Vigorous achalasia: original description requires minor change.

UNLABELLED: Vigorous achalasia was described in 1957 as a subset of achalasia with a higher contraction amplitude (>37 mm Hg), minimal esophageal dilatation, prominent tertiary contractions, and higher incidence of chest pain. GOALS: Ascertain the existence of a distinct achalasia group based on manometric, radiographic, and clinical grounds. STUDY: The records of 209 idiopathic achalasia patients seen over a 9-year interval were reviewed for duration and frequency of dysphagia, chest pain, heartburn, weight loss, and nocturnal symptoms, as well as for treatment outcome. Manometric tracings were reanalyzed for lower esophageal sphincter pressure (LESP), LES residual pressure, distal esophageal contraction amplitude, and presence of repetitive waves. Patients were subsequently divided into classic (amplitude < or =37 mm Hg) and vigorous (amplitude >37 mm Hg) achalasia groups. Esophagrams were reassessed blindly for esophageal diameter both in the upright and recumbent positions and presence of lumen-occlusive tertiary contractions. RESULTS: One hundred forty-four classic and 65 vigorous achalasia patients were identified. These groups were similar in age and gender, as well as duration of symptoms. Chest pain was equally prevalent in both groups. Lower esophageal sphincter pressure was higher ( p < 0.01) and repetitive waves more common ( p < 0.0001) in the vigorous achalasia group. Upright esophageal diameter was smaller ( p = 0.0003) and tertiary contractions more frequent ( p = 0.0004) in this group. CONCLUSION: The original manometric and radiographic description of vigorous achalasia is accurate. The incidence of chest pain is similar to that of patients with classic achalasia.

Simultaneous intraesophageal impedance and pH measurement of acid and nonacid gastroesophageal reflux: effect of omeprazole.

BACKGROUND & AIMS: Nonacid reflux may explain symptoms in acid-suppressed patients. Simultaneous intraesophageal impedance and pH measurement was used to evaluate the frequencies of postprandial acid and nonacid reflux before and after omeprazole administration. METHODS: Twelve heartburn patients underwent two 2-hour studies of intraesophageal impedance and pH in the right lateral decubitus position after a refluxogenic meal; session 1 without medication, session 2 after 7 days of omeprazole twice daily. Acid and nonacid reflux were quantified. RESULTS: Two hundred seventeen reflux episodes were detected before and 261 after omeprazole treatment (P > 0.05). Percentage of acid reflux decreased (from 45% to 3%, P = 0.02) and nonacid reflux increased (from 55% to 97%, P = 0.03) after omeprazole. Heartburn and acid taste were more commonly linked to acid reflux but were also produced by nonacid reflux. Regurgitation was reported equally in acid and nonacid reflux. Delta(pH) > 1 did not help predict the presence of symptoms during nonacid reflux. CONCLUSIONS: During treatment with omeprazole, postprandial reflux becomes predominantly nonacid. Symptoms are more common with acid reflux but are also produced by nonacid reflux. Simultaneous intraesophageal impedance and pH may be useful in evaluating the role of nonacid reflux in symptoms that persist despite adequate acid suppression.

Proton pump inhibitors: better acid suppression when taken before a meal than without a meal.

BACKGROUND: Proton pump inhibitors including omeprazole and lansoprazole inhibit gastric acid secretion by selectively and non-competitively inactivating the H+, K+ ATPase molecules of the parietal cell, but possibly only those that are actively secreting acid. This might imply that stimulation of acid secretion by a meal is necessary for optimal inhibition of gastric secretion. AIM: To quantify and compare the effect on daytime gastric acidity of omeprazole 20 mg or lansoprazole 30 mg daily taken 15 min before breakfast, with that of the same drug taken without a meal. METHODS: Twenty-one healthy volunteers were randomized to receive either omeprazole or lansoprazole. They were given the drug for two separate periods of 7 days in randomized order and at least 7 days apart. During one period the study medication was taken before breakfast; during the other it was taken at the same hour, but with no meal until 12:00 hours. Lunch was standardized. On day 7, intragastric pH-metry was performed, starting at 08:00 hours. Tracings were analysed for the 8-h period from 08:00 hours until 16:00 hours with regard to percentage time for which gastric pH was below 4.0 and 3.0, and median gastric pH. Tracings were also analysed after removing the 1 h breakfast period, to exclude the buffering effect of the meal. RESULTS: When taking the drug with breakfast, the median percentage time for which gastric pH < 4.0 was 17.2 (interquartile range 4.6-45.5), compared with 42.0 (interquartile range 31.4-48.8) when taken without food (P=0.01). Fifteen subjects had better control of gastric acidity when the medication was taken with breakfast. A pH threshold of 3 and median pH showed similar differences. When the breakfast period was removed, the differences were no longer statistically significant. CONCLUSIONS: When therapy with omeprazole or lansoprazole is indicated, medication should be taken before a meal for optimal control of daytime gastric acidity.

