Gastroesophageal Reflux in Achalasia (When Is Reflux Really Reflux?)

An abnormal score during 24-hr esophageal pHmonitoring in achalasia may be associated either with aslow steady drift to below pH 4, or else multiple sharpdips characteristic of typical gastroesophageal reflux. To test the hypothesis that the formerpattern was due to food fermentation and not reflux,samples of chewed bland food (N = 22) were incubatedwith saliva at 37°C for 24 hr and the pH monitored (in vitro study). Further, the pH tracings of20 patients with achalasia before operation and 12patients after operation were studied (in vivo study).The pH of chewed food fell to a median of pH 4.0 during incubation and in seven of 22 samplesfell to below pH 4. Preoperatively, four of the fivepatients with an abnormal pH score showed a slow steadydrift, and all of these had evidence of retained food at endoscopy. Postoperatively, three ofthe six patients with an abnormal pH score had a slowsteady drift to below pH 4. Use of pH 3 as a thresholdclearly distinguished true reflux from foodfermentation, since the patients with reflux all had anabnormal percentage of time below pH 3.     

Prospective Randomized Comparison of Pneumatic Dilatation Technique in Patients with Idiopathic Achalasia

We performed a randomized prospective study ofpneumatic dilatation comparing a 30-mm and 35-mmMicrovasive balloon dilator inflated for either 15 or 60sec in patients diagnosed with idiopathic achalasia who were previously untreated. Twenty-fourpatients, 11 men, 13 women, mean age 45, range 18-81years), were prospectively randomized for dilatation.History and physical examination, esophageal manometry, and barium swallow were performed beforedilatation. Symptom self scores were assessed beforedilatation, and one month and six months afterdilatation. Pneumatic dilatation was successfullycompleted in all 24 patients, with one patient experiencinga confined perforation. Conservative treatment wasemployed, and the patient recovered fully. Two patientsexperienced a recurrence of symptoms and required a second dilatation. Evaluation ofposttreatment symptom self scores indicates nodifference between the 30-mm and 35-mm Microvasiveballoon or inflation durations of either 15 or 60 sec.These data indicate that the more conservative 30-mm dilatorinflated for just 15 sec delivers a symptom responseequal to a more aggressive approach with the largerdilator inflated over longer duration.     

Symptomatic Gastroesophageal Reflux in Acutely Hospitalized Patients

Patients admitted acutely to hospital may be atrisk of increased morbidity and mortality as a result ofgastroesophageal reflux and its complications. Therecognized association of gastroesophageal reflux with cardiac and respiratory disease, the useof drugs that reduce lower esophageal sphincterpressure, and the supine position in which many patientsare nursed may increase the risk of gastroesophageal reflux. This study aimed to determine theprevalence and severity of refluxlike symptoms in aseries of consecutive unselected patients admittedacutely through the accident and emergency department of a district general hospital and to study theeffect of hospitalization on these symptoms. Patientswere interviewed by questionnaire on two occasions:immediately following admission and again 7-10 days later. The frequency of symptoms of heartburn,acid regurgitation, dysphagia, nausea, and belching wererecorded on a 6-point scale, in addition to whetherthese symptoms occurred at night. Medication history, the number of days spent on bed rest,nasogastric intubation, and operation history were alsorecorded. In all, 275 patients were interviewed, of whom229 had a second interview; 27% (62) had symptoms at least once a week (49% reported symptoms atleast once a month) prior to admission, of whom 4% (9)had daily heartburn and/or acid regurgitation. Followingadmission to hospital there was a significant (P < 0.001) fall in the prevalence andfrequency of refluxlike symptoms. There was asignificant association of refluxlike symptoms withnumber of days spent in bed (P < 0.05) and with theuse of nonsteroidal antiinflammatory drugs in hospital(P < 0.0001). Logistic regression analysis confirmedthe association of NSAIDs with refluxlike symptoms.Nasogastric intubation and surgery were not associated with heartburn. In conclusion, symptoms ofheartburn and acid regurgitation become less frequentfollowing admission to hospital. This probably relatesto a reduction in physical exertion following hospital admission but may reflect a reduction inanxiety levels or treatment of underlying disease.Patients on prolonged bed rest and those givennon-steroidal anti-inflammatory drugs are at increasedrisk of refluxlike symptoms and may require antirefluxmeasures.     

