Positioning of the pH-probe by manometry or radiography for monitoring of the esophagus. Influence on diagnostic results?

PURPOSE: To correlate gastroesophageal reflux (GER), demonstrated by radiography using bread and barium, with 24-h pH monitoring in the esophagus, with the pH-probe positioned by manometry or radiology. MATERIAL AND METHODS: In all, 146 patients, 41 females and 105 males, with a median age of 47 years, suspected of GER were examined. Radiography was performed with the patient in the supine right oblique position during mastication and swallowing a piece of rye bread with liver pâté and barium. The test was positive if barium was observed more than 5 cm proximal to the gastroesophageal junction (GEJ). An antimony pH-probe was placed 5 cm above the lower esophageal sphincter determined by manometry, or 5 cm above the GEJ determined by radiography. The total time of esophageal pH <4 exceeding 5% was considered pathological. RESULTS: The radiological method had a specificity of 100% and a sensitivity of 52% compared to 24-h pH monitoring with the pH-probe positioned manometrically, and a specificity of 100% and sensitivity of 67% with the pH-probe positioned by radiography, with no significant difference between the two positionings. CONCLUSION: In 146 patients submitted to 24-h pH monitoring, the pH-probe could be placed as safely by radiography as by manometry.

Which is the better method for location of the gastro-esophageal junction: radiography or manometry?

PURPOSE: To evaluate whether location of the gastro-esophageal junction (GEJ) could be determined with the same accuracy on radiography as by manometry with special reference to pH probe positioning. MATERIAL AND METHODS: Ninety patients with suspected esophageal motility disorders underwent simultaneous manometry and video-radiography. The lower esophageal sphincter pressure (LESP) and location was determined, and pressure recordings were made in the body of the esophagus. The GEJ and any structural changes were diagnosed on radiography during single-barium swallows and continuous barium drinking. Simultaneous radiographic and manometric investigations were performed with the pressure-catheter placed 5 cm proximal to the superior border of the GEJ located by manometry, and the distance to the radiographically determined superior border could be measured directly on the videotapes using a radiopaque metric ruler placed under the patient. RESULTS: On radiography, the GEJ proved to be situated < 2 cm distally as compared to its location determined by manometry in 95.6% of the patients, and the maximal difference was 2.5 cm. The LESP or structural changes had no significant influence on the results. CONCLUSION: The variation of location of GEJ on radiography as compared with manometric findings was sufficiently small to accept both methods as valid in the positioning of the pH probe properly.

Esophageal symptoms with negative influence on social life. Radiographic and manometric findings.

PURPOSE: To correlate the functional changes of the esophagus determined by manometry and radiography using bread and barium with the severity of esophageal symptoms. MATERIAL AND METHODS: Fifty-seven patients, mean age 44.4 years, suspected of primary esophageal motility disorders underwent simultaneous video-radiography and manometry. Based on interviews the patients were divided into subgroups according to predominant symptom - gastro-esophageal reflux symptoms, dysphagia, or chest pain - and to severity of symptoms, i.e., symptoms with negative or no influence on daily life. The manometric diagnosis and esophageal emptying were based on both liquid and solid swallows. RESULTS: There was significant difference in the incidence of esophageal dysmotility disorders both globally and in the subgroup of patients with dysphagia between patients with and those without severe symptoms, but only after solid swallows. CONCLUSION: We suggest employment of bread in esophageal function tests to improve the correlation between symptomatology and positive diagnostics findings.

Intra-esophageal pH probe movement during eating and talking. A videoradiographic study.

