Twenty four hour oesophageal acidity in achalasia before and after pneumatic dilatation.

Radiotelemetric ambulatory 24 hour oesophageal pH measurement was carried out in 17 patients with symptomatic manometrically proven achalasia before and after pneumatic dilatation. Before dilatation an abnormally high percentage acid exposure time was present but typical episodes of gastro-oesophageal reflux occurred in only one patient. In nine patients who had a oesophageal food residue these values were significantly greater than those found in the remaining patients without retained food. Analysis of oesophageal food residues revealed that the low pH was predominantly caused by lactic acid. These findings indicate that preoperative oesophageal pH studies do not offer a valid means of selection of patients in whom an antireflux procedure should be combined with cardiomyotomy. Repeat studies one week after pneumatic dilatation showed a fall in the acid exposure time in patients with initial food residue presumably resulting from improved oesophageal emptying after treatment. A significant rise in acid exposure time after dilatation was seen in those patients without initial food residue presumably resulting from gastro-oesophageal reflux after therapeutic disruption of the lower oesophageal sphincter. Troublesome symptoms of gastro-oesophageal reflux were, however, uncommon after bag dilatation.     

Manometric and pH-metric features in gastro-oesophageal reflux disease patients with and without Helicobacter pylori infection

BACKGROUND: The role of Helicobacter pylori in the pathogenesis and evolution of gastro-oesophageal reflux disease is still debated. AIM: To investigate the impact of Helicobacter pylori infection on the oesophageal function and on intra-gastric and intra-oesophageal pH in patients with gastro-oesophageal reflux. METHODS: Fifty patients with non-complicated-gastro-oesophageal reflux disease classified according to Savary-Miller in: grade O, n=24; grade 1, n=19; grade 2, n=6; grade 3, n=1. Of these patients, 24 were Helicobacter pylori positive and 26 negative. Patients underwent, on two different days, stationary oesophageal manometry and 24-hour gastro-oesophageal pH-metry. RESULTS: No difference was observed between Helicobacter pylori infected and non-infected individuals with regard to lower oesophageal sphincter function, oesophageal peristalsis and gastrooesophageal reflux. These parameters were more impaired in individuals with erosive gastro-oesophageal reflux disease but this result was not dependent on the Helicobacter pylori status. Helicobacter pylori did not influence the pattern of gastric pH; however, considering only individuals with non-erosive gastro-oesophageal reflux disease, gastric pH was significantly higher in infected individuals, who, histologically, also showed a corpus predominant gastritis. CONCLUSIONS: In patients with gastro-oesophageal reflux disease, Helicobacter pylori does not affect the oesophageal motility or the gastro-oesophageal reflux. These parameters are strictly related to the severity of gastro-oesophageal reflux disease as assessed at endoscopy. In patients with non-erosive gastro-oesophageal reflux disease, a corpus predominant Helicobacter pylori gastritis could be responsible for the less severe gastro-oesophageal reflux.     

Ambulatory 24 hour intraoesophageal pH and pressure recordings v provocation tests in the diagnosis of chest pain of oesophageal origin.

Fifty patients with non-cardiac chest pain underwent 24 hour intraoesophageal pH and pressure recording and provocation tests to determine the relative value of both techniques in establishing the oesophageal origin of the chest pain. Twenty six patients (52%) had at least one positive provocation test: the acid perfusion test was positive related in 18 patients (36%), the edrophonium test in 16 patients (32%), the vasopressin test in five patients (10%), and the balloon distension test (performed in only 20 patients) in one (5%). The 24 hour pH and pressure recording correlated spontaneous chest pain attacks with abnormal motility or gastro-oesophageal reflux in 19 patients (38%). Fourteen of these patients also had at least one positive provocation test. Therefore, 24 hour pH and pressure recordings are only slightly better than a set of provocation tests in identifying the oesophagus as the cause of chest pain (10% diagnostic gain). In the case of oesophageal chest pain, however, 24 hour recording appeared to be the only way to identify the nature of the underlying oesophageal abnormality that caused the spontaneous pain attacks--for example, gastro-oesophageal reflux, motility disorders, or irritability of the oesophagus.     

