Makoto Kotoyori

Relationship between postprandial esophageal acid exposure and meal volume and fat content

The effect of meal volume and fat content on gastroesophageal reflux was investigated in 20 asymptomatic healthy subjects. In each subject, intraesophageal pH monitoring was performed during a 3-hr postprandial period (PP) in the same position (supine or upright) on two successive days. On day 1, 500-ml low- and high-fat meals were ingested and, on day 2, an 800-ml low-fat meal was ingested. The acid exposure time was assessed as the percentage of time with a pH<4.0. The acid exposure time in subjects in the upright position was significantly longer in the 800-ml group than in the 500-ml group for the entire PP (2.7 ± 1.5%; mean ±se, 0.7 ± 0.4%;P<0.05). Of subjects in the supine position, the high-fat group showed significantly longer acid exposure time than the low-fat group both for the entire PP (7.6 ± 3.0%, 0.7 ± 0.5%; p<0.05) and for the second hour (P<0.05). We have demonstrated that differences in the meal volume and fat content influence gastroesophageal reflux in healthy asymptomatic subjects and that this influence varies with the position.

Transient Lower Esophageal Sphincter Relaxations (TLESRs) Are the Major Mechanism of Gastroesophageal Reflux but Are Not the Cause of Reflux Disease

In healthy subjects, the rate of acid reflux during transient lower esophageal sphincter relaxations (TLESRs) is more frequent at the proximal margin of the LES. In this study, we investigated the hypothesis that the rate of acid reflux at the proximal margin of LES during TLESRs is similar in reflux disease to that in healthy subjects. Concurrent esophageal manometry and pH monitoring were performed in the sitting position for 3 hr after a standard meal in 10 patients with reflux disease and 10 age-matched healthy controls. The rate of TLESRs in patients with reflux disease (5.0/hr [3.3–6.7]; median [interquartile range]) was similar to that of controls (4.5/hr [3.7–5.7]). The incidence of acid reflux 7 cm above the LES during TLESRs in patients (48.1% [27.2–71.4%]) was significantly higher than that in controls (10.9% [0.0–18.8%]) but there was no difference 2 cm above the LES (75.0 [69.2–87.5] vs. 74.3 [55.5–90.0%]). The rate of TLESRs and the incidence of acid reflux during TLESRs are not increased in reflux disease. These findings, therefore, indicate that reflux disease is not a disorder of TLESRs and relates more to the proximal extent of the refluxate.

Relationship between severity of reflux esophagitis according to the Los Angeles classification and esophageal motility

Purpose. We investigated the relationship between the severity of reflux esophagitis (RE) according to the Los Angeles (LA) classification and esophageal motility. Methods. We examined 28 healthy subjects (HS) and 48 RE patients (grade A of the LA classification, 16 patients; grade B, 16 patients; grade C or D, 16 patients). Esophageal manometry was performed by the intraluminal microtransducer method. Resting lower esophageal sphincter (LES) pressure was assessed by the rapid pull-through method. Esophageal contraction after ten repeated 5-ml water swallowings separated by 30-s intervals was measured at 3, 8, 13, and 18 cm above the LES. Results. The resting LES pressure and the amplitude of esophageal contraction 3 cm above the LES in the grades C + D group were significantly lower than those in the HS group. The amplitude of esophageal contraction 3 cm above the LES in the grade B group was significantly lower than those in the grade A group and the HS group. The frequency of failed peristalsis in the grades C + D group was significantly higher than that in the HS group and the grade A and grade B groups. Conclusions. The present findings suggested that the severity of RE according to the LA classification would be likely to mainly reflect esophageal volume clearance.

Defective triggering of secondary peristalsis in patients with non‐erosive reflux disease

Background and Aim:  The pathophysiology of non‐erosive reflux disease is poorly understood. Triggering of secondary peristalsis is impaired in patients with erosive esophagitis but data in patients with non‐erosive reflux disease are lacking. The aim of this study was to evaluate the difference in esophageal motility between patients with non‐erosive reflux disease and healthy subjects.

Esophageal motility in Japanese patients with Barrett's esophagus

BackgroundThe prevalence of gastroesophageal reflux disease has been increasing in Japan as it has in Western countries, but Barrett’s esophagus (BE) is less common in Japan than in Western countries. The aim of this study, therefore, was to investigate esophageal motility and clinical characteristics in Japanese patients with BE.MethodsTen patients with BE were compared with ten patients with mild reflux esophagitis (RE), ten patients with severe RE, and ten healthy subjects of comparable age and sex. The prevalence of Helicobacter pylori was investigated in the patients with BE. The intraluminal microtransducer method was used to test for esophageal motility. Basal lower esophageal sphincter (LES) pressure was assessed by the rapid pull-through method. The esophageal wave after ten repeated 5-ml water swallowings at 30-s intervals was measured at 3, 8, 13, and 18 cm above the LES.ResultsThe basal LES pressure, the amplitude of the esophageal wave at 3 and 8 cm above the LES, and the frequency of primary peristalsis in the severe RE group and BE group were significantly lower than the values in the healthy subjects and the mild RE group. The amplitude of the esophageal wave 13 cm above the LES in the BE group was significantly lower than that in the healthy subjects and the mild RE group. There was no difference between the severe RE group and the BE group in the basal LES pressure and the amplitude of the esophageal wave. The frequency of primary peristalsis in the BE group, however, was significantly lower than that in the severe RE group. Nine of the ten patients with BE were H. pylori-negative.ConclusionsOur conclusions are that esophageal dysmotility in Japanese patients with BE represents an advanced stage of severe RE, and that most Japanese patients with BE are H. pylori-negative.

