Long-term results of biofeedback treatment for faecal incontinence: a comparative study with untreated controls.

AIM: Long-term results of biofeedback for faecal incontinence are controversial. Moreover, its value compared with standard care has been recently questioned. The study aimed to analyse the long-term efficacy of biofeedback therapy for faecal incontinence to formed stool and to compare it with no treatment. METHOD: Seventy-nine patients with faecal incontinence to solid stool were evaluated at baseline and 1, 6, 36 and 60 months after treatment. To compare the long-term results with no treatment, 40 patients initially evaluated but not referred for therapy were used as controls. RESULTS: More than 80% of patients recovered continence or had a reduction in the number of episodes of incontinence greater than 75% at 1, 6, 36 and 60 months, indicating that the success rate of biofeedback was maintained over time. At 60 months, 86% of patients treated with biofeedback were fully continent or had a > 75% reduction in the number of incontinent episodes compared to 26% of the untreated patients (P < 0.001). CONCLUSION: Biofeedback therapy is effective in patients with faecal incontinence to formed stool compared with no treatment. Overall, clinical improvement is maintained in the long term.

Normal values in ambulatory oesophageal pH monitoring at two levels in Spain.

AIM: Upper oesophageal pH monitoring may play a significant role in the study of extra-oesophageal GERD, but limited normal data are available to date. Our aim was to develop a large series of normal values of proximal oesophageal acidification. METHODS: 155 healthy volunteers (74 male) participated in a multi-centre national study including oesophageal manometry and 24 hours oesophageal pH monitoring using two electrodes individually located 5 cm above the LOS and 3 cm below the UOS. RESULTS: 130 participants with normal manometry completed all the study. Twelve of them were excluded for inadequate pH tests. Twenty-seven subjects had abnormal conventional pH. The remaining 91 subjects (37 M; 18-72 yrs age range) formed the reference group for normality. At the level of the upper oesophagus, the 95th percentile of the total number of reflux events was 30, after eliminating the meal periods 22, and after eliminating also the pseudo-reflux events 18. Duration of the longest episodes was 5, 4 and 4 min, respectively (3.5 min in upright and 0.5 min in supine). The upper limit for the percentage of acid exposure time was 1.35, 1.05 and 0.95%, respectively. No reflux events were recorded in the upper oesophagus in 8 cases. CONCLUSION: This is the largest series of normal values of proximal oesophageal reflux that confirm the existence of acid reflux at that level in healthy subjects, in small quantity and unrelated to age or gender. Our data support the convenience of excluding pseudo-reflux events and meal periods from analysis.

Healing of erosive esophagitis with sucralfate and cimetidine: influence of pretreatment lower esophageal sphincter pressure and serum pepsinogen I levels.

Forty-eight patients with erosive reflux esophagitis were allocated to either sucralfate tablets, 4 g/day, or cimetidine, 1.6 g/day, for 8 weeks in a randomized, prospective, single-blind, cross-over therapeutic trial. Pretreatment lower esophageal sphincter (LES) pressure and serum pepsinogen I (PG-I) levels were investigated as possible predictors of healing with either drug. The trial was completed by 41 patients (21 in the sucralfate group and 20 in the cimetidine group); one patient in each group was removed because of side effects. Symptom improvement occurred to a similar extent in both groups. Endoscopic results after 8 weeks of treatment with sucralfate revealed complete healing of esophageal erosions in 48% (cimetidine, 55%) and improvement in an additional 19% (cimetidine, 20%). Neither of these differences was statistically significant. Some patients refractory to one drug had endoscopic healing of esophagitis when treated with the other drug after crossover. LES pressure did not influence outcome in patients treated with sucralfate, whereas significantly (p = 0.024) more patients refractory to cimetidine had an LES pressure less than 7 mm Hg than did those with a good response to the histamine-2 (H2)-receptor blockade. Patients whose esophagitis healed or improved after sucralfate tended to have lower serum PG-I levels than those with treatment failure (104 +/- 35 ng/mL vs 125 +/- 45 ng/mL), whereas the opposite occurred in patients treated with cimetidine (132 +/- 58 ng/mL in responders vs 78 +/- 27 ng/mL in nonresponders, p = 0.048). The results confirm that sucralfate is a valuable alternative to H2-receptor inhibitors for the treatment of reflux esophagitis. They also provide preliminary evidence that LES pressures and serum PG-I levels may have predictive value of the response to one or the other of these two drugs.

