Influence of endoscopic variceal ligation on oesophageal motility

BACKGROUND: To determine the change of oesophageal manometry in patients with oesophageal varices before and after oesophageal variceal ligation (EVL). METHODS: Forty-five patients who had liver cirrhosis and oesophageal varices with high risk of bleeding were managed by EVL. Oesophageal manometry was performed just prior to the ligation and 4-6 weeks after obliteration of varices. Another 45 age- and sex-matched patients without hepatic, oesophageal or systemic disease served as the control group. RESULTS: At 5 cm above the lower oesophageal sphincter (LES), the amplitude of the contractive wave was significantly lower in patients before EVL (56.9 +/- 31.8 vs 80.1 +/- 30.1, P< 1.05) and returned to the level of control subjects after EVL (76.5 +/- 37.0 vs 80.1 +/- 30.1, P> 0.05). At 10 cm above LES, the amplitude of the contractive wave was significantly lower in patients before and after EVL than the control group (54.3 +/- 29.2 vs 68.1 +/- 29.5, 54.2 +/- 26.0 vs 68.1 +/- 29.5, respectively, P< 0.05). The percentage of tertiary waves was significantly higher in patients before and after EVL than in the control group (31.4 +/- 36.6 vs 5.8 +/- 15.1, 26.9 +/- 32.9 vs 5.8 +/- 15.1, respectively, P< 0.05). However, no significant swallowing disturbance was noted in patients after EVL. There was significantly greater LES length in patients before EVL (4.0 +/- 0.9 vs 3.4 +/- 0.7, P<0.05) but there was no significant difference in the LES length after EVL as compared with the control group. Eighty-six per cent (39/45) of patients developed paraoesophageal varices and 31% (14/45) developed new varices 6 months after variceal obliteration. However, there was no significant difference in manometry at the time of variceal obliteration between patients with variceal recurrence and those without. CONCLUSIONS: The presence of varices affected oesophageal motility. However, such abnormality had little clinical significance. Endoscopic variceal ligation normalized oesophageal motility and may not induce abnormal oesophageal motility. The manometric change can not be used to predict the recurrence of varices in cirrhotic patients after variceal obliteration.     

Endoscopic ligation of oesophageal varices compared with injection sclerotherapy in primary biliary cirrhosis

BACKGROUND AND AIMS: Oesophageal varices are an important complication in primary biliary cirrhosis (PBC). However, there have yet to be any studies made on treatment of oesophageal varices in PBC. We therefore studied the efficacy and related complications of endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS) as an initial treatment in primary biliary cirrhotic patients. METHODS: From December 1985 to March 1999, 29 biliary cirrhotic Japanese patients with portal hypertension and oesophageal varices were treated in our clinics. Eleven patients were treated with EVL and EIS, and 18 patients underwent EIS only. The liver function, renal function and respiratory function were studied before and after endoscopic treatment and any complications were also examined. RESULTS: In stages III and IV, significant differences were observed in the serum levels for total bilirubin and gamma-glutamic pyruvic transaminase only in the EIS group. Significant differences were observed in the rate of appearance of pyrexia, retrosternal pain and pleural effusion between the EIS and EVL groups. CONCLUSION: EVL significantly reduced the adverse effects associated with EIS at the initial session in primary biliary cirrhotic patients.     

Evaluation of endoscopic variceal ligation in prophylactic therapy for bleeding of oesophageal varices: a prospective, controlled trial compared with endoscopic injection sclerotherapy

BACKGROUND: To evaluate the efficacy of endoscopic variceal ligation (EVL) in prophylactic therapy for oesophageal varices, we performed a randomized prospective trial to compare the recurrence of oesophageal varices treated by EVL with those treated by endoscopic injection sclerotherapy. METHODS: Fifty patients with liver cirrhosis were divided into two groups at random, after informed consents were obtained, to receive prophylactic therapy for bleeding of oesophageal varices. Group 1 patients underwent sessions of sclerotherapy with 5% ethanolamine oleate used as the sclerosant. Group 2 patients underwent EVL followed by one or two sessions of sclerotherapy. RESULTS: During the 18 month follow-up period, both the recurrence rate in group 2 (56%) and the incidence of bleeding (20%) were significantly higher compared with group 1 (recurrence rate 16%, bleeding 0%). CONCLUSIONS: This result indicates that EVL is not effective for prophylactic therapy for oesophageal varices in liver cirrhosis.     

