Timed barium esophagram in achalasia types.

Relationships of timed barium esophagram (TBE) findings to achalasia types defined by high-resolution manometry (HRM) have not been elucidated. Therefore, we correlated preoperative TBE and HRM measurements in achalasia types and related these to patient symptoms and prior treatments. From 2006 to 2013, 248 achalasia patients underwent TBE and HRM before Heller myotomy. TBE height and width were recorded at 1 and 5 minutes; HRM measured lower esophageal sphincter mean basal pressure, integrated relaxation pressure (IRP), and mean esophageal body contraction amplitude. Achalasia was classified into types I (25%), II (65%), and III (9.7%). TBE height at 5 minutes was higher for I (median 8 cm; interquartile range 6-12) and II (8 cm; 8-11) than for III (1 cm; 0-7). TBE width at 5 minutes was widest (3 cm; 2-4), narrower in II (2 cm; 2-3), and narrowest in I (1 cm; 0-2), P < 0.001. Volume remaining at 1 and 5 minutes was lower in III (1 m(2) ; 0-16) than I (42 m(2) ; 17-106) and II (39 m(2) ; 15-60), highlighting poorer emptying of I and II. Increasing TBE width correlated with deteriorating morphology and function from III to II to I. Symptoms poorly correlated with TBE and HRM. Prior treatment was associated with less regurgitation, faster emptying, and lower IRP. Although TBE and HRM are correlated in many respects, the wide range of their measurements observed in this study reveals a spectrum of morphology and dysfunction in achalasia that is best characterized by the combination of these studies.

Impedance monitoring shows that posture and a meal influence gastro-oesophageal reflux composition and frequency.

Impedance monitoring determines reflux composition as liquid and/or gas, and we assess with impedance the effect of posture and a meal on reflux composition. Twenty-nine gastro-oesophageal reflux disease (GORD) patients and 10 normal volunteers underwent simultaneous impedance, manometry and pH for three 40-min periods, each 20-min upright, 10-min left side and 10-min right side. One period was fasting, and two postprandial. We found that reflux event composition on the right side was liquid-only near exclusively (93%). In contrast, 85% of reflux on the left side and 74% upright was gas-only or liquid and gas (P < 0.001). More gas-only reflux occurred fasting (80%) than postprandial (P < 0.01). Reflux composition was similar in the study groups and two postprandial periods (P > 0.25). After confirming gas reflux suppression on the right side, a pilot study assessed gastric anatomy as a cause. Five achalasia patients had fluid injected into the stomach at endoscopy, and the EG junction was submerged below liquid-only on the right side. We conclude that reflux is nearly always liquid-only on the right side where the EG junction may be below fluid. Reflux fasting is usually gas-only. Different posture and fasting times may (i) explain variations in acid exposure during pH monitoring and (ii) promote or prevent GORD symptoms.

Esophageal motility in the assessment of esophageal function.

Esophageal manometry assesses lower esophageal sphincter (LES) pressure and its relaxation. In addition, it detects the ability of the esophageal body to initiate a peristaltic contraction and the contraction's amplitude in response to a water bolus. The study is indicated in patients with symptoms suggestive of an esophageal motor disorder and to assist in the diagnosis of some miscellaneous disorders. The most common disorders diagnosed by esophageal manometry are the primary motility disorders, such as achalasia. Manometry is indicated in the subset of patients with gastroesophageal reflux disease (GERD) who are being considered for antireflux surgery or have symptoms after antireflux surgery.

New techniques in measuring nonacidic esophageal reflux.

New techniques in esophageal monitoring are allowing for better differentiation in the role of different gastric refluxates in esophageal mucosal damage and patient symptoms. The Bilitec 2001 (Synectics, Stockholm, Sweden) is a portable spectrophotometer that measures bilirubin as a surrogate marker for bile reflux and multichannel intraluminal impedance (MII) (Sandhill Scientific Inc, Highlands Ranch, CO) is a new technique allowing measurement of esophageal volume refluxate. Both techniques assess the role of nonacidic esophageal reflux. Despite their novel approach in assessing nonacid reflux, both methods have limitations. Future studies in this area, however, will prove beneficial in identifying their role in diagnosis and management of patients with suspected nonacid reflux disease.

Benign structural lesions of the esophagus.

