Excess gastroesophageal reflux in patients with hiatus hernia is caused by mechanisms other than transient LES relaxations

BACKGROUND & AIMS: Esophageal acid exposure is higher in gastroesophageal reflux disease (GERD) patients with hiatus hernia than in those without. We investigated the effect of a sliding hiatus hernia on the mechanisms underlying spontaneous gastroesophageal reflux over 24 hours. METHODS: Twelve GERD patients with and 10 GERD patients without hiatus hernia were studied for 24 hours. Combined esophageal pH and manometric recordings of the pharynx, lower esophageal sphincter (LES), and stomach were performed using a multiple-lumen assembly incorporating a Dent sleeve connected to a portable water-perfused manometric system and a pH glass electrode. RESULTS: Patients with hiatus hernia had greater esophageal acid exposure (7.6% vs. 3.3%; P < 0.01) and more reflux episodes (3.1 vs. 1.8/h; P < 0.001) than those without. LES pressure, the incidence of transient LES relaxations (TLESRs), and the proportion of TLESRs associated with acid reflux were comparable in both groups. Both groups had equal numbers of reflux episodes associated with TLESRs and swallow-associated prolonged LES relaxations. Patients with hiatus hernia had more reflux associated with low LES pressure, swallow-associated normal LES relaxations, and straining during periods with low LES pressure. CONCLUSIONS: The excess reflux in GERD patients with hiatus hernia compared with those without is caused by malfunction of the gastroesophageal barrier during low LES pressure, swallow-associated normal LES relaxations, deep inspiration, and straining.     

Does the duration of gastroesophageal reflux disease and degree of acid reflux correlate with esophageal function? A retrospective analysis of 768 patients

To reconfirm that the duration of symptoms is not associated with esophageal motility in patients with gastroesophageal reflux disease (GERD), esophageal manometric data from 768 patients with GERD were retrospectively analyzed with relation to the duration of symptoms. GERD was defined by positive acid reflux test results monitored by ambulatory 24-hour pH monitoring. Correlation of the duration of symptoms with esophageal body pressures, the presence of dysmotility determined by simultaneous waves, average resting pressure of the lower esophageal sphincter (LES), and abdominal and overall lengths of the LES were statistically analyzed. The median duration of the symptoms was 60 months (range, 1-600). Duration of symptoms was not associated with contraction pressures of the esophageal body at 3 and 8 cm above the LES (r = -0.070 and -0.063, respectively). There was no correlation between LES pressures, LES lengths, or the percentage of simultaneous waves and duration of symptoms. Stricture formation is related to decreased distal esophageal function in GERD patients. In conclusion, the duration of GERD has little influence on esophageal body and LES function.     

胃食管反流病食管测压与24小时pH监测的相关性研究

目的：对５２例有胃食管反流症状的患者进行食管测压及２４小时ｐＨ监测，运用统计学方法分析测压和ｐＨ结果，研究其相关性。方法：应用多导胃肠功能测定仪及便携式ｐＨ监测记录仪，对５２例有胃食管反流症状的患者进行食管测压及２４小时ｐＨ监测。结果：应用多元回归分析发现，ｐＨ的百分比和腹段下食管括约肌（ＬＥＳ）的长度、ＬＥＳ静息压及远端食管的蠕动压明显相关。依据测压及ｐＨ结果，使用ｔ检验方法，结果提示食管蠕动压不仅与ｐＨ＜４的百分化相关，也与酸反流大于５分钟的时间、最长反流时间有关（Ｐ＜００１）。结论：腹段ＬＥＳ的长度及食管下段的蠕动收缩是重要的抗反流屏障。食管酸暴露时间延长减弱食管体部酸清除能力     

Antireflux mechanism of Nissen fundoplication. A manometric study.

To analyze the mechanisms by which Nissen fundoplication controls gastroesophageal reflux, the pre- and post-operative manometric findings in 34 patients were compared. The postoperative assessment showed an increase in both the infradiaphragmatic length and basal pressure of the lower esophageal sphincter and a notable improvement in esophageal motility (increase in the amplitude of the waves and decrease in the mean percentage of deglutitions without response and tertiary waves) in those who preoperatively presented with defective esophageal peristalsis.     