Effect of body position on lower esophageal sphincter pressure.

Abstract: This study examined the effect of body position on lower esophageal sphincter (LES) pressure. In 36 healthy subjects and 31 patients with reflux esophagitis, LES and intragastric pressures were measured with subjects in the supine and sitting positions by the intraluminal microtransducer method. LES pressure was significantly lower in the sitting position than in the supine position in both healthy subjects and patients with reflux esophagitis. Intragastric pressure was significantly higher in the sitting position than in the supine position in both healthy subjects and patients with reflux esophagitis, but this increase was less marked than the decrease in LES pressure in the sitting position. The overlap of LES pressure values between healthy subjects and patients with reflux esophagitis was lower in the sitting position than in the supine position. We conclude that the measurement of LES pressure in the sitting position reflects LES function more accurately.

The appearance of rosette-like esophageal folds (“esophageal rosette”) in the lower esophagus after a deep inspiration is a characteristic endoscopic finding of primary achalasia

BackgroundIn healthy subjects who inspire deeply the lower esophagus usually opens, and the esophageal palisade vessels (EPVs) become visible. However, in patients with achalasia, the full extent of the EPVs does not become visible and, in addition, rosette-like esophageal folds appear in the lower esophagus. The aim of this study was to investigate whether or not these changes at the lower esophagus are characteristic findings of achalasia.MethodsA total of 34 patients with achalasia and no esophageal dilatation following deep inspiration were compared with 34 sex- and age-matched control subjects. Following a deep inspiration, the lower esophagus of all study cohorts was evaluated on (1) whether or not the full extent of the EPVs was visible, (2) whether or not rosette-like esophageal folds appeared in the lower esophagus, and (3) whether or not there were any gastric lesions.ResultsOne patient had secondary achalasia, and the remaining 33 patients had primary achalasia. In the control subjects, the full extent of the EPVs was clearly visible after a deep inspiration, and no esophageal folds appeared in the lower esophagus. In contrast, in the achalasia patients, EPVs were not observed in all patients after a deep inspiration, and rosette-like esophageal folds appeared in 33 of the 34 patients.ConclusionAfter a deep inspiration, the non-visibility of the EPVs and the appearance of rosette-like esophageal folds at the lower esophagus, which we have called “esophageal rosette”, are characteristic endoscopic findings of primary achalasia.

Association between reflux esophagitis and/or hiatus hernia and gastric mucosal atrophy level in Japan

Background and Aims:  The mechanisms involved in reflux esophagitis (RE) are mainly esophageal motor dysfunction and abnormal esophageal acid exposure. Therefore the extent of gastric mucosal atrophy (GMA), which is related to gastric acid secretion, is an important factor in the development of RE. The aim of this study was to evaluate the prevalence of RE and hiatus hernia (HH) according to level of GMA.

The minimum pressure of the lower esophageal sphincter, determined by the rapid pull-through method, is an index of severe reflux esophagitis.

BackgroundBecause of the wide overlap between the groups, patients with reflux esophagitis (RE) cannot be distinguished from healthy subjects by basal lower esophageal sphincter (LES) pressure. The LES has radial asymmetry, with maximum pressure on the left side. It has been noted that one directional LES pressure, determined using the rapid pull-through (RPT) method, in most patients with severe RE is very low, compared with that in healthy subjects. The aim of this study was to examine whether or not the minimum value of four directional LES pressures could become an index of RE by the RPT method.MethodsThirty patients with severe RE (grade C or D of the Los Angeles classification) were compared with 30 patients with mild RE (grade A or B) and 30 healthy subjects of comparable age and sex. LES pressure was measured by the RPT method, with the subject in the supine position. The catheter was withdrawn manually at a rate of 10 mm/s during suspended respiration at the end-expiratory phase after 5-min rest accommodation. LES pressure, with reference to the intragastric fundic pressure, was recorded by three consecutive RPTs, and 12 LES pressures were obtained for each subject.ResultsMinimum LES pressure, mean LES pressure, and maximum LES pressure were calculated from the 12 LES pressures. Wide overlaps in the mean and maximum LES pressures between healthy subjects and patients with mild or severe RE occurred; however, the overlap of minimum LES pressure between these groups was clearly less than that for the mean and maximum LES pressures. If it is accepted that more than the tenth percentile of the minimum LES pressure in healthy subjects is the cutoff value for healthy subjects, the sensitivity was 93.3% and the specificity for severe RE was 93.3%.ConclusionsThis finding would suggest that the minimum LES pressure determined by the RPT method is an index of severe RE.

Changes in endoscopic findings of primary aortoduodenal fistula

Primary aortoenteric fistula is very rare and a highly lethal entity. It is very important not to miss a few chances to diagnose it endoscopically. We report our experience of a case of primary aortoduodenal fistula. An 80‐year‐old woman complained of repeated hematemesis, bloody bowel discharge, and hemorrhagic shock. An abdominal aortic aneurysm was detected by an abdominal angiography. Duodenoscopy was performed 3 and 5 days after hematemesis, showing two different patterns of endoscopic findings. Three days after hematemesis, an undermining ulcer with a dark red clot at its bottom was detected in the third part of the duodenum. Five days after hematemesis, the base of the ulcer was covered with yellowish matter on the red clot. Six days after hematemesis, aortoduodenal fistula was confirmed in the third part of the duodenum at surgery. An ulcer with yellowish matter as well as with a red clot in the third and fourth parts of the duodenum by endoscopy might be indicative of aortoduodenal fistula.