Gastroesophageal reflux disease. Scintigraphic, endoscopic, and histologic considerations

Radionucleotide scintigraphy and esophagoscopy with biopsy were carried out in 101 patients with symptoms strongly suggestive of gastroesophageal reflux (GER) disease. GER was visualized by scintigraphy in 86.1% of the patients. Endoscopic and histologic esophagitis were found in 68.1% and 58.4% patients, respectively, whereas both examinations taken together showed evidence of esophagitis in 82%. Histologic evidence of esophagitis was found in nearly all patients with severe endoscopic changes and in 43.7% patients with no endoscopic abnormality. Scintigraphic reflux was demonstrated more frequently (p less than 0.05) in the patients with severe endoscopic esophagitis (97.5%) than in those with no or only mild endoscopic changes (78.6%). Scintigraphic reflux was found in 91.5% and 78.5% of the patients with and without histologic evidence of esophagitis (p = 0.07). Fifteen of the 18 patients (83.3%) without endoscopic and histologic abnormalities in the esophagus had scintigraphic evidence of reflux. The present study strongly supports the clinical significance of scintigraphy in GER disease and confirms that esophageal biopsy specimens increase the sensitivity of endoscopic evaluation.     

The acid perfusion test in gastroesophageal reflux disease

An acid perfusion test, isotope scanning, endoscopy, and esophageal biopsy were performed in 101 patients with symptoms strongly suggestive of gastroesophageal reflux (GER) disease. A positive acid perfusion test within 30 min (APT) and within 5 min (TAPT) was found in 70.2% and 37.6% of the patients, respectively. A positive APT was found significantly more often in patients with than without endoscopic esophagitis, whereas a positive TAPT was found significantly more often in patients with severe symptoms than in patients with moderate symptoms and in a significantly higher proportion of patients with than without GER by scintigraphy. Neither the APT nor the TAPT showed any dependency on the presence of histologic esophagitis. Most (97%) patients with a negative acid perfusion test, in addition to typical symptoms, also presented with scintigraphic, endoscopic, or histologic evidence of GER disease. Although it shows that the acid perfusion test, particularly when early positive, may serve as a weak predictor of the severity of GER disease, the present study gives little support to the test's clinical usefulness.     

Gastroesophageal Scintigraphy following Gastrectomy: Comparison to Endoscopy and Esophageal Biopsy

We evaluated the relationship between gastroesophageal scintigraphy, endoscopy, and biopsy in 48 gastrectomy patients (33 with reflux and 15 without reflux symptoms). Endoscopic esophagitis was demonstrated in 78.8% of the patients with reflux symptoms, histological esophagitis was found in 72.2% of them, and scintigraphic reflux was found in 81.8%. Either endoscopic or histological esophagitis was recognized in 93.7% of the patients with reflux symptoms, while either scintigraphic reflux or endoscopic esophagitis was demonstrated in 97.0%. Scintigraphic reflux was significantly more common in patients with histological esophagitis than in those without it (92.9% vs. 40%, p < 0.01). In addition, it was found in 74.2% of patients with and 64.7% of patients without endoscopic esophagitis. The reflux index tended to increase as the grades of esophagitis increased; there was an approximate relationship between the two parameters. Our study suggested that scintigraphy reflects histological esophagitis rather than endoscopic esophagitis, and that there was an approximate relationship between the reflux index and the endoscopic grade of esophagitis. In addition, performance of scintigraphy and endoscopy combined with esophageal biopsy increased the diagnostic yield in gastrectomy patients with reflux symptoms.     

