William J. Owen

Effect of omeprazole 20 mg twice daily on duodenogastric and gastro-oesophageal bile reflux in Barrett’s oesophagus

Background—Both acid and duodenal contents are thought to be responsible for the mucosal damage in Barrett’s oesophagus, a condition often treated medically. However, little is known about the effect of omeprazole on duodenogastric reflux (DGR) and duodenogastro-oesophageal reflux (DGOR). Aims—To study the effect of omeprazole 20 mg twice daily on DGR and DGOR, using the technique of ambulatory bilirubin monitoring. Methods—Twenty three patients with Barrett’s oesophagus underwent manometry followed by 24 hour oesophageal and gastric pH monitoring. In conjunction with pH monitoring, 11 patients (group 1) underwent oesophageal bilirubin monitoring and 12 patients (group 2) underwent gastric bilirubin monitoring, both before and during treatment with omeprazole 20 mg twice daily. Results—In both groups there was a significant reduction in oesophageal acid (pH<4) reflux (p<0.005) and a significant increase in the time gastric pH was above 4 (p<0.005). In group 1, median total oesophageal bilirubin exposure was significantly reduced from 28.9% to 2.4% (p<0.005). In group 2, median total gastric bilirubin exposure was significantly reduced from 24.9% to 7.2% (p<0.005). Conclusions—Treatment of Barrett’s oesophagus with omeprazole 20 mg twice daily results in a notable reduction in the exposure of the oesophagus to both acid and duodenal contents. In addition, delivery of duodenal contents to the upper gastric body is reduced.

The relationship between acid and bile reflux and symptoms in gastro-oesophageal reflux disease.

BACKGROUND: The role of bile in the genesis of oesophageal symptoms and disease is incompletely understood. A new method of ambulatory bile monitoring may help to define this role. AIMS: To establish the relationship between symptom events and acid and bile reflux episodes. PATIENTS: 59 consecutive patients presenting for further investigation of gastro-oesophageal reflux disease. METHODS: All patients underwent combined ambulatory pH and bile monitoring. For each patient, a symptom index (SI) was calculated in relation to both acid reflux and bile reflux episodes. RESULTS: Patients were divided into those without (group 1, n = 21) and those with (group 2, n = 38) acid reflux. A total of 394 symptoms were identified in 59 patients. In group 1, there were fewer symptom events per patient (mean 4.1) than group 2 (mean 8.1). Twenty three per cent of symptom events were associated with acid reflux in group 1 and 41% in group 2. Only 6% of symptom events in both groups were related to bile reflux. In group 1 both the acid and bile related SI score were low. In group 2 the bile related SI score was low, but the acid related SI score was high. CONCLUSIONS: Symptoms are much more often related to acid reflux than bile reflux. Bile reflux does not seem to be a major factor in producing oesophageal symptoms.

Intraoperative scanning laser doppler flowmetry in the assessment of gastric tube perfusion during esophageal resection

BACKGROUND Ischemia from tissue hypoperfusion in the gastric tube after esophagectomy is believed to contribute significantly to postoperative complications associated with anastomotic failure. This study assessed the ability of the new technique of laser Doppler flowmetry to measure differential levels of blood flow in human gastric tubes during esophagectomy. STUDY DESIGN Gastric perfusion was measured in 16 patients undergoing esophagectomy by making laser Doppler scans of the stomach before mobilization and after formation of the gastric tube. Mean perfusion was calculated within the whole anterior surface of the stomach or tube and within 1 cm2 regions of interest, each of which contained 1,750 individual measurements of perfusion. These regions represented the cephalic end of the gastric tube, 10 adjacent 1 cm2 regions distally along the tube, and the proposed anastomosis site. Results were expressed as mean perfusion units, and tissue blood flow from each scan in each region was compared. RESULTS There were significant decreases in gastric perfusion measured with the scanning laser Doppler in all patients after formation of the gastric tube. Mean perfusion of the stomach fell 41% (p<0.0005) after mobilization. In all patients there was a gradient of perfusion from the proximal end of the tube where flow was poor, to more distal areas where it was higher. At the proximal end of the tube perfusion fell by a mean of 72%, 5 cm distally the mean fall was 44%, and 10 cm from the proximal end of the tube the mean fall was 28%. At the anastomosis site mean perfusion fell 55%. CONCLUSIONS This new technique can be used intraoperatively and appears to overcome the limitations of single point laser Doppler flowmetry. It has measured large differences in perfusion at different sites within the gastric tubes and could therefore have widespread clinical applications.

