Physiology and pathology of the oesophagus in the elderly patient

In the 1960s, the term 'presbyoesophagus' was introduced for what were felt to be the characteristics of the oesophagus in old age. Since then a number of sophisticated studies using modern manometric, radiological, pH-metric or endoscopic equipment have been performed to better study this subject. Although results in some aspects are still contradictory, these studies have provided us with some more detailed information on the physiology of the ageing oesophagus. Beginning with an overview of what is currently known and discussed about age-induced physiological changes in oesophageal function, this review will then focus on specific problems of oesophagus-related diseases in the elderly. The main topics discussed will include presentation, diagnosis and treatment of primary and secondary motility disorders, oesophageal manifestations of neuromuscular and neurological disease, gastro-oesophageal reflux disease and oesophageal cancer in the elderly.     

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.     

Non-achalasic motor disorders of the oesophagus

Motor abnormalities of the oesophagus are characterised by a chronic impairment of the neuromuscular structures that co-ordinate oesophageal function. The best-defined entity is achalasia, which is discussed in a separate chapter. Other motor disorders with clinical relevance include diffuse oesophageal spasm, oesophageal dysmotility associated with scleroderma, and ineffective oesophageal motility. These non-achalasic motor disorders have variable prevalence but they could be associated with invalidating symptoms such as dysphagia, chest pain and gastro-oesophageal reflux disease. New oesophageal diagnostic techniques, including high-resolution manometry, high-frequency intraluminal ultrasound and intraluminal impedance, allow (1) better definition of peristalsis and sphincter function, (2) assessment of changes in oesophageal wall thickness, and (3) evaluation of pressure gradients within the oesophagus and across the sphincters that can produce normal or abnormal patterns of bolus transport. This chapter discusses recent advances in physiology, pathophysiology, diagnosis and treatment of non-achalasic oesophageal motor disorders.     

Investigation and management of non-cardiac chest pain

Recurring substernal chest pain is an important clinical problem, causing anxiety for patients and their physicians because of the fear of possible cardiac disease. The differential diagnosis includes coronary artery disease, oesophageal disorders such as acid reflux disease and motility disturbances, musculoskeletal problems, psychological disorders including panic attacks, and a new 'fly in the ointment'--microvascular angina. History alone usually cannot distinguish cardiac from non-cardiac chest pain. After exclusion of significant coronary artery disease, attention must be turned to oesophageal disorders, which may be seen in as many as 50% of these patients. Oesophageal motility disorders, particularly the nutcracker oesophagus, are common, but the relationship between pain and abnormal contraction pressures is not well established. Provocative tests such as edrophonium (Tensilon) and balloon distension help to identify the oesophagus as the source of chest pain but do not direct therapy. Recent studies with ambulatory oesophageal monitoring suggest that gastro-oesophageal reflux may be a more common cause of chest pain than motility disorders. This is an important finding as acid reflux is a treatable problem, while therapies for motility disorders may only worsen reflux disease. The recent observation that oesophageal disorders are frequently associated and interact with psychological disorders such as anxiety, depression, somatization and panic attacks complicates the evaluation and understanding of chest pain. How these various abnormalities may be linked is an unresolved issue. Increased central nervous system stimulation and altered visceral and/or central pain sensitivity could be the common factors. It is hoped that further research into these areas will lead to new understandings of and possible solutions to the complex problem of non-cardiac chest pain.     

Evaluation of the magnitude of gastro-oesophageal reflux in Barrett's oesophagus.

A manometric study to determine the role of gastro-oesophageal reflux in Barrett's oesophagus was performed on 20 patients with Barrett's oesophagus and 53 patients with reflux oesophagitis without Barrett's oesophagus (25 with mild oesophagitis and 28 with severe oesophagitis). For the same reason, the 20 patients with Barrett's oesophagus also underwent 24 hour continuous oesophageal pH monitoring, and the results obtained were compared with those of 20 oesophagitis patients without Barrett's oesophagus (10 with mild oesophagitis and 10 with severe oesophagitis). The manometric results show that the motor changes found in the Barrett's group are specific but similar to the motor dysfunction associated with reflux oesophagitis. Motor anomalies are probably related more to the inflammatory process in the oesophageal wall than to the metaplastic changes themselves. The pH monitoring results show that while reflux in the Barrett's oesophagus patients was greater overall than in the oesophagitis group without Barrett's oesophagus, the changes are similar when the results are compared with the severe oesophagitis group. In conclusion there are other factors besides gastro-oesophageal reflux involved in the pathogenesis of Barrett's oesophagus.     

