Endoscopic signs for gastroesophageal reflux objectively evaluated

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.

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.

The yield of a continuously patent gastroesophageal junction during upper endoscopy as a predictor of esophagitis in children

BACKGROUND AND AIMS

Over the last years we have noted an association between the endoscopic finding of a continuously patent gastroesophageal junction (GEJ) throughout the procedure and macroscopic or microscopic esophagitis. We could not find documentation for these endoscopic findings as a predictor of esophagitis in the literature. We aimed to find an association between these findings and microscopic and macroscopic esophagitis.

METHODS

During upper endoscopy, we routinely observe the GEJ for about 60 s and note the behavior of the GEJ and esophageal contractions. Patients with a persistently patent GEJ were recorded. A group of patients referred for upper endoscopy for reasons other than suspected reflux, whose esophagus was normal, and patients with reflux symptoms served as a control groups.

RESULTS

We found 21 patients (3.0%) in whom a patent GEJ had been noted. No significant age differences were noted between study and control groups. Eighteen out of 21 patients (86%) in the study group had varying degrees of microscopic esophagitis ranging from mild to severe (ten with mild esophagitis, three with moderate esophagitis, and five with severe esophagitis). Interestingly, ten out of 18 (55%) study patients with esophagitis on biopsies had no evidence of additional esophageal abnormality. Although all control patients had a normally appearing esophagus on upper endoscopy, 8/26 (31%) had mild esophagitis on biopsies. Differences were statistically significant (p < 0.001).

CONCLUSIONS

A continuously patent GEJ predicts quite accurately the presence of esophagitis in biopsies and may serve an additional endoscopic finding for the diagnosis of esophagitis especially non-erosive GER.

Clinical presentation, diagnosis, and management of gastroesophageal reflux disease

GERD is ubiquitous throughout the adult population in the United States. It commonly adversely affects quality of life and occasionally causes life-threatening complications. The new and emerging medical and endoscopic therapies for GERD and the new management strategies for BE should dramatically reduce the clinical toll of this disease on society.

Diagnostic Tests for Gastroesophageal Reflux Disease

A range of tests is available to the physician pursuing the diagnosis of gastroesophageal reflux disease (GERD). Many times, these studies are unnecessary because the history is sufficiently revealing to identify the presence of troubling reflux disease. 1 However, this may not be the case and the clinician must decide which tests to choose to arrive at a diagnosis in a reliable, timely, and cost-effective manner (Table 1). Furthermore, the various esophageal tests need to be selected carefully depending upon the information desired. For example, identifying the presence of gastroesophageal reflux disease is different from proving that the patient's symptoms are caused by reflux episodes. Additionally, defining that acid reflux exists may not be enough. To tailor appropriate medical or surgical therapy requires knowing whether complications of GERD are present as well as possible mechanisms by which abnormal GER occurs. A thorough and well-devised investigation strategy requires knowledge of testing procedures ranging from radiology and pathology to physiology and endoscopy. An informed background in these areas allows the clinician and investigator to address not only the presence of reflux and its correlation to patient symptoms but also the severity of esophageal injury and even the mechanisms by which the damage is done. By using the available tests judiciously, one can increase the opportunity of making a correct diagnosis of GERD and simultaneously limit the potential inconveniences or cost to the patient.

The role of esophagogastroduodenoscopy in the diagnosis and management of upper gastrointestinal disorders

Esophagogastroduodenoscopy has revolutionized the clinical management of upper gastrointestinal diseases. Millions of EGDs are performed annually in the United States for many indications, such as gastrointestinal bleeding, abdominal pain, dysphagia, or surveillance of premalignant lesions. Esophagogastroduodenoscopy is very safe, with a low risk of serious complications such as perforation, cardiopulmonary arrest, or aspiration pneumonia. It is a highly sensitive and specific diagnostic test, especially when combined with endoscopic biopsy. Esophagogastroduodenoscopy is increasingly being used therapeutically to avoid surgery. New endoscopic technology such as endosonography, endoscopic sewing, and the endoscopic videocapsule will undoubtedly extend the frontiers and increase the indications for endoscopy.

