Esophageal epithelial response to gastroesophageal reflux. A quantitative study

Medical therapy for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) remains a ubiquitous problem, although therapeutic options continue to evolve. Effective therapy calls for understanding the pathogenesis. Key factors associated with GERD include incompetence of the lower esophageal sphincter, esophageal clearance, gastric contents, tissue resistance, and potency of the refluxate. Phase-type directed therapy remains the best treatment approach and histamine (H2)-receptor antagonists are now the cornerstone of therapy for patients not responsive to conservative measures. In a subset of patients with severe esophagitis who do not respond to conventional H2-receptor antagonist therapy, efficacy has been demonstrated with high-dose therapy. The acid suppressant omeprazole, highly effective in erosive esophagitis, is the drug of choice for esophagitis resistant to H2-receptor antagonists. Despite effective forms of therapy, relapse rates are high in patients with severe GERD, and maintenance therapy typically is required. With near uniformity, efficacy end points for these agents have been directed toward relief of heartburn, regurgitation, and dyspepsia. Few data exist correlating relief of GERD and improvement of chest pain. Although therapeutic strategies for treating GERD have improved, empiric treatment of suspected GERD in the patient with noncardiac chest pain does not appear to be the optimal approach and should be reserved for cases where diagnostic testing is limited or unavailable.

Velocity of Candida albicans invasion into host tissues

Using 2 experimental models (candidal vaginitis in leukopenic mice and oral candidosis in neonatal rats) characterized by minimal inflammatory response to the pathogen, the rate of invasive growth of Candida albicans in stratified epithelia of mucosal membranes was defined. The pseudomycelium was found to invade animal epithelia at an average rate of 2 microns per hour, penetrating the entire epithelial thickness during 24-48 h. These data have been extrapolated to clinical pathology. On the basis of experimental data and by measuring the epithelial thickness in some human mucous membranes, the presumable periods of total epithelial penetration were calculated which may lead to vascular invasion and create the danger of dissemination. For different human mucous membranes these periods ranged from 22 to 59 h. These data emphasize the importance of cellular and tissue defense mechanisms, the inhibition of which may allow the fungi normally found on epithelial surfaces as commensals to invade the host tissues and to cause deep and disseminated mycotic lesions within several days.

24-hour intragastric acidity and plasma gastrin during long-term treatment with omeprazole or ranitidine in patients with reflux esophagitis

The reduction in intragastric acidity and the subsequent increase in plasma gastrin were compared during long-term treatment with either omeprazole or ranitidine in 19 patients with erosive reflux esophagitis. The patients received 40 mg omeprazole in the morning or 300 mg ranitidine twice daily. After healing, half the dose was given as maintenance treatment for 1 year. Intragastric acidity and plasma gastrin were measured 24 h before entry and monthly with the high dose and after 1, 6, and 12 months with the low dose. Omeprazole reduced intragastric acidity more effectively than ranitidine (p less than 0.001). This difference in efficacy was more pronounced during the daytime. Plasma gastrin increased more after omeprazole than after ranitidine (p less than 0.01), and both drugs showed a normal postprandial response and approached fasting levels before the next dose. During long-term treatment with 20 mg omeprazole in the morning no progressive alterations were observed in 24-h intragastric acidity or plasma gastrin.

The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury

Occult (silent) gastroesophageal reflux disease (GER, GERD) is believed to be an important etiologic factor in the development of many inflammatory and neoplastic disorders of the upper aerodigestive tract. In order ot test this hypothesis, a human study and an animal study were performed. The human study consisted primarily of applying a new diagnostic technique (double-probe pH monitoring) to a population of otolaryngology patients with GERD to determine the incidence of overt and occult GERD. The animal study consisted of experiments to evaluate the potential damaging effects of intermittent GER on the larynx. Two hundred twenty-five consecutive patients with otolaryngologic disorders having suspected GERD evaluated from 1985 through 1988 are reported. Ambulatory 24-hour intraesophageal pH monitoring was performed in 197; of those, 81% underwent double-probe pH monitoring, with the second pH probe being placed in the hypopharynx at the laryngeal inlet. Seventy percent of the patients also underwent barium esophagography with videofluoroscopy. The patient population was divided into seven diagnostic subgroups: carcinoma of the larynx (n = 31), laryngeal and tracheal stenosis (n = 33), reflux laryngitis (n = 61), globus pharyngeus (n = 27), dysphagia (n = 25), chronic cough (n = 30), and a group with miscellaneous disorders (n = 18). The most common symptoms were hoarseness (71%), cough (51%), globus (47%), and throat clearing (42%). Only 43% of the patients had gastrointestinal symptoms (heartburn or acid regurgitation). Thus, by traditional symptomatology, GER was occult or silent in the majority of the study population. Twenty-eight patients (12%) refused or could not tolerate pH monitoring. Of the patients undergoing diagnostic pH monitoring, 62% had abnormal esophageal pH studies, and 30% demonstrated reflux into the pharynx. The results of diagnostic pH monitoring for each of the subgroups were as follows (percentage with abnormal studies): carcinoma (71%), stenosis (78%), reflux laryngitis (60%), globus (58%), dysphagia (45%), chronic cough (52%), and miscellaneous (13%). The highest yield of abnormal pharyngeal reflux was in the carcinoma group and the stenosis group (58% and 56%, respectively). By comparison, the diagnostic barium esophagogram with videofluoroscopy was frequently negative. The results were as follows: esophagitis (18%), reflux (9%), esophageal dysmotility (12%), and stricture (3%). All of the study patients were treated with antireflux therapy. Follow-up was available on 68% of the patients and the mean follow-up period was 11.6 +/- 12.7 months.(ABSTRACT TRUNCATED AT 400 WORDS)

