Artificial phrenoesophageal ligament. An experimental study in dogs.

This report deals with the preparation of a 'true' artificial phrenoesophageal ligament aimed at restoring effective anchoring of the esophagus to the diaphragm, keeping the esophagogastric sphincter in the abdomen. A total of 24 mongrel dogs were assigned to four groups: (i) Group I (n = 4): the esophageal diaphragm hiatus left wide open; (ii) Group II (n = 8): the anterolateral esophagus walls were attached to the diaphragm by the artificial ligament and the esophageal hiatus was left wide opened; (iii) Group III (n = 5): in addition to the use of the artificial ligament, the esophageal hiatus was narrowed with two retroesophageal stitches; (iv) Group IV (n = 7): the only procedure was the esophageal hiatus narrowing with two retroesophageal stitches. The phrenoesophagogastric connections were released, sparing the vagus nerves. Five animals of groups III and IV, which did not develop hiatal hernia, were submitted to esophageal manometry immediately before and 15 days after surgery. In group I, all animals developed huge sliding hiatal hernias. In group II, two dogs (25%) had a paraesophageal hernia between the two parts of the artificial ligament. In group III, neither sliding hiatal hernia nor paraesophageal hernia occurred. In group IV, two animals (28.6%) developed sliding esophageal hiatus hernia. Regarding esophageal manometry, postoperative significant difference between groups III and IV (P = 0.008) was observed. Thus, the artificial phrenoesophageal ligament maintained the esophagus firmly attached to the diaphragm in all animals and the esophagogastric sphincter pressure was significantly higher in this group.

Saliva transit in patients with gastroesophageal reflux disease.

Saliva is an important factor in the neutralization of the acidity of the refluxed material that comes from the stomach to the esophagus. The impairment of saliva transit from oral cavity to distal esophagus may be one of the causes of esophagitis and symptoms in gastroesophageal reflux disease (GERD). With the scintigraphic method, the transit of 2 mL of artificial saliva was measured in 30 patients with GERD and 26 controls. The patients with GERD had symptoms of heartburn and acid regurgitation, a 24-hour pH monitoring with more than 4.2% of the time with pH below four, 26 with erosive esophagitis, and four with non-erosive reflux disease. Fourteen had mild dysphagia for solid foods. Twenty-one patients had normal esophageal manometry, and nine had ineffective esophageal motility. They were 15 men and 15 women, aged 21-61 years, mean 39 years. The control group had 14 men and 12 women, aged 19-61 years, mean 35 years. The subjects swallowed in the sitting and supine position 2 mL of artificial saliva labeled with 18 MBq of (99m) Technetium phytate. The time of saliva transit was measured from oral cavity to esophageal-gastric transition, from proximal esophagus to esophageal-gastric transition, and the transit through proximal, middle, and distal esophageal body. There was no difference between patients and controls in the time for saliva to go from oral cavity to esophageal-gastric transition, and from proximal esophagus to esophageal-gastric transition, in the sitting and supine positions. In distal esophagus in the sitting position, the saliva transit duration was shorter in patients with GERD (3.0 ± 0.8 seconds) than in controls (7.6 ± 1.7 seconds, P = 0.03). In conclusion, the saliva transit from oral cavity to the esophageal-gastric transition in patients with GERD has the same duration than in controls. Saliva transit through the distal esophageal body is faster in patients with GERD than controls.

Effect of bolus taste on the esophageal transit of patients with stroke.