Comparison of Lower Esophageal Sphincter Manometrics and Gastroesophageal Reflux Measured by 24-Hour pH Recording

We compared lower esophageal sphincter (LES) pressures to parameters of acid reflux measured during 24-h pH monitoring in 81 patients being evaluated for possible reflux disease. Mid-respiratory LES pressures were significantly higher (p less than 0.05) in patients with normal amounts of reflux than in those with abnormal reflux. This difference did not occur with LES pressure measured by end-expiratory station pull-through (SPT) or rapid pull-through (RPT). There was no significant difference in total length or intra-abdominal portion of LES between the two groups. However, the product of LES pressure and total LES length was greater (p less than 0.05) for patients with normal reflux than for these with abnormal reflux. No difference was noted in the percentage of abnormal contractions in the distal esophagus between groups. These studies support the following conclusions: 1) LES pressure may be a more important protective mechanism against reflux than LES length. 2) Mid-respiratory SPT technique appears to identify the LES antireflux barrier better than either end-expiratory SPT or RPT techniques. 3) Acid exposure time seems to be a better measure of gastroesophageal reflux than the number of reflux episodes.     

下食管括约肌运动和功能与胃食管反流病

目的　观察胃食管反流病 (GERD)患者与对照组餐前、餐后食管pH情况 ,下食管括约肌(LES )运动模式的变化以及酸反流事件与一过性下食管括约肌松弛 (TLESR )、低LES压力 (LESP)的关系。方法　两组受试者均接受连续性 4h食管压力测定 (分别为空腹和餐后 1、2、3h)和食管pH监测 (GERD组检测 4h ,对照组检测 2 4h)。结果　GERD组酸反流事件明显高于对照组 (P <0 0 5 )。两组间TLESR发生率差异无显著性 (P >0 0 5 ) ,但与空腹比较 ,两组餐后 1h和 2hTLESR发生率明显增多 ;GERD组伴有酸反流的TLESR明显高于对照组 (P <0 0 0 1)。 4 3% (2 9/ 6 8)的酸反流事件发生在TLESR期间。 31% (2 1/ 6 8)的酸反流事件出现于低LESP状态中。结论　GERD是多因素参与的病理过程。LES运动形式变化和功能不全是GERD的重要背景因素。     

Effect of laparoscopic partial fundoplication on reflux mechanisms

OBJECTIVES: Transient lower esophageal sphincter relaxations (TLESRs) are the main mechanism causing gastroesophageal reflux. Since 1994 we have performed laparoscopic partial instead of complete fundoplication as standard surgical treatment for therapy resistant reflux disease to minimize postoperative dysphagia. To better understand the management of gastroesophageal reflux, we conducted a prospective study of the effects of laparoscopic partial fundoplication on TLESRs and other reflux mechanisms. METHODS: From 1994 to 1999, 65 patients underwent laparoscopic partial fundoplication (180-200 degrees) and 28 of these patients (16 female, 12 male, mean age 43 +/- 2 yr [range, 26-66 yr]) agreed to participate in this prospective study on reflux mechanisms. Before and 6 months after surgery, all patients were evaluated by simultaneous recording of pH and lower esophageal sphincter characteristics, using sleeve manometry. RESULTS: After partial fundoplication basal LES pressure increased significantly (p < 0.05), from 14.3 +/- 1.2 mm Hg to 17.8 +/- 1 mm Hg. Partial fundoplication significantly (p < 0.05) decreased the number of TLESRs, from 3.4 +/- 0.8 to 1.6 +/- 0.3 per hour in the fasting period, and from 4.7 +/- 0.5 to 1.9 +/- 0.3 per hour postprandially. The percentage of TLESRs associated with reflux also decreased significantly (p < 0.05), from 45 +/- 7% to 27 +/- 6% after operation. The number of reflux episodes decreased significantly (p < 0.05), from 4.1 +/- 0.7 to 1.3 +/- 0.3 per hour postoperatively. The majority of these episodes were associated with TLESRs: 57% and 46%, pre- and postoperatively, respectively. CONCLUSIONS: Laparoscopic partial fundoplication significantly increased fasting and postprandial LES pressure and significantly decreased TLESR frequency. This resulted in a significant reduction in esophageal acid exposure, with preservation of postprandial LES characteristics.     

