The mechanisms associated with reflux episodes in ambulant subjects with gastro-esophageal reflux disease

BACKGROUND

The mechanisms associated with gastro-esophageal reflux (GER) episodes were studied using combined High-resolution Impedance Manometry (HRIM) and pH monitoring in ambulant subjects with different patterns of GERD.

METHODS

Sixteen subjects with mild-moderate esophagitis (Los Angeles (LA) grade A&B) (group A) and 11 subjects with severe esophagitis (LA grade C&D) or Barrett's esophagus (BE) were studied before and after a meal, resting, while walking, and during standardized exercise, using a HRIM and a pH probe.

KEY RESULTS

Post-prandial acid GER episodes were more common in group B (median 10 range (3-18) vs A (6.5 (0-18), p = 0.048). Postprandial acid clearance time was much longer in group B (median 0.71( 0.07-2.66 min) vs A (0.17 (0.04-2.44 min), p = 0.02). Transient lower esophageal sphincter relaxation (TLESR) was the most frequent mechanism associated with GER episodes in both groups. Post-prandial TLESRs with GER were more common in group B (median 17 (9-24) vs A 13.5 (7-34), p = 0.014), particularly during exercise (B 8 (6-9) vs A 6 (5-6.8), p = 0.007). Post-prandially TLESR with acid reflux increased during exercise in both groups (A rest median 2.4 (0-6.4) per hour vs exercise 4.7 (0-17.3), p = 0.005 and B 4 (0.8-9.6) vs 5.3 (2.7-13.3) per hour, p = 0.045).

CONCLUSIONS AND INFERENCES

TLESR was the most common mechanism associated with reflux episodes in all subjects. Acid reflux episodes were more common in subjects with severe esophagitis or BE and esophageal acid clearance was much slower. Post-prandial exercise increased TLESR with acid reflux and GERD patients should be encouraged to avoid exercise immediately after a meal.

Four Cases of Desquamative Esophagitis Occurring after Hematopoietic Stem Cell Transplantation

We herein report four patients with desquamative esophagitis that developed one to nine days after peripheral blood stem cell transplantation (PBSCT). Three patients underwent allogeneic PBSCT for leukemia, and the other underwent autologous PBSCT for pineoblastoma. Esophagogastroduodenoscopy revealed mucosal sloughing and fresh blood in the esophagus. Fasting and intravenous proton pump inhibitor therapy in addition to blood transfusion improved the esophageal lesions within five to seven days in three patients. These cases indicate that desquamative esophagitis can occur in patients who receive hematopoietic stem cell transplantation. Although blood transfusions may be required, it can be resolved within seven days.

Esophageal, Gastric, and Duodenal Histologic Findings in Patients with Feeding Difficulties

Currently, there are inconsistencies in the recommendations of when to obtain an esophagogastroduodenoscopy (EGD) in children with feeding difficulties. The aim of our study was to identify EGD findings in patients presenting to a large, outpatient feeding program. Additionally, we investigated the presence of any relationship between abnormal pathology seen on biopsies (inflammation) and symptoms of feeding intolerance such as vomiting, gagging, retching, or abdominal pain. Retrospective analysis of electronic medical records (EMRs) was conducted for all new patients aged 0-17 years presenting to the Multidisciplinary Feeding Clinic. Three hundred and thirty patients (50.2%) had an EGD with complete biopsies. Of these 330 patients, biopsies revealed esophagitis in 40%, gastritis in 33.6%, and duodenitis in 15.2%. Overall, 61.21% had an abnormal pathology in at least one site. We found that children with feeding disorders commonly have esophagitis, gastritis, and/or duodenitis and that symptoms are poor predictors of pathology. This study underscores the importance of gastrointestinal evaluation as part of a multidisciplinary evaluation in patients with feeding difficulties.

Dabigatran-induced esophagitis: A case report

RATIONALE

Dabigatran is an anticoagulant medication that has been widely used to prevent strokes caused by atrial fibrillation, deep vein thrombosis, and pulmonary embolism. However, the potential adverse effect of dabigatran of gastrointestinal mucosal injury is often neglected, and even induces esophagitis.

PATIENT CONCERNS

A 77-year-old woman was admitted to the hospital with symptoms of progressive retrosternal pain, upper abdominal discomfort, and dysphagia.

DIAGNOSIS

Esophagogastroduodenoscopy showed longitudinal sloughing mucosal casts in the distal esophagus. Histological examination showed squamous epithelium with neutrophil infiltration, partial epithelial degeneration, and Helicobacter pylori. Based on a literature review, medical history, and imaging examination, the patient was diagnosed with dabigatran-induced esophagitis.

INTERVENTIONS

The patient recovered with standard H. pylori eradication therapy and proton pump inhibitor without discontinuing dabigatran.

OUTCOMES

After 2 weeks, the retrosternal pain and dysphagia were relieved and upper abdominal discomfort was attenuated.

LESSONS

Our case highlights the importance of physicians' awareness of the clinical and endoscopic characteristics of dabigatran-induced esophagitis and the importance of H. pylori-associated tests and eradication if necessary for patients with long-term dabigatran treatment.

Variations in the Clinical Course of Patients with Herpes Simplex Virus Esophagitis Based on Immunocompetence and Presence of Underlying Esophageal Disease

BACKGROUND AND AIMS

Herpes simplex esophagitis (HSE) is the second most common cause of infectious esophagitis and occurs in both immunocompetent and immunocompromised patients. The aim of this study was to reappraise the clinical course of HSE in different patient populations based on degree of immunocompetence and the presence or absence of underlying esophageal disease.

METHODS

Patients with histopathologically confirmed HSE identified from the Mayo Clinic pathology database from 2006 to 2016 were included in this study. Relevant demographic, clinical, and endoscopic data were retrospectively reviewed and compared between two cohorts: (a) immunocompromised and immunocompetent patients and (b) patients with and without underlying esophageal disorders.

RESULTS

Forty-six patients were included in the study. The most common presenting symptoms were odynophagia (34.8%) and dysphagia (30.4%). Thirty-three (71.7%) patients were immunocompromised, and these patients who experienced longer duration of symptoms (25.5 ± 23.4 days vs. 7.0 ± 5.5 days, p = 0.04) were more likely to require an extension of treatment course (38.1% vs. 8.3%, p = 0.05) compared to their immunocompetent counterparts. Seventeen (37%) patients had underlying esophageal disease, and these patients were more likely to have concomitant esophageal candidiasis (41.2% vs. 10.3%, respectively; p = 0.01).

CONCLUSION

Herpes simplex virus causes esophagitis in both immunocompetent and immunocompromised patients. While the disease course appears to be self-limited for all patient populations, clinical and endoscopic differences in the disease presentation and clinical course based on immune status and the presence or absence of underlying esophageal disease exist.

Chronic Gingivostomatitis with Esophagitis in Cats

BACKGROUND

Chronic gingivostomatitis in cats (FCG) is a debilitating disease with potentially deleterious effects on overall health.

HYPOTHESIS/OBJECTIVES

Little is known about the pathophysiology and overall impact of FCG. The aims of our study were to investigate whether gingivostomatitis occurs concurrently with esophagitis, if FCG treatment contributes to esophagitis and if esophagitis exacerbates signs of FCG.

ANIMALS

Fifty-eight cats with clinical signs of FCG and 12 healthy control cats exhibiting no signs of oral disease, all client-owned.