Utility of upper endoscopy in the evaluation of noncardiac chest pain

The diagnostic yield of esophagogastroduodenoscopy, esophageal manometry, and Bernstein testing was assessed in 100 consecutive patients being evaluated for non-cardiac chest pain. Manometric studies revealed the nutcracker esophagus in 21 patients; non-specific esophageal motility disorders in 19 patients; a hypertensive lower esophageal sphincter in 4 patients; diffuse esophageal spasm in 2 patients; and normal motility in 54 patients. Endoscopy was normal in 38 patients; but revealed grades II to IV esophagitis in 24 patients; gastritis and/or duodenitis in 18 patients; a sliding hiatal hernia without evidence of esophagitis in 14 patients; and gastric or duodenal ulcers in 6 patients. Twenty-five individuals were found to have normal manometric studies in combination with a negative Bernstein test. Among these 25 patients, however, 7 patients had esophagitis (grade II or higher); 6 patients had gastritis and/or duodenitis; five patients had a sliding hiatal hernia without esophagitis; 1 patient had peptic ulcer disease; and only 6 patients had a normal endoscopic exam. Our results indicate that endoscopy can identify a significant number of patients with acid-peptic disease who present with non-cardiac chest pain, that would not have been otherwise diagnosed by esophageal manometry or Bernstein testing alone or in combination.

Omeprazole is more effective than cimetidine in the prevention of recurrence of GERD-associated heartburn and the occurrence of underlying oesophagitis

BACKGROUND

There is documentation of the long-term use of omeprazole 10 mg o.d. in patients with reflux oesophagitis but not in the large number of gastrooesophageal reflux disease (GERD) patients without oesophagitis. There is also a paucity of data on the long-term use of cimetidine in GERD patients.

METHODS

One hundred and fifty-six patients (100 male) who previously had symptomatic non-ulcerative oesophagitis (81%) or symptoms without oesophagitis (19%), were recruited. All patients were in symptomatic remission following 4 weeks of omeprazole 20 mg o.d. or cimetidine 400 mg q.d.s. and, if required, a further 4 weeks of omeprazole 20 mg o.d. Patients were randomized to receive, double-blind, either omeprazole 10 mg o.m. (n = 77) or cimetidine 800 mg nocte (n = 79) for 24 weeks.

RESULTS

A greater proportion of patients receiving omeprazole, compared with cimetidine, were in symptomatic remission after 12 (69 vs. 27%) and 24 weeks (60 vs. 24%) (each P < 0.0001). The median time to symptomatic relapse was longer for patients receiving omeprazole (169 vs. 15 days) (P = 0.0001). Of patients leaving the study in symptomatic remission, a greater proportion receiving omeprazole, compared with cimetidine, was free of oesophagitis (84 vs. 53%) (P < 0.05).

CONCLUSION

Omeprazole 10 mg o.m. is more effective than cimetidine 800 mg nocte in the prevention of recurrence of GERD-associated heartburn and the occurrence of underlying oesophagitis.

Omeprazole is more effective than cimetidine for the relief of all grades of gastro-oesophageal reflux disease-associated heartburn, irrespective of the presence or absence of endoscopic oesophagitis

BACKGROUND

Previous studies have demonstrated greater efficacy for omeprazole compared with cimetidine in patients with endoscopically verified oesophagitis, but excluded the substantial group of gastro-oesophageal reflux disease (GERD) patients with reflux symptoms but without endoscopic abnormality. This prospective, randomized, double-blind study compared omeprazole and cimetidine in the treatment of GERD-associated heartburn both in patients with symptomatic non-ulcerative oesophagitis and in those with heartburn but without oesophagitis.

METHODS

A total of 221 patients with heartburn and oesophageal mucosa grade 0 (normal, n = 51), 1 (no macroscopic erosions, n = 52), 2 (isolated erosions, n = 97) or 3 (confluent erosions, n = 21) were randomized to receive double-blind either omeprazole 20 mg daily or cimetidine 400 mg q.d.s. for a period of 4 weeks. Those still symptomatic after 4 weeks of treatment received omeprazole 20 mg daily for a further 4 weeks.

