Hiatal hernia size is the dominant determinant of esophagitis presence and severity in gastroesophageal reflux disease

OBJECTIVE: Although reflux esophagitis is a multifactorial disease, the relative importance of these pathogenetic factors has not been clearly established. In this study, regression analysis was used to model the major determinants of esophagitis in patients with symptomatic gastroesophageal reflux disease (GERD). METHODS: Sixty-six GERD patients and 16 asymptomatic controls were evaluated. All patients underwent upper endoscopy, esophageal manometry, and 24-h pH monitoring. Esophagrams were performed in 38 of the GERD patients and all controls. Stepwise regression was performed using esophagitis severity as the dependent variable. Logistic regression was performed grouping subjects as controls, nonerosive GERD, or erosive esophagitis. RESULTS: Hiatal hernia size, lower esophageal sphincter pressure, esophageal acid exposure, and number of reflux episodes >5 min significantly correlated with esophagitis severity. Stepwise regression identified hiatal hernia size (p = 0.0001) and lower esophageal sphincter pressure (p = 0.0024) as significant predictors of esophagitis. Logistic regression also identified hiatal hernia size (chi2 = 17.07, p < 0.0001) and lower esophageal sphincter pressure (chi2 = 5.97, p = 0.0146) as significant predictors of erosive esophagitis. CONCLUSION: Esophagitis severity is best predicted by hiatal hernia size and lower esophageal sphincter pressure. Of these, hiatal hernia size is the strongest predictor.     

Study of the influence of hiatus hernia on gastroesophageal reflux

AIM: To explore whether the presence of a sliding hiatus hernia influences gastroesophageal reflux.METHODS: Endoscopy and 24 h pH monitoring were performed for 197 outpatients with gastroesophageal reflux symptoms.RESULTS: Of the 197 patients with symptoms of gastroesophageal reflux, patients with hiatus hernia accounted for 36%. The incidence of esophagitis in patients with hiatus hernia was significantly higher than that in patients without hiatus hernia. The results of 24 h pH monitoring showed that 84 patients had physiological reflux, 37 had pathological reflux without esophagitis, 64 had reflux esophagitis and 12 had physiological reflux concomitant with esophagitis. All the patients with hiatus hernia had a longer percentage time with supine reflux and a higher frequency of episodes lasting over 5 min at night compared to those without hiatus hernia. The incidence of combined daytime and nocturnal reflux in patients with hiatus hernia was significantly higher than that in patients without hiatus hernia.CONCLUSION: Pathological reflux and reflux esophagitis in some patients with symptoms of gastroesophageal reflux represent two different stages of gastroesophageal reflux disease. Pathological reflux is the first stage, in which the lower esophageal sphincter is incompetent but the esophageal mucosal resistance effectively prevents regurgitated acid from damaging the esophageal mucosa. Reflux esophagitis represents the second stage, in which the aggression of the regurgitated acid is so strong that the esophageal mucosa fails to resist it and the epithelium of the esophagus is damaged. Patients with hiatus hernia have a high incidence of combined daytime and nocturnal reflux, with the latter being responsible for esophagitis.     

Effect of hiatal hernia on esophageal manometry and pH-metry in gastroesophageal reflux disease

An increased frequency of reflux events and a prolonged acid clearance have been shown in gastroesophageal reflux (GER) patients with a hiatal hernia as compared to those without. The objective of the present study was to further investigate esophageal motility and patterns of reflux in GER patients, in relation to the presence or absence of hiatal hernia. Esophageal manometry and ambulatory 24-hr esophageal pH-metry were used in 42 patients with GER and 18 controls. Eighteen of the patients were considered to have a nonreducing hiatal hernia on endoscopy. Hiatal hernia patients showed a higher extent of reflux (total composite score,P=0.016; total reflux time,P=0.008, reflux time in supine position,P=0.024; reflux time in upright position,P=0.008), a lower frequency of reflux events (P=0.005), a more severe esophagitis on endoscopy (P<0.01) and a lower amplitude of peristalsis at 5 cm proximal to LES (P=0.0009) as compared to patients without hiatal hernia. The amplitude of peristalsis at the distal esophagus was inversely related to the extent of reflux (P=0.024). Acid clearance was also significantly prolonged in the hernia subgroup (P=0.011). Although LES resting pressure did not differ significantly between the two subgroups of patients, it was inversely related to the extent of reflux in the patients with hiatal hernia (P=0.0005). It is concluded, that GER patients with hiatal hernia present with an increased amount of reflux and more severe esophagitis, which results in more severely impaired esophageal peristalsis as compared to patients without hernia. Prolonged acid clearance and impaired esophageal emptying observed in patients with hiatal hernia could be the result of both the presence of the hernia itself and the reduced peristaltic activity of the esophagus.     

