Basal and residual lower esophageal pressures increase in old age in classic achalasia,but not vigorous achalasia

Background and Aim: The relationship between age and esophageal motility parameters (i.e. basal and residual pressure of the lower esophageal sphincter [LES]) remains to be established in achalasia patients, possibly because most previous studies did not distinguish between classic and vigorous achalasia patients. We investigated the relationship between age and esophageal motility parameters in both classic and vigorous achalasia patients. Methods: A retrospective review of esophageal manometry data in a single center was undertaken. Basal and residual pressure for LES was analyzed. A total of 103 achalasia patients were enrolled, comprising 84 classic and 19 vigorous types. They were subdivided into three different age groups as follows: 21–40 years old (group A), 41–60 years old (group B), and over 60 years old (group C). Results: In classic achalasia patients (M : F = 27:57, mean age = 44 ± 15 years old) the older age group showed a significantly higher basal LES pressure (49.62 ± 19.63 mmHg) than the younger age group (P < 0.0001). Moreover, the older age group also showed significantly high residual LES pressure (20.46 ± 8.61 mmHg) than the younger age group (P = 0.0006). In contrast, in vigorous achalasia patients (M : F = 12:7, mean age: 47 ± 15 years old) there were no difference between age and motility indices (all P > 0.05). Conclusion: In classic achalasia patients there appears to be a correlation between age and esophageal motility indices, especially basal and residual LES pressure. Such correlations do not appear to exist for vigorous achalasia patients.     

The relationship between ineffective esophageal motility and gastro-esophageal reflux disease]

BACKGROUND/AIMS: Ineffective esophageal motility (IEM) is a distinct manometric entity characterized by a hypocontractile esophagus. Recently, IEM replaced the nonspecific esophageal motility disorder (NEMD), and its associations with gastro-esophageal reflux disease (GERD) and respiratory symptoms are well known. We evaluated the relationship of IEM with GERD, and the diagnostic value of IEM for GERD. METHODS: We retrospectively analyzed recent 3-year (Jan. 1998-Sep. 2002) datas of esophageal manometry, acid perfusion test and simultaneous 24 hr-ambulatory pH-metry with manometry studies in 270 consecutive patients with esophageal and/or GERD symptoms. The prevalence of IEM in GERD group and non-GERD group, and the variables of pH-metry and manometry among esophageal motility disorders were compared. In addition, the sensitivity, specificity, positive predictive value, negative predictive value of IEM, esophageal symptom, and acid perfusion test for GERD were calculated. RESULTS: There was no significant difference in IEM prevalence rate between GERD group and non-GERD group. In addition, there was no significant difference in GERD prevalence rate and esophageal acid clearance in variety of motility disorder groups. Total percent time of pH <4 in IEM group did not show any difference when compared with other groups except in the achalasia group. In regard of diagnostic value to detect GERD, all positive results showed high specificity (97%) in IEM with esophageal symptom and positive acid perfusion test. CONCLUSIONS: The diagnosis of IEM using esophageal manometry in patients with various esophageal symptoms does not strongly suggest on association with GERD. However, IEM with concomitant esophageal symptoms and positive acid perfusion test has diagnostic values for GERD.     

Ineffective motility is not a marker for gastroesophageal reflux disease

OBJECTIVE: Previous studies have suggested that ineffective esophageal motility (IEM) may be a marker for gastroesophageal reflux disease (GERD), particularly supraesophageal reflux disease. We evaluated the relationship between esophageal acid exposure and esophageal body motility in patients undergoing both esophageal manometry and 24-h pH metry in the absence of antisecretory therapy. METHODS: We conducted a retrospective database review of 84 patients (mean age 47 yr, 46% male) evaluated in our GI physiology laboratory. The indication for testing was recorded and characterized as esophageal or supraesophageal. Abnormal esophageal acid exposure was defined as a distal esophageal pH <4 for more than 4.2% of the total monitoring time (>6.3% upright, >1.2% supine) or a proximal esophageal acid exposure time of greater than 1.1% total (>1.3% upright, 0% supine). IEM was defined as more than two of 10 ineffective peristaltic waves. RESULTS: Seventy-two patients had esophageal-presenting symptoms, and 12 had supraesophageal symptoms. The prevalence of abnormal esophageal acid exposure was similar in patients with esophageal and supraesophageal symptoms (69% vs 92%, p = 0.17). Abnormal motility was identified in 26 patients (31%). IEM was the most common motility disturbance (77%, 20 patients). The frequency of motility disorders was similar in patients with and without abnormal esophageal acid exposure (30% vs 35%, p = 0.79), in patients with esophageal or supraesophageal symptoms (32% vs 25%, p = 0.75, for all patients; 30% vs 27%, p = 1.00, for patients with abnormal esophageal acid exposure), and among upright, supine, and combined refluxers (33%, 9%, and 35%, p = 0.26).CONCLUSIONS: IEM does not stand alone as a significant marker for the presence of GERD in general or supraesophageal reflux disease in particular.     

