Philippe Pouderoux

Esophageal pH-impedance monitoring and symptom analysis in GERD: a study in patients off and on therapy.

INTRODUCTION:Combined esophageal pH-impedance monitoring allows detection of nearly all gastroesophageal reflux episodes, acid as well as nonacid. However, the role of nonacid reflux in the pathogenesis of symptoms is poorly known. The aim of this study was to evaluate the diagnostic yield of this technique in patients with suspected reflux symptoms while on or off PPI therapy.PATIENTS AND METHODS:The recordings of 150 patients recruited at seven academic centers with symptoms possibly related to gastroesophageal reflux were analyzed. Reflux events were detected visually using impedance (Sandhill, CO) and then characterized by pHmetry as acid or nonacid reflux. The temporal relationship between symptoms and reflux episodes was analyzed: a symptom association probability (SAP) ≥95% was considered indicative of a positive association.RESULTS:One hundred fifty patients were included, 102 women (mean age 52 ± 14 yr, range 16–84). Among the 79 patients off PPI, five did not report any symptom during the recording period. A positive SAP was found in 41 of the 74 symptomatic patients (55.4%), including acid reflux in 23 (31.1%), nonacid reflux in three (4.1%), and acid and nonacid in 15 (20.3%). In the group of patients on PPI (N = 71, 46 women, mean age 51 ± 15 yr), 11 were asymptomatic during the study, SAP was positive in 22 of the 60 symptomatic patients (36.7%), including acid reflux in three (5.0%), nonacid reflux in 10 (16.7%), and acid and nonacid in nine (15.0%). The symptoms most frequently associated with nonacid reflux were regurgitation and cough.CONCLUSION:Adding impedance to pH monitoring improves the diagnostic yield and allows better symptom analysis than pHmetry alone, mainly in patients on PPI therapy. The impact of this improved diagnostic value on gastroesophageal reflux disease management remains to be investigated by outcome studies.

Normal values and day‐to‐day variability of 24‐h ambulatory oesophageal impedance‐pH monitoring in a Belgian–French cohort of healthy subjects

Background : Impedance‐pH monitoring is the most sensitive method for detection and characterization of gastro‐oesophageal reflux episodes. Normal values from European subjects are lacking.

Deglutitive tongue force modulation by volition, volume, and viscosity in humans

BACKGROUND/AIMS Deglutitive tongue biomechanics are complex, involving bolus containment, loading, and propulsion. This study aimed to quantify the modulation of deglutitive pulsive and clearing tongue forces in varied swallowing conditions. METHODS Oropharyngeal pressure and force were recorded using sensing bulbs and strain-gauge manometry in 8 volunteers during swallows of varied volume and viscosity. Volitional modulation was explored with forceful and attenuated swallows. RESULTS Temporal analysis confirmed that bulb recordings corresponded to tongue pulsive force, and the strain-gauge recordings measured tongue clearing pressure. Volition was the most potent modifier of both tongue pulsive force and clearing pressure with values showing a fourfold increase from attenuated to forceful swallows. Bolus viscosity also induced an increase of tongue pulsive force and clearing pressure by the oral tongue. Volitional control as well as adaptation to viscosity was greatest on the anterior and middle part of the oral tongue. There was no force adaptation with increased bolus volume. CONCLUSIONS Tongue pulsive force and clearing pressure during swallow showed substantial modulation for bolus viscosity that can be reproduced by volitional control. The anterior two thirds of the tongue showed both greater forces and greater modulation than did the tongue base.

Timing, propagation, coordination, and effect of esophageal shortening during peristalsis

BACKGROUND & AIMS Minimal information exists on the characteristics and effect of esophageal shortening during peristalsis in the human esophagus. The aim of this study was to quantify esophageal shortening during peristalsis and determine the relationship between shortening, circular muscle contraction, and generation of propulsive force. METHODS Ten volunteers had three metal clips endoscopically affixed at the squamocolumnar junction and 4.5 and 9 cm proximal to it, defining proximal and distal segments in the lower esophagus. A strain gauge manometer was positioned within the proximal segment along with a traction force sensing balloon. Axial clip movement was assessed with concurrent manometry and videofluoroscopy during swallowing to examine the determinants of propulsive force. RESULTS Esophageal shortening was coordinated with circular muscle contraction such that each propagated distally as overlapping segments of contraction at a velocity of about 2.5 cm/s. Propulsive force within the proximal segment occurred after shortening, during the circular muscle contraction, with the magnitude of propulsive force correlated with the degree of distal shortening. CONCLUSIONS (1) Both circular and longitudinal esophageal muscle contraction occur as propagating segments during peristalsis, with the longitudinal muscle contraction leading the circular muscle. (2) Propulsive force occurs during proximal circular and distal longitudinal muscle contraction.

Attenuation of esophageal shortening during peristalsis with hiatus hernia

BACKGROUND & AIMS Minimal quantitative information exists on esophageal shortening during peristalsis in the human esophagus. The aim of this study was to ascertain the effect of hiatus hernia on longitudinal muscle-mediated peristaltic esophageal shortening. METHODS Seven volunteers and 11 patients with hiatal hernia had metal clips endoscopically affixed at the squamocolumnar junction and 3-5 cm proximal to it (n = 11). Location of the lower esophageal sphincter and axial clip movement were assessed using concurrent manometry and videofluoroscopy during barium swallows in a supine and upright posture with and without abdominal compression. RESULTS Three subject groups were defined by the proximity of the squamocolumnar junction to the diaphragmatic hiatus: group 1, < or = 0 cm; group 2, between 0 and 2 cm; and group 3, > or = 2 cm. Peristaltic esophageal shortening was progressively diminished, re-elongation progressively prolonged, and the degree of contraction observed in the distal esophageal segment reduced with progressive degree of hiatus hernia. There was minimal mobility of the squamocolumnar junction relative to the hiatus with posture or abdominal compression. CONCLUSIONS Longitudinal muscle contraction during peristalsis normally causes transient elevation of the squamocolumnar junction above the diaphragm. Esophageal shortening during primary peristalsis is reduced with increasing degree of hiatus hernia, suggesting that there is diminished opposition of longitudinal muscle contraction from the phrenoesophageal attachments.