Esophageal Dysmotility and Gastroesophageal Reflux in Intrinsic Asthma

This study was undertaken to determine theprevalence of esophageal motor abnormalities, theincidence of gastroesophageal reflux, and thecoexistence of gastroesophageal reflux with esophagealdysmotility in patients with intrinsic asthma. Based onclinical criteria, 34 consecutive asthmatics, 15patients with gastroesophageal reflux, and 10 subjectswith upper gastrointestinal symptoms with normal results of esophageal manometry and 24-hr esophageal pHtest (controls) were studied. Esophageal motor disorderswere noted in 23 of 34 asthmatics, and in 10 of 15patients with acid reflux but in none of the subjects of the control group. A positive result of theprolonged esophageal pH study (pH in the distalesophagus less than 4 for more than 4.2% of therecording time) was obtained in 14 of 17 patients withasthma (only 17 of the original patients were testedbecause the others did not give informed consence forthis test) and in all patients with gastroesophagealreflux. None of the members of the control group had positive test results. The findings of thisstudy show that: (1) it is possible to identify a groupof subjects with nonallergic asthma presenting withesophageal dysmotility, (2) the 24-hr esophageal pH study must be properly done in suchpatients; (3) esophageal motor abnormalities are oftenassociated with positive pH results; and (4) more refluxwas observed while in a supine position (especially during the night) than that observed either incontrol or reflux patients. Based on these results,patients with intrinsic asthma with reflux can benefitfrom both acid suppressive and prokinetic drugs with notable clinical implications regardingstandard treatment for asthma, and those with prevalentsupine compared to upright reflux could even benefitfrom surgery.     

Effect of Amino Acids on Lower Esophageal Sphincter Characteristics and Gastroesophageal Reflux in Humans

The effect of a commercially available mixedamino acids solution, when given either intravenously orintragastrically, on lower esophageal sphincter (LES)pressure, frequency of transient LES relaxations (TLESRs) and gastroesophageal reflux (GER) wasinvestigated in six healthy volunteers. LES pressure andesophageal pH were simultaneously recorded on threeseparate occasions 1 hr before (basal) and 3 hr during intravenous or intragastric infusion ofamino acids (250 mg protein/kg/hr) or saline (control).No significant changes in LES pressure were seen in thecontrol experiment. Intravenous amino acids caused a rapid and sustained (P < 0.01)decrease in LES pressure whereas intragastric aminoacids decreased LES pressure only gradually andtemporarily (P < 0.01). In the three experiments nosignificant differences were observed in TLESR frequency,the number of GER episodes, the mechanism of reflux, orduration of acid exposure. In healthy subjects bothintragastric and, especially, intravenous infusion of amino acids significantly decrease LESpressure but do not affect the frequency of TLESRs orGER episodes during a continuous liquid gastricload.     

Pneumatic Dilatation Is Effective Long-Term Treatment for Achalasia

Although pneumatic dilatation (PD) has been anestablished treatment for achalasia for decades, thereis limited information on its long-term clinicalefficacy. We have followed up the clinical status of patients having PD with a 30- or 35-mm balloonby one of us (D.O.C.) over a 25-year period. Of 144patients whose initial records were available forreview, 31 could not be contacted. Of the remaining 113 patients, 72 (64%) responded to a questionnaireassessing swallowing status and patient satisfaction,and this forms the basis of this report. There were 32men and 40 women, with mean age 46 years (range: 17-78); mean length of follow-up since PD was6.5 years (range: 10 months to 25 years). Success wasprimarily defined by the need for no additional therapyfor achalasia other than one or two PD's. PD was effective long-term treatment in 61/72 patients(85% ); only four of these required a second PD overthis time interval. There was no significant differencein any of the following parameters between patients with a treatment success or failure: age, sex,size of pneumatic dilator, and duration of symptomsprior to PD. Response was significantly better (P <0.05) in patients having no prior dilatation (43/47; 91%) than in those in whom another physicianhad performed prior dilatation (18/25; 72%). In responseto the question of whether they would select PD again,68 patients (94%) responded positively. In conclusion, pneumatic dilatation performedusing a consistent technique by an experienced physicianis effective long-term therapy for achalasia patients ofall ages. Most patients require only onedilatation.     

