[Value of long-term ambulatory pH-metry in the assessment of patients with reflux esophagitis]. / Valor de la pH-metría ambulatoria de larga duración en la valoración de los pacientes con esofagitis por reflujo.

The aim of this study is to analyze different reflux-patterns by 24-hour ambulatory pH-metry and to correlate them with clinical symptoms and intensity of esophagitis. 115 patients (50 males/65 females) with a median age of 47 +/- 16 years, typical reflux symptoms have been studied and classified attending to the grade of esophagitis microscopically only 17 cases and endoscopically (grade I = 29, grade II = 44 and grade III/IV = 25 patients). Demeester's score has been used for clinical evaluation. Ambulatory pH-metry has been done with a Holter Synectics Digitrapper MK II, which registered intraesophageal pH-variations every 4 seconds during 24 hours. 28 normal subjects (13 males/15 females) with a median age of 51 +/- 16 years are referred as the control group. Clinical symptoms became more intensified when pH-metric alterations resulted more evident. Thoracic pain was noted in 12 from 115 patients, increasing its frequency in parallel fashion to that of the degree of esophagitis (6% in grade 0, 9% in grades I/II and 20% in grades II/IV). With increasing grades of esophagitis all parameters departed from normality, with significant differences between median values of the different parameters (to the exception of reflux episodes) when comparing patients with low-grade esophagitis (O/I) and high-grade esophagitis (II/III/IV). There is an excellent correlation between severity of esophagitis and % of time to acid exposure (Spearman's correlation coefficient). Only 5% of the patients with esophagitis presented normal pH-metry values and corresponded to esophagitis grade O/I. No patient had only a night reflux pattern, but 10% of our patients had only a day reflux pattern, the mixed pattern being the most frequent one (85%). The fact that 82% of our patients with microscopical esophagitis had a pathological pH-metry recommends the use this method in patients with clinical reflux symptoms and with normal endoscopy.

[The efficacy of Plantago ovata as a regulator of intestinal transit. A double-blind study compared to placebo]. / Eficacia del Plantago ovata como regulador del tránsito intestinal. Estudio doble ciego comparativo frente a placebo.

The effect of Plantago ovata on patients with chronic constipation (CC) with or without irritable bowel syndrome (IBS) has been assessed by a double blind study comprising 20 patients with CC of which 10 had associated IBS. A clinical questionnaire, weight of feces and intestinal transit time measured with radiopaque markers were done. Patients were then randomly distributed, 10 receiving PO and 10 placebo. Similar tests were done after treatment one month later. All patients receiving PO had good results against only one in the placebo group. Frequency of stools increased from 2.5 +/- 1 vs 8 +/- 2.2 stools per week, p less than 0.001 for paired data). A decrease in consistency of stools was also observed in the treated group. Fecal weight and colonic transit time were not significantly modified in placebo patients, while weight increase was observed in the treated ones (124 +/- 71 vs 194 +/- 65, gr/d p less than 0.001 for paired data) as well as a decrease in transit time (48 +/- 15 vs 34 +/- 18 hours p less than 0.05 for paired data). No adverse effects were observed and particularly no flatulence as often seen in patients on bran.

[Oropharyngeal functional assessment in patients with Zenker's diverticulum. Manometric and isotopic study]. / Valoración funcional orofaríngea en pacientes con divertículo de Zenker. Estudio manométrico e isotópico.

Twenty patients with the diagnosis of Zenker's diverticulum were studied clinically and manometrically. In 8 patients oropharyngeal clearance of liquid isotopic markers was done. In three, esophageal emptying of a marked meal was also studied. Clinically, sixteen patients had oropharyngeal dysphagia, while for remained asymptomatic. Dysphagia was severe in only five patients. In half of the patients there were signs of hiatus hernia and/or reflux. Pharyngo-sphincteric incoordination was present in 70% of cases with a mean resting pressure of the LES significantly lower than in controls. There were no differences among patients with or without reflux. Isotopic esophageal clearance was not useful as a test, as there were no significant differences with the control group. On the other hand, esophageal emptying of solid isotopic meals may show the persistence of food in the diverticular sac long time after the meal.

[Continuous monitoring of the upper esophageal sphincter with the Dent device, during acid perfusion or distension with balloon of the esophageal body]. / Monitorización contínua del EES mediante el dispositivo de DENT, durante la perfusión de ácido o la distensión con balón del cuerpo esofágico.

