Comparison of one-week and two-week empirical trial with a high-dose rabeprazole in non-cardiac chest pain patients

Background:  In patients with non-cardiac chest pain (NCCP), the optimal duration of an empirical trial with a high-dose proton pump inhibitor (PPI) is unclear. We aimed to compare the efficacy of one-week and two-week PPI trial in patients with weekly or more than weekly NCCP and to determine its optimal duration for diagnosing gastroesophageal reflux disease (GERD)-related NCCP.
Methods:  Forty-two patients with at least weekly NCCP were enrolled. The baseline symptoms were assessed using a daily symptom diary for seven days. Also, esophago-gastro-duodenoscopy and 24 h esophageal pH monitoring were performed for the diagnosis of GERD. Then, patients were treated with rabeprazole 20 mg twice daily for 14 days. To assess NCCP improvement during the PPI trial, the first week and the second week symptom diary were kept for 1–7 and 8–14 days. The PPI test was considered positive if a symptom score improved (50% compared to the baseline.
Results:  There was no significant difference for a positive PPI test between GERD-related NCCP group ( n  = 8, 50%) and non GERD-related NCCP group ( n  = 6, 23%) during the first week of the PPI test. However, during the second week, GERD-related NCCP had a higher positive PPI test ( n  = 13, 81%) than non GERD-related NCCP ( n  = 7, 27%) ( P  = 0.001) with a sensitivity and specificity of 81% and 62%, respectively.
Conclusions:  The rabeprazole empirical trial was diagnostic for patients with GERD-related NCCP, and its optimal duration was determined to be at least two weeks.     

食管混合性酸反流和低动力在非心源性胸痛发作的作用研究

目的胃食管反流病（GERD）是引起非心源性胸痛（NCCP）的最常见因素,本研究探讨酸反流和食管动力障碍在NCCP患者中的作用。 方法按照纳入、排除标准选取2018年9月至2019年6月在新疆维吾尔自治区人民医院急救中心以及微创,疝和腹壁外科住院收治的40例NCCP患者和50例典型GERD症状患者,两组患者均行食管24 h pH监测以及高分辨率食管测压监测。 结果NCCP组食管远端收缩平均积分（DCI）明显低于GERD组,并具有统计学意义（P＜0.05）,提示食管运动功能受损。在NCCP组患者中,与胸痛有关的混合性酸反流明显高于GERD组（P＜0.05）。在NCCP组患者中,与NCCP相关的反流发作在食管5、9和15cm处的反流清除时间比GERD组患者期长（28.3±4.21)s vs(22.6±3.28)s;(13.7±1.32)s vs (18.3±1.47)s;(9.58±1.02)s vs(14.3±1.06)s（P＜0.05）。 结论酸反流性质,食管运动功能受损和延缓反流清除时间与NCCP患者症状发作可能存在密切的关系。     

胃食管反流病相关非心源性胸痛患者食道患病率调查研究

ObjectiveTo investigate the prevalence and clinical characteristics of esophagus in patients with non-cardiac chest pain (NCCP). MethodsPatients who diagnosed with NCCP from January 2018 to April 2019 in Xinjiang Uygur Autonomous Region People's Hospital were selected as the study subjects. Detailed medical history, physical examination, upper gastrointestinal endoscopy, high resolution esophageal manometry and 24 h dynamic esophageal pH monitoring were performed on all subjects. ResultsThe total number of subjects was 85, of which male 45(52.94%), with an average age of 41.2±12.4 years;female was 40 (47.06%), with an average age of 43.3±10.9 years. The most common symptoms in NCCP patients were acid reflux 43.53%, dysphagia 31.76%, heartburn 24.71%. Endoscopic abnormalities of upper gastrointestinal tract accounted for 31.76%, esophageal manometry abnormalities accounted for 67.06%, and dynamic pH monitoring abnormalities accounted for 34.76%. The prevalence of GERD was 42.36% determined by upper gastrointestinal endoscopy combined with 24 h pH monitoring. According to manometric results, ineffective esophageal motility in 23.53% of NCCP patients was the most common cause of NCCP. ConclusionBy analyzing the causes of esophagogenous NCCP, it is helpful for clinicians to exclude other high-risk factors leading to chest pain and to provide appropriate treatment for their diagnosis and treatment     

