Clinical, endoscopic, and functional studies in 408 patients with Barrett's esophagus, compared to 174 cases of intestinal metaplasia of the cardia

OBJECTIVE: The pathophysiology of gastroesophageal reflux disease (GERD) has been studied extensively in patients with long-segment Barrett's esophagus (LSBE), but few reports have explored GERD pathophysiology in patients who have short-segment Barrett's esophagus (SSBE) or intestinal metaplasia at the cardia (IMC). We aimed to compare clinical, endoscopic, histological, and functional features in patients with LSBE, SSBE, and IMC. METHODS: We identified 582 patients who had intestinal metaplasia at the squamocolumnar junction in the distal esophagus and divided them into three groups based on the extent of columnar-lined esophagus observed endoscopically: 1) patients with IMC who had no columnar-lined esophagus (i.e., the squamocolumnar and gastroesophageal junctions coincided), 2) patients with LSBE who had >3 cm of columnar-lined esophagus, and 3) patients with SSBE who had <3 cm of columnar-lined esophagus. All patients had esophageal manometric evaluation, and 24-h esophageal pH monitoring was performed to determine the extent of acid and bile (bilirubin) reflux. RESULTS: There were 174 patients with IMC, 155 with LSBE, and 25 with SSBE. Compared to patients with LSBE and SSBE, patients with IMC had significantly lower frequencies of GERD symptoms, hiatal hernia, and erosive esophagitis; significantly higher lower esophageal sphincter pressures; and significantly shorter durations of acid and bile reflux. Between patients with SSBE and LSBE, significant differences were found in the frequency of hiatal hernia and duration of acid reflux (both greater in the patients with LSBE). Also, dysplasia was significantly more frequent in patients with LSBE than in those with SSBE or IMC. CONCLUSION: GERD symptoms, signs, and physiological abnormalities are found more often in patients with Barrett's esophagus than in those with IMC, and the duration of acid reflux in patients with LSBE is greater than that in patients with SSBE. These findings suggest that the extent of intestinal metaplasia in the esophagus is related directly to the severity of underlying GERD.     

Acid and bile reflux in erosive reflux disease, non-erosive reflux disease and Barrett's esophagus

BACKGROUND/AIMS: Gastroesophageal reflux disease (GERD) may occur with acid, bile or in a mixed form. Endoscopic injury and mucosal metaplasia are a known sequlae to pathological GERD. The aim of the study was to determine the contribution of acid and duodenogastroesophageal reflux (DGER) to endoscopic severity in patients with GERD and Barrett's esophagus. METHODS: Ninety-one patients complaining of reflux symptoms were studied with upper gastrointestinal endoscopy and graded to non-erosive reflux disease (NERD), erosive reflux disease (ERD) and Barrett's esophagus (BE). Esophageal manometry and simultaneous ambulatory 24-h esophageal pH and bilirubin monitoring (Bilitec 2000) were done to all patients. RESULTS: Seventy one patients (78.0%) had ERD (Savary-Miller (grade I-III), 11 patients (12.1%) had NERD and 9 patients (9.9%) had BE suspected endoscopically and diagnosed by histological esophageal biopsy. Combined 24-h esophageal bilirubin and pH monitoring revealed that 39 patients (42.9%) had mixed acid and bile reflux, 16 (17.6%) had pathological acid reflux only, 18 (19.8%) had bile reflux only and 18 patients (19.8%) had no evidence of abnormal reflux. The percentage of the total time of bilirubin absorbance above 0.14, in 71 patients with ERD was (8.18 +/- 11.28%), and in 9 patients with BE was (15.48 +/- 30.48%) which was significantly greater than that in 11 patients with NERD (4.48 +/- 8.99%), p < 0.05 and p = 0.01 respectively. All BE patients had abnormal esophageal bile reflux (3 bile alone and 6 mixed bile and acid); 44 of 71 patients (61.97%) with ERD had abnormal esophageal bile reflux (13 bile alone and 31 mixed bile and acid); meanwhile 15 of them (21.2%) had abnormal acid exposure alone. Of the 11 patients with NERD, 4 patients (36.4%) had abnormal esophageal bile reflux, 2 of them mixed with acid. CONCLUSIONS: The Bilitec method reliably identifies the presence of bilirubin and quantitatively detects duodenogastroesophageal reflux of bile. Mixed reflux (acid and bile) is the chief pattern of reflux in GERD patients in this study. Bile reflux either alone or mixed with acid reflux contributes to the severity of erosive and non-erosive reflux disease as well as to Barrett's esophagus.     

