Raffaella Grasso

Manometric study of hiatal hernia and its correlation with esophageal peristalsis.

The pathogenesis of gastroesophageal refluxdisease (GERD) is considered multifactorial, butalterations of the esophagogastric junction (EGJ) andhiatal hernia play a prominent role. The correlationsbetween hiatal hernia and the other pathogeneticfactors are as yet unclear, and they need to beinvestigated by a methodological approach based on newanatomic and functional criteria. Our aim was to study,by stationary manometry, the relationships betweensmall reducible hiatal hernia, identified by endoscopy,and esophageal peristalsis, in patients with and withoutGERD. According to the absence or presence of esophagitis (E), and the absence or presenceof hiatal hernia (H), 58 subjects were divided into fourgroups: controls 10; H 14; E 10; and HE 24. Stationarymanometry was performed by the rapid pull-through (RPT) technique, with catheter water perfused,to study the lower esophageal high pressure zone [loweresophageal sphincter (LES) and diaphragmatic crura] andthe parameters of esophageal peristalsis. In patients with hiatal hernia, the variouscombinations of peak and/or deflection of manometricline pressure identified five EGJ profiles, only one ofwhich reveals (by one-peak profile due to superimposed LES and diaphragmatic crura) the reducibilityof the hernia. The frequency of the five profiles wascalculated in the HE and H groups: a two-peak profilewas significantly more prevalent in these patients, although less so in the group with esophagitis.In E patients the distal amplitude and the distalpropagation of esophageal waves were significantly lowerthan in the other three groups (P < 0.05 vs controls and group HE; P < 0.01 vs group H).Furthermore, the distal amplitude was significantlyhigher in the group H than in the HE (P < 0.01). Ourresults show a better definition of hiatal hernia morphology, via the RPT technique, disclosingfive pressure profiles. In addition, a significant linkwas found between small reducible hiatal hernia withoutGERD and wave amplitude of the distal esophagus. The amplification of peristaltic clearing maybe considered the initial protective process againstacid reflux; the breakdown of this mechanism may triggerthe pathological sequence of GERD.

Acid exposure and altered acid clearance in GERD patients treated for Helicobacter pylori infection

BACKGROUND After the eradication of Helicobacter pylori, an increased incidence of gastroesophageal reflux disease and acid gastric secretion have been reported. AIM To evaluate the effect of Helicobacter pylori-eradication on proximal and distal gastroesophageal reflux and acid clearance in patients with gastroesophageal reflux disease. PATIENTS AND METHODS Sixty-eight gastroesophageal reflux disease patients (age range 18-61 years) were studied by upper endoscopy. All underwent esophageal manometry and dual probe 24-h pH-metry. RESULTS Percent of time at pH<4 was significantly increased in the proximal esophagus of Helicobacter pylori-eradicated patients compared to Helicobacter pylori-negative (2.4+/-0.5 vs. 1.0+/-0.2; p<0.01); no differences were found in the distal esophagus (14.0+/-3.7 vs. 9.0+/-1.4%, NS). The total number of reflux episodes was significantly higher in the proximal oesophagus of Helicobacter pylori-eradicated patients (37+/-3 vs. 22+/-3, p<0.05). In the distal esophagus, acid clearance was significantly longer, both during total time (1.4+/-0.2 vs. 0.8+/-0.7 min, p<0.01), and in the supine period (8.5+/-2.7 vs. 2.7+/-0.4 min, p<0.05). No differences were reported in the manometric parameters of the two groups of patients. CONCLUSION In patients with gastroesophageal reflux disease, Helicobacter pylori eradication is associated with increased acid exposure of the proximal esophagus and delayed distal acid clearance.

Role of diaphragmatic crura and lower esophageal sphincter in gastroesophageal reflux disease : Manometric and pH-metric study of small hiatal hernia

The rapid pull-through (RPT) technique during esophageal manometry helps to identify various pressure profiles of hiatal hernia (HH), based on the presence of two high pressure zones: the diaphragmatic crura (DC) and the lower esophageal sphincter (LES). Our aim was to correlate different HH profiles with frequency of reflux episodes in patients with gastroesophageal reflux disease (GERD). Seventy-eight patients with GERD and HH underwent esophageal manometry with RPT and were grouped according to the prevalent pressure profile of HH. Twenty-four-hour pH-metry served to quantify traditional (TR) and nontraditional refluxes (drop of 1 pH unit with pH > 4 or pH < 4 and time < 5 sec) (NTR) during total, upright, and recumbent periods. The group with a prevalent “flat” HH profile, representing LES and DC impairment, had significantly more TRs in total time of reflux (P < 0.01) and in recumbent and upright periods (P < 0.05) compared to the group with a prevalence of the two pressure peaks, corresponding to LES and DC efficiency. However, the group with the flat profile had significantly more NTRs + TRs than the group with pressure peaks in total time (P < 0.01) and recumbent position (P < 0.001) but not in the upright position. Hiatal hernia predisposes to GERD, but only the associated impairment of the LES and diaphragmatic crura pressures represents a condition of high risk for gastroesophageal reflux events.

Symptoms and pathophysiological correlations in patients with constipation and functional dyspepsia.

Introduction: Patients with constipation often report dyspeptic symptoms, but whether constipation is associated with specific dyspeptic symptoms and altered gastrointestinal (GI) motility, remains to be established. Our aim was to study symptoms association and GI motility parameters in patients with constipation and functional dyspepsia. Patients and Method: 42 patients with different symptoms and severity of constipation and dyspepsia were enrolled. Scintigraphic gastric emptying, colonic transit time and gallbladder contraction were studied in all subjects. Results: No significant association was observed between individual symptoms of constipation and dyspepsia. Patients with more severe constipation did not have higher dyspepsia severity scores. Colonic transit time, gastric half emptying and gallbladder contraction were not significantly correlated. Although patients with severe nausea had faster colonic transit than those with absent/mild symptom (19 ± 2 vs. 48 ± 7 h; p < 0.05), the multivariate analysis only revealed a significant association between severe postprandial fullness, delayed t1/2 (OR 1.05, CI 1–1.1) and impaired gallbladder contraction (OR 0.94, CI 0.89–0.99). Conclusions: Constipation was not associated with severity, or any particular dyspeptic symptom. Although motor abnormalities of both colon and proximal GI tract regions existed in the subset of constipated dyspeptic patients, they did not seem associated with the genesis of different dyspeptic symptoms.