Stroke is a frequent cause of oropharyngeal dysphagia but may also cause alterations in esophageal motility. The aim of this investigation was to evaluate the effect of bolus taste on the esophageal transit of patients with stroke and controls. Esophageal transit and clearance were evaluated by scintigraphy in 36 patients in the chronic phase of stroke (44-82 years, mean: 63 years) and in 30 controls (33-85 years, mean: 59 years). The patients had a stroke 1-84 months (median: 5.5 months) before the evaluation of esophageal transit. Eight had dysphagia. Each subject swallowed in random order and in the sitting position 5 mL of liquid boluses with bitter (pH=6.0), sour (pH=3.0), sweet (pH=6.9), and neutral (pH=6.8) taste. Transit and clearance duration and the amount of residues were measured in the proximal, middle, and distal esophageal body. There was no difference between patients and controls in esophageal transit or clearance duration. In the distal esophagus, the transit and clearance durations were longer with the sour bolus than with the other boluses in both patients and controls. The amount of residues in the esophageal body was greater in patients than in controls after swallows of the neutral bolus. In control subjects, after swallows of a sour bolus, there was an increase in the amount of residues in the middle and distal esophagus compared with the other boluses. In conclusion, a sour bolus with low pH causes a longer transit and clearance duration in the distal esophageal body. There was no effect of bolus taste or pH on the esophageal transit of patients in the chronic phase of stroke compared with normal volunteers. The longer transit and clearance duration in the distal esophageal body with the sour bolus appears to be a consequence of the low pH of the bolus.

Effect of bolus volume on proximal esophageal contractions of patients with Chagas' disease and patients with idiopathic achalasia.

Chagas' disease and idiopathic achalasia patients have similar impairment of distal esophageal motility. In Chagas' disease, the contractions occurring in the distal esophageal body are similar after wet or dry swallows. Our aim in this investigation was to evaluate the effect of wet swallows and dry swallows on proximal esophageal contractions of patients with Chagas' disease and with idiopathic achalasia. We studied 49 patients with Chagas' disease, 25 patients with idiopathic achalasia, and 33 normal volunteers. We recorded by the manometric method with continuous water perfusion the pharyngeal contractions 1 cm above the upper esophageal sphincter and the proximal esophageal contractions 5 cm from the pharyngeal recording point. Each subject performed in duplicate swallows of 3-mL and 6-mL boluses of water and dry swallows. We measured the time between the onset of pharyngeal contractions and the onset of proximal esophageal contractions (pharyngeal-esophageal time [PET]), and the amplitude, duration, and area under the curve (AUC) of proximal esophageal contractions. Patients with Chagas' disease and with achalasia had longer PET, lower esophageal proximal contraction amplitude, and lower AUC than controls (P≤ 0.02). In Chagas' disease, wet swallows caused shorter PET, higher amplitude, and higher AUC than dry swallows (P≤ 0.03).There was no difference between swallows of 3- or 6-mL boluses. There was no difference between patients with Chagas' disease and with idiopathic achalasia. We conclude that patients with Chagas' disease and with idiopathic achalasia have a delay in the proximal esophageal response and lower amplitude of the proximal esophageal contractions.

Primary and secondary esophageal contractions in patients with gastroesophageal reflux disease.

We studied the primary and secondary esophageal peristalsis in 36 patients with heartburn and acid regurgitation and in 14 asymptomatic volunteers. Primary peristalsis was elicited by ten swallows of a 5-mL bolus of water and secondary peristalsis was elicited by intra-esophageal infusion of 5, 10, and 15 mL water, 0.1 N hydrochloric acid and air. Esophageal contractions were measured by an 8-lumen manometric catheter assembly incorporating a 6-cm sleeve device. Contractions were registered at 3, 9, and 15 cm from the upper margin of the sleeve and the infusion was done through a side hole located at 12 cm. Twenty patients had normal endoscopic esophageal examination, 10 with normal (group I) and 10 with abnormal pH-metric examination (group II), and 16 had esophagitis (group III). The amplitude of contractions after swallows was lower (97.8 +/- 10.0 mmHg) in the distal esophagus of group III patients than in controls (142.3 +/- 14.0 mmHg). Patients of group III had fewer secondary contractions (water: 25% of infusion) than patients of the other groups and controls (67% of infusion). Patients of group III also had a lower amplitude of secondary peristalsis in the distal esophagus (water: 70.1 +/- 9.6 mmHg) than controls (129.2 +/- 18.2 mmHg). We conclude that patients with esophagitis have an impairment of primary and secondary peristalsis in the distal esophagus.