胆汁在胃食管反流病中的作用

随着24 h食管pH监测和胆汁监测技术的开展,胃、十二指肠液混合反流在胃食管反流病(GERD)的发生、发展中的作用已被逐步认识.胆汁反流在GERD发病过程中所扮演的角色,成为近年来人们研究的焦点之一.基础研究证明胆汁在不同酸碱环境、不同浓度对食管黏膜的损伤作用是不同的.不少临床试验对GERD进行研究发现,胆汁反流与症状和食管损伤严重度存在一定关系,但研究结果不尽一致,胆汁在GERD中的作用仍有争议.明确胆汁在GERD中的作用,有助于为预防此类疾病开辟新的道路.本文就有关胆汁反流在胃食管反流病中的作用的研究进展作一综述.     

Role of duodenogastroesophageal reflux in the pathogenesis of esophageal mucosal injury and gastroesophageal reflux symptoms.

BACKGROUND AND AIM: Patients with gastroesophageal reflux disease (GERD) usually suffer from acid reflux and duodenogastroesophageal reflux (DGER) simultaneously. The question of whether DGER has an important effect on the development of GERD remains controversial. The aim of the present study was to investigate the role of DGER in the pathogenesis of GERD and its value for the diagnosis of nonerosive reflux disease (NERD). METHODS: GERD was initially diagnosed using the reflux disease questionnaire. For further diagnosis, results of the upper gastrointestinal endoscopy (excluding a diagnosis of Barrett's esophagus) were considered in conjunction with simultaneous 24 h esophageal pH and bilirubin monitoring. RESULTS: According to endoscopic findings, 95 patients (43 men, 50+/-10 years of age) were divided into two groups: the reflux esophagitis (RE) group (n=51) and the NERD group (n=44). Three DGER parameters, the percentage of time with absorbance greater than 0.14, the total number of reflux episodes and the number of bile reflux episodes lasting longer than 5 min, were evaluated in the study. For the RE group, the values of the DGER parameters (19.05%+/-23.44%, 30.56+/-34.04 and 5.90+/-6.37, respectively) were significantly higher than those of the NERD group (7.26%+/-11.08%, 15.68+/-20.92 and 2.59+/-3.57, respectively, P<0.05 for all) but no significant difference was found in acid reflux. Of NERD patients, 18.5% were diagnosed with simple DGER. The positive diagnosis rate of NERD could be significantly elevated from 65.9% to 84.1% (P<0.05), if bilirubin monitoring was employed in diagnosis. CONCLUSIONS: DGER may occur independently but plays an important role in the development of RE and GERD symptoms. Simultaneous 24 h esophageal pH and bilirubin monitoring is superior to simple pH monitoring in helping identify patients at risk for NERD.     

胆汁反流检测在胃食管反流病中的意义

目的 研究食管胆汁反流的发生情况,探讨其与酸、碱反流的关系及其对胃食管反流病（ＧＥＲＤ）的诊断意义。方法 应用便携式２４小时ｐＨ监测仪及胆汁监测仪同步检测反流性食管炎（ＲＥ）、胃切除术后者及健康志愿者共３４例的食管内２４小时ｐＨ变化及胆汁反流情况。结果 ＲＥ组食管酸暴露时间比对照组及胃手术后组均显著增加。各组间ｐＨ〉８总时间百分比结果相似,均较低。食管胆汁反流用胆红素吸收值≥０．１４的时间百分比表     