Evaluation of symptom index in identifying gastroesophageal reflux disease-related noncardiac chest pain

BACKGROUND: Symptom index (SI), which represents the percentage of perceived gastroesophageal reflux-related symptoms that correlate with esophageal acid reflux events (pH <4), has been suggested as a measure to improve diagnosis of gastroesophageal reflux (GER)-related noncardiac chest pain (NCCP). Because no study has evaluated the value of the symptom index in NCCP patients, data to support this claim have yet to be elucidated. AIM: To evaluate the value of SI in identifying gastroesophageal reflux disease (GERD)-related NCCP patients. METHODS: Patients enrolled in this study were referred by a cardiologist after a comprehensive work-up excluded a cardiac cause for their chest pain. All patients underwent upper endoscopy to determine esophageal inflammation and 24-hour esophageal pH monitoring to assess esophageal acid exposure. Patients were instructed to record all chest pain episodes during the pH test. Patients with a positive SI (> or =50%) underwent the proton pump inhibitors (PPI) test, which is a therapeutic trial using a short course of high dose PPI. RESULTS: A total of 94 patients with NCCP were included in this study. Forty-seven (50%) had either a positive upper endoscopy or an abnormal pH test and were considered GERD-Positive. Forty-seven patients (50%) had both tests negative and were considered GERD-Negative. Total number of reflux episodes and percent total, supine and upright time pH less than 4, were significantly higher in the GERD-Positive group as compared with the GERD-Negative group (P < 0.0001, P < 0.0001, P = 0.0045, and P < 0.0001 respectively). Only 9 (19.1%) patients in the GERD-Positive group and 5 (10.6%) patients in the GERD-Negative group had a positive SI (p = ns). Eight (89%) out of the 9 patients who had a positive SI in the GERD-Positive group and 2 (40%) out of 5 patients in the GERD-Negative group responded to the PPI test. CONCLUSION: Positive SI is relatively uncommon in NCCP patients, regardless if GERD is present or absent. Hence, symptom index provides very little improvement in diagnosing GERD-related NCCP.     

Is ineffective esophageal motility gastropharyngeal reflux disease？

AIM： TO evaluate the association between IEM and gastropharyngeal reflux disease （GPRD） in patients who underwent ambulatory 24-h dual-probe pH monitoring for the evaluation of supraesophageal symptoms.
METHODS： A total of 632 patients who underwent endoscopy, esophageal manometry and ambulatory 24-h dual-pH monitoring due to supraesophageal symptoms （e.g. globus, hoarseness, or cough） were enrolled. Of them, we selected the patients who had normal esophageal motility and IEM. The endoscopy and ambulatory pH monitoring findings were compared between the two groups.
RESULTS;： A total of 264 patients with normal esophageal motility and 195 patients with the diagnosis of IEM were included in this study. There was no difference in the frequency of reflux esophagitis and hiatal hernia between the two groups. All the variables showing gastroesophageal reflux and gastropharyngeal reflux were not different between the two groups. The frequency of GERD and GPRD, as defined by ambulatory pH monitoring, was not different between the two groups.
CONCLUSION： There was no association between IEM and GPRD as well as between IEM and GERD. IEM alone cannot be considered as a definitive marker for reflux disease.     

Clinically distinct characteristics in patients younger than 40 years old with non-cardiac chest pain