Presence of bile in the oesophagus is associated with less effective oesophageal motility

BACKGROUND/AIMS: Reflux of bile to the oesophagus has been shown to be of importance in the development of gastro-oesophageal reflux disease. This study aims to assess oesophageal motility patterns in relation to acid and bile reflux to the oesophagus. METHODS: Forty-nine subjects with and without reflux disease underwent 24-hour ambulatory recordings of oesophageal pH, bile and 3-channel manometry. Gastroscopy was performed to assess severity of oesophagitis. The percentage of effective peristaltic contractions (oesophageal contractions with a peristaltic pattern and a pressure >30 mm Hg) were correlated to the degree of acid and bile reflux. Ten subjects were re-evaluated within 2 years post-fundoplication. RESULTS: Acid and bile reflux were associated with fewer effective contractions (R(2) = 0.07, p = 0.06 and R(2) = 0.21, p = 0.008, respectively). However, in a multivariate model including acid, bile, age and gender dependency, only bile could show a systematic effect on the variation in percentage of effective peristaltic contractions (R(2) = 0.22, p = 0.001). One year after laparoscopic fundoplication, 24-hour oesophageal motility was unchanged. CONCLUSION: Reflux of duodenal juice to the oesophagus is associated with less effective oesophageal motility, which in turn can perpetuate the disease by less effective oesophageal clearance of bile and acid. The reduced oesophageal motility is not reversed by fundoplication.     

Nutcracker oesophagus: Association with chest pain and dysphagia controlling for gastro-oesophageal reflux

BACKGROUND: The association between nutcracker oesophagus, gastro-oesophageal reflux and their symptoms is controversial. AIM: To evaluate the association of nutcracker oesophagus with chest pain and dysphagia controlling for gastro-oesophageal reflux. METHODS: From a database of 935 consecutive patients investigated with oesophageal manometry and pH-metry, we selected all patients with nutcracker oesophagus including diffuse and segmental patterns. Patients with normal oesophageal peristalsis served as controls. Symptoms assessment, manometry testing and 24h oesophageal pH monitoring off acid-suppressive medications were performed following a standardized protocol. The associations between nutcracker oesophagus and symptoms were assessed by logistic regression analysis. RESULTS: Nutcracker oesophagus was found in 60 patients (6.4%), of which 30 had diffuse nutcracker oesophagus and 30 had segmental nutcracker oesophagus. The control group was composed by 656 patients with normal oesophageal peristalsis. Diffuse nutcracker oesophagus was associated with chest pain (odds ratio 4.3; 95% CI 1.9-9.9; P<0.0001) and dysphagia (odds ratio 5.3; 95% CI 2.3-12.2; P<0.0001), whereas segmental nutcracker oesophagus was associated with chest pain (odds ratio 2.8; 95% CI 1.1-6.9; P=0.026), controlling for total oesophageal acid exposure, age, sex and lower oesophageal sphincter (LOS) pressure. CONCLUSION: This study suggests that both diffuse and segmental nutcracker oesophagus should be regarded as meaningful abnormalities and not mere manometric curiosities.     

Pharyngo-oesophageal diverticulum (Zenker's). Clinical, therapeutic and morphological aspects

In a series of 100 surgically treated patients, Zenker's diverticulum (ZD) appeared mostly as a typical geriatric disorder (50% over 70 years) in which not only oesophageal symptoms but also pulmonary symptoms (37%) may lead to a life-threatening situation. In 60% of the patients, associated upper gastrointestinal pathology was observed, most frequently being gastro-oesophageal reflux (30 patients). In 30% of the manometric studies of the oesophageal body and lower oesophageal sphincter, clear pathological patterns were observed. Morphological examinations, enzymohistochemistry, immunohistochemistry showed clear pathological changes not only at the level of the cricopharyngeal muscle but also at the level of the striated muscles of the cervical oesophagus. These clinical, manometric and morphological changes suggest that ZD is one expression of a more complex neurogenic disorder. They also justify the extramucosal myotomy of the cricopharyngeal wall and the striated muscle wall of the cervical oesophagus as well, as the cardinal step of operation. This myotomy was combined with a diverticulopexy resulting in no post-operative mortality and a minimum of morbidity. The mean longterm follow-up in this series is 4 years, showing excellent and very good results in 96% of the patients for the oesophageal symptoms and in 92% for the full spectrum of oesophageal and pulmonary symptomatology. With this single step operation, no recurrence has been seen seen as opposed to the endoscopic procedure.     