Esophageal manometry and ambulatory 24-hour pH monitoring in patients with short and long segment Barrett’s esophagus

Objective: Short segment Barrett’s esophagus (SSBE) is defined as the presence of specialized intestinal metaplasia (SIM) in the distal 2–3 cm of the esophagus. Although gastroesophageal reflux and heartburn is very common in these patients, the pathophysiology of the development of a short segment of SIM versus a longer segment of Barrett’s epithelium is not clear. The aim of this study was to assess the extent of gastroesophageal reflux in short versus long segments of SIM. Methods: Of 203 consecutive patients undergoing endoscopy with two biopsies performed just distal to the squamocolumnar junction, 28 patients were identified as having SSBE as evidenced by SIM on biopsy. Twenty-two SSBE patients underwent esophageal manometry and 24-h dual pH monitoring, and the results were compared with 18 long segment Barrett’s esophagus (LSBE) patients and 15 patients with normal 24-h pH studies. Results: SSBE and LSBE patients were significantly older than normal subjects (p < 0.0001). Also, lower esophageal sphincter pressure was significantly greater in SSBE patients compared with LSBE patients (12.3 ± 1.6 vs 5.2 ± 1.0 mm Hg, p < 0.0008). LSBE patients had a significantly lower distal esophageal peristaltic amplitude as compared with normals (p < 0.012). At 5 cm proximal to the LES, SSBE patients had significantly lower total 24-h pH scores, percent upright and percent supine reflux as compared with LSBE patients. Similarly, when measured at the proximal LES (0 cm), SSBE patients had significantly lower 24-h pH scores when compared with LSBE patients (p < 0.03), whereas percent upright and percent supine reflux were not significantly different. Both LSBE and SSBE patients had a greater degree of GER measured at 5 cm above and just proximal to the LES when compared with normals. Conclusion: As a group, SSBE patients have more competent LES sphincters and less gastroesophageal reflux at 0 and 5 cm above the LES as compared with patients with LSBE. These data indicate that the degree and length of acid exposure in the esophagus are important factors in the pathogenesis of SIM involvement of the esophagus.     

Importance of duodeno-gastro-esophageal reflux in the medical outpatient practice

BACKGROUND/AIMS: The role of acid and duodeno-gastro-esophageal reflux (DGER), also termed bile reflux, in esophageal mucosal injury is controversial. Several recent developments, especially availability of the recent bilirubin monitoring device (Bilitec), have resulted in clarifications in this area. In order to better understand the role of acid and DGER in esophageal mucosal injury, we summarized the recent publications in this area. METHODOLOGY: Review of published medical literature (MEDLINE) on the clinical consequence of esophageal exposure to gastric acid or DGER. RESULTS: Recent data suggest that esophageal pH monitoring and pH > 7 is a poor marker for reflux of duodenal contents into the esophagus. DGER in non-acidic environments (i.e., partial gastrectomy patients) may cause symptoms but does not cause esophageal mucosal injury. Acid and duodenal contents usually reflux into the esophagus simultaneously, and may be contributing to the development of Barrett's metaplasia and possibly adenocarcinoma. Proton pump inhibitors decrease acid and DGER by reducing intragastric volume available for reflux and raising intragastric pH. The promotility agent cisapride decreases DGER by increasing LES pressure and improving gastric emptying. CONCLUSIONS: 1) The term "alkaline reflux" is a misnormer and should no longer be used in referring to reflux of duodenal contents. 2) Bilitec is the method of choice in detecting DGER and should always be used simultaneously with esophageal pH-monitoring for acid reflux. 3) DGER alone is not injurious to esophageal mucosa, but can result in significant esophageal mucosal injury when combined with acid reflux. 4) Therefore, controlling esophageal exposure to acid reflux by using proton pump inhibitors also eliminates the potentially damaging effect of DGER.     