Endoscopic variceal ligation is a sufficient procedure for the treatment of oesophageal varices in patients with hepatitis C liver cirrhosis: comparison with injection sclerotherapy

AIMS: Endoscopic variceal ligation (EVL) is a recently developed alternative to endoscopic injection sclerotherapy (EIS) for the treatment of oesophageal varices. Endoscopic variceal ligation and EIS were compared in an attempt to clarify the efficacy and safety of EVL for patients with cirrhosis due to hepatitis C. METHODS: Endoscopic variceal ligation was performed in 60 patients and EIS in 30. Varices were eradicated in all patients by EVL and 87% (26 out of 30) by EIS. RESULTS: There was no significant difference between EVL and EIS in relation to the incidence of bleeding and the 5 year survival rate after treatment. There were no severe complications except mild substernal pain after EVL, while pulmonary embolism occurred in one patient receiving EIS. CONCLUSIONS: Endoscopic variceal ligation is a safe and effective technique for eradicating oesophageal varices in patients with hepatitis C cirrhosis.     

Oesophageal motility and lower oesophageal sphincter competence in progressive systemic sclerosis and localized scleroderma

Oesophageal motility and lower oesophageal sphincter (LOS) competence were investigated in 13 patients with progressive systemic sclerosis (PSS) and in 16 patients with localized scleroderma (LS) by means of oesophageal manometry and 24-h pH monitoring of the distal oesophagus. Results were compared with those of a control group consisting of asymptomatic volunteers. Marked abnormalities in oesophageal motility and in acid exposure in the distal oesophagus were observed in PSS patients only. The mean resting pressure of the LOS was 10.1 +/- 1.5 mmHg in PSS, 21.4 +/- 1.1 mmHg in LS, and 23.8 +/- 2.0 mmHg in asymptomatic controls. Overall sphincter length was 24.1 +/- 3.4 mm in PSS, 31.1 +/- 1.6 mm in LS, and 39.0 +/- 2.0 mm in the control group. Spincter abdominal length was 12.1 +/- 2 mm, 15.4 +/- 1 mm, and 25.0 +/- 1 mm, respectively. The amplitude and duration of oesophageal waves were markedly reduced at 5, 10, and 15 cm above the LOS in PSS patients, with only the upper part of their gullet being spared. An abnormal acid exposure in the distal oesophagus was observed in 84.6% of PSS patients, whereas only 18.2% (2 of 11) of pH-tested LS patients had an abnormal 24-h pH test. These data show that a marked oesophageal involvement is present only in the systemic form of scleroderma. Oesophageal tests may be useful for a circumstantial diagnosis whenever the diagnosis of PSS is uncertain; however, their use does not seem to be justified as routine in patients with LS.     

Patterns of acid reflux in complicated oesophagitis.

Oesophageal manometry and 24 hour ambulatory pH recordings from the distal oesophagus were carried out in 25 patients with complications of oesophagitis (stricture, Barrett's oesophagus or oesophageal ulcer) and compared with 25 patients with uncomplicated oesophagitis. Acid reflux was more severe in the complicated group with 26.2% of time below pH 4 compared with 11.3% in uncomplicated patients (p less than 0.01). This difference was most marked at night, when complicated patients had long periods of acid reflux with 35.6% time less than pH 4 compared with 5.2% uncomplicated (p less than 0.001). The mean duration of nocturnal acid reflux was 15.4 minutes (2.1 minutes uncomplicated, p less than 0.001). Oesophageal motility was markedly abnormal in all groups, but with no demonstrable differences in lower oesophageal sphincter pressure or peristalsis between the groups. Patients with complications of oesophagitis have different patterns of acid reflux from uncomplicated patients, with prolonged nocturnal bathing of the oesophageal mucosa, which may be the cause of stricture formation, metaplasia, or ulceration.     

