Esophageal motility patterns are altered in older adult patients. / Los patrones de motilidad esofágica están alterados en pacientes adultos mayores.

INTRODUCTION AND AIMS: Since the 1960s, several studies have shown the effect of aging on esophageal motility, with inconsistent results. The aim of the present study was to evaluate the manometric results in older adult patients (=60 years of age) with an esophageal disorder and compare them with adults under 60 years of age. MATERIALS AND METHODS: A cross-sectional, retrospective study was conducted that included a sample of 1,175 patients (936 older adults and 239 non-older adults). The patients were evaluated and compared with respect to (i) sex, (ii) main complaint for which esophageal manometry was indicated, (iii) comorbidities, (iv) current medications, (v) smoking, and (vi) manometry results. RESULTS: Patient age ranged from 19 to 92 years (women made up 76.5% of the older adults and 72.8% of the non-older adults). Normal lower esophageal sphincter relaxation and normal peristalsis were more frequent in the non-older patient group (91.1% vs. 84.8% and 87.4% vs. 76%, respectively). The manometry results for the non-older adults vs. the older adults, respectively, were: achalasia (2.9% vs. 5.9%); hypercontractile disorder (9.2% vs. 10.4%); hypocontractile disorder (38.5% vs. 47.6%); and normal values (49.4% vs. 36.1%). After excluding the variables that could change esophageal motility, the results revealed significant differences between the two study groups. CONCLUSIONS: Esophageal manometry demonstrated statistically significant differences between the older adult and non-older adult study population evaluated.

Prolonged measurement improves the assessment of the barrier function of the esophago-gastric junction by high-resolution manometry.

BACKGROUND: Etiology of gastro-esophageal reflux disease (GERD) is multifactorial, but incompetence of the esophago-gastric junction (EGJ) appears to be of crucial importance. Established manometric parameters for assessment of EGJ barrier function are sub-optimal, potentially because they reflect only a very brief (up to 30 seconds), not necessarily representative period. This prospective, case-control study tested the performance of novel, high-resolution manometry (HRM) parameters of EGJ function in the assessment of GERD. METHODS: Patients with reflux symptoms and healthy controls (HC) underwent standard HRM and 24-hour pH±impedance measurements. EGJ morphology, lower esophageal sphincter pressure integral (LES-PI), EGJ contractile integral (EGJ-CI) were compared with total-EGJ-CI, a novel parameter summarizing EGJ barrier function during the entire HRM protocol. Esophageal acid exposure ≥4.2%/24 h (A-Reflux-pos) or ≥73 reflux episodes in 24 hours (V-Reflux-pos) were considered pathological. KEY RESULTS: Sixty five HC and 452 patients completed HRM, 380 (84%) patients underwent ambulatory reflux-monitoring. LES-PI, EGJ-CI and total-EGJ-CI correlated with EGJ morphology subtypes (all P<.00001). Only total-EGJ-CI was consistently lower in A-Reflux-pos and V-Reflux-pos subjects compared with HC and patients without GERD. Total-EGJ-CI was also the single best parameter for prediction of pathological reflux (optimal cut-off 47 mmHg cm, AUC 0.746, P<.0001). This cut-off value, approximately 1 SD below the mean normal value, showed modest sensitivity 54% and positive predictive value 46%, but good specificity 85% and negative predictive value 89% for GERD diagnosis. CONCLUSION & INFERENCES: Total EGJ-CI, a new metric that summarizes EGJ contractility over time, allows an improved assessment of EGJ barrier function. Pathological reflux is unlikely if this metric is within the upper two-thirds of the normal range.

Increase of lower esophageal sphincter pressure after osteopathic intervention on the diaphragm in patients with gastroesophageal reflux.

