Impact of Ingested Liquids on 24-Hour Ambulatory pH Tests

A prospective investigation of the impact ofingested liquids on 24-hr pH test scores was conducted.Eighty-two patients contributed 142 samples. The liquidsused were coffee/tea (N = 35), water (N = 32), fruit juice (N = 29), cola (N = 34), and beer (N =12). The pH of cola, juice, and beer are approximately3.0. The parameters studied included: total test time,total drink time, total minutes of pH < 4.0 during drink, minutes of pH < 4.0 10 min beforedrink, and minutes of pH < 4.0 10 min followingdrink. Analysis was performed using one-way ANOVA andrepeated measures. Age of patients, total test time, and total time pH < 4.0 were notsignificantly different (P > 0.05). The total time toconsume the drink was significantly greater (P <0.05) for beer than all other liquids. The total time(7.7 ± 6.0 min) pH < 4.0 for cola wassignificantly different (P < 0.023) than beer (3.3± 3.7 min), tea/coffee (1.4 ± 6.5 min),and water (1.1 ± 2.5 min). The percentage oftotal time pH < 4.0 was not significantly different (P >0.05) among any of the liquids. The percentage of timepH < 4.0 during the drink was the highest for cola(63 ± 47%) and juice (51 ± 57%); water,coffee/tea, and beer were not significantly different (P> 0.05). Although the impact of cola and juice werethe greatest, none of these had an impact that exceeded0.5%. The lack of impact of beer appears to be due to the increased period of time it takes toconsume. We conclude that the impact of ingested fluidsis minimal and can probably be disregarded in mostpatient groups.     

Case Report: Determination of Primary Foci of Metastatic Tumors by p53 Mutational Analysis in Intraesophageal Multiple Carcinomas

It is well known that squamous carcinomasfrequently develop multifocally, either synchronously ormetachronously, in the upper aerodigestive tract (1).Such phenomena were first reported by Slaughter et al in 1953, and they were named fieldcancerization (2). Using recent molecular biologytechniques, these multiple carcinomas have been revealedto arise from independent origins (3). Esophagealcarcinomas have been reported to frequently metastasize tothe lymph nodes even at the early stage of tumorextension (4). Furthermore, simultaneous multifocalcancer development is not rare in the esophagus (5). In cases of intraesophageal multiple carcinomaswith lymph node metastases, the primary focus of themetastatic tumors cannot be identified by conventionalhistologic examination. Here we report a case of intraesophageal multiple carcinomas in whichthe attributed foci of lymph nodal metastases could beclearly identified by analyzing the p53 gene mutationalstatus used as a clonal marker.     

Achalasia (The Usefulness of Manometry for Evaluation of Treatment)

Although manometry is used with increasingfrequency to evaluate the effectiveness of differenttreatments for achalasia, the criteria for a successfulmanometric response have not been well defined.Manometric responses were collected before and after 43treatments in 35 patients with achalasia in order todetermine manometric changes after different clinicaloutcomes: 15 unsuccessful outcomes and 28 successful outcomes were reported. In the latter, restingpressure of the lower esophageal sphincter decreased to12.8 mm Hg, whereas in unsuccessful outcomes this wassignificantly higher (28.2 mm Hg). A decrease of lower esophageal sphincter pressure below 17mm Hg or more than 40% of the pretreatment level wasassociated with successful outcomes. Our data suggestthat manometry is a good indicator of therapeutic effectiveness and we propose that it be usedsystematically for objective evaluation of achalasiatreatment.     

Esophageal Varices in Rat Models of Liver Cirrhosis

Animal models resembling the human situation arevery useful to investigate human disease. However, therehas been no evidence of esophageal varices in rats withliver cirrhosis. In the present study, to determine whether intrahepatic portalhypertension produced by liver cirrhosis inducesesophageal varices in rats, the esophagus was examinedendoscopically in rat models of liver cirrhosis. Allrats given carbon tetrachloride or thioacetamide and sixof seven rats given a choline-deficient diet hadesophageal varices or venous dilatation after 16 weeksof treatment, although the varices in one rat given carbon tetrachloride and in two rats given acholine-deficient diet were reduced from weeks 16 to 18.These findings suggest that timing is important whenstudying esophageal varices in rat models of liver cirrhosis. It is concluded that certain modelsof liver cirrhosis in rats could be used as models ofesophageal varices due to intrahepatic portalhypertension.     