Impact of endoscopic suturing of the gastroesophageal junction on lower esophageal sphincter function and gastroesophageal reflux in patients with reflux disease

OBJECTIVES: Plication of the gastroesophageal junction by endoscopic suturing has been reported to improve symptoms and reduce acid exposure in patients with gastroesophageal reflux disease (GERD). The mechanisms underlying these effects are not well defined. The aims of our study were to determine the impact of endoscopic suturing of the gastroesophageal junction on lower esophageal sphincter (LES) function in patients with GERD. METHODS: In 15 patients (7 males) with GERD (heartburn, % time esophageal pH < 4 greater than 4%, +/- history of erosive esophagitis within 6 months), two plications were performed circumferentially 1 cm below the gastroesophageal junction. Endoscopy and combined postprandial esophageal manometry and pH monitoring were performed before and 6 months after treatment; 24-h ambulatory pH monitoring and symptom assessment were also performed before, and at 6 and 12 months after treatment. RESULTS: Six months after treatment, the rate of transient LES relaxations (tLESRs) was decreased by 37% (p < 0.05) and basal LES pressure had increased from 4.3 +/- 2.2 mmHg to 6.2 +/- 2.1 mmHg (p < 0.05). The rate of postprandial reflux events and acid exposure time were not altered. Endoscopic suturing significantly reduced 24-h esophageal acid exposure from 9.6% (9.0-12.1) to 7.4% (3.9-10.1) at 6 months, due predominantly to a reduction in upright acid exposure. The reduction in total 24-h acid exposure was sustained to 12 months. At repeat endoscopy, only one plication was evident in 6 patients (40%) at 6 months. Seven patients (47%) remained off medications at 6 and 12 months follow-up. CONCLUSIONS: In patients with GERD, endoscopic suturing of the gastroesophageal junction results in a reduction in the rate of tLESRs, and an increase in basal LES pressure. These changes in LES function result in only a modest reduction in gastroesophageal reflux.     

The role of excessive esophageal acid exposure in patients with gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD), especially reflux esophagitis (RE), is characterized by excessive esophageal acid exposure. Transient lower esophageal sphincter (LES) relaxation is the major mechanism of acid reflux episodes in both healthy subjects (HS) and patients with GERD. In the sitting position, where acid reflux episodes often occur, there is no difference in the frequency of transient LES relaxations between these two groups; however, in patients with GERD, at 5 cm above the LES, the proportion of acid reflux episodes during transient LES relaxations is significantly greater than in the HS group. This difference is considered to be one of the causes of excessive esophageal acid exposure in patients with GERD, but its cause is still unclear. A recent study, which investigated the proportion of acid reflux episodes during transient LES relaxations at 2 and 7 cm above the LES, showed that there was no difference at 2 cm above the LES between HS and patients with RE, but at 7 cm they were significantly greater in patients with RE than in HS. Evaluation of acid reflux at 2 cm above the LES is difficult to measure, but the proximal extent of refluxate could be one of the important factors of excessive acid esophageal exposure in patients with RE. Ineffective esophageal motility, found in patients with moderate to severe RE, impairs esophageal bolus clearance of acid, therefore both the proximal extent of refluxate and the delay of esophageal bolus clearance of acid could be major causes of excessive esophageal acid exposure. Hiatus hernia also causes acid reflux, due to its association with hypotensive LES, and also impairs esophageal bolus clearance of acid.     