Gastric emptying and duodeno-gastro-oesophageal reflux in gastro-oesophageal reflux disease

BACKGROUND: Previous studies present conflicting results regarding relationship between gastric emptying and gastro-oesophageal reflux disease. Reflux of duodenal content to oesophagus is generally considered to be associated with more severe disease. AIM: To assess presence of a gastric emptying disorder in persons with reflux of duodenal contents to oesophagus and to identify any correlation with gastric emptying and oesophageal motility. METHODOLOGY: A total of 15 subjects with (B+) and 15 subjects without (B-) bile reflux to oesophagus determined by 24-hour bilirubin monitoring were studied with scintigraphic solid gastric emptying and 24-hour oesophageal manometry. RESULTS: There was no difference in lag phase [median 23.7 (range 10.8-44.0) vs 24.6 (8.1-40.1) min], half emptying time [74.6 (48.0-93.6) vs 82.8 (54.4-153.9) min] or emptying rate [0.89 (0.59-1.34) vs 0.83 (0.36-1. 15)%/min] for B- and B+ subjects, respectively. In addition, there was no difference in emptying rate of gastric fundus between B- and B+ subjects. Subjects with bile reflux had less effective oesophageal contractions of oesophageal body [9.4(3.3-37)%] compared to subjects without bile reflux [32(19-47)%, p = 0.002]. However, there was no correlation between oesophageal motility and gastric emptying. CONCLUSION: Results suggest that a gastric emptying disorder is a less likely contributing cause of bile reflux to the oesophagus, but bile reflux is associated with less effective oesophageal motility.     

Changes in Oesophageal pH Associated with Gastro-Oesophageal Reflux: Are Traditional Criteria Sensitive for Detection of Reflux?

Wyman JB, Dent J, Holloway RH. Changes in oesophageal pH associated with gastro-oesophageal reflux. Are traditional criteria sensitive for detection of reflux? Scand J Gastroenterol 1993;28:827-832.

Traditionally, gastro-oesophageal reflux is deemed to have occurred when oesophageal pH falls below 4. Other ‘non-traditional’ pH changes that do not fall below pH4, that fall below 4 for only brief intervals, or that occur when basal pH is less than 4 are usually disregarded. The aim of this study was to determine whether these non-traditional pH changes represent gastro-oesophageal reflux or are artefactual. The 3-h postprandial combined oesophageal pH and manometric records of 22 patients referred for investigation of suspected gastro-oesophageal reflux were reviewed. All pH falls of ≥0.5 pH units were analysed for manometric evidence of reflux that was classified as definite, probable, or possible. In total, 196 traditional and 223 non-traditional pH events were scored and analysed. The majority of traditional (80%) and non-traditional (60%) events were associated with definite manometric evidence of reflux, although a greater proportion of non-traditional events were associated with only probable evidence of reflux (33%) compared with traditional events (18%). The proportions of possible reflux were similar in the two groups. Limiting pH events to only those satisfying traditional criteria excluded an additional 32% with definite manometric evidence of reflux and 49% with definite or probable evidence of reflux. Most pH falls that remained above 4 or fell across 4 for <15 sec occurred in the 1st h postprandially, compared with traditional pH events, which occurred equally throughout the 3-h period. We conclude that traditional criteria for scoring pH episodes substantially underestimate the number of reflux episodes.     

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.     

Effect of coffee on gastro-oesophageal reflux in patients with reflux disease and healthy controls

BACKGROUND: Many patients with gastro-oesophageal reflux disease (GORD) report that coffee aggravates their symptoms and doctors tend to discourage its use in GORD. OBJECTIVE: To assess the effect of coffee ingestion on gastro-oesophageal acid reflux. DESIGN: A randomized, controlled, crossover study. PARTICIPANTS: Seven GORD patients and eight healthy subjects. METHODS: After 1 day of coffee abstinence, participants underwent 24-h oesophageal pH and manometric monitoring. At well-defined times, they ingested either 280 ml of regular paper-filtered coffee or 280 ml of warm water. Coffee or water was drunk 1 h after breakfast, during lunch, 1 h after dinner and after an overnight fast Reflux and oesophageal motility parameters were assessed for the first hour after each coffee or water intake. RESULTS: Coffee had no effect on postprandial acid reflux time or number of reflux episodes, either in GORD patients or in healthy subjects. Coffee increased the percentage acid reflux time only when ingested in the fasting period in the GORD patients (median 2.6, range 0-19.3 versus median 0, range 0-8.3; P = 0.028), but not in the healthy subjects. No effect of coffee on postprandial lower oesophageal sphincter pressure (LOSP), patterns of LOSP associated with reflux episodes or oesophageal contractions was found. CONCLUSION: Coffee has no important effect on gastro-oesophageal acid reflux in GORD patients, and no effect at all in healthy subjects.     