Background and Aim: Little is known about non‐cardiac chest pain (NCCP) in young patients. We aimed to examine the proportion of gastroesophageal reflux disease (GERD) in young patients with NCCP compared to the average‐aged NCCP patients and to evaluate their symptomatic characteristics and the clinical efficacy of a 2‐week proton pump inhibitor (PPI) trial. Methods: Ninety‐six patients with NCCP ≥ 1/week were classified into the young‐aged (≤ 40 years, n = 38) and the average‐aged groups (> 40 years, n = 58). Typical reflux symptoms were assessed. The patients were defined into a GERD group and non‐GERD group according to reflux esophagitis on esophagogastroduodenoscopy and/or pathologic acid exposure on 24‐h esophageal pH monitoring. Then the patients were treated with 30 mg of lansoprazole bid for 14 days. Results: Nine patients (23%) in the young‐aged group and 22 patients (38%) in average‐aged group were diagnosed with GERD‐related NCCP (P = 0.144). The proportion of typical reflux symptoms was higher in the GERD group compared with the non‐GERD group in both age groups. A PPI test improved symptoms in the GERD group irrespective of age, but this improvement was not observed in non‐GERD group. Conclusions: In young NCCP patients, the prevalence of GERD was relatively low compared to average‐aged NCCP, but the difference was insignificant. The PPI test was very effective in diagnosing GERD in the NCCP patients in both age groups. Therefore, in young NCCP patients, if there is a negative response to a 2‐week PPI trial, the possibility of extra‐esophageal disease origin needs to be considered.     

Recent advances in noncardiac chest pain in Korea

Gastroesophageal reflux disease (GERD) is the most common cause of noncardiac chest pain (NCCP) and is present in up to 60% of patients with NCCP in Western countries. In Korea, after a reasonable cardiac evaluation, GERD is reported to underlie 41% of NCCP cases. Typical reflux symptoms are frequent in Korean patients suffering from NCCP. Therefore, a careful history of the predominant symptoms, including heartburn and acid regurgitation, is relatively indicative of the GERD diagnosis in Korea. In Korea, in contrast to Western countries, patients aged 40 years and over who have been diagnosed with NCCP but who are without alarming features should undergo endoscopy to exclude gastric cancer or peptic ulcers because of the higher prevalence of peptic ulcer disease and gastric cancers in the region. In a primary care setting, in the absence of any alarming symptoms, a symptomatic response to a trial of a proton pump inhibitor (PPI) is sufficient for the presumptive diagnosis of GERD. In addition, the optimal duration of a PPI test may be at least 2 weeks, as GERD symptoms tend to be less frequent or atypical in Korean patients than in patients from Western countries. In patients diagnosed with GERD-related NCCP, long-term therapy (more than 2 months) with double the standard dose of a PPI is required to alleviate symptoms. Esophageal dysmotility is relatively uncommon, and pain modulators seem to offer significant improvement of chest pain control in non-GERD-related NCCP. Most traditionally available tricyclics or heterocyclics have many undesirable effects. Therefore, newer drugs with fewer side effects (for example, the serotonin - norepinephrine reuptake inhibitors) may be needed.     

老年人反流性食管炎食管外表现与酸反流的关系

目的 探讨老年人反流性食管炎(reflux esophagitis,RE)食管外表现与酸反流的关系.方法 选择经胃镜检查证实为RE老年患者69例,入选者均有胃灼热、反酸等胃食管反流症状及咳嗽、喉炎,哮喘等食管外症状.对所有患者行24 h食管pH值监测,根据监测结果将患者分为中重度病理性酸反流组(中重度组)40例和轻度病理性酸反流组(轻度组)29例.两组均给予口服埃索美拉唑治疗(20 mg,3次/d),疗程8周,观察治疗后症状改善情况. 结果酸反流中重组食管外症状总积分(14.4±2.71)分.明显高于酸反流轻度组(8.2±2.0)分,经埃索美拉唑治疗后,两组患者食管外症状比治疗前均有好转,治疗后中重度组食管外症状总积分为(12.2±1.9)分,较治疗前明显改善(P<0.01). 结论老年RE患者的食管外症状与酸反流显著相关.老年患者因慢性咳嗽、慢性喉炎及哮喘长期就诊而治疗效果不佳时,应详细询问病史,考虑到GERD的可能性,尽早行胃镜及24 h食管pH监测,以明确诊断,尽早治疗.     

