Lawrence F. Johnson

Patterns of gastroesophageal reflux in health and disease.

Twenty-four-hour pH monitoring of the distal esophagus quantitates gastroesophageal reflux in a near physiologic setting by measuring the frequency and duration of acid exposure to the esophageal mucosa. Fifteen asymptomatic volunteers were studied with 24-hour pH and esophageal manometry. The normal cardia was more competent supine than in the upright position. Physiologic reflux was unaffected by age, rarely occurred during slumber, and was the rule after alimentation. One hundred symptomatic patients with an abnormal 24-hour pH record (2 S.D. above the mean of controls) could be divided into three patterns of pathological reflux: those who refluxed only in the upright position (9), only in the supine position (37), and in both positions (54). Upright differed from supine refluxers by excessive aerophagia causing reflux episodes by repetitive belching. Compared to controls, they had excessive post-prandial reflux, lower DES pressure, and less DES exposed to the positive pressure of the abdomen. Supine differed from upright refluxers by having a higher incidence of esophagitis and an inability to clear the esophagus of acid after a supine reflux episode. Compared to controls, they had only a lower DES pressure. Combined refluxers had a higher incidence of esophagatis than supine refluxers. Stricture (15%) was seen only in this group. They were similar to supine refluxers in their inability to clear a supine reflux episode. Compared to controls, they had a lower DES pressure and less DES exposed to the positive pressure of the abdomen. Forty of the 100 patients had an antireflux procedure (4 upright, 8 supine, 28 combined). The most severe postoperative flatus and abdominal distention was seen in the upright refluxers. It is concluded that minimal reflux is physiological. Patients with pathological reflux all have lower DES pressure. Patients with upright reflux have less of their DES exposed to the positive pressure environment of the abdomen. Patients with supine reflux have an inability to clear the esophagus of reflux acid and are prone to develop esophagitis. Patients with both upright and supine reflux have the most severe disease and are at risk in developing strictures. In patients with only upright reflux, aerophagia and delayed gastric emptying may be an important etiological factor.

Evaluation of Current Operations for the Prevention of Gastroesophageal Reflux

A prospective randomized study was done on 45 patients to evaluate the effectiveness of the Hill, Nissen or Belsey anti-reflux procedure. All patients had symptoms of GE reflux unresponsive to medical therapy, a + standard acid reflux test (SART), and esophagitis (38/45) or + Burnstein test (7/45). Esophageal symptomatic, radiographic, manometric and pH (SART and 24-hr monitoring) evaluation was done pre- and 154 days (ave.) postsurgery. All procedures improved the symptoms of pyrosis. The best improvement was seen after the Nissen repair. All procedures increased the distal esophageal sphincter (DES) pressures over preoperative levels. The Nissen and Belsey increased it more than the Hill. Sphincter length and dynamics remained unchanged. The Nissen procedure placed more of the manometric sphincter below the respiratory inversion point in the positive pressure environment of the abdomen. The esophageal length was increased by the Nissen and Hill repairs. This was thought to account for the high incidence of temporary postsurgery dysphagia following the Nissen and Hill repairs and the lower incidence following the Belsey repair. Reflux was most effectively prevented by the Nissen repair, as shown by the SART and the 24-hr esophageal pH monitoring, a sensitive measurement of frequency and duration of reflux. The average length of hospital stay was 20 days for Belsey and 12 days for both Nissen and Hill procedure. Postsurgery complications were more common following the thoracic than the abdominal approach. Ability to vomit postrepair was greatest with the Hill and least with the Belsey and Nissen repair. All procedures temporarily increased amount of flatus. It is concluded that the Nissen repair best controls reflux and its symptoms by providing the greatest increase in DES pressure and placing more of the sphincter in the positive abdominal environment. This is accomplished with the lowest morbidity but at the expense of temporary postoperative dysphagia and a 50% chance of being unable to vomit after the repair.