RESULTS

There was no correlation between severity of heartburn and endoscopic grade at entry (correlation coefficient = 0.196). After 4 weeks of treatment, the proportion of patients in whom heartburn was controlled (no more than mild symptoms on no more than 1 day in the previous 7) on omeprazole (66%; 74/112) was more than double that on cimetidine (31%; 34/109) (P < 0.0001). There was no significant difference between the relief of heartburn in the 47% of patients without unequivocal oesophagitis (endoscopic grade 0 or 1) and in the 53% of patients with erosive oesophagitis (grade 2 or 3) (P = 0.31). Only treatment with omeprazole (P < 0.0001) and lower severity of heartburn at entry (P < 0.01) were significant in predicting heartburn relief. Amongst those patients requiring an additional 4 weeks of treatment with omeprazole, 67% (54/81) reported that their heartburn was controlled after 8 weeks of treatment.

CONCLUSION

We conclude that omeprazole is superior to cimetidine for the relief of all grades of heartburn in GERD, whether or not the patient has unequivocal endoscopic oesophagitis.

Respiratory complications of gastroesophageal reflux disease

There is a relationship between gastroesophageal reflux disease and certain respiratory symptoms and findings. Among these are cough, laryngitis, and wheezing dyspnea. The pathophysiology of these conditions can vary from actual aspiration of gastric content to esophageal mucosal inflammation with the respiratory symptoms induced by a vagally mediated reflex mechanism.

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.

Correlation of lower esophageal mucosal ring and lower esophageal sphincter pressure

We assessed the relationship of lower esophageal sphincter pressure (LESP) to presence and absence of lower esophageal mucosal ring (LEMR) in 66 patients to determine if the LEMR was more likely related to prolonged sphincter hypotension. This potential relationship is of interest because LEMR may be due to reflux esophagitis. Each patient had radiographic and manometric studies, and both examinations were done within one week of each other. The mean LESP in patients with LEMR was 23.8 mm Hg (range 4.2-64 mm Hg) compared to 28.7 mm Hg (range 8-59 mm Hg) in patients without LEMR; the difference was not statistically significant. Patients with LEMR were also divided into three subgroups according to the diameter of the rings (< or = 13 mm, 14-19 mm, > or = 20 mm). There was no significant relationship between the caliber of LEMR and LESP (P > 0.05). Presence of LEMR did not affect the amplitude or duration of primary esophageal peristalsis. These results do not support a relationship between LEMR and prolonged LESP hypotension or abnormal esophageal motility. However, other pathogenetic mechanisms involved in producing reflux esophagitis not related to prolonged sphincter hypotension were not studied.

Gastroesophageal reflux

Gastroesophageal reflux is a common disease that accounts for approximately 75% of esophageal pathology. Motility abnormalities of the esophagus and stomach, including an incompetent lower esophageal sphincter, are responsible for pathologic reflux in the majority of patients. Surgical treatment offers the only chance for long-term cure. Obtaining optimal results following surgery of the esophagus is one of the most challenging aspects of modern surgical therapy. Given a precise diagnosis, careful patient selection, critical attention to detail in the perioperative period, and the meticulous performance of the appropriate anti-reflux procedure, long-term success can be assured in more than 90% of patients.

The value of endoscopy and endosonography in the diagnosis of the dysphagic patient

The value of endoscopy in dysphagia is limited in the diagnosis of motility disorders and small structures, webs, and hiatal hernias. Endoscopy is of special use for the clarification of an organic cause of dysphagia. Intraluminal tumors can be seen and in a high percentage of cases be definitely diagnosed by taking biopsies; a malignant degeneration in Barrett's esophagus is detectable by endoscopy in 89.1% of cases. Gastroesophageal reflux disease can be diagnosed on endoscopy as it leads to an endoscopically visible inflammatory reaction; however, normal findings on endoscopy cannot exclude reflux disease. Endoscopy is the method of choice in the diagnosis of nonreflux esophagitis, especially Candida and viral esophagitis. A further advantage of endoscopy is the fact that a microscopic diagnosis can be obtained and endoscopic treatment can be performed simultaneously. Submucosal or extramural lesions can be missed by endoscopy. Endosonography, the combination of endoscopy and ultrasonography (EUS) yields additional information in diagnosing submucosal and extramural lesions of the esophagus which is missed by other imaging procedures. One of the main advantages of EUS is the detection of small and submucosal lesions. The most important indication is the local staging of esophageal carcinomas; the accuracy of endosonography in determining the depth of infiltration ranges between 79% and 92%. The detection of paraesophageal lymph nodes is successful in 60%-82%, although EUS cannot differentiate benign from malignant lymph nodes. Submucosal tumors can be visualized by endosonography and their size, echopattern, and the layers of origin can be determined with high accuracy. Further indications for EUS are the exclusion of focal lesions in achalasia or peptic strictures.