METHODS

Prospective study. Physical, oral and endoscopic examinations were performed on all cats. Measurements of salivary and esophageal lumen pH were obtained from both groups. Biopsies were acquired from sites of esophageal inflammation in cats with FCG and from normal-appearing esophageal mucosa in control cats.

RESULTS

The majority of cats with clinical signs of FCG exhibited some degree of esophagitis especially in the proximal (44/58) and distal (53/58) parts (P < 0.001) with or without columnar metaplasia, compared to controls. All cats lacked signs related to gastrointestinal disease. Salivary and esophageal lumen pH were not statistically different compared to controls.

CONCLUSIONS AND CLINICAL IMPORTANCE

Feline chronic gingivostomatitis seems to occur concurrently with esophagitis. Esophagitis also should be managed in cats with chronic gingivostomatitis because it may aggravate the existing condition.

Motility, digestive and nutritional problems in Esophageal Atresia

Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is a rare congenital malformation. Digestive and nutritional problems remain frequent in children with EA both in early infancy and at long-term follow-up. These patients are at major risk of presenting with gastroesophageal reflux and its complications, such as anastomotic strictures. Esophageal dysmotility is constant, and can have important consequences on feeding and nutritional status. Patients with EA need a systematic follow-up with a multidisciplinary team.

Autofluorescence imaging endoscopy can distinguish non-erosive reflux disease from functional heartburn: A pilot study

AIM: To investigate whether autofluorescence imaging (AFI) endoscopy can distinguish non-erosive reflux disease (NERD) from functional heartburn (FH).

METHODS: In this prospective observational trial, 127 patients presenting with typical reflux symptoms for > 6 mo were screened. All the participants underwent endoscopy, during which white light imaging (WLI) was followed by AFI. Finally 84 patients with normal esophageal appearance on WLI were enrolled. It was defined as being suggestive of NERD if one or more longitudinal purple lines longer than one centimeter were visualized in the distal part of the esophagus during AFI endoscopy. Ambulatory 24-h multichannel intraluminal impedance and pH monitoring was also performed. After standard proton-pump inhibitor (PPI) tests, subjects were divided into an NERD group and an FH group and the diagnostic performance of AFI endoscopy to differentiate NERD from FH was evaluated.

RESULTS: Of 84 endoscopy-negative patients, 36 (42.9%) had a normal pH/impedance test. Of these, 26 patients with favorable responses to PPI tests were classified as having NERD. Finally 10 patients were diagnosed with FH and the others with NERD. Altogether, 68 (81.0%) of the 84 patients were positive on AFI endoscopy. In the NERD group, there were 67 (90.5%) patients with abnormal esophageal findings on AFI endoscopy while only 1 (10%) patient was positive on AFI endoscopy in the FH group. The sensitivity and specificity of AFI in differentiating NERD from FH were 90.5% (95%CI: 81.5%-96.1%) and 90.0% (95%CI: 55.5%-99.7%), respectively. Meanwhile, the accuracy, positive predictive value and negative predictive value of AFI in differentiating between NERD and FH were 90.5% (95%CI: 84.2%-96.8%), 98.5% (95%CI: 92.1%-99.9%) and 56.3% (95%CI: 30.0%-80.2%), respectively.

CONCLUSION: Autofluorescence imaging may serve as a complementary method in evaluating patients with NERD and FH.

Interferon γ-Induced Nuclear Interleukin-33 Potentiates the Release of Esophageal Epithelial Derived Cytokines

Background

Esophageal epithelial cells are an initiating cell type in esophageal inflammation, playing an essential role in the pathogenesis of gastroesophageal reflux disease (GERD). A new tissue-derived cytokine, interleukin-33 (IL-33), has been shown to be upregulated in esophageal epithelial cell nuclei in GERD, taking part in mucosal inflammation. Here, inflammatory cytokines secreted by esophageal epithelial cells, and their regulation by IL-33, were investigated.

Methods

In an in vitro stratified squamous epithelial model, IL-33 expression was examined using quantitative RT-PCR, western blot, ELISA, and immunofluorescence. Epithelial cell secreted inflammatory cytokines were examined using multiplex flow immunoassay. IL-33 was knocked down with small interfering RNA (siRNA) in normal human esophageal epithelial cells (HEECs). Pharmacological inhibitors and signal transducers and activators of transcription 1 (STAT1) siRNA were used to explore the signaling pathways.

Results

Interferon (IFN)γ treatment upregulated nuclear IL-33 in HEECs. Furthermore, HEECs can produce various inflammatory cytokines, such as IL-6, IL-8, monocyte chemoattractant protein 1 (MCP-1), regulated on activation normal T-cell expressed and presumably secreted (RANTES), and granulocyte-macrophage colony-stimulating factor (GM-CSF) in response to IFNγ. Nuclear, but not exogenous IL-33, amplified IFN induction of these cytokines. P38 mitogen-activated protein kinase (MAPK) and janus protein tyrosine kinases (JAK)/STAT1 were the common signaling pathways of IFNγ-mediated induction of IL-33 and other cytokines.

Conclusions

Esophageal epithelial cells can actively participate in GERD pathogenesis through the production of various cytokines, and epithelial-derived IL-33 might play a central role in the production of these cytokines.

Upper Gastrointestinal Symptoms Predictive of Candida Esophagitis and Erosive Esophagitis in HIV and Non-HIV Patients: An Endoscopy-Based Cross-Sectional Study of 6011 Patients

Upper gastrointestinal (GI) symptoms are common in both HIV and non-HIV-infected patients, but the difference of GI symptom severity between 2 groups remains unknown. Candida esophagitis and erosive esophagitis, 2 major types of esophagitis, are seen in both HIV and non-HIV-infected patients, but differences in GI symptoms that are predictive of esophagitis between 2 groups remain unknown. We aimed to determine whether GI symptoms differ between HIV-infected and non-HIV-infected patients, and identify specific symptoms of candida esophagitis and erosive esophagitis between 2 groups.We prospectively enrolled 6011 patients (HIV, 430; non-HIV, 5581) who underwent endoscopy and completed questionnaires. Nine upper GI symptoms (epigastric pain, heartburn, acid regurgitation, hunger cramps, nausea, early satiety, belching, dysphagia, and odynophagia) were evaluated using a 7-point Likert scale. Associations between esophagitis and symptoms were analyzed by the multivariate logistic regression model adjusted for age, sex, and proton pump inhibitors.Endoscopy revealed GI-organic diseases in 33.4% (2010/6.011) of patients. The prevalence of candida esophagitis and erosive esophagitis was 11.2% and 12.1% in HIV-infected patients, respectively, whereas it was 2.9% and 10.7 % in non-HIV-infected patients, respectively. After excluding GI-organic diseases, HIV-infected patients had significantly (P < 0.05) higher symptom scores for heartburn, hunger cramps, nausea, early satiety, belching, dysphagia, and odynophagia than non-HIV-infected patients. In HIV-infected patients, any symptom was not significantly associated with CD4 cell count. In multivariate analysis, none of the 9 GI symptoms were associated with candida esophagitis in HIV-infected patients, whereas dysphagia and odynophagia were independently (P < 0.05) associated with candida esophagitis in non-HIV-infected patients. However, heartburn and acid regurgitation were independently (P < 0.05) associated with erosive esophagitis in both patient groups. The internal consistency test using Cronbach's α revealed that the 9 symptom scores were reliable in both HIV (α, 0.86) and non-HIV-infected patients (α, 0.85).This large-scale endoscopy-based study showed that HIV-infected patients have greater GI symptom scores compared with non-HIV-infected patients even after excluding GI-organic diseases. None of the upper GI symptoms predict candida esophagitis in HIV-infected patients, but dysphagia and odynophagia predict candida esophagitis in non-HIV-infected patients. Heartburn and acid regurgitation predict erosive esophagitis in both patient groups.