This article discusses a wide spectrum of intrinsic benign structural lesions of the esophagus. Additionally discussed are extrinsic benign structural lesions that may cause esophageal symptoms. Because any congenital anomaly or disease of a structure that normally impinges on the esophagus, or is adjacent to it, may distort the esophagus, we review disorders from several different organ systems.

Importance of additional reflux events during esophageal acid clearing.

Decreased swallow frequency and low-amplitude or nonconducted primary peristaltic contractions are reported to prolong acid clearing in gastroesophageal reflux disease (GERD) patients. The aim of this study is to investigate which of these, or other factors, have a dominant role in long-duration pH reflux events (pHRE). Simultaneous manometry and pH monitoring was performed for 40 min before and after (beginning 40 min postprandial) a test meal. We arbitrarily chose 180 sec to divide pHREs into long or short pHREs. Twenty GERD patients with and without esophagitis were studied. Esophagitis patients had threefold more long pHREs than patients without esophagitis. In most (56%) long pHREs, additional reflux events during acid clearing was the only finding. Only 11% of long pHREs had either a decreased swallow rate (3%) or decreased peristaltic contraction amplitude (8%), as the only finding contributing to poor acid clearing. However, 18% of long pHREs had one of these peristaltic dysfunctions in combination with additional reflux events prolonging acid clearing. Only 15% of long pHREs had no apparent reason for poor acid clearing. In interpreting 24-hr pH monitoring, one should not assume prolonged acid clearing is due to peristaltic dysfunction; instead, it is often due to additional reflux events.

Origin of atypical reflux symptoms. A case study showing the importance of reflux composition and posture.

In summary we evaluated a 39-year-old man two years after partial esophagectomy and gastroesophageal anastomosis. He had developed recurrent Barrett's esophagus and atypical reflux symptoms. We found free reflux and no antireflux barrier at the hiatus or the esophagogastric anastomosis. Three different reflux techniques performed simultaneously demonstrated that the composition of refluxant varied with posture, explaining the atypical nature of the symptoms. In the left recumbent posture, the refluxate was comprised of acidified liquid and gaseous gastric contents with the patient complaining of heartburn and chest pain. In the right recumbent posture the refluxate was composed of only nonacidic gas, and the patient complained of chest pain without heartburn. We propose that multiple reflux tests performed simultaneously in the setting where a patient experiences his atypical symptoms may help clarify their origin. Furthermore, this case illustrates how posture may dramatically influence refluxant composition.

Upright refluxers without esophagitis differentiated from bipositional refluxers with esophagitis by simultaneous manometry and pH monitoring conducted in two postures before and after a meal.

OBJECTIVE: To determine whether two dissimilar groups characterized by 24-h esophageal pH monitoring would have individual reflux events that occur under the same or different circumstances when challenged by a meal and monitored in different postures. These groups consisted of upright refluxers without esophagitis (n = 10) versus biopositional refluxers with esophagitis (n = 8). METHODS: Our evaluation consisted of a questionnaire completed prior to simultaneous manometry and pH monitoring. This monitoring was conducted over a 120-min period that incorporated the upright and recumbent postures both before and after a meal. Three of our four criteria for reflux were independent of a classic pH event. RESULTS: From the questionnaire, it was apparent that dyspeptic symptoms almost always occurred in the upright refluxers. In addition, provocation for their heartburn had atypical characteristics regarding posture, and their degree of regurgitation was intensified by the postprandial state. During dual monitoring, the upright posture and the meal provoked an increase in frequency of reflux in the upright refluxers, as opposed to only recumbency in the bipositional refluxers. Moreover, reflux events in the upright refluxers usually were associated with Valsalva maneuvers and were recognized as symptoms, two features that were less true in the bipositional refluxers. A similar percentage of reflux events occurred over a low basal lower esophageal sphincter pressure and after a lower esophageal sphincter relaxation, in both groups. CONCLUSION: The two groups manifested distinctively different reflux characteristics, presumably due to dissimilar mechanisms.

Hiccups associated with reflux esophagitis.