PURPOSE: To registrate the oscillations of the pH probe in the esophagus during phonation and swallowing in the erect and supine positions. MATERIAL AND METHOD: Sixty-seven patients with suspicion of gastroesophageal reflux disease underwent manometry, 24-h pH monitoring, and videoradiography. In 43 patients the effect of dry, wet, and solid swallows in the erect and supine positions was determined, making a total of 258 swallows. In another 24 patients the effect of pH probe movement during phonation was studied. RESULTS: During every swallow the probe moved in the proximal direction from 0.5 to 2.0 cm, returned to baseline, and in 48 swallows an additional descendent movement of up to 2.0 cm was seen, the last mentioned more pronounced during solid swallows. In the erect position, no significant difference was observed for the different swallowing types, whereas in the supine position, movements were significantly more pronounced during solid food swallows. During phonation the pH probe only ascended and returned to the baseline, with no descending part. CONCLUSION: The pH probe movements are dependent on body position, bolus size, bolus composition, and talking. The ascending movements can only partially compensate for the esophageal shortening during swallow because of the time difference, and could perhaps explain the variation in results and reproducibility of 24-h pH monitoring.

Gastro-esophageal reflux demonstrated by radiography in infants less than 1 year of age. Comparison with pH monitoring.

PURPOSE: To correlate gastro-esophageal reflux (GER) demonstrated on radiography, with reflux determined on 24-h pH monitoring among infants of less than 1 year of age. MATERIAL AND METHODS: Twenty-one infants with suspected GER were examined. In the supine position the infants drank 20-60 ml of barium contrast, and the presence or absence of hiatal hernia, gastric outlet obstruction, or intestinal malrotation was evaluated. The infant was placed in the 25 degrees right oblique supine position and fed 2-3 swallows of milk by a feeding bottle. GER was scored as positive on radiography when the contrast column reached a level of at least 3 vertebral segments above the gastro-esophageal junction (GEJ). An antimony intraluminal esophageal pH probe was positioned 2 vertebral segments above the GEJ as identified by the barium swallow, confirmed on radiography after positioning and prior to probe removal. A total time of esophageal pH <4 exceeding 5% was assigned as pathological. RESULTS: The radiological method of GER evaluation showed a specificity of 50% and a sensitivity of 29%, as compared to 24-h pH monitoring. CONCLUSION: The radiological method was of no value among infants of less than 1 year when demonstrating GER.

Gastro-oesophageal reflux demonstrated by radiography. A supplement to 24-h pH monitoring.

PURPOSE: Gastro-oesophageal reflux (GOR) is demonstrated by radiography as a supplement to 24-h pH monitoring. MATERIAL AND METHODS: Forty-two patients (mean age 44 years) with suspicion of GOR disease were assessed according to a standard questionnaire. GOR was investigated by 24-h pH-monitoring and by radiography. Oesophageal emptying and the presence of rings or strictures were registered as well. Mucosal biopsies, classified as normal, light oesophagitis, severe oesophagitis, or Barrett's oesophagus, were correlated to age, gender, symptomatology, pH monitoring, and oesophageal emptying. GOR and morphological changes demonstrated by radiography were correlated to pH monitoring and mucosa biopsies. RESULTS: Based on pH monitoring, patients with severe oesophagitis and Barrett's oesophagus had a significantly higher acid exposure compared to patients with normal mucosa and light oesophagitis, with no difference concerning age, gender, and symptoms. Severe oesophagitis, including Barrett's oesophagus, was found only in patients with a positive test for radiologic GOR. Eleven patients had rings or strictures independent of oesophageal mucosal changes. CONCLUSION: GOR demonstrated by radiography identified patients where complications could be expected, which was not possible by pH monitoring alone.

Oesophageal manometry and video-radiology in patients with systemic sclerosis: a retrospective study of its clinical value.

The aim of this retrospective study was to evaluate the initial video-radiology and manometry in 40 consecutive patients with systemic sclerosis (n=21) or suspected systemic sclerosis (n = 19) in relation to oesophageal symptoms; and, furthermore, to evaluate the consequence of radiographic or manometric findings in the oesophagus on diagnosis and treatment. Evaluating oesophageal abnormalities in relation to diagnosis and treatment has, to our knowledge, not been reported before. Video-radiology together with manometry demonstrated oesophageal dysfunction in 80% of patients. Thirteen patients (33%) were asymptomatic in spite of identified motility abnormalities. Following the radiographic and manometric investigation, 9 patients (23%) had a change of diagnosis and, in 20 patients (50%), systemic treatment was instituted or intensified. The study confirms that both manometry and video-radiology are important for the identification of oesophageal motility abnormalities in patients with systemic sclerosis. Oesophageal symptom profiles alone do not predict abnormal findings.

