Wallace C. Wu

Esophageal Manometry in 95 Healthy Adult Volunteers Variability of Pressures with Age and Frequency of "Abnormal" Contractions

Although esophageal manometry is widely used in clinical practice, the normal range of esophageal contraction parameters is poorly defined. Therefore, 95 healthy volunteers (mean age: 43 years; range 22–79 years) were studied with a low-compliance infusion system and 4.5-mm-diameter catheter. All subjects were given 10 wet swallows (5 cc H2O) and 38 subjects also were given 10 dry swallows. Results: Amplitude, but not duration, was greater (P<0.05) after wet compared to dry swallows. Both distal mean contractile amplitude and duration of wet swallows significantly increased with age and peaked in the fifties. Double-peaked waves frequently occurred after both wet (11.3%) and dry (18.1%) swallows, but triple-peaked waves were rare (<1%). Nonperistaltic contractions were more common (P<0.001) after dry compared to wet swallows (18.1% vs 4.1%). This difference resulted from frequent simultaneous contractions after dry swallows (12.6% vs 0.4%). Conclusions: (1) Distal esophageal contractile amplitude and duration after wet swallows increases with age. (2) Triple-peaked waves and wet-swallow-induced simultaneous contractions should suggest an esophageal motility disorder. Double-peaked waves are a common variant of normal. (3) Dry swallows have little use in the current evaluation of esophageal peristalsis.

Reflux laryngitis and its sequelae: The diagnostic role of ambulatory 24-hour pH monitoring

Summary Ambulatory 24-h intraesophageal pH monitoring was performed in 32 patients with hoarseness, documented laryngeal pathologic findings or lesions, globus, and/or chronic cough. The laryngeal lesions included granulomas, stenoses, and carcinomas. Twenty-two (68.8%) of the patients had no symptoms specific for reflux. One-half of the patients underwent pH monitoring with a double probe, one probe being placed in the distal esophagus and the second being placed in the hypopharynx just behind the laryngeal inlet. Twenty-four (75%) of the patients had abnormal studies, i.e., significant reflux. Of those, 17 (70.8%) had upright reflux, 13 (54.2%) had supine nocturnal reflux, and 10 (41.7%) had both types. Seven of the 16 patients undergoing double-probe-type monitoring had reflux into the pharynx (43.8%). These data suggest that occult gastroesophageal reflux may be involved in the pathogenesis of many conditions commonly encountered in otolaryngologic practice.

Sucralfate treatment of nonsteroidal anti-inflammatory drug-induced gastrointestinal symptoms and mucosal damage

In a randomized, double-blind trial, sucralfate therapy, 1 g four times daily, was compared with placebo in 143 symptomatic patients to assess the treatment of gastrointestinal symptoms and gastric mucosal damage associated with nonsteroidal anti-inflammatory drugs (NSAIDs). All patients followed a fixed regimen of NSAIDs, were assigned to one of two groups based on the presence or absence of gastric erosions at baseline endoscopy, and were then assigned randomly to receive sucralfate or placebo for four weeks. Patients were then followed for up to six months while receiving open-label sucralfate 1 g twice daily to up to 1 g four times daily. After four weeks of double-blind therapy, patients taking either nonsalicylate NSAIDs or long half-life NSAIDs and who were treated with sucralfate experienced a significant reduction in both peptic symptom frequency and intensity (p less than 0.03) as compared with patients receiving placebo. Sucralfate-treated patients with baseline endoscopic lesions showed a significant reduction in lesion scores (p less than 0.005) at four weeks as compared with baseline, whereas no improvement was observed in gastric mucosal lesions of patients given placebo. Long-term sucralfate therapy resulted in continued improvement in gastrointestinal symptoms and gastric lesion scores in patients receiving all types of NSAIDs. The results indicate that sucralfate used in conjunction with NSAIDs may allow patients to continue therapy by relieving gastrointestinal symptoms and mucosal damage associated with NSAID therapy.

Endoscopic biopsy is diagnostic in gastric antral vascular ectasia. The "watermelon stomach".

Gastric antral vascular ectasia was endoscopically diagnosed in seven patients. Pathologic characteristics of this entity were defined retrospectively, by studying endoscopic pinch biopsy slides from these seven patients and antrectomy specimens from five patients. A scoring system was developed, and the seven patients were compared prospectively with various control groups. Abnormalities of mucosal vessels (fibrin thrombi and/or ectasia) consistently distinguished patients from control antrectomies, normal biopsies, acute gastritis biopsies and atrophic gastritis biopsies (P=0.02, all comparisons). Spindle cell proliferation into mucosa also was characteristic of gastric antral vascular ectasia, distinguishing this disease from normals, acute gastritis, and atrophic gastritis (P≤0.039, each comparison). The presence of abnormal mucosal vessels (fibrin thrombi and/or ectasia) and spindle cell proliferation was similar in patient antrectomies compared to patient endoscopic biopsies. Therefore, we conclude that endoscopic biopsies can reliably diagnose gastric antral vascular ectasia, a vascular disorder characterized by abnormal mucosal vessels and spindle cell proliferation.