Effect of treatment of dentofacial deformities on the electromyographic activity of masticatory muscles.

Individuals with dentofacial deformities present changes in masticatory muscles. The objective of the present study was to determine the influence of interdisciplinary treatment in cases of class III dentofacial deformities regarding the EMG activity of the temporal (T) and masseter (M) muscles. The study was conducted on 15 patients with class III dentofacial deformities who were submitted to orthodontic, oromyofunctional and surgical treatment and assigned to groups P1 (before surgery) and P2 (6-9 months after surgery). Fifteen individuals with no alterations in facial morphology or dental occlusion and without signs or symptoms of temporomandibular joint dysfunction were used as controls (CG). The T and M muscles were submitted to EMG bilaterally in the situations of mastication and mastication plus biting, with analysis of amplitude interval and root mean square. For all muscles tested, there was a difference between CG, P1 and P2; CG was higher than P2 and P2 higher than P1 in all situations assessed. We conclude that there was an increase in EMG activity in the T and M muscles after surgical correction of the dentofacial deformity accompanied by interdisciplinary treatment, although the values were still lower than those obtained for CG.

Residence of liquids in the infra-junctional portion of the proximal stomach in patients with gastroesophageal reflux disease.

Patients with gastroesophageal reflux disease may have disturbances of gastric motility, which could play a role in the pathophysiology of the disease. Recent studies have suggested that the gastric region just below the gastroesophageal junction may have a distinct physiological behavior. We determined whether patients with gastroesophageal reflux disease have abnormal residence of food in the infra-junctional portion of the stomach after ingesting a liquid nutrient meal. Fasted adult patients with reflux disease (N = 11) and healthy volunteers (N = 10) ingested a liquid meal (320 ml; 437 kcal) labeled with 99m technetium-phytate and their total gastric emptying half-time and regional emptying from the stomach infra-junctional region were determined. In 8 patients, episodes of postprandial acidic reflux to the esophagus were measured for 2 h using pH monitoring. There were no differences between reflux patients and controls regarding total gastric emptying time (median: 68 min; range: 39-123 min vs 65 min and 60-99 min, respectively; P > 0.50). Food residence in the infra-junctional area was similar for patients and controls: 23% (range: 20-30) vs 27% (range: 19-30%; P = 0.28) and emptying from this area paralleled total gastric emptying (Rs = 0.79; P = 0.04). There was no correlation between residence of food in the infra-junctional area and episodes of gastroesophageal reflux (Rs = 0.06; P = 0.88). We conclude that it is unlikely that regional motor disturbances involving the infra-junctional region of the stomach play a relevant role in the pathogenesis of acidic gastroesophageal reflux.

Aging, esophageal motility, and gastroesophageal reflux.

OBJECTIVES: To compare esophageal motility and gastroesophageal reflux characteristics in young, middle-aged, and older healthy volunteers. DESIGN: Comparison of conventional esophageal manometry and scintigraphic study of gastroesophageal reflux in volunteers aged 20 to 30 years, 50 to 60 years, and 70 to 80 years. SETTING: Gastroenterology and nuclear medicine laboratories of a tertiary care university hospital. PARTICIPANTS: Forty healthy adult volunteers recruited from the community, 20 aged 20 to 30 years, 10 aged 50 to 60 years, and 10 aged from 70 to 80 years. MEASUREMENTS: Each volunteer underwent conventional esophageal manometry and scintigraphic study of gastroesophageal reflux. Contractile wave amplitude, duration, velocity, and lower esophageal sphincter relaxation duration, as well as the presence of abnormal peristalsis, were correlated with the proportion of volunteers with gastroesophageal reflux and the number and duration of gastroesophageal reflux episodes. RESULTS: Quantitative manometric parameters showed no correlation with gastroesophageal reflux patterns. Abnormal peristalsis was found more frequently in the older volunteers. The number of gastroesophageal reflux episodes per volunteer was similar in the three age groups, but the duration of gastroesophageal reflux episodes was longer in the older volunteers. CONCLUSION: Healthy older persons have impaired clearance of refluxed materials associated with a high incidence of defective esophageal peristalsis. This may explain the higher severity of reflux esophagitis in older people.