Reliability of 24-hour oesophageal pH monitoring under standardized conditions

BACKGROUND: Twenty-four-hour pH monitoring is an investigation technique that can give both false-positive and false-negative results, depending on patient factors such as diet and different activities. The aim was to study the reproducibility of 24-h oesophageal pH monitoring under as standardized conditions as possible in patients with symptoms of gastro-oesophageal reflux disease. METHODS: Antimony pH electrodes were used in 22 adult patients who were investigated twice, 6 weeks apart, under identical conditions. They were hospitalized and were served a standardized diet which had been tested to contain no lower than pH 5.0. Neither coffee nor smoking was allowed. The patients had to refrain from proton-pump inhibitors for 10 days and H2 blockers for 2 days prior to the investigation. The paired t test was used. RESULTS: There was no significant difference in total reflux time, upright or supine reflux time, or longest reflux periods between the two test occasions. However, there were discordant results in six patients who had normal total reflux time on one test occasion but pathological results on the other. CONCLUSION: Since the biological variability of gastro-oesophageal reflux is not negligible from time to time, a normal 24-h oesophageal pH test should be assessed with caution.     

Reliability of 24-Hour Oesophageal pH Monitoring Under Standardized Conditions

Background : Twenty-four-hour pH monitoring is an investigation technique that can give both false-positive and false-negative results, depending on patient factors such as diet and different activities. The aim was to study the reproducibility of 24-h oesophageal pH monitoring under as standardized conditions as possible in patients with symptoms of gastro-oesophageal reflux disease. Methods : Antimony pH electrodes were used in 22 adult patients who were investigated twice, 6 weeks apart, under identical conditions. They were hospitalized and were served a standardized diet which had been tested to contain no lower than pH 5.0. Neither coffee nor smoking was allowed. The patients had to refrain from proton-pump inhibitors for 10 days and H 2 blockers for 2 days prior to the investigation. The paired t test was used. Results : There was no significant difference in total reflux time, upright or supine reflux time, or longest reflux periods between the two test occasions. However, there were discordant results in six patients who had normal total reflux time on one test occasion but pathological results on the other. Conclusion : Since the biological variability of gastro-oesophageal reflux is not negligible from time to time, a normal 24-h oesophageal pH test should be assessed with caution.     

Reflux related symptoms in patients with normal oesophageal exposure to acid.

Several studies, using pH monitoring with event markers, have identified patients with normal oesophageal exposure to acid despite an apparent relation between symptoms and reflux episodes. In this series of 771 consecutive patients referred for 24 hour oesophageal pH monitoring, a probability calculation was used to evaluate the relation between symptoms and reflux episodes. Oesophageal exposure to acid was normal in 462 of 771 recordings (59.9%); despite this, 70.8% (327 of 462) of these patients used at least once the event marker. In 96 patients (12.5% of total patients) with normal oesophageal exposure to acid, there was a statistically significant association between symptoms and reflux episodes. The symptom cluster of such patients was similar to that usually seen in patients with gastro-oesophageal reflux disease, but symptoms like belching, bloating, and nausea were common thus overlapping with the symptom pattern of functional dyspepsia. In these patients both the duration and the minimum pH of reflux episodes (either symptom related or asymptomatic) were significantly shorter and higher, respectively, when compared with those of patients with gastro-oesophageal reflux disease. These results are consistent with the idea that oesophageal hypersensitivity to acid is the underlying pathophysiological feature of this syndrome.     

Ambulatory 24 hour intraesophageal pH-monitoring in the diagnosis of gastroesophageal reflux disease.

The results of ambulatory 24 hour oesophageal pH monitoring in 20 patients with established gastro-oesophageal reflux disease were compared with those of 20 healthy individuals with normal endoscopy. Cut off limits of pH 3, 4, and 5 were superior to pH 2 with respect to the discrimination of patients from normal subjects, and for the detection of pathological reflux. Using pH 4 as a cut off limit, the ambulant and recumbent periods of pH monitoring were more discriminatory than the postprandial period. Furthermore, it was possible to get complete separation between patients and normal subjects using several combinations of two reflux variables. Another group of 30 patients and 30 controls were investigated. Using percentage time at pH less than 4 as a single determinant of gastro-oesophageal reflux, the sensitivity and specificity were 87% and 97%, respectively, with 3.4% as upper limit for normality. Twenty four hour oesophageal pH monitoring in an ambulatory outpatient environment afforded clinically useful diagnostic accuracy in separating patients with gastro-oesophageal reflux disease from asymptomatic controls.     