Impairment of esophageal emptying with hiatal hernia

Concurrent videofluoroscopy and manometry were used to analyze esophageal emptying during barium swallows in 22 patients with axial hiatal hernias and in 14 volunteers. Subjects were divided into three groups: (a) volunteers with maximal phrenic ampullary length less than 2 cm (controls); (b) patients or volunteers with maximal ampullary/hiatal hernia length greater than or equal to 2 cm that reduced between swallows (reducing-hernia group); and (c) patients with hernias that did not reduce between swallows. Complete esophageal emptying without retrograde flow was achieved in 86% of test swallows in the controls, 66% in the reducing-hernia group, and 32% in the nonreducing-hernia group (P less than 0.05). Impaired emptying in the reducing-hernia group was attributable to "late retrograde flow," whereby barium squirted retrograde from the hernia during emptying. Impaired emptying in the nonreducing-hernia group was attributable to "early retrograde flow" that occurred immediately after LES relaxation. The nonreducing-hernia group also had longer acid clearance times than the controls (P less than 0.05). We conclude that gastroesophageal junction competence is severely impaired in patients with nonreducing hiatal hernias, suggesting a mechanism whereby this subgroup of hiatal hernia is involved in the pathogenesis of reflux disease.

The effect of esophageal acid volume on arousals from sleep and acid clearance

To assess the effect of different volumes of acid infused into the esophagus, seven normal volunteers were studied in the waking and sleep state. All subjects were studied for three nights in the sleep laboratory, which included complete polysomnographic monitoring and esophageal pH recording. Multiple infusions of either 5, 15, or 25 ml of 0.1 N HCL were administered each night. Similar infusions were also accomplished in the waking state. The results showed a significant (p less than 0.05) decrease in the arousal from sleep with 25-ml vs 5-ml infusions. During sleep, the latency to the first swallow was significantly (p less than .05) shorter with the 25-ml infusion when compared with that of the 5-ml infusion. While awake, the infusion volume did not affect the latency to the first swallow. The acid clearance times were not significantly altered by the different volumes infused. It is concluded that the larger volumes of acid in the esophagus create an afferent "warning" signal to the central nervous system to produce a rapid arousal from sleep along with a shortened interval to the first swallow. These responses rapidly empty the larger acid volumes from the esophagus.

Double blind comparison of omeprazole (40 mg od) versus cimetidine (400 mg qd) in the treatment of symptomatic erosive reflux oesophagitis, assessed endoscopically, histologically and by 24 h pH monitoring

This double blind, double dummy study compares the rate of healing of erosive reflux oesophagitis, assessed endoscopically, with four and eight weeks treatment using omeprazole or cimetidine, and the effect of four and eight weeks treatment of reflux oesophagitis with omeprazole or cimetidine on reflux symptoms, microscopic healing, and in a subgroup of patients, oesophageal pH measurements. Omeprazole 40 mg once daily achieves (i) greater and more rapid symptom relief, (ii) more rapid and sustained endoscopic and histological healing, and (iii) greater reduction of oesophageal acid exposure than cimetidine 400 mg four times daily.