A 67-yr-old man with protracted hiccups, as well as reflux esophagitis and a stricture, was found to have heartburn and water brash only during episodes of hiccups. Intraesophageal pH monitoring showed acid gastroesophageal reflux increased during these episodes and decreased with cessation of hiccups. After all attempts failed to relieve his hiccups, a Nissen fundoplication relieved heartburn, healed the esophagitis, and stopped excessive reflux of acid gastric juice, even though the hiccups persisted. These observations showed that reflux provoked by prolonged hiccups could either have adversely affected preexistent reflux esophagitis and stricture or conceivably could have caused these complications.

Scintigraphy in gastroesophageal reflux disease: a comparison to endoscopy, LESp, and 24-h pH score, as well as to simultaneous pH monitoring.

We compared scintigraphy to other reflux tests in 45 symptomatic patients. Sensitivity of 24-h pH score was 82%, endoscopy 64%, and LESp 33%. Scintigraphy was insensitive (36%), although 50% of patients with esophagitis had a positive test. Specificity and positive predictive value were good (all greater than or equal to 88%) in discerning patients with an abnormal 24-h pH score and esophagitis. We suggest scintigraphy as the first diagnostic test to confirm frequent reflux events (REs) and normal clearance in the subgroup of patients with severe endoscopic esophagitis, and manometry and 24-h pH monitoring when scintigraphy is negative. We also compared scintigraphy to simultaneously performed pH monitoring in detecting individual postprandial REs and their clearance. The two methods agreed in only 25% of total reflux events. Scintigraphy was superior at detection of reflux of buffered gastric contents and detection of additional REs during acid clearing intervals, whereas only the pH probe detected REs after gastric emptying. We conclude that scintigraphy has a limited role as a diagnostic test in gastroesophageal reflux disease, and much potential as a research tool, especially in combination with the pH probe.

Esophageal hematoma. Four new cases, a review, and proposed etiology.

We report four cases of esophageal hematoma and emphasize that endoscopically and radiographically it may simulate a neoplasm. After a review of 26 cases, we found that patients with normal hemostasis often had esophageal hematoma occur distally after vomiting. Most of these hematomas probably originated from a Mallory-Weiss laceration. In contrast, patients with impaired hemostasis had esophageal hematoma occur proximally or at multiple sites. Many of these hematomas occurred spontaneously, without a history of vomiting, and probably resulted from impaired coagulation. Regardless of etiology most esophageal hematomas were associated with a benign course.

Simultaneous esophageal pH monitoring and scintigraphy during the postprandial period in patients with severe reflux esophagitis.

To compare reflux events detected by intraesophageal pH monitoring with that of scintigraphy, we simultaneously performed both techniques along with esophageal manometry in nine patients with severe reflux esophagitis. Two hundred eighteen reflux events were detected in the recumbent posture after a meal during a 40-min interval. Both techniques simultaneously detected only 23% of all reflux events. Scintigraphy alone detected 61% of all reflux events as opposed to 16% for pH monitoring. Of those reflux events diagnosed only by scintigraphy, more occurred while the intraesophageal pH was less than 4 (ie, during an acid-clearing interval) than while the intraesophageal pH was greater than 4 (ie, when intragastric contents were neutralized by the meal). Most reflux events occurred during periods of stable, but low LES pressure. While reflux events diagnosed by scintigraphy significantly decreased during the second of two 20-min postprandial intervals, those by pH monitoring tended to increase. That simultaneous scintigraphy and pH monitoring agreed on less than 1/3 of all reflux events not only underscores the fact that both techniques measured different physical components of the esophageal refluxate (ie, volume vs acid concentration, respectively), but also were influenced by different physiologic events such as the ingestion of a meal, gastric emptying, and esophageal acid clearance.

Gastric emptying of solid food in patients with gastroesophageal reflux.

While delayed gastric emptying of solid food has been reported in patients with symptoms of gastroesophageal reflux, the study populations were not defined by 24-h intraesophageal pH monitoring. Moreover, the influence that the gastric emptying rate may have on patterns of reflux during the day or night, as well as on esophagitis, is not known. In this study, we compared the gastric emptying rate of solid food (in vivo intracellular labeled chicken liver) observed in asymptomatic control volunteers (n = 15) with that of symptomatic patients with an abnormal 24-h pH record who had either the presence (n = 22) or absence (n = 11) of endoscopic esophagitis. We found no significant difference in the gastric emptying rate between the asymptomatic control volunteers and the symptomatic patients with and without esophagitis. Moreover, there was no significant correlation between the gastric emptying rate and the degree of daytime or nighttime distal esophageal acid exposure found during 24-h intraesophageal pH monitoring. Only 6% of the symptomatic patients had a gastric emptying rate that exceeded the mean value plus 2 SD of that found in the asymptomatic control volunteers. We believe these support a de-emphasis of the role that delayed gastric emptying of solid food may play in the pathophysiology of gastroesophageal reflux in most patients.