Antireflux surgery for symptomatic gastroesophageal reflux

To determine the effects of Nissen fundoplication upon the symptoms of reflux and the diagnostic tests employed to evaluate reflux and to examine the relationship between gastroesophageal reflux and lower esophageal sphincter pressure before and after fundoplication, 10 patients with symptomatic reflux were studied before and after operation. Clinical evaluation, barium esophagography, endoscopy with mucosal biopsy, esophageal manometry, acid-perfusion and acid-reflux testing, and gastroesophageal scintiscanning were performed on each patient before and after surgery. Following fundoplication, marked symptomatic, radiographic, endoscopic, and histologic improvement was observed. Serial acid-reflux tests at increasing gastroesophageal pressure gradients returned to normal after surgery. Lower-esophageal-sphincter (LES) pressure increased from 8.2±1.3 to 12.0±1.5 mm Hg (P<0.01). In addition, surgery resulted in a significant decrease in the gastroesophageal reflux index from 17.4±2.4 to 2.7±1.1% (P<0.001). Surprisingly, the pre- and postoperative resting LES pressures did not correlate significantly with corresponding gastroesophageal reflux indices for individual patients. We conclude that increased LES pressure alone does not explain adequately the functional and clinical improvement which follows fundoplication.     

腹腔镜Nissen和Toupet胃底折叠术治疗食管裂孔疝合并胃食管反流病的术后效果评价

目的探讨腹腔镜Nissen和Toupet胃底折叠术治疗食管裂孔疝合并胃食管反流病的疗效和术后并发症。 方法回顾性分析2014年7月至2016年7月,在中国医科大学附属盛京医院行腹腔镜下食管裂孔疝修补联合胃底折叠术的57例食管裂孔疝合并胃食管反流病患者的临床资料,其中24例行Nissen胃底折叠术式(Nissen组),33例行Toupet胃底折叠术式(Toupet组)。观察并比较2组患者的术后抗反流效果及发生术后并发症情况。 结果57例均顺利完成腹腔镜下手术,无中转开腹,手术时间68～115 min,平均手术时间(75.8±6.4)min;术中出血量15～30 ml,平均出血量(22±5)ml;2组患者均使用补片行食管裂孔疝修补术;术后24 h进流食,术后平均住院日(10.5±3)d。2组患者手术时间,出血量,住院日无明显差别。57例患者均得到随访,随访时间为6个月至2.5年,平均随访时间为18个月。术后均未出现反酸,烧心等胃食管反流病典型症状,无复发病例。Nissen组术后有2例(8.2%)患者出现吞咽困难,Toupet组术后有8例(24.2%)出现吞咽困难,Toupet组术后并发症发生率明显高于Nissen组。术前伴有胃食管反流病的患者行胃镜检查均有不同程度的食管炎症,所有患者术后均复查胃镜、食管测压及食管24 h pH值监测。复查结果显示,2组患者术后较术前食管下括约肌压力均有明显改善,食管下括约肌长度也均明显延长。 结论腹腔镜下Nissen术式在术后出现吞咽困难发生率上少于Toupet术式,但2种术式抗反流效果无明显差异。     

Transient Lower Esophageal Sphincter Relaxations and Gastroesophageal Reflux Episodes in Healthy Subjects and GERD Patients During 24 Hours

Still little is known about the 24-hr pattern of transient lower esophageal sphincter relaxations (TLESRs), particularly in patients with GERD. The aim of our study was to evaluate the 24-hr esophageal and LES motor pattern and esophageal pH and to identify the relationship between TLESRs and gastroesophageal reflux in healthy subjects and in GERD patients. Ten healthy subjects and nine patients with esophagitis (grade I–II) underwent a 24-hr pH manometric recording by means of a portable electronic device. The recording aimed at identifying the temporal relationships between reflux episodes and LES motor events. The GERD patients showed a greater number of either reflux episodes or TLESRs during the 24 hr as compared to controls. While most refluxes occurred during TLESRs in both groups, a small percentage of TLESRs was followed by reflux episodes in healthy people, with only a slight increase in GERD patients. In conclusion, although representing an important motor pattern during gastroesophageal reflux both in healthy subjects and in patients with GERD, TLESR could probably be considered one of the pathophysiologic mechanisms of gastroesophageal reflux more than the primary cause of reflux episodes.     