Effects of Omeprazole on Mechanisms of Gastroesophageal Reflux in Childhood

Prolonged recordings of esophageal motility haveshown that dynamic changes of lower esophageal sphincter(LES) pressure such as transient LES relaxation and LESpressure drifts are the most common mechanisms underlying gastroesophageal reflux (GER). Thecoexistence of a delayed gastric emptying has also beenreported in a high proportion of patients with refluxdisease. However, not much information is available on the effects of antireflux therapy on thepathogenetic mechanisms of GER. The purpose of thisstudy was to determine in a group of children withsevere reflux disease the effect of omeprazole therapy on motor changes of LES underlying GER as wellas on gastric emptying time. Twenty-two children (medianage: 6.6 years) with GER disease, refractory to combinedranitidine and cisapride administration, entered into an eight-week omeprazole course.Ten subjects with moderate GER disease served ascontrols (median age: 6.0 years). Before and afteromeprazole administration, the following variables were assessed: esophagitis grading, fasting and fedsimultaneous prolonged recording of distal esophagealsphincter pressure (with a sleeve catheter) andintraesophageal pH, LES and esophageal peristalsisamplitude, and gastric emptying time of a mixedsolid-liquid meal (measured with gastric ultrasound). Ascompared to controls, patients showed a higher rate oftransient LES relaxation and LES pressure drift (P <0.01), a reduced amplitude of basal sphincter pressure(P < 0.01) and peristalsis (P < 0.05), and a moreprolonged gastric emptying time (P < 0.05). Afterending omeprazole, there was no significant change inany of the motor abnormalities of the esophagus and ingastric emptying time despite a marked improvement ofsymptoms and esophagitis in all patients. Sixteenpatients were symptomatic when reevaluated on a clinical basis two months after ending therapy. Weconclude that in children with severe GER disease, anabnormally high rate of both transient LES relaxationand LES pressure drift and slow gastric emptying are not affected by omperazole treatment, eventhough esophageal mucosal damage is markedly improved orcured. These abnormalities represent a primary motordisorder and can be implicated in the refractoriness of reflux disease.     

Prevalence and Impact of Symptoms Suggestive of Gastroesophageal Reflux Disease

Few studies have focused on the impact ofgastroesophageal reflux disease on general health and onwork absenteeism. Our aim was to evaluate the prevalenceand severity of symptoms suggestive of gastroesophageal reflux disease in two samples of Italianemployees. We interviewed 424 subjects of S. MatteoHospital staff and 344 subjects of the Military Factoryof Pavia regarding the frequency and severity ofheartburn and acid regurgitation during the last 12months. Subjects were specifically asked whethersymptoms interfered with the quality of work activitiesor determined work absenteeism. In all, 91% of eligible subjects responded. The prevalence rate per 100of any heartburn or regurgitation experienced at leastmonthly was 21. This value increased to 45% taking intoconsideration symptoms experienced occasionally. Mild or moderate symptoms were more frequentthan severe symptoms (P < 0.001). Only 2.6% ofsubjects answered that symptoms have a negativeinfluence on the quality of their work. No workabsenteeism was recorded. The study confirms that typicalgastroesophageal reflux symptoms are common conditions,but mainly of mild or moderate degree.     

