David A. Katzka

Globus sensation is associated with hypertensive upper esophageal sphincter but not with gastroesophageal reflux

Globus sensation (globus) is best described asa constant feeling of a lump or fullness in the throat.Although the etiology of globus remains unclear, it hasbeen attributed to a hypertensive upper esophageal sphincter (UES) resting pressure and togastroesophageal reflux (GER). The aim of this studywas, therefore, to determine if significant associationsexisted among globus, UES resting pressure, and GER. We reviewed the records of all patients who hadstationary esophageal manometry over a 21 -year intervalwith specific attention to symptoms of globus, UESpressures, and ambulatory pH studies. Patients with hypotensive UES (<30 mm Hg) wereexcluded. Chi square (χ2) test was usedto determine significant associations. Six hundred fiftypatients had normal UES resting pressures and 101patients had hypertensive UES (>118 mm Hg). Seventeen ofthe 650 (3%) (16 women/1 man; mean age: 48, range 32-81years) with normal UES described globus. Conversely, 28of the 101 (28%) (15 women/13 men; mean age: 43, range 23- 61 years) patients withhypertensive UES described globus. There was asignificant association between hypertonicity of the UESand globus (χ2 = 93.42, P < 0.0001).In patients with normal UES, globus occurred predominantly infemales (χ2 = 6.33, P < 0.01).Twenty-three (16 women/7 men; mean age: 43, range 23-60years) of the 45 patients with globus had priorambulatory pH studies. Six of 23 (26%) had GER. Compared to an age-,sex-, and UES-pressure-matched group of 23 patients (16women/7 men; mean age: 44, range 22-75 years) withoutglobus, nine (39%) had GER, thus showing no significant association of globus with GER (P = 0.35).There also was no significant association of GER withnormal UES or with hypertensive UES in these patients.In conclusion, there is a significant association between hypertensive UES and globus. The datasuggest two possible etiologies: female patients withnormal UES pressure potentially having increasedafferent sensation and a group with equal sexdistribution but abnormally elevated UES resting pressure.This study does not support GER as an etiology ofglobus.

Effect of different recumbent positions on postprandial gastroesophageal reflux in normal subjects

Abstract OBJECTIVE: Gastroesophageal reflux (GER) is increased in the right compared to the left recumbent position. Esophageal acid exposure is related to the acidity at the cardia, but the effect of body position on the acidity at the cardia has not yet been investigated. We aimed to investigate the mechanisms underlying increased esophageal acid exposure in the right recumbent position. METHODS: On 2 separate days a 4-h combined esophageal and lower esophageal sphincter (LES) manometry and pH recording of esophagus, gastric cardia, and corpus was performed in the right and left recumbent position after a high fat meal in 10 healthy subjects. RESULTS: In the right recumbent position a prolonged esophageal acid exposure (7.0% vs 2.0%, p CONCLUSIONS: Increased esophageal acid exposure in the right recumbent position relative to the left recumbent position is the result of a higher incidence of GER episodes caused by an increased incidence of TLESRs and higher percentage of TLESRs associated with GER. Body position does not affect the acidity at the gastric cardia and corpus.

Use of botulinum toxin as a diagnostic/ therapeutic trial to help clarify an indication for definitive therapy in patients with achalasia

Use of botulinum toxin as a diagnostic/ therapeutic trial to help clarify an indication for definitive therapy in patients with achalasia

Effective gastric acid suppression after oral administration of enteric-coated omeprazole granules.