[Characteristics of esophageal motility in patients with non-erosive reflux disease and reflux esophagitis]

OBJECTIVE

To explore the characteristics of esophageal motility in patients with non-erosive disease (NERD) and reflux esophagitis (RE).

METHODS

For this single-blind retrospective study, adult patients with typical reflux symptoms underwent esophageal manometry from January 2008 to December 2011. Their course of disease, age, gender, esophageal manometry, hiatal function and 24 h pH monitoring were analyzed by univariate and binary Logistic regression analyses.

RESULTS

A total of 244 adult patients (RE = 85, NERD = 159) were enrolled into this study. Age and course of disease were significantly higher in RE group than those in NERD group ((50.7 ± 1.2) vs (46.5 ± 0.9) yrs,(4.8 ± 0.5) vs (3.4 ± 0.3) yrs, both P < 0.05) while no difference existed in gender (P > 0.05).Lower esophageal sphincter (LES) length, LES pressure, peristaltic contraction amplitude of distal esophageal body and rate of effective peristaltic contraction of distal esophageal body were significantly lower in RE group than those in NERD group ((1.91 ± 0.06) vs (2.19 ± 0.04) cm,(6.98 ± 0.31) vs (8.54 ± 0.31)mmHg,(56.76 ± 3.21) vs (75.57 ± 3.47) mmHg, 54.1% (46/85) vs 76.1% (121/159), all P < 0.05) . However, there was no inter-group difference in LES relaxation rate and upper esophageal sphincter (UES) function (both P > 0.05). Rate of hiatal hernia (HH) and hiatal flabby (HF) in RE group significantly increased versus NERD group (23.5% (20/85) vs 1.9% (3/159), 24.7% (21/85) vs 11.3% (18/159), both P < 0.05) . Positive rate of 24 h esophageal pH monitoring, reflux number and percent of reflux were significantly higher in RE group than those in NERD group (59.1% (26/44) vs 32.5% (38/117), 71.0 (13.5, 119.0) vs 25.0 (8.0, 56.0), 5.0% (0.4%, 10.9%) vs 1.1% (0.2%, 5.0%), all P < 0.05) . Binary Logistic regression analysis showed that LES length, rate of effective peristaltic contraction of distal esophageal body and HH were risk factors for RE (OR = 2.781,0.037, 21.722, 95%CI:1.057-7.313, 0.009-0.152, 5.433-86.845).

CONCLUSIONS

Impaired anti-reflux barrier at esophagogastric junction and impaired clearance of esophageal body are important causative factors for RE. And abnormal anatomy in esophagogastric junction should raise alerts.

[Gastrointestinal features in systemic sclerosis]

Systemic sclerosis (SSc) is a rare disorder associating vasculopathy, tissue fibrosis and autoimmunity. The gastro-intestinal tract (GIT) is frequently involved with any segment being potentially affected from mouth to anus. The esophagus is the most common localization resulting in reflux and its complications such as erosive esophagitis and Barrett's esophagus. Gastric involvement is less frequent but may be complicated by hemorrhage due to gastric antral vascular ectasia (GAVE or watermelon stomach). Intestinal involvement may lead to malabsorption, intestinal pseudo-obstruction or bacterial overgrowth. Anorectal involvement can cause fecal incontinence and rectal prolapse. GIT involvement greatly affects morbimortality in SSc and therapeutic approaches essentially aim at relieving the symptoms.

[Clinical aspects of gastroesophageal reflux disease in elderly patients: results of a 5-year prospective study]

AIM

To evaluate the clinical manifestations and changes of non-erosive reflux disease, erosive reflux disease, and Barrett's esophagus (BE) in a cohort of elderly patients during a 5-year follow-up.

SUBJECTS AND METHODS

A continuous method was used to compare the clinical manifestations of gastroesophageal reflux disease (GERD) in 950 patients aged 60 to 75 years and 453 patients aged 36 to 60 years. All the patients underwent clinical examination using the Mayo clinic questionnaire and fibroesophagogastroduodenoscopy. A prospective cohort study was performed in 950 patients aged 60 to 75 years for an average of 5 years. GERD was diagnosed on the basis of the Montreal Consensus guidelines (2006); the degree of esophageal mucosal injury was evaluated according to the Los-Angeles classification (1999). The diagnosis of BE was morphologically verified.

RESULTS

The frequency of weekly heartburn was 10% higher in the mature-aged patients; but that of nocturnal heartburn, belching, and BE prevailed in the elderly patients. The 5-year prospective follow-up revealed a significant increase in the rate of erosive esophagitis and BE in the elderly patients with GERD. The risk factors of the latter were no maintenance therapy with proton pump inhibitors, as well as obesity and hiatal hernia.

CONCLUSION

GERD shows clinical features and progression in the elderly patients.

Relationship among symptoms, mucosal injury, and acid exposure in gastroesophageal reflux disease

BACKGROUND

Symptoms, endoscopy, and pH monitoring form the basis of diagnosis of gastroesophageal reflux disease (GERD). Their relationship was meaningful for primary care physicians, but still unclear. Our research aimed to compare questionnaire, endoscopy, and pH monitoring and to analyze their correlations.

METHODS

Three hundred patients who underwent the Reflux Disease Questionnaire (RDQ), endoscopy, and esophageal 24-hour pH monitoring from March 2007 to December 2010 in Peking University People's Hospital were enrolled. We analyzed the characteristics of different investigations and their relationships.

RESULTS

Male (OR for mild reflux esophagitis (RE) = 2.433, severe RE = 8.386), body mass index (BMI) (OR for mild RE = 1.222, severe RE = 1.297), and hernia (OR for mild RE = 6.059, severe RE = 17.547), were found to be the risk factors for RE; age (OR = 1.074) was correlated with severe RE. The consistency of questionnaire, endoscopy, and pH monitoring was poor: RDQ did not agree well with pH monitoring (κ = 0.061), nor with endoscopy (κ = 0.044); pH monitoring did not agree well with endoscopy (κ = 0.316). However, the severity of mucosa injury in RE was associated with pathological acid exposure (PAE): reflux episodes of >5 minutes (P = 0.035), the percentage time pH <4 (P = 0.017), and the DeMeester score (P = 0.016) increased significantly in patients with severe RE. Chest pain had poor relationship with RE or PAE.

CONCLUSIONS

Male, age, BMI, and hernia were probably risk factors for esophagitis. RDQ, endoscopy, and pH monitoring have their own focus and reinforce each other in diagnosis. Of the GERD symptoms, chest pain had negative correlation with RE or PAE.

Gastroesophageal reflux disease: Update on inflammation and symptom perception

Although gastroesophageal reflux disease (GERD) is a common disorder in Western countries, with a significant impact on quality of life and healthcare costs, the mechanisms involved in the pathogenesis of symptoms remain to be fully elucidated. GERD symptoms and complications may result from a multifactorial mechanism, in which acid and acid-pepsin are the important noxious factors involved. Prolonged contact of the esophageal mucosa with the refluxed content, probably caused by a defective anti-reflux barrier and luminal clearance mechanisms, would appear to be responsible for macroscopically detectable injury to the esophageal squamous epithelium. Receptors on acid-sensitive nerve endings may play a role in nociception and esophageal sensitivity, as suggested in animal models of chronic acid exposure. Meanwhile, specific cytokine and chemokine profiles would appear to underlie the various esophageal phenotypes of GERD, explaining, in part, the genesis of esophagitis in a subset of patients. Despite these findings, which show a significant production of inflammatory mediators and neurotransmitters in the pathogenesis of GERD, the relationship between the hypersensitivity and esophageal inflammation is not clear. Moreover, the large majority of GERD patients (up to 70%) do not develop esophageal erosions, a variant of the condition called non-erosive reflux disease. This summary aims to explore the inflammatory pathway involved in GERD pathogenesis, to better understand the possible distinction between erosive and non-erosive reflux disease patients and to provide new therapeutic approaches.