Olmesartan-associated enteropathy: results of a national survey

Recently, a new enteropathy has been described: olmesartan‐associated enteropathy. However, the association has been questioned: a phase 3 trial and a cohort study found no association between gastrointestinal events and olmesartan.

Esophageal solid bolus transit: studies using concurrent videofluoroscopy and manometry

ObjectiveOur aim was to assess the efficacy and mechanism of solid bolus transit through the esophagus.MethodsEight healthy volunteers were studied with concurrent manometry and videofluoroscopy while swallowing 5 ml liquid barium, a 5–6 mm diameter bread ball, and 4 g chewed bread in both a supine and upright posture. As many as four successive swallows were performed until clearance was achieved.ResultsThe esophageal clearance of liquid barium was 100% with the first swallow. Clearance of the unchewed bread ball occurred with the first swallow in only 6.7% of trials in the upright posture and 5.9% in the supine posture. After four swallows, clearance was 100% and 52.9% in the upright and supine postures, respectively. Chewed bread was more readily cleared than unchewed bread, with 100% clearance after two swallows in the upright posture and 91% clearance after four swallows in the supine posture. The most common locus of bread stasis was at the aortic arch and carina. The bread boluses were noted to move more effectively when localized in the head as opposed to the tail of the bolus composite. Nonocclusive contractions often occurred at the bolus tail despite the increased peristaltic amplitude seen with the chewed bread. Failed peristalsis, a frequent cause for solid clearance failure, was observed during 30% of all bread swallows. This usually occurred distal to the stopping point of the bolus, suggesting it to be the result rather than the cause of impaired transit.ConclusionsAlthough infrequently perceived by these normal subjects and in contradistinction to liquid clearance, bread is rarely cleared from the esophagus with a single swallow. Mastication and an upright posture facilitate the esophageal transport of solids. Bolus composition and impaired bolus transit alter the amplitude and conductance of peristalsis. Manometric data pertaining to liquid clearance through the esophagus do not readily apply to bread.

Ambulatory 24-h oesophageal impedance–pH recordings: reliability of automatic analysis for gastro-oesophageal reflux assessment

Abstract  Oesophageal pH–impedance monitoring allows detection of acid and non‐acid gastro‐oesophageal reflux (GOR) events. Visual analysis of impedance recording requires expertise. Our aim was to evaluate the efficacy of an automated analysis for GOR assessment. Seventy‐three patients with suspected GORD underwent 24‐h oesophageal pH–impedance monitoring. Recordings analysis was performed visually (V) and automatically using Autoscan function (AS) of Bioview® software. A symptom index (SI) ≥50% was considered for a significant association between symptoms and reflux events. AS analysis detected more reflux events, especially non‐acid, liquid, pure gas and proximal events. Detection of oesophageal acid exposure and acid reflux events was similar with both analyses. Agreement between V and AS analysis was good (Kendalls coefficient W > 0.750, P < 0.01) for all parameters. During pH–impedance studies, 65 patients reported symptoms. As compared to visual analysis, the sensitivity and specificity of a positive SI determined by AS were respectively 85.7% and 80% for all reflux events, 100% and 98% for acid reflux and 33% and 87.5% for non‐acid reflux. Despite good agreement with visual analysis, automatic analysis overestimates the number of non‐acid reflux events. Visual analysis remains the gold standard to detect an association between symptoms and non‐acid reflux events.

Clinical trial: Radiofrequency energy delivery in proton pump inhibitor-dependent gastro-oesophageal reflux disease patients.

Background  Radiofrequency (RF) energy delivery is an endoscopic procedure developed for the treatment of gastro‐oesophageal reflux disease.

Infectious complications, prognostic factors and assessment of anti-infectious management of 212 consecutive patients with acute pancreatitis

AIM Acute pancreatitis is an important cause of morbidity and mortality, mainly due to sepsis. The aim of this study was to determine the incidence of infectious complications and their impact on mortality in patients hospitalized for acute pancreatitis. PATIENTS AND METHODS Patients admitted for acute pancreatitis were retrospectively included within a period between 1995 and 2000. Incidence of abdominal and extra-abdominal sepsis and specific care were specifically analyzed. Risk factors for death were evaluated by uni- and multivariated analysis. RESULTS Two hundreds and twelve consecutive patients (128 males, median age 54 years) were included. Mortality was 10.8%. At least one infectious episode was collected in 25% of the patients with an abdominal sepsis (26.8%), bacteriemia (24.4%), respiratory (24.4%) and urinary tracts (19.5%) infections. Infection was polymicrobial in 37.5%. An antibiotic prophylaxis was administered in 10.8%, more often in patients with severe pancreatitis. It did not alter mortality or incidence of infections but significantly delayed occurrence of sepsis. Mortality of patients treated with more than one line of antibiotics was higher. However in this study infectious complications were not an independent factor for mortality. CONCLUSION Infections are frequent and polymicrobial but are not an independent prognostic factor during acute pancreatitis.