Prolonged ambulatory pH monitoring in patients following oesophageal transection and control subjects

Oesophageal motility and gastro-oesophageal reflux: effect of variceal eradication by endoscopic sclerotherapy

Endoscopic injection sclerotherapy (EIS) is known to produce oesophageal structural and motility changes; however, alterations in frequency and severity of gastro-oesophageal reflux (GER) following EIS have not been investigated in detail. We studied 22 patients with cirrhosis and oesophageal varices before EIS and 26 after variceal eradication with intravariceal EIS using manometry and 24 h pH monitoring. The post-EIS group had reduced oesophageal sphincter pressure (19.2+/-11.4 vs 26.1 +/-16.4 mmHg, P< 0.05) and slower velocity of oesophageal peristalsis (2.47+/-0.71 vs 3.06+/-0.77 cm/s, P< 0.01) than the pre-EIS patients. There was no difference in the amplitude or duration of the contraction. Abnormal contraction wave-forms were observed more frequently in post-EIS than in the pre-EIS patients (3/22 vs 12/26, P< 0.05). Various quantitative parameters for GER were not increased in post-EIS compared with pre-EIS patients. Abnormal GER was present in nine of 21 pre-EIS and eight of 17 post-EIS patients (no significant difference). These results suggest that although persistent oesophageal motility changes are frequent after intravariceal EIS, these do not lead to a significant increase in GER.

Gastric secretion and peptic ulceration in cirrhosis

Stomach function and secretions are altered significantly in patients with cirrhosis, both with or without portal hypertension. This review covers the abnormalities of gastric acid and pepsin secretion, and gastrin release. Histological and endoscopic changes, and the impaired cytoprotection associated with cirrhosis, are discussed in the context of abnormal gastric secretion. In addition, the symptomatology and association of H. pylori, and treatment of duodenal ulceration in cirrhosis are discussed. It is clear from this review that additional studies are needed to further understand gastric function in cirrhotic patients.

Comparison of postoperative results following terminal esophagoproximal gastrectomy and esophageal transection for esophageal varices

The results of 44 terminal esophagoproximal gastrectomies (TEPG) and 53 esophageal transections (ET) for esophageal varices, performed during the period between January, 1975 and March, 1989, were retrospectively compared. The results examined prognosis, recurrence of esophageal varices and late postoperative complications. The 5-year survival rates for patients who underwent selective or prophylactic surgery were 85.9% following TEPG and 81.6% following ET. However, the 10-year survival rate for the former group was significantly lower than that for the latter group at 59.3% versus 70.0% (P < 0.05) because of the number of deaths due to hemorrhage and liver failure caused by anastomotic ulcers. The respective 5-year recurrence rates of varices for the TEPG and ET groups were 18.4% and 26.4%, respectively, while the 10-year recurrence rate for the former group was again significantly lower than that for the latter group at 27.1% versus 53.7% (P < 0.01). As for postoperative late complications, reflux esophagitis and/or anastomotic ulcers were found twice as frequently after TEPG as after ET. Thus, although TEPG was more effective for preventing variceal recurrence it left the potential for an anastomotic ulcer to develop, which was the dominant cause of death more than 5 years after surgery.

Bleeding from staple line erosion after esophageal transection: effect of omeprazole

Esophageal staple transection effectively controls acute variceal bleeding, but up to 50% of these patients will have recurrent upper gastrointestinal bleeding. In our experience, most of these bleeding episodes are caused by total or partial circumferential ulceration at the level of the staple transection: staple line erosion. It caused rebleeding in 29 (40%) of our patients. Whereas the pathogenesis of this lesion is unknown, acid reflux is a consequence of transection surgery. Assuming that staple line erosion could be healed by acid suppression therapy, thereby preventing recurrent bleeding, an acid suppression regimen was evaluated prospectively in 24 patients. Only six (25%) healed with daily standard (300 mg) or high-dose (1,200 mg) ranitidine combined with sucralfate (4 gm). The remaining 18 (75%) healed after omeprazole administration (40 mg/day) for 1 mo. Maintenance ranitidine alone (300 mg/day) was introduced, but 11 (48%) had relapse of erosions. All 11 healed with omeprazole (40 mg/day) for 2 mo, but again on maintenance ranitidine, 10 relapsed. All healed with further omeprazole and healing persisted with long-term administration (20 mg/day). Fifteen rebleeding episodes occurred in eight patients on maintenance ranitidine. Whereas relapse of staple line erosions did occur in the absence of rebleeding, all rebleeding episodes were associated with the relapse of staple line erosion. Omeprazole is more effective than ranitidine alone and combined with sucralfate in healing staple line erosion. Omeprazole prevents rebleeding, which may enhance the long-term benefits of staple transection for acute variceal bleeding.

Normal 24-hr ambulatory esophageal pH values. Influence of study center, pH electrode, age, and gender

Although the most sensitive and specific test for diagnosing gastroesophageal reflux disease, normal standards for prolonged esophageal pH monitoring are based on small sample sizes with questions raised about the effects of pH electrode, older age, gender, and methods of data analysis on pH variables. Recently three groups have established normal data bases using similar methodology. Multiple regression and nonparametric analyses showed that the values for the six traditional pH parameters were comparable across study centers. Therefore, the groups were combined for a total study population of 110 healthy subjects (47 men, 63 women, mean age 38 years with a range of 20-84 years). Further nonparametric analyses revealed the following: (1) type of pH electrode (antimony vs glass) is not significantly related to parameters of physiologic acid reflux; (2) age is not independently related to pH parameters; (3) men tend to have more physiologic reflux than women; and (4) older men tend to experience longer episodes of reflux than younger men and women. There was a significant effect of gender and a significant interaction between age and gender on the number of episodes greater than 5 min (P = 0.008). Nearly significant differences were found for percentage of total acid exposure time (P = 0.03), total reflux episodes (P = 0.02), and the longest reflux episode (P = 0.02). We believe these normal esophageal pH values can be used confidently as standards in any laboratory, and consideration should be given to developing separate standards for men and women.

Staple-line erosion: a common source of recurrent bleeding following stapled oesophageal transection

Recurrent bleeding after stapled oesophageal transection was studied in 73 patients with cirrhosis transected for acute variceal bleeding. The most frequent source of bleeding was partial or total circumferential oesophageal erosion at the transection: staple-line erosion. This lesion occurred in 36 (49 per cent) patients and was the source of rebleeding in 29 (40 per cent) patients with 54 episodes. Rebleeding in 22 (30 per cent) patients was due to varices in nine (12 per cent), peptic ulcer in six (8 per cent), gastric erosions in two (3 per cent) and unknown sources in five (7 per cent), accounting for 33 episodes. The mean(s.e.m.) blood transfusion requirement for bleeding from staple-line erosions were 1.5 (0.25) units per bleed versus other sources, 6.5(1.0) units per bleed (P less than 0.001). Staple-line erosion was present at the first postoperative endoscopy in 11 (15 per cent) patients but the time to appearance varied widely. The lesion was more common in patients with Pugh's grade A liver disease at the time of transection, reflecting the increased survival rate of these patients. Staple-line erosion is a common source of minor recurrent bleeding following stapled oesophageal transection.