Margot A. van Herwaarden

Gastroesophageal Pressure Gradients in Gastroesophageal Reflux Disease: Relations With Hiatal Hernia, Body Mass Index, and Esophageal Acid Exposure

OBJECTIVES:The roles of intragastric pressure (IGP), intraesophageal pressure (IEP), gastroesophageal pressure gradient (GEPG), and body mass index (BMI) in the pathophysiology of gastroesophageal reflux disease (GERD) and hiatal hernia (HH) are only partly understood.METHODS:In total, 149 GERD patients underwent stationary esophageal manometry, 24-h pH-metry, and endoscopy.RESULTS:One hundred three patients had HH. Linear regression analysis showed that each kilogram per square meter of BMI caused a 0.047-kPa increase in inspiratory IGP (95% confidence interval [CI] 0.026–0.067) and a 0.031-kPa increase in inspiratory GEPG (95% CI 0.007–0.055). Each kilogram per square meter of BMI caused expiratory IGP to increase with 0.043 kPa (95% CI 0.025–0.060) and expiratory IEP with 0.052 kPa (95% CI 0.027–0.077). Each added year of age caused inspiratory IEP to decrease by 0.008 kPa (95% CI –0.015–−0.001) and inspiratory GEPG to increase by 0.008 kPa (95% CI 0.000–0.015). In binary logistic regression analysis, HH was predicted by inspiratory and expiratory IGP (odds ratio [OR] 2.93 and 2.62, respectively), inspiratory and expiratory GEPG (OR 3.19 and 2.68, respectively), and BMI (OR 1.72/5 kg/m2). In linear regression analysis, HH caused an average 5.09% increase in supine acid exposure (95% CI 0.96–9.22) and an average 3.46% increase in total acid exposure (95% CI 0.82–6.09). Each added year of age caused an average 0.10% increase in upright acid exposure and a 0.09% increase in total acid exposure (95% CI 0.00–0.20 and 0.00–0.18).CONCLUSIONS:BMI predicts IGP, inspiratory GEPG, and expiratory IEP. Age predicts inspiratory IEP and GEPG. Presence of HH is predicted by IGP, GEPG, and BMI. GEPG is not associated with acid exposure.

Are Manometric Parameters of the Upper Esophageal Sphincter and Pharynx Affected by Age and Gender

The effects of age and gender on the upper esophageal sphincter’s (UES) and pharyngeal manometric parameters were investigated in 84 healthy subjects (45 men, 39 women, mean age=44 years, range = 18–91). Manometric recordings were performed with solid-state circumferential transducers. Subjects older than 60 years (n = 23) showed a significant lower UES resting pressure. In addition, during water swallows they had a higher UES residual pressure, shorter UES relaxation interval and UES relaxation duration, and a decreased UES relaxation rate. Furthermore, pharyngeal contraction had significant higher amplitude and longer duration in subjects older than 60 years during water swallows. Some of these findings were also observed during cookie and pudding swallows. Women had a higher UES resting pressure and a longer UES relaxation interval than men. The observed changes with increasing age indicate loss of basal tone and decreased compliance of the UES. Increased pharyngeal contraction amplitude and its prolonged duration in the elderly might be compensatory to this. These physiologic effects of age and gender on UES and pharyngeal parameters should be taken into account during analysis of manometric studies.

Concomitant functional dyspepsia and irritable bowel syndrome decrease health-related quality of life in gastroesophageal reflux disease

Objective. Previous studies have reported an overlap between gastroesophageal reflux symptoms, functional dyspepsia (FD) and irritable bowel syndrome (IBS). The aim of this study was to investigate the prevalence of FD and IBS in gastroesophageal reflux disease (GERD) and the effect on health-related quality of life (HRQoL). Material and methods. FD and IBS prevalence and HRQoL were assessed by means of questionnaires in 215 referred and 48 non-referred (non-care-seeking) GERD patients, proven with 24-h pH-metry. HRQoL in 131 matched controls was used for comparison. Results. In this group of GERD patients 25% had FD (Dutch general population 13–14%), 35% had IBS (Dutch general population 0.6–6%) and 5% had both FD and IBS. Only 35% had neither FD nor IBS. Among referred GERD patients, the prevalence of FD and IBS was higher (p=0.002 versus non-referred). Compared with controls, GERD patients without FD/IBS had lower HRQoL scores on only one of the nine SF-36 subscales (p≤0.001); GERD+FD patients had lower scores on six subscales (p≤0.0005); GERD+IBS patients had lower scores on eight subscales (p <0.0005) and GERD+FD+IBS patients had lower scores on seven subscales (p≤0.001). Compared with patients with GERD only, GERD+FD patients had lower scores on five subscales (p≤0.001); GERD+IBS patients had lower scores on eight subscales (p <0.0005) and GERD+FD+IBS patients had lower scores on six subscales (p≤0.001). Conclusions. In patients with proven GERD, FD and IBS are more prevalent than in the general population. This prevalence is higher among care-seeking GERD patients. Only those GERD patients with concomitant FD/IBS have a much lower HRQoL. This suggests that in GERD, when properly treated, HRQoL is affected mainly by concomitant functional disorders and not by GERD itself.