Prolonged clearance is the primary abnormal reflux parameter in patients with progressive systemic sclerosis and esophagitis.

The purpose of this study is to determine if frequent reflux events from an incompetent LES or poor clearance from decreased peristalsis is the predominant abnormality in PSS patients with severe reflux esophagitis. Seven patients with both classic manometric findings of PSS and endoscopic findings of esophageal ulcerations and/or Barrett's esophagus were compared to nine patients with similar endoscopic findings but with no evidence of a connective tissue disorder. All patients underwent simultaneous intraesophageal pH monitoring and scintigraphy for a total of 40 min after a radiolabeled meal. Four of the PSS patients and all the non-PSS patients had simultaneous manometry. We found that PSS patients had significantly fewer reflux events (P less than 0.01), but the reflux events had significantly longer duration (P less than 0.01) compared to patients with similar severity of esophagitis and no connective tissue disease. We conclude that decreased smooth muscle peristalsis appears to be the primary contributor to acid exposure and esophageal injury in PSS.

Sucralfate used as adjunctive therapy in patients with severe erosive peptic esophagitis resulting from gastroesophageal reflux.

A total of 36 patients with grade 2 or greater erosive esophagitis and an abnormal 24-h pH monitor study, were treated in a randomized, double-blind fashion to assess the efficacy of sucralfate suspension as adjunctive therapy to cimetidine for severe esophagitis secondary to gastroesophageal reflux. Treatment consisted of cimetidine, 300 mg qid and either sucralfate suspension (1 g/10 ml) or an identical placebo suspension, 10 ml after meals and 20 ml hs. Patients were treated for 12 wk unless endoscopic healing occurred earlier. Initial evaluation and monthly follow-up consisted of symptom monitoring, endoscopic evaluation and pre- and post-therapy esophageal manometry, Bernstein test, and 24-h pH monitoring. The combination of cimetidine and sucralfate suspension was superior to cimetidine alone in improving daytime heartburn symptoms (p less than 0.05) but not nighttime heartburn, dysphagia, or regurgitation. Sucralfate plus cimetidine improved the overall endoscopic outcome of esophagitis more than cimetidine alone (p less than 0.05). More patients exhibited endoscopic healing in the adjunctive sucralfate group than in the cimetidine-only group. Endoscopic healing, however, was not statistically different between groups. We conclude that sucralfate used as adjunctive therapy to cimetidine resulted in improvement of some of the symptoms of reflux, and probably increases the likelihood of complete healing of esophagitis, compared with cimetidine alone.

Adult duodenal web associated with reflux esophagitis.

Duodenal webs are the third leading cause of alimentary tract obstruction in infants. They rarely present in adulthood, with 47 cases reported in the literature. These seems to be an association with peptic ulcer disease. They most frequently occur in the vicinity of the ampulla of Vater. A case of adult duodenal web associated with peptic ulcer disease and reflux esophagitis is reported. This appears to be the second reported case associated with significant reflux esophagitis. Etiology, presentation, diagnosis, and management are discussed.

Cycling, a manometric phenomenon due to repetitive episodes of gastroesophageal reflux and clearance.

We studied intraesophageal pressure changes in patients with symptoms of gastroesophageal reflux and an abnormal 24-hr pH monitoring record (N = 52). Our method was simultaneous esophageal manometry and pH monitoring. We observed a three-component esophageal manometric sequence (EMS). When this sequence recurred over and over, we termed this phenomenon "cycling." We found cycling in 35% of the patients (18/52). Those with cycling had lower basal LES pressures, more acid exposure, and an increased incidence of endoscopic esophagitis. That cycling resulted from repeated reflux events and their esophageal clearance was documented by scintigraphy during simultaneous manometry and pH monitoring (N = 7 patients). Cycling was found on the routine esophageal manometry record of 25% of symptomatic patients (N = 112) with an abnormal 24-hr pH score. In conclusion, cycling represents an esophageal manometric phenomenon due to repetitive reflux events. Its recognition during esophageal manometry may denote a severe reflux diathesis.