A new method for the detection of incomplete lower esophageal sphincter relaxation in patients with achalasia.

BACKGROUND: In patients with early stages of achalasia manometry is of significant diagnostic value. Technically, however, measurement of lower esophageal sphincter (LES) relaxation is not always easy. Accordingly, we looked for a simpler way of measuring incomplete LES relaxation. METHODS: In 186 consecutive patients referred to esophageal motility testing the esophageal body base-line pressure was measured during continuous swilling of 180 ml fluid within 20 sec. RESULTS: Seventeen of the 186 patients had achalasia. Fourteen of these patients were compliant for the swill test, and all had a positive test, characterized by a steady increase in base-line pressure with negative deflections on deglutition. All nonachalasia patients could complete the test, which was negative in all except one patient, who had a severe peptic stricture. CONCLUSIONS: The swill test is diagnostic for incomplete lower esophageal relaxation in achalasia in compliant patients without organic stenosis.

Esophageal rings and strictures. Manometric characteristics in patients with food impaction.

PURPOSE: The purpose was to investigate the manometric characteristics in patients with lower esophageal rings or strictures with special reference to food impaction. MATERIAL AND METHODS: The material comprised 344 patients (158 female and 186 male). Lower esophageal rings or strictures were diagnosed radiologically by the full column technique. Manometry was performed with triple lumen catheters connected to a hydraulic capillary system and external transducers. RESULTS: Forty patients had rings, and 21 patients strictures. The reference group comprised 283 patients. Dysphagia was seen most frequently in patients with rings. Food impaction was seen only in patients with rings or strictures, whereas chest pain and heartburn appeared with the same incidence in all 3 groups. Non-specific motor disorders were seen most frequently in patients with strictures, but as delayed esophageal emptying with no influence on the tendency to food impaction. Only ring diameter, but not stricture diameter, was of any significance with a higher incidence of food impaction in patients with narrow rings. CONCLUSION: Radiology rather than manometry should be the first diagnostic step in patients with benign dysphagia suffering from food impaction.

Bread and barium. Diagnostic value in patients with suspected primary esophageal motility disorders.

PURPOSE: To evaluate the significance of bread and barium studies as a diagnostic tool as well as a supplement to manometric investigation of the esophagus in patients with suspected esophageal motility disorders. MATERIAL AND METHODS: Eighty-nine patients suspected for primary esophageal motility disorders were examined. All patients were interviewed before the investigation to determine the prevalence of symptoms like heartburn, chest pain, and dysphagia. The patients underwent simultaneous roentgenologic and manometric investigations in the supine position during wet and solid barium swallow, and during continuous drinking, followed by investigation for gastroesophageal reflux (GER). The manometric examination was performed with triple-lumen catheters connected to a hydraulic capillary infusion system and external transducers. RESULTS: All patients with normal esophageal clearing (n=31) had normal manometry. Patients with delayed esophageal clearing (n=58) required manometry for identifying concommittant motility disorders; achalasia and diffuse esophageal spasms were found only in patients with delayed liquid and solid emptying. GER and/or esophageal rings was demonstrated in 31 patients. CONCLUSION: We suggest bread and barium as the first diagnostic step in patients with clinical suspicion of primary esophageal motility disorders.

Radiological demonstration of gastroesophageal reflux. Diagnostic value of barium and bread studies compared with 24-hour pH monitoring.

PURPOSE: To correlate gastroesophageal reflux (GER), demonstrated by a radiological method using food, with the reflux events, as determined by 24-h pH monitoring. MATERIAL AND METHODS: One hundred and seventeen patients with a median age of 47 years (86 male and 31 female) were examined. In the supine left position, the patient consumed 360 ml of barium contrast. Fluoroscopy was performed with the patient in the supine right oblique position during mastication and swallowing a piece of rye bread with liver pate and barium. The test was positive if barium was observed > or =5 cm proximal to the gastroesophageal junction. An antimony pH-probe was placed 5 cm above the lower esophageal sphincter, previously determined by manometry. The position was controlled by radiography after positioning and before removal. The total time of esophageal pH<4 exceeding 5.0% was considered pathological. RESULTS: The radiological method had a specificity of 100% and a sensitivity of 52% compared to 24-h pH monitoring. CONCLUSION: The high specificity of this radiological method justify direct therapeutic consequence of a positive test. However, a negative test still renders the problem unsolved.

