Hubert J. Stein

Composition and concentration of bile acid reflux into the esophagus of patients with gastroesophageal reflux disease

BACKGROUND Reflux of duodenal contents into the esophagus of patients with gastroesophageal reflux disease has been suggested by pH and bilirubin monitoring but is rarely directly measured. A portable device has been developed and was used to collect and quantitate material refluxed into the esophagus under ambulatory conditions during a prolonged time period. The objective of this study was to use this device to quantitate the composition and concentration of bile acids refluxed into the esophagus of patients with gastroesophageal reflux disease. METHODS Esophageal aspiration was performed on 43 normal subjects and 37 patients with reflux disease during a 17-hour period. Aspiration was performed through a modified 16F Salem sump tube, positioned 5 cm above the lower esophageal sphincter and connected to a portable, battery powered pump that aspirated continuously at 100 mm Hg pressure. Validation studies showed that minimal amounts of saliva and swallowed liquids were aspirated and that gastric pressure was not altered. Postprandial, upright, and supine collections were performed. Total bile acids were assayed by a standard enzymatic assay; specific conjugated bile acids were analyzed by high-performance liquid chromatography. RESULTS There was no difference in the total aspiration volume between normal volunteers and patients with gastroesophageal reflux disease, although patients tended to have a higher volume in the supine and postprandial periods. Bile acids could be detected in 58% of normal subjects and 86% of patients (p < 0.003). The mean concentration of bile salt exposure (micromole per liter) was higher in patients during the postprandial and supine periods. The mean bile acid reflux rate (micromole per hour) during all three aspiration periods was significantly higher in patients. On a molar basis the composition of the bile acids was 60% glycocholic acid, 16% glycodeoxycholic acid, and 15% glycochenodeoxycholic acid. Taurocholic, taurodeoxycholic, taurochenodeoxycholic, and glycolithocholic acid constituted the remaining 10%. CONCLUSIONS Patients with reflux disease have an increased concentration of bile acids in their esophageal aspirates. Most of the exposure occurs during the postprandial and supine periods. A variety of bile acids were detected, most of which were in their glycine conjugated form.

Role of esophageal body function in gastroesophageal reflux disease: implications for surgical management

BACKGROUND Effective esophageal peristalsis is a major determinant of esophageal clearance function. The relation of esophageal body function with a mechanically defective lower esophageal sphincter and the development of esophageal mucosal injury in patients with gastroesophageal reflux disease is unclear. STUDY DESIGN We analyzed the relations among the manometrically determined esophageal clearance function, lower esophageal sphincter dysfunction, esophageal acid exposure, and the presence and severity of esophageal mucosal injury in patients with gastroesophageal reflux disease. Normal values for the manometric assessment of esophageal clearance function were established in 50 normal volunteers and subsequently applied to 160 symptomatic patients with increased esophageal exposure to gastric juice and various grades of esophageal mucosal injury (no minimal surgery, esophagitis, stricture, and Barretts esophagus). RESULTS Defective clearance function was present in 47.5% of the patients; a defective lower esophageal sphincter was documented in 63.1%. Compromised esophageal clearance function was significantly more common in patients with a defective lower esophageal sphincter than in those with normal sphincter function (55% versus 33.8%). Esophageal acid exposure time and the prevalence and severity of esophageal mucosal injury were highest in patients with a defective sphincter and compromised clearance function. CONCLUSIONS These data show that esophageal motor function deteriorates with increasing severity of mucosal injury. This appears to be due to persistent reflux of gastric juice across a mechanically defective lower esophageal sphincter. This may influence the choice and outcome of antireflux surgery. Surgical correction of a mechanically defective sphincter before the loss of esophageal body function is advocated.

Foreign body entrapment in the esophagus of healthy subjects—A manometric and scintigraphic study

Foreign body entrapment and mucosal injury caused by oral medications are increasingly reported to occur in the upper esophagus in apparently normal subjects. We performed esophageal manometry in 40 normal volunteers to determine whether a unique motility pattern in the upper third of the esophagus predisposes to entrapment of foreign bodies at this site; 18 normal volunteers also had transit scintigraphy of a gelatine capsule filled with a radionuclide. The esophageal body was divided into five consecutive segments starting proximally, with each segment corresponding to 20% of the total length. Amplitude, slope, and velocity of the esophageal contraction were markedly decreased in the second segment compared with the other segments. Entrapment and dissolution of a gelatine capsule occurred in 39% of volunteers in the proximal eosphagus correlating to the second segment, i.e., the segment with the lowest amplitude, slope, and velocity of esophageal contractions. The observation that wet swallows have greater amplitudes (P<0.01) and steeper slopes (P<0.05) than dry swallows explains why the occurrence of pill entrapment was reduced when taken with sufficient water. However, even with a water chaser of 120 mL, pill entrapment occurred at the second segment of the esophagus in 1 of 18 volunteers. The observed motility pattern in the proximal eosphagus provides a better explanation for the entrapment of foreign bodies at this site than compression of the esophagus by the left main stem bronchus, aortic arch, or left atrium as suggested by other investigators.