小儿食管裂孔疝反流和手术抗反流机制的研究

目的了解小儿食管裂孔疝（ＨＨ）发生反流和手术抗反流的作用机制。方法２０例经钡餐造影确诊的ＨＨ患儿进行手术前后食管２４小时ｐＨ监测和食管动力功能检查。结果２０例患儿均有病理性胃酸反流；术后各项反流指标除了平均反流周期外均显著改善，下食管括约肌长度（ＬＥＳＬ）显著增加（从１．１７ｃｍ增加到１．９４ｃｍ．Ｐ＜０．０１）．主要是腹内食管段增加明显（从０．５４ｃｍ增加到１．３０ｃｍ，Ｐ＜０．０５）。胃内压降低（从２．８６ｍｍＨｇ降到１．７８ｍｍＨｇ，Ｐ＜０．０１）：术后腹内食管段长度影响治疗效果，长度长则疗效好（Ｐ＜０，０５）；手术前后下食管括约肌压力（ＬＥＳＰ）无显著差别（Ｐ＞０．０５）。结论小儿ＨＨ发生反流的机制是由于ＬＥＳ长度不足，主要是腹内食管段长度不足甚至消失及胃内压增高引起；手术抗反流的机制定增加了ＬＥＳ的长度，主要是增加了腹内食管段的长度。     

Drug effects on esophageal smooth muscle

To assess which manometric parameters should be evaluated to discriminate health and esophageal motility disorders, we established normal values for lower esophageal sphincter pressure (LESP), LES residual pressure, percentage and duration of LES relaxation, contraction amplitude in the esophageal body, duration of the contractile waves, mode of wave propagation, and shape of contraction amplitudes as well as upper esophageal sphincter pressure (UESP) in 40 healthy volunteers. The values obtained were compared to values in 25 patients with achalasia, 48 patients with nonspecific motility disorders, and 28 patients with reflux esophagitis. Although significant differences of mean values could be found between health and diseased states of esophageal motility, it was impossible to establish clear cutoff points in individuals due to a large overlap of manometric parameters in healthy volunteers and patients. Further prospective studies are necessary to determine sensitivity, specificity, and predictive values of cutoff lines of manometric data. In addition to the inability to define esophageal motility disorders on the basis of motility parameters alone, there is a lack of correlation between the severity of esophageal symptoms and manometric findings. For example, in diffuse esophageal spasm and related disorders, amplitude, duration, configuration, and propagation of esophageal body contractions are not closely related to the severity of symptoms. In reflux esophagitis, mean LESP does not reflect the extent of symptoms or mucosal damage. Only in achalasia, do LESP and resting pressure of the esophageal body seem to be correlated to dysphagia. It is concluded that drug effects on esophageal motility should be evaluated not primarily by manometric data but by clinical effects.     

食管动力和反流事件在OSAHS发病机制中意义

目的探讨阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome,OSAHS)与胃反流性疾病(gastroesophageal reflux disease)的关系。 方法2013年2月至2014年6月期间就诊于新疆维吾尔自治区人民医院的OSAHS患者30例,采用多导睡眠监测、24 h多通道腔阻抗-pH监测和高分辨率胃肠动力学检查系统进行监测,观察食管上、下括约肌、食管动力学特点及反流事件相关指标,并与10例健康成人对照组比较,比较组间各测量指标差异。 结果OSAHS组较对照组食管上括约肌松弛持续时间、食管上括约肌松弛恢复时间、食管下括约肌长度、远端收缩积分平均值均减小,收缩前沿速度增加,差异均具有统计学意义(t＝－2.061、－2.044、－2.525、－2.076、2.522,P均<0.05)。OSAHS组与对照组中DeMeester评分中位数(M[P25;P75])分别为11.3[5.1;37.8]、3.8[2.8;11.1]分。食管近端反流总次数分别为41.5[23.8;65.3]、24.5[16.3;27.8]次,酸反流次数分别为20.0[10.0;32.0]、10.5[7.8;14.3]次。OSAHS组食管近端反流总次数、酸反流次数及DeMeester评分均较对照组增加,差异均有统计学意义(z＝－2.438、－2.361、－2.140,P均<0.05)。 结论OSAHS部分患者存在食管上、下括约肌结构和功能障碍,存在胃食管反流现象,食管近端反流以酸性物质为主。     

