Study of gastroesophageal reflux in cirrhotic patients with esophageal varices and without endoscopic treatment

ABSTRACT

The aim of this work is to study prevalence of abnormal gastroesophageal reflux [GER] by pH recording in cirrhotic patients with esophageal varices and without previous endoscopic treatment and its possible predicting factors. Sixty five patients [38 men, 27 women] with liver cirrhosis, were selected from those admitted at the Internal Medicine Department of Benha University Hospitals. Their ages ranged from 38 to 59 years [with a mean age of 54.4 +/- 10.5 years]. Diagnosis of liver cirrhosis was based on clinical laboratory, abdominal ultrasonographic image and histological findings. All patients had esophageal varices confirmed by endoscopy and were submitted to a questionnaire about typical gastroesophageal reflux disease symptoms [heartburn and or acid regurgitation]. pH recording was performed with the probe placed 5 cm above the superior lower esophageal sphincter limit as determined by manometry. Abnormal pH reflux [pHR] was defined as percentage total time with pH < 4 was greater than 4.5%. The pH recording demonstrated abnormal pHR in 25 patients [38.5%] 6 [24%] just in upright position, 9 [36%] in supine position and 10 [40%] in both positions. Regarding the caliber of the esophageal varices [EV], 15 patients [44.1%] out of 34 with small size varices, 6 patients [31.6%] out of 19 patients with medium size varices and 4 patients [33.3%] out of 12 patients with large size varices, had abnormal pHR. There was no statistical significant difference between patients with small variceal size and abnormal reflux and those with medium and large variceal sizes [P> 0.05 respectively]. As for patients with congestive gastropathyt 10 of them [34.5%] out of 29 had abnormal pHR and 15 patients [41.7%] without congestive gastropathy out of 36 had abnormal pHR. There was no statistical significant difference between patients with congestive gastropathy and abnormal reflux and those without [P >0.05]. Regarding the severity of the disease as assessed by Child Pug classification, 13 patients [35.1%] out of 37 patients with Child's A, 5 patients [41.7%] out of 12 with Child's B and 7 patients [43.8%] out of 16 with Child's C had abnormal pHR. There was no statistical significant difference between patients with Child's A and abnormal reflux and those with Child's B and Child's C [P>0.05 respectively]. As for ascites, 12 of them [42.9%] out of 28 patients presented with an abnormal pHR and 13 patients [35.1%] oat of 37 patients without ascites had abnormal pHR. There was no statistical significant difference between patients with ascites and abnormal reflux and those without ascites [P>0.05]. Also, no statistical significant difference was found between patients with severe ascites and abnormal reflux and those with mild and moderate degree of ascites [P>0.05 respectively].Thirty five patients [53.8%] had typical reflux symptoms, 19 of them [54.3%] presented with abnormal pHR and 6 [20%] out of 30 patients without typical reflux symptoms, had abnormal pHR. There was a statistical significant difference between patients with typical reflux symptoms and abnormal reflux and those without typical reflux symptoms [P< 0.05]. Regarding the lower esophageal sphincter [LES] pressure, there was no statistical significant difference in the mean levels of the LES pressure between neither the severity of the disease [as assessed by Child's A, B and C], degree of ascites, grades of EV nor the normal and abnormal reflux disease [P>0.05 respectively]. The prevalence of abnormal gastroesophageal reflux was high [38.5%] in patients with hepatic cirrhosis and esophageal varices. Only typical gastroesophageal reflux disease symptoms predicted these findings. Long-term ambulatory follow-up of this group of patients is important since, if the "erosive" theory holds true, patients with abnormal reflux could present a higher incidence of variceal bleeding. This, however, needs to be demonstrated