Oesophageal function in patients with angina pectoris: a comparison of patients with normal coronary angiograms and patients with coronary artery disease

Oesophageal function was assessed in 52 patients with angina pectoris whose coronary angiograms were completely normal and in 21 patients with angina pectoris who had significant coronary artery disease. During a standard oesophageal manometric study, abnormalities were found in 23 (44%) patients with normal coronary angiograms but in only 2 (10%) patients with coronary artery disease (p less than 0.01). Twenty-four (46%) patients with normal coronary angiograms were found to have gastro-oesophageal reflux disease during 24-hour oesophageal pH monitoring. Of the 52 patients with normal coronary angiograms, 19 (37%) had gastro-oesophageal reflux disease and abnormal oesophageal motility, 5 (10%) had gastro-oesophageal reflux disease alone, and 7 (13%) had oesophageal motility disorder alone. The use of provocation procedures, including intravenous edrophonium during oesophageal manometry and treadmill exercise testing during pH monitoring, enabled the oesophageal abnormality to be demonstrated simultaneously with chest pain in 25 of these 31 patients. Typical angina pectoris, coincident with abnormal oesophageal motility, was precipitated in a subgroup of patients who had been shown to have oesophageal manometric abnormalities and gastro-oesophageal reflux disease by the infusion of hydrochloric acid into the oesophagus; both the chest pain and manometric abnormality resolved following the oral administration of antacid.     

Gastro-oesophageal reflux in the irritable bowel syndrome.

Symptomatic assessment and oesophageal investigations were done in 25 consecutive patients with the irritable bowel syndrome attending a gastroenterological clinic. Symptoms of gastro-oesophageal reflux, dysphagia, and a globus sensation were significantly commoner than in a control group of fracture clinic patients. Ambulatory oesophageal pH monitoring showed clearly abnormal reflux in 11 of 22 patients (50%). Nine patients had macroscopic endoscopic changes and a further 11 biopsy changes alone, of oesophagitis which was thus present in 80% overall. Lower oesophageal sphincter pressure was significantly less in irritable bowel patients than in age and sex matched controls, but upper oesophageal sphincter pressure was comparable in the two groups and disordered peristalsis was not found. Oesophageal symptoms in the irritable bowel syndrome are mainly caused by gastro-oesophageal reflux predisposed to by a subnormal lower oesophageal sphincter pressure, rather than by oesophageal spasm.     

Oesophagitis, signs of reflux, and gastric acid secretion in patients with symptoms of gastro-oesophageal reflux disease

In a study comprising 100 patients referred to a surgical clinic with symptoms suggestive of gastro-oesophageal reflux disease the value of different diagnostic procedures was investigated. Positive acid perfusion and 24-h pH tests were the commonest findings. Forty-nine per cent showed a normal oesophageal mucosa or diffuse oesophagitis at endoscopy. The severity of heartburn and regurgitation did not differ between patients with normal oesophageal mucosa and oesophagitis of various severities. The severity of macroscopic oesophagitis was significantly correlated to the total reflux time, the presence of reflux or a hiatal hernia at radiology, an open cardia or reflux at endoscopy, pressure transmission or reflux and low lower oesophageal sphincter pressure at manometry. Gastric hypersecretion was found in 66% of the patients. Gastric acid secretion was not correlated to the severity of oesophagitis or to the findings at 24-h pH test. In patients with severe oesophagitis the sensitivity for radiologic, manometric, and endoscopic signs of incompetence of the gastro-oesophageal junction was 94%.     

Gastro-oesophageal reflux disease and respiratory disease

Abstract An epidemiological survey showed that respiratory symptoms with gastro-oesophageal reflux (GER) were twice as high as those without GER symptoms. In 46 cases of unknown chronic cough or asthma, 67% had positive oesophageal pH monitoring. Of 34 patients with snoring and reflux symptoms, 16 (47.1%) were confirmed as positive for obstructive sleep apnoea (OSA) and GER. Anti-reflux therapy significantly improved both GER and OSA.     

