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 Barrett's 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.

Investigation of gastro-oesophageal reflux in patients with an intact stomach: is oesophageal bilirubin monitoring a useful addition to pH monitoring?

OBJECTIVES: Ambulatory bilirubin monitoring has helped to establish the role of duodenal contents in gastro-oesophageal reflux disease. This study aims to define the clinical role of oesophageal bilirubin monitoring in reflux patients with an intact stomach. METHODS: In total, 113 consecutive patients with reflux symptoms were prospectively studied using combined ambulatory oesophageal pH and bilirubin monitoring. Patients were categorized as follows: no pathological reflux, isolated acid reflux, isolated bilirubin reflux, combined acid and bilirubin reflux. RESULTS: Thirty-eight patients (33%) had no pathological reflux, 49 patients (44%) had combined pathological acid and bilirubin reflux, and 17 patients (15%) had isolated pathological acid reflux. Only nine patients (8%) had isolated pathological bilirubin reflux. In these nine, the extent of pathological bilirubin reflux was small (median total bilirubin exposure time 12.2%, range 6.5%-20.7%) and mucosal damage was minimal (five had grade 1 oesophagitis, four had a normal oesophagus). In one patient, symptoms were temporally related to acid reflux, and in none were symptoms temporally related to bilirubin reflux. CONCLUSIONS: Isolated oesophageal bilirubin reflux in patients with an intact stomach is uncommon. In these patients mucosal injury is minimal, and reflux symptoms are not related to bilirubin reflux episodes. Further work is needed to define the role for oesophageal bilirubin monitoring in the investigation of reflux disease in patients with an intact stomach.

Investigation of oesophageal reflux symptoms after gastric surgery with combined pH and bilirubin monitoring.

BACKGROUND: Little is known about the role of bile in gastro-oesophageal reflux disease in patients with previous gastric surgery. This has partly been due to a lack of suitable techniques for identifying bile reflux objectively. METHODS: Some 28 patients with reflux symptoms and previous gastric surgery underwent oesophageal manometry, and 24-h ambulatory oesophageal pH and bilirubin monitoring. RESULTS: A wide variety of operations had been performed, most commonly Pólya gastrectomy (seven patients), vagotomy and pyloroplasty (six) and vagotomy and gastrojejunostomy (four). Three patients had isolated acid reflux, eight had isolated bile reflux, six had combined acid and bile reflux, and 11 patients had no reflux. Two-thirds of heartburn symptoms were not associated with reflux. However, one-quarter were associated with acid reflux and only 7 per cent with bile reflux. Erosive oesophagitis was present in five patients: two with combined acid and bile reflux, and three with isolated bile reflux. CONCLUSION: Acid and/or bile reflux can be present after a wide variety of gastric operations. Symptoms are more frequently associated with acid reflux than with bile reflux. Erosive oesophagitis can occur in the presence of isolated bile reflux. Combined pH and bilirubin monitoring determines the nature of the refluxate, and may help in the management of these patients.

Esophageal body length, lower esophageal sphincter length, position and pressure in health and disease.

We compared esophageal dimensions in control subjects and patients with differing motility disorders and severities of reflux disease. Patients (1108) and healthy controls (36) underwent manometry and 24-h pH monitoring. Subjects were grouped according to pH and manometry data into seven groups. Mean (s.e.m.) esophageal body length is greatest in achalasia [22.41 (0.27) cm] and least in reflux disease [20.06 (0.13) cm, p < 0.05]. Lower esophageal sphincter (LES) pressure is greatest in achalasia [17.46 (1.06) mmHg] and least in reflux disease [6.57 (0.24) mmHg, p < 0.05]. LES length is least in achalasia patients and control subjects. The ratio of intra-abdominal to intrathoracic LES is greatest in achalasia (1.29), no reflux and normal motility group, and controls and least in reflux disease (1.04, p < 0.05). In conclusion, esophageal body length is greatest in achalasia and least in reflux disease. This is associated with caudal movement of the LES in achalasia and cranial movement of the LES in reflux disease, relative to the diaphragm.

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 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 Barrett's 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 Barrett's 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.