The treatment of gastroesophageal reflux disease may be clinical or surgical. The clinical consists basically of the use of drugs; however, there are new techniques to complement this treatment, osteopathic intervention in the diaphragmatic muscle is one these. The objective of the study is to compare pressure values in the examination of esophageal manometry of the lower esophageal sphincter (LES) before and immediately after osteopathic intervention in the diaphragm muscle. Thirty-eight patients with gastroesophageal reflux disease - 16 submitted to sham technique and 22 submitted osteopathic technique - were randomly selected. The average respiratory pressure (ARP) and the maximum expiratory pressure (MEP) of the LES were measured by manometry before and after osteopathic technique at the point of highest pressure. Statistical analysis was performed using the Student's t-test and Mann-Whitney, and magnitude of the technique proposed was measured using the Cohen's index. Statistically significant difference in the osteopathic technique was found in three out of four in relation to the group of patients who performed the sham technique for the following measures of LES pressure: ARP with P= 0.027. The MEP had no statistical difference (P= 0.146). The values of Cohen d for the same measures were: ARP with d= 0.80 and MEP d= 0.52. Osteopathic manipulative technique produces a positive increment in the LES region soon after its performance.

Low levels of adherence with proton pump inhibitor therapy contribute to therapeutic failure in gastroesophageal reflux disease.

To assess adherence to proton pump inhibitor (PPI) treatment and associated variables in patients with gastroesophageal reflux disease (GERD). Cross-sectional and prospective comprising 240 consecutive adult patients, diagnosed with GERD for whom continuous use of standard or double dose of omeprazole had been prescribed. Patients were ranked as ne-GERD (162: 67.5%) or e-GERD classified according to the Los Angeles classification as A (48:20.0%), B (21:8.6%), C (1:0.5%), D (1:0.5%), and Barrett's esophagus (7:2.9%). The Morisky questionnaire was applied to assess adherence to therapy and a GERD questionnaire to assess symptoms and their impact. Adherence was correlated with demographics, cotherapies, comorbidities, treatment duration, symptoms scores, endoscopic findings, and patient awareness of their disease. 126 patients (52.5%) exhibited high level of adherence and 114 (47.5%) low level. Youngers (P= 0.002) or married (O.R. 2.41, P= 0.03 vs. widowers) patients had lower levels of adherence; symptomatic patients exhibited lower adherence (P= 0.02). All other variables studied had no influence on adherence. Patients with GERD attending a tertiary referral hospital in São Paulo exhibited a high rate of low adherence to the prescribed PPI therapy that may play a role in the therapy failure. Age <60 years, marital status and being symptomatic were risk factors for low adherence.

The importance of socioeconomic factors in symptoms of heartburn.

INTRODUCTION: Patients' socioeconomic status is rarely assessed during medical consultations. OBJECTIVE: To correlate patients' socioeconomic conditions with symptoms of heartburn. METHODS: 1184 patients who answered a questionnaire in three cities on the coast of the State of Sä Paulo, Brazil, were evaluated prospectively. Socioeconomic status was assessed using several criteria: number of bathrooms, consumer goods present at home, health conditions at home, comfort (cars and/or home helps), monthly family income and head of household's educational level. RESULTS: 583 patients (49.2%) reported occurrences of heartburn over the 30 days preceding the consultation, with frequencies ranging from five to thirty episodes over this period. Among patients from the city of Guarujá (low socioeconomic condition), 9.7% had never felt heartburn, while 65.7% reported occurrences, reaching statistical significance in relation to patients of medium socioeconomic condition (city of Sä Vicente) (p = 0.012). There was no difference between patients from medium socioeconomic condition and patients from Santos (high socioeconomic condition) (p = 0.997). There was a statistically significant difference in occurrence of heartburn between the patients with high socioeconomic condition and those of low socioeconomic condition (p = 0.002). CONCLUSIONS: The least favored socioeconomic status patients, as confirmed according to a variety of socioeconomic factors, presented greater incidence of heartburn than did the most favored social class.

The effect of antireflux treatment on patients with gastroesophageal reflux disease undergoing a mental arithmetic stressor.