[Thoracic pain of esophageal origin. Assessment of 125 consecutive patients with resting angina and angiographically normal coronary arteries]. / Dolor torácico de origen esofágico. Evaluación de 125 pacientes consecutivos con angina de reposo y arterias coronarias angiográficamente normales.

BACKGROUND: The esophagus may be the origin of chest pain clinically indistinguishable from that of myocardial ischemia. Gastroesophageal reflux (GER) and esophageal motility disorders (EMDs) are the main causes of esophageal chest pain, and esophageal motility tests are important for an appropriate diagnosis. We studied 125 unselected patients with angiographically normal coronary arteries presenting with atypical (resting) angina which was shown not to be of cardiac origin. METHODS: Stationary esophageal manometry and 24-hour pH studies were performed in all patients, and 116 of them were submitted to edrophonium provocation test (Tensilon, 10 mg as IV bolus). RESULTS: Spastic EMDs were identified as an isolated abnormality in 23 patients (18%), whereas GER was documented in 70 patients (56%). Esophageal dysmotility at baseline manometry (n = 40), a positive edrophonium test (n = 19), abnormal acid reflux indices by 24-hour pH recording (n = 62), and association of chest pain with acid reflux during pH testing (n = 24) variably overlapped in many patients. The esophagus was directly blamed as the source of atypical angina in 33 patients (26%) who had induction of their usual chest pain by cholinergic stimulation and/or association of spontaneous pain events with acid reflux. CONCLUSIONS: Esophageal dysfunction in common in patients with atypical angina considered not to be of cardiac origin and contributes to patients' symptoms. Because they may detect treatable causes of chest pain such as GER or contribute to management by assessing the diagnosis of EMD, esophageal motility tests are indicated in many patients with noncardiac chest pain.

Incomplete esophageal myotomy and early recurrence of an epiphrenic diverticulum.

The established management of epiphrenic diverticula combines diverticulectomy with myotomy of the distal esophagus including the lower esophageal sphincter. We report a patient with prompt recurrence of an epiphrenic diverticulum after laparoscopic transhiatal diverticulectomy associated with esophagomyotomy and partial posterior fundoplication due to an incomplete myotomy.

Lack of effect of a 5-HT3 antagonist, pancopride, on lower oesophageal sphincter pressure in volunteers.

Effects of pancopride (5 and 10 mg, intravenously), on lower oesophageal sphincter pressure (LOESP), were assessed in healthy volunteers by means of oesophageal manometry. After pancopride 10 mg, the LOESP was higher than placebo and 5 mg pancopride but there were no differences among the three treatments (P = 0.42). The areas under the curve were similar without differences, neither with absolute measurements (P = 0.53) nor after a baseline correction (P = 0.16). In conclusion, pancopride has no clinically relevant effect on lower oesophageal sphincter pressure.

Esophageal motor function in primary Sjögren's syndrome.

To evaluate esophageal motor function in patients with primary Sjögren's syndrome (PSS) and its relation to the presence of dysphagia, 20 outpatients, who met the four criteria for PSS proposed by Fox et al. were prospectively studied by esophageal manometry after dry or wet swallows. Dysphagia was present in 15 (75%) patients, although the presence or severity of the symptom was not related to any specific motility pattern. Moreover, this study did not show any correlation between dysphagia and degree of inflammatory infiltrate of the labial minor glands, the parotid flow rate, or the presence of autoantibodies. In conclusion, although dysphagia is a common complaint in patients with PSS, esophageal motor studies have failed to show any consistent pattern.