Deterioration of esophageal motility with age: a manometric study of 79 healthy subjects

OBJECTIVE: Data are limited on the effect of age on esophageal function. We evaluated whether aging influences the motor activity of the esophagus. METHODS: Standard esophageal manometry was performed in 79 healthy, nonpaid volunteers of both sexes, 18-73 yr of age. Lower (LES) and upper esophageal sphincter (UES) characteristics and the properties of esophageal peristaltic waves were assessed by age groups: < or = 25 yr, 26-35 yr, 36-45 yr, 46-55 yr, 56-65 yr, and > 65 yr. RESULTS: Age correlated inversely with LES pressure and length, UES pressure and length, and peristaltic wave amplitude and velocity, and correlated directly with the proportion of simultaneous contractions. Age was inversely correlated with the upper limits of normality (95th percentiles) of LES pressure (r = -0.943, p = 0.005), UES pressure (r = -0.943, p = 0.005), middle and lower peristaltic wave amplitude (r = -0.947, p = 0.004, and r = -0.844, p = 0.035, respectively), upper/middle peristaltic progression speed (r = -0.943, p = 0.005), and the proportion of simultaneous contractions (r = 0.926, p = 0.008), but not with the lower normal limits (5th percentiles) of these variables. Gender did not affect esophageal motility variables. The 95th percentiles of LES pressure differed by 20 mm Hg, those of lower peristaltic amplitude by 82 mm Hg, and those of percent simultaneous contractions by a factor of 2, between the younger and the older age groups. CONCLUSIONS: The results suggest that normal esophageal motility deteriorates with advancing age. Thus, age-related normality limits of esophageal pressures should be considered before establishing the manometric diagnosis of hypercontractile esophageal motility disorders.     

Endoscopic,deep mural implantation of Enteryx for the treatment of GERD: 6-month follow-up of a multicenter trial

OBJECTIVES: This prospective, multicenter, single-arm study evaluated the safety and efficacy of the endoscopic implantation of Enteryx, a biocompatible, non-biodegradable liquid polymer for the treatment of GERD. METHODS: Eighty-five patients with heartburn symptoms responsive to proton pump inhibitor (PPI) use were enrolled. Inclusion requirements were HRQL score < or = 11 on PPI and > or = 20 off PPI, and 24-hour PH probe with > or = 5% total time at PH < or = 4. Patients with a hiatus hernia > 3 cm, grade 3 or 4 esophagitis, or esophageal motility disorder were excluded. Using a 4-mm needle tipped catheter during standard endoscopy, implants were made in 3-4 quadrants deep into the wall of the cardia. Use of PPI medications, pH-metry, manometry, GERD symptoms, and patient quality of life were assessed over a 6-month follow-up period. RESULTS: At 6 months, PPI use was eliminated in 74% and reduced by > 50% in 10% of patients. The median HRQL score improved from 24.0 pre-implant (baseline off PPIs) to 4.0 at 6 months (p < 0.001). Mean total esophageal acid exposure time was 9.5% pretherapy and 6.7% at 6 months (p < 0.001). Mean LES length increased from 2.0 cm at baseline to 3.0 cm posttherapy (p = 0.003). There were no clinically serious adverse events. Transient mild-to-moderate chest pain commonly occurred after implantation. CONCLUSIONS: The endoscopic implantation of Enteryx is a safe and effective therapy for eliminating or decreasing the need for PPI medications, improving GERD symptoms and patient quality of life, and decreasing esophageal acid exposure among patients suffering from GERD.     

Impaired visceral sensitivity to acid reflux in patients with Barrett''s esophagus. The role of esophageal motility*

Patients with Barrett's esophagus have been reported to have impaired visceral sensitivity to acid perfusion and distension compared with non-Barrett's refluxers, but the mechanism is poorly understood. Esophageal motility and clearance mechanisms may be important, and this study explored the relationship of motility with symptoms. Seventy-four patients with Barrett's esophagus were compared with 216 patients with gastro-esophageal reflux disease (GERD) with abnormal acid reflux scores, and 50 symptomatic patients who had normal acid exposure. All patients had esophageal manometry and 24-h pH monitoring. Thirty-six Barrett's patients also had 24-h bile reflux monitoring. Symptoms were assessed by Symptom Index (SI) during 24-h pH monitoring. Barrett's patients with normal motility had a significantly lower SI than GERD patients for similar acid exposure (P < 0.001). Barrett's patients with abnormal motility had higher acid exposure than those with normal motility (P < 0.05), but the SI values for this group was not significantly different from the GERD patients. SI and Bile reflux in Barrett's esophagus was not significantly different in patients with normal or abnormal motility. Barrett's patients had less sensitivity than GERD patients for similar acid exposure. Normal motility in Barrett's esophagus is associated with the poorest sensitivity and the presence of increased acid exposure is required in order to achieve sensitivity levels comparable with GERD patients.     