Obesity Correlates with Gastroesophageal Reflux

Thirty morbidly obese patients presenting forbariatric surgery were evaluated for symptomatic andobjective evidence of gastroesophageal reflux. Sixteenpatients had heartburn while 14 were asymptomatic. All underwent esophageal function testing;manometry was performed in all patients, pH monitoringin 28. Patients with esophageal pH < 4 for more than5% of observed time weighed more than those with normal acid exposure, 165.2 vs 129.8 kg (P <0.01), and had significantly higher body mass indices,56.5 vs 48.3 kg/m² (P < 0.05). Similarly,morbidly obese patients with abnormal reflux scores weighed significantly more and hadgreater body mass indices than patients with normalscores (P < 0.05). Lower esophageal sphincterpressure was higher in patients with normal esophagealacid exposure than in those with abnormal findings,15.5 vs 12.5 mm Hg (P < 0.05). This studydemonstrates a correlation between both weight and bodymass index with gastroesophageal reflux.     

Efficacy and Safety of Cardiomyotomy in Patients with Achalasia After Failure of Pneumatic Dilatation

In patients with achalasia, it has beensuggested that pneumatic dilatation could makecardiomyotomy more difficult to perform, diminishing itsefficacy and safety. Our aim was to evaluate theefficacy and safety of elective cardiomyotomy afterfailure of pneumatic dilatation in achalasia. During 14years, 32 of 276 consecutive patients with achalasiahave been operated on because of failure of dilatation therapy. Twenty patients have been followed-upfor at least one year after surgery. After failure ofdilatation, Heller's cardiomyotomy and 180 anteriorfundoplication were performed. Clinical status was evaluated before and after surgery. Loweresophageal sphincter pressure and esophageal body basalpressure were measured by manometry, esophageal diameterby barium meal, and gastroesophageal reflux by endoscopy and 24-hr esophageal pH monitoring.No technical difficulties were found during operation.Postoperative morbidity was infrequent and mortality wasabsent. Cardiomyotomy improved clinical status in 19 of 20 patients. The results of surgerywere considered excellent or good in 16 patients (80%;CI: 56-94%). The pressure of the lower esophagealsphincter was significantly reduced, falling in most patients to under 10 mm Hg. Gastroesophagealreflux appeared after surgery in eight patients, four ofthem with endoscopic esophagitis, but it was controlledin all patients with medical therapy. In conclusion, cardiomyotomy is a safe and effective therapyin achalasia after failed pneumaticdilatation.     

Gastroesophageal Reflux Disease (Relationship Between Clinical and Histological Features)

Our purpose was to evaluate the relationshipbetween the clinical and histological features in acohort of patients who had gastroesophagealreflux-related lesions diagnosed after upper digestiveendoscopy. In all, 589 patients scheduled for electiveendoscopy in a multicentric prospective study wereevaluated. Multiple biopsies from the distal esophagusshowing aspects of esophagitis or metaplastic epithelium were taken. Esophagitis was histologicallydetected in 25.6%, gastric-type Barrett's esophagus in36.2%, and specialized columnar epithelium in 33.1%. Thefrequency of esophagitis was constant across age decades. Patients with specialized columnarepithelium were significantly older (P = 0.01) and hada greater extent of metaplastic epithelium (P <0.0001). Specialized columnar epithelium was observed in 15% of patients with only distalesophagitis. In conclusion, endoscopic esophagitis wasconstant across age strata. The presence of specializedcolumnar epithelium was associated with older age andwith longer segments of Barrett's esophagus. Shortareas of esophagitis should be biopsied in view of theirpotential for holding areas of specialized columnarepithelium.     

Globus Sensation Is Associated with Hypertensive Upper Esophageal Sphincter but Not with Gastroesophageal Reflux