Effects of red wine on 24-hour esophageal pH and pressures in healthy volunteers.

The purpose of this study was to assess the effects of red wine taken with meals on esophageal motility, esophageal exposure to acid, and gastric pH. Following a randomized design, 14 healthy male volunteers (mean age 25 years, range 18-35 years were given 360 ml of red wine or tap water during lunch or dinner. All subjects underwent ambulatory 24-hr esophageal motility and esophagogastric pH monitoring studies. Three different periods were analyzed: during meals (30 min), postprandial (3 hr), and 8-hr supine. Two volunteers complained of heartburn after wine ingestion. An increase in the number of high amplitude waves (> 125 mm Hg, 95th percentile of our motility unit controls) was observed during meals accompanied by wine: water 1.2 (0-10.2), wine 1.6 (0-32.6), P = 0.02 [median (range)]. No other esophageal motility changes occurred. Percent reflux time increased during the postprandial period after wine ingestion in comparison with water: 1.7 (0-14.9) vs 0.1 (0-0.8), P < 0.05. Gastric pH was unaffected by the type of drink. Ingestion of moderate amounts of red wine with meals increases postprandial esophageal exposure to gastric acid in healthy persons.

Chest pain at rest in patients with coronary artery disease. Myocardial ischemia, esophageal dysfunction, or panic disorder?

Severe nonexertional (resting) chest pain may be due to myocardial ischemia, esophageal dysfunction, psychiatric disorder, or any combination thereof and frequently poses a difficult diagnostic challenge. Our aim was to investigate causes of chest pain in patients with coronary artery disease. Forty-five patients with angiographically proven obstructive coronary lesions and recurrent chest pain at rest were studied; 18 had refractory pain despite cardiac therapy (problem group), and 27 had documented myocardial ischemia (control group). Esophageal manometry, edrophonium provocation, 24-hr pH studies, and psychiatric interview were performed in all patients. The clinical evolution and the outcome of specific treatment during follow-up was used to establish the etiology of chest pain. Esophageal dysfunction was identified in all problem patients and in 52% of controls, and the esophagus was incriminated as the source of pain in 8 (44%) and 5 (18.5%), respectively. After a mean follow-up of 49 months (range 24-76 months), the cause of chest pain in the problem group was identified as panic disorder in 9 patients (50%), gastroesophageal reflux in 6 (33%), esophageal dysmotility in 2 (11%), and gallstone disease in 1 (6%). Of the control patients, 18 (67%) had ischemic pain alone, while 9 had concurrent causes: panic disorder in 5 (19%) and esophageal dysfunction in 4 (15%). Esophageal dysfunction and psychiatric disturbances are common in patients with coronary artery disease presenting with resting chest pain, and may contribute to patients' symptoms.

Deterioration of esophageal motility with age: a manometric study of 79 healthy subjects.

OBJECTIVE: Data are limited on the effect of age on esophageal function. We evaluated whether aging influences the motor activity of the esophagus. METHODS: Standard esophageal manometry was performed in 79 healthy, nonpaid volunteers of both sexes, 18-73 yr of age. Lower (LES) and upper esophageal sphincter (UES) characteristics and the properties of esophageal peristaltic waves were assessed by age groups: < or = 25 yr, 26-35 yr, 36-45 yr, 46-55 yr, 56-65 yr, and > 65 yr. RESULTS: Age correlated inversely with LES pressure and length, UES pressure and length, and peristaltic wave amplitude and velocity, and correlated directly with the proportion of simultaneous contractions. Age was inversely correlated with the upper limits of normality (95th percentiles) of LES pressure (r = -0.943, p = 0.005), UES pressure (r = -0.943, p = 0.005), middle and lower peristaltic wave amplitude (r = -0.947, p = 0.004, and r = -0.844, p = 0.035, respectively), upper/middle peristaltic progression speed (r = -0.943, p = 0.005), and the proportion of simultaneous contractions (r = 0.926, p = 0.008), but not with the lower normal limits (5th percentiles) of these variables. Gender did not affect esophageal motility variables. The 95th percentiles of LES pressure differed by 20 mm Hg, those of lower peristaltic amplitude by 82 mm Hg, and those of percent simultaneous contractions by a factor of 2, between the younger and the older age groups. CONCLUSIONS: The results suggest that normal esophageal motility deteriorates with advancing age. Thus, age-related normality limits of esophageal pressures should be considered before establishing the manometric diagnosis of hypercontractile esophageal motility disorders.