Esophageal Acid Exposure in Upright and Recumbent Postures: Roles of Lower Esophageal Sphincter, Esophageal Contractile and Transport Function, Hiatal Hernia, Age, Sex, and Body Mass

This study aimed to assess, using multiple regression analyses, the roles of lower esophageal sphincter, esophageal contractile and transport function, hiatal hernia, age, sex, and body mass for esophageal acid exposure in upright and recumbent postures and for esophagitis. In 116 patients with reflux symptoms, acid exposure was recorded by 24-hr pH monitoring, motility manometrically, bolus transport scintigraphically, hiatal hernia and esophagitis endoscopically. In upright posture, the percentage time at pH <4 increased significantly with higher body mass index and lower distal esophageal amplitude, the number of episodes >5 min at pH <4 with lower distal amplitude, slower transport, and higher body mass, and the longest episode at pH <4 with lower distal amplitude. In recumbency, the percentage time at pH <4 increased with lower percentage of effective esophageal contraction waves and male sex, and the number of episodes and the longest episode with lower percentage effective waves. The severity of esophagitis augmented with slower supine transport and male sex. In both postures, acid exposure and esophagitis seem to be determined primarily by impaired esophageal motility and the ensuing slow bolus transport rather than by compromised lower esophageal sphincter function and the presence and size of a hiatal hernia.     

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

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

Gastroesophageal reflux in healthy subjects. Significance of endoscopic findings, histology, age, and sex

BACKGROUND: Our aim was to evaluate which specific factors are of importance for the gastroesophageal reflux seen in presumably healthy subjects. METHODS: We investigated 57 healthy, asymptomatic volunteers with computer-aided medical history interrogation, endoscopy, biopsy specimens from the distal esophagus, manometry, and 24-h ambulatory pH-monitoring. RESULTS: Eight subjects (14%) claimed intermittent reflux symptoms at the computer interview, but they did not have more acid reflux at pH-monitoring than asymptomatic volunteers. Thirteen subjects (23%) had abnormalities at endoscopy, 3 of whom had an erosion in the distal esophagus, and 12 had hiatus hernia. Subjects with hiatus hernia had increased acid reflux at 24-h pH-monitoring compared with those without hernia. If subjects with hernia were excluded, the degree of acid reflux was similar in all age groups. Men had more acid reflux than women, and these differences persisted if subjects with hernia were excluded. There was no correlation of histologic signs of esophagitis in the distal esophagus, lower esophageal sphincter pressure, smoking habit, or body mass index with reflux of acid to the esophagus. CONCLUSION: Hiatus hernia is a common finding in healthy subjects, and it predisposes to gastroesophageal acid reflux. Histologic abnormalities are poorly related to acid reflux in healthy volunteers. We found increased acid reflux in healthy men compared with women, but larger studies are needed to confirm these findings. Symptom evaluation is not sufficient to exclude significant gastroesophageal reflux in healthy volunteers, and we suggest that the possibility of esophageal abnormalities should be excluded by endoscopy in comparative studies of gastroesophageal reflux disease.     

Erosive esophagitis and nonerosive reflux disease (NERD): comparison of epidemiologic, physiologic, and therapeutic characteristics

Nonerosive reflux disease (NERD) and erosive esophagitis are the main presentations of gastroesophageal reflux disease. However, NERD is the most common presentation of gastroesophageal reflux disease in community-based patients. Patients with NERD differ in demographic characteristics from patients with erosive esophagitis, primarily in sex distribution, weight/body mass index, and prevalence of hiatal hernia. Physiologically, patients with NERD tend to have normal lower esophageal sphincter resting pressure, minimal esophageal body motility abnormalities, low esophageal acid exposure profile and minimal nighttime esophageal acid exposure. Patients with NERD have a lower symptom response rate to proton pump inhibitor once daily than patients with erosive esophagitis. Additionally, NERD patients demonstrate a longer lag-time for symptom resolution and lack of difference in symptom response rate between half to full dose proton pump inhibitor as compared with patients with erosive esophagitis.     