Effect of successive swallows on oesophageal motility of normal volunteers, patients with Chagas' disease and patients with idiopathic achalasia.

Most frequently, ten swallows of a 5-mL bolus of water are performed during oesophageal manometry. Our hypothesis is that five swallows may produce the same results. We studied the oesophageal contraction parameters of 40 volunteers, 75 patients with Chagas' disease and 14 patients with idiopathic achalasia. Motility was recorded at 5, 10 and 15 cm above the lower oesophageal sphincter. The subjects performed ten swallows of a 5-mL bolus of water alternated with ten dry swallows with an interval of at least 30 s. We measured the amplitude, duration, peristaltic velocity, number of failed and number of simultaneous contractions of the initial five and final five dry and wet swallows. The comparison of dry and wet swallows showed the differences already known. The comparison of the parameters of the initial five swallows with those of the final five swallows showed no differences. Thus, when the initial five or the final five swallows were considered, there was no change in the conclusions reached by the comparison of patients and volunteers and of dry and wet swallows. We conclude that five swallows may be sufficient for the manometric examination of oesophageal parameters in Chagas' disease and idiopathic achalasia.

A scintigraphic study of oropharyngeal swallowing dynamics in Chagas' disease.

We studied oropharyngeal function in patients with Chagas' disease and oesophageal disease. Twenty-four patients with Chagas' disease, 17 of them with oesophageal disease, were submitted to scintigraphic oropharyngeal transit. A single swallow of a 10-mL bolus of water labelled with 40 MBq 99m Tc-phytate, followed by image acquisition at 20 images s-1 yielded time-activity curves in which oropharyngeal dynamics was evaluated. Thirteen normal volunteers were used as controls. Oral transit was longer for chagasics with oesophageal disease than for controls (P=0.004) or for chagasics with a normal oesophagus (P=0.028). Oesophageal filling rate, measured by the slope of the ascending aspect of the oesophageal radioactivity curve, was lower for chagasics with oesophageal disease than for controls (P=0.037). Also, maximum oesophageal filling rate was lower (P=0. 021) and occurred later (P=0.003) for chagasics with oesophageal disease than for controls. Pharyngeal clearance was positively correlated with oral transit (r=0.603, P=0.002). We conclude that chagasic oesophageal disease is associated with oral transit delay and a slower oesophageal filling rate.

The influence of ageing on oesophageal motility after ingestion of liquids with different viscosities.

OBJECTIVES: To verify the influence of ageing on oesophageal motility elicited by the swallowing of liquids with different viscosities. DESIGN: In order to study the effect of ageing on oesophageal function, healthy volunteers of three age groups were studied by manometric and scintigraphic methods during the swallowing of water and a high viscosity liquid. METHODS: Forty healthy volunteers (20 aged 20 to 30 years, 10 aged 50 to 60 years and 10 aged 70 to 80 years) were submitted to oesophageal manometry during 10 swallows of water, 10 swallows of sugar cane syrup and 10 "dry' swallows. Basal pressure of the upper oesophageal sphincter and the lower oesophageal sphincter, amplitude, duration and velocity of contraction and the duration of the lower oesophageal sphincter relaxation were measured. Morphology and peristalsis of contractile waves were studied. The same volunteers underwent scintigraphic oesophageal transit studies with the same boluses. Oesophageal clearance time and patterns of transit were studied. RESULTS: Water and sugar cane syrup did not differ as to quantitative contraction parameters, but sugar cane syrup led to a higher incidence of synchronous contractions. The three age groups had similar amplitude and velocity of contractile waves. The youngest group had shorter duration of contractile waves 10 and 5 cm above the lower oesophageal sphincter. The oldest group had markedly more frequent synchronous contractions and failures of contraction after both water and sugar cane syrup swallows. This was associated with a high incidence of scintigraphic transit abnormalities in this group. CONCLUSION: Abnormal oesophageal peristalsis and incomplete oesophageal emptying of both low and high viscosity liquids are significantly more frequent in healthy elderly persons than in younger persons.