Increased acid and bile reflux in Barrett's esophagus compared to reflux esophagitis, and effect of proton pump inhibitor therapy

OBJECTIVES: Barrett's metaplasia is an acquired condition resulting from longstanding gastroesophageal reflux disease. Approximately 10% of esophagitis patients develop Barrett's esophagus. There is increasing evidence that duodenogastroesophageal reflux plays a role in the progression of disease. We further analyzed the correlation of acid and biliary reflux with reflux esophagitis and Barrett's esophagus and tested the effects of proton pump inhibitor therapy. METHODS: Patients with either reflux esophagitis (group 1) or Barrett's esophagus (group 2) prospectively underwent simultaneous 24-h esophageal pH and bile reflux testing without any therapy affecting acid secretion or GI motility. A total of 16 patients in group 1 and 18 patients in group 2 were tested again under proton pump inhibitor therapy. RESULTS: Acid and bile exposure were significantly increased in Barrett's patients (n = 23) compared to 20 esophagitis patients (median percentage of time that pH was <4 was 24.6% vs 12.4%, p = 0.01, median percentage of time that bilirubin absorbance was >0.2 was 34.7% vs 12.8%, p < 0.05). During therapy, both acid and bile reflux decreased significantly in both groups. Median percentage of time that pH was <4 and bilirubin absorbance was >0.2 before and during therapy was 18.2%/2.3% and 29.8%/0.7% (p = 0.001 and p = 0.001) in Barrett's esophagus patients versus 14.5%/3.6% and 21.5%/0.9% (p = 0.002 and p = 0.011) in esophagitis patients. There was no significant difference between the groups. In two esophagitis patients, bile reflux increased during therapy. CONCLUSIONS: There is a good correlation of the duration of esophageal exposure to acid and bile with the severity of pathological change in the esophagus. Both acid and bile reflux is significantly suppressed by proton pump inhibitor therapy with exceptions among individual esophagitis patients. The prolonged simultaneous attack of bile and acid may play a key role in the development of Barrett's metaplasia.     

Barrett's esophagus, gastroesophageal acid reflux and duodenogastric reflux during the digestive and postprandial period]

Pathologic gastroesophageal acid reflux appears to be involved in the pathogenicity of Barrett's esophagus. The possible pathogenic role of duodenogastric reflux, however, has been suggested by several studies. The aim of this prospective study was to assess the prevalence of acid or duodenogastric reflux in patients with Barrett's esophagus. Nine patients with histologically proven Barrett's esophagus (mean length: 7.7cm; range: 2-13 cm) were studied by esophageal manometry and 24 hour pHmetry. Duodenogastric reflux was measured in the interdigestive period by aspiration and during the postprandial period using an isotopic method. The results of these different investigations were compared with healthy volunteers (n = 20 to 27). Three patients had complicated Barrett's esophagus (Barrett's ulcer: n = 2, high-grade dysplasia: n = 1). The results of the different investigations showed that a) all patients had abnormal acid exposure and an esophageal motor dysfunction (decrease in lower esophageal sphincter pressure, amplitude and duration of contractions and increase in percentage of peristaltic dysfunction); b) none of the patients had any pathologic duodenogastric reflux neither in the interdigestive nor in the postprandial period. These results a) confirm the high prevalence of acid reflux in patients with Barrett's esophagus, b) show that bile or pancreatic secretions are not involved in the pathogenicity of Barrett's esophagus.     

十二指肠胃食管反流在胃食管反流病中的作用

目的　研究十二指肠胃食管反流 (DGER)在胃食管反流病发病机制中的作用及其对非糜烂性反流病 (NERD)的诊断价值。方法　 95例患者根据内镜检查的结果分为反流性食管炎和NERD组 ,对其均进行 2 4h食管 pH和胆汁联合监测。 结果　反流性食管炎患者DGER的各项指标 :吸光度值 >0 14时间百分比 (% )、总反流次数和反流 >5min的次数分别为 19 0 5± 2 3 4 4、30 5 6±34 0 4和 5 90± 6 37,均显著高于NERD组相应的 7 2 6± 11 0 8、15 6 8± 2 0 92和 2 5 9± 3 5 7(P <0 0 5 ) ,而酸反流差异无显著性 ,随着反流性食管炎的程度加重DGER发生率增高 ;18 2 %的NERD患者存在单纯DGER ,联合胆汁监测可使NERD诊断阳性率由 6 5 9%升高到 84 1%。结论　DGER可以单独发生 ,在引起反流性食管黏膜损伤或症状方面都有作用 ,2 4h食管 pH和胆汁联合监测有助于NERD的诊断。     