The aim of the present study was to evaluate pressure changes of the UES under conditions that simulate the effects of gastroesophageal reflux (GER), that are, balloon esophageal distension and acid perfusion 0.1 N. Studies were performed in eight healthy subjects and fourteen patients with reflux esophagitis (RE), divided in two groups according to symptoms, 6 patients with heartburn and 8 patients with heartburn and regurgitation. We have employed the Dent sleeve to monitor UES pressure. The catheter was located with the help of a side-hole manometric catheter placed in the opposite side of the Dent sleeve; thereafter, it was anchorated. Perfusion of acid at 5 and 10 cm below the UES induces a pressure increase statistically significant, (paired data). This pressure increase is shown when mean values of the 5 minutes are considered as well for every minute. On the after hand, esophageal balloon distension did not produce pressure increases in any of the groups.

[Response of the upper esophageal sphincter to various esophageal stimuli in patients with reflux esophagitis]. / Respuesta del esfínter esofágico superior a diferentes estímulos esofágicos en pacientes con esofagitis por reflujo (EPR).

The clinical symptoms, including oropharingeal dysphagia and bronchial symptoms, have been analyzed in 18 normal controls and in 48 patients with reflux esophagitis. Patients with reflux and pyrosis and regurgitation usually have a disease of longer duration, more bronchial symptoms, greater severity of endoscopic lesions and less pressure in the U.E.S. area than those who only have heartburn. In 10 normals as well as in 28 patients (15 with pyrosis and 13 with both pyrosis and regurgitation) the pressure behavior of the superior esophageal sphincter has been studied with a specially designed instrument after different stimuli: acid perfusion at 5 and 10 cm of the U.E.S. during 5 minutes and esophageal balloon distention at 10 cm. In normal individuals none of the stimuli modified the pressure at rest of the U.E.S., while in patients with reflux esophagitis only HCl perfusion at 5 cm was able to significantly increase pressure. This finding was independent of the clinical symptoms of the patients.

[Pressure of the anal canal in patients with hemorrhoids or with anal fissure. Effect of the topical application of an anesthetic gel]. / Estudio presivo del canal anal en pacientes con hemorroides o con fisura anal. Efecto de la aplicación tópica de un gel anestésico.

The pressure measurements and clinical sensation of 11 patients with hemorrhoids and 8 patients with posterior and fissure were analyzed before and after the topical administration of an anesthetic gel containing tetracaine in the anal canal. A significant increase of the maximal basal pressure (p less than 0.01) was observed in comparison with a control group of the same age and sex. No differences in the maximal pressure of voluntary contractions. The anesthetic gel produced a significant decrease of the maximal basal pressure in subjects with hemorrhoids, as well as a lessening of pain in 37% of patients with anal fissure and in 55% of those with hemorrhoids. This symptomatic improvement was not correlated with changes in pressure. Therefore we conclude that the hypertonicity of the anal canal is not secondary to pain and must be evaluated as a disturbance related to the subjacent lesion.

Chronic idiopathic constipation: the importance of transit time studies.

Chronic idiopathic constipation includes a very heterogeneous group of alterations which cannot be correctly defined only by their clinical appearance and require an examination of the colonic transit time. This test is performed by using a specific number of radiopaque markers and a fixed number of X-ray observations. By means of transit time study, we can classify the constipated patients into 4 groups: a) patients with stasis in the right colon (17-53% of cases) which implies an alteration of propulsive forces or absence of mass movements and segmentary motor activity; b) stasis in the left colon (13-27% of cases) which could be due to a "reflux" of colonic contents or to a hyperactive sigmoid; c) rectosigmoid stasis (20-33% of cases) which is secondary to a megarectum. Internal anal sphincter (IAS) and/or external anal sphincter (EAS) function failure and d) normal transit time (greater than 40 of cases) which is commonly due to psychological problems or to a low-fiber-content diet. We can conclude that transit time study is not necessary in mild constipation, but it is advised for those patients who do not respond to standard medical therapy or when surgery is being contemplated.

Alteration of recto-anal motility in chronic idiopathic constipation.

We studied anorectal function in 10 controls and 13 constipated patients (chronic idiopathic constipation, outlet obstruction and inertia coli). We did not find any difference among the 3 groups as regards the internal anal sphincter (IAS) basal tone, the recto-anal inhibitory reflex (RAIR) and the maximal voluntary contraction, whereas some significant differences were observed in the sensitivity threshold. In fact, we observed that all patient groups required larger volumes in order to perceive the minimum sensation. Moreover, the patients with distal obstruction showed higher threshold for a permanent defecation stimulus. The reduction of rectal sensitivity in these patients was confirmed by the infusion of 1500 cc of saline solution. On the basis of our experience constipated patients are characterized by both normal IAS tone, RAIR appearance, squeezing capacity, and lower rectal sensitivity.