The initial experience of safety and efficacy of argon plasma coagulation (APC) in the primary prevention of variceal bleeding

Background and study aimsThe well-known complications of variceal bleeding together with the high mortality rate mandate effective prophylaxis. Because of the intolerance, failure of response and lack of compliance related to B blockers and because of the high incidence of variceal recurrence after endoscopic variceal ligation (EVL), other alternatives should be investigated. As APC provides coagulation at a shallow depth, it has been considered an ideal procedure to promote mucosal fibrosis for oesophageal varices. This study aims to investigate the safety and effectiveness of APC application to the oesophagus post-variceal obliteration in an attempt to decrease variceal recurrence and bleeding, as compared to EVL.Patients and methodsThis study included 60 patients with chronic liver disease and portal hypertension referred to the Gastrointestinal Endoscopy Unit, Kasr Al-Aini Hospital, Cairo University, during the period from August 2008 till January 2010. Patients had to have large-sized varices (F3), without history of bleeding, portal hypotensive drugs or intervention.Patients were allocated into either group I that included 30 patients for whom EVL was performed and sequentially followed by one session of APC or group II that included 30 patients for whom EVL alone was done. Patients underwent surveillance endoscopy at 3 and 6 months to evaluate variceal recurrence (F1 or more).ResultsBoth groups were comparable in terms of the demographic features, hepatic functional reserve and endoscopic findings. Post-APC, fever was reported in 6.7%, dysphagia in 3.3%, procedure-related bleeding in 0% and stricture in 3.3%. At 3 and 6 months follow-up, both groups were comparable in terms of variceal recurrence and none of the patients in both groups developed variceal bleeding.ConclusionAlthough, APC application to the oesophageal mucosa is a safe technique, its additive benefit in terms of variceal recurrence and re-bleeding is comparable to EVL alone. This is encountered when only a single session of APC is applied. A more beneficial effect of multiple sessions of APC awaits further studies.     

Endoscopic sclerotherapy of oesophageal varices in rabbits. The long-term effect on oesophageal collagen content and mechanical strength

Sixteen rabbits with oesophageal varices were randomized to no treatment (n = 8) or endoscopic paravenous sclerotherapy of the varices (n = 8). Eight other rabbits served as sham-operated controls. Four months after sclerotherapy the animals were killed, and the mechanical strength and collagen content of the oesophagus were determined at proximal, middle, and distal levels. In animals treated by sclerotherapy there was a 15% increase in collagen content at the distal level when compared with controls and non-treated animals (2p less than 0.05). This was not accompanied by changes in the mechanical strength. At middle and proximal levels there were no differences between the groups. It is concluded that the late effect of one single session of paravenous sclerotherapy of oesophageal varices is a slight fibrosis in the distal oesophagus, with no changes in the mechanical properties of the oesophageal wall.     

Combined multichannel intraluminal impedance and manometry testing

Oesophageal manometry has been considered the "gold standard" test for the evaluation of oesophageal motility. Oesophageal manometry allows physicians to assess peristalsis by using informations about the shape, amplitude and duration of the oesophageal contraction, but it does not offer direct information about bolus transit through the oesophagus. Recent studies demonstrate that combined impedance-manometry provides important additional information about oesophageal motility as compared to conventional manometry such as: (1) monitoring of bolus transport patterns without the use of radiation, (2) calculation of bolus transit parameters, (3) evaluation of bolus clearance and (4) investigation of the relationships between bolus transit and LES relaxation. These changes could potentially improve diagnostic accuracy of oesophageal motility testing, advancing both clinical and basic research. This review focuses on current aspects of the novel technology of combined impedance-manometry for oesophageal motility testing.     

