Effects of age on the gastroesophageal junction, esophageal motility, and reflux disease.

BACKGROUND & AIMS: The prevalence of complicated gastroesophageal reflux disease (GERD) increases with age; however, the mechanism by which this occurs is uncertain. This study assessed (1) whether physiologic degradation of the gastroesophageal junction and esophageal motility occurs with aging, and (2) whether these effects are associated with increased esophageal acid exposure and reflux symptoms in the elderly. METHODS: Retrospective study of 1307 patients referred for investigations of reflux symptoms (median age, 49 years; range, 15-92 years) was conducted. Manometry assessed LES pressure, LES length, and esophageal peristalsis. Ambulatory pH studies assessed esophageal acid exposure (% time pH <4) during a period of 24 hours; reflux symptoms were assessed by validated questionnaire. RESULTS: On multivariate regression, esophageal acid exposure was associated independently with decreasing LES pressure (P < .0001) and abdominal LES length (P < .0004). Dysmotility exacerbated reflux in the recumbent position (P < .004). Acid exposure increased with age (P < .0001), a 1.1%/24 hours (95% confidence interval, 0.4%-1.4%) increase in acid exposure every decade (more pronounced in the recumbent position). The age-related increase in acid exposure was associated independently with decreasing abdominal LES length (P < .001) and increasing dysmotility (P < 0.01). Reflux symptoms increased with acid exposure (P < .001); however, at any given level of exposure, symptom severity was less in the elderly (P < .006). CONCLUSIONS: Age was associated with an increase in esophageal acid exposure; however, the severity of reflux symptoms reduced with age. These changes were associated with progressive decrease in abdominal LES length and esophageal motility. Increasing GERD severity in the elderly is related to degradation of the gastroesophageal junction and impaired esophageal clearance.

The relationship between gastro-oesophageal reflux symptoms and achalasia.

BACKGROUND AND AIMS: Patients with achalasia can experience heartburn, which may be misinterpreted as gastro-oesophageal reflux disease (GORD), leading to a delay in diagnosis and subsequent treatment. We investigated the relationship between gastro-oesophageal reflux (GOR) and reflux symptoms in a large cohort of patients with achalasia. METHODS: The symptoms of all patients with a manometric diagnosis of achalasia made over the past 15 years were studied. The types of treatment, onset and pattern of heartburn, lower oesophageal sphincter pressure (LOSP) and 24-h oesophageal pH studies were compared. RESULTS: A total of 110 out of 225 untreated (48.9%) and 57 out of 99 treated (57.6%) patients experienced heartburn. An oesophageal pH study was performed on 80 patients and GOR was found in only six out of 57 untreated (10.5%) and 10 out of 23 treated (43.5%) patients. A low LOSP (<10 mmHg) was associated with an increased risk of GOR [odds ratio (OR) 14.2; 95% confidence interval (CI) 1.6-128.7; P<0.02). Treated patients were also more likely to develop GOR (OR 7.9; 95% CI 2.0-32.1; P<0.005). Neither the LOSP nor previous treatment was, however, a predictor of heartburn. The timing of the onset of dysphagia and heartburn was categorized in 111 patients. There was no significant difference in mean (or median) LOSP between these three groups, indicating that the LOSP is unlikely to predict the occurrence of symptoms. CONCLUSIONS: Heartburn is common in patients with untreated and treated achalasia, but is a poor predictor of GORD. Such patients should always be investigated with a 24-h oesophageal pH study to clarify the presence of GORD.

Determinants of Abnormal Supine Reflux in 24-Hour pH Recordings.

A previous study showed that supine gastroesophageal reflux occurs mainly in the early nighttime period and is greater if the patient retires within 2 hr of a meal. We analyzed 306 consecutive esophageal pH studies between January and July 2003. Ninety-two patients had abnormal supine reflux. The recumbent period was divided into quarters (Q1-Q4) and reflux parameters were calculated for each period. Reflux was maximal in Q1, and decreased progressively from Q1 to Q4 (P<0.001). Median time between evening meal and retiring was no different from that for 44 upright gastroesophageal reflux patients. Patients retiring within 2 hr of a meal had a higher percentage supine reflux time (P=0.012), but no increase in reflux was observed in those retiring within 3 hr. Supine reflux occurs maximally in the early nighttime period. Although not fully explained as a postprandial phenomenon, these patients should avoid going to bed within 3 hr of a meal.

Acid perfusion test: a useful test for evaluating esophageal acid sensitivity.

The acid perfusion test (APT) is a test of esophageal acid sensitivity. In gastroesophageal reflux disease (GERD), the APT has largely been superseded by indexes derived from 24-hr esophageal pH monitoring: symptom index (SI), symptom sensitivity index (SSI), and symptom association probability (SAP). To evaluate the role of APT in patients with GERD we compared values of SI, SSI, and SAP in 126 APT+ and 146 APT- patients. Median values for SI, SSI, and SAP were higher in the APT+ compared with the APT- group (P < 0.001). More patients had a positive SI, SSI, and SAP in the APT+ compared with the APT- group (SI, P < 0.0001; SSI and SAP, P < 0.001). Patients with a negative APT were unlikely to have symptoms caused by acid reflux (negative predictive value, 86%). APT may be useful in detecting acid sensitivity in patients who do not report symptoms on 24-hr esophageal pH monitoring.