Esophageal motor disorders in adults with eosinophilic esophagitis

BACKGROUND

An association between eosinophilic esophagitis (EoE) and esophageal motility disorders has been described in small studies.

AIMS

The aim of this study was to describe the prevalence of esophageal motor disorders in a large cohort of adults with EoE and examine whether an association exists between esophageal dysmotility and dysphagia.

METHODS

A retrospective review of esophageal manometry studies in adult EoE patients was performed. Tracings were reviewed for abnormalities including nutcracker esophagus and ineffective swallows, defined as low amplitude peristalsis (<30 mmHg) or non-propagating contractions. Ineffective esophageal motility (IEM) was categorized as mild (30-40% ineffective swallows), moderate (50-60% ineffective swallows), and severe (≥70% ineffective swallows). Dysphagia was graded on a 0-3 scale for frequency and severity.

RESULTS

Seventy-five tracings from EoE patients were reviewed (85% male, mean age 41 ± 12 years). IEM was identified in 25 patients and categorized as mild (n = 13), moderate (n = 6), and severe (n = 6). Nutcracker esophagus was found in three patients. There was no significant difference in eosinophil count among the motility groups: normal 46.5 ± 3.1, mild IEM 56.9 ± 36.9, moderate IEM 45.5 ± 23.7, severe IEM 34.3 ± 12.6 (P = 0.157).

CONCLUSIONS

In this cohort of EoE patients, the majority had normal esophageal motility studies, although a subset of these patients had some esophageal dysmotility. It is unlikely that esophageal dysmotility is a major contributing factor to dysphagia, although it is reasonable to consider esophageal manometry testing in EoE patients to identify potential abnormalities of the smooth muscle esophagus.

[Exhaled nitric oxide in patients with esophagitis]

INTRODUCTION

Assessment of nitric oxide (NO) concentration in exhaled air is broadly used to monitor the airway inflammation in asthma. High level of NO are also observed in paranasal sinuses and gastrointestinal tract (GT). The intact esopahageal sphincters are responsible for maintain the NO within the GT. It is not known how much the GT and especially esophageal motility disorders can affect the FeNO measurements. The aim of the study was to assess if the gastroesophageal reflux disease has any impact on level of NO in exhaled air in patients who do not suffer from any airway disease.

MATERIAL AND METHODS

In 51 patients, in whom asthma, nasal polyps or atopy were excluded, gastroscopy with biopsy was performed. In 13 of them no esophageal pathology was found and they were considered as the control group. In the other 38 patients the esophagitis was diagnosed based on Los Angeles classification.

RESULTS

The concentration of NO in exhaled air in patients with endoscopical gastro-esophageal changes did not differ significantly from the NO concentration in patients without inflammatory changes in stomach and esophagus (p = 0.68). Moreover, the presence of hiatal hernia did not affect the FeNO (p = 0.67). There was also no significant dependence between NO level and infection with Helicobacter pylori (p = 0.18).

CONCLUSIONS

The gastroesophageal pathologies did not significantly affect NO concentration in exhaled air.

[Duodenogastral reflux burden gastroesophageal reflux disease]

The article presents research data of duodenogastral reflux (DGR) role in patients with gastroesophageal reflux disease. It is shown that in the presence DGR, the reflux esophagitis is detected at a higher frequency and outside of esophageal manifestations of the disease. The comorbidities of hepatobiliary zone and pancreas contributes to the DGR development, as well as the syndrome of bacterial overgrowth in the small intestine.

The role of delayed gastric emptying and impaired oesophageal body motility

Delayed gastric emptying in a variable proportion of patients with gastro-oesophageal reflux disease has been observed in most series, however a relationship between delayed gastric emptying and increased gastro-oesophageal reflux has not been convincingly demonstrated. Enhanced postprandial accommodation and delayed emptying of the proximal stomach have been described, but some controversy exists. Impaired primary peristalsis is often present especially in patients with oesophagitis and its prevalence increases with increasing severity of inflammatory mucosal lesions. Patients with gastro-oesophageal reflux disease often have defective triggering of secondary peristalsis independently of presence of oesophagitis. It is presently unclear if impaired oesophageal motility is a primary defect or an irreversible consequence of inflammation. Attempts at pharmacological improvement of impaired oesophageal motility have been so far disappointing. Patients with partially preserved neuromuscular structures need to be identified in order to select them for new prokinetic therapy.

The proton pump inhibitor test for gastroesophageal reflux disease: optimal cut-off value and duration

BACKGROUND

There is no accepted gold standard for the diagnosis of gastroesophageal reflux disease (GERD).

AIM

To assess the optimal cut-off value and duration of the proton pump inhibitor (PPI) test in GERD patients with and without oesophagitis.

METHODS

Prospective study of 544 patients undergoing upper GI endoscopy and treated for 2 weeks with PPIs at double dose, and for 3 additional months at standard dose. The status of the patient at end of treatment was used as an independent diagnostic standard, i.e. patients completely asymptomatic were considered as "true" GERD patients.

RESULTS

PPI test was positive in 89.7-97.8% of the patients according to the cut-off or duration of test used. Test sensitivity ranged from 95.5% to 98.8%, whereas specificity did not exceed 36.3%. Positive predictive values ranged from 87% to 80%, negative predictive values ranged from 58% to 70%, respectively.

CONCLUSIONS

The PPI test is a sensitive but poorly specific test in GERD patients. Its optimal duration is 1 week, and the optimal cut-off value is a decrease of heartburn score ≥75%. The diagnostic yield is higher in erosive oesophagitis compared with non-erosive reflux disease patients, similarly to the symptomatic response to 3-month PPI therapy.

Eosinophilic esophagitis

Eosinophilic esophagitis is specific disease that involves an isolated esophageal eosinophilic inflammation and clinical symptoms that do not respond to acid-suppression therapy or are associated with normal esophageal pH monitoring. To establish the diagnosis, upper endoscopy with esophageal biopsies is required. Referral to an allergist and food allergen testing is recommended. Dietary and topical corticosteroid therapies are commonly used and are effective in the majority of patients.

Histologic and manometric studies on the esophagus following endoscopic sclerotherapy

OBJECTIVE

The aim of this work was to study the histologic and manometric changes in the distal esophagus beyond 2 years following endoscopic sclerotherapy (EST) and/or surgical intervention, and to try to understand the etiological factors associated with these changes.

PATIENTS AND INTERVENTIONS

Forty patients, with an average age of 61.5 years, were studied for 2-12 years following sclerotherapy and/or surgical intervention. The causes of liver disease were alcoholic cirrhosis (78.6%), primary biliary cirrhosis (14.3%), and chronic aggressive hepatitis (7.1%). A predominant number of cases (65%) had a mesocaval interposition shunt due to the failure of EST, 32.5% EST alone, and 2.5% esophageal devascularization. All patients had esophageal manometry following mucosal biopsies taken in duplicate endoscopically from three levels of the distal esophagus.