Impedance characteristics of normal oesophageal motor function

OBJECTIVE: To obtain detailed data about the correlation between oesophageal peristalsis and bolus transport for clinical oesophageal motility testing. METHODS: Oesophageal motility testing was performed in 25 healthy subjects by using the newly developed technique of concurrent impedancometry and manometry. Parameters of oesophageal motility and bolus transport as well as the correlation between transit and motility were analysed after swallowing saline or yogurt. RESULTS: Detailed data about bolus transport and oesophageal motility could be obtained during a single investigation step. Air was observed in front of the bolus in 76% of the swallows. Resting baseline impedance was significantly higher in the oesophagus than in the stomach (2832+/-118 Omega vs 688+/-119 Omega). The deglutitive impedance gradient was 222+/-26 Omega for saline and 482+/-38 Omega for yogurt. Bolus propagation velocity and bolus transit time as impedance parameters of bolus transport discriminated fluid from semisolid bolus (4.0+/-0.1 cm/s vs 3.2+/-0.1 cm/s and 9.9+/-0.2 s vs 11.5+/-0.2 s, for saline vs yogurt), while contraction wave amplitude as a manometry parameter of oesophageal motor function did not (91.4+/-7.5 mmHg vs 80.7+/-9.4 mmHg, for saline vs yogurt). There was a poor correlation between bolus propagation velocity and contraction wave amplitude. CONCLUSIONS: Impedance parameters of normal oesophageal motor function have been characterized. Impedancometry and manometry provide different but complementary data about oesophageal motor function. Concurrent impedancometry and manometry allows detailed monitoring of oesophageal motility and bolus transit, which may open new perspectives for comprehensive oesophageal motility testing.     

Effects of low-power argon plasma coagulation thermoablation of Barrett's epithelium on oesophageal motility

INTRODUCTION: Oesophageal dysmotility contributes to the pathogenesis of Barrett's epithelium (BE) allowing prolonged mucosal contact with injurious refluxate. Argon plasma coagulation (APC) is effective for BE ablation, but it is unknown whether the procedure affects oesophageal motility. AIM: To assess the effect of low power (30 W) APC therapy on oesophageal motility in patients with BE. METHODS: Thirty-three patients with at least 4 cm of BE underwent oesophageal manometry before and after APC ablation. All were on proton pump inhibitors. Oesophageal body peristaltic wave duration and amplitude, and lower oesophageal sphincter (LOS) pressure and length were compared before and after treatment. RESULTS: In a total of 28 men and five women, with a mean age of 63.4 years (range 39-79) and mean BE length 6.5 cm (range 4-19), macroscopic clearance was achieved in 28 patients. A small statistically significant (P<0.05) increase in peristaltic wave amplitude was seen after APC [mean (SD) mmHg before versus after: 30.4 (15.2) versus 36.2 (20.1) at 13.5 cm, 47.6 (27.1) versus 54.5 (26.8) at 8.5 cm, and 51.2 (35.3) versus 58 (34.4) at 3.5 cm above the LOS]. No changes in either peristaltic wave duration or LOS parameters [mean (SD) pressure 10.6 (5.6) versus 10.3 (4.3) mmHg; length 2.8 (1.3) versus 2.8 (1.0) cm] were observed. CONCLUSION: APC ablation of BE at a power setting of 30 W does not impair oesophageal motility.     

Oesophageal motility during acid-provoked heartburn and chest pain

Oesophageal motility was studied in 59 patients before and again after prolonged acid perfusion. In group 1 (n = 16), who were asymptomatic during the acid perfusion, no significant motility differences were obtained by perfusion. In group 2 (n = 18), who had heartburn, and in group 3 (n = 25), who had angina-like chest pain during acid perfusion, significant (p less than 0.01-0.001) changes of motility were seen: these included higher peristaltic amplitude, longer contraction duration, and slower peristaltic velocity. In addition, patients in group 3 showed a decrease (p less than 0.01) of peristaltic propagation and had secondary wave activity more often (p less than 0.01) during acid perfusion. Significantly (p less than 0.01) more patients in group 3 showed secondary wave activity after acid perfusion than in group 2. Pretest motility investigation did not separate the two acid-sensitive groups from the acid-unsensitive one, whereas the investigation of the lower oesophageal sphincter (LOS) did. Thus, LOS incompetence was significantly (p less than 0.01) commoner in the two symptomatic groups than in the asymptomatic group. We suggest that the motility changes observed during acid perfusion are secondary to increased sensory stimulation from the oesophagus but are not the cause of the symptoms. However, nervous reflex reactions from other chest organs, such as the heart, may also explain the results.     