Hiatus hernia in gastroesophageal reflux disease

Upper gastrointestinal endoscopy and radiologic examination were performed in 101 patients with symptoms strongly suggestive of gastroesophageal reflux (GER) disease. Hiatus hernia (HH) was found in 50 patients diagnosed by radiography or endoscopy, or both, in 22, 19, and 9 patients respectively. Severe endoscopic esophagitis (grades III and IV) was found more often (p less than 0.05) in the patients with HH than in those without. The same was true for the early positive timed acid perfusion tests (p less than 0.02). Furthermore, the patients with HH more often had reflux by the standard acid reflux test (42 of 50 versus 28 of 51; p less than 0.01), gastroesophageal scintigraphy (47 of 50 versus 40 of 51; p less than 0.05), and radiography (20 of 50 versus 2 of 51; p less than 0.001) than the patients without HH. The results show that severe GER disease can occur without an associated HH and indicate that patients with symptoms of GER disease and associated HH are likely to have a more severe GER disease than those without HH.     

Scintigraphy, pH measurement, and radiography in the evaluation of gastroesophageal reflux

Scintigraphy as a diagnostic tool has been explored in 69 patients with gastroesophageal reflux (GER) symptoms and endoscopic esophagitis. In all subjects the presence of reflux was also evaluated by radiography and intraesophageal pH measurements (standard acid reflux test). The overall sensitivity of scintigraphy (85.5%) was significantly higher than those of radiography (27.5%) and pH measurements (69.5%). Scintigraphy was performed with normal saline and with acidified orange juice as the transport medium for the isotope 99mTc. The yield of positive scintigrams was higher (22.3 to 61.1%, depending on the grade of endoscopic esophagitis) with the latter variant. Moreover, demonstration of spontaneous reflux was greatly facilitated by the acid scintigraphy. This was particularly obvious in the grade I esophagitis, in which the frequency of spontaneous reflux with the saline method was 3.4% and with the acid medium, 34.3%. Reflux (induced or spontaneous) was seen in 2 of 22 normal control subjects with the saline method and in 1 subject only with the acid method. On the basis of these findings, it is concluded that scintigraphy, especially the acid variant of the technique, is a valuable diagnostic procedure in GER disease.     

Fasting and postprandial mechanisms of gastroesophageal reflux in children with gastroesophageal reflux disease

In order to define the mechanisms of gastroesophageal reflux (GER) in children, we performed simultaneous intraluminal, esophageal motility and pH studies in 24 children with symptomatic reflux and abnormal prolonged pH probe study, ten (group A) without endoscopic and histologic esophagitis, 14 (group B) with endoscopic and histologic esophagitis. Median (ranges) age (years) was 5.0 (6 months-10 years) and 3.0 (6 months-12 years), respectively. Recordings were done for 1 hr before and 1 hr after feeding apple juice (15 ml/kg; pH 4.0). All episodes of GER in group A patients and 77.1% in group B patients were accounted for by abrupt transient lower esophageal sphincter (LES) relaxation (TLESR); 22.9% of reflux events in group B patients occurred during gradual drifts of LES pressure (LESP) to undetectable levels. Esophageal refluxate exposure (mean percentage time with esophageal pH<4.0) the rate of TLESR (number of episodes/hr), and the percentage of TLESRs associated with reflux significantly increased in the fed period both in group A (18.5±5.4%, 6.2±2.65, 87.1%) and in group B (29.7±6.5 7.8±3.05, 84.9%) as compared to the fasting state (group A: 10.8±3.9, 3.9±3.17, 46.1%; group B: 16.1±2.6, 4.14±3.06, 55.17%) (p<0.01). The rate of LESP drifts (number of episodes/hr) was also significantly higher postprandially (4.85±1.24 vs 1.8±0.9,p<0.01); furthermore there was a postfeeding increase of the LESP drift percentage associated with reflux (79.41% vs 46.15%,p<0.01). Residual pressure of TLESRs associated with reflux was significantly lower than that of TLESRs without GER in both groups of patients, during fasting (group A:p<0.01; group B:p<0.05) and fed state (p<0.05), whereas duration of relaxation and LESP in the 1-min period before each TLESR did not discriminate TLESRs associated with reflux from those without reflux. In children with GER disease, TLESR is the most common mechanism of reflux, but gradual LESP drift is associated with more severe disease; the postprandial increase in the esophageal acid exposure is mainly due to increased rate of TLESRs and LESP drifts; degree of sphincter inhibition during TLESRs is a critical factor for the induction of reflux.Presented in part at the 91st Annual Meeting of the American Gastroenterological Association, San Antonio, Texas, May 12–18, 1990.     