Effect of sodium valproate on esophageal motility in healthy subjects and patients with gastroesophageal reflux

BACKGROUND: There is experimental evidence to show that upper gastrointestinal tract motility is influenced by a GABAergic mechanism. Sodium valproate acts as a GABA agonist, and has been proven to affect the human internal anal sphincter. The aim of this study was to evaluate any possible effect of sodium valproate on esophageal motility in healthy subjects and patients with gastroesophageal reflux disease (GERD). METHODS: Ten healthy volunteers (4 M, 6 F; age range: 20-61 years) and 12 patients (4 M, 8 F; age range: 25-70 years) with GERD were included in the study. Standard esophageal manometry and ambulatory 24-h esophageal pH monitoring were performed before and 5 days after oral administration of sodium valproate (400 mg four times per day). Main measurements included a) lower esophageal sphincter (LES) resting pressure and amplitude and duration of peristalsis at 5, 10 and 15 cm proximal to LES, and b) percentage of time with esophageal pH <4 and number of reflux episodes. RESULTS: Sodium valproate (i) significantly increased LES resting pressure in both groups (P<0.05), without affecting either the LES postdeglutition relaxation or any of the parameters of the esophageal peristaltic activity, (ii) significantly reduced the number of reflux episodes at the postprandial period in both healthy subjects (P=0.02) and reflux patients without hiatal hernia (P=0.04) and (iii) the time percentage with esophageal pH <4 at the postprandial period in reflux patients (P=0.01). CONCLUSIONS: Sodium valproate increases normal and reduced tonic activity of the human LES and reduces the number of reflux episodes in health and GERD. This action could be attributed to a central GABAergic mechanism.     

难治性胃食管反流病食管动力异常与反流特点的研究

目的研究难治性胃食管反流病(refractory gastroesophageal reflux disease,rGERD)食管动力学特征和反流特点。方法应用高分辨率食管测压(HRM)监测87例GERD患者和70例rGERD患者食管动力学数据,同时应用便携式24 h食管pH-阻抗监测仪记录两组患者的酸暴露特点、反流类型及反流特点,分析比较两组患者间差异。结果rGERD患者中UES压力、LES压力显著低于GERD患者(P<0.05),rGERD患者LES的长度与GERD患者比较,差异无统计学意义(P>0.05)。rGERD患者中食管动力障碍比例高于GERD患者(70.00%vs 33.33%,χ2=4.891,P<0.05),DCI下降为特征的食管蠕动收缩障碍及间断收缩为特征的食管收缩节律障碍者比例两组比较,差异无统计学意义(57.14%vs 62.07%;42.86%vs 37.93%,χ2=3.275、2.822,P>0.05)。rGERD患者DeMeester评分高于GERD患者(P=0.014),rGERD患者反流性质中弱酸反流及非酸反流明显多于GERD患者(P弱酸=0.001,P非酸=0.017),而酸反流次数差异无统计学意义(P酸=0.385);rGERD患者反流性状中气体反流及气液混合反流次数多于GERD患者(P气=0.022,P气液=0.031),而液体反流次数差异无统计学意义(P液=0.742)。结论rGERD患者与GERD患者相比,存在UES压力偏低、LES压力下降和食管蠕动收缩障碍等食管动力学异常;rGERD患者反流以弱酸反流及碱反流为主,而GERD患者以酸反流为主,同时rGERD患者中气液混合反流所占比例大,而GERD患者以液体反流为主。     