Noncardiac chest pain

Noncardiac chest pain (NCCP) affects approximately 1 quarter of the adult population in the United States. The pathophysiology of the disorder remains to be fully elucidated. Identified underlying mechanisms for esophageal pain include gastroesophageal reflux disease (GERD), esophageal dysmotility, and visceral hypersensitivity. Aggressive antireflux treatment has been the main therapeutic strategy for GERD-related NCCP. NCCP patients with or without spastic esophageal motor disorders are responsive to pain modulators. The value of botulinum toxin injection, endoscopic treatment for GERD, and antireflux surgery in alleviating NCCP symptoms is limited.     

Prevalence of upper gastrointestinal tract findings in patients with noncardiac chest pain versus those with gastroesophageal reflux disease (GERD)-related symptoms: results from a national endoscopic database

BACKGROUND: Available data on the prevalence of esophageal and upper gut findings in patients with noncardiac chest pain (NCCP) are scarce and limited to one center's experience. AIM: To determine the prevalence of esophageal and upper gut mucosal findings in patients undergoing upper endoscopy for NCCP only versus those with gastroesophageal reflux disease (GERD) symptoms only, using the national Clinical Outcomes Research Initiative (CORI) database. METHODS: During the study period, the CORI database received endoscopic reports from a network of 76 community, university, and Veteran Administration Health Care System (VAHCS)/military practice sites. All adult patients who underwent an upper endoscopy for NCCP only or GERD-related symptoms only were identified. Demographic characteristics and prevalence of endoscopic findings were compared between the two groups. RESULTS: A total of 3,688 consecutive patients undergoing an upper endoscopy for NCCP and 32,981 for GERD were identified. Normal upper endoscopy was noted in 44.1% of NCCP patients versus 38.8% of those with GERD (P<0.0001). Of the NCCP group, 28.6% had a hiatal hernia (HH), 19.4% erosive esophagitis (EE), 4.4% Barrett's esophagus (BE), and 3.6% stricture/stenosis. However, HH, EE, and BE were significantly more common in the GERD group as compared with the NCCP group (44.8%, 27.8%, and 9.1%, respectively, P<0.0001). In univariate analysis of patients with NCCP, male gender was a risk factor for BE (OR 1.86, 95% CI 1.35-2.55, P=0.0001) and being nonwhite was protective (OR 0.43, 95% CI 0.22-0.86, P=0.02). In this group, male gender was also a risk factor for EE (OR 1.31, 95% CI 1.11-1.54, P=0.001) and age>or=65 yr was protective (OR 0.73, 95% CI 0.6-0.89, P=0.002). The NCCP group had a significantly higher prevalence of peptic ulcer in the upper gastrointestinal tract as compared with the GERD group (2.0% vs 1.5%, P=0.01). CONCLUSIONS: In this endoscopic prevalence study, most of the endoscopic findings in NCCP were GERD related, but less common as compared with GERD patients.     

Role of clinical presentation in diagnosing reflux-related non-cardiac chest pain

INTRODUCTION: Non-cardiac chest pain (NCCP) presents as a frequent diagnostic challenge, with patients tending to use a disproportionate level of health-care resources. Gastroesophageal reflux disease (GERD) is the most frequent cause of NCCP. Thus the typical symptoms of reflux, such as heartburn and regurgitation, when present as predominant symptoms are quite specific for diagnosing GERD but in patients with NCCP the clinical diagnosis of reflux is difficult, and invasive methods or the omeprazole test are required for its detection. The aim of the present study was to evaluate the role of clinical presentation when diagnosing GERD among patients with NCCP. METHODS: Patients with NCCP underwent upper endoscopy, Bernstein and omeprazole tests. The patients were divided into two groups based on GER- or non-GER-related chest pain, and clinical presentation was compared between these two groups. Gastroesophageal reflux disease was considered positive when at least two methods were positive. RESULTS: From 78 NCCP patients (41 male; mean age 50.4 +/- 2.3 years), the chest pain was related to GERD in 35 patients (44.8%). The two groups were the same based on sex and age. The chest pain severity, site, radiation and relation to food, exercise, and sleep were equal in the two groups, except for two symptoms: pain that was relieved by antacid (P < 0.031) and presence of classical reflux symptoms (P < 0.009), seen in the GERD patients. With regard to recent patient history, heartburn and regurgitation symptoms were seen more frequently in GERD patients (P < 0.036 and P < 0.002, respectively). DISCUSSION: Clinical presentation is important in diagnosing GERD in NCCP. Although the chest pain is the same in reflux- and non-reflux-related NCCP, the symptoms of heartburn or regurgitation in the present or recent patient history are diagnostic for GERD-related chest pain.     