Gastric acid hypersecretion in refractory gastroesophageal reflux disease

We prospectively evaluated gastric acid output (mEq/h), gastric volume output (ml/h), ambulatory 24-h esophageal pH monitoring, and the endoscopic appearance of the esophagus in 23 patients undergoing treatment of chronic long-standing pyrosis. Twelve of these 23 individuals (52%) remained symptomatic after 3 mo of standard antisecretory treatment with ranitidine, 150 mg twice daily. When compared with initial responders, those patients who did not experience complete symptomatic relief on therapy had significantly higher basal acid output (p less than 0.001), basal volume output (p less than 0.02), and basal upright (but not supine) reflux time (p less than 0.05). Nine of the 12 patients who did not respond to initial treatment had gastric acid hypersecretion (basal acid output greater than 10 mEq/h), and 10 of the 12 had Barrett's epithelium compared with only 1 patient in the initial-responder group (p less than 0.001). All 12 nonresponders were treated for an additional 3 mo with increased doses of ranitidine (mean, 1280 mg/day; range, 600-1800 mg/day), and complete disappearance of pyrosis occurred in 10 of the 12, although no significant endoscopic regression was observed in the extent of the underlying columnar mucosa in those with Barrett's esophagus over the 6-mo duration of the study. A significant correlation was shown between the daily ranitidine dose required to eliminate symptoms and the pretreatment basal acid output (r = 0.81, p less than 0.001); gastric acid output had to be almost totally suppressed (i.e., less than 1 mEq/h) for pyrosis to disappear completely. No side effects occurred with any of these high doses of ranitidine. We conclude that a subgroup of patients with long-standing symptomatic gastroesophageal reflux disease who do not respond to standard ulcer-healing doses of histamine2-receptor antagonists are hypersecretors of basal gastric acid and require increased acid-suppressive therapy. Many of these individuals also have underlying Barrett's epithelium.

Gastroesophageal reflux and posterior laryngitis

Esophageal acid exposure was assessed by 23-hour ambulatory pH monitoring and compared with a biopsy of the posterior larynx and proximal esophagus in 97 patients with hoarseness, burning pharyngeal discomfort, or globus sensation. Patient results were compared with normal acid exposure times obtained in 54 control subjects. In 24 patients there were laryngeal abnormalities but both esophageal biopsy results and acid exposure times were normal. Laryngeal disease was found in association with prolonged acid exposure time or esophagitis in only 17 of the 97 patients (17.5%) studied. Recent reports appear to have overestimated the importance of acid reflux as a cause of posterior laryngitis.

Genesis and decay of the foregut: development and repair

The microscopic anatomy of the oesophago-gastric territory is interpreted as the result of the interaction of three main phenotypes: squamous, oxyntic and intestinal. This synthesis allows the comparison between phenotype development, atrophy and metaplasia. The concomitances in the processes of development and repair lead to the proposal of an intestinalization gradient inherent to the oesophago-gastric field. This hypothesis permits an integration of the epithelial changes associated with gastritis and oesophagitis together with ontogenesis. The global tendencies in epithelial development and repair are discussed; a link between the two appears evident. The shifting potential of the progenitor gland zones in development and repair is in consonance with Wolpert's theory of positional information.

24-hour esophageal pH monitoring before and after medical therapy for reflux esophagitis

Medical treatment of gastroesophageal reflux disease often results in improvement of symptoms. The purpose of this study was to determine if improvement in symptoms and endoscopic appearance after treatment was associated with a reduction in reflux, as measured with 24-hr pH recordings. Twenty patients with severe chronic reflux esophagitis participated in an eight-week double-blind trial of medical therapy with metoclopramide and cimetidine versus placebo and cimetidine. Significant symptom score improvement was noted in 11 patients. Eleven patients also had improvement in the endoscopic appearance of the esophageal mucosa, and eight of these patients had significant symptom improvement. Initial 24-hr pH recordings were abnormal in all patients, evidenced by an esophageal pH less than 4 during 20% of the study period. Improvement in 24-hr results was noted in only five patients--three with clinical and endoscopic improvement, and two with no improvement. In conclusion, there was no relationship between clinical improvement and the results of 24-hr pH recordings. Successful symptom relief and endoscopic healing of esophagitis during medical treatment may occur despite persistent reflux of gastric contents.

Congenital esophageal cysts in adults

Sixteen adult patients with congenital esophageal cysts were operated on between 1957 and 1979. Preoperatively, 7 patients (44%) were asymptomatic and the cyst was found incidentally on a routine chest roentgenogram. Esophageal symptoms were present in only 3 patients (19%), whereas most symptomatic patients had precordial sensations or arrhythmias. A correct preoperative diagnosis was made in only 1 patient. After enucleation of the cyst, preoperative symptoms were alleviated in all patients and short-term results were excellent. However, long-term follow-up 13.2 +/- 5.6 (+/- standard deviation) years later revealed moderate reflux in 9 (64%) of the surviving 14 patients. During esophagoscopy, macroscopic esophagitis was found in 12 (92%) of 13 patients. On histological examination of specimens obtained by forceps biopsy, esophagitis was present in 10 (77%) of 13 patients and included Barrett esophagus in 2. We conclude that, despite excellent early results, long-term follow-up of patients who undergo operation for congenital esophageal cysts is indicated because of the increased incidence of reflux esophagitis.