Globus sensation (globus) is best described asa constant feeling of a lump or fullness in the throat.Although the etiology of globus remains unclear, it hasbeen attributed to a hypertensive upper esophageal sphincter (UES) resting pressure and togastroesophageal reflux (GER). The aim of this studywas, therefore, to determine if significant associationsexisted among globus, UES resting pressure, and GER. We reviewed the records of all patients who hadstationary esophageal manometry over a 21 -year intervalwith specific attention to symptoms of globus, UESpressures, and ambulatory pH studies. Patients with hypotensive UES (<30 mm Hg) wereexcluded. Chi square (²) test was usedto determine significant associations. Six hundred fiftypatients had normal UES resting pressures and 101patients had hypertensive UES (>118 mm Hg). Seventeen ofthe 650 (3%) (16 women/1 man; mean age: 48, range 32-81years) with normal UES described globus. Conversely, 28of the 101 (28%) (15 women/13 men; mean age: 43, range 23- 61 years) patients withhypertensive UES described globus. There was asignificant association between hypertonicity of the UESand globus (² = 93.42, P < 0.0001).In patients with normal UES, globus occurred predominantly infemales (² = 6.33, P < 0.01).Twenty-three (16 women/7 men; mean age: 43, range 23-60years) of the 45 patients with globus had priorambulatory pH studies. Six of 23 (26%) had GER. Compared to an age-,sex-, and UES-pressure-matched group of 23 patients (16women/7 men; mean age: 44, range 22-75 years) withoutglobus, nine (39%) had GER, thus showing no significant association of globus with GER (P = 0.35).There also was no significant association of GER withnormal UES or with hypertensive UES in these patients.In conclusion, there is a significant association between hypertensive UES and globus. The datasuggest two possible etiologies: female patients withnormal UES pressure potentially having increasedafferent sensation and a group with equal sexdistribution but abnormally elevated UES resting pressure.This study does not support GER as an etiology ofglobus.     

Effects of Omeprazole Versus Placebo in Treatment of Noncardiac Chest Pain and Gastroesophageal Reflux

Gastroesophageal reflux (GER) occurs in 22-66%of patients with noncardiac chest pain (NCCP). Althoughopen-label investigations have shown beneficial effectsof antireflux therapy in NCCP, no double-blind, prospective, placebo-controlled studies havebeen conducted. The purpose of this study was toevaluate the effects of omeprazole compared to placeboin a prospective, double-blind, randomized trial ofpatients with NCCP and GER. Thirty-six consecutivepatients with NCCP and GER documented by 24-hrambulatory pH testing entered this study. The subjectswere randomized to omeprazole, 20 mg by mouth twice aday (17 patients), or placebo (19 patients) foreight weeks. Patients on omeprazole obtainedsignificantly more improvement in the fraction of chestpain days (P = 0.006) and severity (P = 0.032) whencompared to placebo. More patients in the omeprazolegroup reported improvement in individual daily painscores (81% vs 44%, P = 0.03) and individual severityscores (81% vs 50%, P = 0.057). Thirteen (81%) of the subjects in the treatment arm reported overallsymptomatic improvement versus one (6%) in the placebogroup (P = 0.001). The results of this study indicatethat acid suppression with omeprazole effectively improves chest pain in patients with NCCP andGER.     

Effects of Previous Treatment on Results of Laparoscopic Heller Myotomy for Achalasia

Until recently, pneumatic dilatation andintrasphincteric injection of botulinum toxin (Botox)have been used as initial treatments for achalasia, withmyotomy reserved for patients with residual dysphagia. It is unknown, however, whether thesenonsurgical treatments affect the performance of asubsequent myotomy. We compared the results oflaparoscopic Heller myotomy and Dor fundoplication in 44patients with achalasia who had been treated withmedications (group A, 16 patients), pneumatic dilatation(group B, 18 patients), or botulinum toxin (group C, 10patients). The last group was further subdivided according to whether there was (C2, 4 patients)or was not (C1, 6 patients) a response to the treatment.Results for groups A, B, C1, and C2, respectively, were:anatomic planes identified at surgery (% of patients) — 100%, 89%, 100%, and 25%;esophageal perforation (% of patients) — 0%, 5%,0%, and 50%; hospital stay (hrs)-26 ± 8, 38± 25, 26 ± 11, and 72 ± 65; andexcellent/good results (% of patients) — 87%, 95%, 100%, and50%. These results show that: (1) previous pneumaticdilatation did not affect the results of myotomy; (2) inpatients who did not respond to botulinum toxin, the myotomy was technically straightforward and theoutcome was excellent; (3) in patients who responded tobotulinum toxin, the LES muscle had become fibrotic(perforation occurred more often in this setting, and dysphagia was less predictably improved);and (4) myotomy relieved dysphagia in 91% of patientswho had not been treated with botulinum toxin. Thesedata support a strategy of reserving botulinum toxin for patients who are not candidates forpneumatic dilatation or laparoscopic Hellermyotomy.     