BACKGROUND: Acute stress exacerbates heartburn in gastroesophageal reflux disease (GERD) patients by enhancing the perceptual responses to intraesophageal acid. The aim of the study was to determine if antireflux treatment can still alter stimulus response functions to acid in patients undergoing acute stress as compared with placebo. METHODS: Symptomatic GERD patients with erosive esophagitis (EE) or an abnormal pH test were included. Patients underwent stimulus response functions to intraesophageal acid perfusion using the mental arithmetic stressor test. Thereafter, patients were randomized (2 : 1 ratio) to either esomeprazole 40 mg once daily or placebo for 8 weeks. On the last day of treatment, subjects underwent stimulus response functions to intraesophageal acid perfusion using a similar stressor as baseline. KEY RESULTS: A total of 31 patients were randomized into the treatment arm (mean age 48.6 ± 2.8, M/F 21/10) and 16 into the placebo arm (mean age 52.3 ± 4.3, M/F 12/4). In the esomeprazole group, there was a significant increase in lag time to symptom perception (P = 0.02) and decreased in intensity rating (P = 0.01) as well as acid perfusion sensitivity score (P = 0.01). There was no significant difference in any of the stimulus response functions to acid in the placebo group between baseline and treatment. Interpersonal sensitivity was the only independent clinical predictor factor for response to antireflux treatment. CONCLUSIONS & INFERENCES: Long-term antireflux treatment with a proton pump inhibitor is effective in reducing esophageal perception responses to acid during acute stress.

Increased oesophageal acid exposure at the beginning of the recumbent period is primarily a recumbent-awake phenomenon.

BACKGROUND: A significant increase in oesophageal acid exposure during early recumbent period has been demonstrated. AIM: To determine if acid reflux during the early recumbent period occurs in the recumbent-asleep or recumbent-awake period using a novel integrative actigraphy and pH programme. METHOD: Thirty-nine subjects with heartburn at least three times a week were included. Subjects underwent pH testing concomitantly with actigraphy. Simultaneously recorded actigraphy and pH data were incorporated using a novel integrative technique to determine sleep and awake periods. Characteristics of acid reflux were compared between the recumbent-awake and recumbent-asleep periods. RESULTS: Seventeen (44.7%) subjects had acid reflux events during recumbent-awake period as compared to seven (18.4%) in the corresponding recumbent-asleep period (P = 0.046). The mean number of acid reflux events in recumbent-awake period was significantly higher than in the corresponding recumbent-asleep period (8.1 +/- 4.4 vs. 3.2 +/- 1.5, P < 0.001). In the recumbent-awake period, 38.4% of acid reflux events were associated with GERD-related symptoms as compared with 3.7% of acid reflux events during the corresponding recumbent-asleep period (P = 0.01). CONCLUSION: Increased acid reflux in the early recumbent period occurs primarily during the recumbent-awake and not during the recumbent-asleep period.

Riser's reflux--an eye-opening experience.

BACKGROUND: Patients with gastro-oesophageal reflux disease (GORD) commonly report waking up in the morning with a sour or bitter taste in their mouth. The aim of the study was to compare the prevalence and frequency of acid reflux events prior to and immediately after awakening from sleep in the morning between GORD patients and normal subjects. METHODS: Thirty-nine patients with heartburn at least three times a week and abnormal pH test and nine healthy controls were included. All subjects were evaluated by demographic and GORD Symptom Checklist questionnaires. Subjects underwent pH testing concomitantly with actigraphy. A novel technology that simultaneously integrates raw actigraphy and pH monitoring data was utilized to determine the presence, frequency, and characteristics of acid reflux events prior to (up to 1 h) and immediately after (10 and 20 min) awakening from sleep in the morning. KEY RESULTS: Nineteen (48.7%) of the GORD patients had an acid reflux event within the first 20 min after awakening from sleep in the morning as compared to only seven (17.9%) during the hour prior to awakening. Within the first 10 and 20 min after awakening, patients had a total of 32 and 60 acid reflux events, respectively, as compared to 14 during the 1 h prior to awakening (P < 0.05). None of the healthy control patients demonstrated any reflux events during these three studied periods (P < 0.001). CONCLUSIONS & INFERENCES: Riser's reflux is very common among GORD patients and possibly may explain reports of early-morning GORD symptoms.

