography showed a decreased antral area at all the various study times, with no significant difference between patients and controls; final gastric emptying time was also significantly lower than before treatment (p less than 0.009). Furthermore, in the GER patients there was a significant correlation between gastric emptying time and the sum of the various reflux times recorded in the 2 h after all meals over the 24 h.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical analysis of gastroesophageal reflux after PEG

BACKGROUND: It is difficult to predict whether or not gastroesophageal reflux (GER), such as aspiration or vomiting, will occur after PEG. OBJECTIVE: To identify factors that would support the prediction of aspiration after PEG. DESIGN: Case-control study. SETTING: Patients who underwent PEG from February 1998 to June 2005 in our hospital. PATIENTS: The study included 178 patients. INTERVENTIONS: Endoscopic observation was carried out during PEG tube placement and at PEG tube replacement to determine the presence of hiatus hernia and/or reflux esophagitis. MAIN OUTCOME MEASUREMENTS: Gastric emptying and GER index (GERI) were measured by using a radioisotope technique. RESULTS: The patients were divided into 2 groups: the non-GER (NGER) group (n = 108), who had no symptoms of GER, and the GER group (n = 70), who showed these symptoms. No significant differences were observed between the groups in age, sex, morbidity, the presence of reflux esophagitis at PEG tube placement, gastric emptying, or serum albumin levels. The presence of a hiatus hernia (P = .028) and reflux esophagitis grading Los Angeles classification C or D (P = .008) were significantly more frequent in the GER group compared with the NGER group. The GERI was also significantly higher in the GER group than in the NGER group (P < .0001). CONCLUSIONS: The presence of hiatus hernia, severe reflux esophagitis, and a high GERI might be predictive factors of aspiration or vomiting after PEG tube placement.     

Pathogenetic factors affecting gastroesophageal reflux in patients with esophagitis and concomitant duodenal ulcer: a multivariate analysis

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Relevance of ineffective esophageal motility and hyperactive acid sensitization in patients with gastroesophageal reflux

BACKGROUND AND AIM: Esophageal motor abnormalities including ineffective esophageal motility (IEM) and visceral hypersensitivity have been frequently observed in patients with gastroesophageal reflux. The aim of this study was to observe the incidences of hypersensitivity to acid infusion and motor abnormalities in non-erosive reflux disease (NERD) compared with erosive esophagitis. METHODS: We performed upper GI endoscopy, an acid perfusion test and esophageal manometry on 113 NERD patients and 37 erosive esophagitis patients. RESULTS: The frequency of acid sensitization was 69.9% in NERD and 67.6% in erosive esophagitis. The frequency of esophageal motor abnormality in patients with erosive esophagitis (48.6%) was higher than in patients with NERD (25.7%, P = 0.014). The most frequent esophageal motor abnormality was IEM. The frequency of IEM was 15.9% in NERD patients, 42.9% in Los Angeles grade A, 53.8% in Los Angeles grade B and 66.7% in Los Angeles grade C esophagitis (chi(2) = 16.67, P < 0.0001). CONCLUSION: Our results suggest that no difference exists between visceral hypersensitivity in patients with NERD and those with erosive esophagitis, and that IEM occurs in NERD as well as erosive esophagitis patients. The occurrence of IEM is associated with the endoscopic severity of gastroesophageal reflux disease.     

The Effect of Hiatal Hernia on Gastroesophageal Reflux Disease and Influence on Proximal and Distal Esophageal Reflux

Introduction Gastroesophageal reflux disease (GERD) is a very common disorder that substantially affects the patient's quality of life. Aim Our aim was to detect the frequency of GERD in patients with hiatal hernia (HH), to compare the acid reflux pattern in patients with and without HH, and to search the relationship between the erosive gastroesophageal reflux (GER) and HH. Methods Forty patients with HH diagnosed by at least two methods, and 121 patients with GERD as a control group were studied. The frequency of GERD in patients with HH, the acid reflux pattern, the relation of body mass index and erosive esophagitis with HH and control group was studied. Results Among patients with HH 67.5% of patients had GER. On comparison of acid reflux pattern, the isolated distal esophageal reflux was seen more in patients with HH than in the control group (P < 0.0001). Erosive GERD was seen more in patients with HH than in the control group (P = 0.017). There was no difference in body mass indices between patients with HH and erosive gastroesopahgeal reflux disease and patients with HH and nonerosive GERD. Conclusion Hiatal hernia is very closely associated with GERD, and isolated distal esophageal reflux is seen more in patients with HH than in patients without HH. There is no effect of body mass index on GER in patients with HH.     