Alkaline gastroesophageal reflux

Abstract Twenty-four hour monitoring provides a continuous record of the pH of the lower esophagus in a near physiologic setting. The upper level of physiologic reflux was determined from the percentage of time and the number of episodes that the pH was less than 4 or more than 7 and the mean duration of each episode in fifteen asymptomatic subjects. One hundred patients with symptoms of gastroesophageal reflux were divided into four groups on the basis of twenty-four hour pH monitoring: those with abnormal acid but normal alkaline reflux, termed acid refluxers (51 patients); those with both abnormal acid and alkaline reflux, termed acid-alkaline refluxers (25); those with normal acid and abnormal alkaline reflux, termed alkaline refluxers (6); and those with both normal acid and alkaline reflux, termed nonrefluxers (18). Nonrefluxers had a similar incidence of heartburn, regurgitation, and dysphagia as acid and acid-alkaline refluxers, proving the inaccuracy of symptoms for detecting reflux. Alkaline refluxers had a lesser incidence of heartburn but a greater incidence of regurgitation, and four alkaline reflux patients presented with severe pulmonary disease secondary to aspiration. Similar incidence and degree of esophagitis was seen in acid, acid-alkaline, and alkaline refluxers. All three groups of symptomatic refluxers had a mean distal esophageal sphincter pressure significantly lower than that of the control asymptomatic subjects. There was no difference in the distal esophageal sphincter pressure between controls and symptomatic nonrefluxers. Nine of the patients with acid-alkaline reflux and one of the patients with alkaline reflux underwent an antireflux procedure and were restudied three months postoperatively. All ten patients had a 24 hour pH acid score within normal limits, but two had an abnormal 24 hour pH alkaline score. In both patients, reflux was demonstrated after placing an acid load in the stomach. It is concluded that symptomatic gastroesophageal reflux in patients with an intact gastrointestinal tract is a mixture of both acid and alkaline secretions, with one or both abnormal due to different degrees of acid production and pyloric regurgitation. Patients with alkaline reflux may develop serious complications of reflux in the absence of typical symptoms of heartburn. Twenty-four hour pH monitoring of the esophagus is useful in the identification of these patients and in evaluating the ability of an antireflux procedure to control both abnormal acid and alkaline reflux.

The Evaluation of Objective Measurements of Gastroesophageal Reflux and Their Contribution to Patient Management

Even when symptoms are typical, there is good reason to use objective measurements of gastroesophageal reflux since there are diseases which often masquerade as this problem. The symptoms complex is indistinguishable from that of gastroesophageal reflux, but the etiology is not a result of regurgitation of sour gastric contents into the esophagus.

Interaction of lower esophageal sphincter pressure and length of sphincter in the abdomen as determinants of gastroesophageal competence

This study defines the components of distal esophageal sphincter function which predict gastroesophageal competence and examines the mechanisms by which three antireflux procedures restore competence to the cardia. In a prospective study, the reflux status of 391 patients was determined by 24 hour pH monitoring. Distal esophageal sphincter pressure and length of sphincter exposed to the positive pressure environment of the abdomen was measured by esophageal infusion manometry. Similar pre- and postoperative studies were performed in 45 patients who were randomized to three equal groups for the Hill, Belsey and Nissen antireflux procedures. Two hundred sixty-seven (68 percent) of the 391 patients had a positive 24 hour pH test. Competence of the cardia was related to pressure in the distal esophageal sphincter, to the length of sphincter in the abdomen and to an interaction between both (all p less than 0.05). Thus, competence of the cardia requires an adequate pressure and length of sphincter in the abdomen. In determining competence, the pressure and length effects are not additive, but have an interacting relationship. Sphincter pressure and abdominal length are independently corrected by surgery. Restoration of competence requires increases in both. The gastric fundic wrap best augments distal esophageal sphincter pressure by application of normal functioning smooth muscle to the lower esophagus. Sphincter dynamics are normal after a wrap as the gastric fundus and distal esophageal sphincter share the functions of synchronous contractions and simultaneous relaxation on deglutition.

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.

Gastrointestinal blood loss associated with running a marathon

Gastrointestinal bleeding has been observed in long-distance runners. We prospectively studied participants of the Eighth Annual Marine Corps Marathon to determine the incidence of gastrointestinal blood loss associated with long-distance running. Of 600 runners contacted, 125 (21%) returned a questionnaire as well as pre- and postmarathon stool specimens. Stool specimens converted from Hemoccult negative to positive in 29/125 (23%) of the participants, indicating that running the marathon was associated with gastrointestinal blood loss (P<0.001). The incidence of this conversion (negative to positive) was significant for both males (N=68,P<0.001) and females (N=57,P<0.05). Gastrointestinal bleeding appeared to be independent of age, race time, abdominal symptoms, and the recent ingestion of aspirin, vitamin C, or steak.

Evaluation of the nissen antireflux procedure by esophageal manometry and twenty-four hour pH monitoring

Fifteen normal volunteers without symptoms of gastroesophageal reflux and sixteen patients with symptoms of gastroesophageal reflux unresponsive to medical management and having endoscopic esophagitis had esophageal manometry and twenty-four hour pH monitoring of the distal esophagus. The symptomatic patients underwent a Nissen antireflux procedure and were restudied at four months. After surgery, patients had less reflux, a higher sphincteric pressure, and an equal amount of sphincter within the abdomen as did asymptomatic control subjects.

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 <4 (ie, during an acid-clearing interval) than while the intraesophageal pH was >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.

Esophageal emptying in achalasia quantitated by a radioisotope technique.

Delayed esophageal emptying of a radiolabeled meal distinguished symptomatic achalasia patients from asymptomatic controls. Esophageal emptying of the isotope meal significantly improved in ten achalasia patients after pneumatic dilation, and in one patient after surgical myotomy. The emptying curve in some patients after treatment simulated that of control subjects. Quantitation of esophageal emptying by a radiolabeled meal is a physiologic test that may be useful in evaluating results of therapy for achalasia.