Duodenogastroesophageal reflux: results of medical treatment and antireflux surgery

BACKGROUND/AIMS: Recent studies have shown that reflux of the duodenal content to the esophagus plays an important role in esophageal mucosal damage. The aim of the study is to compare the duodenogastroesophageal (DGER) reflux with the severity of reflux esophagitis and evaluate its response to either medical and/or antireflux surgery. METHODOLOGY: Ninety-six patients with DGER were subjected to thorough history, upper GI endoscopy, barium study, esophageal manometry and 24-hr esophageal pH metry combined with Bilitec 2000. Medical treatment was given for all, while Nissen fundoplication was done for 28 patients. All patients were evaluated after Nissen fundoplication and treatment. RESULTS: The age of studied patients was 36.26+/-12.7 years with male to female ratio 2:1. The chief symptom was heartburn in 73 (76%) patients. Upper GI endoscopy revealed, 30 (31.2%) patients had grade I reflux, 30 (31.2%) patients had grade II reflux, 7 patients had grade III reflux, 5 patients had grade VI reflux, Barrett's esophagus in 14 patients (14.5%), hiatus hernia (HH) in 26 (27%) patients. Barium study revealed that, 40 (41.6%) patients had evidence of reflux, while 34 (35.4%) patients had reflux with HH. Esophageal motility revealed the mean LESP (12.7+/-7.6), 68 patients (70.8%) had normotensive body while ineffective esophageal body motility was encountered in 28 (29.1%) patients. Esophageal 24-hr pH study and Bilitec 2000 revealed that 54 (56.2%) patients had bile reflux with pathological acid reflux, while 42 (43.7%) patients had bile reflux in alkaline pH. Medical treatment gave excellent to good response in 68 (70.8%) patients, while Nissen fundoplication was done for 28 (29.2%) patients. Endoscopic examination 6 months after Nissen fundoplication showed marked improvement in endoscopic injury. Barium study after Nissen fundoplication revealed repair of HH and control of GERD in all patients except one. Esophageal motility, 24 hr pH study and Bilitec 2000, after 6 months of Nissen shows high significant increase in LESP, decrease in acid and bile reflux. No significant difference between open or laparoscopic fundoplication in LESP, acid and bile reflux. CONCLUSIONS: DGER in acid medium is more injurious to the esophagus than DGER in alkaline pH. The severity of esophageal injury does not correlate with the severity of acid or bile reflux but has a direct correlation with impaired distal esophageal motility. Medical treatment gives satisfactory control of symptoms and healing of esophageal lesion in 70% of DGER. The response to medical treatment does not depend on the severity of esophageal injury but depends on the severity of bile and acid reflux. Nissen fundoplication in refractory patients, either open or laparoscopic, was effective in control of heartburn in 95% of patients contrary to 50% in mixed symptoms.     