The effect of esomeprazole 20 mg twice daily on acoustic and perception parameters of the voice in laryngopharyngeal reflux.

BACKGROUND: Randomized, placebo-controlled studies have failed to demonstrate a significant treatment effect for laryngopharyngeal reflux (LPR) using traditional clinical endpoints. We compared the effect of esomeprazole 20 mg twice daily (b.i.d.) vs placebo on voice and acoustic-related measures in patients with LPR. METHODS: Patients with LPR underwent endoscopy and pH testing. Subsequently, patients underwent videostroboscopic recordings of the larynx, acoustic voice and speech analysis. A voice use and quality diary and oesophageal symptom diary were completed at baseline. Thereafter, patients were randomized to esomeprazole 20 mg twice daily vs placebo for 3 months. The voice use and quality diary and oesophageal symptom dairy were repeated during the last week of treatment. Videostroboscopy and acoustic voice and speech analysis were also performed at the end of treatment. KEY RESULTS: Twenty-four patients were randomized to the esomeprazole group and 17 to the placebo group. There was no significant difference in videostroboscopic reflux finding scores from baseline to post-treatment. Acoustic measures also failed to demonstrate significant differences within the same or between groups, even when a sub-group analysis of patients with endoscopically documented oesophageal inflammation at baseline was performed. Additionally, no significant differences were found between groups when using voice use and quality diary. CONCLUSIONS & INFERENCES: Use of more specific laryngeal functional parameters such as voice-related acoustic measures of pitch range, fundamental frequency and intensity also failed to demonstrate a significant response to proton pump inhibitor treatment as compared to placebo in patients with suspected LPR.

Oral cavity is not a reservoir for Helicobacter pylori in infected patients with functional dyspepsia.

INTRODUCTION: Helicobacter pylori infection is very prevalent in Brazil, infecting almost 65% of the population. The aim of this study was to evaluate the presence of this bacterium in the oral cavity of patients with functional dyspepsia (epigastric pain syndrome), establish the main sites of infection in the mouth, and assess the frequency of cagA and vacA genotypes of oral H. pylori. METHODS: All 43 outpatients with epigastric pain syndrome, who entered the study, were submitted to upper gastrointestinal endoscopy to rule out organic diseases. Helicobacter pylori infection in the stomach was confirmed by a rapid urease test and urea breath tests. Samples of saliva, the tongue dorsum and supragingival dental plaque were collected from the oral cavity of each subject and subgingival dental plaque samples were collected from the patients with periodontitis; H. pylori infection was verified by polymerase chain reaction using primers that amplify the DNA sequence of a species-specific antigen present in all H. pylori strains; primers that amplify a region of urease gene, and primers for cagA and vacA (m1, m2, s1a, s1b, s2) genotyping. RESULTS: Thirty patients harbored H. pylori in the stomach, but it was not possible to detect H. pylori in any oral samples using P1/P2 and Urease A/B. The genotype cagA was also negative in all samples and vacA genotype could not be characterized (s-m-). CONCLUSION: The oral cavity may not be a reservoir for H. pylori in patients with epigastric pain syndrome, the bacterium being detected exclusively in the stomach.

Esophageal involvement and interstitial lung disease in mixed connective tissue disease.