Familial aggregation of Barrett's oesophagus,oesophageal adenocarcinoma,and oesophagogastric junctional adenocarcinoma in Caucasian adults

BACKGROUND: Although familial clusters of Barrett's oesophagus and oesophageal adenocarcinoma have been reported, a familial predisposition to these diseases has not been systematically investigated. AIMS: To determine whether Barrett's oesophagus and oesophageal (or oesophagogastric junctional) adenocarcinoma aggregate in families. PATIENTS AND METHODS: A structured questionnaire eliciting details on reflux symptoms, exposure history, and family history was given to Caucasian case (n=58) subjects with Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma, and to Caucasian control (n=106) subjects with symptomatic gastro-oesophageal reflux disease without Barrett's oesophagus. Reported diagnoses of family members were confirmed by review of medical records. RESULTS: The presence of a positive family history (that is, first or second degree relative with Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma) was significantly higher among case subjects compared with controls (24% v 5%; p<0.005). Case subjects were more likely to be older (p<0.001) and male (74% v 43% male; p<0.0005) compared with control subjects. In a multivariate logistic regression analysis, family history was independently associated with the presence of Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma (odds ratio 12.23, 95% confidence interval 3.34-44.76) after adjusting for age, sex, and the presence of obesity 10 or more years prior to study enrollment. CONCLUSIONS: Individuals with Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma are more likely to have a positive family history of Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma than individuals without Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma. A positive family history should be considered when making decisions about screening endoscopy in patients with symptoms of gastro-oesophageal reflux.     

Recent developments in gastrointestinal motility

In the past decade, the results of many studies on gastrointestinal motility and perception have been published that may be relevant to the clinician. A new classification of oesophageal motor disorders has been proposed in which "ineffective oesophageal motility" largely replaces the former "non-specific oesophageal motor disorders". Recent studies have shown that the incidence of transient lower oesophageal sphincter relaxations can be reduced pharmacologically, and this may open doors to a new therapeutic approach in gastro-oesophageal reflux disease. The mechanisms through which hiatus hernia promotes reflux have become clearer. The recently developed technique of intraluminal impedance monitoring has made it possible to study oesophageal transit, non-acid reflux and its role in the generation of reflux symptoms, as well as the characteristics of belching. Measurement of gastric emptying by means of a non-radioactive isotope and breath-testing has become widely available but, unfortunately, this development has not yet been accompanied by the advent of new therapeutic options for gastroparesis. The term "enteric dysmotility" has been coined for the condition in which upper abdominal symptoms are associated with distinct small intestinal bowel motility disorders in the absence of ileus-like episodes. The role of high-amplitude propagated contractions in the pathogenesis of constipation has been further defined. In cases of suspected sphincter of Oddi dysfunction, manometry of both sphincters (IBD and pancreatic) is now felt to be advisable.     

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.     

Standards for oesophageal manometry A position statement from the Gruppo Italiano di Studio Motilità Apparato Digerente (GISMAD)

Manometry is an important tool in the diagnosis of oesophageal motility, disorders, but proper instruments and methods are needed to obtain useful clinical information. The authors reviewed the minimal technical requirements, operative aspects, which information the final report should contain as well as indications and contraindications of the text itself. Technical requirements: At least a three-channel, multiple-lumen catheter perfused with a pneumo-hydraulic capillary infusion system which ensures deltaP/deltaT>150-200 mmHg/sec.; data should be recorded at a sampling rate of > or =8 Hz to study the oesophageal body and lower oesophageal sphincter; lower oesophageal sphincter tonic (pressure) and phasic activity (relaxations) and oesophageal body amplitude and peristaltic activity should be recorded. The final report must contain the patient's details, the indication for the test and a manometric diagnosis. Indications for manometry: Dysphagia (after ruling out any organic pathology); non- cardiac chest pain (after ruling out any cardiopulmonary involvement); systemic collagenosis (to investigate oesophageal involvement); gastro-oesophageal reflux disease (if surgery is planned). Contraindications are limited to: pharyngeal or upper oesophageal obstructions, oesophageal bullous disorder, cardiac conditions in which vagal stimulation may not be tolerated, severe coagulopathy and patient non-compliance.     

Diagnosis of reflux disease.