Identification of an abnormal esophageal clearance response to intraluminal distention in patients with esophagitis.

Esophageal clearance responses were studied by a new technique comprising a miniature electronic strain gauge attached to an inflatable balloon in 30 normal volunteers and 48 patients with gastroesophageal reflux disease. The pressure changes around the balloon and traction forces acting on the balloon were measured during graded balloon distention (0-12 mL of air for 30 seconds each inflation) in the lower and midesophagus. All normal volunteers responded to distention with development of swallow independent contractions above the balloon [65 mm Hg/30 s (range, 45-100 mm Hg/30 s)] together with generation of an aboral traction force [15 g (range, 9-20 g)]. Patients with reflux esophagitis showed a higher distention threshold for initiation of these responses, induced fewer proximal contractions [24 mm Hg/30 s (range, 0-38 mm Hg/30 s); P less than 0.01 vs. normal], and generated weaker traction forces [4 g (range, 0-6 g) at 10 mL P less than 0.01 vs. normal]. Patients with the most severe esophagitis showed greatest impairment of the clearance response (correlation = 0.7, P less than 0.01) and the greatest esophageal residence of refluxed acid (correlation = 0.5, P less than 0.01). These abnormalities appear to be of relevance to the pathophysiology of esophageal reflux disease although it remains to be determined whether they are the cause, or the result, of the esophagitis.     

Gastric emptying of solids in gastroesophageal reflux

Delayed gastric emptying has been assumed to play an important role in the pathogenesis of gastroesophageal reflux (GER), even though this relationship has not been definitely established. Eleven patients with symptomatic GER were studied by esophageal manometry, endoscopy, gastroesophageal scintiscanning and gastric emptying of a mixed meal. Nine healthy subjects served as controls. Gastric emptying of solids (evaluated both as emptying half-time and emptying index) in GER patients was significantly slower than in controls. In comparison with a "normal" range previously established in 50 healthy subjects, only 2 of 11 (18.2 p. 100) of GER patients had a normal emptying rate. In addition, a significant correlation was found between the emptying half-time and the degree of esophageal lesions. These results suggest that impaired motor function of the gastric antrum could influence the natural history of GER disease and especially the appearance of esophagitis. The lack of esophageal lesions in the only two patients with "normal" emptying strongly supports this hypothesis.     

Esophageal striated muscle contractions in patients with gastroesophageal reflux symptoms

Although there are studies showing that the amplitude of contraction in the distal esophageal body may be lower in gastroesophageal reflux (GER) disease than in asymptomatic subjects, there are no data about proximal striated muscle contraction in this disease. We studied the esophageal contraction 2 or 3 cm below the upper esophageal sphincter in response to swallowing a 5-ml bolus of water in 122 consecutive patients submitted to esophageal manometry who complained of heartburn and acid regurgitation. Sixty-nine had esophagitis seen at endoscopy. Thirty-three also complained of dysphagia. No patients had esophageal stenosis, esophageal motility abnormalities in distal esophagus, chest pain, or extraesophageal manifestations of GER. We also studied 20 patients with systemic sclerosis (SSc), a disease with no involvement of striated muscle. When we measured the amplitude, duration, and area under the curve (AUC) of the proximal esophageal contraction, we did not find any differences (P > 0.05) between patients with esophagitis (N = 69) or without esophagitis (N = 53), with dysphagia (N = 33) or without dysphagia (N = 89), with mild (N = 55) or severe (N = 14) esophagitis, or younger than 40 years (N = 45) or older than 60 years (N = 19). There was also no difference between patients with GER symptoms and patients with SSc (P > 0.05). We conclude that patients with GER symptoms with or without esophagitis and with or without dysphagia have similar esophageal striated muscle contractions.     