The irritable bowel syndrome: diagnostic strategies.

The irritable bowel syndrome (IBS) is characterized by abdominal pain, abdominal distension and altered bowel habits. The diagnosis is usually made by excluding other diseases. The diagnosis of IBS must be based on a) medical history (i.e. symptoms, bowel habits, normal physical examination, absence of intestinal infections or parasites) b) physiopathological evaluation (hyperactivity of the distal colon, hypersensitivity to stimuli, stress), and c) physiological evaluation of the patient. The diagnosis of IBS can be supposed in patients with typical symptoms in the absence of other diseases that were excluded by complementary examinations.

Colonic sensitive-motor alterations in the irritable bowel syndrome.

The pathogenetic factors involved in the genesis of the irritable bowel syndrome (IBS) has not been fully explained yet. The abnormalities observed in these patients are a hypersensitivity to distension and an amplification of painful sensations. The motor activity of sigmoid colon shows an increased motility index in IBS patients with constipation and a low motility index in those with diarrhea. An hypercaloric meal induces a hypermotility in these patients. In our experience rectal distension evokes abdominal pain in 78% of cases at volumes of 100ml (less than than controls and constipated patients). The perfusion of rectum induces continuous abdominal pain in 89% of IBS patients. We can say that the motility of the whole colon over prolonged periods of time may represent an important progress in understanding the motor function in these patients.

[Oropharyngeal dysphagia due to a primary change in the pharyngeal musculature. A manometric and isotopic study]. / Disfagia orofaríngea por alteración primaria de la musculatura faríngea. Estudio manométrico e isotópico.

Twenty-five patients with oropharyngeal dysphagia due to a variety of disorders (4 with muscular dystrophy, 4 with myasthenia gravis and 13 with inflammatory myopathies) were studied clinically by esophageal manometry and isotopic clearance. Clinically patients had moderate dysphagia and 45% other symptoms such as nasal regurgitation, bronchial aspiration, etc. The most important manometric abnormality was the feeble contractions of the pharyngeal musculature, more pronounced in patients with severe dysphagia (grade II). Isotopic clearance of the oropharynx showed slowing of the pharyngeal emptying curve and an increased residual activity in this area. Isotopic oropharyngeal clearance is a useful, comfortable and noninvasive test for determining the clinical improvement which accompanies the manometric recovery of the pharyngeal muscular contraction.

[Reoperations after esophagomyotomy in esophageal motility disorders]. / Reoperaciones tras la esofagomiotomía en los trastornos motores esofágicos.

Out of 96 patients with the diagnosis of primary esophageal motor disorders and treated by esophagomyotomy, a group of 9 patients is reported in whom reoperation was necessary because of persistence or worsening of the previous symptoms (8 patients) or persistent reflux esophagitis (one patient). Clinical and laboratory examinations together with the operative findings allowed classification of these patients: incomplete myotomy proximally (4 patients) or distally (one patient), fibrotic scar at the site of previous myotomy (2 patients), persistence of intact muscle fibers (one patient) and reflux esophagitis for lack of an antireflux intervention during myotomy. Treatment consisted of completing myotomy proximally or distally, resection of the fibrous tissue and an antireflux operation when indicated. Clinical results were excellent in 6 patients (66.6%), fair in 2 patients (22.2%) and bad in one case (11.1%). Fair or bad results were seen in patients with total absence of motor response to deglutition. After operation there was disappearance of vigorous contractions in the esophagus, as shown by manometry and recovery of esophageal peristalsis in another patient. We conclude that in order to improve the results of the surgical treatment of motor esophageal disorders it is essential to correctly classify the type of disorder present by means of manometry and to add a partial funduplication to ensure absence of reflux without dysphagia.

The colon as oesophageal substitute in non-malignant disease. Long-term clinical results and functional studies.

