Esophageal emptying and acid neutralization in patients with symptoms of esophageal reflux

Scintigraphic Evaluation of Esophageal Motility and Gastroesophageal Reflux in Patients Presenting with Upper Respiratory Tract Symptoms

Purpose of Study

The purpose is to evaluate the findings and utility of esophageal transit scintigraphy (ETS) and gastroesophageal reflux scintigraphy (GES) in patients presenting with upper respiratory tract (URT) symptoms suspected to be due to gastroesophageal reflux (GER) disease.

Materials and Methods

Thirty patients aged between 19 and 60 years underwent nasopharyngolaryngoscopy (NPL), ETS, and GES. Correlation between GER, esophageal motility, and NPL was evaluated. Inclusion criteria include patients with recurrent URT symptoms such as chronic dry cough/hoarseness of voice and itching/foreign body sensation in throat. Those with typical gastrointestinal (GI) symptoms of GER, URT symptoms relieved by antibiotics, surgical intervention in abdomen, cardiac/hepatobiliary diseases, etc. were excluded from the study.

Results

Significant correlation was found between GER and NPL in 28/30 patients. More the grade of reflux, more severe was the NPL findings. Two patients with Grade II reflux had normal NPL suggesting structural inflammatory changes due to acidic pH of refluxate which have not yet manifested or symptoms could be due to nonacid refluxate. Incidence of esophageal motility disorder was statistically significant in patients with GER disease (GERD). Patients who had symptoms, but no demonstrable GER showed delayed ET in supine position suggesting the presence of esophageal motility disorder even before GERD.

Conclusion

GES demonstrated GER in patients presenting with URT symptoms without typical GI symptoms. ETS showed coexistence of esophageal motility disorder in most patients presenting with URT symptoms even without an associated reflux disease. We hypothesize that primary abnormal esophageal motility leads to delayed esophageal clearance and consequently to URT symptoms. Addition of ETS to GES is easily feasible with no significant additional cost, time, or radiation burden.

Radionuclide Esophageal Transit Scintigraphy in Primary Hypothyroidism

Background/Aims

Esophageal dysmotility is associated with gastrointestinal dysmotility in various systemic and neuroregulatory disorders. Hypothyroidism has been reported to be associated with impaired motor function in esophagus due to accumulation of glycosaminoglycan hyaluronic acid in its soft tissues, leading to changes in various contraction and relaxation parameters of esophagus, particularly in the lower esophageal sphincter. In this study we evaluated esophageal transit times in patients of primary hypothyroidism using the technique of radionuclide esophageal transit scintigraphy.

Methods

Thirty-one patients of primary hypothyroidism and 15 euthyroid healthy controls were evaluated for esophageal transit time using 15-20 MBq of Technetium-99m sulfur colloid diluted in 10-15 mL of drinking water. Time activity curve was generated for each study and esophageal transit time was calculated as time taken for clearance of 90% radioactive bolus from the region of interest encompassing the esophagus. Esophageal transit time of more than 10 seconds was considered as prolonged.

Results

Patients of primary hypothyroidism had a significantly increased mean esophageal transit time of 19.35 ± 20.02 seconds in comparison to the mean time of 8.25 ± 1.71 seconds in healthy controls (P < 0.05). Esophageal transit time improved and in some patients even normalized after treatment with thyroxine. A positive correlation (r = 0.39, P < 0.05) albeit weak existed between the serum thyroid stimulating hormone and the observed esophageal transit time.

Conclusions

A significant number of patients with primary hypothyroidism may have subclinical esophageal dysmotility with prolonged esophageal transit time which can be reversible by thyroxine treatment. Prolonged esophageal transit time in primary hypothyroidism may correlate with serum thyroid stimulating hormone levels.

Efficacy of a motilin receptor agonist (ABT-229) for the treatment of gastro-oesophageal reflux disease

BACKGROUND

ABT-229 is a potent motilin agonist without significant antibiotic activity. It has been shown to improve gastric emptying in humans and to increase lower oesophageal sphincter pressure in cats.

AIM

To assess the efficacy of four different doses of ABT-229 (1.25 mg, 2.5 mg, 5 mg, 10 mg b.d.) compared to placebo in the treatment of gastro-oesophageal reflux disease, and to determine its safety in patients with gastro-oesophageal reflux disease.

METHODS

In a double-blind, multicentre study, 324 patients with heartburn were randomized to receive four different doses of ABT-229 or placebo for 8 weeks. The efficacy was evaluated by Patient Symptom Questionnaire, daily diary, endoscopy and global evaluation of efficacy.

RESULTS

There were no statistically significant improvement scores for any of the ABT-229 treatment groups vs. the placebo group in any of the efficacy parameters. Reflux symptom scores were significantly worse after treatment in the dyspeptic group. ABT-229 appeared to be well tolerated and safe in total daily doses up to 20 mg.