Reflux Esophagitis: Radiographic and Endoscopic Correlation

Although the value of endoscopy in reflux esophagitis is accepted, the role of radiology has not been well defined. The radiographic and endoscopic findings in 75 patients were correlated. A grading system was employed to stage the severity of involvement. Thirty-five appeared normal on endoscopy and 40 had esophagitis of differing stages of severity. The results indicate that radiography is insensitive in mild degrees of inflammation but that its sensitivity and accuracy improves in more severe grades of esophagitis.

Predictive relationship of hiatal hernia to reflux esophagitis

The relationship between hiatal hernia and reflux esophagitis was compared in 93 patients who underwent both radiographic and endoscopic examination of the esophagus. In 46 patients with a normal esophagus shown endoscopically, hiatal hernia was present in 59%, while 94% of 47 patients with reflux esophagitis had hiatal hernia. The positive and negative predictive values for hiatal hernia in diagnosing or excluding esophagitis were 62% and 86%, respectively. Extrapolation of these data and review of the literature suggest that much of the confusion concerning the relationship between hiatal hernia and reflux esophagitis is based on reports of populations with considerable variation in the prevalence of esophagitis and in which the radiographie criteria for diagnosing hiatal hernia have not been uniformly applied.

Reflux esophagitis revisited: Prospective analysis of radiologic accuracy

A prospective radiologic-endoscopic study of the esophagogastric region in 266 patients, including 206 normals and 60 with esophagitis, is reported. The endoscopic classification grading severity of esophagitis was grade 1 — normal; grades 2, 3, and 4 — mild, moderate, and severe esophagitis, respectively. Radiology detected 22% of patients with mild esophagitis, 83% with moderate esophagitis, and 95% with severe esophagitis. Although hiatal hernia was present in 40% of normals and 89% with esophagitis, absence of radiographic hiatal hernia excluded esophagitis with 95% accuracy. The implications of this study regarding the role of radiology in evaluating patients with suspected reflux esophagitis are discussed.

Antiinflammatory Drugs and Gastric Mucosal Damage

N ONSTEROIDAL antiinflammatory drugs (NSAIDs) are among the most often used medications in the United States and throughout the world. Fifteen to 20 billion aspirin tablets are consumed each year in the United States.’ Prescriptions for nonsalicylate NSAIDs represented over 4% of the total prescription market in 1983, with consumers spending over a billion dollars for these medications.’ Approximately 3% of the United States population requires treatment for a rheumatic disorder, and NSAIDs are prescribed in most types of noninfectious arthritis.3,4 NSAIDs may cause gastrointestinal (GI) symptoms, erosions and/or ulcers, and upper GI tract bleeding. Therefore, gastric mucosal damage resulting from NSAID use is potentially a major health problem. Corticosteroids are used in a wide variety of medical conditions, including rheumatoid arthritis (RA), bronchial asthma, allergic disorders, and dermatologic diseases. The relationship of corticosteroids to gastric mucosal damage is controversial. Corticosteroids may increase the incidence of peptic ulcer disease and GI hemorrhage’ and potentiate gastric mucosal injury when used in combination with NSAIDs such as aspirin.6*7 This review is divided into two sections. The first part surveys data regarding NSAID induced gastric mucosal injury, and the second portion discusses the role of corticosteroids in causing gastric mucosal damage.

Radiographic evaluation of esophagus immediately after pneumatic dilatation for achalasia.

Forty-one (98%) of 42 patients with achalasia of the esophagus had pneumatic dilatation performed successfully using the Brown-McHardy dilator. One to four dilatations (mean, 1.9) were done on each patient with inflation pressures of 8–15 psi (mean, 11.1 psi). Immediately after the procedure, all patients were examined radiographically by injection of contrast material into the lower esophagus through a nasoesophageal tube. Two immediate and two delayed perforations occurred. Six intramural hematomas were noted, five of which resolved spontaneously. The luminal diameter at the esophagogastric junction increased from a mean of 4.2 mm before dilatation to 7.5 mm following treatment. Four patients with previous Heller myotomy were dilated without complications. Perforation was more common in patients with a minimal change in the esophagogastric diameter. Thirty-five patients (85%) improved symptomatically within several days following pneumatic dilatation. Excluding patients with perforation, the postdilatation appearance of the lower esophagus poorly correlated with clinical response.

Cowden's disease: A case report and literature review

Cowdens disease, or multiple hamartoma syndrome, is an uncommon condition with characteristic mucocutaneous lesions associated with abnormalities of the breast, thyroid, and gastrointestinal tract. We describe a 51-year-old man with hyperplastic polyposis of the entire alimentary tract as the most prominent feature of this disease. We also present a review of 85 cases of this entity as reported in the English medical literature, and summarize the pertinent findings.