Influence of spontaneous sleep positions on nighttime recumbent reflux in patients with gastroesophageal reflux disease.

OBJECTIVE: Body position has been shown to influence postprandial and fasting gastroesophageal reflux (GER) in patients and normal volunteers when they are assigned to lie in a prescribed position. No published studies have evaluated the effect of spontaneous sleeping positions on recumbent reflux in patients with GER. METHODS: Ten patients, three female and seven male (mean age 47.6 yr, range 30-67 yr) with abnormal recumbent esophageal pH <4 on 24-h pH-metry participated. A standardized high fat dinner (6 PM) and a bedtime snack (10 PM) were administered to all patients. GER during spontaneous sleep positions was assessed with a single channel pH probe placed 5 cm above the lower esophageal sphincter (LES) and with a position sensor taped to the sternum. Data were recorded with a portable digital data logger (Microdigitrapper-S, Synectics Medical) and analyzed for recumbent percent time pH <4 and esophageal acid clearance time in each of four sleeping positions. Time elapsed between change in sleeping position and GER episodes was also calculated. RESULTS: Right lateral decubitus was associated with greater percent time pH <4 (p < 0.003) and longer esophageal acid clearance (p < 0.05) compared to the left, supine, and prone. GER episodes were more frequent in the supine position (p < 0.04) and occurred within 1 min after change in sleeping position 28% of the time. CONCLUSIONS: The left lateral decubitus position is preferred in patients with nocturnal GER. Measures to aid patients in sleeping in this position should be developed.

Early liver dysfunction in schistosomiasis.

BACKGROUND/AIMS: Liver dysfunction is said to occur only late in the course of schistosomiasis. As albumin levels tend to be normal, the observed prolonged prothrombin time is thought to arise from subclinical consumption coagulopathy. The aim of this study was to further evaluate this matter by studying the role of Schistosoma mansoni and liver function in the genesis of the compromised haemostasis tests in chronic "pure" schistosomiasis patients. METHODS: Twenty-five adults with chronic "pure" schistosomiasis were selected: 12 with the hepatointestinal form (group 2) and 13 with the compensated hepatosplenic form (group 3), as well as 10 matched control individuals (group 1). Alcoholism, viral hepatitis B and C, malnutrition (BMI<20 kg/m2), use of anticoagulant or anti-aggregant drugs and chronic diseases apart from schistosomiasis were carefully excluded. All patients were submitted to abdominal ultrasound and upper digestive endoscopy. Blood samples were used for routine hepatic tests and for transthyretin, prothrombin, antithrombin and protein C antigen determinations by immunodiffusion. Laboratory markers of coagulation activation (prothrombin fragment1+2(F1+2), serine esterases-antithrombin complexes (ATM) and plasminogen activator, tissue type activity (t-PA) were also assayed by ELISA and photometric determination, respectively. RESULTS: Decreased plasma levels of transthyretin (p<0.001), protein C (p:0.006), prothrombin (p:0.022) and antithrombin (p:0.008) contrasted with normal albuminaemia (p:0.094), F1+2 (p:0.061) and ATM (p:0.714) plasma levels in group 3 patients; t-PA activity (p:0.001) on the other hand, were increased in this group. CONCLUSIONS: These results suggest impairment of liver clearance and protein synthesis capacity rather than consumption coagulopathy. They also indicate that changes in liver function are not a late event in the course of schistosomiasis.