Lower esophageal sphincter pressure in normal individuals and patients with gastroesophageal reflux. A comparison between end-hole and side-hole recording techniques

The advantage of a single-lumen end-hole catheter compared with the usual composite side-hole catheter for lower esophageal sphincter (LES) manometry has been studied in vitro and in vivo. In the present study LES pull-through manometry was performed with a special catheter, enabling simultaneous end-hole and side-hole recording of LES pressure. Eighteen normal individuals with normal 24-h pH-monitoring (control group) and 42 reflux patients with pathologic 24-h pH-monitoring (reflux group) were studied. End-hole recorded resting sphincter pressure (RSP) in the control group was 15.4 +/- 5.0 cm H2O and in the reflux group 6.4 +/- 6.4 (p less than 0.0005). Side-hole recorded RSP (mean S1-S3) was 20.8 +/- 11.6 and 11.9 +/- 6.8, respectively (p less than 0.005). End-hole recorded total sphincter length (SL) in the control group was 34 +/- 9 mm and in the reflux group 27 +/- 12 (p less than 0.025) and abdominal sphincter length (ASL) 23 +/- 7 and 16 +/- 9, respectively (p less than 0.005). Side-hole recorded SL was 30 +/- 7 and 30 +/- 12, respectively (NS) and ASL 22 +/- 6 and 18 +/- 9 respectively (NS). After intake of 500 ml of water both LES pressure and length decreased in both groups but the separation between the groups was neither improved nor impaired. The results support the view that LES insufficiency is an important cause of gastroesophageal reflux. That LES had a lower pressure and was shorter in patients with reflux was best demonstrated by end-hole recorded pressure.     

Esophageal body length, lower esophageal sphincter length, position and pressure in health and disease

We compared esophageal dimensions in control subjects and patients with differing motility disorders and severities of reflux disease. Patients (1108) and healthy controls (36) underwent manometry and 24-h pH monitoring. Subjects were grouped according to pH and manometry data into seven groups. Mean (s.e.m.) esophageal body length is greatest in achalasia [22.41 (0.27) cm] and least in reflux disease [20.06 (0.13) cm, p < 0.05]. Lower esophageal sphincter (LES) pressure is greatest in achalasia [17.46 (1.06) mmHg] and least in reflux disease [6.57 (0.24) mmHg, p < 0.05]. LES length is least in achalasia patients and control subjects. The ratio of intra-abdominal to intrathoracic LES is greatest in achalasia (1.29), no reflux and normal motility group, and controls and least in reflux disease (1.04, p < 0.05). In conclusion, esophageal body length is greatest in achalasia and least in reflux disease. This is associated with caudal movement of the LES in achalasia and cranial movement of the LES in reflux disease, relative to the diaphragm.     

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.     

Concurrent Fluoroscopy and Manometry Reveal Differences in Laparoscopic Nissen and Anterior Fundoplication

A prospective double-blind randomized trial wasinitiated to examine two types of laparoscopicfundoplication (Nissen and anterior). Thirty-twopatients with proven gastroesophageal reflux diseasepresenting for primary laparoscopic antireflux surgerywere randomized to undergo either Nissen fundoplication(N = 13) or anterior hemifundoplication (N = 19).Postoperative fluoroscopic and manometric examinationwas carried out concomitantly. Nissenfundoplication resulted in significantly greaterelevation of resting (33.5 vs 23 mm Hg) and residuallower esophageal sphincter pressures (17 vs 6.5 mm Hg)and lower esophageal ramp pressure (26 vs 20.5 mm Hg) than theanterior partial fundoplication. A smallerradiologically measured sphincter opening diameter wasseen following Nissen fundoplication (9 mm) comparedwith anterior fundoplication (12 mm). Lower esophageal ramppressure correlated weakly (r = 0.37, P = 0.04) withpostoperative dysphagia. It is concluded that the typeof fundoplication performed significantly influences postoperative manometric and video bariumradiology outcomes. The clinical relevance of thisrequires further investigation.     