The extent of duodenogastric reflux in gastro-oesophageal reflux disease

Background It is known that duodenogastro-oesophageal reflux (DGOR) increases with worsening gastro-oesophageal reflux disease (GORD). It is unclear whether this is accompanied by increasing duodenogastric reflux (DGR). Objective To investigate the extent of DGR in a control group and 66 patients with GORD, using the technique of ambulatory gastric bilirubin monitoring. Methods Sixty-six patients with reflux symptoms (30 grade 0 or 1 oesophagitis (group 1), 16 grade 2 or 3 oesophagitis (group 2), 20 Barretts oesophagus (group 3)) and 17 healthy controls were studied. All underwent oesophageal manometry followed by 24-h ambulatory oesophageal and gastric pH monitoring and gastric bilirubin monitoring. Results Median per cent total oesophageal acid exposure (pH < 4) was significantly less in the control group (0.6%) than in group 1 (2.8%, P < 0.05) and groups 2 and 3 (7.5% and 7.8% respectively, P < 0.001). There was no significant difference between any group in median per cent total time gastric pH was greater than 4. There was no significant difference in median per cent total gastric bilirubin exposure (absorbance > 0.14) between any group. However, in each group gastric bilirubin exposure was greater in the supine position than the upright position, being significantly greater in the control group (P < 0.05) and group 1 (P < 0.001). Conclusions Gastric bilirubin exposure is similar across the spectrum of GORD severity. It is greater in the supine than in the upright position.

Effect of Cholecystectomy on gastroesophageal and duodenogastric reflux

OBJECTIVE:The majority of patients experience resolution of their symptoms after cholecystectomy, but a minority either find their symptoms unchanged or complain of new upper GI symptoms. It has been suggested that the effect of cholecystectomy on upper GI motility, sphincter function, or bile delivery may account for these postoperative symptoms. We aimed to determine whether cholecystectomy affects gastroesophageal reflux or duodenogastric reflux by using 24-h ambulatory pH and gastric bilirubin monitoring before and after surgery.METHODS:Seventeen symptomatic patients with gallstones underwent 24-h ambulatory esophageal and gastric pH-metry and gastric bilirubin monitoring. Helicobacter pylori status was ascertained in all patients by 14C urea breath test and serology. Combined pH and bilirubin monitoring was repeated 3 months after cholecystectomy. Eleven healthy subjects served as a control group.RESULTS:Three (17%) patients complained of persistent or new symptoms after surgery, whereas 14 (83%) patients were asymptomatic. Two patients (12%) underwent open cholecystectomy, and (88%) had the operation performed laparoscopically. No significant differences were detected in esophageal acid exposure (pH < 4), gastric alkaline shift (pH > 4), or gastric bilirubin exposure (absorbance > 0.14) after surgery. Three (17%) patients tested positive for Helicobacter pylori; the presence of infection did not appear to affect pre- or postoperative values.CONCLUSIONS:Cholecystectomy does not result in increased bile reflux into the stomach or increased gastroesophageal acid reflux. Those patients who had increased postoperative duodenogastric reflux were entirely asymptomatic. The symptoms of postcholecystectomy syndrome are unlikely to be related to increased duodenogastric reflux after surgery.

Effect of omeprazole in patients with chest pain and normal coronary anatomy: Initial experience

Gastroesophageal reflux is frequently found in patients with chest pain despite normal coronary anatomy, but little data on the effect of specific medication exist. After performing 24 h ambulatory pH monitoring and the Bernstein test on 23 patients with normal coronary anatomy, we gave omeprazole, 40 mg nocte, for six weeks to these and to a control group of ten patients with coronary disease. Pain episodes per fortnight fell from 16.2 to 12.0 (P=0.02) in the patients with normal anatomy and from 19.6 to 17.1 (nonsignificant) in the patients with coronary disease. Improvement occurred in seven (30%) of the patients with normal coronary anatomy compared with one (10%) of those with coronary disease, while complete resolution occurred in four (17%) and none, respectively. Improvement or complete resolution were not predicted by the results of 24 h pH monitoring, although there was a trend towards the prediction of efficacy by the Bernstein test. Omeprazole shows promise as a treatment for patients with chest pain despite normal coronary anatomy and larger placebo-controlled trials should now be undertaken.

A prospective study of oesophageal function in patients with normal coronary angiograms and controls with angina

