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.

MRI of periprostatic venous plexus in staging of early prostatic carcinoma

The periprostatic venous plexus can be observed as a bright rim in coronal magnetic resonance (MR) images obtained by spin-echo (SE) 2060/60 technique. A carcinoma of the prostate which penetrates through the capsule into the periprostatic tissues interrupts or obliterates this rim, whereas an intact rim indicates that the tumor is confined within the prostatic capsule. One hundred patients with proven prostatic carcinoma were prospectively imaged by MR to detect periprostatic involvement. The results were compared with those obtained by cystoscopy and digital rectal examination under general anesthesia. The imaging and clinical methods agreed with each other in 76% of the patients.

Electrical and mechanical activity in the human lower esophageal sphincter during diaphragmatic contraction

To determine the effect of contraction of the diaphragm on the lower esophageal sphincter (LES) pressure, we studied eight healthy volunteers during spontaneous breathing, maximal inspiration, and graded inspiratory efforts against a closed airway (Muller's maneuver). Electrical activity of the crural diaphragm (DEMG) was recorded from bipolar esophageal electrodes, transdiaphragmatic pressure (Pdi) was calculated as the difference between gastric and esophageal pressures, and LES pressure was recorded using a sleeve device. During spontaneous breathing, phasic inspiratory DEMG was accompanied by phasic increases in Pdi and LES pressure. With maximal inspiration, DEMG increased 15-20-fold compared with spontaneous inspiration, and LES pressure rose from an end-expiratory pressure of 21 to 90 mmHg. Similar values were obtained during maximal Muller's maneuvers. LES pressure fell promptly when the diaphragm relaxed. Graded Muller's maneuver resulted in proportional increases in the Pdi, LES pressure, and DEMG. The LES pressure was always greater than Pdi and correlated with it in a linear fashion (P less than 0.001). We conclude that the contraction of the diaphragm exerts a sphincteric action at the LES, and that this effect is an important component of the antireflux barrier.

Effect of the diaphragmatic contraction on lower oesophageal sphincter pressure in man

The effect of diaphragmatic contraction and relaxation on the lower oesophageal sphincter (LOS) pressure was studied in 10 healthy volunteers. Pressures in the oesophagus, LOS, and stomach were measured in three phases. Phase I, end tidal expiration; phase II, subjects inspired to total lung capacity (TLC) and kept the airway open (sustained diaphragmatic contraction); and phase III, at TLC subjects relaxed against a closed glottis (diaphragm relaxed). The LOS pressure in phase II was significantly higher than in phase I, while in phase III it was significantly lower compared with phase I. There was a net increase in LOS pressure of 32 mmHg in phase II as compared to phase I. After phase II, as subjects moved into phase III, there was a sudden drop in the LOS pressure. The LOS pressure in phase II correlated with the transdiaphragmatic pressure in a linear fashion. These observations suggest that diaphragmatic contraction in man enhances the LOS pressure and this augmentation of sphincter tone may be a vital component of the antireflux mechanism.

Reversibility of gastric dysmotility in cortisol deficiency

This case documents scintigraphically that gastric dysmotility associated with hypoadrenalism secondary to hypothalamic-pituitary dysfunction was reversed when the adrenal insufficiency was treated. The patient reported upon received almost immediate relief of symptoms after corticosteroid replacement therapy and improvement of gastric motility, as demonstrated by both liquid and solid phase 99mTc-labeled studies. This experience suggests that glucocorticoids are important permissive hormones for normal gastrointestinal motor function and may have a role in the pathophysiology of gastrointestinal tract disease.

Comparison of esophageal manometric characteristics in asymptomatic subjects and symptomatic patients with high-amplitude esophageal peristaltic contractions

The aim of this study was to examine systematically the manometric characteristics of symptomatic patients with high-amplitude peristaltic esophageal contractions, or the nutcracker esophagus (n = 20), in comparison to normal subjects (n = 30). In both normals and patients, amplitude and duration of contractions were more at 5 cm than at 10 cm above the lower esophageal sphincter. The patients differed significantly from normals not only in amplitude at 5 cm, but also at 10 cm and in duration at both sites. Bipeaked waves were seen more frequently in patients than in normals at either 5 or 10 cm above the sphincter. Two patients, but none of the normal subjects, had triple-peaked waves. Lower esophageal sphincter pressure was significantly elevated in patients as compared to normals. Although percent relaxation of the sphincter was the same in patients and normals, the postrelaxation residual, or nadir, sphincter pressure was higher in patients. We conclude that patients with high-amplitude peristaltic contractions may also have abnormalities in duration of contractions, percent bipeaked waves, triple-peaked waves, or in parameters of the lower esophageal sphincter.