Upper esophageal sphincter pressure in patients with Chagas' disease and primary achalasia.

The most important component of the upper esophageal sphincter (UES) is the cricopharyngeal muscle. During the measurement of sphincter pressure the catheter passed through the sphincter affects the pressure value. In Chagas' disease and primary achalasia there is an esophageal myenteric plexus denervation which may affect UES pressure. We measured the UES pressure of 115 patients with Chagas' disease, 28 patients with primary achalasia and 40 healthy volunteers. We used a round manometric catheter with continuous perfusion and the rapid pull-through method, performed in triplicate during apnea. Pressures were measured in four directions, and the direction with the highest pressure (anterior/posterior) and the average of the four directions were measured. The highest UES pressure in Chagas' disease patients without abnormalities upon radiologic esophageal examination (N = 63) was higher than in normal volunteers (142.8 +/- 47.4 mmHg vs 113.0 +/- 46.0 mmHg, mean +/- SD, P<0.05). There was no difference in UES pressure between patients with primary achalasia and patients with Chagas' disease and similar esophageal involvement and normal volunteers (P>0.05). There was no difference between patients with or without esophageal dilation. In the group of subjects less than 50 years of age the UES pressure of primary achalasia (N = 21) was lower than that of Chagas' disease patients with normal radiologic esophageal examination (N = 41), measured at the site with the highest pressure (109.3 +/- 31.5 mmHg vs 149.6 +/- 45.3 mmHg, P<0.01) and as the average of the four directions (64.2 +/- 17.1 mmHg vs 83.5 +/- 28.6 mmHg, P<0.05). We conclude that there is no difference in UES pressure between patients with Chagas' disease, primary achalasia and normal volunteers, except for patients with minor involvement by Chagas' disease, for whom the UES pressure at the site with the highest pressure was higher than the pressure of normal volunteers and patients with primary achalasia.

Effect of bolus volume and consistency on swallow-induced submental and infrahyoid electromyographic activity.

1. The effect of the volume of swallowed bolus and the form of barium delivered (liquid vs paste) on the timing of bolus transit, submental and infrahyoid electromyographic activity and hyoid movement during the oral and pharyngeal phase of swallowing was studied in 9 healthy volunteers. Using videofluoroscopy, we recorded concurrent submental electromyographic (EMG) activity from over the mylohyoid, geniohyoid and anterior digastric muscle complex (SM EMG) and from over the infrahyoid muscles, which consisted mainly of the thyrohyoids (IH EMG). 2. Bolus volume (2 to 20 ml) did not change the timing or the duration of SM EMG and IH EMG activity, transit of the bolus tail through the mouth and pharynx, or the onset and duration of hyoid movement, for either liquid or paste. 3. Although not volume dependent, the magnitude of SM EMG (2 ml, 79 +/- 9% vs 44 +/- 6%, mean +/- SEM) and IH EMG (2 ml, 73 +/- 15% vs 42 +/- 8%) was greater for barium paste than for liquid barium. 4. Large bolus volumes increased the duration of barium flow through the upper esophageal sphincter (UES), for both liquid (0.30 s, 0.40 s, 0.46 s, 0.50 s for 2, 5, 10, 20 ml) and paste (0.32 s, 0.43 s, 0.53 s, 0.61 s for 2, 5, 10, 20 ml).(ABSTRACT TRUNCATED AT 250 WORDS)

Gender effects on esophageal motility.