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

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

胃酸在十二指肠液反流诱发食管腺癌中的作用

目的　探讨胃酸在十二指肠液反流诱发食管腺癌 (EAC)过程中的作用。方法　采用SD大鼠 ,通过手术产生三个实验组 :胃食管反流 (GER)组、十二指肠食管反流 (DER)组以及十二指肠胃食管反流 (DGER)组 ,并设无反流的假手术 (SO)对照组。术后 2 0周观察各组动物食管黏膜病变。结果　SO组未见明显病理学改变。各反流组均引发不同程度的食管炎。DER和DGER组基底细胞增生、鳞状上皮不典型增生和溃疡发生率显著高于GER组 (P <0 .0 1)。GER组没有出现Barrett’s食管 (BE)和食管腺癌 (EAC)。DER和DGER组BE发生率分别为 91.4 %和 84 .4 % ,EAC发生率分别为 2 5 .7%和5 3.1% ,均显著高于GER组 (P <0 .0 1)。DGER组EAC发生率显著高于DER组 (P <0 .0 5 )。结论　胃、十二指肠液反流均造成食管黏膜损伤 ,后者更为严重 ;十二指肠液反流在BE、EAC发展中发挥着尤为关键性的作用 ;胃酸在十二指肠液反流诱发EAC过程中起促进作用 ,显著增加十二指肠液反流诱发EAC的危险性     

The frequency of Barrett's esophagus in high-risk patients with chronic GERD

BACKGROUND: The reported frequency of Barrett's esophagus (BE) in patients with reflux symptoms varies from 5% to 15%. The exact frequency of long-segment BE (LSBE) (>3 cm) and short-segment BE (SSBE) (<3 cm) in patients with chronic symptoms of GERD is uncertain. The aim of this study was to determine the frequency of LSBE and SSBE in consecutive patients presenting for a first endoscopic evaluation with GERD as the indication. METHODS: Consecutive patients presenting to the endoscopy unit of a Veterans Affairs Medical Center for a first upper endoscopy with the indication of GERD were prospectively evaluated. Demographic information (gender, race, age), data on tobacco use and family history of esophageal disease, and body mass index (BMI) were recorded for all patients. Before endoscopy, all patients completed a validated GERD questionnaire. The diagnosis of BE was based on the presence of columnar-appearing mucosa in the distal esophagus, with confirmation by demonstration of intestinal metaplasia in biopsy specimens. All patients with erosive esophagitis on the initial endoscopy underwent a second endoscopy to document healing and to rule-out underlying BE. Patients with a history of BE, alarm symptoms (dysphagia, weight loss, anemia, evidence of GI bleeding), or prior endoscopy were excluded. RESULTS: A total of 378 consecutive patients with GERD (94% men, 86% white; median age 56 years, range 27-93 years) were evaluated. A diagnosis of BE was made in 50 patients (13.2%). The median length of Barrett's esophagus (BE) was 1.0 cm (range 0.5-15.0 cm). Of the patients with BE, 64% had short-segment BE (SSBE) (overall SSBE frequency 8.5%). The overall frequency of long-segment BE (LSBE) was 4.8%. A hiatal hernia was detected in 62% of the patients with BE. Of the 50 patients with BE (median age 62 years, range 29-81 years), 47 (94%) were men and 98% were white. Eighteen patients (36%) were using tobacco at the time of endoscopy; 23 (46%) were former users. The median body mass index (BMI) of patients with BE was 27.3 (overweight). There were no significant differences between patients with LSBE and SSBE with respect to age, gender, ethnicity, BMI, and GERD symptom duration. CONCLUSIONS: The frequency of BE in a high-risk patient group (chronic GERD, majority white men, age > 50 years) who sought medical attention is 13.2%, with the majority (64%) having SSBE. These data suggest that the frequency of BE in patients with GERD has not changed. The true prevalence of BE in the general population, including those who do not seek care, is undoubtedly lower, currently and historically. The majority of patients with BE are overweight and have a hiatal hernia. Demographic data for patients with LSBE and SSBE are similar, indicating that these are a continuum of the same process.     