Effect of hiatal hernia on esophageal manometry and pH-metry in gastroesophageal reflux disease

An increased frequency of reflux events and a prolonged acid clearance have been shown in gastroesophageal reflux (GER) patients with a hiatal hernia as compared to those without. The objective of the present study was to further investigate esophageal motility and patterns of reflux in GER patients, in relation to the presence or absence of hiatal hernia. Esophageal manometry and ambulatory 24-hr esophageal pH-metry were used in 42 patients with GER and 18 controls. Eighteen of the patients were considered to have a nonreducing hiatal hernia on endoscopy. Hiatal hernia patients showed a higher extent of reflux (total composite score,P=0.016; total reflux time,P=0.008, reflux time in supine position,P=0.024; reflux time in upright position,P=0.008), a lower frequency of reflux events (P=0.005), a more severe esophagitis on endoscopy (P<0.01) and a lower amplitude of peristalsis at 5 cm proximal to LES (P=0.0009) as compared to patients without hiatal hernia. The amplitude of peristalsis at the distal esophagus was inversely related to the extent of reflux (P=0.024). Acid clearance was also significantly prolonged in the hernia subgroup (P=0.011). Although LES resting pressure did not differ significantly between the two subgroups of patients, it was inversely related to the extent of reflux in the patients with hiatal hernia (P=0.0005). It is concluded, that GER patients with hiatal hernia present with an increased amount of reflux and more severe esophagitis, which results in more severely impaired esophageal peristalsis as compared to patients without hernia. Prolonged acid clearance and impaired esophageal emptying observed in patients with hiatal hernia could be the result of both the presence of the hernia itself and the reduced peristaltic activity of the esophagus.     

Evaluation of gastroesophageal reflux as a cause of idiopathic hoarseness

Eleven patients presenting to an ear, nose, and throat specialist were diagnosed as having idiopathic hoarseness and prospectively evaluated for evidence of gastroesophageal reflux (GER) to determine if an association existed. Testing for GER included voice analysis, EGD, esophageal manometry, Bernstein test, and ambulatory 24-hr pH monitoring. Six of the 11 (55%) hoarse patients studied had GER by pH monitoring (mean score 105 +/- 23), and most reflux episodes were supine and prolonged (20.9 +/- 8.2% supine pH less than 4.0, longest 129 min). All patients with abnormal pH monitoring had endoscopic esophagitis (Barrett's esophagus in two, peptic stricture in one, and erosive esophagitis in three), while none of the patients with normal scores had esophagitis. Symptoms of throat pain or nocturnal heartburn were more common in the GER-positive patients (6 of 6 vs 1 of 5), and clinically helpful in discriminating which hoarse patients had pathologic GER. Treatment with ranitidine 150 mg per os twice a day for 12 weeks improved esophagitis in all patients, but the voice improved in only one of the two patients with completely healed esophagitis. This study suggests that (1) GER is frequently seen in patients with idiopathic hoarseness (55%), (2) hoarse patients with throat pain or nocturnal heartburn are likely to have severe esophagitis and should be evaluated by EGD, and (3) additional antireflux and voice therapy may be necessary to heal esophagitis and improve the voice.     

The acid perfusion test in gastroesophageal reflux disease

An acid perfusion test, isotope scanning, endoscopy, and esophageal biopsy were performed in 101 patients with symptoms strongly suggestive of gastroesophageal reflux (GER) disease. A positive acid perfusion test within 30 min (APT) and within 5 min (TAPT) was found in 70.2% and 37.6% of the patients, respectively. A positive APT was found significantly more often in patients with than without endoscopic esophagitis, whereas a positive TAPT was found significantly more often in patients with severe symptoms than in patients with moderate symptoms and in a significantly higher proportion of patients with than without GER by scintigraphy. Neither the APT nor the TAPT showed any dependency on the presence of histologic esophagitis. Most (97%) patients with a negative acid perfusion test, in addition to typical symptoms, also presented with scintigraphic, endoscopic, or histologic evidence of GER disease. Although it shows that the acid perfusion test, particularly when early positive, may serve as a weak predictor of the severity of GER disease, the present study gives little support to the test's clinical usefulness.