CONCLUSION

ABT-229 appears to have limited, if any, clinical utility in the treatment of gastro-oesophageal reflux disease.

Multivariate analysis of pathophysiological factors in reflux oesophagitis

BACKGROUND

Reflux oesophagitis is considered a multifactorial disease, but the respective roles of the main factors involved in its pathophysiology have not been clearly established.

AIMS

To attempt to assign these roles by means of a multivariate logistic regression analysis of the main parameters associated with reflux oesophagitis.

PATIENTS

Eighty seven patients with gastro-oesophageal reflux disease were studied: 41 without oesophagitis and 46 with reflux oesophagitis grade 1 to 3.

METHODS

(1) Monovariate comparison of patients' characteristics and of parameters derived from in hospital 24 hour oesophageal pH monitoring, oesophageal manometry, double isotope gastric emptying studies, and basal and pentagastrin stimulated gastric acid and pepsin output determinations, between patients with and without oesophagitis. (2) Multivariate logistic regression analysis including the parameters significant in the monovariate analysis.

RESULTS

Among the 16 significant parameters from monovariate analysis, three significant independent parameters were identified by multivariate logistic regression analysis: number of refluxes lasting more than five minutes, reflecting oesophageal acid clearance (p = 0.002); basal lower oesophageal sphincter pressure (p = 0.008); and peak acid output (p = 0.012). These three parameters were not correlated with each other. The multivariate model was highly discriminant (correct classification of 81.3% of the cases (95% confidence intervals 0.723, 0.903). Risk for oesophagitis increased as a function of the tercile threshold values of the three parameters. Odds ratios of the three parameters for oesophagitis risk were similar, regardless of whether they were calculated when the patients were compared as a function of oesophagitis grade or the presence or absence of oesophagitis.

CONCLUSIONS

This multivariate approach adds evidence that impaired oesophageal acid clearance and hypotonic lower oesophageal sphincter are the two major independent pathophysiological factors of oesophagitis, but also showed that the acid secretion level is an independent pathophysiological factor.

What has the surgeon to know about pathophysiology of reflux disease?

Much has been learned about the pathophysiology of gastro-esophageal reflux (GER) since it was initially described by Asher Winkelstein in 1935. With the development and refinement of esophageal function tests in the past decades, the diagnostic modalities have become available for a deliberate and systematic evaluation of antireflux mechanisms. Some of the newer concepts of the pathogenesis of reflux esophagitis are reviewed in this article.

Sucralfate versus cimetidine in the treatment of reflux esophagitis, with special reference to the esophageal motor function

Sixty patients entered a double-blind clinical trial comparing the effect of 1 g of sucralfate granulate given four times daily and cimetidine, 400 mg twice daily. Twenty-six patients treated with sucralfate and 26 treated with cimetidine were examined with short-term pH monitoring before and after 12 weeks of treatment. Thirty patients, 19 treated with cimetidine and 11 treated with sucralfate, had esophageal motility studied by a radionuclide test before and after 12 weeks of treatment. The efficacy of the treatments was judged by symptoms and endoscopic response after 4, 8, and 12 weeks of treatment. The endpoint healing rate was approximately 60% in both groups and symptoms were relieved in half of the patients in both groups (difference not significant). The effect of the treatments on pH and number of spikes reflected the different pharmacodynamic profiles of the drugs, whereas the mean transit time (MTT) was not changed by the treatments. The residual activity after radionuclide transit in the sitting position was significantly increased after treatment with cimetidine. The data support the hypothesis that primary dysmotility might be involved in the pathogenesis of reflux esophagitis in about 33% of the patients. Possibilities for a combination therapy with sucralfate and cimetidine are stressed.

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)

Sucralfate versus cimetidine in reflux oesophagitis. The effect on oesophageal pH and motility

Sixty patients with endoscopically verified oesophagitis entered a double-blind study comparing the effect of 1 g of sucralfate granulate given four times a day and cimetidine, 400 mg twice a day. Fifty-two patients, 26 treated with cimetidine and 26 with sucralfate, were examined with short-term pH monitoring before and after 12 weeks of treatment. In about half of the patients, 19 treated with cimetidine and 11 treated with sucralfate, the oesophageal motility was studied with a radionuclide test before and after treatment. The sucralfate treatment did not affect either mean pH or the emptying rate but reduced the number of spikes. The cimetidine treatment increased mean pH and reduced the number of spikes but did not affect emptying rates. Both groups had significantly prolonged mean transit time (MTT) compared with healthy volunteers. MTT did not change after either treatment. The residual activity in the sitting position was significantly increased after cimetidine. It is concluded that the pharmacodynamic effect on oesophageal motility is different for the two drugs in question. Primary dysmotility might be involved in the pathogenesis of oesophagitis.

