Globus jugularis and dysphagia in patients with hiatus hernia.

The aim of the article was to study if there is any relationship between globus sensation in the jugular fossa (GJ), intermittent esophageal dysphagia (IED), and the presence of a hiatus hernia, and if GJ can be relieved after hiatus hernia repair. 167 patients with a hiatus hernia (Group A) and 61 other patients with hiatus hernia and gastroesophageal reflux disease who were surgically treated with Nissen fundoplication (Group B), filled in a symptom questionnaire on GJ and IED. GJ was found in 66% and IED in 68% of patients in group A. In group B, 49% had GJ and 64% IED before surgery. At surgical follow-up 16% (P < 0.005) and 43% (P < 0.05) had GJ and IED, respectively. The combination of GJ and IED was found in 28% of IED patients before operation and in 31% at surgical follow-up. The high frequency of GJ in patients with hiatus hernia and the significant relief of GJ after hiatus hernia repair imply that GJ most likely is a referred sensation from the esophagus. IED and GJ are two parallel phenomena in patients with hiatus hernia, but do not seem to have any causal relationship.

Issues in the treatment of noncardiac chest pain.

Evaluation of therapy for noncardiac chest pain calls for a systematic analysis of all relevant factors. Central chest pain is often experienced as a threat to life. Fear and anxiety concerning heart disease or cancer can increase pain and hamper therapy. The relief of pain can result from factors other than the actual treatment employed (i.e., placebo effects, relief of anxiety, spontaneous improvement, changes in life-style not related to treatment, or other, concomitant therapies prescribed). Therapeutic failure may be explained by diagnostic error, incorrect treatment, insufficient duration of therapy, incorrect dosage regimen, individual response to pharmacologic agents, poor drug absorption, drug interactions, poor compliance, poor surgical technique, and, finally, lack of effective therapeutic options. The rational evaluation of therapy for noncardiac chest pain is also hampered by its multifactorial etiology and the difficulty of selecting study patients with identical pain etiology. Controversies in the treatment of noncardiac chest pain reflect the uncertainty regarding pathophysiology. A primary issue is whether to treat patients medically with life-style modifications and pharmacologic agents, or surgically. A variety of pharmacologic agents and surgical techniques have been used to treat noncardiac chest pain. Treatment includes psychosocial considerations in addition to medical or surgical therapy. The most important role for the physician of a patient with noncardiac chest pain is to listen well, to be confirming and understanding, and to treat the patient not just as an apparatus that needs repair but as a socially integrated human being.

Esophageal acid perfusion, airway function, and symptoms in asthmatic patients with marked bronchial hyperreactivity.

It is believed that GER can trigger asthma by the stimulation of acid-sensitive receptors in the esophagus. The aim of this study was to determine whether esophageal acid stimulation in asthmatic patients can provoke clinically detectable bronchospasm and if a possible response is correlated to bronchial reactivity. Eight patients with chronic asthma and GER disease were investigated on three occasions with a histamine challenge test followed by acid provocation of the esophagus. Assessment of bronchial function was made by FEV1, chest auscultation, and respiratory symptoms. While symptoms and signs of bronchoconstriction induced by esophageal acid stimulation were not detected clinically on any occasion, there was a significant correlation between histamine reactivity and the subclinical bronchospasm following acid provocation. It is concluded that esophageal acid stimulation during daytime in the majority of asthmatic patients is not a strong and immediate trigger of asthma.

Responses in skin microcirculation to vestibular stimulation before and during motion sickness.

BACKGROUND: Observation of physiological changes during motion sickness is required to quantify the degree of sickness. The review of the literature does not show unifying results. An objective symptom of motion sickness is facial pallor. It reflects changes in skin microcirculation which have not been measured so far. METHODS: Eleven healthy volunteers susceptible to motion sickness were subjected to eccentric vertical axis rotation. The dynamics and the correspondence of the changes in skin blood flow in two segments, forehead and finger, were measured by laser Doppler flowmeter. RESULTS AND CONCLUSIONS: The difference in the microcirculatory skin blood flow across the phases of motion sickness is significant for the forehead but not for the fingertip: the established dynamics of the forehead blood flow during motion sickness will be of benefit in quantifying the degree of sickness; there is no correlation between the blood flow changes in both measured areas; the rhythmic blood flow fluctuation increases during motion sickness; there is a difference between the blood flow responses to vestibular stimulation before the appearance of motion sickness and in the course of the sickness. Laser Doppler flowmetry is a reliable method in quantifying the degree of motion sickness.

Esophageal dysfunction in patients with contact ulcer of the larynx.