Outcome 5 years after 360 degree fundoplication for gastro-oesophageal reflux disease

Forty patients with a mean age of 45 (range 22-65) years were operated on between 1982 and 1985 for gastro-oesophageal reflux disease with a short floppy 360 degree fundoplication. The results of the operation were determined by endoscopy, oesophageal manometry, ambulatory 24-h pH recording and symptom evaluation 6 months and 5 years after operation. These results were compared with findings in healthy controls. The median pressure in the lower oesophageal high-pressure zone was 13.3 (interquartile range (i.q.r.) 11.3-21.3) mmHg after 5 years, which did not differ significantly from the value at 6 months' follow-up or from that in controls. It was, however, significantly higher than the preoperative pressure. The median intra-abdominal length of the high-pressure zone was 1.7 (i.q.r. 1.3-2.3) cm after 5 years, significantly less than at 6 months but equal to control length. Measurement of the proportion of total time at pH < 4 at 5 years (median 0.2 (i.q.r. 0.0-0.6) per cent) and 6 months after operation revealed a significant reduction in acid reflux compared with preoperative values and normal controls. There was no significant difference in acid exposure between the two postoperative investigations. Endoscopy showed that 27 patients had no oesophagitis, three had erythema and three persistent Barrett's oesophagus 5 years after operation. Normal belching was possible in 22 patients and 18 experienced increased flatulence 5 years after fundoplication. An independent gastroenterologist found that the result was excellent in 16 patients, good in 16 and fair in four; two patients had a poor overall outcome of the operation. It is concluded that a 360 degree fundoplication provides good long-term control of reflux and that slight symptoms of overcompetence are common among patients operated on without affecting the overall result.

Evaluation of routine upper digestive tract endoscopy before laparoscopic cholecystectomy

Endoscopy of the upper digestive tract was performed in 376 patients with symptomatic gallstone disease before elective laparoscopic cholecystectomy. Abnormalities were found in 60 patients (16.0 per cent); these included peptic ulcer (n = 14), gastric erosions (n = 15) and oesophagitis (n = 11). Thirty patients were treated medically and two by endoscopic polypectomy. In four patients endoscopy led to cancellation of cholecystectomy; in two the complaints have persisted. Statistical analysis of 28 variables showed few significant differences in symptoms between patients with normal and those with abnormal appearances at endoscopy. It is concluded that routine endoscopy before laparoscopic cholecystectomy is neither clinically useful nor cost effective in patients with symptomatic gallstone disease. This conclusion is related exclusively to patients with typical gallstone symptoms according to the definition used in this department.

Relationship between endoscopic hiatus hernia and gastroesophageal reflux symptoms

Little is known about the relationship between hiatus hernia (HH) and gastroesophageal reflux symptoms (GERS). Nine hundred and thirty patients submitted to gastroscopy because of symptoms completed a self-administered questionnaire. Fourteen per cent showed esophagitis (ES) and 17% HH. Forty-nine per cent of the patients with HH had endoscopic ES, and 60% of those with ES had HH. The severity of ES was dependent (p less than 0.05) on both the presence and the size of HH. After exclusion of patients with peptic ulcer and malignancy, patients with and without HH and ES were compared with regard to the presence of single symptoms and a weighted GERS score based on symptoms proven to be typical for ES. Only borderline differences were found between patients with ES and HH and those with ES and no HH. The former group, however, presented with significantly (p less than 0.001) more GERS than the patients with HH only. Nevertheless, the patients with HH as the only pathologic finding had significantly (p less than 0.01) more GERS than the patients with no major endoscopic abnormality. This study indicates a close association between HH and gastroesophageal reflux disease and supports the clinical significance of an endoscopically detected HH.