Daytime gastro-oesophageal reflux is important in oesophagitis

Fifty two patients were studied to investigate the patterns of gastro-oesophageal reflux during ambulatory pH monitoring and the relationship of reflux to presence and severity of oesophagitis. Twenty nine had evidence of oesophagitis which was graded according to severity. Acid exposure (pH less than 4) was calculated in each case for the total study period, the recumbent and upright periods, and the three hour period after the evening meal. Exposure in the upright period correlated closet (r=0.92: p less than 0.001) with that during the total period. Recumbent exposure correlated with both upright and postprandial exposure (p less than 0.001). Acid exposure during all four periods correlated significantly with the severity of oesophagitis, but postprandial acid exposure correlated best and recumbent acid exposure least well. Although acid clearance in the total, recumbent and upright periods correlated with oesophagitis, postprandial clearance showed the closest relationship. Thus the magnitude of daytime reflux, especially postprandial reflux and acid clearance, is more closely related than nocturnal reflux to oesophagitis. The results do not support the contention that night time reflux is inherently more injurious than daytime reflux to the oesophageal mucosa.

Esophagitis in scleroderma. Prevalence and risk factors

Of 53 patients with scleroderma (43 women and 10 men) evaluated by esophagoscopy and biopsy, 32 (60%) had erosive esophagitis. Symptoms of heartburn and dysphagia were significantly more frequent in the patients who had erosive esophagitis but often were present in those without this condition. Abnormal motility characterized by loss of peristalsis in the distal esophagus was present in all patients with erosive esophagitis, including the 5 who were asymptomatic. No patient with normal esophageal motility had erosive esophagitis at endoscopy. The patients with erosive esophagitis also had significantly diminished lower esophageal sphincter pressures and increased frequency and duration of gastroesophageal reflux episodes. Stricture was present in 13 of 32 patients with erosive esophagitis and was absent in the other 21 patients. The duration of disease, rate of gastric emptying, and fungal smear and culture were not significantly different in those with or without esophagitis. Treatment of fungal infection for a month had little beneficial effect. The pattern of esophageal motility in scleroderma identifies high and low risk groups for esophagitis and stricture, and can be used to select those who require further investigation, irrespective of symptoms.

Gastric emptying of solid food in patients with gastroesophageal reflux

While delayed gastric emptying of solid food has been reported in patients with symptoms of gastroesophageal reflux, the study populations were not defined by 24-h intraesophageal pH monitoring. Moreover, the influence that the gastric emptying rate may have on patterns of reflux during the day or night, as well as on esophagitis, is not known. In this study, we compared the gastric emptying rate of solid food (in vivo intracellular labeled chicken liver) observed in asymptomatic control volunteers (n = 15) with that of symptomatic patients with an abnormal 24-h pH record who had either the presence (n = 22) or absence (n = 11) of endoscopic esophagitis. We found no significant difference in the gastric emptying rate between the asymptomatic control volunteers and the symptomatic patients with and without esophagitis. Moreover, there was no significant correlation between the gastric emptying rate and the degree of daytime or nighttime distal esophageal acid exposure found during 24-h intraesophageal pH monitoring. Only 6% of the symptomatic patients had a gastric emptying rate that exceeded the mean value plus 2 SD of that found in the asymptomatic control volunteers. We believe these support a de-emphasis of the role that delayed gastric emptying of solid food may play in the pathophysiology of gastroesophageal reflux in most patients.

Is 24 h ambulatory oesophageal pH monitoring useful in a district general hospital?

53 of 61 patients successfully completed 24 h ambulatory monitoring of oesophageal pH. The indications were: symptoms suggestive of gastro-oesophageal reflux but with normal endoscopy (19 cases); atypical chest pain with normal endoscopy (21 cases); or respiratory symptoms possibly due to reflux (13 cases). A temporal association between abnormal reflux and the presenting symptoms was demonstrated in 25 patients (47%). 6 patients were shown to have respiratory symptoms after episodes of reflux which resolved on treatment of the reflux alone. Reflux occurring only in the erect posture was observed in some patients and may have been a manifestation of the irritable bowel syndrome. Reflux as a cause of symptoms was excluded in 14 patients. The procedure was well tolerated in most patients, simple to operate, and inexpensive.