Comparison of gastroesophageal reflux in 100 patients with or without prior gastroesophageal surgery

Background and purpose  The role of duodenogastroesophageal reflux (DGER) in gastroesophageal reflux disease (GERD) remains controversial. Few studies of reflux have compared patients with an intact stomach to those without intact stomach after gastroesophageal surgery. This study aimed to investigate differences of the refluxate between patients with and without prior gastroesophageal surgery and to assess the role of DGER in GERD. Methods  One hundred patients (34% with reflux symptoms) were divided into four groups: 23 with an intact stomach, and 27, 42, and 8 with esophagectomy followed by gastric tube reconstruction, distal gastrectomy, and total gastrectomy, respectively. Reflux symptoms were evaluated, and endoscopy and simultaneous 24-h monitoring of esophageal pH and bilirubin were performed. Results  Of 44 patients with increased DGER but without increased acid reflux, three had severe reflux esophagitis and seven had Barrett’s esophagus. DGER was most frequent under weakly acidic conditions in the intact stomach, esophagectomy, and distal gastrectomy groups. Pure acid reflux and DGER at any pH were elevated in GERD patients with an intact stomach, while weakly acidic and alkaline DGER were elevated in GERD patients after gastrectomy. Esophagectomy patients had reflux with the combined characteristics of those in the intact stomach and gastrectomy groups. Weakly acidic or alkaline DGER was correlated with symptoms and esophageal mucosal changes in gastrectomy patients. Conclusion  The refluxate causing GERD differed between patients with and without prior gastroesophageal surgery. Weakly acidic or alkaline DGER may cause both symptoms and esophageal mucosal damage.     

Esophageal pH and bile monitoring for detecting duodenogastroesophageal reflux and evaluating the effectiveness of treatment

OBJECTIVE: To study methods of diagnosing duo­denogastroesophageal reflux (DGER) and to evaluate the role of bile reflux in gastroesophageal reflux disease (GERD). METHODS: Simultaneous 24‐h esophageal mucosal bilirubin level and pH monitoring were performed in 20 healthy subjects and 52 patients with symptoms suggesting gastroesophageal reflux. Data were gathered by using an ambulatory duodenogastric reflux monitoring system (Bilitec 2000) and an ambulatory pH recorder (Digitrapper MKIII). An absorbance value of ≥0.14 was designated as the threshold value for the presence of bile reflux. Patients suffering from mixed pathological reflux of acid and bile were treated with hydrotalcite and cisapride for 4 weeks, then the monitoring was repeated. RESULTS: No pathological acid reflux was found in the 20 healthy subjects. Based on findings from 24‐h esophageal pH monitoring, 47 of 52 patients (including 12 with esophagitis) were found to have patho­logical reflux. The total fraction of time with bile reflux was greater in the patients (n = 52) than in the healthy subjects (n = 20; 2.67 ± 3.23%vs 0.47 ± 0.71%; P < 0.05) and was greater in the patients with esophagitis (n = 12) than in the patients without esophagitis (n = 35; 5.41 ± 4.93%vs 1.68 ± 1.76%; P < 0.05). Of the 47 patients with GERD, 15 (32%) had abnormal mixed acid and bile reflux. Eight of the 15 patients with esophagitis were found to have mixed reflux and only four of 32 had acid reflux only (P < 0.05). After treatment with hydrotalcite and cisapride, the total fraction of time with acid and bile reflux in the 15 patients with mixed reflux decreased significantly (P < 0.05). Esophagitis was cured in seven of eight patients. CONCLUSION: The ambulatory duodenogastric reflux monitoring system is a useful tool for detecting DGER and evaluating the efficacy of treatment. Approximately 32% (15/47 cases) of patients with GERD were found to have DGER. Bile reflux may play a significant role in causing esophageal mucosal damage in patients suffering from GERD.     