Pulmonary aspiration shown by scintigraphy in gastroesophageal reflux-related respiratory disease

OBJECTIVES: Gastroesophageal reflux (GER) may underlie respiratory manifestations via vagally mediated airway hyperresponsiveness or microaspiration, and intraesophageal pH monitoring is generally used to identify GER in patients with such manifestations. We aimed to establish the frequency of retrograde pulmonary aspiration in patients with unexplained respiratory manifestations. METHODS: Fifty-one patients with refractory respiratory symptoms (cough, n = 18; pneumonia, n = 14; apnea, n = 8; asthma, n = 7; and laryngitis, n = 4) were prospectively evaluated. They underwent 24-h intraesophageal pH monitoring and gastroesophageal 99Tc scintigraphy with lung scan 18 to 20 h after the test meal. RESULTS: Thirteen of 51 patients (25.5%) had abnormal intraesophageal pH study results (mean reflux index, 11.3%; range, 6.5 to 50%); and in 25 of 51 patients (49%), overnight scintigraphy showed pulmonary aspiration. Nineteen of these 25 patients had entirely normal pH study results, whereas 6 of 13 patients with abnormal pH study results had aspiration. Pulmonary aspiration was demonstrated in all patients with apnea and 61.5% of patients with recurrent pneumonia. Nine of 25 patients (36%) with aspiration had histologic evidence of esophagitis, whereas histologic esophagitis was present in 5 of 13 patients (38.4%) with pathologic GER as shown by intraesophageal pH monitoring. CONCLUSIONS: Pulmonary aspiration as demonstrated by overnight scintigraphy is common in children with unexplained and refractory respiratory manifestations, suggesting that GER could be the underlying cause of these manifestations. Since only a few children with chronic or recurrent respiratory symptoms have a pathologic gastroesophageal acid reflux, a normal intraesophageal pH study result does not rule out GER in these children.     

Reasons of PEG failure to eliminate gastroesophageal reflux in mechanically ventilated patients

AIM: To investigate factors predicting failure of percutaneous endoscopic gastrostomy (PEG) to eliminate gastroesophageal reflux (GER).METHODS: Twenty-nine consecutive mechanically ventilated patients were investigated.Patients were evaluated for GER by pH-metry pre-PEG and on the 7th post-PEG day.Endoscopic and histologic evidence of reflux esophagitis was also carried out.A beneficial response to PEG was considered when pH-metry on the 7th post-PEG day showed that GER was below 4%.RESULTS: Seventeen patients responded (RESP group) and 12 did not respond (N-RESP) to PEG.The mean age, sex, weight and APACHE Ⅱ score were similar in both groups.GER (%) values were similar in both groups at baseline, but were significantly reduced in the RESP group compared with the N-RESP group on the 7th post-PEG day [2.5 (0.6-3.8) vs 8.1 (7.4-9.2, P < 0.001)].Reflux esophagitis and the gastroesophageal flap valve (GEFV) grading differed significantly between the two groups ( P = 0.031 and P = 0.020, respectively).Histology revealed no significant differences between the two groups.CONCLUSION: Endoscopic grading of GEFV and the presence of severe reflux esophagitis are predisposing factors for failure of PEG to reduce GER in mechanically ventilated patients.     