Oesophagitis, signs of reflux, and gastric acid secretion in patients with symptoms of gastro-oesophageal reflux disease

In a study comprising 100 patients referred to a surgical clinic with symptoms suggestive of gastro-oesophageal reflux disease the value of different diagnostic procedures was investigated. Positive acid perfusion and 24-h pH tests were the commonest findings. Forty-nine per cent showed a normal oesophageal mucosa or diffuse oesophagitis at endoscopy. The severity of heartburn and regurgitation did not differ between patients with normal oesophageal mucosa and oesophagitis of various severities. The severity of macroscopic oesophagitis was significantly correlated to the total reflux time, the presence of reflux or a hiatal hernia at radiology, an open cardia or reflux at endoscopy, pressure transmission or reflux and low lower oesophageal sphincter pressure at manometry. Gastric hypersecretion was found in 66% of the patients. Gastric acid secretion was not correlated to the severity of oesophagitis or to the findings at 24-h pH test. In patients with severe oesophagitis the sensitivity for radiologic, manometric, and endoscopic signs of incompetence of the gastro-oesophageal junction was 94%.

Microscopic appearance of the esophageal mucosa in a consecutive series of patients submitted to upper endoscopy. Correlation with gastroesophageal reflux symptoms and macroscopic findings

The histologic finding of basal-layer hyperplasia and papillosis as consequences of gastroesophageal reflux still constitute an area of controversy. Consequently, a prospective study of symptoms and endoscopy and biopsy interpretation was undertaken in 200 patients consecutively submitted to upper endoscopy, whereof 12 were excluded. Complete agreement among all three variables was found in half of the patients and harmony between two of the variables in one fourth. In the last fourth the outcome was positive in one variable only, equally distributed among the symptoms, endoscopy, and histology. It is concluded that histology is of considerable value in gastroesophageal reflux disease.

Esophageal motor function and response to acid perfusion in patients with symptomatic reflux esophagitis

There is much evidence to suggest that peristaltic function is defective in esophagitis patients and that this defect may contribute to prolonged acid exposure, promoting esophageal mucosal injury. Abnormal peristalsis may also be related to the generation of reflux symptoms. We evaluated primary peristalsis and its relationship to symptoms under basal conditions and during saline and HCl perfusion in 15 symptomatic reflux patients with gross esophagitis and 15 healthy controls. In the basal state, LES pressure (15.3 vs 25.1 mm Hg) and peristaltic amplitude (74.2 vs 104.8 mm Hg) were significantly lower in subjects with gastroesophageal reflux disease (GERD) (P less than 0.05). During HCl perfusion, peristaltic amplitude and duration increased slightly, and peristaltic velocity slightly decreased similarly in both groups. There was no difference in the incidence of nonpropagated, segmental, or swallow-initiated simultaneous contractions, or change in resting intraesophageal pressure during HCl perfusion in control and GERD groups. This study identified abnormal contractile amplitude as a specific defect in the primary peristaltic wave of esophagitis patients but does not support a role for acid-induced motility changes in the generation of symptoms in GERD.

Bile acid concentrations in the gastric juice of patients with erosive oesophagitis

Intragastric total bile acid concentrations were measured before and after a corn oil test meal in 16 patients with erosive oesophagitis and symptoms of gastro-oesophageal reflux. Sixteen age and sex matched control subjects were also studied. No significant difference was detected between fasting or postprandial gastric bile acid concentrations in patients and in control subjects although a wide range of bile acid concentrations was detected among individuals in both groups. Gastric juice pH was less than 3.5 in seven patients when intragastric bile acid concentrations were greater than 200 mumol/l. These results do not support a role for abnormal duodenogastric reflux in the pathogenesis of erosive oesophagitis. The detection of acid reflux in such patients during intra-oesophageal pH monitoring, however, does not exclude the presence of bile acids which may contribute to the cytotoxic potential of gastric juice.