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.

Oesophageal motor responses to gastro-oesophageal reflux in healthy controls and reflux patients.

AIMS: To compare oesophageal motor responses to gastro-oesophageal reflux (GOR) in 16 healthy controls (group 1) and 25 reflux patients, 15 without (group 2) and 10 with (group 3) oesophagitis. METHODS: All subjects underwent 24 hour ambulatory oesophageal pH measurements (5 cm above the lower oesophageal sphincter (LOS)) combined with pressure monitoring (5, 10, and 15 cm above the LOS for oesophageal body motility and 27 cm above the LOS for voluntary swallow detection). Contraction patterns (peristaltic, simultaneous, isolated, mixed type, and non-transmitted swallows) and peristaltic contraction wave characteristics (amplitude, duration, and velocity) during GOR were compared in the three groups. RESULTS: The average number of motor activities per minute was significantly higher in group 1 (p < 0.05). In all groups, the most common motor contraction pattern was peristaltic. The percentage of peristaltic activity per subject was significantly higher in group 1 (p < 0.05). There were no significant differences in other contraction patterns among the three groups (p > 0.05). Of the peristaltic contraction wave characteristics there were no significant differences in any parameters (amplitude, duration, and velocity) among the three groups (p > 0.05). The average pH increment in response to motor activities was significantly higher in group 1 (p < 0.05). CONCLUSIONS: Motor responses to GOR were found to be predominantly primary peristaltic in all groups. During GOR, reflux patients have less frequent activity, a smaller proportion of activity is peristaltic, and the average pH increment in response to motor activities is reduced compared with controls.

Primary peristalsis is the major acid clearance mechanism in reflux patients.

This study examined the clearance of gastric acid from the oesophagus in ambulant patients with gastro-oesophageal reflux. Eighteen patients with proved reflux disease were studied, nine with (group 1) and nine without (group 2) endoscopic oesophagitis. Oesophageal pressure and pH were recorded over 24 hours. Pressures were measured by a probe with five sensors: a 5 cm long sensor in the lower oesophageal sphincter, three sensors in the body of the oesophagus, and one at the pharynx to detect swallowing. Oesophageal pH was monitored 5 cm above the lower oesophageal sphincter. Manometric activities were classified as either peristaltic or ineffective. The latter included simultaneous, non-transmitted, and low amplitude peristaltic contractions. A reflux episode was defined as starting when pH fell to less than 4 and ending when the pH rose to 5. When the rise to pH 5 took place in three or more discrete steps after motor responses to gastro-oesophageal reflux, the pH steps were labelled as initial change (I), middle changes (M), and last change (L). A total of 595 episodes of gastro-oesophageal reflux and 1626 associated motor events were analysed. Of these, 1331 (81.9%) were classed as primary peristaltic activity, 174 (10.7%) as primary ineffective activity, 46 (2.8%) as secondary peristaltic activity, and 75 (4.6%) as secondary ineffective activity. There were no significant differences in initial change (p > 0.05), middle changes (p > 0.05), and last change (p > 0.05) between group 1 and group 2. In all patients, the successive changes of pH in response to motor activity were significantly different (p = 0.0001) between initial, middle, and last changes. Last change was significantly higher when compared with initial (p=0.001) and middle changes (p<0.001). Primary oesophageal peristalsis was the most frequent motor response to gastro-oesophageal reflux. The last motor activity during reflux showed the greatest change in pH.

Computerized analysis of the caloric response.

Caloric responses from 50 consecutive patients, referred routinely for investigation of hearing and/or balance problems, were evaluated by computer and manual methods of analysis. Using measures of nystagmic slow-phase velocity, there was found to be a high degree of correlation between the two methods. Of the 50 patients, the manual method of analysis identified 20 as having abnormal caloric patterns. All of these patients (and an additional 3) were similarly identified by the computer method. The computerized technique was found to be effective, even in the evaluation of irregular signals, making it suitable for use in the clinical situation. Since no decision making on the part of the operator is required, the method described is considered to be a significant advance in computerized methods of analysis of nystagmic slow-phase velocity.