Characteristics and frequency of transient relaxations of the lower esophageal sphincter in patients with reflux esophagitis

Electromyogram of the submental muscles, esophageal manometry, and pH studies were simultaneously performed in an unselected group of 12 patients with subjective and objective evidence of gastroesophageal reflux (GER) disease to determine the frequency of transient relaxation of the lower esophageal sphincter (LES) and mechanisms of GER. Findings from these patients were compared with data from 10 asymptomatic healthy volunteers. Recordings were obtained for 1 h in the fasting state and 3 h after a standard 850-kcal meal. Transient relaxation of the LES was the only mechanism of acid reflux in normal subjects and accounted for 73.0% of the episodes of acid reflux in patients with GER disease. In both normal subjects and patients with GER, a large number of transient relaxations were associated at their onset with an attenuated submental EMG complex, a small pharyngeal contraction, and an esophageal contraction. The incidences of these associated events were similar in the two study populations. The frequency of transient relaxation of the LES in patients with GER was identical to that of controls. The frequency did not differ even in 9 patients with GER disease who had endoscopic esophagitis. Thirty-six percent of transient relaxations in the normal subjects were accompanied by pH evidence of reflux, but in the GER patients with endoscopic esophagitis 65% of the transient LES relaxations resulted in a reflux event. Acid reflux at the moment of deep inspiration was the second most common mechanism of GER in our patients. Four patients who demonstrated this mechanism had hiatal hernias and more severe esophagitis than the rest of the group. Our findings confirm that transient relaxation of the LES is the major mechanism of GER in patients with reflux esophagitis. However, the similar frequency of this relaxation in GER patients and in healthy asymptomatic subjects suggests that factors other than transient LES relaxation play an important role in the pathogenesis of GER disease.     

Esophageal intra-abdominal ultrasonographic in children with gastroesophageal reflux: correlation between endoscopic and histopathologic data]

Gastroesophageal reflux disease has been very often in children and one of its most critical complications is the peptic esophagitis disease. The diagnosis of peptic esophagitis is obtained based on the endoscopic changes and the histologic features. The pressure reduction of the lower esophageal sphincter is one of the elements of the esophagitis pathogenesis. The pressure is related with the length of the esophageal abdominal segment, which can be measured by ultrasonography. The research presented in this paper aims to relate ultrasonographic measurements of esophageal abdominal segment length with endoscopic changes and with esophageal biopsy obtained from children with gastroesophagel reflux disease. We submitted 16 children with gastroesophagel reflux disease, between 10 and 156 months old (median 63.5 months old), to endoscopy and to esophageal biopsy. We verified the following results from endoscopy and biopsy: six of the 16 patients had endoscopic peptic esophagitis and, in five of these (six patients), the same diagnosis was confirmed by biopsy. Ten of the 16 patients had normal endoscopy, but the biopsy of four of these 10 patients showed histologic changes compatible with esophagitis. We observed no relationship between endoscopy and biopsy, when all degrees of histologic change were used to diagnose esophagitis. However, we found high relationship when the mild histologic changes were considered as only a consequence of the reflux. We verified the following results from ultrasonography: five of the six patients with endoscopic peptic esophagitis and all patients with esophagitis determined by biopsy (excluding those with mild histologic changes) had reduced esophageal abdominal segment length. In conclusion, we have found relationship between endoscopic changes and histologic features in the diagnosis of esophagitis and correlation between the reduced esophageal abdominal segment length and the presence of esophagitis.     

Gastric Acid Secretion and Pattern of Gastroesophageal Reflux in Patients with Esophagitis and Concomitant Duodenal Ulcer: A Multivariate Analysis of Pathogenetic Factors

This study was designed to assess the relationship between gastric acid output (GAO) and both pattern of gastroesophageal reflux (GER) and severity of esophageal lesions. Gastric acid secretory testing and 24-h intraesophageal pH-monitoring were performed in 31 patients with esophagitis and concomitant duodenal ulcer (E + DU) and compared with those of 72 patients with esophagitis (E). The second aim of this study was to evaluate the role of GAO and other potential pathogenetic factors in the development of esophagitis. The results of the study showed that GAO in patients with E + DU was significantly higher than in patients with E (p < 0.05). There was no significant difference between the two groups of patients with regard to endoscopic findings or GER variables (p > 0.05). Multiple regression analysis with stepwise deletion showed that the presence of hiatal hernia, GER in the upright position and age appear to correlate significantly with the presence of esophagitis. We conclude that no parallel relationship exists between GAO and severity of GER or esophageal lesions in patients with E + DU and that GAO is not a major pathogenetic factor in GER disease.     