Oesophagitis,Signs of Reflux,and Gastric Acid Secretion in Patients with Symptoms of Gastro-Oesophageal Reflux Disease

Johansson K-E, Ask P, Boeryd B, Fransson S-G, Tibbling L. Oesophagitis, signs of reflux, and gastric acid secretion in patients with symptoms of gastro-oesophageal reflux disease. Scand J Gastroenterol 1986, 21, 837-847

In a study comprising 100 patients referred to a surgical clinic with symptoms suggestive of gastro-oesophageal reflux disease the value of different diagnostic procedures was investigated. Positive acid perfusion and 24-h pH tests were the commonest findings. Forty-nine per cent showed a normal oesophageal mucosa or diffuse oesophagitis at endoscopy. The severity of heartburn and regurgitation did not differ between patients with normal oesophageal mucosa and oesophagitis of various severities. The severity of macroscopic oesophagitis was significantly correlated to the total reflux time, the presence of reflux or a hiatal hernia at radiology, an open cardia or reflux at endoscopy, pressure transmission or reflux and low lower oesophageal sphincter pressure at manometry. Gastric hypersecretion was found in 66% of the patients. Gastric acid secretion was not correlated to the severity of oesophagitis or to the findings at 24-h pH test. In patients with severe oesophagitis the sensitivity for radiologic, manometric, and endoscopic signs of incompetence of the gastro-oesophageal junction was 94%.     

High prevalence of abnormal acid gastro-oesophageal reflux in idiopathic pulmonary fibrosis.

The aim of this prospective study was to determine the prevalence and characteristics of acid gastro-oesophageal reflux (GER) in patients with idiopathic pulmonary fibrosis (IPF). Sixty-five consecutive patients with well-defined IPF were subjected to 24-h pH monitoring and oesophageal manometry. A total of 133 consecutive patients with intractable asthma and symptoms of GER were used as comparisons. The prevalence of abnormal acid GER in IPF patients was 87%, with 76% and 63% demonstrating abnormal distal and proximal oesophageal acid exposures, respectively. Abnormal acid GER was significantly more common in IPF patients than asthma patients. Only 47% of IPF patients experienced classic GER symptoms. Despite treatment with standard doses of proton pump inhibitors (PPIs), 12 out of 19 patients receiving PPIs during the 24-h pH monitoring had abnormal oesophageal acid exposures by pH probe. There was no correlation between IPF severity and acid GER severity. In conclusion, abnormal acid gastro-oesophageal reflux is highly prevalent, but often clinically occult in patients with idiopathic pulmonary fibrosis. Standard doses of proton pump inhibitors may not suppress the acid gastro-oesophageal reflux in this population. Therefore, further studies are needed to determine if acid abnormal gastro-oesophageal reflux represents an important risk factor for idiopathic pulmonary fibrosis development or progression, and if optimal suppression of acid gastro-oesophageal reflux slows the progression of idiopathic pulmonary fibrosis and/or decreases episodic exacerbations of idiopathic pulmonary fibrosis.     

Is ambulatory 24-h dual-probe pH monitoring useful in suspected ENT manifestations of GERD?

BACKGROUND AND AIMS: The present study is aimed at assessing the relationship between ear, nose and throat manifestations and proximal reflux in gastro-oesophageal reflux disease by using 24-h dual-probe pH monitoring. PATIENTS AND METHODS: Fifty-eight patients were included: (;) 28 patients with suspected ear, nose and throat manifestations of gastrooesophageal reflux disease: (ii) 18 patients with typical symptoms of gastro-oesophageal reflux disease without extraoesophageal manifestations of gastro-oesophageal reflux disease; (iii) 12 healthy volunteers. Ambulatory 24-h dual-probe pH monitoring was performed in all patients. Oesophagogastroscopy was performed in all patients of groups I and II. Ear, nose and throat examination was performed in all patients with ear, nose and throat complaints. RESULTS: At the upper oesophageal sphincter, results of pH monitoring were significantly different between groups I and III (0.009 < P < 0.02) and between groups I and II (0.008 < P < 0.03). When comparing data at the lower oesophageal sphincter, we found a significant difference between groups II and III (0.002 < P < 0.009) and between groups I and III (0.001 < P < 0.002). Endoscopic examination of the oesophagus did not show any significant difference between groups I and II. Laryngoscopy was abnormal in 86% of the patients with ear, nose and throat symptoms. CONCLUSIONS: Ambulatory 24-h dual-probe pH monitoring is useful in the assessment of patients with suspected ear, nose and throat manifestations of gastro-oesophageal reflux disease, especially in the case of abnormal laryngoscopy.     