RATIONALE: Mixed connective tissue disease is a systemic inflammatory disorder that results in both pulmonary and esophageal manifestations. OBJECTIVES: We sought to evaluate the relationship between esophageal dysfunction and interstitial lung disease in patients with mixed connective tissue disease. METHODS: We correlated the pulmonary function data and the high-resolution computed tomography findings of interstitial lung disease with the results of esophageal evaluation in manometry, 24-hour intraesophageal pH measurements, and the presence of esophageal dilatation on computed tomography scan. MEASUREMENTS AND MAIN RESULTS: Fifty consecutive patients with mixed connective tissue disease, according to Kasukawa's classification criteria, were included in this prospective study. High-resolution computed tomography parenchymal abnormalities were present in 39 of 50 patients. Esophageal dilatation, gastroesophageal reflux, and esophageal motor impairment were also very prevalent (28 of 50, 18 of 36, and 30 of 36, respectively). The presence of interstitial lung disease on computed tomography was significantly higher among patients with esophageal dilatation (92% vs. 45%; p<0.01) and among patients with severe motor dysfunction (90% vs. 35%; p<0.001). CONCLUSIONS: Although we were not able to prove a causal relationship between esophageal and pulmonary involvement, our series revealed a strong association between esophageal motor dysfunction and interstitial lung disease in patients with mixed connective tissue disease.

Clinical trial: the effect of Johrei on symptoms of patients with functional chest pain.

BACKGROUND: Patients with functional chest pain (FCP) represent a therapeutic challenge for practising physicians. AIM: To determine the efficacy of Johrei as compared to wait-list in improving symptoms of FCP patients. METHODS: Patients with chest pain of noncardiac origin for at least 3 months were enrolled into the study. All patients had to have negative upper endoscopy, pH testing and oesophageal manometry prior to randomization. Subsequently, patients were randomized to either Johrei or wait-list control. Patients received 18 Johrei sessions from a Johrei practitioner for 6 weeks. RESULTS: A total of 21 FCP patients enrolled into the Johrei group and 18 into the wait-list group. There was no difference in symptom intensity score between Johrei group and wait-list group at baseline (20.28 vs. 23.06, P = N.S.). However, there was a significant pre- and post-treatment reduction in symptom intensity in the Johrei group (20.28 vs. 7.0, P = 0.0023). There was no significant reduction in symptom intensity score between baseline and at the end of the study in the wait-list group (23.06 vs. 20.69, P = N.S.). CONCLUSION: This pilot study shows that Johrei may have a role in improving FCP symptoms; however, future studies are needed to compare Johrei treatment with sham Johrei or supportive care.

Radionuclide imaging for the assessment of esophageal motility disorders in mixed connective tissue disease patients: relation to pulmonary impairment.

Esophageal functional abnormalities may lead to regurgitation, chronic esophagitis and life-threatening conditions such as aspiration pneumonia. In mixed connective tissue disease patients, previous reports showed that esophageal dysfunction varies according to the method employed for investigation. Our study was conceived to: (i) assess esophageal motility and mucosal aspects in patients with mixed connective tissue disease by endoscopy, cine-esophogram and scintigraphy focusing on the prevalence of each exam; and (ii) verify the association between pulmonary and esophageal dysfunctions. Twenty-four mixed connective tissue disease patients were enrolled for this study. Cine-esophogram and upper digestive endoscopy with mucosal biopsy were performed according to previous standardization. Radionuclide esophageal scintigraphy was performed with a semisolid meal with (99m)Tc. Eleven healthy individuals voluntarily submitted to scintigraphy as controls. Cine-esophogram showed esophageal delayed emptying in 90% of patients. At scintigraphy there was a significant delay in total esophageal transit time in the group of patients when compared to healthy controls (35.3 +/- 8.2 s. vs. 13.6 +/- 9.5 s.; P < 0.0001). The whole esophageal body showed dysmotility in 96% of patients. The cine-esophogram detected functional esophageal impairment similar to scintigraphic findings. Histopathologic examination found esophagitis in 95% of studied patients. Reduced lung volumes were associated with esophagitis and delayed esophageal clearance at scintigraphy, observed at the distal portion of the esophagus. Esophageal scintigraphy is easy to perform, with good acceptance by patients with low radiation exposition. It is a useful non-invasive test for follow-up and interventional studies concerning esophagus dysfunction.