Gastric emptying patterns of a liquid meal in newborn infants measured by epigastric impedance.

Epigastric impedance was used to measure the gastric emptying patterns of a liquid non-caloric meal (5 mL water kg-1) in 30 healthy newborn infants. Twenty-six mature infants were examined in the first eight days of life, and four preterm infants were examined within 6 weeks after birth. The recordings consisted of two components: the emptying signal (the DC component), and a phasic 3 cycles per minutes (CPM) signal (the AC component). In some of the infants the phasic 3 CPM signal was also seen during the fasting state. For mature infants the median half emptying time (T50) was 6.9 min. For a second meal given within one hour after the first meal the half emptying time was 5.5 min (P < 0.01). In preterm infants the emptying times were not significantly different from mature infants. Day-to-day variation was low with a coefficient of variation of 17% in nine infants. A periodic change of the impedance signal, the phasic 3 CPM signal, was observed after a meal in 24 of the infants. The median frequency was 3.0 CPM in 20 mature and 2.9 CPM in four preterm infants. In nine infants a phasic 3 CPM signal was also observed during the fasting state, with a median frequency of 2.9 CPM. Measurement of gastric emptying pattern with epigastric impedance is a simple investigation for the evaluation of gastric emptying time and phasic activity in mature and preterm infants. However, the method is sensitive to spontaneous movements of the children, resulting in non-valid measurements in around one fourth of the infants.

[24-hour esophageal pH in children]. / 24 timers esophagus-pH-måling på børn.

Continuous 24-hour esophageal pH-monitoring was performed in 89 infants. Of 38 patients with respiratory symptoms 74% were found to have a pathological 24-h pH monitoring. The same number of pathological monitorings (71%) were found in 38 patients with clinical symptoms of gastro-oesophageal reflux. We found pathological monitorings in only 25% of eight patients with unusual posturing and five healthy children all had normal monitorings. Gastrooesophageal reflux is common in children with clinical gastrointestinal symptoms as well as in children with respiratory symptoms.

Prospective study of prevalence and endoscopic and histopathologic characteristics of duodenal polyps in patients submitted to upper endoscopy.

BACKGROUND: Retrospective studies of duodenal polyps have shown a prevalence of 0.3%-1.5% in patients referred to upper endoscopy, and histopathologic classifications have been inconsistent. METHODS: A prospective consecutive study was carried out in 584 patients referred to diagnostic upper endoscopy. Symptoms were registered on a questionnaire, endoscopic and histopathologic findings on standard forms. The same pathologist evaluated all biopsy specimens. RESULTS: Twenty-seven patients had polyps in the first and/or second part of the duodenum, for a prevalence 4.6%. Sixteen polyps were either inflammatory (nine polyps) or ectopic gastric mucosa (seven polyps). Both of these polyp types were practically always non-solitary, sessile, small, and located in the duodenal bulb. Seven polyps were covered by normal mucosa, three being endoscopically typical lipomas. Two polyps were adenomas (0.4% of all the patients and 7% of the polyps), and both were found in the descending part. One hyperplastic polyp of the gastric type and one case of fibrosis were found. CONCLUSIONS: 1) Duodenal polyps are found in 4.6% of patients referred to upper endoscopy and should therefore be looked for. 2) Multiple, small polyps in the duodenal bulb are always benign and need neither biopsy nor treatment (in patients with familial polyposis biopsy is recommended). 3) In the descending duodenum polyps are rare, but a substantial number of them are adenomas. Biopsy is therefore mandatory in this localization.