Evaluation of gastroesophageal reflux as a cause of idiopathic hoarseness

Eleven patients presenting to an ear, nose, and throat specialist were diagnosed as having idiopathic hoarseness and prospectively evaluated for evidence of gastroesophageal reflux (GER) to determine if an association existed. Testing for GER included voice analysis, EGD, esophageal manometry, Bernstein test, and ambulatory 24-hr pH monitoring. Six of the 11 (55%) hoarse patients studied had GER by pH monitoring (mean score 105 +/- 23), and most reflux episodes were supine and prolonged (20.9 +/- 8.2% supine pH less than 4.0, longest 129 min). All patients with abnormal pH monitoring had endoscopic esophagitis (Barrett's esophagus in two, peptic stricture in one, and erosive esophagitis in three), while none of the patients with normal scores had esophagitis. Symptoms of throat pain or nocturnal heartburn were more common in the GER-positive patients (6 of 6 vs 1 of 5), and clinically helpful in discriminating which hoarse patients had pathologic GER. Treatment with ranitidine 150 mg per os twice a day for 12 weeks improved esophagitis in all patients, but the voice improved in only one of the two patients with completely healed esophagitis. This study suggests that (1) GER is frequently seen in patients with idiopathic hoarseness (55%), (2) hoarse patients with throat pain or nocturnal heartburn are likely to have severe esophagitis and should be evaluated by EGD, and (3) additional antireflux and voice therapy may be necessary to heal esophagitis and improve the voice.

Endoscopic diagnosis and treatment of mucosal lesions of the esophagus

The rapid evolution of fiberoptic endoscopes over the past three decades has greatly enhanced our understanding of esophageal diseases and has stimulated significant improvements in their management. With the early endoscopic diagnosis of infectious and inflammatory lesions, specific medical or surgical treatment can be initiated promptly and the results monitored easily. Although the diagnosis of malignant lesions is still commonly delayed because of the absence of early symptoms, surveillance of Barrett's esophagus offers the hope of more definitive management in these patients. Endoscopy has assumed an increasingly important therapeutic role in patients with inoperable cancer because it provides access for new ablative techniques or the placement of palliative prosthetic devices. Continuing advances in the use of endoscopic ultrasound, the delivery of photodynamic therapy, and the adjunctive application of intraluminal irradiation promise to further broaden the scope of fiberoptic intervention.

Assessment of oesophagitis by histology and morphometry

Morphometric measurements of nuclear area, nuclear concentration and nucleolar dimensions in defined tissue zones of orientated oesophageal biopsy sections were compared between three patient groups--asymptomatic/normal endoscopy (n = 8); symptomatic reflux/normal endoscopy (n = 17); and symptomatic/endoscopic oesophagitis (n = 15). No significant differences could be shown for any mean parameter between clinical groups. In a further group of 16 patients, identical morphometric measurements were made in non-orientated grasp biopsies and correlated with prolonged ambulatory pH data. No significant correlations could be shown between nuclear parameters and acid reflux measurements. These results suggest that morphometric measurement cannot be recommended as a diagnostic tool in the diagnosis of oesophagitis, although it may be useful in the assessment of individual therapeutic response in clinical trials.

Utility of inpatient 24-hour intraesophageal pH monitoring in diagnosis of gastroesophageal reflux

The aims of the present study were to evaluate the accuracy of 24-hr intraesophageal pH monitoring in the diagnosis of gastroesophageal reflux in the hospital setting and to establish whether there were any differences in terms of reflux events between patients with and without endoscopic esophagitis. Fifteen control subjects and 47 patients with proven gastroesophageal reflux disease were studied. A composite score of reflux events (number of reflux episodes; total, upright, and supine reflux time; number of refluxes lasting more than 5 min; and duration of the longest reflux) provided the best discrimination between controls and patients (94% sensitivity and 100% specificity). Patients with esophagitis showed concurrently a longer total reflux time and supine reflux time, and more prolonged reflux episodes than those without esophagitis. On the other hand the severity of esophagitis was directly related to the duration of both total and supine reflux. The results indicate that inpatient 24-hr pH-metry is very accurate in the diagnosis of gastroesophageal reflux. They also suggest that prolonged esophageal exposure to acid, particularly at night, and slow esophageal acid clearing are factors that determine the appearance and/or perpetuation of esophagitis in patients with reflux.