It has been suggested that there are no gender effects on esophageal motility. However, in previous studies the subjects did not perform multiple swallows and the quantitative features of esophageal contractions were not evaluated. In order to investigate the gender effects on esophageal motility we studied 40 healthy normal volunteers, 20 men aged 37 +/- 15 years (mean +/- SD), and 20 women aged 38 +/- 14 years. We used the manometric method with an eight-lumen polyvinyl catheter and continuous perfusion. The upper and lower esophageal sphincter pressures were measured by the rapid pull-through method. With the catheter positioned with one lumen opening in the lower esophageal sphincter, and the others at 5, 10 and 15 cm above the sphincter, ten swallows of a 5-ml water bolus alternated with ten dry swallows were performed. Statistical analysis was done by the Student t-test and Mann-Whitney test. Gender differences (P < 0.05) were observed for wet swallows in the duration of contractions 5 cm above the lower esophageal sphincter (men: 3.7 +/- 0.2 s, women: 4.5 +/- 0.3 s, mean +/- SEM), and in the velocity of contractions from 15 to 10 cm above the lower esophageal sphincter (men: 4.7 +/- 0.3 cm/s, women: 3.5 +/- 0.2 cm/s). There was no difference (P > 0.05) in sphincter pressure, duration and percentage of complete lower esophageal sphincter relaxation, amplitude of contractions, or in the number of failed, multipeaked and synchronous contractions. We conclude that gender may cause some differences in esophageal motility which, though of no clinical significance, should be taken into consideration when interpreting esophageal motility tests.

Gastric accommodation to distension and early gastric emptying in diabetics with neuropathy.

Gastric accommodation to distension and gastric emptying were assessed in diabetics with neuropathy and in control subjects. Gastric accommodation was measured by recording intragastric pressures during the air insufflation of the stomach and gastric emptying was measured by the double sample test meal after intragastric instillation of 500 ml of saline into the empty stomach. Maximal intragastric pressures during air insufflation were significantly higher in diabetics (N = 6) than in control subjects (N = 15), 16.2 +/- 4.5 vs 10.8 +/- 2.6. The liquid volumes in the stomach five minutes after the instillation of the test meal was significantly smaller in diabetics (N = 10) than in control subjects (N = 17), 208 +/- 90 vs 294 +/- 48 ml, but no differences in volume were detected thereafter. We conclude that diabetics with neuropathy have an impaired gastric accommodation to distension and, probably as a consequence, a rapid early phase of liquid meal gastric emptying.

Plasma gastrin and gastric acid responses to insulin hypoglycemia in Chagas' disease.

Plasma gastrin and gastric acid responses to intravenous injection of insulin (0.2 IU/kg) were measured in 8 patients with Chagas' disease, which is known to be associated with extensive reduction of the intramural neurons of the digestive tract, and in 6 control subjects. All subjects developed hunger, sweating and tachycardia, and exhibited less than 50 mg/dl venous blood glucose. Plasma gastrin responses in Chagas' disease patients (median: 3.60 nmol L-1 min-1; range: 1:12 to 10.60 nmol L-1 min-1) were significantly higher than for control subjects (median: 0.52 nmol L-1 min-1; range: 0.25 to 1.09 nmol L-1 min-1). Gastric acid output was significantly lower in Chagas' disease patients (median: 3.5 mmol/h; range: 2.1 to 13.6 mmol/h) than in controls (median: 30.3 mmol/h; range: 7.3 to 38.2 mmol/h). These data show that chagasic patients have abnormally high gastrin release and low gastric acid secretion in response to insulin, and thus indicate that loss of intrinsic innervation of the stomach does not abolish the gastrin response to insulin hypoglycemia.

Cholinergic innervation of the lower esophageal sphincter in Chagas' disease.

1. The effect of 12 micrograms/kg iv atropine on the lower esophageal sphincter (LES) pressure was studied by continuous perfusion manometry in 14 Chagasic patients, 9 controls, and 3 patients with achalasia, and the effect of 3 ml iv saline was studied in 7 Chagasic patients. 2. Resting LES pressure did not differ between Chagasic patients (11.5 +/- 4.1 mmHg) and controls (15.9 +/- 4.9 mmHg, P greater than 0.05). 3. Atropine caused a significant decrease in LES pressure in both Chagasics and controls, but the reduction in controls was significantly greater (56%) than in Chagasics (25%). 4. Saline did not change the LES pressure of Chagasics. Atropine caused a similar reduction of LES pressure in achalasia patients (49%) and in controls (56%). 5. These results suggest that the cholinergic excitatory nerves are impaired in Chagas' disease, but not in achalasia, where they were either normal or only minimally impaired.