Gastric Electrical Stimulation (GES) with Parameters for Morbid Obesity Elevates Lower Esophageal Sphincter (LES) Pressure in Conscious Dogs

Background: Treatment of obese patients with the implantable gastric stimulator (IGS) was reported to improve reflux symptoms, independent of weight loss. We evaluated the effect of gastric electrical stimulation on LES pressure in conscious dogs. Methods: 8 dogs were studied. GES with three sets of parameters was randomly applied via a pair of electrodes implanted in the fundus on separate days. Manometry was performed with a Dent-Sleeve catheter passed through an esophageal canula. The involvement of the cholinergic pathway was also tested. Results: 1) Stimulation with IGS parameters (40 Hz, 0.3 ms, 6 mA, 2 seconds on and 3 seconds off) induced a significant increase in LES pressure (29.9±4.8 mmHg), and remained significantly higher during the post-stimulation period (32.6±9.6 mmHg) compared to baseline (24.5±3.8 mmHg), P<0.01.2) Long pulse stimulation (10 cpm, 300 ms, 8 mA) tended to increase LES pressure from 29.6±4.4 mmHg of baseline to 31.8±4.9 mmHg with stimulation, to 32.6±4.5 mmHg after discontinuation (P=0.08); 3) Modified IGS parameters (40 Hz, 2 ms, 6 mA, 2 seconds on and 3 seconds off) did not induce a significant change in LES pressure during and after stimulation. 4) Effect of stimulation with IGS parameters on LES pressure was blocked by intravenous atropine. Conclusion: GES with IGS parameters significantly increases LES pressure in conscious dogs. This effect is mediated by the cholinergic pathway. These results suggest that GES may be able to benefit GERD patients and obese patients with GERD.     

Manometric Abnormalities and Gastroesophageal Reflux Disease in the Morbidly Obese

Background: Obesity is an epidemic in the USA. Many disorders are associated with obesity including gastroesophageal reflux disease (GERD). However, the prevalence of GERD and esophageal motility disorders in the morbidly obese population is unclear. Methods: During evaluation for bariatric surgery, 61 morbidly obese patients underwent preoperative 24-hr pH and esophageal manometry. A single reviewer evaluated all 24-hr pH and manometric tracings. Johnson-DeMeester score >14.7 was considered diagnostic of GERD. Manometric criteria for motility disorders were from published values. All values are given as mean ± SD. Results: Mean age was 44.4 + 10.3 years. 55 of the patients (90%) were female. Mean BMI was 50.1 ± 7.2 kg/m². 23 patients (38%) complained of GERD symptoms (reflux and/or heartburn). 1 patient (2%) complained of noncardiac chest pain. Mean Johnson-DeMeester score was 19.6 ± 17.8. Mean intragastric and intrabolus pressures were both elevated (8.3 ± 1.6 mmHg and 15 ± 9 mmHg). 33 patients (54%) had abnormal manometric findings: 10 had a mechanically defective LES, 11 had a hypertensive LES, 2 had diffuse esophageal spasm, 3 had nutcracker esopha gus,1 had ineffective esophageal disorder and 14 had nonspecific esophageal motility disorder. Some patients had more than one disorder. 20 patients (33%) had significantly elevated (>180 mmHg) contraction amplitudes at the most distal channel (210.0 ± 28.7 mmHg). Conclusions: Prevalence of manometric abnormalities in the morbidly obese is high. Presence of a nut cracker-like distal esophagus in the morbidly obese is significant and warrants further evaluation.     

Comparison of Ultrasound-Secretin Test and Sphincter of Oddi Manometry in Patients with Recurrent Acute Pancreatitis