Omeprazole is inactivated by exposure to gastricacid and is formulated as a gelatin capsule containingenteric-coated granules that release the drug inalkaline medium. In clinical situations where patients are unable to take the capsule orally, theoptimum means of administration is uncertain. Elevennormal volunteers were given omeprazole 20 mg every dayfor one week before breakfast in random order as either a 20-mg capsule with water or freeenteric-coated granules with either 8 oz of orangejuice, 8 oz of water with 2 Alka-Seltzer antacid tablets(aspirin free), or 1 teaspoon of apple sauce. On day 7of each regimen, an 8-hr intragastric pH study wasperformed following omeprazole 20 mg and standardbreakfast. The median percentage of time of gastric acidpH > 4 after an omeprazole capsule was 68.5 (25-100); after granules with orange juice 59 (43-100);after granules in Alka-Seltzer solution 63 (31-100), andafter granules in apple sauce 65 (30-99), with nosignificant differences (ANOVA). The time for the gastric pH to reach <4′ after havingbeen above was also similar for all four regimens(ANOVA). Omeprazole granules administered orally in avariety of ways achieve gastric acid suppression aseffectively as the intact capsule.

Barrett's esophagus: continuing questions and controversy

was a proponent of the upward migration of the junctional epithelium of the esophagus and stomach. A major breakthrough in the understanding of the pathogenesis of Barrett’s esophagus occurred with the landmark publication by Bremner et al.4 in 1970. They reported on their ability to re-epithelialize a denuded segment of the squamous mucosa with columnar mucus-secreting cells in dogs with surgically created persistent gastroesophageal reflux and induced gastric hypersecretion.4 Bremner et al.4 used the term “creeping substitution” to suggest a migration of columnar epithelium upward to replace squamous epithelium destroyed by persistent gastroesophageal reflux. It is now accepted that Barrett’s esophagus is an acquired condition and is one of the complications of chronic gastroesophageal reflux. It is also much more likely to be present in patients with other complications of severe GERD (that is, esophageal ulcer or stricture). In fact the common association between Barrett’s epithelium and distal esophageal ulcers has led to the use of the term “Barrett’s ulcer” to describe this condition. Most authorities in this field now agree that a true Barrett’s epithelium consists of a “specialized columnar epithelium” that resembles intestinal mucosa with a villiform surface containing both columnar and goblet cells and with underlying crypts reminiscent of the lining of the small intestine (that is, intestinal metaplasia). This contrasts with the gastric type epithelium originally described by Barrett. Thus even in its primary definition, the question of what truly constitutes a Barrett’s esophagus has been controversial and often confusing. Although much has been learned about Barrett’s esophagus since 1950, many unanswered questions remain. General agreement exists about its pathogenesis and the association between this condition and adenocarcinoma of the esophagus. Some aspects of the continuing questions and controversy are summarized below.

Effect of Cyclic Hormonal Changes During Normal Menstrual Cycle on Esophageal Motility

Pregnancy has an inhibitory effect on motilityof the gastrointestinal tract most likely related toincreased levels of circulating female sex hormones.Similar fluctuations of hormones occur during the normal menstrual cycle, but to a much lesserdegree. We studied the effect of these sequentialhormonal changes on esophageal motility and acidexposure by performing an ambulatory esophagealmotility/pH study (AEM/pH) during the follicular (days 2-4)and luteal phases [days 4-8 after the luteinizinghormone (LH) surge] of the menstrual cycle. Ten normalmenstruating women aged 21-39 years, (mean age 31) were studied with a Konigsberg catheterpositioned such that the pH probe was 5 cm above andpressure transducers 7 and 15 cm above the LES.Ovulation was predicted by LH detection kit, and serumprogesterone levels were obtained in the luteal phase. Eachstudy was performed for 16 hr and included meal,upright, and supine periods. Peristaltic contractionsincreased during the meal periods and decreased during supine periods. Simultaneous and isolatedcontractions increased during supine periods anddecreased with meals. Number and amplitude of distalesophageal contractions did not differ significantlybetween follicular and luteal phase during meal,upright and supine periods. Median percentage of time ofdistal esophageal pH < 4 and median acid clearancewere similar between the two phases. In conclusion, esophageal motility and acid exposure, asmeasured by AEM/pH, are not affected by the hormonalchanges that occur during the menstrual cycle.