胃食管反流病食管酸暴露和食管动力学变化特征

目的探讨无效食管动力(IEM)在胃食管反流病(GERD)中的作用,以及体质量对食管酸暴露及食管动力的影响。方法77例GERD典型症状患者全部行食管高分辨率压力测定(HRM)和24 h食管动态pH监测,分析IEM及正常食管动力患者酸暴露情况。结果 77例典型GERD症状患者中病理性酸暴露者38例(49%),在病理性酸暴露组中IEM 9例(24%),正常酸暴露组中IEM 5例(13%)。IEM组LES压力低于食管动力正常组(15.15±3.60 vs 22.15±6.73,P0.01);IEM组总pH4时间(百分比)较正常食管动力组高[(14.78±3.8)%vs(4.30±2.68)%,P0.01];IEM组患者BMI值较高。结论 IEM在GERD中较常见,其食管动力障碍中绝大多数为IEM,IEM与食管远端酸暴露密切相关。     

Prevalence of ineffective esophageal motility and its relevance to symptoms and esophageal acid exposure in korean patients referred for foregut symptoms

BACKGROUND/AIMS: The prevalence and clinical significance of ineffective esophageal motility (IEM) in a population with low prevalence of gastroesophageal reflux disease are not known. Our aim was to investigate the prevalence and its relevance to symptoms and esophageal acid exposure in Korean patients referred for foregut symptoms. METHODS: A total of 112 consecutive patients who underwent esophageal manometry, 24-hour esophageal pH monitoring and endoscopy for foregut symptoms were analyzed. IEM was defined as >20% of wet swallows with amplitudes of <30 mm Hg or lack of peristalsis. RESULTS: IEM and abnormal acid exposure were observed in respectively 29 and 19% of all subjects. The prevalence of individual symptoms did not differ between IEM and non-IEM groups. Hypotensive lower esophageal sphincter (LES) was significantly more prevalent in IEM patients. The prevalence of abnormal acid exposure in IEM and non-IEM groups was comparable. The prevalence of IEM was similar between patients with and without abnormal acid exposure. Erosive reflux esophagitis was significantly more prevalent in IEM patients compared with non-IEM patients. CONCLUSION: IEM is not a significant marker for a specific symptom or abnormal acid exposure. However, the presence of IEM is associated with a higher prevalence of hypotensive LES and erosive reflux esophagitis.     

高分辨率食管测压下胃食管反流病吞咽延迟时间与食管动力的相关性研究

目的探讨高分辨率食管测压（HRM）下胃食管反流病（GERD）患者吞咽延迟时间（DL）与食管动力的关系。方法51例行HRM且24h食管pH监测诊断为GERD的患者根据HRM结果是否存在食管异常蠕动分成动力异常组（n=28）和阴性组（n=23）,另选择14例非GERD者行HRM作为对照（对照组）,统计分析各组HRM监测结果。结果动力异常组DL（7．27±1．44）S明显高于阴性组的（6．704±41）S和对照组的（5．86±0．96）2,差异均有统计学意义（P〈0．01）,且阴性组也明显高于对照组（P〈0．01）;动力异常组的远端收缩积分（712．49±703．10）mmHg·s·cm明显低于阴性组的（1285．85±850．83）mmHg·s·cm和对照组的（1109．74±611．70）mmHg·s·cm,差异均有统计学意义（P〈0．01）,而阴性组与对照组比较差异无统计学意义（P〉0．05）;各组间食管下括约肌压力、收缩前沿速度及食管下括约肌处食团内部压力差异均无统计学意义（P〉0．05）。结论HRM下DL的延长与GERD患者食管蠕动减弱明显相关,GERD患者表现为更长的DL,证明食管动力的改变是GERD发生发展的重要环节。     

Upper esophageal sphincter abnormalities and high-resolution esophageal manometry findings in patients with laryngopharyngeal reflux

Background: The association between laryngopharyngeal reflux (LPR) and abnormalities of upper esophageal sphincter (UES) and esophageal motility is not clearly known. High-resolution esophageal manometry (HREM) has allowed accurate measurement and evaluation of UES and esophageal function.

Goals: To evaluate the UES function and esophageal motility using HREM in patients with LPR and compare them to patients with typical gastroesophageal reflux disease (GERD).

Study: All patients evaluated for GERD or LPR symptoms with esophageal function testing including HREM, ambulatory distal pH monitoring and upper endoscopy between 2006 and 2014 were retrospectively studied (n?=?220). The study group (group A, n?=?57) consisted of patients diagnosed with LPR after comprehensive evaluation. They were compared to patients who had typical GERD symptoms only (group B, n?=?98) and patients with both GERD and LPR symptoms (group C, n?=?65).