Sucralfate prevents experimental peptic esophagitis in rabbits

Sucralfate was tested in a rabbit model for its ability to prevent experimental esophagitis. Esophagitis was assessed by gross appearance and microscopic examination by an uninformed observer. In addition, the permeability of the esophagus to a number of probe molecules was measured to assess barrier function. Animals were exposed for 1 h to either acid alone (HCl at pH 2), acid plus pepsin (0.8 mg/ml), or acid plus taurocholic acid (5 mM), as well as to the same injurious agents with the addition of 1 g of sucralfate. At the completion of this hour, the perfusate was removed and all animals were again perfused for 1 h with HCl at pH 2 while mucosal permeability was assessed by measuring erythritol, glucose, potassium, and sodium fluxes. The animals were then killed. Sucralfate significantly diminished esophagitis and the attendant mucosal permeability changes induced by pepsin. The viscous sucralfate gel was shown to adhere tenaciously to the esophageal mucosa, but this characteristic of sucralfate was found not to be critical for its protective action because a clear sucrose sulfate solution with no gel present was also protective. Hence, it was not necessary for the gel to be present for the drug to be effective. Several in vitro tests suggested that the clear sucrose sulfate solution, like the sucralfate gel, probably acts through a topical protectant effect, rather than through pepsin inactivation. Although the degree of esophagitis induced by the bile acid was significantly less than that observed with pepsin, the mucosal permeability changes were comparable. Sucralfate did not significantly reduce the flux rates of glucose, potassium, and sodium nor did it affect the morphology of the mucosa after exposure to taurocholic acid. In conclusion, the binding of sucralfate to pepsin substrates in tissue results in this agent being very effective in preventing experimental peptic esophagitis.

Histological appearances of oesophagus, antrum and duodenum and their correlation with symptoms in patients with a duodenal ulcer

Clinical data and histology from the oesophagus, gastric antrum, and duodenum were collected from 36 patients undergoing surgery for duodenal ulcer. Gastritis was present in 94% of the patients (25% of atrophic type), oesophagitis in 72% and duodenitis in 39%. Abnormal biopsies were present from all three sites in 33% of the patients. Only one patient showed three normal biopsies. The low incidence of duodenitis does not support the theory that duodenitis is part of the same spectrum as duodenal ulcer. Heartburn was related to the presence of gastritis (100%) and oesophagitis (76%) but not to duodenitis (52%). No relationship was found between the length of history, severity of pain, and histological abnormalities.

Computerized 24-hour ambulatory esophageal pH monitoring and esophagogastroduodenoscopy in the reflux patient. A comparative study

Ambulatory 24-hour esophageal pH monitoring and esophagogastroduodenoscopy were performed in 72 patients with symptoms suggestive of gastroesophageal reflux. Additionally, 22 asymptomatic healthy volunteers underwent pH monitoring. In patients with classic reflux symptoms and endoscopic esophagitis, a mean of 5.41 minutes/hour of reflux below pH 4 was found compared to 0.70 minutes/hour in controls (p less than 0.0001). The mean number and duration of reflux events in this group were 1.51 events/hour and 4.0 minutes/event, compared with 0.31 events/hour and 2.26 minutes/event in volunteers (p less than 0.001, p less than 0.01). A new system for ambulatory esophageal pH monitoring is presented using a pH-sensitive radiotelemetry pill or a pH probe and computerized methods for ambulatory data collection, analysis, and storage. An overall sensitivity of 76% was obtained with a 91% selectivity for detection of acid reflux in 51 patients having classic symptoms of gastroesophageal reflux. Ambulatory pH monitoring was positive for acid reflux in seven of 11 patients with normal endoscopic findings. Conversely, eight of 12 patients with normal pH monitoring had endoscopic esophagitis. In 19 patients presenting with atypical symptoms or previous gastric surgery, endoscopic findings were normal in 15. Nine of these 15 were identified as acid refluxers by pH monitoring. A combined approach using both pH monitoring and endoscopy is warranted for maximal detection and quantification of disease. A clear clinical role for pH monitoring is seen in the early diagnosis of acid reflux, particularly in patients having normal endoscopic findings with nonspecific gastrointestinal complaints or previous gastric operations.

Histologic evaluation of chronic gastroesophageal reflux. An evaluation of biopsy methods and diagnostic criteria

Controversy exists regarding the appropriate method for biopsy confirmation of esophageal reflux injury. We have compared endoscopic pinch biopsy (PB) with endoscopically directed Rubin tube suction biopsy (SB) in 40 patients with symptomatic gastroesophageal reflux disease (GERD). Utilizing a plastic tube attached alongside the endoscope, SB at specific sites in the esophagus can be easily obtained. Suction biopsy was rated superior to PB for adequacy of tissue, ability to make an interpretation, and certainty in diagnosis. These differences were most pronounced in patients with endoscopic grades 0 and 1 + esophagitis in which 59% of PBs were uninterpretable compared to 23% of SBs. The passage of the Rubin tube was easily done and could be performed repeatedly. Six of 40 patients (15%) developed substernal chest discomfort in the 24 hr following SB. We conclude that SB is the most appropriate way to evaluate histologic changes related to reflux injury and that this method is mandatory in symptomatic patients with minimal endoscopic evidence of esophagitis (0-1 +).