The role of hiatus hernia in gastro-oesophageal reflux disease

This article gives an overview of the role of sliding hiatus hernia in gastro-oesophageal reflux disease (GORD). The crural diaphragm acts as an external sphincter of the anti-reflux barrier. Contractions of the crural diaphragm increase lower-oesophageal-sphincter (LOS) pressure during each inspiration and in situations of increased abdominal pressure, whereas these contractions are inhibited when gas and/or a bolus has to pass the gastro-oesophageal junction. A hiatus hernia is associated with GORD symptoms, increased oesophageal acid exposure, and oesophagitis and its severity. In patients with hiatus hernia, the incidence of reflux episodes is increased during periods with low LOS pressure, straining and swallowing. These findings underline the importance of the crural diaphragm, which, when surrounding the LOS, protects against gastro-oesophageal reflux.

Increased intragastric pressure gradients are involved in the occurrence of acid reflux in gastroesophageal reflux disease

Objective. Increased pressure gradients across the esophagogastric junction (▵EGJp) play a role in gastroesophageal flow during TLESR. The aim of this study was to further explore ▵EGJp in patients with gastroesophageal reflux disease (GERD) and controls. Material and methods. Twenty GERD patients were studied along with 20 control subjects. High-resolution manometry and pH recording were performed 1 h before and 2 h after a liquid meal (500 ml/300 kcal). ▵EGJp was calculated at the start of a TLESR and at 180, 60, and 10 s before TLESR. Results. ▵EGJp at the start of a TLESR and at 180, 60, and 10 s before TLESR was markedly increased in GERD patients compared with that in control subjects (9.9 mmHg and 7.5 mmHg, respectively; p<0.05). Whilst intragastric pressure gradients in GERD patients were increased compared with those in controls (4.6 mmHg and 2.5 mmHg, respectively; p<0.01), intraesophageal pressure gradients were similar in both groups. Furthermore, in controls, first- and second-hour postprandial intragastric pressures were decreased compared with in fasting periods (1.9±0.4 mmHg and 2.1±0.4 mmHg versus 3.5±0.4 mmHg; p<0.05), while this was not observed in GERD patients. Conclusions. In GERD patients, ▵EGJp is greater than that in controls both before and during TLESR. This phenomenon is caused by increased intragastric pressure and might contribute to increased rates of acid reflux during TLESR in GERD patients.

Functional dyspepsia and irritable bowel syndrome in patients with achalasia and its association with non-cardiac chest pain and a decreased health-related quality of life

Objective. In patients with achalasia, little is known about symptoms of the gastrointestinal tract other than the esophagus. The purpose of this study was to determine the prevalence of two functional disorders, functional dyspepsia (FD) and irritable bowel syndrome (IBS), in a group of treated achalasia patients and to assess the additional impact of these disorders on health-related quality of life (HRQoL). Material and methods. Questionnaires assessing the Rome II criteria for FD and IBS together with the Eckardt clinical symptom score and RAND-36 were sent to 171 treated achalasia patients. Results. Of these patients, 76.6% returned their questionnaires. In the group of achalasia patients, 23% fulfilled the criteria for FD (Dutch general population 13–14%), and 21% fulfilled the criteria for IBS (Dutch general population 1–6%). The prevalence of frequent chest pain (at least weekly) was higher in patients with FD and/or IBS than in those without these symptoms (54.2% versus 28.2%; p=0.004). Female patients with achalasia and with frequent chest pain showed a higher probability of fulfilling the FD and/or IBS criteria (adjusted OR 2.90 (1.18–7.14) and 3.35 (1.4–8.1), respectively; both with p <0.05). Patients fulfilling the FD and/or IBS criteria scored a lower HRQoL on the RAND-36 subscales – pain, social functioning, and vitality – as compared with patients not fulfilling these criteria (p <0.006). Conclusions. Symptoms of FD and IBS in patients with treated achalasia are common and have a negative impact on HRQoL. Therefore, this has to be included in the standard evaluation of achalasia patients. The association with chest pain suggests a mutual underlying mechanism.

Relationship between the mechanism of gastro-oesophageal reflux and oesophageal acid exposure in patients with reflux disease

Abstract  This study investigated the relationship between the oesophageal acid exposure time and the underlying manometric motor events in patients with gastro‐oesophageal reflux disease (GORD). In 31 patients, 3‐hour oesophageal motility and pH were measured after a test meal. Ten patients underwent 24‐hour ambulatory manometry and pH recording. In the 3‐hour postprandial study, of 367 reflux episodes 79% was associated with a transient lower oesophageal sphincter relaxation (TLOSR), 14% with absent basal lower oesophageal sphincter (LOS) pressure and the remaining 7% with other mechanisms, representing 62, 28 and 10% of the acid exposure time, respectively. Acid reflux duration per motor mechanism was longer for absent basal LOS pressure than for TLOSR (189 ± 23 s and 41 ± 5 s, respectively, P < 0.001). In the 24‐hour ambulatory study, the contribution of TLOSRs to reflux frequency vs acid exposure time were 65 vs 54% interprandially and 74 vs 53% after the meal. During the night, absence of basal LOS pressure accounted for 36% of reflux events representing 71% of acid exposure time. In conclusion, the duration of oesophageal acid exposure following a TLOSR is shorter than reflux during absent basal LOS pressure. TLOSRs are, the major contributor to oesophageal acid exposure during the day. At night, however, reflux during absent basal LOS pressure is the major contributor to acid exposure.