Aims—To compare the incidence of oesophageal abnormalities and their correlation with chest pain in patients with normal coronary angiograms, and in controls with angina. Patients—Sixty one patients with normal coronary angiograms (NCA group) referred to a single cardiac centre between March 1990 and April 1991; 25 matched controls with confirmed coronary artery disease (CAD group). Setting—Cardiac referral centre and oesophageal function testing laboratory. Main outcome measures—Oesophageal manometry, provocation tests, and 24 hour ambulatory pH monitoring. Results—Simultaneous contractions were more common (6.7% versus 0.8%, p<0.01), and the duration of peristaltic contractions was longer (2.9 versus 2.4 seconds, p<0.01) in the NCA group than in the CAD group. There were no group differences in the amplitude of peristaltic contractions, and none had nutcracker oesophagus. Ten (16%) patients with NCA and no patients with CAD had diffuse spasm (p=0.03). Twenty one (34%) patients with NCA, and five (20%) patients with CAD had abnormal gastro-oesophageal reflux (p>0.05). There was no significant difference between the groups in the number of patients whose pain was temporally related to pH events. Particular chest pain characteristics, or the presence of additional oesophageal symptoms, were not predictive of an oesophageal abnormality. Conclusion—Oesophageal function tests commonly implicate the oesophagus as a source of pain in patients with normal coronary angiograms. With the exception of simultaneous contractions during manometry however, the incidence of abnormalities and in particular the correlation of pH events with chest pain are as common in patients with normal coronary angiograms as in controls with angina. The oesophagus may often be an unrecognised source of pain in both groups of patients.

The temporal relationship between oesophageal bile reflux and pH in gastro-oesophageal reflux disease

Objective Damage caused to oesophageal mucosa by bile constituents is pH dependent. The aim of this study was to evaluate the relationship between pH and duodeno-gastro-oesophageal reflux in gastro-oesophageal reflux disease at night in the supine position. Design A prospective study of 113 patients with reflux symptoms [63 without erosive oesophagitis (group 1), 23 with erosive oesophagitis (group 2), 27 Barretts oesophagus (group 3)] and 15 controls. Methods All subjects underwent 24 h ambulatory oesophageal pH and bilirubin and gastric pH monitoring. For the supine period, oesophageal pH during episodes of bile reflux was calculated, and the temporal relationship between individual oesophageal and gastric alkaline shift and oesophageal bile reflux episodes was established. The supine period was divided into four equal segments and the temporal patterns of acid and bile reflux and alkaline shift in each of the four supine time segments were investigated. Results Both acid and bile reflux are severe in Barretts oesophagus, particularly at night. Nocturnal oesophageal bile reflux occurs mostly between pH 4 and 7 in all groups: 67.6%, 76.5% and 41.4% of the supine period for groups 1, 2 and 3 respectively (P< 0.001 vs. pH < 4 or > 7). Individual oesophageal bile reflux and oesophageal or gastric alkaline shift episodes rarely coincide. Acid reflux predominates in the first half of the night (P> 0.001), oesophageal bile reflux and alkaline shift continue throughout the night, gastric alkaline shift increases towards the end of the night (P > 0.001). Conclusion Duodenal contents in the oesophagus exist at a wide pH range, and may have passed through an acid or an alkaline stomach. This has implications for the damage which individual constituents are able to cause.

Gastro-oesophageal reflux and duodenogastric reflux before and after eradication in Helicobacter pylori gastritis.

Objective Helicobacter pylori and duodenogastric reflux (DGR) are both associated with chronic gastritis, peptic ulcer and gastric cancer. The nature of their interrelationship remains unclear. H. pylori eradication has also been reported to result in new or worsening acid gastro-oesophageal reflux (GOR). The aim of this study was to investigate the relationship between GOR, DGR and H. pylori infection. Method 25 patients with H. pylori gastritis underwent ambulatory 24-hour oesophageal and gastric pHmetry and gastric bilirubin monitoring before and 12 weeks after H. pylori eradication, confirmed by 14C urea breath testing (UBT). Ten healthy subjects served as a control group. Results There were no differences between patient and control groups for gastric alkaline exposure or gastric bilirubin exposure (P > 0.25 in all categories). Oesophageal acid reflux was higher in the study group (P < 0.02). No differences were detected in oesophageal acid reflux, gastric alkaline exposure, or gastric bilirubin exposure (P = 0.35, 0.18 and 0.11, respectively) before and after eradication. Conclusions Acid GOR is not increased by H. pylori eradication. DGR in patients with H. pylori gastritis is similar to that in healthy, non-infected subjects. H. pylori eradication produces no change in GOR or DGR. In patients with chronic gastritis, H. pylori infection and DGR appear to be independent of each other.

Dental erosion: a presenting feature of gastro-oesophageal reflux disease

Objective To investigate the association between gastro-oesophageal reflux and dental erosion. Methods Observation of dental erosion patterns suggestive of gastro-oesophageal reflux and a review of the literature. Results Gastro-oesophageal reflux with regurgitation into the mouth will cause acid erosion of the palatal surfaces of the upper incisor teeth in susceptible individuals. Eroded teeth can be a presenting feature in diagnosing gastro-oesophageal reflux disease (GORD). In patients without any obvious symptoms of reflux, the teeth may be the only clinical sign indicating the presence of GORD. Conclusions Damage to teeth after long periods of undiagnosed GORD can be catastrophic requiring very expensive and complicated dental treatment. It is important that the appearance of the palatal surfaces of the upper incisor teeth are examined in patients suspected of suffering from GORD.