轻度反流性食管炎与非糜烂性反流病远端食管酸暴露和食管动力学变化

目的:探讨轻度反流性食管炎(RE)与非糜烂性反流病(NERD)食管远端酸暴露及食管动力变化特点.方法:符合洛杉矶诊断标准的RE30例(LA-A16例,LA-B14例),NERD16例,健康对照组10例被纳入本研究,所有患者及对照组均接受24h食管pH监测及压力测定,比较食管pH监测及测压结果.结果:LA-A组、LA-B组、NERD组DeMeester评分明显高于对照组,差异显著(P<0.05).LA-A组与NERD组比较DeMeester评分无明显差异,但NERD组的立位反流时间百分比与长反流周期数多于LA-A组,差异显著;LA-B组DeMeester评分比LA-A组和NERD组明显增高,LA-B组与LA-A组比较食管pH监测各项指标均存在明显差异.LA-A组、NERD组及对照组比较下食管括约肌静息压(LESP)、食管体部蠕动波幅度(PA)无显著差异,LA-A组和NERD组食管下段PA有增高趋势;LA-B组与LA-A组、NERD组及对照组比较LESP明显降低(P<0.05),LA-B组食管下段PA明显低于LA-A组(P<0.05).RE组无效食管运动(IEM)明显高于对照组,差异显著.结论:轻度RE(LA-B)与NERD远端食管酸暴露存在差异.DeMeester评分、LES功能不全及食管蠕动功能障碍与RE的严重程度呈正相关.LES功能不全及食管蠕动功能障碍可能不是轻度RE(LA-A)及NERD的主要致病因素.IEM与RE关系密切,且与RE有关的食管动力异常主要为IEM.     

反流性食管炎食管外表现与酸反流关系的研究

目的探讨反流性食管炎食管外表现与酸反流的关系。方法研究对象为2006年1月至2007年2月在卫生部北京医院消化科、呼吸科及耳鼻喉科门诊和住院的患者,均经胃镜检查证实为反流性食管炎(RE),具有烧心、反酸等胃食管反流和(或)RE的食管外症状(咳嗽、咽喉痛、咽部异物感、声音嘶哑等)。依据患者的主要症状分为食管外表现组及对照组(不具有食管外表现)。食管外表现组32例,对照组35例。所有患者在治疗前均进行24 h食管pH监测,并于治疗前、后对症状积分评定。所有患者均给予质子泵抑制剂(PPI)治疗。结果食管外表现组与对照组PPI治疗的有效率分别为86.4%与91.7%,差异无统计学意义(P>0.05)。结论反流性食管炎的食管外症状与酸反流显著相关。     

Factors predictive of gastroesophageal reflux disease and esophageal motility disorders in patients with non-cardiac chest pain

Background: Patients with non-cardiac chest pain (NCCP) are referred for esophageal motility testing and pH monitoring since gastroesophageal reflux disease (GERD) and esophageal motility disorders are frequently encountered in these patients. Our aim was to determine the prevalence and distribution of these disorders and to identify predictors of abnormal esophageal function testing.

Methods: We performed a retrospective study of NCCP patients who presented after a negative cardiac evaluation and underwent esophageal manometry, esophageal pH monitoring and upper endoscopy from January 2010 to January 2017.

Key results: In a total of 177 patients, esophageal motility disorders were diagnosed in 31% and GERD in 35% of the patients. The most common diagnoses were ineffective esophageal motility (IEM) in 14.1%, jackhammer esophagus in 6.8%, diffuse esophageal spasm in 5.1% and achalasia in 2.3% patients. Older age [for every 5-year increment, odds ratio (OR) 1.2 (95% confidence intervals (CI) 1.00–1.3) p?=?.047] and dysphagia [OR 3.8 (95% CI, 1.9–7.5) p?p?=?.032] was predictive of GERD. Abnormal esophageal testing was associated with male gender [OR 2.2 (95% CI, 1.04–4.6) p?=?.039], older age [for every 5-year increment, OR 1.2 (95% CI, 1.03–1.3) p?=?.016] and Caucasian race [OR 3.1 (95% CI, 1.1–8.7) p?Conclusions: Approximately two thirds of patients presenting with NCCP have GERD or esophageal motility disorders. Esophageal function testing in NCCP should be considered in older patients, men, Caucasians and those presenting with dysphagia.     