Acid reflux is a poor predictor for severity of erosive reflux esophagitis

It is unknown which factors determine the severity of mucosal damage in gastroesophageal reflux disease (GERD). Our aim was to test whether the amount of esophageal acid exposure could predict the severity of esophageal injury in erosive reflux esophagitis. A total of 644 outpatients with symptomatic GERD underwent an esophagogastroduodenoscopy followed by esophageal manometry and 24-h pH monitoring. GERD was graded according to the endoscopic severity of mucosal damage as no erosions, single erosions, confluent erosions, esophageal ulcers, and strictures. A multiple linear regression was used to assess the joint influences of demographic characteristics, social habits, endoscopic anatomy, and various parameters of esophageal function tests on the severity of erosive reflux disease. No clear-cut association between the amount of acid reflux and the severity of erosive reflux esophagitis could be established. All individual parameters of esophageal pH monitoring, such as upright or supine acid contact time, frequency of all or only long reflux episodes, and an overall summary score of pH-metry, revealed no or only a weak correlation with the severity grade of erosive reflux esophagitis. Similarly, the pressure of the lower esophageal sphincter was only slightly more decreased in patients with extensive erosive esophagitis as compared to subjects without esophageal erosions. In the multiple linear regression, the presence of hiatus hernia was a stronger predictor of disease severity than any of the other parameters. In conclusion, factors other than exposure of the esophageal mucosa to acid must contribute to the development of erosive esophagitis.     

Esophageal motility in patients with sliding hiatal hernia and reflux esophagitis

OBJECTIVE: To study the radiographic and esophageal motility changes that are characteristic of patients with both sliding hiatus hernia (HH) and reflux esophagitis. METHODS: Thirty patients were diagnosed with HH by using gastroscopy. These patients were divided into two groups according to the severity of their esophagitis: group HH1 (grades A and B, n= 18); group HH2 (grades C and D, n= 12). Sliding HH was confirmed by barium meal examination. Radiographic techniques were used to test for spasms and strictures, the coarseness of the mucosa, and to study the types of reflux and clearance. Esophageal pH (24‐h), lower esophageal sphincter pressure and the frequency and amplitude of esophageal peristalsis during reflux were also studied. RESULTS: Radiography revealed that the mucosa was coarse in all cases. Eighty percent of patients had sucking reflux and 36.7% had passive clearance. The percentages of total, supine and upright acid exposure times were greater in patients with HH than those in the controls (P < 0.01), but the difference between the HH1 and HH2 groups was not significant. Lower esophageal sphincter resting pressure was less in the HH group than that in the control group (P < 0.05). However, there were no differences in the length of the sphincter among groups. During episodes of acid reflux, the frequency and amplitude of peristalsis, and the percentage of normal primary esophageal peristalsis were all lower in HH patients than in the controls, and the duration of peristalsis was increased relative to that of the controls (P < 0.05). CONCLUSIONS: Sucking reflux and passive clearance are very important in HH. Esophageal acid exposure time does not correlate with the severity of esophagitis. Lowered lower esophageal sphincter resting pressure, decreased frequency and amplitude, and increased duration of esophageal peristalsis during the episode of reflux may play an important role in the pathogenesis of sliding HH.     

Esophageal strictures and lower esophagus lined with columnar epithelium

Radiographic, manometric, simultaneous radiographic-manometric, endoscopic, histologic and gastric secretory studies were performed on 12 consecutive patients with a benign peptic esophageal stricture. All patients had a segment of esophagus lined with columnar epithelium below the stricture and a small hiatal hernia. Four of them had a normotensive competent gastroesophageal sphincter and no evidence for reflux. Eight patients had free gastroesophageal reflux through a weak, incompetent sphincter. Esophagitis was not universally present. The type of heterotopic mucosa as well as the gastric secretory values showed no uniform pattern. Four patients with a fundic type of epithelium in the lower esophagus had discrete esophageal ulcers, but only 2 of them had evident gastroesophageal reflux. Local secretion of gastric juice seems to play a role in the genesis of these ulcers. There are strong arguments in favor of a congenital heterotopic mucosal lining in the lower esophagus in some patients, although a contributing role for reflux esophagitis cannot be excluded in others.     