Gender variation in oesophageal motor function: Analysis of 129 healthy individuals

BackgroundOesophageal manometry is the standard for diagnosis of oesophageal motor disorders. Minimal data exist assessing the effect of gender on normal oesophageal manometry values.AimEvaluate the impact of gender on normal oesophageal manometry values.MethodsHealthy volunteers were recruited from the Jacksonville metropolitan area. Exclusion criteria were symptoms suggestive of oesophageal disease, medication use or concurrent illness that could affect oesophageal manometry. All underwent oesophageal manometry using a solid-state system with wet swallows.ResultsSixty-three males and 66 females were enrolled. All completed oesophageal manometry without difficulty. Resting lower oesophageal sphincter pressure, distal oesophageal contraction duration and distal oesophageal body contraction amplitude values were significantly higher in females while distal oesophageal body contraction velocity was significantly lower in females (p < 0.05). No differences were seen in other oesophageal manometry parameters.ConclusionSignificant gender differences exist in normal oesophageal manometry. Gender-specific reference values for oesophageal manometry are needed for accurate diagnosis of oesophageal motility disorders.     

High amplitude contractions in the middle third of the oesophagus: a manometric marker of chronic alcoholism?

BACKGROUND--Oesophageal motor abnormalities have been reported in alcoholism. AIM--To investigate the effects of chronic alcoholism and its withdrawal on oesophageal disease. PATIENTS--23 chronic alcoholic patients (20 men and three women; mean age 43, range 23 to 54). METHODS--Endoscopy, manometry, and 24 hour pH monitoring 7-10 days and six months after ethanol withdrawal. Tests for autonomic and peripheral neuropathy were also performed. Motility and pH tracings were compared with those of age and sex matched control groups: healthy volunteers, nutcracker oesophagus, and gastro-oesophageal reflux disease. RESULTS--14 (61%) alcoholic patients had reflux symptoms, and endoscopy with biopsy showed oesophageal inflammation in 10 patients. One patient had an asymptomatic squamous cell carcinoma. Oesophageal motility studies in the alcoholic patients showed that peristaltic amplitude in the middle third was > 150 mm Hg (95th percentile (P95) of healthy controls) in 13 (57%), the ratio lower/ middle amplitude was < 0.9 in 15 (65%) (> 0.9 in all control groups), and the lower oesophageal sphincter was hypertensive (> 23.4 mm Hg, P95 of healthy controls) in 13 (57%). All three abnormalities were present in five (22%). Abnormal reflux (per cent reflux time > 2.9, P95 of healthy controls) was shown in 12 (52%) alcoholic patients, and was unrelated to peristaltic dysfunction. Subclinical neuropathy in 10 patients did not effect oesophageal abnormalities. Oesophageal motility abnormalities persisted at six months in six patients with ongoing alcoholism, whereas they reverted towards normal in 13 who remained abstinent; reflux, however, was unaffected. CONCLUSIONS--Oesophageal peristaltic dysfunction and reflux are frequent in alcoholism. High amplitude contractions in the middle third of the oesophagus seem to be a marker of excessive alcohol consumption, and tend to improve with abstinence.     

