Manometry of individual segments of the distal esophageal sphincter. Its relation to functional incompetence.

The major components of the lower esophageal sphincter, the pressure it exerts, its total length, and the length of sphincter affected by abdominal pressure are usually expressed as means of several recordings from different radial segments of the sphincter. In segmental manometry, the individual readings for these components in each segment, rather than the mean values, are analyzed. We used segmental manometry to study 50 normal volunteers and 200 patients with symptoms suggestive of gastroesophageal reflux. Of the latter, 100 had increased esophageal acid exposure and 100 did not. An increased number of defective segments was associated with a greater prevalence of increased esophageal acid exposure. Segmental analysis disclosed the same number (52) of defective sphincters (defined as sphincters with two or more defective segments) in the 100 patients with increased acid exposure as did standard analysis. However, the relationship between a defective lower esophageal sphincter and the number of reflux episodes was clearer when a defective sphincter was defined using standard analysis. Segmental analysis of the lower esophageal sphincter has no clear advantage over standard analysis.

The cause of dysphagia in uncomplicated sliding hiatal hernia and its relief by hiatal herniorrhaphy. A roentgenographic, manometric, and clinical study.

Patients with an uncomplicated sliding hiatal hernia frequently experience dysphagia. The present study shows, using video barium contrast esophagograms, that the cause of dysphagia in 60% of these patients is an obstruction to the passage of the swallowed bolus by diaphragmatic impingement on the herniated stomach. Manometrically this was reflected by a double-hump high pressure zone (HPZ) at the gastroesophageal junction, and specifically to the length and amplitude of the distal HPZ and the length of the intervening segment between the two HPZs. The former represents the degree of the diaphragmatic impingement on the herniated stomach and the latter the size of the supradiaphragmatic herniated stomach. Surgical reduction of the hernia resulted in relief of dysphagia in 91% of the patients.

Gastric acid and pepsin secretion in response to modified sham feeding in active and inactive duodenal ulcer disease.

Gastric secretion of acid and pepsin were studied under basal conditions, in response to modified sham feeding (MSF), and in response to pentagastrin in 15 male controls and in 11 and 10 male patients with active and inactive duodenal ulcer disease, respectively. In general, patients with ulcer disease produced more acid and pepsin than controls. No differences between the two ulcer groups were found for basal and pentagastrin-stimulated secretions. The response patterns to MSF, however, were different in the two groups. After an early peak, acid and pepsin responses rapidly decreased, approaching basal level in patients with active duodenal ulcer and in controls. In patients with inactive disease, however, the decrease was less marked, and in some patients the secretion continued to increase for 60 min. When expressed as fractions of the responses to pentagastrin, the acid and pepsin responses during the fourth 15-min period were significantly greater in patients with inactive duodenal ulcer disease than in patients with active disease and in controls. The findings indicate that the gastric response to vagal stimulation is different in patients with active and inactive duodenal ulcer disease.

Operative management of typhoid perforation in children.

Nine children admitted with typhoid perforation of the ileum underwent a modified ileostomy procedure. The following conclusions were drawn: 1. X-rays do not help in diagnosis in the majority of cases. 2. Blood urea is raised in almost all cases and vigorous attempts should be made to bring its level to normal before operation. 3. Leukopenia does not exist in patients with typhoid perforation; leukocytosis is the usual finding. A positive Widal test is not generally found in these cases and positive blood cultures should not be expected. 4. Ileostomy through the site of perforation, as described, is a simple, safe and short operation in a critically ill patient with a necrotic bowel. Also, resuscitative drugs are not needed.