Endoscopic manometry of the sphincter of Oddi and the pancreatic and biliary ducts in patients with chronic pancreatitis.

Sphincter of Oddi activity and the common bile duct (CBD) and pancreatic duct (PD) pressures were measured by means of endoscopic manometry in 15 patients (11 men and 4 women aged 18-77 (median, 40) years) with various degrees of chronic pancreatitis. Eleven of the 15 patients studied had an abnormal manometric pattern: elevated base-line pressures were seen in 8 patients, elevated duct pressures in 6 patients, abnormal peristalsis in 6 patients, and discoordination in 4 patients. There was no relation between the severity of chronic pancreatitis as shown by endoscopic retrograde pancreatography and the pancreatic function test and the manometric findings. However, a positive correlation between the sphincter of Oddi base-line pressure and the pancreatic duct pressure was found. It is concluded that manometric abnormalities are common findings in patients with chronic pancreatitis. Whether this is primary or secondary to the inflammatory process is still uncertain.

The influence of a solid and liquid bolus on food-stimulated gastroesophageal reflux.

Using a radiological method to demonstrate food-stimulated gastroesophageal reflux (GER), a comparative study was carried out employing a solid, already validated bolus versus a liquid one. One hundred and four consecutive patients received both a solid and a liquid bolus in randomized order. GER was observed in 37 (35.6%) patients receiving the solid bolus versus 28 (26.9%) with the liquid one. This means that the solid bolus provokes significantly more reflux (P less than 0.02). GER, grade II (reflux above the level of the carina), occurred equally often as a result of both types of bolus, however. The study suggests that significant, food-stimulated GER is independent of the consistency of the foodstuffs and may be detected employing a liquid bolus. This result might be used in the examination of infants for GER, using milk as a food stimulus.

Diagnosis of esophageal motor disorders: a prospective study comparing barium swallow, food barium mixture, and continuous swallows with manometry.

Radiography and manometry of the esophagus were compared in 77 patients consecutively referred for manometric investigation on suspicion of esophageal motility disorder. Radiography and manometry were carried out simultaneously, and the results were assessed blindly. The examination comprised barium swallow, bread barium swallow, and barium swilling. Considering manometry as the standard, the overall sensitivity and specificity of the radiologic examinations were 90.4% and 92.0%, respectively. We conclude that radiology is an excellent investigation for the separation of patients with and without esophageal motility disorders, but correct subclassification often required manometry.

Effect of cholecystectomy on the relationship between hydrostatic common bile duct pressure and sphincter of Oddi motility.

The sphincter of Oddi (SO) motility before and after an artificial elevation of the common bile duct pressure was studied by means of endoscopic manometry in nine female subjects, seven of whom had undergone previous cholecystectomy. An increase in the hydrostatic common bile duct pressure resulted in total inhibition of the phasic SO contractions in the two patients with gallbladders in situ, as well as in four of the cholecystectomized patients. The results thus indicate that the inhibitory effect of hydrostatic common bile duct pressure on the SO motility previously demonstrated in the cat is also present in man. On the other hand, as the inhibition of the phasic contractions failed to occur in three of the postcholecystectomy patients, the findings also suggest that cholecystectomy may result in altered regulation of SO motility in some patients. This mechanism could then contribute to development of pain in susceptible subjects postcholecystectomy. Finally, the results also showed that pain experienced by some patients upon contrast injection during ERCP bears no relationship to SO motility, but is due to an interindividually variable sensitivity of the bile duct wall to the intraluminal pressure variation.

Postprandial gastro-oesophageal reflux demonstrated by radiology.

An investigation to detect food-stimulated gastro-oesophageal (GE) reflux was carried out in 54 consecutive fasting patients, 35 of whom experienced reflux while 19 did not. All patients then received a standard meal (566 kcal), and the investigation was repeated 1 h later. Out of the 35 with GE reflux in the fasting state, 33 also had GE reflux in the postprandial state, and 17 of the 19 patients with no GE reflux while fasting also had none in the postprandial state. It is concluded that the radiological method can identify most patients in whom food-stimulated GE reflux could be of clinical significance.