Upper gastrointestinal video capsule endoscopy: The state of the art

BackgroundVideo capsule can illuminate the entire gastrointestinal mucosa. Upper gastrointestinal capsule endoscopy (UGICE) has the potential to survey for oesophageal, gastric and duodenal pathology and determine whether biopsy or intervention is indicated.AimsThis review traces the evolution of foregut video capsule endoscopy.MethodsA broad literature research was performed independently by two investigators. Extracted articles were organized and evaluated to interpret all current data.ResultsIn contrast to small bowel capsule, UGICE required sequential innovations to deal with rapid oesophageal transit, the irregular shape of the stomach and unpredictable gastric peristalsis. Oesophageal capsule endoscopy required the development of a two-camera device operating at a high frame rate, and postural change was developed to improve image capture, especially at the level of the Z-line, thus providing good imaging of Barrett's oesophagus, erosive oesophagitis and oesophageal varices, with optimal patients’ tolerance. UGICE in patients presenting to the emergency room with acute bleeding has demonstrated accuracy when deciding on the need for emergency intervention. The latest development of a high frame rate UGICE, designed to image the oesophagus, stomach and duodenum has overtaken dedicated oesophageal capsule development. Capsule control is possible by exposing a magnetised capsule to an external magnetic field, and early reports indicate high accuracy in the oesophagus and stomach with high levels of patient acceptability. There is little information on cost-benefit.ConclusionsCapsule endoscopy offers gastroenterologists a new device to investigate the upper gastrointestinal tract with promising future potential.     

Which patients with primary biliary cirrhosis or primary sclerosing cholangitis should undergo endoscopic screening for oesophageal varices detection?

BACKGROUND: Recent guidelines from an AASLD Single Topic Symposium suggest that patients with cirrhosis, including those with primary biliary cirrhosis (PBC) or primary sclerosing cholangitis (PSC), should be screened for oesophageal varices when the platelet count is <140,000/mm3. AIM: To determine the validity of these guidelines in clinical practice in patients with PBC or PSC. METHODS: Retrospective review of individuals undergoing screening upper endoscopy for oesophageal varices at a single centre. Oesophageal varices were reported as being present or absent. RESULTS: A total of 235 patients with chronic liver disease, including 86 patients with PBC (n=79) or PSC (n=7), 104 patients with chronic viral hepatitis, and 45 with non-alcoholic cirrhosis of differing aetiologies, underwent a single screening endoscopy between 1996 and 2001. Oesophageal varices were detected in 26 (30%) of the PBC/PSC group, 38 (37%) of the viral hepatitis group, and 21 (47%) of the "other" group. Applying multiple logistic regression analysis to the data in the group with PBC/PSC, platelets <200,000/mm3 (odds ratio (OR) 5.85 (95% confidence interval (CI) 1.79-19.23)), albumin <40 g/l (OR 6.02 (95% CI 1.78-20.41)), and serum bilirubin >20 micromol/l (OR 3.66 (95% CI 1.07-12.47)) were shown to be independent risk factors for oesophageal varices. Prothrombin time was unhelpful. The values at these cut offs were not useful in predicting oesophageal varices in the other groups. CONCLUSION: We conclude that current guidelines recommended by the AASLD Single Topic symposium are invalid in our cohort of patients with PBC and PSC. Patients with a platelet count <200,000/mm3, an albumin level <40 g/l, and a bilirubin level >20 micromol/l should be screened for oesophageal varices.     

Oesophageal varices: prophylactic treatment?

Oesophageal varices: prophylactic treatment? Patients with oesophageal varices as a result of liver cirrhosis are at risk of bleeding from these varices. Because of the high mortality, specially from the first variceal haemorrhage, it would seem justified to pose the question: does prophylactic treatment of oesophageal varices reduce the risk of bleeding and improve life expectancy? A review of the literature shows that until now no mode of prophylactic therapy has succeeded in accomplishing these goals. It is not, therefore, possible at this time to advise the use of prophylactic treatment of oesophageal varices as a routine therapy.     

Quantitative assessment of the response to therapy in achalasia of the cardia.