Intra-oesophageal acid suppression in complicated gastro-oesophageal reflux disease: esomeprazole versus lansoprazole

BACKGROUND: Acid suppression is the mainstay of therapy in gastro-oesophageal reflux disease. Esomeprazole 40 mg is more effective than lansoprazole 30 mg in healing mucosal lesions in severe erosive reflux oesophagitis. However, data comparing esomeprazole with lansoprazole in patients with complications of gastro-oesophageal reflux disease, such as ulcerative reflux oesophagitis and Barrett's oesophagus, are lacking. AIM: To compare the efficacy of esomeprazole and lansoprazole at their standard dosages in suppressing oesophageal acid exposure in complicated gastro-oesophageal reflux disease. METHODS: Thirty patients with complicated gastro-oesophageal reflux disease (7 with ulcerative reflux oesophagitis and 23 with Barrett's oesophagus), randomly assigned to receive 40 mg esomeprazole (n=16) or 30 mg lansoprazole (n=14) once daily, underwent oesophageal 24-h pH monitoring while on therapy. Total, upright diurnal and supine nocturnal percentage acid reflux time were assessed. RESULTS: Esomeprazole was significantly more effective than lansoprazole in decreasing oesophageal acid exposure. Normalisation of both total and supine nocturnal percentage acid reflux time was obtained in 12 of 16 (75%) patients treated with esomeprazole but only in 4 of 14 (28%) cases treated with lansoprazole (p=0.026). CONCLUSIONS: Normalisation of oesophageal acid exposure can be achieved in the majority of complicated gastro-oesophageal reflux disease cases with esomeprazole 40 mg once daily.     

Inflammation at the cardio-oesophageal junction: relationship to acid and bile exposure

BACKGROUND: The aetiology of inflammation in cardiac mucosa at the gastro-oesophageal junction (carditis) is unclear, although gastro-oesophageal reflux has been suggested. OBJECTIVES: To correlate histological features of carditis with oesophageal acid exposure (gastro-oesophageal reflux) and proximal gastric bile exposure (duodenogastric reflux) in patients with symptoms of gastro-oesophageal reflux disease (GORD). METHODS: Sixty-six patients with reflux symptoms underwent endoscopy with biopsy, oesophageal manometry, 24-h oesophageal pH testing and 24-h proximal gastric Bilitec 2000 testing. Inflammation in glandular mucosa was assessed using the updated Sydney System. Fifteen healthy volunteers underwent pH and Bilitec 2000 testing and served as controls. RESULTS: There was no correlation between either the presence or histological grade of carditis and oesophageal acid exposure or proximal gastric bilirubin exposure. Patients with reflux symptoms had as much duodenogastric reflux into the proximal stomach as did control subjects. CONCLUSIONS: We were unable to establish either gastro-oesophageal or duodenogastric reflux as the predominant cause of inflammation in cardiac mucosa.     

Ambulatory 24-hour oesophageal pH monitoring in normal subjects: a multicentre study in Italy. G.I.S.M.A.D. GOR Study Group.

A multicentre study was performed in Italy in order to establish normal values for acid gastro-oesophageal reflux. In 73 healthy subjects 24-hour oesophageal pH measurements were carried out under standardized conditions. The hourly number of reflux episodes and oesophageal acid exposure was assessed and analyzed by means of a computerized system. The distribution frequency of both parameters was skewed to the left, thus exhibiting a non-normal pattern. Acid reflux was lowest during the night and highest after meals. The oesophageal acid exposure and the number of reflux episodes were correlated both over 24 hours and in the subsets studied. A good agreement was found with data from previous reports. Our findings should be helpful in establishing a data base for physiological gastro-oesophageal reflux.     