RESULTS

In the EST and shunt groups, 88.5% had manometric abnormalities, esophagitis, and chronic inflammatory changes. In the EST group, all but two patients had manometric abnormalities and chronic inflammatory changes. Analysis of the patient groups on the basis of the number of EST sessions and the amount of sclerosant injected showed that both histologic changes and dysmotility were more profound in those treated over five times with EST. The differences were significant.

CONCLUSION

It appears that EST causes persistent manometric abnormalities and chronic inflammatory changes in the distal esophagus, the severity of which seems to vary directly with the frequency of sclerotherapy and not amount of sclerosant injected.

Eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory disease of the esophagus characterized by abnormal infiltration of eosinophils. The incidence of the disease that occurs in children and adults has been rapidly increasing in the last decade. Diagnosis and management of EoE warrants consultation with an allergist and a gastroenterologist.

Gastric emptying in patients with gastroesophageal reflux disease and postprandial distress syndrome--preliminary results

BACKGROUND

Gastric motor disturbances are observed in patients with both Gastroesophageal Reflux Disease (GERD) forms - with (ERD) and without (NERD) esophageal inflammatory changes, and in Functional Dyspepsia (FD) patients, particularly in those with Postprandial Distress Syndrome (PDS). Gastric Helicobacter pylori (Hp) infection is often present in these entities. We tried to evaluate if there is any influence of Hp on gastric emptying (GE) in reflux and dyspeptic patients.

MATERIAL AND METHODS

25 GERD patients aged 45.7+/-13.1 yrs (10 NERD; 5 Hp+ and 5 Hp- and 15 ERD with grade A esophagitis according to Los Angeles classification; 5 Hp+ and 10 Hp-) and 15 PDS patients (5 Hp+ and 10 Hp-) aged 47.9+/-14.0 yrs participated in our study. All patients underwent upper gastrointestinal tract endoscopy, Hp status verification, stationary esopageal manometry, 24-hour ambulatory pH-metry and gastric scintigraphy with a liquid test meal.

RESULTS

In general, both GERD groups and PDS patients had prolonged GE (T1/2 - NERD-54.9 +/- 6.3 [min], ERD-41.7 +/- 14.8 [min] and PDS-54.3 +/- 24.8 [min] vs. 35.2 +/- 13.9 [min] in control; p<0,05). According to Hp infection, we found in both NERD and PDS groups prolonged GE in Hp+ subjects in comparison to Hp-ones (respectively: T 1/2 - 66.5 +/- 21.2 [min] vs. 43.8 +/- 11.4 [min] in NERD; p<0.05; 63.5 +/- 29.0 [min] vs. 48.0 +/- 27.7 [min] in PDS; p<0.05). These differences were less pronounced in ERD subjects: 44.5 +/- 17.7 [min] Hp+ vs. 37.4 +/- 15.2 [min] in Hp- ERD; p>0.05).

CONCLUSIONS

Both NERD and PDS patients had more decreased GE half-time compared to those with inflammatory esophageal changes. In particular groups, Hp infection was associated with slower GE rate and elongated T 1/2 in NERD and PDS group but with no effect in ERD patients.

Patient and caregiver perspective on pediatric eosinophilic esophagitis and newly developed symptom questionnaires*

OBJECTIVE

Eosinophilic esophagitis (EE), a rare chronic inflammatory condition of the esophagus, is predominantly observed in children and is primarily manifested with feeding difficulties. To our knowledge, no self- or caregiver-reported questionnaires are available to assess pediatric EE symptoms and their impact as reported directly by children or their parents/caregivers. The objectives of this study were to characterize the symptoms and impact of EE among children as reported by patients and parents/caregivers and to assess the content validity of two newly developed pediatric eosinophilic esophagitis symptom questionnaires, one parent/caregiver-reported questionnaire for ages 2-7 years and one child-reported questionnaire for ages 8-17 years. The questionnaires were developed based on a review of the literature and clinical expert consultation.

RESEARCH DESIGN AND METHODS

This cross-sectional study involving one-on-one interviews with patients and caregivers was conducted at an American Partnership for Eosinophilic Disorders conference. Parents of patients aged 2-7 years (n = 12) and patients aged 8-17 years (n = 16) were first asked about symptoms and their impact on everyday life, using open-ended questions. Participants then completed the appropriate symptom questionnaire and were asked to provide feedback on the relevance, comprehensiveness, and clarity of each item and other questionnaire issues (time to complete, length, format, etc.). All reported symptoms were enumerated, and the feedback on the symptom questionnaires was analyzed qualitatively.

RESULTS

The majority of study participants were white (82%) and male (86%). The most frequently reported symptoms of 2-7-year olds were vomiting (92%), "reflux" (50%), dysphagia (25%), abdominal pain (25%), and trouble sleeping (25%). The 8-17-year group reported abdominal pain (56%), vomiting (31%), throat pain (25%), diarrhea (25%), and food getting stuck (25%). Symptoms and treatment were reported to have a major impact on daily life, particularly on school, after-school activities and social events, feeling frustrated regarding symptoms and treatment, and feeling "different". Overall, participants thought that the questionnaires were clear, relevant, and appropriate for symptom assessment.

LIMITATION

This study was based on a small and convenient sample of participants attending an EE conference and hence may not be representative of the general EE patient population.

CONCLUSIONS

EE is associated with a range of symptoms that vary in terms of the type, frequency and severity across and within patients. The results provide adequate support for the content validity of the self- and caregiver-reported versions of the symptom-specific questionnaires. Minor modifications were made based on the feedback obtained. A psychometric evaluation of the revised questionnaires is needed next to assess the construct validity, reliability, and responsiveness of the measures.

NERD, GERD, and Barrett's esophagus: role of acid and non-acid reflux revisited with combined pH-impedance monitoring

INTRODUCTION

Gastroesophageal reflux is the most important factor in the development of Barrett's metaplasia. The effect of acid reflux is commonly accepted today, but there is controversy about the role of non-acid reflux. With introduction of combined esophageal pH-impedance monitoring, a precise diagnostic test for acid and non-acid reflux is now available.

METHODS

Ninety two consecutive patients (33 women) off acid-suppressive therapy underwent diagnostic work-up for suspected gastroesophageal reflux disease including upper-GI endoscopy, esophageal manometry, barium swallow, and combined esophageal pH-impedance monitoring. Patients were subdivided into three groups according to symptoms and endoscopic appearance: typical symptoms without esophagitis (n = 28; NERD); erosive esophagitis (n = 52, ERD), and patients with intestinal metaplasia (n = 12, BE).

RESULTS

Pathologic acid reflux during pH-metry was found in 35.7%, 63.5%, and 75.0% for NERD, ERD, and BE patients, respectively (P = 0.022). Likewise, the percentage of time pH < 4 rose significantly during upright, supine, and total phases. In contrast, combined pH-impedance monitoring showed no significant difference between groups for the number of acid reflux events and for percentage of acid bolus reflux time. However, BE patients had significantly more non-acid reflux events and a higher percentage of non-acid bolus reflux time during the supine (P = 0.043, P = 0.020, respectively), but not during the upright phase (P = 0.740, P = 0.730, respectively).

CONCLUSION

Patients with BE are exposed to increased supine non-acid reflux and to increased acid reflux during upright and supine phases. This observation supports the concept that nocturnal non-acid reflux may play a role in the pathogenesis of BE.