Radionuclide oesophageal transit studies and manometry have been carried out in 15 patients with achalasia of the cardia, before treatment, after a course of nifedipine and after pneumatic bag dilatation. Transit studies were also done in 10 patients after cardiomyotomy and in 10 normal subjects. Images were recorded with the subjects seated in front of a gamma camera while swallowing a 10 ml bolus of 99Tcm-tin colloid and then after a further drink of 50 ml water. There was marked retention of tracer in the oesophagus in patients with achalasia compared with rapid clearance in control subjects. Bag dilatation significantly reduced lower oesophageal sphincter pressure but there was no significant difference in the 50% clearance time or percentage dose retained at 100s before and after the treatments. Oesophageal clearance of tracer after the additional drink of water, was improved by bag dilatation. Oesophageal transit in the patients after cardiomyotomy was similar to that in patients who had undergone bag dilatation. There was considerable retention of the tracer in the oesophagus overnight, but this did not result in pulmonary aspiration. Radionuclide oesophageal transit studies provided a quantitative assessment of therapy in achalasia and the proportion of tracer retained after the additional drink proved to be a sensitive measure of response to treatment. Nifedipine proved ineffective as a treatment for achalasia. Bag dilatation and cardiomyotomy were of similar value.     

Studies of acid exposure immediately above the gastro-oesophageal squamocolumnar junction: evidence of short segment reflux

BACKGROUND AND AIMS: Oesophageal pH is conventionally recorded from a point 5 cm above the lower oesophageal sphincter. However, the mucosal changes of reflux oesophagitis and intestinal metaplasia tend to affect the segment of oesophagus distal to this and close to the squamocolumnar junction. This study set out to investigate oesophageal acid exposure of squamous mucosa close to the squamocolumnar junction. METHODS: Dual channel 24 hour pH monitoring was carried out in 11 patients with endoscopy negative dyspepsia and no evidence of gastro-oesophageal reflux by conventional oesophageal pH metry. Oesophageal pH was recorded from electrodes positioned 5 mm and 55 mm proximal to the squamocolumnar junction. A novel technique was developed using metal clips to secure the pH catheter to the oesophageal mucosa and maintain these electrode positions. Oesophageal manometry indicated that the distal electrode was within the high pressure zone of the lower oesophageal sphincter. RESULTS: We found that 24 hour oesophageal acid exposure (per cent time pH <4) was greater 5 mm above the squamocolumnar junction compared with the conventional position 5 cm more proximal (11.7% v 1.8%; p<0.001). The greater acid exposure at the distal versus the conventional site was apparent in both the upright (12.7% v 2.3%) and supine (10.5% v 1.3%) positions, as well as during preprandial (14.2% v 1.6%) and postprandial (21.8% v 2.8%) periods (p<0.001 for each). The number of reflux events recorded close to the squamocolumnar junction was also higher than at the conventional position (168 v 33; p<0.001). There was no correlation between acid exposure at the two sites. CONCLUSIONS: The squamous mucosa of the most distal oesophagus is exposed to substantial acidic reflux, even in patients without evidence of conventional reflux disease. This short segment reflux may explain the high incidence of metaplasia and neoplasia at the gastro-oesophageal junction.     

Systematic comparison of conventional oesophageal manometry with oesophageal motility while eating bread.

Conventional oesophageal manometry is seldom accompanied by symptoms and may indeed be normal in patients with a history of dysphagia. We have recently shown that oesophageal manometry during eating may be helpful in the evaluation of patients with dysphagia but there has been little systematic comparison of fed oesophageal motor patterns with conventional clinical manometry. Oesophageal manometry in response to water swallows and during eating was therefore examined in 58 consecutive patients who had been referred for clinical oesophageal function studies. The patients were divided into three groups according to the percentage of peristaltic activity during conventional manometry: group 1 (n = 21) had 100% peristalsis; group 2 (n = 29) had 1-99% peristalsis and group 3 (n = 8) were aperistaltic. All the patients in group 3 had achalasia and remained aperistaltic during eating, however, was less than with water swallows in both group 1 (53% compared with 100%) and group 2 (49% compared with 82.3%) patients. Synchronous contractions and non-conducted swallows were correspondingly increased during eating. Although there was a significant correlation between the amplitude of peristaltic contractions with water and bread in groups 1 and 2, mean peristaltic amplitudes were less with bread than with water swallows. The data show that there are substantial differences in the distal oesophageal motility patterns produced by water swallows and by eating. Conventional manometry with water swallows does not allow prediction of the fed oesophageal motility pattern, except in patients with achalasia.