Correlation of oesophageal acid exposure with Barrett's oesophagus length

BACKGROUND: Gastro-oesophageal reflux disease (GORD) plays a major role in the development of Barrett's oesophagus. However, it has yet to be elucidated what factors determine the length of Barrett's mucosa in each individual patient. AIMS: To determine if there is a correlation between oesophageal acid exposure and the length of Barrett's mucosa. We also compared the extent of oesophageal acid exposure between patients with short segment (SSBE) and long segment (LSBE) Barrett's oesophagus. METHODS: Twenty seven patients with Barrett's oesophagus were recruited prospectively into the study from the outpatient gastroenterology clinic at the Southern Arizona VA Health Care System. Diagnosis of Barrett's oesophagus and its anatomical characteristics were determined during upper endoscopy. Ambulatory 24 hour oesophageal pH monitoring assessed the extent of oesophageal acid exposure. RESULTS: There was a significant correlation between per cent total time pH less than 4 and length of Barrett's mucosa (r=0.6234, p=0.0005). In addition, there was a significant correlation between per cent upright and supine time pH less than 4 and length of Barrett's mucosa (r=0.5847, p=0.0014 and r=0.6265 p=0.0006, respectively). Patients with SSBE had significantly less oesophageal acid exposure than patients with LSBE, in terms of both per cent total time and per cent supine time pH less than 4 (p<0.05). CONCLUSIONS: The length of Barrett's mucosa correlated with the duration of oesophageal acid exposure. Patients with LSBE experienced significantly more oesophageal acid exposure than patients with SSBE. Duration of oesophageal acid exposure appears to be an important contributing factor in determining the length of Barrett's mucosa.     

Is Barrett's esophagus characterized by more pronounced acid reflux than severe esophagitis?

Objective: Barrett's esophagus is related to gastroesophageal reflux disease (GERD). However, only a small fraction of patients with GERD develop Barrett's esophagus. We evaluated whether gastroesophageal acid reflux is more pronounced in Barrett's patients than in patients with moderate or severe endoscopic esophagitis.
Methods: Retrospective evaluation of results of esophageal manometry and 24 hour ambulatory pH monitoring performed between 1990 and 1996 at the Leiden University Medical Center in those patients who also underwent endoscopy ≤3 months before pH-metry. Included were 51 patients with Barrett's esophagus, 30 patients with severe esophagitis, 45 patients with moderate esophagitis, and 24 healthy control subjects.
Results: Patients with Barrett's esophagus had significantly increased acid reflux time (   p < 0.01  –0.05) compared to patients with moderate, but not compared to patients with severe esophagitis. Distal esophageal body motility and LES pressure were significantly (   p < 0.01  –0.05) reduced in patients with Barrett's esophagus compared to patients with moderate esophagitis but not compared to those with severe esophagitis.
Conclusion: Although acid reflux is increased in patients with Barrett's esophagus and esophageal motility is impaired, other factors apart from acid exposure and motility contribute to the development of Barrett's esophagus.     

Barrett's esophagus is common in older men and women undergoing screening colonoscopy regardless of reflux symptoms

BACKGROUND: Although Barrett's esophagus (BE) is the precursor of esophageal adenocarcinoma (ACA), most patients with ACA present outside of a BE surveillance program. This could be due to undiagnosed symptomatic GER and BE or BE/ACA occurring in patients without reflux symptoms. We have, therefore, studied the prevalence of BE and symptom status in older patients referred for colonoscopy. METHODS: All patients referred for outpatient colonoscopy were eligible if they were at least 65 yr old and had not previously undergone esophagoscopy. After informed consent, the patients completed detailed GER questionnaires. During the research endoscopy, the endoscopist recorded the squamocolumnar junction (SCJ) as either long-segment BE (LSBE), short-segment BE (SSBE), or normal. If the SCJ was felt to be "irregular" the endoscopist was asked to predict, in their judgment, if BE was present. All patients had biopsies below the SCJ, which were examined by a gastrointestinal pathologist who was blinded to the endoscopic findings. RESULTS: BE esophagus was present in 50 of the 300 patients studied (16.7%). BE was more common in men (35 of 161, 21.7%) than in women (15 of 139, 10.8%) (p < 0.025). GERD symptoms were reported in 106 patients (35%) and BE was present in 19.8% of symptomatic and 14.9% of asymptomatic cases (NS). The majority of the BE in this study was less than 3 cm in length (92%). The questionnaires did not predict the presence of BE. CONCLUSIONS: BE is common in unscreened male and female patients at least 65 yr of age who are referred for colonoscopy. Men were more likely than women to have BE although it occurred in both sexes. Reflux symptoms were fairly common but a poor predictor of BE.