Correlation of esophageal pH and motor abnormalities with endoscopic severity of reflux esophagitis

Motility abnormalities, common in gastroesophageal reflux disease, are likely to be related to endoscopic esophagitis. We studied pH and manometry parameters in relation to the severity of esophagitis. Forty-seven patients with symptomatic gastroesophageal reflux disease for > 3 months were evaluated by: (i) endoscopy (grading of esophagitis by Savary-Miller classification); (ii) mucosal biopsy; (iii) manometry; and (iv) 24-h pH-metry. We found Savary-Miller's grades of: 0 (9 patients out of 47), I (16/47), II (16/47), III (4/47), IV (2/47). Distal esophageal contraction amplitude was lower in severe (grade II to IV) as compared with mild (grade 0 and I) esophagitis (49 [7-182] versus 83 [27-196] mmHg [P = 0.001]). The length and pressure in the lower esophageal sphincter (LES), duration and velocity of contraction in the body, number of episodes of reflux and long-duration reflux, longest reflux, median pH, per cent of time with pH < 4 and DeMeester scores were not significantly different between the two groups. The area under pH 4 showed a negative correlation with LES pressure and amplitude of distal esophageal contractions. We conclude that higher endoscopic grades of esophagitis are associated with lower amplitude of contraction in distal esophagus. Lower LES pressure and distal esophageal contraction amplitude are associated with greater area under curve for pH below 4.     

Determinants of gastroesophageal junction incompetence: hiatal hernia, lower esophageal sphincter, or both?

OBJECTIVE: To examine the effects of hiatal hernia and lower esophageal sphincter (LES) pressure on the competence of the gastroesophageal junction under conditions of abrupt increases in intra-abdominal pressure. DESIGN: Acute experiments. SETTING: University-hospital-based gastroenterology practice. PARTICIPANTS: Sixteen asymptomatic volunteers and 34 patients with endoscopic findings suggestive of hiatal hernia. INTERVENTION: A series of eight provocative maneuvers entailing abrupt changes in intra-abdominal pressure. MEASUREMENTS: Five radiographic measurements relevant to the presence and extent of hiatal hernia were made from videotaped barium-swallow examinations. Lower esophageal sphincter pressure was measured immediately before each maneuver. The percentage of maneuvers that resulted in gastroesophageal reflux was calculated as the reflux score. A stepwise regression analysis was then used to model the relation between measured variables of the gastroesophageal junction (manometric and radiographic) with reflux score. RESULTS: Patients with hiatal hernia had substantially higher reflux scores and lower LES pressures than either patients without hernias or volunteers. In diminishing order of significance, the terms in the model of susceptibility to reflux were axial length of hernia measured between swallows; LES pressure; and an interaction term in which a progressive increase occurred in the risk for reflux associated with a hypotensive lower esophageal sphincter as hernia size increased. CONCLUSIONS: Gastroesophageal junction competence during abrupt increases in intra-abdominal pressure is compromised by both hiatal hernia and low LES pressure. These factors interact with each other to determine susceptibility to reflux.     

Clinical and manometric findings in benign peptic strictures of the esophagus

To determine the possible factors that may contribute to the development of peptic stricture of the esophagus, clinical and manometric features were compared in patients with symptomatic gastroesophageal reflux and those with peptic strictures of the esophagus. Patients with stricture were older and had a longer duration of heartburn than patients without a stricture. Most importantly, patients with stricture had a more marked decrease in lower esophageal sphincter (LES) pressure, 4.9±0.5 mm Hg, than patients without a stricture, 7.5±0.6 mm Hg, P<0.01. The LES pressure in all patients with stricture was below 8 mm Hg, and did not overlap with normal values. Patients with stricture had either a nonspecific motor abnormality or aperistalsis (64%), compared to patients with symptomatic reflux (32%), P<0.05. Thus, peptic stricture of the esophagus is commonly associated with a long duration of reflux symptoms in patients with a very low LES pressure and esophageal motor disorder.