Diverticula of the esophagus: current therapy

Osophagusdivertikel werden in Pulsionsdivertikel und Traktionsdivertikel unterteilt. Den Hauptanteil der Pulsionsdivertikel bilden die Zenker-Divertikel oder Hypopharynxdivertikel. Symptomatische Zenkerdivertikel stellen eine absolute Operationsindikation dar. Bestandteil der Operation ist die Myotomie des oberen Osophagussphinkters mit oder ohne begleitende Divertikelabtragung. Als Alternative zur konventionellen, offenen Operation hat sich bei groseren Divertikeln auch die transorale Schwellenspaltung etabliert. Fur die Behandlung des epiphrenischen Divertikels (Pulsionsdivertikel) spielt die Therapie der zugrunde liegenden Motilitatsstorung die entscheidende Rolle fur das operative Vorgehen. Typische Traktionsdivertikel sind die parabronchialen Divertikel. Eine Operationsindikation ist hier nur in Ausnahmefallen gegeben. Unabhangig von ihrer Lokalisation und Genese liegt die Erfolgsrate der chirurgischen Therapie der Osophagusdivertikel bei adaquater Indikationsstellung bei uber 90%.

An Alkaline Stomach Is Common to Barrett's Esophagus and Gastric Carcinoma

The interdigestive pH environment of the stomach fluctuates from 1 to 2. A rise in pH to above 3 occurs either from decreased acid secretion, as in achlorhydria, or iatrogenic acid reduction (anti-secretory drugs: H2-blockers, proton pump inhibitors), neutralization of acid from swallowed food, or reflux of alkaline pancreatic and biliary secretions from the duodenum.

Therapy of noncardiac chest pain: Is there a role for surgery?

Esophageal distention, motor abnormalities, or exposure of the esophageal mucosa to acidic gastric juice can cause chest pain indistinguishable from that of myocardial ischemia in patients with and without coronary artery disease. In these situations the exact cause of the symptom needs to be established prior to any surgical therapy. An antireflux procedure relieves chest pain in patients with increased esophageal acid exposure more reliably than medical therapy. The best results are obtained in patients in whom a direct correlation of the symptom with reflux episodes can be documented on 24-hour esophageal pH monitoring. Ambulatory 24-hour esophageal motility monitoring shows that esophageal motor disorders are a less frequent cause of noncardiac chest pain than suggested by standard manometry or provocation tests. Furthermore, chest pain episodes in patients with esophageal motor abnormalities are not associated with single contractions of excessively high amplitude or duration. Rather, the symptom appears to be triggered by an increased frequency of simultaneous, multipeaked, and repetitive motor activity. In appropriately selected patients with chest pain and dysphagia secondary to an esophageal motor abnormality, a long esophageal myotomy eliminates the ability of the esophagus to produce these contractions, reduces or eliminates dysphagia, and decreases the frequency and severity of chest pain episodes.

Alkalischer gastroösophagealer Reflux — Quantifizierung und klinische Relevanz

Die gastroosophageale Refluxkrankheit ist eine der haufigsten Erkrankungen des oberen Gastrointestinaltrakts in der westlichen Welt mit einer geschatzten Pravalenz von 0,36%. Bei etwa der Halfte der Patienten, bei denen die Refluxerkrankung durch 24-Stunden Osophagus pH-Metrie objektiviert wird, findet sich in der Endoskopie eine Osophagitis, peptische Osophagus-stenose, ein osophageales Ulcus, oder ein Barrett Osophagus. Ein inkompetenter unterer Osophagussphincter, gestorte peristaltische oder Clearance-Aktivitat des tubularen Osophagus, ein Defekt der protektiven Schleimhautmechanismen, und die Zusammensetzung des Refluxes sind alle einzeln oder in Kombination fur die Entstehung dieser Komplikationen der Refluxerkrankung verantwortlich gemacht worden [1,2].

Symptoms and Functional Foregut Abnormalities in Patients with Complications of Gastroesophageal Reflux Disease

The factors predisposing to the development of Barrett’s esophagus in patients with gastroesophageal reflux disease are unclear. Assessing symptoms, esophageal acid and alkaline exposure (pH 7), lower esophageal sphincter resistance, esophageal clearance function, the gastric secretory state, gastric emptying, and duodenogastric reflux, we compared 15 patients with Barrett’s esophagus to 24 patients with esophagitis, and 22 normal subjects. Compared to patients with esophagitis, patients with Barrett’s esophagus had less heartburn and regurgitation, but an increased frequency and duration of reflux episodes, and increased percentage of time at pH 7 on ambulatory 24-hour esophageal pH monitoring. This was associated with decreased lower esophageal sphincter resistance, a decreased contraction amplitude in the distal esophagus, an increased frequency of nonperistaltic contractions and contractions <30 mmHg on 24-h ambulatory esophageal motility monitoring, increased basal and stimulated gastric acid secretion, and a higher prevalence of excessive duodenogastric reflux. These data show that despite having less symptoms, patients with Barrett’s esophagus have a markedly increased esophageal acid and alkaline exposure compared to patients with esophagitis. This appears to be due to persistent reflux of concentrated gastric acid and duodenal contents across a mechanically defective lower esophageal sphincter, in combination with inefficient esophageal clearance function.