Reduction of abdominal pressure in patients with ascites reduces gastroesophageal reflux.

The effect of the reduction of intra-abdominal pressure on the lower esophageal sphincter pressure (LESP) and the 24-hour pH monitoring were studied in 16 patients with ascites before and after paracentesis. LESP did not change (P > 0.05) with the reduction of intra-abdominal pressure (before paracentesis: 17.48 mmHg and postparacentesis: 18.67 mmHg). The results were divided into two groups according to the achieved reduction in intra-abdominal pressure group A were those in who the reduction was greater than 70% and B consisted of those a reduction of less than 70%. LESP did not change even when results for each group were considered separately (P > 0.05): group A (before: 15.60 mmHg; after: 18.09 mmHg); group B (before: 23.09 mmHg; after: 20.40 mmHg). However the 24-h pH monitoring showed pathological reflux in patients with ascites that was reduced with the paracentesis (P < 0.05; total number of reflux episodes before paracentesis was 520.26, and after, 136.26). All pH-monitoring parameters were statistically different (P < 0.05) before and after the reduction of intra-abdominal pressure for group A but not for group B. LESP does not change significantly (P > 0.05) when the intra-abdominal pressure is significantly reduced (P < 0.05). Patients with ascites showed gastroesophageal reflux. Intra-abdominal pressure reduction greater than 70% lead to a significant reduction in gastroesophageal reflux.

The screening sensitivity of endoscopy, acid perfusion test and 24-hour pH-monitoring to evaluate esophagitis in patients with heartburn and histological esophagitis.

The sensitivity of endoscopic examinations, acid perfusion test and 24-hour esophageal pH-monitoring, were studied in patients with heartburn. Thirty six adult patients with histological esophagitis were included in this prospective study. Endoscopy showed esophageal lesion in 18/36 (sensitivity of 50%): esophagitis grade I in 10 (55.6%) and, grade II in eight (44.4%). Acid perfusion test was positive in 10/25 (sensitivity of 40%) of the patients submitted to the test. Twenty-four-hour pH-monitoring was positive in 17/29 patients (sensitivity of 58.6%): eight (61.5%) did not have esophageal lesion at endoscopy, two (25%) had esophagitis grade I and seven (87.5%) had esophagitis grade II. In the patients submitted to 24-hour pH-monitoring, a greater number or reflux episodes in orthostatic position than in supine position (P < 0.0001) was observed. The total number of reflux episodes, the most prolonged reflux and the total pH time < 4 were statistically higher in post-prandial period than during meals (P = 0.005).

Disfuncoes do esfincter de Oddi / Oddi's sphincter dysfunction

Desde a primeira descricao de uma estrutura esfincteriana no ducto biliar terminal, em 1681, por Glisson, inumeras publicacoes contribuiram para melhor compreensao da funcao do esfincter de Oddi. Estudos manometricos do esfincter de Oddi abriram novas perspectivas para redefinicao de velhos conceitos como a discinesia biliar e a sindrome pos-colecistectomia, e permitiram uma avaliacao mais racional dos resultados obtidos apos esfincterotomia. Os autores realizaram revisao da literatura no que se refere aos aspectos fisiologicos, farmacologicos, diagnosticos e terapeuticos das disfuncoes do esfincter de Oddi.

[Oddi's sphincter dysfunction]. / Disfunções do esfíncter de oddi.

Since the first description by Glisson in 1681 many papers about the sphincter of Oddi have been published contributing to the understanding of its physiology. Sphincter manometry has brought to light new facts that allow a better understanding of old concepts such as the biliary dyskinesia and the post-cholecystectomy syndrome as well as a more rational evaluation of the clinical results of the sphincterectomy. A review of the physiologic, pharmacologic, diagnostic and therapeutic aspects of the dysfunction of the sphincter of Oddi is presented.