Diagnosis of chest pain with foregut symptoms in Chinese patients

AIM： To evaluate the diagnosis of chest pain with foregut symptoms in Chinese patients.
METHODS： Esophageal manometric studies, 24-h introesophageal pH monitoring and 24-h electrocardiograms （Holter electrocardiography） were performed in 61 patients with chest pain.
RESULTS： Thirty-nine patients were diagnosed with non-specific esophageal motility disorders （29 patients with abnormal gastroesophageal reflux and eight patients with myocardial ischemia）. Five patients had diffuse spasm of the esophagus plus abnormal gastroesophageal reflux （two patients had concomitant myocardial ischemia）, and one patient was diagnosed with nutcracker esophagus.
CONCLUSION： The esophageal manometric studies, 24-h intra-esophageal pH monitoring and Holter electrocardiography are significant for the differential diagnosis of chest pain, particularly in patients with foregut symptoms. In cases of esophageal motility disorders, pathological gastroesophageal reflux may be a major cause of chest pain with non-specific esophageal motility disorders. Spasm of the esophageal smooth muscle might affect the heart-coronary smooth muscle, leading to myocardial ischemia.     

Pathological bolus exposure plays a significant role in eliciting non-cardiac chest pain

Background and Aim: Pathological bolus exposure is defined in the present study as cases in which all reflux percentage times are above 1.4% of the total reflux number, as revealed by impedance–pH monitoring. The role of pathological bolus exposure in the pathogenesis of non‐cardiac chest pain (NCCP) is poorly known. We aimed to classify and characterize NCCP using combined impedance–pH monitoring. Methods: Seventy‐five consecutive patients with NCCP were prospectively enrolled from January 2006 to October 2008. All the patients underwent upper endoscopy, esophageal manometry, and 24‐h multichannel intraluminal impedance (MII)–pH metering. Results: Sixteen patients (21.3%) had esophageal erosion upon endoscopy. Upon esophageal manometry, 37 patients (49.3%) had esophageal dysmotility. When the patients were classified based on MII–pH metering, 16 (21.3%) showed pathological acid exposure, and 40 (53.3%) showed pathological bolus exposure. The DeMeester score of patients with pathological acid exposure was higher than that of patients with pathological bolus exposure (P = 0.002). There was no significant difference in age, sex, typical esophageal symptoms, presence of esophageal erosion, esophageal dysmotility, improvement with proton pump inhibitor medication, symptom index ≥50%, percentage of time clearance pH below 4 ≥4%, and all reflux time ≥1.4% in the fasting period between the two groups. When the patients were divided into gastroesophageal reflux disease (GERD)‐related NCCP and non‐GERD‐related NCCP groups based on MII–pH metering and upper endoscopy, there was no difference between the two groups. Conclusions: Combined impedance–pH monitoring improves the detection and characterization of NCCP. This study suggests that pathological bolus exposure plays a major role in eliciting NCCP.     

Autofluorescence imaging endoscopy can distinguish non-erosive reflux disease from functional heartburn: A pilot study