Medication-induced esophageal injury: survey of the literature

A review of the 127 cases of drug-induced esophagitis reported since 1970 indicates that commonly used medications may be a source of esophageal injury. Retrosternal pain, odynophagia, and dysphagia were the most commonly reported symptoms and most cases were self-limited with 7 to 10 days of symptomatic therapy. Occasionally, severe odynophagia or dysphagia necessitated hospitalization. Emepronium bromide, tetracycline, and its derivatives, potassium chloride, and quinidine accounted for 89% of the reported cases; the remaining 11% were caused by 14 other medications. Serious sequelae, including death, have been linked to potassium-induced esophageal injury. With other medications, however, serious complications were rare. The diagnostic study of choice for suspected medication-induced esophageal injury is endoscopy, although air contrast barium swallow may often detect subtle mucosal abnormalities. In uncomplicated cases the history alone may be sufficient to make the diagnosis. Concurrent ingestion of adequate amounts of fluid and avoidance of unnecessary bedtime medications may help to prevent medication-induced esophageal injury.

Characteristics of transient lower esophageal sphincter relaxation in humans

Transient lower esophageal sphincter relaxations (TLESR) were studied in 10 normal healthy subjects. Electrical activity of mylohyoid muscle measured by an electromyogram (MEMG), pressures from pharynx, three esophageal sites, lower esophageal sphincter, and stomach were simultaneously recorded for 1 h, while fasting and 3 h after an 850 kcal meal. Reflux of acid into esophagus and/or occurrence of belching accompanying a TLESR was also monitored. TLESRs occurred with an equal frequency in fasting and postprandial state (6.2 vs. 6.4 h). However, frequency of an acid reflux during a TLESR was much greater postprandially than after fasting (44.8 vs. 9.6%). Belching coincided with 8% of TLESRs. A small MEMG complex and a small pharyngeal complex were present at onset of TLESR in 41.6 and 26.9% of instances, respectively. TLESRs were then categorized as either postswallow, if it occurred within 10 s of a preceding swallow-induced LES relaxation, or isolated, if its onset to previous swallow was greater than 10 s. Esophageal contractions were noticed at onset of 84% of isolated TLESRs. When present at two distal sites, this contraction was always of a simultaneous nature. Esophageal contractions at onset of postswallow TLESR were less frequent (33.3%) but when present were usually observed at the proximal esophageal site. At completion of a TLESR, the LES never recovered without an associated esophageal contraction, the latter was either swallow mediated or a spontaneous simultaneous esophageal contraction. Our data indicate that 1) MEMG and pharyngeal motor events may accompany TLESRs; and 2) esophageal contraction frequently heralds the onset, and it always occurs at completion of a TLESR.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastric emptying disorders. Tests and treatments

Tests to measure the volume of gastric contents are necessary to determine the nature of a gastric emptying disorder. The conditions that can affect gastric emptying are as varied as peptic ulcer disease, achlorhydria, viral and bacterial infections of the stomach, diabetes, scleroderma, anorexia nervosa, and CNS lesions; some patients experience gastric emptying problems after surgery for peptic ulcer disease. The future of electrical pacing of the stomach and perhaps the gastrointestinal tract in general is very exciting, as is the future use of antiarrhythmic drugs.

Do bile acids reflux into the esophagus? A study in normal subjects and patients with gastroesophageal reflux disease