Gastroesophageal Reflux After Combined Lower Esophageal Sphincter and Diaphragmatic Crural Sling Inactivation in the Rat

This study tests the hypothesis that eitherselective or combined destruction of the loweresophageal sphincter and the diaphragmatic crural slingshould induce reflux in the rat. Pull-through perfusion manometry was performed before and after loweresophageal myectomy, crural myotomy, or both. pHmonitoring was used to detect reflux. Unmanipulated ratsserved as controls. Paired t tests were used for comparison of pre- and postoperative pressurevalues and contingency tables with Fisher's tests forexamining the association between the interventions andthe appearance of reflux. Esophageal myectomy decreased only sphincteric pressure from 25.9± 15.5 to 9 ± 6 mm Hg (P < 0.01),whereas crural myotomy decreased only sling pressurefrom 26.2 ± 13.3 to 7.3 ± 3.9 mm Hg (P< 0.01). Simultaneous performance of both procedures decreasedsphincteric and crural pressures from 20.4 ± 7.5to 7.6 ± 4.3 mm Hg (P < 0.01) and from 45.9± 20.6 to 18.2 ± 7.4 mm Hg (P < 0.01),respectively. None of the control, myectomy, or myotomy animalsshowed reflux upon pH-metry but 5/8 rats in which bothprocedures were performed had prolonged acid exposure.No esophagitis was seen. In conclusion, normal rats do not have reflux. Selective destructionof either the sphincter or the crural sling does notinduce reflux, despite causing flattening of theirrespective manometric profiles. Conversely, combined inactivation of both components issignificantly associated with reflux.     

Esophageal Swallowing Phase Assessed by Audiosignal Recording (Relationship with Manometry in Gastroesophageal Reflux Disease Patients)

The acoustic technique has been used forpharyngeal exploration but to date no such technique hasbeen devised to assess esophageal motility. The aim ofthis study was to demonstrate that displacement through the esophagus can be quantified using thismethod in healthy subjects and in patients withgastroesophageal reflux. Concurrent manometric andacoustic recordings were also performed in the patients.Fifteen controls (38.5 ± 13 years old) and 10patients (34.9 ± 6 years old) were included. Allwere recorded during wet and dry swallow sequences withmicrophones placed below the cricoid cartilage and onthe xiphoid appendix. Standard manometry wasperformed for lower esophageal sphincter (LES)exploration. For the acoustic technique, the frequencyof xiphoid signals (FX), esophageal transit time (ETT),duration of xiphoid sound (SD), and for the manometricstudy, the duration of LES relaxation (RD) were recordedand mean values were calculated (FXm), (ETTm), (SDm),(RDm). FXm for wet (94 vs 81.6%) and dry swallows (86 vs 66.6%) decreased in patients. ETTm wassignificantly higher (P < 0.01) for wet than for dryswallows (5.6 ± 0.9 vs 5.2 ± 1.2 sec) forcontrols but not for patients. ETTm was significantly higher for patients for wet (7.2 ± 2.1sec) and for dry swallows (6.5 ± 2.3 sec) thanfor controls and SDm was lower. Xiphoid sound appearedin the second half of LES relaxation. Our noninvasiveacoustic technique is simple and reproducible. It iswell correlated with manometry, and it allowscharacterization of the displacement of the bolusthrough the esophagus and the LES. The technique couldbe used alone to determine appropriate pharmacologicaland surgical treatments for esophageal motilitydisorders.     