Between 1974 and 1987, we performed 18 left colonic interpositions for benign oesophageal disease: caustic lesions in 6 patients, undilatable reflux stenosis in 5, reoperative peptic strictures in 5, penetrating wound in 1 and iatrogenic stricture following oesophagogastric transection for bleeding in 1. Four patients were women. The mean age was 40 +/- 19 years. In 10 patients a left thoracotomy was used; in the other 8 a cervico-abdominal approach was employed. One patient died postoperatively from liver failure. The mean follow-up was 11 +/- 4 years. Clinical results were excellent or good in 12 of the remaining 17 patients (71%). These results varied according to the length of colon interposition; in patients with long colonic interposition, poorer results were achieved. The motor activity of the colonic transplant was evaluated by manometric studies. After intraluminal injection of 30 ml of liquid, the colon responded uniformly with sequential peristaltic waves. Transmission of the oesophageal waves through the oesophagocolic anastomosis was studied in 2 patients. After wet swallows, the oesophageal contractile waves were followed by colonic waves. Solid radionuclide colonic transit studies were carried out in 18 control subjects and in 18 patients with colon interposition. In subjects with a normal oesophagus, the general pattern was rapid emptying of the bolus through the oesophagus. Findings in patients with a short transplant were similar to those observed in normal oesophagi. In most patients with long transplants the transit was abnormal.(ABSTRACT TRUNCATED AT 250 WORDS)

[Oropharyngeal functional evaluation in patients subjected to total laryngectomy with phonatory prosthesis. Manometric and isotopic study]. / Valoración funcional orofaríngea en los pacientes sometidos a laringuectomía total (LT) con prótesis fonatoria (PF). Estudio manométrico e isotópico.

Our goal in this paper is to evaluate the motor function of the oropharinx using esophageal manometry and isotopic study, in patients that underwent total laryngectomy (TL) with phonatory prosthesis (PP), and with or without cricopharyngeal myotomy (CM). 50 por 100 of the laryngectomized patients showed oropharyngeal dysphagia, more frequent and stronger in patients without CM. Voice quality was considered good or medium in 12/20. With manometry we achieve that after TL there is an intense pressure reduction of the UES, higher in patients with CM, there aren't differences for other manometrics parameters. The oropharyngeal isotopic clearance is clearly disturbed in all patients, there aren't differences due to the type of surgery, neither the degree of dysphagia nor the CM. The association of a CM to PL plus PP is a surgical procedure that improves markedly the manometric and clinic results in these patients.

New method for quantitative evaluation of esophageal sensibility.

A method for quantitating esophagus sensibility by an electric stimulation test is described. Square stimulus waveform at different voltages and durations were transmitted to the esophagus, three series of electric stimuli being used in successive durations (0.5, 1, 2, 4, 8 and 16 ms); in each series the voltage discharge was increased progressively from 0 mV, until the subject noted the first sensation. This procedure was carried out at all esophageal levels. The following parameters were analyzed: sensitive threshold along the esophagus; the relation of threshold sensibility (mV) duration of stimulus (ms), and reobase and cronaxia for each esophageal level. At all esophageal levels, the sensitive threshold was regular and coherent; in the middle esophagus a zone was found having higher sensitive threshold than the proximal and distal esophageal zones. The relationship between sensitive threshold and inverse of the stimulus duration indicated that esophageal sensibility follows the basic law of excitation of WEISS, at least with this type of stimulus, reobase and cronaxia being representative of the sensibility threshold along the esophagus. Quantitative esophageal sensibility, therefore is concluded to be particularly suited to evaluation by electric stimulation.

Motor activity of esophageal substitute (stomach, jejunal, and colon segments).

Manometric studies were performed to evaluate motor activity of several types of esophageal substitutes: total stomach (5 patients), isoperistaltic gastric tube (5 patients), jejunal Roux-en-Y loops (4 patients), and isoperistaltic left colon (15 patients). Motor behavior of substitutes was assessed following dry swallows and following several stimuli: intraluminar injection of 30 ml of water or 0.1N hydrochloric acid and swallowing pills. Following dry swallows, there was no response with either stomach or isoperistaltic gastric tube, jejunum showed a variable response, and a response was infrequent in patients with colon transplants. After dry swallows, transmission of the pressure wave through the anastomosis was not observed in any patient. Total stomach and isoperistaltic gastric tube did not respond to any stimulus. Jejunum responded with progressive waves after water and solid stimuli, and had a hyperkinetic response after acid injection. Colon had a constant (80 to 90%) and homogeneous response with progressive waves after all stimuli. After wet swallows, there was transmission through the anastomosis in 2 patients with colon transplants. Our data indicate that stomach and isoperistaltic gastric tubes do not contribute actively to the onward transmission of food in the digestive tract. Jejunum may contribute actively in digestive transit, but its responses are variable. Having steady and homogeneous responses, colon segments take an active part in transit.