Manometry is considered the gold standard forevaluating sphincter of Oddi dysfunction. It hasrecently been demonstrated that the ultrasound (US)secretin test proposed a few years ago as a noninvasive test for the study of sphincter of Oddidysfunction yields a substantial percentage ofpathological findings in patients with acute recurrentpancreatitis. The aim of this study was to compare theresults of the US secretin test with sphincter of Oddimanometry findings in a consecutive series of patientswith recurrent acute pancreatitis. Forty-seven patientsadmitted to our gastrointestinal unit suffering from recurrent acute pancreatitis underwentultrasonographic measurement of the main pancreatic ductat baseline and for 60 min after maximal stimulationwith secretin at 1 IU/kg. According to the US secretin test findings in 35 healthy control subjects,the test results were considered to indicate pathologywhen the duct was still dilated after 20 min. Withinthree to seven days the same patients underwent perendoscopic manometry. Thirty-six patients(17 men, 19 women; mean age 41 ± 15 years) had asuccessful US secretin test and sphincter of Oddimanometry. Eleven patients (30.6%) presented normalmanometric findings. Two of these had an abnormal USsecretin test. Twenty-five patients had abnormalmanometry findings, revealing stenosis in 19 (52.7%) (17with abnormal US secretin test) and dyskinesia in six (five with an abnormal US secretin test).Compared to manometry findings, the US secretin testsensitivity and specificity for sphincter of Oddidysfunction were 88% and 82%, respectively. Inconclusion, most patients with recurrent acute pancreatitishave sphincter of Oddi dysfunction documented by both atthe US secretin test and sphincter of Oddi manometry;results of the US secretin test are reliable compared to sphincter of Oddi manometry, andtherefore the US secretin test may offer a validalternative to the more expensive and invasivemanometric procedure for assessing sphincter of Oddidysfunction in patients with recurrent acutepancreatitis.     

Obesity Correlates with Gastroesophageal Reflux

Thirty morbidly obese patients presenting forbariatric surgery were evaluated for symptomatic andobjective evidence of gastroesophageal reflux. Sixteenpatients had heartburn while 14 were asymptomatic. All underwent esophageal function testing;manometry was performed in all patients, pH monitoringin 28. Patients with esophageal pH < 4 for more than5% of observed time weighed more than those with normal acid exposure, 165.2 vs 129.8 kg (P <0.01), and had significantly higher body mass indices,56.5 vs 48.3 kg/m² (P < 0.05). Similarly,morbidly obese patients with abnormal reflux scores weighed significantly more and hadgreater body mass indices than patients with normalscores (P < 0.05). Lower esophageal sphincterpressure was higher in patients with normal esophagealacid exposure than in those with abnormal findings,15.5 vs 12.5 mm Hg (P < 0.05). This studydemonstrates a correlation between both weight and bodymass index with gastroesophageal reflux.     

Pneumatic Dilatation Is Effective Long-Term Treatment for Achalasia

Although pneumatic dilatation (PD) has been anestablished treatment for achalasia for decades, thereis limited information on its long-term clinicalefficacy. We have followed up the clinical status of patients having PD with a 30- or 35-mm balloonby one of us (D.O.C.) over a 25-year period. Of 144patients whose initial records were available forreview, 31 could not be contacted. Of the remaining 113 patients, 72 (64%) responded to a questionnaireassessing swallowing status and patient satisfaction,and this forms the basis of this report. There were 32men and 40 women, with mean age 46 years (range: 17-78); mean length of follow-up since PD was6.5 years (range: 10 months to 25 years). Success wasprimarily defined by the need for no additional therapyfor achalasia other than one or two PD's. PD was effective long-term treatment in 61/72 patients(85% ); only four of these required a second PD overthis time interval. There was no significant differencein any of the following parameters between patients with a treatment success or failure: age, sex,size of pneumatic dilator, and duration of symptomsprior to PD. Response was significantly better (P <0.05) in patients having no prior dilatation (43/47; 91%) than in those in whom another physicianhad performed prior dilatation (18/25; 72%). In responseto the question of whether they would select PD again,68 patients (94%) responded positively. In conclusion, pneumatic dilatation performedusing a consistent technique by an experienced physicianis effective long-term therapy for achalasia patients ofall ages. Most patients require only onedilatation.     

Effect of Octreotide on Human Sphincter of Oddi Motility Following Liver Transplantation

The effect of octreotide on sphincter of Oddimotility was investigated in six liver transplantpatients, employing percutaneous (through the T-tubetract) manometry. Continuous and simultaneous sphincter of Oddi and duodenal motor activities wererecorded before and for 60 min after the administrationof octreotide (100 g subcutaneously) and after theinjection of cholecystokinin (0.02 g/kgintravenously). With octreotide, contraction frequency andbasal pressure significantly increased (P < 0.05).This effect lasted more than 60 min, long afteroctreotide-induced duodenal migrating motor complexphase III activity had ceased. Sphincter of Oddicontraction amplitude and duration were unaffected byoctreotide. Subsequent cholecystokinin administrationtransiently reduced sphincter of Oddi basal pressure and contraction frequency. We conclude thatoctreotide significantly increases sphincter of Oddibasal pressure and contraction frequency. This effect isdistinct from octreotide induction of migrating motor complex phase III activity, persists for aprolonged period, and is inhibited bycholecystokinin.