AIM: To investigate whether autofluorescence imaging(Af I) endoscopy can distinguish non-erosive reflux disease(NERD) from functional heartburn(fh).METHODS: In this prospective observational trial, 127 patients presenting with typical reflux symptoms for 6 mo were screened. All the participants underwent endoscopy, during which white light imaging(WLI) was followed by Af I. finally 84 patients with normal esophageal appearance on WLI were enrolled. It was defined as being suggestive of NERD if one or more longitudinal purple lines longer than one centimeter were visualized in the distal part of the esophagus during Af I endoscopy. Ambulatory 24-h multichannel intraluminal impedance and ph monitoring was also performed. After standard proton-pump inhibitor(PPI) tests, subjects were divided into an NERD group and an fh group and the diagnostic performance of Af I endoscopy to differentiate NERD from fh was evaluated.RESULTS: Of 84 endoscopy-negative patients, 36(42.9%) had a normal ph/impedance test. Of these, 26 patients with favorable responses to PPI tests were classified as having NERD. finally 10 patients were diagnosed with fh and the others with NERD. Altogether, 68(81.0%) of the 84 patients were positive on Af I endoscopy. In the NERD group, there were 67(90.5%) patients with abnormal esophageal findings on Af I endoscopy while only 1(10%) patient was positive on Af I endoscopy in the fh group. The sensitivity and specificity of AFI in differentiating NERD from FH were 90.5%(95%CI: 81.5%-96.1%) and 90.0%(95%CI: 55.5%-99.7%), respectively. Meanwhile, the accuracy, positive predictive value and negative predictive value of Af I in differentiating between NERD and fh were 90.5%(95%CI: 84.2%-96.8%), 98.5%(95%CI: 92.1%-99.9%) and 56.3%(95%CI: 30.0%-80.2%), respectively.CONCLUSION: Autofluorescence imaging may serve as a complementary method in evaluating patients with NERD and fh.     

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.     

十二指肠球部溃疡伴胃食管反流患者食管动力及胃内pH值监测

目的：探讨胃食管反流(GER)常见于十二指肠球部溃疡的原因。方法：选择近5年我院接受胃食管动力检查并行胃镜检查明确诊断为十二指肠球部溃疡的患者46例。食管pH监测胃食管酸反流阳性或胃镜检查存在反流性食管炎(RE)者为反流组，食管pH值监测胃食管酸反流阴性者为非反流组。比较两组食管下括约肌(IES)、食管体部及食管上括约肌(UES)等功能差别，同时对两组胃pH值监测进行比较。结果：十二指肠球部溃疡患者为GER／RE的高发人群，反流组与非反流组LES长度、功能压、食管体部清除功能、UES静息压比较差异无显著性。反流组每日不同时限胃酸分泌高于非反流组。结论：十二指肠球部溃疡易合并GER／RE与胃酸增高有关，与食管动力变化关系不大。     

Ineffective esophageal motility: the most common motility abnormality in patients with GERD-associated respiratory symptoms

OBJECTIVE: The association of gastroesophageal reflux disease (GERD) and respiratory symptoms is well known. The coexistence of ineffective esophageal motility (IEM, low-amplitude [< 30 mm Hg] or nontransmitted contractions in > or = 30% of 10 wet swallows in the distal esophagus) in patients with GERD has recently been demonstrated. Our aim was to determine the prevalence of IEM in patients with GERD-associated respiratory symptoms. METHODS: Manometry and pH studies of 98 consecutive patients with respiratory symptoms and abnormal reflux shown by pH-metry were reviewed. Symptoms were chronic cough (n = 43), asthma (n = 13), and laryngitis (n = 42). Sixty-six patients with heartburn with no extraesophageal manifestations were used as a control group. Total esophageal acid clearance (EAC) time was calculated for each patient. RESULTS: IEM was the most common motility abnormality seen in all groups of GERD patients. It was seen significantly more often in patients with chronic cough (41%) (p = 0.003) or asthma (53%) (p = 0.01), and numerically more often in patients with laryngitis (31%) than in patients with heartburn (19%). Diffuse esophageal spasm and nutcracker esophagus were rarely seen. Incidence of hypertensive or hypotensive lower esophageal sphincter was similar across all groups. The total EAC time was longer (median: 1.51 min/episode) (p = 0.01) in patients with GERD-associated respiratory symptoms than in patients with heartburn (median: 0.72 min/episode). CONCLUSIONS: IEM is the most prevalent motility abnormality in patients with GERD-associated respiratory symptoms. Coexistence of IEM with GER may place patients at high risk for respiratory symptoms due to the associated delayed esophageal acid clearance seen with this motility abnormality.