Symptoms and endoscopic findings in the diagnosis of gastroesophageal reflux disease

Two hundred and twenty patients with symptoms suggestive of pathologic gastroesophageal reflux were investigated to elucidate the ability of symptoms and endoscopic findings in establishing a diagnosis of reflux disease as measured by ambulatory 24-h pH-monitoring. Daily occurrence of heartburn or acid regurgitation had positive predictive values of 59% and 66%, respectively. pH-monitoring showed pathologic reflux in 75% of patients with esophageal mucosal erosions. Endoscopic erythema of the distal esophagus predicted reflux disease in only 53%. Symptom registration during ambulatory 24-h pH-monitoring showed that about half of the symptomatic events reported by patients with pathologic reflux occurred within 5 min of a reflux episode. The corresponding figure for patients with normal pH-monitoring was less than 20%. We conclude that it is difficult to establish a diagnosis of gastroesophageal reflux disease by patient history alone, that erythema at endoscopy correlates poorly with pathologic reflux, and that reflux disease may be present even with normal endoscopy findings.

Effect of cigarette smoke on esophageal epithelium of the rabbit

Cigarette smoking is a recognized risk factor for esophageal mucosal disease. For this reason we investigated the effects of smoke on esophageal epithelial electrolyte transport and barrier function in the rabbit. Studies were performed using an extract of cigarette smoke (EOCS) prepared from high-tar, high-nicotine cigarettes. Epithelia were exposed to EOCS in vivo or in vitro in the Ussing chamber. Acute in vivo exposure to EOCS lowered in vivo esophageal potential difference by 61%, and in vitro studies established that this was due to inhibition of active Na transport from mucosa to serosa. Exposure to an EOCS had no effect on net Cl transport or epithelial permeability, the latter reflected by the absence of change in electrical resistance or mannitol flux. The ability of an EOCS to lower potential difference (and inhibit Na transport) was dose-related and equally effective whether contact occurred with the luminal or serosal surface of the tissue. Similar studies performed with an EOCS prepared from filtered smoke established that the component(s) in EOCS responsible for the effects on transport resided in the particulate phase of smoke (i.e., nicotine and "tars"). However, nicotine only inhibited Na transport from the serosal side of the tissue, thus indicating that one or more tars either cause or contribute to the effect of an EOCS on transport. The inhibition by smoke of ion transport in esophageal epithelium may well be an early deleterious link in the pathophysiological chain between cigarette smoking and esophageal mucosal disease.

Nissen fundoplication for gastroesophageal reflux disease. Evaluation of primary repair in 100 consecutive patients

One hundred consecutive patients had a primary Nissen fundoplication for gastroesophageal reflux disease. None of the patients had previous gastric or esophageal surgery or evidence of esophageal stricture or motility disorder. The primary symptom was persistent heartburn in 89 patients and aspiration in 11. An abnormal pattern of esophageal acid exposure was documented in all patients with 24-hour esophageal pH monitoring. By actuarial analysis, the operation was 91% effective in the control of reflux symptoms over a 10-year period. The incidence of postoperative symptomatic gas bloat and increased flatus was lower in patients with preoperative abnormal manometric measurements of the distal esophageal sphincter (p less than 0.05). Three modifications in operative technique were made during the course of the study to minimize the side effects of the operation. First, enlarging the caliber of the bougie to size the fundoplication reduced the incidence of temporary swallowing discomfort from 83 to 39% (p less than 0.01). Second, shortening the length of the fundoplication decreased the incidence of persistent dysphagia from 21 to 3% (p less than 0.01). Third, mobilizing the gastric fundus for construction of the fundoplication increased the incidence of complete distal esophageal sphincter relaxation on swallowing from 31 to 71% (p less than 0.05). This was done to prevent the delayed esophageal acid clearance secondary to incomplete sphincter relaxation observed after operation in five of 36 studied patients. It is concluded that by proper patient selection and the incorporation of the above surgical techniques, the Nissen fundoplication can re-establish a competent cardia and provide relief of reflux symptoms with minimal side effects.