Esophageal striated muscle contractions in patients with Chagas' disease and idiopathic achalasia.

Chagas' disease causes degeneration and reduction of the number of intrinsic neurons of the esophageal myenteric plexus, with consequent absent or partial lower esophageal sphincter relaxation and loss of peristalsis in the esophageal body. The impairment of esophageal motility is seen mainly in the distal smooth muscle region. There is no study about esophageal striated muscle contractions in the disease. In 81 patients with heartburn (44 with esophagitis) taken as controls, 51 patients with Chagas' disease (21 with esophageal dilatation) and 18 patients with idiopathic achalasia (11 with esophageal dilatation) we studied the amplitude, duration and area under the curve of esophageal proximal contractions. Using the manometric method and a continuous perfusion system we measured the esophageal striated muscle contractions 2 to 3 cm below the upper esophageal sphincter after swallows of a 5-ml bolus of water. There was no significant difference in striated muscle contractions between patients with heartburn and esophagitis and patients with heartburn without esophagitis. There was also no significant difference between patients with heartburn younger or older than 50 years or between men and women or in esophageal striated muscle contractions between patients with heartburn and Chagas' disease. The esophageal proximal amplitude of contractions was lower in patients with idiopathic achalasia than in patients with heartburn. In patients with Chagas' disease there was no significant difference between patients with esophageal dilatation and patients with normal esophageal diameter. Esophageal striated muscle contractions in patients with Chagas' disease have the same amplitude and duration as seen in patients with heartburn. Patients with idiopathic achalasia have a lower amplitude of contraction than patients with heartburn.

Effect of nifedipine on the lower esophageal sphincter pressure in chagasic patients.

The effect of 10 mg of sublingual nifedipine on the lower esophageal sphincter pressure (LESP) was studied by continuous perfusion manometry in 15 Chagasic patients and 9 controls. Resting LESP was lower in Chagasic patients (13.51 +/- 2.37 mmHg) than in controls (19.60 +/- 2.51 mmHg, P less than 0.02). Nifedipine caused a gradual decrease in the LESP in both Chagasics and controls. Maximal reductions occurred 50 minutes after the drug administration when LESP was reduced to 60% of the resting LESP in the control group and to 43% in the Chagasic group. These results indicate that the striking abnormalities found in the intramural plexuses of the alimentary canal of Chagasic patients do not affect the responsiveness of LESP to nifedipine, and that nifedipine may be useful to reduce LESP in Chagasic megaesophagus.

Effect of gastroesophageal reflux on hypertrophy of the base of the tongue.

The objective of this study was to determine a possible association between pharyngolaryngeal signs of gastroesophageal reflux (GER) and hypertrophy of the lymphoid follicles at the base of the tongue (HBT). For this purpose, 306 patients submitted to videolaryngoscopy were studied retrospectively and classified according to the presence and size of follicles on the base of the tongue. HBT was considered to be present when the follicles prevented the view of the vallecula. The patients were grouped according to the presence of videolaryngoscopic signs of GER and further subdivided according to the presence of esophageal, pharyngolaryngeal, and esophagopharyngolaryngeal symptoms, with an attempt made to relate these symptoms to the presence of HBT. HBT was detected in 62.4% (63/101) of the patients with signs of GER and in 29.3% (60/205) of patients with no signs of GER. When HBT incidence was studied according to the symptoms reported by the patient, the condition was found to be present in 57.2% (8/14) of patients with exclusively esophageal symptoms, in 63.6% (21/33) with esophagopharyngolaryngeal symptoms, and in 75% (15/20) with exclusively pharyngolaryngeal symptoms. We conclude therefore that HBT is associated with GER.