Sequential esophageal motility studies after endoscopic injection sclerotherapy: a prospective investigation.

To assess prospectively the effects of endoscopic intravariceal sclerosis (EIS) on esophageal function, we performed esophageal manometry on 13 cirrhotic patients before EIS, 24 h after the second session and 4 wk after the fourth session. EIS had no impact on lower esophageal sphincter pressure. However, a significant decrease in the amplitude of peristaltic waves was observed immediately post-EIS in the lower two-thirds of the esophagus. There was no modification of duration or velocity of progression of peristaltic waves. A four-fold increase in simultaneous contractions was observed early after EIS. These changes were reversible, as assessed by late esophageal testing after EIS. No correlations were demonstrated between esophageal motor parameters and doses of sclerosant. We conclude that sclerosant injection into the esophageal wall acutely impairs esophageal motility, but motor function is partially restored 4 wk after completion of EIS, suggesting that dysmotility is reversible.

Dysphagia and esophageal motor dysfunction in gastroesophageal reflux are corrected by fundoplication.

Abnormalities in esophageal peristaltic function and acid clearance appear to be responsible for prolonged esophageal acid exposure, a major determinant of the reflux esophagitis and esophageal stricture. We evaluated esophageal motility by manometry in 50 healthy controls and in 35 symptomatic reflux patients before, within 6 months, and 1 year after Nissen fundoplication. Preoperative motility was analyzed in relation to the presence or absence of both nonobstructive dysphagia and erosive esophagitis. We found that (a) preoperative dysphagia was related more to peristaltic dysfunction than to esophagitis; (b) peristaltic wave amplitude and duration were significantly lower than control values in patients with reflux, without correlation to degree of esophagitis or lower esophageal sphincter hypotension; (c) dysphagia ceased in most patients after antireflux surgery at the same time that normal motility was restored independently of lower esophageal sphincter pressure increments. These results suggest that motility disturbances are an important cause of dysphagia in reflux disease, and that reflux is the cause of, rather than the consequence of, peristaltic dysfunction.

Lack of effect of metoclopramide and domperidone on esophageal peristalsis and esophageal acid clearance in reflux esophagitis. A randomized, double-blind study.

The acute effects of oral metoclopramide (40 mg/day) and domperidone (80 mg/day) on esophageal motor activity and acid reflux were assessed in a randomized, double-blind, placebo-controlled study in 20 patients with erosive reflux esophagitis. Esophageal motor function was assessed by standard manometry with wet swallows, and reflux events were evaluated by ambulatory 24-hr pH-monitoring. Both drugs caused a significant (P less than 0.05) increase in lower esophageal sphincter pressure lasting at least 120 min. However, neither esophageal body motility, duration of esophageal exposure to acid, nor esophageal clearance were effected by drug administration in comparison to placebo. Side effects were reported in two patients who received metoclopramide, while no adverse effects occurred after domperidone intake. In conclusion, the so-called motility agents metoclopramide and domperidone have few acute effects on esophageal motility in patients with erosive reflux esophagitis.

High amplitude contractions in the middle third of the oesophagus: a manometric marker of chronic alcoholism?