Results: Abnormalities in UES pressures and relaxation were found in about one-third of patients in all groups. There were no significant differences between the groups. Group B had higher prevalence of abnormal esophageal motility compared to others (group A vs. B vs. C?=?20.8% vs. 28% vs. 12.5%, p?=?.029). Group B patients also had higher prevalence of Barrett’s esophagus compared to others (group A vs. B vs. C?=?0% vs.12.2% vs. 4.6%, p?=?.01). Distal pH testing revealed no significant differences between the three groups.

Conclusions: Abnormal UES function was noted in one-third of patients with LPR or GERD. However, there were no abnormalities on esophageal function testing specific for LPR.     

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.     

Gastroesophageal reflux before and after Helicobacter pylori eradication. A prospective study using ambulatory 24-h esophageal pH monitoring

The aim of this study was to assess prevalence of GERD before and after Helicobacter pylori (HP) eradication utilizing 24-h esophageal pH/manometry studies. Helicobacter pylori status was confirmed by the Campylobacter like organism test. Those testing positive underwent 24-h pH/manometry followed by HP eradication therapy and urea breath test. Patients were followed up at 6 months and then at 1 year when they underwent a repeat 24-h pH/manometry. Twenty patients, 10 with non-ulcer dyspepsia (NUD) and 10 with duodenal ulcer (DU) were enrolled, though only 10 patients attended for a repeat 24-h pH/manometry study. The patients were well matched, though patients with NUD had a significantly higher symptom score at entry compared with the DU group (8.5 vs 5.7, P < 0.05). The pH and esophageal manometry data were similar in the two groups. Overall nine patients (45%; DU = 5, NUD = 4) had evidence of GERD prior to HP eradication and it persisted one year after cure of the infection. The reflux disease occurred in the presence of normal LES pressure (mean 15.6 +/- 3.3 mmHg). New onset GERD was uncommon after cure of HP infection, occurring in only one patient with NUD. Overall HP eradication had no impact on percentage of time pH < 4 (4.69 +/- 3 vs 4.79 +/- 3), episodes > 5 min (9.8 +/- 16 vs 15.5 +/- 25.3) and Johnson DeMeester Score (16.8 +/- 7.5 vs 26.8 +/- 18). In addition successful cure of HP produced no significant changes in LES pressure (17.9 +/- 3.8 mmHg vs 19.3 +/- 4.6 mmHg), and other esophageal manometry data. Half of HP-positive patients with NUD and DU have evidence of GERD before HP eradication. This persists after successful cure of the infection. New onset GERD occurs very uncommonly one year after HP eradication.     

食管运动功能在重度反流性食管炎中的地位

目的　通过对重度反流性食管炎(RE)治愈前后食管体部运动功能的研究,了解食管体部运动功能在重度RE中的地位。方法　对70例胃食管反流病患者进行食管压力测定。从中筛选23例重度RE(内镜诊断为洛杉矶C和D级食管炎);且24h食管内pH监测证实为病理性酸反流;食管压力测定证实有食管体部运动障碍患者。给予兰索拉唑30mg/d治疗3~6个月至内镜下食管炎完全愈合后,再行食管压力测定,观察下食管括约肌静息压(LESP)及食管体部运动功能的变化。以湿咽成功率、食管远端收缩波幅和食管蠕动的传导速度作为食管体部运动功能的指标。结果　食管炎治愈前后,LESP[ (6 00±0 86 )mmHg比(5 10±0 87)mmHg, 1kPa=7 5mmHg, P=0 476],食管远端收缩波幅[ (34 1±4 1)mmHg比(37 2±4 0)mmHg,P=0 593]、湿咽成功率[ (33 5±6 5)%比(38 6±7 1 )%,P=0 592 ]比较差异均无统计学意义,其均值仍显著低于正常对照组。结论　治愈食管炎并不能提高LESP及改善食管体部的运动功能。食管体部运动功能障碍和酸反流是RE的重要发病机制,尤其是重度RE。     