Study in oral cavity alterations in patients with gastroesophageal reflux disease

BACKGROUND: The gastroesophageal reflux disease, which has become highly and increasingly incident, may be manifested by typical (pyrosis and regurgitation) and atypical (pulmonary, otorhinolaryngological and buccal) symptoms. AIM: To analyze alterations in the oral cavity patients with gastroesophageal reflux disease. METHODS: One hundred patients were studied being 50 gastroesophageal reflux disease patients (group 1) and 50 controls (group 2). All patients were submitted to an oral clinical exam and specific survey. Patients in group 1 were submitted to upper endoscopy, manometry and esophageal pH monitoring. RESULTS: The upper endoscopy revealed esophagitis in all patients, 20 erosive esophagitis, 30 no-erosive esophagitis and 38 hiatal hernia. Average pressure of the lower esophageal sphincter was 11 +/- 4,8 mm Hg and of the upper esophageal sphincter 75 +/- 26,5 mm Hg. In 42 patients of group 1 (84%) pathological gastroesophageal reflux was observed. Clinical exams revealed: dental erosions in group 1: 273 faces and in group 2: 5 tooth decays in group 1: 23 and 115 in group 2; abrasion in group 1: 58 and in group 2: 95; attrition wear: 408 in group 1 and 224 in group 2. The most damages was the palatine face. In group 1, 21 patients complained about frequent episodes of canker sores, 35 of tooth sensibility, 26 of burning mouth and 42 of sour taste in the mouth. In group 2 the complaints were observed in lower number of patients. CONCLUSIONS: Patients with gastroesophageal reflux disease present higher incidence of dental erosion, canker sores, mouth burning sensation, sensitivity and sour taste than controls. Patients with gastroesophageal reflux disease show lower incidence of tooth decays as compared to controls.     

Mechanisms underlying excessive esophageal acid exposure in patients with gastroesophageal reflux disease

The cause of reflux esophagitis (RE) is excessive esophageal acid exposure. Acid reflux and acid clearance after acid reflux are important factors related to excessive esophageal acid exposure. The main mechanism responsible for acid reflux is transient lower esophageal sphincter relaxation (TLESR), which is LES relaxation not associated with swallowing, and acid reflux caused by low LES pressure is rare. The frequency of TLESR in the postprandial period does not significantly differ between healthy subjects and gastroesophageal reflux disease (GERD) patients; however, the proportion of acid reflux episodes during TLESR is significantly higher in GERD patients. The layer of acid that appears above the dietary layer immediately below the esophagogastric junction (acid pocket) is attracting increasing attention as a cause of the difference in the proportion of acid reflux episodes during TLESR. The proportion of acid reflux episodes during TLESR is significantly higher when the acid pocket is present in the hernia sac than when it is located below the diaphragm. The acid pocket also shows upward migration and reaches the esophageal side of the esophagogastric junction, and the acid pocket itself has been suggested to cause mucosal damage in the lower esophagus. The amplitude and success rate of primary peristalsis decreases with increases in the severity of RE, leading to excessive esophageal acid exposure. Furthermore, the success rate of secondary peristalsis is lower in GERD patients than in healthy subjects.     

Effects of hiatal hernia, reflux esophagitis, and glucagon on the quality of double-contrast esophagram

The possible effect of hiatal hernia, reflux esophagitis, and glucagon on the quality of the double-contrast esophagram was studied in 177 patients. Overall, the quality of the double-contrast esophageal views were judged poor in 46 (26%) patients and good in 131 (74%). No significant improvement in quality was evident in patients receiving glucagon, or in those with hiatal hernia or documented reflux esophagitis. Although the presence of gastroesophageal reflux or the lowering of esophageal sphincter pressure by glucagon would be expected to promote gaseous reflux from the stomach, no improvement in the quality of the double-contrast views of the esophagus was evident in our study.     