To determine if bile acids reflux into the esophagus in patients with gastroesophageal reflux disease and in normal subjects during physiological gastroesophageal reflux episodes, esophageal aspiration and pH monitoring were performed simultaneously in 16 patients with gastroesophageal reflux disease and 8 normal subjects. Esophageal samples were collected for 30 min in the fasting state and for 3 h (as hourly samples) after the ingestion of a test meal (egg salad sandwich, peaches, and milk). Bile acids were assayed by a standard enzymatic assay and also by a sensitive and specific assay, liquid secondary ion mass spectrometry. Bile acids were not detected by enzymatic assay in any of the fasting samples. In 6 of the 8 normal subjects and 15 of the 16 patients with gastroesophageal reflux disease, bile acid-like reactivity was detected by the enzymatic assay in postprandial samples. However, bile acid-like reactivity was also found by enzymatic assay in aliquots of the homogenized test meal in concentration similar to the highest concentrations detected in esophageal aspirates. Bile acids were not detected by the liquid secondary ion mass spectrometry method in any of the fasting or postprandial esophageal aspirates (limit of detection greater than 2 microM). However, this assay accurately identified samples to which exogenous bile acids were added as controls. Our results suggest that bile acids did not reflux into the esophagus of patients with gastroesophageal reflux disease whom we studied and caution must be exercised in the use of enzymatic assay for bile acids in postprandial gastrointestinal fluids, as the commonly used hydroxysteroid dehydrogenase assay is not specific for bile acids alone.

Surgical myotomy in patients with high-amplitude peristaltic esophageal contractions. Manometric and clinical effects

High-amplitude peristaltic esophageal contractions, or the nutcracker esophagus, may be associated with chest pain or dysphagia. Medical treatment for this disorder is sometimes not satisfactory. We report the manometric and clinical effects of myotomy in four patients with high-amplitude peristaltic contractions who underwent surgery because of the severity of their symptoms and recalcitrance to various medical treatments. Manometry 1-5 years after surgery showed a reduction in amplitude, duration, and percent bipeaked waves at 5 and 10 cm above the lower esophageal sphincter. Peristalsis was abolished or decreased in the distal 10 cm of the esophageal body but was not affected more proximally. Lower esophageal sphincter pressure was decreased in all patients. The manometric changes were least marked in one patient, who was the only one who had some chest pain when last seen five years after myotomy. We conclude that in severely symptomatic patients with high-amplitude peristaltic contractions, myotomy results in marked manometric changes and marked clinical improvement. Patients with this disorder and whose chest pain is recalcitrant to extensive medical therapy may be successfully treated by surgical myotomy.

Identification and mechanism of delayed esophageal acid clearance in subjects with hiatus hernia

To determine if hiatus hernia (HH) contributes to the delayed clearance of acid from the esophagus in patients with gastroesophageal reflux (GER), we performed simultaneous esophageal pH recordings and radionuclide studies in three study populations: 12 GER patients with HH, 5 GER patients with no HH, and 8 subjects with HH but no GER symptoms. Acid clearance was measured at 5 cm. above the manometrically located lower esophageal sphincter (LES) after injecting a 15-ml. bolus of 0.1 N HCl at 15 cm. above the LES. The acid was labeled with 200 mu Ci of 99mTc-sulfur colloid. Acid clearance was also measured at 10 cm. above the LES after injection of a 15-ml. bolus of 0.1 N HCl at 20 cm. above the LES. Acid clearance at 5 cm. above the LES was faster in GER patients with no HH compared to GER patients with HH and asymptomatic HH subjects. Acid clearance was faster at 10 cm. than 5 cm. above the LES in all HH and non-HH subjects studied. In non-HH subjects, each swallow resulted in an increase in pH (a monophasic pH response) at 5 and 10 cm. above the LES. In symptomatic as well as asymptomatic HH subjects, swallows resulted in an initial fall followed by a rise in pH at 5 cm. above the LES (a biphasic pH response). Radionuclide studies showed reflux of the isotope-labeled acid into the esophagus followed by clearance (a biphasic response) accompanying swallows in 15 of the 20 HH subjects. Swallow-induced reflux was not detected by radionuclide scanning in non-HH subjects. Based on these observations, we conclude that during acid clearance a small amount of acid is trapped in the HH sac and refluxes into the esophagus during subsequent swallows when there is relaxation of the LES, and these repeated episodes of acid reflux from the HH account for the delayed acid clearance observed in GER patients with HH.

The significance of intraepithelial eosinophils in the histologic diagnosis of gastroesophageal reflux

Detection of intraepithelial eosinophils in esophageal mucosal biopsies has been suggested as histologic evidence of symptomatic gastroesophageal reflux (GER) disease in both children and adults. Previous studies have primarily examined symptomatic persons, and only one study included a comparison with normal controls. In the present study, the authors examined esophageal mucosal biopsies obtained by the hydraulic suction technic for the presence of intraepithelial eosinophils from 73 adult patients with subjective and objective evidence of GER disease and 12 asymptomatic adult volunteers in whom a series of esophageal function tests were normal. Intraepithelial eosinophils were identified in 23 (31.5%) of adult patients and in 4 (33.3%) of the asymptomatic volunteers. No clinical aspects in the GER patients correlated with the presence of eosinophils. By crude quantitation, rare eosinophils added little to more conventional assessment of histologic esophagitis and were present in one-third of normal subjects. The authors conclude that rare eosinophils in esophageal biopsies may not be a reliable criterion for the histologic assessment of GER disease.