Left ventricular function and oesophageal function in patients with angina pectoris and normal coronary angiograms

Left ventricular function and oesophageal function (including oesophageal manometry and pH monitoring) were investigated and a psychiatric assessment carried out in 63 patients with angina pectoris and normal coronary angiograms. Twenty two (35%) patients had regional abnormalities of left ventricular wall motion (group A). Thirty six (57%) patients had an oesophageal abnormality (group B); 19 patients had gastro-oesophageal reflux and abnormal oesophageal motility, five had gastro-oesophageal reflux alone, and 12 had abnormal oesophageal motility alone. Only four had regional abnormalities of the left ventricular wall and abnormal oesophageal function. In nine (14%) patients left ventricular and oesophageal function were normal (group C). Psychiatric morbidity was significantly less common in group A than in groups B and C and was similar in group B and group C. A definite abnormality of left ventricular function, oesophageal function, or psychiatric morbidity is present in a high proportion of patients with angina pectoris and normal coronary angiograms and in some instances this may lead to specific treatment. If quantitative assessment of left ventricular function is normal, oesophageal investigations should be performed. Endoscopy of the upper gastrointestinal tract may demonstrate oesophageal disease, but, if findings are normal, oesophageal manometry and ambulatory oesophageal pH monitoring (including during treadmill exercise testing) should be carried out.     

Left ventricular function and oesophageal function in patients with angina pectoris and normal coronary angiograms.

Left ventricular function and oesophageal function (including oesophageal manometry and pH monitoring) were investigated and a psychiatric assessment carried out in 63 patients with angina pectoris and normal coronary angiograms. Twenty two (35%) patients had regional abnormalities of left ventricular wall motion (group A). Thirty six (57%) patients had an oesophageal abnormality (group B); 19 patients had gastro-oesophageal reflux and abnormal oesophageal motility, five had gastro-oesophageal reflux alone, and 12 had abnormal oesophageal motility alone. Only four had regional abnormalities of the left ventricular wall and abnormal oesophageal function. In nine (14%) patients left ventricular and oesophageal function were normal (group C). Psychiatric morbidity was significantly less common in group A than in groups B and C and was similar in group B and group C. A definite abnormality of left ventricular function, oesophageal function, or psychiatric morbidity is present in a high proportion of patients with angina pectoris and normal coronary angiograms and in some instances this may lead to specific treatment. If quantitative assessment of left ventricular function is normal, oesophageal investigations should be performed. Endoscopy of the upper gastrointestinal tract may demonstrate oesophageal disease, but, if findings are normal, oesophageal manometry and ambulatory oesophageal pH monitoring (including during treadmill exercise testing) should be carried out.     

Increased gastro-oesophageal reflux disease in patients with severe COPD.

The prevalence and clinical consequences of gastro-oesophageal reflux disease (GERD) in chronic obstructive pulmonary disease (COPD) are not well characterised. The present study prospectively studied 42 males with COPD (forced expiratory volume in one second % predicted: 35%, range 20-49) and 16 healthy volunteers of similar age without respiratory or gastro-oesophageal symptoms. The diagnosis of GERD was confirmed using oesophageal 24 h pH monitoring. In the current study group, reflux symptoms were measured using the Vigneri score, cough and dyspnoea with the modified Medical Research Council questionnaire, and pulmonary function with bronchodilator response and health status using St George's Respiratory Questionnaire. Pathological reflux was documented in 26 out of 42 patients (62%) and in three volunteers (19%). In patients with GERD, 15 patients (58%) did not report any reflux symptoms. There were no differences in symptoms, health status, bronchodilator treatment and pulmonary function test between patients with and without GERD. Oxygen desaturation coincided with episodes of increased oesophageal acidity in 40% of patients with GERD. Patients with severe chronic obstructive pulmonary disease have a high prevalence of asymptomatic gastro-oesophageal reflux. The association between this reflux and oxygen desaturation deserves further attention.