Gastroesophageal pressure gradients in gastroesophageal reflux disease: relations with hiatal hernia, body mass index, and esophageal acid exposure

OBJECTIVES

The roles of intragastric pressure (IGP), intraesophageal pressure (IEP), gastroesophageal pressure gradient (GEPG), and body mass index (BMI) in the pathophysiology of gastroesophageal reflux disease (GERD) and hiatal hernia (HH) are only partly understood.

METHODS

In total, 149 GERD patients underwent stationary esophageal manometry, 24-h pH-metry, and endoscopy.

RESULTS

One hundred three patients had HH. Linear regression analysis showed that each kilogram per square meter of BMI caused a 0.047-kPa increase in inspiratory IGP (95% confidence interval [CI] 0.026-0.067) and a 0.031-kPa increase in inspiratory GEPG (95% CI 0.007-0.055). Each kilogram per square meter of BMI caused expiratory IGP to increase with 0.043 kPa (95% CI 0.025-0.060) and expiratory IEP with 0.052 kPa (95% CI 0.027-0.077). Each added year of age caused inspiratory IEP to decrease by 0.008 kPa (95% CI -0.015-0.001) and inspiratory GEPG to increase by 0.008 kPa (95% CI 0.000-0.015). In binary logistic regression analysis, HH was predicted by inspiratory and expiratory IGP (odds ratio [OR] 2.93 and 2.62, respectively), inspiratory and expiratory GEPG (OR 3.19 and 2.68, respectively), and BMI (OR 1.72/5 kg/m(2)). In linear regression analysis, HH caused an average 5.09% increase in supine acid exposure (95% CI 0.96-9.22) and an average 3.46% increase in total acid exposure (95% CI 0.82-6.09). Each added year of age caused an average 0.10% increase in upright acid exposure and a 0.09% increase in total acid exposure (95% CI 0.00-0.20 and 0.00-0.18).

CONCLUSIONS

BMI predicts IGP, inspiratory GEPG, and expiratory IEP. Age predicts inspiratory IEP and GEPG. Presence of HH is predicted by IGP, GEPG, and BMI. GEPG is not associated with acid exposure.

Acute necrotizing esophagitis: case report and review of the literature

Acute necrotizing esophagitis (ANE) is a rare disease typically presenting as a diffuse blackening of the esophageal mucosa with necrosis on histologic examination. For this reason, ANE is often considered to be synonymous with'black esophagus'. Recently, however, cases of ANE have been reported with a "non-black" esophagus, and this is believed to be an earlier or later stage in the evolution of ANE to/from its black form. Here we present a case report of ANE that illustrates such an evolution in endoscopic appearance from non-black to black esophagus. We also provide a review of the literature to highlight what is currently known about this color change and other clinical aspects of this relatively uncommon esophageal disease.

Association of body mass index with heartburn, regurgitation and esophagitis: results of the Progression of Gastroesophageal Reflux Disease study

BACKGROUND

Overweight and obesity are believed to be risk factors for gastroesophageal reflux disease (GERD). The aim of the present study was to analyze the impact of body mass index (BMI) on the severity and frequency of reflux symptoms and esophagitis in a large cohort of reflux patients.

METHODS

As part of the Progression of Gastroesophageal Reflux Disease (ProGERD) study, 6215 patients with clinically assessed GERD were included in the present investigation (53% male, 52 +/- 14 years; 47% female, 56 +/- 14 years). Heartburn and regurgitation symptoms were assessed using the validated Reflux Disease Questionnaire. Endoscopies were performed and patients were subsequently classified as having non-erosive or erosive disease. To examine the association between BMI, GERD symptoms, and esophagitis, odds ratios (OR) and 95% confidence intervals (95%CI) were calculated using logistic regression models.

RESULTS

In patients with GERD, higher BMI was associated with more frequent and more severe heartburn and regurgitation, as well as with esophagitis. The effects were more pronounced for regurgitation than for heartburn. The strongest association was between obesity and severity of regurgitation symptoms (women: OR 2.11, 95%CI 1.60-2.77; men: OR 2.15, 95%CI 1.59-2.90). Obese women, but not men, had an increased risk of severe esophagitis compared to women with normal weight (OR 2.51, 95%CI 1.53-4.12).

CONCLUSIONS

In patients with GERD, higher BMI was associated with more severe and more frequent reflux symptoms and esophagitis.

Cyclic AMP dependent down regulation in the relaxation of smooth muscle cells of cat esophagitis

We investigated whether the signal mechanism for relaxation may be affected by inflammation of the cat esophagus. Acute esophagitis was induced by perfusion with 0.1N HCI at a rate of 1 mL/min for 45 min over three consecutive days. We then isolated esophageal smooth muscle cells by enzymatic digestion with collagenase. We pre-contracted the isolated smooth cells with acetylcholine (ACh) (10(-5) M) and compared the agonist-induced relaxation of pre-con tracted normal cells with those of esophagitic cells. Vasoactive intestinal polypeptide (VIP) caused a dose-dependent relaxation in normal cells, and this curve was down shifted in esophagitic cells. Sodium nitroprusside (SNP) or SIN-1 (NO donor) produced dose-dependent relaxation in normal cells, which was not affected by esophagitis. 8-Br-cGMP (a cGMP ana log) also induced dose-dependent relaxation to a similar extent in both normal and esoph agitic cells. Forskolin (a cAMP activator) or db-cAMP (a cAMP analog) produced dose-dependent relaxation in normal cells, and this relaxation curve was down shifted in esoph agitic cells. Western blotting was used to determine what subtype of adenylyl cyclase was involved in the cAMP pathway. Western blot analysis of homogenates derived from esophageal smooth muscle using antibodies against adenylyl cyclase types II, III, IV and V/VI revealed the presence of type V and/or type VI only. This result suggests that relaxation via a cAMP-dependent pathway rather than a cGMP dependent-pathway is down regulated in cat acute esophagitis. This subsensitivity of the cAMP related pathway may be related to the activ ity of adenylyl cyclase V/VI.

Endoscopic, bioptic, and manometric findings in eosinophilic esophagitis before and after steroid therapy: a case series

BACKGROUND AND AIM

Eosinophilic esophagitis can be associated with a wide range of endoscopic patterns. The aim of the present case series report is to describe and classify endoscopic appearances before and after corticoid therapy in relation to histopathology and manometry.

PATIENTS AND METHODS

In 30 patients (m : f, 27 : 3; mean age 36.2 years) with eosinophilic esophagitis, endoscopic findings were prospectively classified according to luminal diameter and mucosal pattern. Manometric and bioptic histopathologic findings were also recorded. Endoscopy was repeated following a 3-month course of steroid therapy.

RESULTS

In total, 20 % of patients showed a concentric esophageal stricture, and in 57 % simultaneous contraction rings were visible. Mucosal alterations consisted of granular mucosa (20 %), longitudinal furrows (33 %) and transversal undulations (3 %). Lower esophageal sphincter dysfunction and distal esophageal dysfunctional manometry were seen in 73 % and 57 % of cases, respectively. Following steroids, the esophagus showed a normal caliber in 97 % of patients, and 63 % of patients had normal mucosa.

CONCLUSIONS

The most frequent findings were narrowing of the esophageal lumen, which returned to normal following steroid treatment to a larger extent than mucosal alterations.

Esophageal involvement in juvenile localized scleroderma: a pilot study

OBJECTIVES

To evaluate the esophageal involvement in patients with juvenile localized scleroderma (JLS).

METHODS

A cohort of patients with JLS underwent esophageal stationary manometry to evaluate esophageal motility and lower esophageal sphincter (LES) function, distal esophagus 24-hour pH-monitoring to detect gastroesophageal reflux (GER) and upper gastrointestinal (GI) endoscopy to evaluate the presence of esophagitis.