Gastroesophageal reflux. Simple measures often suffice

Regurgitation of the gastric contents into the esophagus is common and often unnoticed. When symptoms such as heartburn, a sour or bitter taste in the mouth, or even chest pain mimicking angina pectoris or myocardial ischemia prompt a patient to seek help, the factor or factors responsible for reflux must be sought. The possible underlying causes are numerous, as Dr Bachman points out in this discussion of the pathophysiology, diagnosis, and treatment of gastroesophageal reflux. The desired end point of management was well stated by Seneca over 2,000 years ago as "a good-humored stomach."

The defense mechanisms of the esophagus

Gastroesophageal reflux is a normal event, and the gastrointestinal tract possesses mechanisms to deal with the refluxed content so that symptoms are not produced. When the amount of refluxed material increases, or the quality changes, or one or more of the defense mechanisms breaks down, then the consequences occur in the esophagus. The variability of symptoms, of mucosal changes, and of motility patterns in response to pathologic gastroesophageal reflux imposes difficulties when one is trying to assess this disorder objectively.

Properly conducted fundoplication reverses histologic evidence of esophagitis

Little is known about the fate of histologic changes of esophagitis following an antireflux procedure. In a widely quoted paper (Gastroenterology 1979; 76:1393), initial healing of esophagitis was reported, but it was noted that normal biopsies reversed to abnormal in a small number of patients who were followed for up to 69 months. The authors studied esophageal histology in 21 patients undergoing a Nissen fundoplication by a standardized technique. All patients underwent biopsy after operation from 5 to 96 months (mean, 39 months). Nineteen of 21 patients had esophagitis typified by leukocytic infiltration shown on preoperative biopsy. Only two patients had these changes after operation, and one subsequently returned to normal. No patient had evidence of worsening of his esophageal mucosa over time, but several persisted with epithelial changes that included basal cell hyperplasia and papillary elevation. The authors conclude that the Nissen fundoplication, when performed by a standardized technique, leads to reversal of histologic evidence of esophagitis, even for follow-up periods of 96 months, and that the symptomatic status of a patient correlates well with the histologic level of esophagitis.

Morphological alterations in experimental esophagitis. Light microscopic and scanning and transmission electron microscopic study

The morphology of esophagitis, both in the presence and absence of acid, was studied by light microscopy and transmission and scanning electron microscopy. For this purpose the rabbit esophagus was isolated in situ and perfused with agents known to cause esophageal mucosal damage (HCl, pepsin, taurocholate, and deoxycholate). In addition, changes in the permeability of the plasma membrane of the esophageal epithelial cells were assessed by staining the esophageal epithelium with trypan blue and antinuclear antibodies. The results indicate that HCl alone causes relatively few changes in the esophageal epithelium. However, when combined with pepsin or taurocholate, severe ulcerative changes were caused within an hour. Deoxycholate, which is formed in the upper gastrointestinal tract under nonacidic conditions, also causes severe damage. Further, it was shown that the esophagitis caused by pepsin and bile salts are clearly morphologically different. Bile salts affect primarily the cell membrane and intracellular organelles, while pepsin seems to affect the intercellular substance causing the epithelial cells to be shed. In contrast, the presence or absence of acid per se does not seem to influence the nature of the epithelial damage, since the lesions caused by the two bile salts (deoxycholate vs taurocholate + HCl) were morphologically similar.

Mucosal biopsy of the esophagus, stomach, and proximal duodenum

The past decade has occasioned the development and extensive use of flexible endoscopes for visualization of large areas of the alimentary tract. Numerous small grasp biopsies are now performed to determine the diagnosis and course of a large variety of inflammatory and neoplastic disorders. In this review, the authors have concentrated on the uses and interpretation of endoscopy and biopsy of the upper alimentary tract including the esophagus, stomach, and proximal duodenum. They have also commented on the limitations of endoscopic biopsy with respect to its size, superficial nature, and imperfect orientation in the evaluation of some disorders.

New concepts and methods in the study and treatment of gastroesophageal reflux disease

This paper reviews progress in the use of 24-hour distal esophageal pH monitoring in the study of gastroesophageal reflux. This technique records acid exposure as numbers of reflux episodes and time required by the esophagus to return this acid juice to the stomach. These data afford an opportunity to conceptualize the pathophysiology of gastroesophageal reflux disease in relation to physiologic activities such as alimentation, sleep, and postural change. This knowledge will enable the clinician to critically focus attention on important issues of patient management and therapy as they relate to the pathophysiology of this disease.