Gastroesophageal reflux disease. Scintigraphic, endoscopic, and histologic considerations

Radionucleotide scintigraphy and esophagoscopy with biopsy were carried out in 101 patients with symptoms strongly suggestive of gastroesophageal reflux (GER) disease. GER was visualized by scintigraphy in 86.1% of the patients. Endoscopic and histologic esophagitis were found in 68.1% and 58.4% patients, respectively, whereas both examinations taken together showed evidence of esophagitis in 82%. Histologic evidence of esophagitis was found in nearly all patients with severe endoscopic changes and in 43.7% patients with no endoscopic abnormality. Scintigraphic reflux was demonstrated more frequently (p less than 0.05) in the patients with severe endoscopic esophagitis (97.5%) than in those with no or only mild endoscopic changes (78.6%). Scintigraphic reflux was found in 91.5% and 78.5% of the patients with and without histologic evidence of esophagitis (p = 0.07). Fifteen of the 18 patients (83.3%) without endoscopic and histologic abnormalities in the esophagus had scintigraphic evidence of reflux. The present study strongly supports the clinical significance of scintigraphy in GER disease and confirms that esophageal biopsy specimens increase the sensitivity of endoscopic evaluation.

Analysis of a multiphasic radiographic examination for detecting reflux esophagitis

Radiographic and endoscopic findings were correlated in 46 normal patients and in 49 with reflux esophagitis to assess the efficacy of a multiphasic examination employing mucosal relief full-column, and double-contrast techniques. Esophagitis was graded endoscopically as mild, moderate, or severe, and the quality and sensitivity of each technique and of the examination as a whole were determined. The radiographic specificity in the normal patients was 98%. The overall sensitivity was 65% for all grades of esophagitis, and 90% for the moderate and severe grades. Sensitivities of the individual techniques were: mucosal relief: 43%; full-column: 53%; double-contrast: 45%. These differences were not statistically significant. We conclude that a combination of radiographic techniques is needed to detect reflux esophagitis optimally.

Hiatus hernia in gastroesophageal reflux disease

Upper gastrointestinal endoscopy and radiologic examination were performed in 101 patients with symptoms strongly suggestive of gastroesophageal reflux (GER) disease. Hiatus hernia (HH) was found in 50 patients diagnosed by radiography or endoscopy, or both, in 22, 19, and 9 patients respectively. Severe endoscopic esophagitis (grades III and IV) was found more often (p less than 0.05) in the patients with HH than in those without. The same was true for the early positive timed acid perfusion tests (p less than 0.02). Furthermore, the patients with HH more often had reflux by the standard acid reflux test (42 of 50 versus 28 of 51; p less than 0.01), gastroesophageal scintigraphy (47 of 50 versus 40 of 51; p less than 0.05), and radiography (20 of 50 versus 2 of 51; p less than 0.001) than the patients without HH. The results show that severe GER disease can occur without an associated HH and indicate that patients with symptoms of GER disease and associated HH are likely to have a more severe GER disease than those without HH.

Oesophageal histology in reflux oesophagitis

Multiple specimens taken at oesophageal suction biopsy were obtained from 56 patients, of whom 44 had symptoms of gastro-oesophageal reflux and 24 had endoscopic evidence of erosive oesophagitis. Biopsies were examined independently by two histopathologists for the following criteria for reflux: epithelial hyperplasia, vascular dilatation and congestion, neutrophil infiltration, and eosinophil infiltration. The incidence of these criteria in patients with and without endoscopic evidence of oesophagitis or symptoms of reflux was investigated. It was concluded that vascular dilatation and epithelial hyperplasia, defined as basal zone thickness greater than or equal to 15% and papillary elongation greater than or equal to 66%, can be detected most reliably, but their diagnostic accuracy is limited unless multiple biopsies are examined.

The Angelchik anti-reflux prosthesis--some reservations

A prospective study has been made of the use of the Angelchik prosthesis in the treatment of hiatus hernia and gastro-oesophageal reflux. Forty-one patients under the care of one surgeon were studied over a 3-year period. The operation is simple and safe to perform. Twelve patients suffered transient dysphagia which spontaneously resolved within 3 months. Satisfactory results were obtained thereafter in 80.9 per cent. Seven of the prostheses have been removed (17.1 per cent), all within 18 months of performing the operation. Dysphagia and recurrent symptoms were the main reasons for removal and in two of these stricturing was present pre-operatively. We feel the presence of an established stricture is a contraindication to the use of the device. We have, however, been impressed by its use as a second procedure when previous surgery has failed and when revisional surgery for recurrent hiatus hernia is difficult due to dense adhesion formation. While it is still early to assess the legacy that the use of this prosthesis might incur, we would recommend conservatism if not abandonment of its use until longer-term evaluation is available.