RESULTS

Fourteen patients (10 female, mean age 13.3 yrs, mean disease duration 4.7 yrs), took part in the study. Ten had linear scleroderma, three deep morphea, and one generalized morphea. Esophageal abnormalities were found in 8/14 patients (57%): pathological acid exposure on 24-hour pH-monitoring was found in 7; non-specific esophageal motor abnormalities in 5 and endoscopy-proved esophagitis in 5 symptomatic patients. Interestingly, 5 out of 8 patients with esophageal abnormalities were found to be ANA positive, and 2 were also RF positive.

CONCLUSION

Esophageal involvement is not unusual in patients with juvenile localized scleroderma, even in the absence of specific symptoms. These preliminary findings, if confirmed in a larger cohort of patients, may support the indication for an extensive GI evaluation especially in presence of positive autoantibodies or specific GI symptoms.

Duodenogastro-esophageal reflux in children with refractory gastro-esophageal reflux disease

OBJECTIVE

To determine the role of duodenogastro-esophageal reflux (DGER) in the pathogenesis of refractory gastro-esophageal reflux disease (GERD) in children.

STUDY DESIGN

Twenty-two patients (12 boys, mean age, 13.2 years) with GERD symptoms that persisted on omeprazole (1 mg/kg) underwent upper gastrointestinal endoscopy and barium x-ray, 24-hour pH and DGER (Bilitec) monitoring, and a 13C octanoic acid gastric emptying breath test.

RESULTS

Patients presented mainly with epigastric pain, regurgitation, and nausea. Endoscopy revealed persistent esophagitis in 15 patients (68%). Pathologic acid and DGER exposure were present in 12 (55%) and 15 (68%) children, respectively, with combined pathologic reflux in 10 (45%). Acid exposure did not differ according to the presence of esophagitis, but patients with grade II esophagitis had significantly higher DGER exposure than those without esophagitis (9.1 +/- 5.3% vs 26.7 +/- 10.9% of the time, P < .05). Gastric emptying rate was not associated to acid or DGER exposure or persisting esophagitis. Symptoms improved after adding a prokinetic drug to the proton pump inhibitor therapy or referral for surgery (n = 5).

CONCLUSIONS

DGER may play a role in the pathophysiology of proton pump inhibitor-refractory GERD and esophagitis in children.

Nutrition and Gastrointestinal Tract Assessment and Management of Children with Dysphagia

Limited ability to take in nutrients places young patients with dysphagia at risk for malnutrition and failure to gain weight. These children require careful evaluation and ongoing monitoring of growth and nutritional status. Gastroesophageal reflux and recurrent vomiting may contribute to dysphagia when the refluxate causes laryngopharyngeal irritation and can increase the morbidity in patients prone to aspiration. A paucity of evidence-based literature on relevant topics demands both clinical judgment and an interdisciplinary approach for management decisions for these issues. Advances in nutrition and management of aerodigestive conditions related to dysphagia will be reviewed.

Manometric findings in adult eosinophilic oesophagitis: a study of 12 cases

OBJECTIVE

To describe the manometric findings detected in adult patients with dysphagia that were diagnosed of eosinophilic oesophagitis, and to compare with the cases of eosinophilic infiltration of the oesophagus reported in the literature.

PATIENTS AND METHODS

We present 12 adult patients diagnosed as suffering from this disorder in our department in a 1.5-year period, according to histological criteria and discarding any other cause of eosinophilic infiltration of the oesophagus. Stationary oesophageal manometry using a hydropneumocapillary perfusion system was performed in every case. The recommendations of the Spanish Group of Digestive Motility were followed for the interpretation of the results. In seven patients who presented motor disorder in manometric evaluation, treatment with steroid oesophageal lavage using fluticasone propionate was carried out and these patients were subsequently re-evaluated.

RESULTS

All patients were young predominantly men, and the first endoscopic examination showed regular concentric stenosis or a 'ring oesophagus'. Six patients had a severe nonspecific oesophageal motor disorder characterized by up to 80% of nontransmitted or very low-amplitude waves in the lower two-thirds of the organ. Three patients presented a manometric disturbance characterized by hyperkinetic peristaltic waves in distal oesophageal third. One patient had an alteration of the oesophageal motor dynamics characterized by 80% of deglutory complexes formed by a primary simultaneous wave in the two lower oesophageal thirds followed by a secondary peristaltic wave in 50% of cases that had a normal duration and amplitude. The remaining two patients had normal oesophageal motility. The upper oesophageal sphincter showed no alterations, and the manometric evaluation of the lower oesophageal sphincter tone proved normal in 10 patients, with slight hypotension in two cases. In seven of the nine patients who presented an oesophageal motor disorder, treatment with steroid oesophageal lavage using fluticasone propionate was administered and a new oesophageal manometry was performed afterwards, in which the motor disorder was clearly improved as soon as dysphagia, endoscopic lesions and histopathologic alteration disappeared.

DISCUSSION

In the literature, 61 cases of eosinophilic infiltration of the oesophageal mucosa subjected to oesophageal manometric study had been described, and 60.6% of them showed evidence of different types of manometric alterations, mainly with spastic or hypercontractility characteristics. Although six of our cases showed very deficient peristalsis with very low-amplitude or nontransmitted waves, and in another three high-amplitude peristaltic waves were recorded. Motor disorders improved parallel to the disappearance of the eosinophilic infiltration of the mucosa. These data suggest that motor disorders in eosinophilic oesophagitis are a consequence of eosinophil infiltration of the oesophagus and should be considered in the differential diagnosis of dysphagia. These manometric alterations could be considered as primary nonspecific disorders and included in the 'ineffective oesophageal motility' group.

Gastroesophageal reflux disease is a progressive disease

It is controversial whether gastrooesophageal reflux disease represents a spectrum disease from a nonerosive to a complicated one, or whether it is a categorial disease, i.e. it can be divided into three categories, such as nonerosive gastrooesophageal reflux disease, erosive gastrooesophageal reflux disease and Barrett's esophagus (BE) with little or no transition from one category to the other. This controversy might be of general interest, because it has some implications in the management of the patient. However, literature data concerning the natural history of gastrooesophageal reflux disease are very limited, and in particular very few papers have dealt with the issue of describing the natural history of patients with nonerosive gastrooesophageal reflux disease. Aim of the present review is to reassess these scanty data, and to try to demonstrate that progression from milder to more severe forms of gastrooesophageal reflux disease is possible and documented.

Prolonged esophagitis after primary dysfunction of the pyloric sphincter in the rat and therapeutic potential of the gastric pentadecapeptide BPC 157

Seven or fourteen days or twelve months after suturing one tube into the pyloric sphincter (removed by peristalsis by the seventh day), rats exhibit prolonged esophagitis with a constantly lowered pressure not only in the pyloric, but also in the lower esophageal sphincter and a failure of both sphincters. Throughout the esophagitis experiment, gastric pentadecapeptide BPC 157 (PL 14736) is given intraperitoneally once a day (10 microg/kg, 10 ng/kg, last application 24 h before assessment), or continuously in drinking water at 0.16 microg/ml, 0.16 ng/ml (12 ml/rat per day), or directly into the stomach 5 min before pressure assessment (a water manometer connected to the drainage port of a Foley catheter implanted into the stomach either through an esophageal or duodenal incision). This treatment alleviates i) the esophagitis (macroscopically and microscopically, at either region or interval), ii) the pressure in the pyloric sphincter, and iii) the pressure in the lower esophageal sphincter (cmH2O). In the normal rats it increases lower esophageal sphincter pressure, but decreases the pyloric sphincter pressure. Ranitidine, given using the same protocol (50 mg/kg, intraperitoneally, once daily; 0.83 mg/ml in drinking water; 50 mg/kg directly into the stomach) does not have an effect in either rats with esophagitis or in normal rats.