BACKGROUND: Oesophageal motor abnormalities have been reported in alcoholism. AIM: To investigate the effects of chronic alcoholism and its withdrawal on oesophageal disease. PATIENTS: 23 chronic alcoholic patients (20 men and three women; mean age 43, range 23 to 54). METHODS: Endoscopy, manometry, and 24 hour pH monitoring 7-10 days and six months after ethanol withdrawal. Tests for autonomic and peripheral neuropathy were also performed. Motility and pH tracings were compared with those of age and sex matched control groups: healthy volunteers, nutcracker oesophagus, and gastro-oesophageal reflux disease. RESULTS: 14 (61%) alcoholic patients had reflux symptoms, and endoscopy with biopsy showed oesophageal inflammation in 10 patients. One patient had an asymptomatic squamous cell carcinoma. Oesophageal motility studies in the alcoholic patients showed that peristaltic amplitude in the middle third was > 150 mm Hg (95th percentile (P95) of healthy controls) in 13 (57%), the ratio lower/ middle amplitude was < 0.9 in 15 (65%) (> 0.9 in all control groups), and the lower oesophageal sphincter was hypertensive (> 23.4 mm Hg, P95 of healthy controls) in 13 (57%). All three abnormalities were present in five (22%). Abnormal reflux (per cent reflux time > 2.9, P95 of healthy controls) was shown in 12 (52%) alcoholic patients, and was unrelated to peristaltic dysfunction. Subclinical neuropathy in 10 patients did not effect oesophageal abnormalities. Oesophageal motility abnormalities persisted at six months in six patients with ongoing alcoholism, whereas they reverted towards normal in 13 who remained abstinent; reflux, however, was unaffected. CONCLUSIONS: Oesophageal peristaltic dysfunction and reflux are frequent in alcoholism. High amplitude contractions in the middle third of the oesophagus seem to be a marker of excessive alcohol consumption, and tend to improve with abstinence.

Comparison of stationary vs ambulatory 24-hour pH monitoring systems in diagnosis of gastroesophageal reflux disease.

Twenty-four-hour intraesophageal pH monitoring is presently considered the most reliable diagnostic test for gastroesophageal reflux. Prolonged esophageal pH measurements can be obtained in hospitalized patients with a stationary technique and in ambulant outpatients by means of a portable device; however, there have been no studies that have examined whether the two approaches provide a similar diagnostic accuracy. We performed a prospective study to compare stationary and ambulatory pH-metry in the diagnosis of gastroesophageal reflux. Seventy-seven control subjects and 178 patients with proven gastroesophageal reflux disease were randomized to either ambulant or static pH-metry, which was performed with standard pH electrodes, sensors, and recorders. Reflux events (intraesophageal pH < 4.0) analyzed were: number of episodes; total, upright, and supine reflux time; number of episodes lasting > 5 min; and duration of the longest episode. A composite score of all reflux events according to DeMeester was also calculated. The limits of normality were defined as the 95th percentiles of the control groups. Both controls and patients assigned to either pH monitoring method were comparable. Of 255 studies attempted, 243 (95%) were completed successfully. The results showed similar median values of reflux events for the two control groups and for the two patients groups. Percent total reflux time provided a good separation between normal and abnormal reflux, with a sensitivity of 0.92 for static pH-metry and 0.68 for the ambulant procedure (respective 95th percentiles, 3.4 and 4.6).(ABSTRACT TRUNCATED AT 250 WORDS)

Value of Nissen fundoplication in patients with gastro-oesophageal reflux judged by long-term symptom control.

A total of 160 patients treated by Nissen fundoplication for uncomplicated gastro-oesophageal reflux disease were studied over a 20-year period. Recurrent reflux and side-effects were assessed yearly after surgery. No objective tests for reflux were performed during follow-up if patients were asymptomatic. Perioperative mortality and technique-related morbidity rates were both 2 per cent. At the latest evaluation, 79 per cent of patients were completely relieved of reflux symptoms, 85 per cent had symptoms of Visick grade 1 or 2 and 89 per cent would be willing to undergo surgery again under the same conditions. Actuarial analysis showed that the success rate of fundoplication was 92 per cent at 20 years. Fourteen patients (9 per cent) developed side-effects after fundoplication and had continuing disability. Nissen fundoplication achieves permanent control of reflux symptoms in most patients with few complications and has a high degree of patient satisfaction.