Most asthmatics have gastroesophageal reflux with or without bronchodilator therapy

The relationship between gastroesophageal reflux and asthma has not been clearly defined. We measured the lower esophageal sphincter pressures and studied gastroesophageal reflux patterns over 24 hours using an ambulatory Gastroreflux Recorder (Del Mar Avionics, Irvine, CA) in 44 controls and 104 consecutive adult asthmatics. The presence or absence of reflux symptoms was not used as a selection criterion for asthmatics. All asthmatics had discrete episodes of diffuse wheezing and documented reversible airway obstruction of at least 20%. Patients underwent reflux testing while receiving, if any, their usual asthmatic medications: 71.2% required chronic bronchodilators and 28.8% required no bronchodilators. Compared with controls, asthmatics had significantly decreased lower esophageal sphincter pressures, greater esophageal acid exposure times, more frequent reflux episodes, and longer clearance times in both the upright and supine positions (P less than 0.0001 for all parameters tested). There were no differences in any of the measured reflux parameters between asthmatics who required bronchodilators and those who did not. Thus, the decreased lower esophageal sphincter pressures and increased levels of acid reflux in asthmatics were not entirely caused by the effects of bronchodilator therapy. Receiver-operating characteristic analysis generated reflux values that discriminated asthmatics from controls. More than 80% of adult asthmatics have abnormal gastroesophageal reflux. We conclude that most adult asthmatics, regardless of the use of bronchodilator therapy, have abnormal gastroesophageal reflux manifested by increased reflux frequency, delayed acid clearance during the day and night, and diminished lower esophageal sphincter pressures.     

食管动力和反流事件在OSAHS发病机制中意义

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

Esophageal epithelial response to gastroesophageal reflux

Exposure of the distal esophageal mucosa to acid gastric juice was quantitated by 24-hr pH monitoring in 100 individuals and was correlated with morphologic data derived from esophageal biopsies. The degree of acid exposure to the distal esophagus correlated directly with increases in both relative and absolute length of the subepithelial papillae and to relative basal zone hyperplasia. Both papillary length and basal zone hyperplasia decreased after antireflux surgery had reduced acid exposure to normal. Reflux in the recumbent position resulted in prolonged exposure of the mucosa to acid because of poor acid clearing from the esophagus. This caused longer papillae than did upright reflux, where there were more frequent reflux episodes, but with rapid acid clearance. The presence of a hiatal hernia was associated with longer papilae, lower DES pressure, increased reflux frequency, and prolonged recumbent acid clearance. Twenty-four hour pH monitoring correlated better with papillary length than did symptoms or other clinical measures of gastroesophageal reflux.     

Gastroesophageal reflux: the features in elderly patients

INTRODUCTlONWiththeintroduction0fintraesophageal24-hpH-m0nitoringinclinicalpractice,itisnowpossibletoidentifypatternsofgastroesophagealreflux(GER)inthehealthypeopleandpatientsandtoassesstheeffectofH2blockersandH oc adenosinetriphosphatase(ATPase)inhibitorsonGERdiseasesL1Ai7I.ItisincreasinglyrecognizedthatsymptomaticGERmayoccurinthepatients0fallages.However,littleinformationisavailableonsymptomaticGERpatternsintheelderly.Recently,Moldetal,investigatedGERdisease(GERD)inpatientsag…     

Clinical significance of hiatal hernia

The relationship between hiatal hernias and gastroesophageal reflux disease (GERD) has been greatly debated over the past decades, with the importance of hiatal hernias first being overemphasized and then later being nearly neglected. It is now understood that both the anatomical (hiatal hernia) and the physiological (lower esophageal sphincter) features of the gastroesophageal junction play important, but independent, roles in the pathogenesis of GERD, constituting the widely accepted "two-sphincter hypothesis." The gastroesophageal junction is an anatomically complex area with an inherent antireflux barrier function. However, the gastroesophageal junction becomes incompetent and esophageal acid clearance is compromised in patients with hiatal hernia, which facilitates the development of GERD. Of the different types of hiatal hernias (types I, II, III, and IV), type I (sliding) hiatal hernias are closely associated with GERD. Because GERD may lead to reflux esophagitis, Barrett's esophagus and esophageal adenocarcinoma, a better understanding of this association is warranted. Hiatal hernias can be diagnosed radiographically, endoscopically or manometrically, with each modality having its own limitations, especially in the diagnosis of hiatal hernias less than 2 cm in length. In the future, high resolution manometry should be a promising method for accurately assessing the association between hiatal hernias and GERD. The treatment of a hiatal hernia is similar to the management of GERD and should be reserved for those with symptoms attributable to this condition. Surgery should be considered for those patients with refractory symptoms and for those who develop complications, such as recurrent bleeding, ulcerations or strictures.     