Esofagitis eosinofílica. Revisión de los conceptos fisiopatológicos y clínicos actuales

Eosinophilc esophagitis (EE) is an emerging disease which is characterized by a dense infiltration of the esophagus by eosinophilic leukocytes. The main symptoms of this disease are dysphagia and frequent food impaction in esophagus, and they are due to a hypersentivity response to different foods or aeroallergens. Eosinophil accumulation in the esophageal epithelium is determined by local production of eosinophilotropic cytokines and chemokines, which have been well defined as a TH2-type hypersensitivity reaction in animal models of the disease. Esophageal epithelium, after T CD4+ lymphocytes stimulation, contains all the necessary cell types for the development of local immunoallergic responses. However, there is increasing data on the significant role that humoral immunity could play in the pathophysiology of EE, by means of the action of IgE over mast cells function. The high density of T CD8+ lymphocytes in inflammatory infiltrate suggests that a TH1-type reaction could also participate in the mechanism of the disease. Proteins contained in cytoplasmic granules of activated eosinophils and mast cells could act over neural and muscular components of the esophageal wall, triggering motor disturbances which can be measured by means of manometric recordings and justify the esophageal symptoms. This paper aims to review the newest clinical aspects of EE and the results of studies directed at investigating the pathophysiology of the disease. Furthermore, we carry out a critical review of available therapeutic options.

Do acid and bile reflux into the esophagus simultaneously? Temporal relationship between duodenogastro-esophageal reflux and esophageal pH

BACKGROUND

Duodenogastro-esophageal reflux (DGER) is an important factor in the pathogenesis of reflux esophagitis. Animal studies have demonstrated that the injurious effect of duodenal juice components depends on pH. The purpose of the present study was to investigate the temporal relationship between DGER and esophageal pH.

METHODS

Seventy-six children with symptoms of gastro-esophageal reflux disease (27 without, 31 with mild, 18 with severe esophagitis) underwent 24 h simultaneous esophageal pH and bilirubin monitoring with Bilitec 2000. The recordings were analyzed for (i) pH at the beginning of DGER episodes; (ii) relative duration of DGER in eight defined pH intervals of 1 pH unit; and (iii) differences in relative duration of DGER between the three groups of children.

RESULTS

DGER episodes most frequently began at pH between 6 and 7. DGER was present in the esophagus across the spectrum of esophageal pH, with the biggest relative duration between pH 3 and 5. However, in children without esophagitis relative duration of DGER was longest between pH 5 and 6, in children with mild esophagitis between pH 4 and 5, while in those with severe esophagitis it was between pH 2 and 4 (P < 0.001).

CONCLUSIONS

DGER appears across the whole esophageal pH spectrum. The more severe the esophagitis, the lower the pH at which DGER occurs, resulting in simultaneous damaging effects of acid and duodenal juice components.

Food allergies and eosinophilic gastrointestinal illness

Eosinophilic gastrointestinal disorders are characterized by eosinophilic infiltration and inflammation of the gastrointestinal tract in the absence of previously identified causes of eosinophilia, such as parasitic infections, malignancy, collagen vascular diseases, drug sensitivities, and inflammatory bowel disease. These disorders include eosinophilic esophagitis, eosinophilic gastroenteritis, eosinophilic enteritis, and eosinophilic colitis. This article focuses mainly on eosinophilic esophagitis and eosinophilic gastroenteritis.

An experimental model of prolonged esophagitis with sphincter failure in the rat and the therapeutic potential of gastric pentadecapeptide BPC 157

We report a simple novel rat model that combines prolonged esophagitis and parallel sphincters failure. The anti-ulcer gastric pentadecapeptide BPC 157, which was found to be stable in gastric juice, and is being evaluated in inflammatory bowel disease trials, is an anti-esophagitis therapy that recovers failed sphincters. Twelve or twenty months after the initial challenge (tubes sutured into sphincters for one week and then spontaneously removed by peristalsis), rats exhibit prolonged esophagitis (confluent hemorrhagic and yellowish lesions, thinner epithelium and superficial corneal layer, with stratification derangement); constantly lowered pressure of both sphincters (assessed by using a water manometer connected to the drainage port of a Foley catheter implanted into the stomach either through esophageal or duodenal incision); and both lower esophageal and pyloric sphincter failure. Throughout the esophagitis experiment, BPC 157 was given at either 10 micro g/kg, i.p., once a day (last application 24 h before assessment) or alternatively, it was given continuously in drinking water at 0.16 micro g/ml (12 ml/rat). This treatment recovers i) esophagitis (macroscopically and microscopically, at either region or investigated time period) and ii) pressure in both sphincters (cmH2O). In addition, BPC 157 (10 micro g/kg) or saline (1 ml/rat, 5 ml/kg) was specifically given directly into the stomach; pressure assessment was performed at 5 min thereafter. The effect of BPC 157 is specific because in normal rats, it increases lower esophageal sphincter-pressure, but decreases pyloric sphincter-pressure. Ranitidine, given as the standard drug using the same protocol (50 mg/kg, i.p., once daily; 0.83 mg/ml in drinking water; or 50 mg/kg directly into the stomach) had no effect.

[Is antisecretory therapy of patients with chemical burn of the esophagus mandatory?]

Intragastric pH-metry and esophagogastroduodenoscopy has been performed in 64 patients with chemical burn of the esophagus. It has been revealed that 51.6% patients had hyperacidity, 25% - normacidity, and 23.4% - hypoacidity. Gastroesophageal reflux has been diagnosed in 50% patients according to pH-metry examination and in 80-100% patients according to esophagogastroduodenoscopy, duodenogastric reflux - in 25 and 34.4% cases, respectively. A direct correlation exists between gastroesophageal reflux and basal gastric acidity, severity of chemical burn of the esophagus. It is concluded that antisecretory therapy is mandatory in complex treatment of patients with chemical burn of the esophagus.

Esophageal acid exposure in upright and recumbent postures: roles of lower esophageal sphincter, esophageal contractile and transport function, hiatal hernia, age, sex, and body mass

This study aimed to assess, using multiple regression analyses, the roles of lower esophageal sphincter, esophageal contractile and transport function, hiatal hernia, age, sex, and body mass for esophageal acid exposure in upright and recumbent postures and for esophagitis. In 116 patients with reflux symptoms, acid exposure was recorded by 24-hr pH monitoring, motility manometrically, bolus transport scintigraphically, hiatal hernia and esophagitis endoscopically. In upright posture, the percentage time at pH <4 increased significantly with higher body mass index and lower distal esophageal amplitude, the number of episodes >5 min at pH <4 with lower distal amplitude, slower transport, and higher body mass, and the longest episode at pH <4 with lower distal amplitude. In recumbency, the percentage time at pH <4 increased with lower percentage of effective esophageal contraction waves and male sex, and the number of episodes and the longest episode with lower percentage effective waves. The severity of esophagitis augmented with slower supine transport and male sex. In both postures, acid exposure and esophagitis seem to be determined primarily by impaired esophageal motility and the ensuing slow bolus transport rather than by compromised lower esophageal sphincter function and the presence and size of a hiatal hernia.