There are numerous tests for which a diagnostic value in the context of gastro-oesophageal reflux disease has been claimed. Some of these tests (e.g. the acid perfusion test) have become obsolete after the advent of 24-hour oesophageal pH monitoring. With the latter test not only can excessive reflux be identified, but also, and more importantly, a temporal relationship can be demonstrated between a patient's symptoms and reflux episodes. Radiographical examination of the oesophagus has largely been replaced by endoscopy, although the use of the former test is still indicated in certain circumstances (e.g. in the differentiation of sliding from para-oesophageal hiatus hernia). In clinical practice, the so-called proton pump inhibitor test has gained considerable popularity. Despite several studies on the specificity and sensitivity of this test, its value has not yet been established with sufficient accuracy. Conventional manometric evaluation of lower oesophageal sphincter pressure has been over-emphasized as a diagnostic test in gastro-oesophageal reflux disease.     

Primary peristalsis is the major acid clearance mechanism in reflux patients.

This study examined the clearance of gastric acid from the oesophagus in ambulant patients with gastro-oesophageal reflux. Eighteen patients with proved reflux disease were studied, nine with (group 1) and nine without (group 2) endoscopic oesophagitis. Oesophageal pressure and pH were recorded over 24 hours. Pressures were measured by a probe with five sensors: a 5 cm long sensor in the lower oesophageal sphincter, three sensors in the body of the oesophagus, and one at the pharynx to detect swallowing. Oesophageal pH was monitored 5 cm above the lower oesophageal sphincter. Manometric activities were classified as either peristaltic or ineffective. The latter included simultaneous, non-transmitted, and low amplitude peristaltic contractions. A reflux episode was defined as starting when pH fell to less than 4 and ending when the pH rose to 5. When the rise to pH 5 took place in three or more discrete steps after motor responses to gastro-oesophageal reflux, the pH steps were labelled as initial change (I), middle changes (M), and last change (L). A total of 595 episodes of gastro-oesophageal reflux and 1626 associated motor events were analysed. Of these, 1331 (81.9%) were classed as primary peristaltic activity, 174 (10.7%) as primary ineffective activity, 46 (2.8%) as secondary peristaltic activity, and 75 (4.6%) as secondary ineffective activity. There were no significant differences in initial change (p > 0.05), middle changes (p > 0.05), and last change (p > 0.05) between group 1 and group 2. In all patients, the successive changes of pH in response to motor activity were significantly different (p = 0.0001) between initial, middle, and last changes. Last change was significantly higher when compared with initial (p=0.001) and middle changes (p<0.001). Primary oesophageal peristalsis was the most frequent motor response to gastro-oesophageal reflux. The last motor activity during reflux showed the greatest change in pH.     

Reflux-associated nutcracker oesophagus in a 49-year-old patient with non-cardiac chest pain (NCCP)

A 49-year-old woman was admitted to our department because of intermittent left-sided chest pain for the past 2 years. The patient reported an increasing frequency and duration of the symptoms which were independent from food intake, medication or physical exercises. A cardiac cause of the chest pain was excluded before admittance to our hospital. The initially performed upper endoscopy revealed a small oesophageal hiatal hernia but no signs of acute or chronic inflammation. Basal oesophageal manometry and pH monitoring confirmed the presence of a nutcracker oesophagus, defined by high-amplitude contractions of the distal oesophagus, in combination with a gastro-oesophageal reflux disease. The patient was treated with high-dose pantoprazole for 8 weeks before re-examination. Interestingly, the symptoms completely disappeared upon medication and the relief of the chest pain was accompanied by normalisation of the nutcracker oesophagus pattern. Thus, our observation provides evidence for a causative role of acid reflux in the pathophysiology of the nutcracker oesophagus and, in addition, suggests that effective acid suppression might be a useful therapeutic tool to deal with this painful motility disorder of the oesophagus.     

Laryngospasm and reflex central apnoea caused by aspiration of refluxed gastric content in adults.

Two patients with attacks of choking caused by aspiration of gastric contents in the laryngotracheal tube are presented. One had such severe attacks of respiratory arrest, that tracheostomy was done. The common symptoms of gastro-oesophageal reflux such as pirosis, acid regurgitation, or retrosternal burning were absent in both patients and upper gut radiological and endoscopic examinations were negative. Histology of the oesophageal mucosa showed a deep chronic eosophagitis, and the 24-hour pH-monitoring of the upper oesophagus showed frequent gastro-oesophageal refluxes. Manometry showed hypotonic lower oesophageal sphincter with marked alterations of peristalsis. In the patient with tracheostomy a 24 pH monitoring of the hypolaryngeal zone showed decreased pH at the time of choking attacks. In the other patient further investigations showed that amyotrophic lateral sclerosis was the cause of the oesophageal motility disorder. An intense antireflux treatment abolished the respiratory attacks in both patients.