<Emphasis Type="Italic">Helicobacter pylori</Emphasis> infection and hiatal hernia do not affect acid reflux and esophageal motility in patients with gastro-esophageal reflux

Background. The association of H. pylori and hiatal hernia in patients with gastroesophageal reflux disease, in terms of acidity and esophageal motility, is not well defined. The purpose of this work was to assess whether, in patients with gastroesophageal reflux, the presence of H. pylori and hiatal hernia affects the severity of esophagitis. Methods. Reflux symptoms, endoscopy, H. pylori, esophageal manometry, and 24-h pH monitoring were evaluated in 37 patients with esophageal reflux and 14 healthy volunteers. Results. A total of 75.6% of patients with esophageal reflux was positive for H. pylori; 81% had hiatal hernia, and only 43.2% showed an acid score by 24-h pHmetry. Esophageal reflux patients with H. pylori, hiatal hernia, and an acid score demonstrated higher acid parameters compared with those in healthy volunteers. Patients with an acid score who were negative for H. pylori tended toward more acid reflux events than patients with an acid score who were positive for H. pylori, a difference that did not reach significance. The same situation existed with patients with an acid score and hiatal hernia who were negative for H. pylori, but the tendency did not achieve significance. Independent analysis of patients with Savary-Miller stage II and III esophagitis showed results that were not different from the combined analysis of stage II and III patients. Amplitude and contraction-duration parameters of the esophageal wave, and the number of high-pressure and prolonged contractions were not different among the reflux groups. Wave amplitude in the lower third of the esophagus was significantly lower in esophagitis stage III patients with hiatal hernia and in esophagitis stage II and III patients, combined, with H. pylori, compared with findings in the healthy volunteers. Conclusions. These results suggest that H. pylori and hiatal hernia in patients with esophageal reflux do not constitute risk factors that affect the severity of esophagitis. Received: April 12, 2001 / Accepted: September 14, 2001     

Effect of sodium valproate on esophageal motility in healthy subjects and patients with gastroesophageal reflux

BACKGROUND: There is experimental evidence to show that upper gastrointestinal tract motility is influenced by a GABAergic mechanism. Sodium valproate acts as a GABA agonist, and has been proven to affect the human internal anal sphincter. The aim of this study was to evaluate any possible effect of sodium valproate on esophageal motility in healthy subjects and patients with gastroesophageal reflux disease (GERD). METHODS: Ten healthy volunteers (4 M, 6 F; age range: 20-61 years) and 12 patients (4 M, 8 F; age range: 25-70 years) with GERD were included in the study. Standard esophageal manometry and ambulatory 24-h esophageal pH monitoring were performed before and 5 days after oral administration of sodium valproate (400 mg four times per day). Main measurements included a) lower esophageal sphincter (LES) resting pressure and amplitude and duration of peristalsis at 5, 10 and 15 cm proximal to LES, and b) percentage of time with esophageal pH <4 and number of reflux episodes. RESULTS: Sodium valproate (i) significantly increased LES resting pressure in both groups (P<0.05), without affecting either the LES postdeglutition relaxation or any of the parameters of the esophageal peristaltic activity, (ii) significantly reduced the number of reflux episodes at the postprandial period in both healthy subjects (P=0.02) and reflux patients without hiatal hernia (P=0.04) and (iii) the time percentage with esophageal pH <4 at the postprandial period in reflux patients (P=0.01). CONCLUSIONS: Sodium valproate increases normal and reduced tonic activity of the human LES and reduces the number of reflux episodes in health and GERD. This action could be attributed to a central GABAergic mechanism.