The effect of posture on gastroesophageal reflux event frequency and composition during fasting.

OBJECTIVE: To examine the influence of three postures (upright and left and right recumbent) on gastroesophageal reflux event (RE) frequency and composition and a possible mechanism for the observations. METHODS: A) Forty fasting patients with (E+, n = 20) and without (E-, n =20) esophagitis were studied. Simultaneous manometry and pH monitoring were conducted in the left and right recumbent (10 min each) as well as the upright posture (20 min). RE were classified by the pH probe and/or the manometry catheter as acid or gas RE. B) In 23 patients referred for UGI series, radiographs were taken in the left and right recumbent and upright postures after barium and Fizzies. RESULTS: A) Upright RE were similar in frequency in E+ and E- patients (2.6 +/- 0.5 vs 3.05 +/- 0.6). However, E+ patients had more recumbent RE (16.3 +/- 3 vs 0.65 +/- 0.2, p = 0.0001) than E- patients; moreover, the left recumbent posture had more recumbent RE than the right (10.9 +/- 2 vs 5.3 +/- 1, p < 0.02). Moving from recumbent to the upright posture had an opposite effect on RE in the two groups; RE decreased sixfold in E+ patients (16.3 +/- 3 vs 2.6 +/- 0.5, p = 0.0001) but increased fourfold in E- patients (0.65 +/- 0.2 vs 3.05 +/- 0.6, p = 0.0001). In examining RE composition in the E+ patients, RE were twofold more likely to be gas in the left recumbent posture (7.6 +/- 2 vs 3.3 +/- 1, p < 0.1); in direct contrast, RE were eightfold more likely to be acid in the right recumbent posture (4.7 +/- 1 vs 0.6 +/- 0.5, p = 0.0001). As expected from this observation, acid exposure was greater in the right than left posture (52 +/- 8 vs 15 +/- 6%, p < 0.0001). Although RE were too infrequent in E- patients to reach statistical significance, the effect of posture on the composition of the few RE that did occur mirrored that of the E+ patients. B) In 17/23 (74%) radiographs in the right recumbent posture, the EG junction was submerged in a barium pool below the air-barium interface in the stomach. In contrast, this occurred in 0/23 patients in the left recumbent and 1/23 patients in the upright postures because the EG junction was in the air above the barium pool. CONCLUSION: Posture has an influence on RE frequency and composition while fasting, and the latter is likely due to whether the EG junction is submerged below liquid gastric contents or in the air above the liquid gastric contents.

Suture granuloma masquerading as malignancy of the biliary tract.

Eighteen years after having a duodenal leiomyosarcoma resected, a patient presented with weight loss, pruritus, and abdominal pain. ERCP was consistent with a cholangiocarcinoma with proximal hepatic duct stricture and nonfilling of the cystic duct. CAT scan revealed no extrinsic masses compressing the gallbladder or biliary tract. At surgical exploration, the patient was found to have a suture granuloma with surrounding fibrosis within the common bile duct. There was no evidence of malignancy.

Alcohol sclerosis for polycystic liver disease and obstructive jaundice: use of a nasobiliary catheter.

We report the use of a nasobiliary catheter in the management of a 55-yr-old female with autosomal dominant polycystic kidney disease who developed obstructive jaundice from a hepatic cyst. The patient presented with a 2-wk history of fatigue, jaundice, nausea, vomiting, and abdominal pain. Physical examination was remarkable for tender hepatomegaly. Computerized tomography revealed multiple hepatic cysts and dilated intrahepatic biliary radicles. Endoscopic stent placement failed to relieve the obstruction. Computerized tomography guided percutaneous aspiration of the obstructing hepatic cyst was successful with the aid of a nasobiliary cholangiogram allowing visualization of the biliary tree and identification of the obstructing hepatic cyst. However, the cyst rapidly accumulated fluid, and the obstruction recurred within 1 wk of simple aspiration. Relief of symptoms was maintained only after alcohol sclerosis of the obstructing hepatic cyst. Review of the literature shows that alcohol sclerotherapy is a safe and effective nonsurgical means of treating symptomatic hepatic cysts.