Gastroesophageal Scintigraphy and Endoscopy in the Diagnosis of Esophageal Reflux and Esophagitis

The value of gastroesophageal (G/E) scintigraphy in the diagnosis of gastroesophageal reflux was assessed in 51 subjects, who presented with heartburn and had endoscopic evidence of reflux esophagitis. G/E scintigraphy was done using 99mTc sulfur-colloid in acidified orange juice. The G/E reflux index was calculated according to previous reports. The mean (+/- SD) G/E reflux index in 18 patients with severe esophagitis and 30 patients with moderate esophagitis were 1.6% (+/- 1.5) and 3.2% (+/- 5.0), respectively. The mean G/E reflux index in 14 control subjects was 2.4% (+/- 1.1). There was no significant difference between the esophagitis and control groups. Furthermore, if 4% was taken as upper limit of normal, this will include almost all the esophagitis patients and controls. It is concluded that the G/E reflux index based on G/E scintigraphy is of little value in the diagnosis of G/E reflux.     

Assessment of gastro-esophageal reflux disease: comparison of reflux scintigraphy with endoscopy biopsy and esophageal pH monitoring

In a study designed to evaluate reflux scintigraphy in 79 patients with gastro-esophageal reflux disease, quantitated reflux scintigraphy was found to have predictive values of 73% in detecting reflux as judged by esophageal pH monitoring, of 63% in detecting esophagitis as judged by esophagoscopy and biopsy, and of 77% in detecting the presence of either esophagitis or reflux. However, its sensitivity was only 48, 58 and 42%, respectively. Gastro-esophageal reflux scanning has little value in the routine clinical diagnosis of mild to moderate gastroesophageal reflux disease, but none of the other tests (biopsy, endoscopic appearances of 24 hour esophageal pH monitoring) were sufficiently specific to be taken as a sole diagnostic criterion ("gold standard"). Investigation of gastro-esophageal reflux disease could probably best be limited to endoscopy (especially to detect ulceration or metaplasia and to exclude neoplasia) with 24 hour pH monitoring in addition for those patients with suspected reflux disease but negative endoscopy.     

Pattern of Acid Reflux in Patients with Reflux Esophagitis ‘Resistant’ to H2-Receptor Antagonists

Ambulatory 24-h esophageal pH monitoring was carried out in 54 patients with erosive/ulcerative reflux esophagitis before a 12- to 24-week treatment with either ranitidine, 150 to 300 mg twice daily, or famotidine, 20 to 40 mg twice daily. After this period, 21 patients continued to present endoscopic evidence of esophagitis. Patients who did not respond to the therapy showed a more severe pretreatment pattern of acid reflux than those who healed, with regard to both median percentage time of reflux (16.2% versus 11.0%, respectively, p < 0.05) and median number of reflux episodes (88.0 versus 55.0; p < 0.05). Ambulatory 24-h esophageal pH-metry is therefore to be recommended in all patients with acid reflux symptoms, even in those who already show endoscopic lesions of the esophageal mucosa, since this test is a valid prognostic indicator of response to treatment.     