无效食管运动在胃食管反流病中发病作用的观察

目的　探讨食管无效收缩 (IEM)在胃食管反流病 (GERD)的发病作用。方法　对GERD病人行食管测压和 2 4h食管pH监测 ,分析IEM在GERD的发生率以及比较IEM与食管酸暴露、酸清除和食管炎的关系。结果　 86例GERD病人中 5 9例 (6 8 6 % )存在非特异性食管动力障碍 (NEMD) ;其中 5 5例 (占 93 2 % )符合IEM诊断标准 ;GERD病的IEM发生率为 6 3 95 %。IEM的GERD患者总的pH <4时间 (% ) (5 91)及立位 (4 4 3)和卧位 (6 92 )pH <4时间 (% )显著大于食管正常蠕动的GERD患者 (分别为 3 16 ,1.6 1,和 4 31) ,尤以卧位明显 (P <0 0 1)。IEM患者平均卧位食管酸清除时间 (EAC)为每次 12 6 3min ,显著长于正常食管动力GERD患者的每次 3 15min(P<0 0 1) ,而立位EAC则与正常食管动力组无差异。 2 7例正常食管动力GERD有 10例 (37% )有糜烂性食管炎 ;5 5例IEM患者有 19例 (35 % )有食管炎 ,二组间食管炎发生比例差异无显著性 (P >0 0 5 )。结论　GERD病的食管动力障碍大多数系IEM。IEM比正常食管动力患者更易发生反流和存在食管酸清除障碍。IEM是GERD病的主要异常表现。     

Correlation between esophageal contraction amplitude and lower esophageal sphincter pressure in patients with nutcracker esophagus

Nutcracker esophagus (NE) is a primary esophageal motility disorder characterized by high-wave amplitude at the distal esophagus. The aim of this study was to analyze patients with NE and determine the relationship between distal esophageal contraction amplitude and lower esophageal sphincter (LES) pressure. Esophageal manometry tracings of patients with NE, defined as the presence of distal contraction amplitude of more than 182 mmHg after wet swallow, were analyzed. LES pressure was measured as the mean end-expiratory value. Spearman's correlation coefficient analysis was used to compare esophageal contraction amplitude with LES pressure. This comparison was also performed in patients with isolated hypertensive LES (HLES) and in subjects with normal manometry. Forty patients (25 female, 15 male; mean age 54 years) with NE were included in the study. Mean (SD) distal esophageal contraction amplitude was 230 (35.7) mmHg and mean LES pressure was 27.3 (5.7) mmHg. Esophageal contraction amplitude showed a positive correlation with LES pressure (r = 0.49, P < 0.01). In contrast, no correlation was found in patients with HLES (r = 0.21, P > 0.05) and in those with a normal manometric study (r = 0.18, P > 0.05). It is concluded that in patients with nutcracker esophagus a positive correlation exists between distal esophageal contraction amplitude and LES pressure, suggesting a diffuse hypertensive pattern involving smooth muscle at the distal esophagus and adjacent LES.     

Effects of a pH electrode across the lower esophageal sphincter

Recent studies have suggested that combined monitoring of the esophagus and stomach for prolonged periods may be the best method for investigating patients with upper gastrointestinal complaints. However, the effects of an electrode across the LES on esophageal reflux parameters have not been extensively studied. We studied 10 healthy volunteers and 10 patients with GERD twice with 24-hr pH monitoring. In phase 1, two glass electrodes were placed 1 cm below the UES and 5 cm above the LES. One week later in phase 2, patients were restudied with one electrode 5 cm above and one 5 cm below the LES. Although total acid exposure remained the same in healthy volunteers, three volunteers who spontaneously refluxed at night had abnormal prolongation of their supine acid exposure during phase 2 of the study. In patients with GERD, the electrode across the LES resulted in significant (P=0.01) increase in supine acid exposure and showed a strong tendency for the number of reflux episodes >5 min supine (P=0.02) and longest reflux episode supine (P=0.06) to increase without a change in the number of reflux episodes. In conclusion, a small glass electrode across the LES results in prolongation of supine acid exposure in both healthy volunteers spontaneously refluxing at night and the majority of patients with GERD. This results from the electrode interfering with clearance of refluxed acid in the supine position. Thus, combined esophageal and gastric pH monitoring may have important limitations in investigating gastroesophageal symptoms.