Abnormal gastric adaptive relaxation in patients with gastrooesophageal reflux

Gastric adaptive relaxation was measured in 15 healthy volunteers (control group) and in 12 patients with symptomatic gastrooesophageal reflux confirmed by 24 hour pH monitoring (reflux group). The control group were: 13 men, two women; median age 30 years, range 22-41; median body weight 70 kg, range 50-79 kg. All were asymptomatic on no medication. The reflux group were: eight men, four women, median age 48 years, range 23-65; median body weight 77 kg, range 60-92 kg. Medication was withheld for 12 hours before the study. Endoscopy showed no abnormality in five patients, oesophagitis in three patients and oesophagitis with hiatus hernia in four patients. Fasted subjects were intubated with a Ryle's tube containing a pressure microtransducer within a flaccid plastic bag (800 ml). Gastric corpus-fundus pressure was recorded during distension of the bag with 460 (20) ml mean (SD) of air over 30 seconds. Pressure indices (median: range) derived from areas under the pressure curves during distension were: control: 12.7 (7.5-17.1) cm H2O; reflux: 9.1 (6.4-13.3) cm H2O, p less than 0.01 (Mann Whitney U test). Similar results were obtained from pressure indices derived from recordings during the immediate postdistension period. No correlation was found between pressure indices and age, sex or body weight. The results indicate that the gastric pressure response to distension is reduced in patients with gastrooesophageal reflux.

Reflux oesophagitis and oesophageal transit: evidence for a primary oesophageal motor disorder

Patients with reflux oesophagitis have a diminished capacity for distal oesophageal clearance. This is considered to be secondary to acid reflux damage to the oesophageal wall. We have postulated that the observed oesophageal dysmotility is a primary phenomenon. Using 24 hour oesophageal pH monitoring and the solid bolus oesophageal egg transit test, we evaluated the oesophageal transit of 55 patients, with symptomatic reflux oesophagitis, and 16 healthy volunteers. The transit for the entire oesophagus was significantly prolonged in the patient group. This delay was evident in all three segments of the oesophagus. Amongst the patients, there was significant correlation between the oesophageal transit time and the number of prolonged reflux events. No correlation was found, however, between symptom score or severity of endoscopic oesophagitis and transit time. These results would indicate that the oesophageal dysmotility is an integral part of gastrooesophageal reflux disease, and is more of a cause than an effect.

Does healing of esophagitis improve esophageal motor function?

This study investigates whether healing of erosive esophagitis leads to an improvement of esophageal motor abnormalities. Manometric studies were performed in 18 patients with erosive esophagitis before and after healing of the mucosal lesions and in 15 healthy controls. Nine patients were treated with a Nissen fundoplication and nine with H2-receptor antagonists. After healing, patients were followed for a mean duration of 3.0 +/- 0.4 years. Compared to controls, patients had significantly lower contraction amplitudes and lower esophageal sphincter pressures (P less than 0.01), while the duration and velocity of esophageal contractions was similar in both groups. Lower esophageal sphincter pressure increased after surgical treatment, while no such changes were observed in medically treated patients. In both groups amplitude, duration, and velocity of esophageal contractions were not affected by healing of esophagitis. On extended follow-up, all surgically treated patients remained asymptomatic while eight of nine medically treated patients developed a symptomatic relapse which was accompanied by erosive esophagitis in six of them. The lack of improvement in esophageal motor function after healing of esophagitis may contribute to the frequent occurrence of relapse in medically treated patients.

The efficacy of ranitidine in children

The effect of preoperative oral ranitidine on intragastric pH and volume of aspirate was evaluated in anaesthetized children. Five groups of eight randomly assigned children were evaluated. The first group acted as control and the other groups received 2, 2.5, 3, 3.5 mg kg-1 ranitidine, respectively. The drug was administered 1-4 h preoperatively. The intragastric pH was measured by a pH electrode through an orogastric tube, and the volume of aspirate was recorded every hour. At the time of first measurement oral ranitidine was significantly effective (P less than 0.001) in increasing the pH of intragastric contents to above the safe level of 2.5 in 94% of the children. At the second measurement an hour later, it was effective in all the children. Ranitidine has no significant effect on the volume of gastric aspirate and also there was no significant difference in the effect on the pH of the various doses of ranitidine studied. Oral ranitidine at doses of 2-3.5 mg kg-1 is effective in decreasing gastric acidity in children.

Pathophysiology of gastroesophageal reflux

Reflux esophagitis was first described 50 years ago, and understanding of abnormal gastroesophageal reflux, its complications, and treatment have been recent additions to medical and surgical knowledge. The process by which this information has been acquired, current techniques for measuring abnormal reflux and its complications, mechanisms by which reflux is controlled normally and after antireflux surgery, and the relationship between hiatal hernia and gastroesophageal reflux are the subjects of this presentation.