Vocal abuse is the best-known etiological factor in contact ulcer. Other factors, such as hiatus hernia and gastroesophageal reflux have been discussed. A 12-year study of 58 male patients (mean age 52 years) with present or previous contact ulcers, is reported. Forty-three patients were investigated with esophageal function tests, ie, esophageal manometry including pH monitoring, acid-perfusion test, and acid-clearing test. Esophageal dysfunction was found in 74% which is significantly higher than the 30% found in the general population.

Wrong-way swallowing as a possible cause of bronchitis in patients with gastroesophageal reflux disease.

A new theory was tested that swallowing the wrong way is the cause of the strong correlation between bronchial symptoms and gastroesophageal reflux disease (GERD). One hundred and nineteen patients who were operated on for hiatal hernia and GERD were compared with 89 patients treated with the proton pump inhibitor omeprazole concerning bronchial symptoms before and after treatment. Both groups had a frequency of cough of 34% before treatment. Omeprazole did not give any significant relief of cough, whereas patients who were operated on with fundoplication and crural repair showed a highly significant reduction of cough and bronchitis. It is believed that the distal anchoring of the longitudinal esophageal muscle by surgery improves esophageal transit and restores the delicate coordination in the swallowing centre between deglutition, the opening of the upper esophageal sphincter, and the epiglottic closure of the laryngeal entrance. It is concluded that the main reason for chronic bronchitis in patients with GERD is intermittent aspiration due to partial mis-swallowing.

A simple device measuring differences in level in the oesophagus.

A device for measuring the difference in level between the pressure transducer and a point of measurment is described. It can be used in oesophageal manometry with waterfilled catheters to measure and compensate for superimposed hydrostatic pressure. The practical application of the method is illustrated.

Vestibular and cardiac reactions to open-sea exposure.

Nineteen healthy male volunteers were exposed to a 72-hour open-sea stay in a lifeboat in order to study whether randomized protracted stimulation of different parts of the vestibular system would cause a decrease of vestibular activity as assessed by unilateral calorization of the horizontal vestibular canal. The influence on the autonomic nervous system was investigated by calculating the heart rate by the R-R intervals at ECG at rest and at maximum speed of the nystagmus slow phase. Calorization and ECG investigations were performed immediately before and after the open-sea exposure. Seven healthy males who were not exposed to the open sea served as controls. They were investigated in the same manner as the test subjects, that is twice, 3 days apart. All test subjects experienced seasickness. After the sea stay, the caloric nystagmus response had decreased significantly more than in the controls. In 7 subjects with the most pronounced vestibular habituation, the resting heart rate decreased significantly after the sea exposure. Caloric stimulation of the labyrinths did not cause any specific change of the heart rate. It is concluded that prolonged open-sea exposure causes vestibular habituation to unilateral labyrinthine stimulation. Furthermore, there are some indications that the mechanism that is responsible for vestibular habituation to some extent influences the function of the autonomic nervous system, resulting in a decreased pulse rate.

Characteristics of the autonomic response in the visually evoked reflex in humans.

This study aimed (a) to investigate the effect of the visuogenic reflex on the skin microcirculation of the hand and foot, and (b) to compare it to that evoked by thermal stimuli. Fifteen volunteers took part in this study. The laser Doppler technique was used for measuring blood flow (BF). The results showed that a flash of light with a duration of 300 ms caused a significant decrease in BF (mean 38.4 +/- 14.8%) in 10 out of 15 subjects in the hand but not in the foot. The latency was 5.05 +/- 0.7 s and the duration 7.2 +/- 1.8 s. The reaction did not show a significant change when a longer stimulus of 14 s was applied. Repetitive stimuli evoked habituation (p < 0.01). There is significant difference (p < 0.01) between autonomic responses to visuogenic and to calorically evoked reflexes.

Esophageal body motor disturbances in gastroesophageal reflux and the effects of fundoplication.

Thirty-seven patients with gastroesophageal reflux disease (GERD) were included in an esophageal manometry study before and six months after fundoplication. The motility pattern of the body of the esophagus in the patient group was compared with that of 15 healthy controls. No differences in swallowing amplitudes were found between patients with different degrees of esophagitis or between GERD patients and controls. Peristaltic activity was slightly impaired in patients with endoscopic esophagitis compared with controls. No correlation was found between dysphagia and chest pain symptoms on the one hand and on peristaltic pattern and swallowing amplitudes on the other. It was concluded that conventional esophageal manometry has little to contribute to the investigation of symptoms such as non-burning chest pain and dysphagia in GERD. Effective anti-reflux surgery eliminates these symptoms with little influence on the esophageal motility pattern.