Clinical Effect of Endoscopic Pneumatic Dilation for Achalasia

Although pneumatic dilation is an accepted method for the treatment of achalasia, this therapy has high recurrence and complication rates, and prolonged follow-up studies on the parameters associated with various outcomes are rare. In this prospective 10-year follow-up study, a satisfactory therapeutic effect was achieved without serious complications. We report the therapeutic experience with pneumatic dilation, having aimed to evaluate the long-term clinical safety and efficacy of pneumatic dilation.In total, 35 consecutive patients with idiopathic achalasia who underwent pneumatic dilation were followed up at regular intervals in person or by a phone interview over a 10-year period. The mean duration of the follow-up was 43.03 ± 26.34 months (range 6–120 months). Remission was assessed by the dysphagia classification and symptom scores. Patients’ clinical symptom scores were calculated before and at 6 to 36 months, 37 to 60 months, and >60 months after therapy. The influence of the patients’ age, gender, and disease duration on the therapeutic effect was analyzed.The success rate of the operation was 97.2% (35/36), without massive hemorrhaging, perforation or other serious complications. Dysphagia after the therapy was significantly eased (P < 0.01). In total, 35 patients have been followed up for 6 to 36 months after therapy, 21 cases for 37 to 60 months, and 5 cases for >60 months, and the patients’ symptom scores separately decreased significantly compared with the pretherapy scores (P < 0.01). For these patients, the 6 to 36 months remission rate was 85.7% (30/35), the 37 to 60 months rate was 61.9% (13/21), and the >60 months rate was 40% (2/5). The dilation effect had no relationship to the patient''s age, gender, and disease duration (P > 0.05). The patients in 30 cases (85.7%) were successfully treated with a single dilation, in 4 cases (11.4%) with 2 dilations, and in 1 case (2.9%) with 3 dilations.These results suggest that endoscopic pneumatic dilation is an achalasia therapy with a good response; it is a simple and safe procedure with long-term clinical effectiveness. It is a preferred method in the treatment of achalasia.     

Gastroesophageal Reflux Disease Is a Common Cause of Noncardiac Chest Pain in a Country with a Low Prevalence of Reflux Esophagitis

Gastroesophageal reflux disease is believed tobe uncommon in the East. This study aimed to determineif such a condition was a significant cause ofnoncardiac chest pain in Singapore. Eighty consecutive patients with recurrent chest pain, who hadcardiac and other obvious causes excluded, underwentesophagogastroduodenoscopy, standard manometry, acidperfusion test, and prolonged ambulatory pH and pressure monitoring. Endoscopic esophagitis, positiveacid perfusion tests, pathologic reflux, and positivechest pain-reflux correlation were detected in 7/80(8.8%), 11/70 (15.7%), 14/61 (23.0%), and 12/25 (48.0%) patients, respectively. Among thosewith pathologic reflux, endoscopic esophagitis waspresent in only two (14.3%). Overall, 32 (40%) patientshad gastroesophageal reflux disease. Esophageal motility disorder, alone or in association withgastroesophageal reflux disease, was demonstrated inonly five (6.3%) patients. Our results confirmed westernreports that gastroesophageal reflux disease was a common cause of noncardiac chest pain,whereas motility disorder was an infrequent cause ofsuch pain.     

Importance of Additional Reflux Events During Esophageal Acid Clearing

Decreased swallow frequency and low-amplitude ornonconducted primary peristaltic contractions arereported to prolong acid clearing in gastroesophagealreflux disease (GERD) patients. The aim of this study is to investigate which of these, or otherfactors, have a dominant role in long-duration pH refluxevents (pHRE). Simultaneous manometry and pH monitoringwas performed for 40 min before and after (beginning 40 min postprandial) a test meal. Wearbitrarily chose 180 sec to divide pHREs into long orshort pHREs. Twenty GERD patients with and withoutesophagitis were studied. Esophagitis patients hadthreefold more long pHREs than patients withoutesophagitis. In most (56%) long pHREs, additional refluxevents during acid clearing was the only finding. Only11% of long pHREs had either a decreased swallow rate (3%) or decreased peristaltic contractionamplitude (8%), as the only finding contributing to pooracid clearing. However, 18% of long pHREs had one ofthese peristaltic dysfunctions in combination with additional reflux events prolonging acidclearing. Only 15% of long pHREs had no apparent reasonfor poor acid clearing. In interpreting 24-hr pHmonitoring, one should not assume prolonged acidclearing is due to peristaltic dysfunction; instead, itis often due to additional reflux events.