Endoscopic measurement of oesophageal transmucosal potential difference in reflux oesophagitis

Oesophageal transmucosal potential difference (PD) was measured in 76 patients during endoscopy. Twelve patients with no symptoms of gastro-oesophageal reflux, and normal oesophageal appearance on endoscopy and mucosal biopsy had a PD of -18.3 +/- 3.8 mV (mean +/- SD). Thirty three patients had reflux symptoms but the oesophagus appeared normal at endoscopy. Eighteen of these patients had reflux change on oesophageal suction biopsies and the PD in the same region of the oesophagus in this group was -18.1 +/- 7.5 mV. In 15 of the patients, mucosal biopsies were normal and the PD in this group was -18.8 +/- 9.9 mV. Thirty one patients had erosive oesophagitis and PD values in this group were markedly reduced. Twenty seven of these patients had PD values less than -10 mV. We conclude that PD measured by our technique is abnormal in erosive oesophagitis but that it is of no value in the diagnosis of mild mucosal damage in patients with reflux symptoms when endoscopic findings are normal.

Reflux esophagitis: radiologic-endoscopic correlation in 39 symptomatic cases

Thirty-nine consecutive patients with symptoms suggestive of reflux esophagitis underwent a double contrast upper gastrointestinal series and subsequently had endoscopy with biopsy. In a control group of 164 consecutive patients without symptoms of esophagitis a double contrast examination was done with the same method. We have found a significant increase of the diameter of the esophagus in its distal or cardiac segment (IDCE) in patients with esophagitis of Grades 1 and 2 when compared with the control group (p less than 0.001). Radiology was found to have correctly diagnosed 35 of the 39 cases (89.7%) and the majority of the patients had endoscopic signs of mild esophagitis.

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."

Ethanol-induced mucosal injury in rabbit oesophagus

The pathogenesis of oesophagitis associated with ethanol ingestion was studied experimentally by perfusing isolated rabbit oesophagus in situ with 20% and 40% (v/v) ethanol. Since ingestion of ethanol increases duodenogastric and gastro-oesophageal reflux, the effects of HCl and bile salts (in combination with ethanol) were also investigated. The severity of oesophageal mucosal damage was assessed by using transmucosal potential difference, net ion fluxes of H+ and Na+, and mucosal permeability to two neutral molecules of different sizes, 3H-H2O and 14C-erythritol, as indicators of mucosal integrity. Macroscopic changes in the mucosa were also recorded. The results showed that the lower ethanol concentration (20%) is relatively harmless to the oesophageal mucosa. Furthermore, addition of 20% ethanol did not intensify the effects on the mucosa caused by HCl or bile salts alone. In contrast, the stronger ethanol solution (40%) did cause significant mucosal damage when used alone, and this damage was further potentiated by the presence of HCl.

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.

An alternative fundoplicative maneuver for gastroesophageal reflux

Twenty-two patients with gastroesophageal reflux undergoing an original antireflux operative procedure are presented. The mean time between operation and follow-up was 19 months. The technique consists of a semifundoplicative maneuver with firm intraabdominal fixation of the esophagus by suturing the fundoplication to the diaphragm. There was no mortality. The patients were free of reflux symptoms and complications, and the standard reflux test was negative in all cases. All patients had postoperative lower esophageal sphincter pressure within the normal range. The phenomenon of gas-bloat as not observed, nor was inability to vomit or belch. These results confirm the observations made earlier in a series of 110 patients operated on with the same method. A long-term prospective randomized study is in progress, with the aim of comparing the technique described herein and the Nissen fundoplication.

Relationship of hiatal hernia to endoscopically proved reflux esophagitis

The relationship between reflux esophagitis and hiatal hernia was studied using fiberoptic endoscopy. Of 293 patients having upper-gastrointestinal endoscopy during an 18-month period, 64 (22%) had a hiatal hernia and 38 (13%) had esophagitis. Half the patients with a hiatal hernia had esophagitis, whereas the vast majority (84%) of patients with esophagitis had a concomitant hiatal hernia. The association between esophagitis and hiatal hernia was highly significant (P less than 0.0001). There was no statistically significant association between the size of the hiatal hernia and the degree of esophagitis on endoscopy. A permissive role of hiatal hernia in the genesis of reflux esophagitis is suggested.

Esophageal epithelial response to gastroesophageal reflux. A quantitative study

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 papillae, 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.