Abnormal acid reflux in asthmatic patients in a region with low GERD prevalence

Background A high prevalence of gastroesophageal reflux disease (GERD) in asthmatic patients has been reported from North America and Europe. However, only a few data from Asia are available. This study evaluated the incidence of abnormal gastroesophageal reflux (GER) in asthmatic patients in Taiwan.Methods Fifty-six consecutive ambulatory patients with clinically stable asthma (41 men and 15 women; age, 57.7 ± 12.4 years; range, 24 to 74 years) were evaluated prospectively. All patients underwent esophagogastroduodenoscopy, esophageal manometry, and 24-h esophageal pH monitoring.Results Twenty-nine patients (51.8%) had abnormal GER, as defined by 24-h esophageal pH monitoring. There were 42 patients without endoscopic evidence of esophagitis, 10 patients with Los Angeles (LA) grade A esophagitis, and 4 patients with LA grade B esophagitis. The esophageal motility function studies revealed 21 patients with normal esophageal motility, 23 patients with ineffective esophageal motility (IEM), and 12 patients with nonspecific esophageal motility disorders other than IEM. Although the lower esophageal sphincter (LES) basal pressure was higher in the patients without GER, the difference was not statistically significant.Conclusions Abnormal GER seems to be a clinically significant problem in asthmatic patients in Taiwan. The most common esophageal motility dysfunction is IEM. However, the status of Helicobacter pylori infection plays no role in abnormal GER.     

Evaluation of gastroesophageal reflux as a cause of idiopathic hoarseness

Eleven patients presenting to an ear, nose, and throat specialist were diagnosed as having idiopathic hoarseness and prospectively evaluated for evidence of gastroesophageal reflux (GER) to determine if an association existed. Testing for GER included voice analysis, EGD, esophageal manometry, Bernstein test, and ambulatory 24-hr pH monitoring. Six of the 11 (55%) hoarse patients studied had GER by pH monitoring (mean score 105 +/- 23), and most reflux episodes were supine and prolonged (20.9 +/- 8.2% supine pH less than 4.0, longest 129 min). All patients with abnormal pH monitoring had endoscopic esophagitis (Barrett's esophagus in two, peptic stricture in one, and erosive esophagitis in three), while none of the patients with normal scores had esophagitis. Symptoms of throat pain or nocturnal heartburn were more common in the GER-positive patients (6 of 6 vs 1 of 5), and clinically helpful in discriminating which hoarse patients had pathologic GER. Treatment with ranitidine 150 mg per os twice a day for 12 weeks improved esophagitis in all patients, but the voice improved in only one of the two patients with completely healed esophagitis. This study suggests that (1) GER is frequently seen in patients with idiopathic hoarseness (55%), (2) hoarse patients with throat pain or nocturnal heartburn are likely to have severe esophagitis and should be evaluated by EGD, and (3) additional antireflux and voice therapy may be necessary to heal esophagitis and improve the voice.     

Scintigraphy in Gastroesophageal Reflux Disease: A Comparison to Endoscopy, LESp, and 24-H pH Score, as Well as to Simultaneous pH Monitoring

We compared scintigraphy to other reflux tests in 45 symptomatic patients. Sensitivity of 24-h pH score was 82%, endoscopy 64%, and LESp 33%. Scintigraphy was insensitive (36%), although 50% of patients with esophagitis had a positive test. Specificity and positive predictive value were good (all greater than or equal to 88%) in discerning patients with an abnormal 24-h pH score and esophagitis. We suggest scintigraphy as the first diagnostic test to confirm frequent reflux events (REs) and normal clearance in the subgroup of patients with severe endoscopic esophagitis, and manometry and 24-h pH monitoring when scintigraphy is negative. We also compared scintigraphy to simultaneously performed pH monitoring in detecting individual postprandial REs and their clearance. The two methods agreed in only 25% of total reflux events. Scintigraphy was superior at detection of reflux of buffered gastric contents and detection of additional REs during acid clearing intervals, whereas only the pH probe detected REs after gastric emptying. We conclude that scintigraphy has a limited role as a diagnostic test in gastroesophageal reflux disease, and much potential as a research tool, especially in combination with the pH probe.     