Morphometric study of the esophageal mucosa in cirrhotic patients with variceal bleeding

A morphometric study of the distal esophageal mucosa (within 5 cm above the gastroesophageal junction) has been carried out in a group of 11 cirrhotic patients undergoing esophageal transection with SPTU gun for variceal bleeding. The relative thickness of the papillae (62.2 +/- 3.9%) and basal zone (11.8 +/- 1.9%) were within normal limits. Polymorphonuclear infiltrates were not found either in the lamina propria or in the epithelium. The absence of histopathologic changes in the esophageal mucosa from patients with liver cirrhosis and bleeding esophageal varices confirms the hypothesis that gastroesophageal reflux does not play a pathogenic role in the development of variceal bleeding.

Evaluation of elevation of the head of the bed, bethanechol, and antacid form tablets on gastroesophageal reflux

To ascertain how elevation of the head of the bed, bethanechol, and antacid foam tablets affect gastroesophageal reflux, we used prolonged intraesophageal pH monitoring in 55 symptomatic patients. Acid exposure was separated into reflux frequency and esophageal acid clearance time and recorded during the day in the upright posture and recumbent at night. Values before and during each therapy were compared to physiologic reflux in 15 asymptomatic controls. Ten patients slept with the head of the bed elevated and had a 67% improvement in the acid clearance time (P less than 0.025); however, the frequency of reflux episodes remained unchanged. Twelve patients given 25 mg of bethanechol 4 times a day had a 50% decrease in recumbent acid exposure only (P less than 0.05), due to a trend towards decreased reflux episodes and acid clearance in time. Bethanechol combined with head of bed elevation in 19 other patients decreased both reflux frequency (30%) and acid clearance time (53%, all P less than 0.05). Antacid foam tablets failed to significantly diminish acid exposure. Nocturnal reflux responded the best to those therapies tested.

Esophageal biopsy in the diagnosis of reflux esophagitis

Esophagitis in infancy and childhood produces characteristic histologic changes in the mucosa and lamina propria of the distal esophagus. The use of biopsy in addition to endoscopic evaluation considerably enhances the accuracy of the diagnosis of esophagitis, particularly when the degree of inflammatory change is mild. In the absence of severe inflammatory changes, such as ulceration or mucosal slough, esophageal biopsy appears to be essential for the accurate diagnosis of esophagitis. In children of any age with GER who have symptoms of esophagitis, antacid therapy and vigorous efforts to control reflux are indicated. Failure to respond to this program is an indication for esophageal biopsy to confirm or rule out the presence of esophagitis. The degree of inflammatory change in the biopsy is a reliable guide to expected response to antiacid therapy.

Acid clearance during sleep in the pathogenesis of reflux esophagitis

Impaired esophageal clearing of refluxed gastric contents during sleep has been implicated in the pathogenesis of reflux esophagitis. To more directly evaluate this hypothesis, 13 symptomatic patients with esophagitis and 13 normal controls had 15 ml of 0.1 N HCl instilled into the esophagus in the recumbent position while awake and during polygraphically monitored sleep. When sleep was maintained for the majority of the acid-clearing duration, the clearance times for both patients and controls were significantly prolonged when compared to those while awake (P less than 0.01). However, when sleep was maintained for less than 50% of the acid-clearing interval, the patients showed significantly longer acid clearance times. The swallowing rate did not differentiate the two groups under any condition. These data show that sleep impairs esophageal acid clearance. Acid clearance occurred predominantly in association with arousals from sleep. The defective acid clearance found in patients with esophagitis probably plays a major role in the pathogenesis of this disorder.

Oesophageal epithelial ultrastructure after incubation with gastrointestinal fluids and their components

Oesophageal biopsies from endoscopically normal patients were incubated in the following for up to 30 min-Ham's F10 medium:isotonic saline:0.1 N HCl:20, 2 and 0.2 mM bile acids:trypsin:pepsin:lipase; autologous gastric and duodenal juices. The biopsies were then examined by electron microscopy. No morphological change was produced by Ham's F10 or saline. HCl caused little damage. Gastric juice produced widespread severe damage, as did pepsin. Duodenal juice and the enzymes tested caused lysis and internalisation of desmosomes and peripheral cytoplasmic vacuolation. Bile acids split desmosomes and induced microvesiculation of cell membranes. Similar microvesiculation was also induced by duodenal juice. All media except hydrochloric acid eventually produced organelle damage and leaky and disrupted cells. The functional and superficial cells appeared to be able to withstand attack from these experimental media better then did prickle and basal cells. Membrane coating granules were secreted in the presence of hydrochloric acid, but not with enzymes.