Urethral disease and interventional cystourethrography

The innovation of balloon dilatation of urethral stricture and prostatic hypertrophy is a major contribution to interventional radiology. The procedure involves minimal trauma, produces immediate relief of symptoms, and probably results in less frequent and less difficult redilatations. The sparsity of reports in the literature on this subject reflects the reluctance of urologists to refer patients for balloon dilatation of urethral strictures. Every effort must be made by the radiologist to impress the urologist with the value of this procedure, which would eliminate the production of false passages and likely reduce the recurrence rate. Initial results with this procedure are encouraging, but larger series are required and long-term follow-up is necessary for evaluation of cure rate, rate of recurrence, and possible complications.

Medication-induced oesophageal injury. Survey of the literature

This is a review of the 127 cases of drug-induced oesophagitis reported in the English language literature since 1970. The most common symptoms reported were retrosternal pain, odynophagia, and dysphagia. Most cases were self-limited and symptoms resolved in 7 to 10 days with symptomatic therapy. Occasionally, severe odynophagia or dysphagia necessitated hospitalisation. Emepronium bromide, tetracycline and its derivatives, potassium chloride, and quinidine account for 89% of the reported cases of medication-induced oesophageal injury. 14 other medications have been reported to injure the oesophagus. Serious sequelae, including death, have been linked to potassium-induced oesophageal injury. With other medications, however, serious complications were rare. The diagnostic study of choice is endoscopy; an air-contrast barium swallow may also detect the often subtle mucosal abnormalities produced by medication injury. However, the diagnosis does not require confirmation by radiographical or endoscopic means in all cases, and the history alone may be sufficient to make the diagnosis in uncomplicated cases. Medication-induced oesophageal injury is preventable if pills are taken with an adequate amount of fluid and if the practice of taking medications immediately before bedtime is avoided.

Effects of morphine and naloxone on esophageal motility and gastric emptying in man

We studied the effect of morphine and naloxone on lower esophageal sphincter pressure, esophageal contraction amplitude, and gastric emptying of solids and liquids in ten normal healthy subjects. Morphine sulfate in a dose of 8 mg intravenous bolus significantly decreased sphincter pressure with a maximum fall of 22.8% of the basal tone. Naloxone, 5 mg intravenous bolus, resulted in a 20% increase in the baseline pressure. There was no change in the esophageal contraction amplitude, duration, or frequency of peristalsis with either morphine or naloxone. Gastric emptying was measured using a dual-isotope technique to simultaneously assess the emptying rates of both solid and liquid meal components. Morphine, 8 mg intravenous bolus, led to a significant inhibition (P less than 0.05) of the gastric emptying of both solids (99mTc sulfur colloid-labeled chicken liver) and liquids (111In DTPA-labeled water). Naloxone, 5 mg intravenous bolus, accelerated the gastric emptying of both solid and liquid components, but this did not achieve statistical significance. These observations suggest that: morphine's inhibitory effect on gastric emptying and lower esophageal sphincter pressure may contribute to its potent emetic properties; the human lower esophageal sphincter and stomach may have opiate receptors and further investigations should be addressed to determining if endogenous opiates play a role in the modulation of sphincter pressure and gastric emptying in humans.

Transition from peristaltic esophageal contractions to diffuse esophageal spasm

A patient with dysphagia and chest pain was shown by manometry to have high-amplitude peristaltic esophageal contractions (nutcracker esophagus). Worsening symptoms over the next two years led to the performance of repeated manometric studies, which showed diffuse esophageal spasm. This demonstration of a transition from nutcracker esophagus to diffuse esophageal spasm lends further support for consideration of the nutcracker esophagus as a manometric disorder associated with chest pain or dysphagia. Furthermore, it suggests a pathophysiologic relationship between the nutcracker esophagus, a disorder with preserved peristalsis, and diffuse esophageal spasm, the classic dysmotility considered to be of neurogenic origin.