Prolonged clearance is the primary abnormal reflux parameter in patients with progressive systemic sclerosis and esophagitis

The purpose of this study is to determine if frequent reflux events from an incompetent LES or poor clearance from decreased peristalsis is the predominant abnormality in PSS patients with severe reflux esophagitis. Seven patients with both classic manometric findings of PSS and endoscopic findings of esophageal ulcerations and/or Barrett's esophagus were compared to nine patients with similar endoscopic findings but with no evidence of a connective tissue disorder. All patients underwent simultaneous intraesophageal pH monitoring and scintigraphy for a total of 40 min after a radiolabeled meal. Four of the PSS patients and all the non-PSS patients had simultaneous manometry. We found that PSS patients had significantly fewer reflux events (P<0.01), but the reflux events had significantly longer duration (P<0.01) compared to patients with similar severity of esophagitis and no connective tissue disease. We conclude that decreased smooth muscle peristalsis appears to be the primary contributor to acid exposure and esophageal injury in PSS.The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.     

Gastroesophageal reflux as a pathogenic factor in the development of symptomatic lower esophageal rings

Gastroesophageal reflux (GER) has been suggested as a cause of the lower esophageal (Schatzki) ring. We looked for the presence of GER and reflux injury in a series of 20 patients with lower esophageal ring and dysphagia, using a 24-hour esophageal pH monitoring and upper endoscopy with biopsy. Abnormal GER was documented in 13 of the patients (65%), 10 of whom had erosive reflux changes in the distal esophagus. Seven patients (35%) showed no evidence of pathologic GER or reflux esophagitis. All patients also underwent esophageal manometry. Nonspecific esophageal body motor dysfunction may have contributed to dysphagia in five patients, two of whom had no evidence of abnormal GER. We conclude that GER disease is a frequent cause of the gradually progressive ring stricturing and dysphagia seen in patients with lower esophageal ring. Antireflux therapy, as an adjunct to esophageal dilatation, may be appropriate for many symptomatic lower esophageal ring patients.     

Nonpropulsive Esophageal Contractions and Gastroesophageal Reflux

Nonpropulsive esophageal contractions radiologically described as tertiary contractions or "corkscrew" esophagus suggest the presence of an underlying motility disorder and may lead to impaired acid clearance. The goals of this study were to determine the prevalence and role of gastroesophageal reflux (GER) in patients with tertiary contractions. Thirty-five consecutive patients with spontaneous, repetitive, nonpropulsive esophageal contractions noted on esophagography were studied with endoscopy, infusion esophageal manometry, and 24-h ambulatory pH monitoring. All patients had esophageal symptoms, mainly dysphagia, heartburn, and chest pain, but only three were found to have esophagitis by endoscopy and biopsy. Nineteen patients had repetitive, nonlumen-obliterating, nonperistaltic (tertiary) contractions, six had corkscrew esophagus, and 10 had forceful, lumen-obliterating simultaneous contractions (rosary bead esophagus). Twenty patients (58%) had GER by pH criteria with mean values: % time pH less than 4, 40.9; %upright pH less than 4, 41; %supine pH less than 4, 44.3%; number of episodes with greater than 5 min of pH less than 4, 12. Esophageal motility revealed "nutcracker" esophagus in eight, low LESP in two, and nonspecific esophageal motility disorder in 10. Symptoms or severity of nonperistaltic contractions did not correlate with GER. Radiologically demonstrable free reflux or the presence of heartburn did not predict GER. We conclude that 1) GER occurs in up to 58% of patients with nonpropulsive (tertiary) esophageal contractions on esophagography, and may play a role in the induction of abnormal peristaltic activity of the esophageal body; 2) GER is usually not associated with endoscopic evidence of esophagitis or characteristic symptoms, and is recognized by 24-h pH monitoring. We speculate that detection and treatment of GER may improve the symptomatic management of patients with nonpropulsive esophageal contractions.