Search

Purpose: The nature of pancreatic acinar metaplasia (PAM) in the gastro-oesophageal junction (GOJ) remains obscure. We aimed to estimate its prevalence and investigate into its risk factors in a population-based series of first-time endoscopy patients., Methods: We investigated consecutive patients, endoscoped for the first time, representing defined catchment area populations. Biopsies were taken immediately below the GOJ and from the distal oesophagus. Endoscopy room-based cross-sectional clinical data were supplemented with exposure data from 160 population controls. Associations, expressed as odds ratios (OR), were modelled with multivariable logistic regression. A subsample of 26 patients underwent oesophageal pH monitoring., Results: Among 644 patients (mean age 53 years, 43% men), PAM was found in 121 patients (19%), exclusively above the GOJ in 40 (6%), below GOJ in 67 (10%), and both above and below GOJ in 14 (2%). PAM exclusively above the GOJ and PAM exclusively below the GOJ were both borderline associated with age (2% increase in prevalence per year). PAM exclusively above the GOJ was significantly associated with female gender (OR 2.8, 95% CI 1.3-6.3) and presence of Helicobacter pylori immediately below the GOJ (OR 2.6, 95% CI 1.3-5.4). Out of 21 patients with Barrett's oesophagus (BO), 8 (38%) had PAM above the GOJ. The mean value for percentage time with oesophageal pH < 4.0 was 7.3% (95% CI 4.3-10.2%) among patients who had PAM above the GOJ (reference value 3.4%)., Conclusions: Pancreatic acinar metaplasia might be an age-dependent lesion, associated with H. pylori, female gender and gastro-oesophageal reflux if located above the GOJ.

The frequencies of laryngeal symptoms and smoking habits were investigated in 60 patients referred to 24-hour pH-metry because of esophagus-related symptoms. Group 1 comprised 30 consecutively referred patients who exhibited pathological gastroesophageal reflux by pH-metry, and group 2 comprised 30 consecutively referred patients who showed normal pH-metry. The patients, as well as 30 age-matched controls (not investigated by pH-metry), answered a questionnaire about voice problems and smoking habits. The 60 patients reported a frequency of voice problems comparable to the 30 controls. The various voice problems did not differ significantly in frequency between refluxers and patients with a normal reflux pattern in spite of the fact that there were significantly more smokers among the refluxers compared to nonrefluxers. We concluded that voice problems were not more common among patients with abnormal reflux patterns than among patients with a normal reflux defence.

One hundred and ten patients with suspected oesophageal symptoms were investigated by means of oesophageal endoscopy (OE), 24-h pH-metry, and oesophageal scintigraphy (ES). When 24-h pH-metry formed the basis for diagnosis of gastrooesophageal reflux disease (GERD), the sensitivity for ES at abdominal compression was 64%, but no statistically significant differences were found among erect refluxers (ER), supine refluxers (SR), and combined refluxers (CR). Only 4% of the GERD patients had pathologic oesophageal clearing at ES. The more severe the macroscopic oesophagitis found by OE, the more pronounced were the abnormal findings at 24-h pH-metry and at ES with abdominal compression. Increased postprandial reflux was associated with gastro-oesophageal reflux and hiatal hernia at ES with abdominal compression and the most severe form of oesophagitis, respectively. It was concluded that ES had too low sensitivity to be recommended as a screening test for GERD. Nevertheless, the specificity of 76% can to some extent help us to rule out GERD in patients.

The frequency of different kinds of oesophageal dysfunction (OD) namely hiatal hernia at manometry, dysmotility, hypotension of the lower oesophageal sphincter (LES) and positive acid perfusion test was investigated in 97 patients with bronchial asthma seen at a hospital clinic. Thirty-six patients had signs of hiatal hernia, 37 of dysmotility, 26 of LES hypotension and 23 had a positive acid perfusion test. Four per cent of all the asthma patients fulfilled four criteria for OD and 10%, 28% and 25% fulfilled three, two and one criteria respectively. The incidence of OD was significantly higher in patients with Exogenous (95%) than in patients with endogenous asthma (58%, P less than 0.01). The history of asthma in patients with OD was of significantly longer duration (mean 16.9 years) than that of the OD itself (mean 6.5 years, P less than 0.01). Productive cough and frequent wheezing were more common in patients with OD (46%) than in patients without (19%, P less than 0.01). Spirometric lung volumes did not differ between asthmatics with OD and those without. Asthmatics with OD seem therefore to suffer more from respiratory symptoms than asthmatics without OD.

Esophageal acid clearing in normal subjects was studied in different body positions, with an assessment of reproducibility, after dry and water swallows, after smoking, and after alcohol intake. A significant increase in the number of swallows to raise the distal esophageal pH to 5.0 was found in the head-down position (p less than 0.003), after smoking (p less than 0.003), and after alcohol intake (p less than 0.001). It is proposed that the outcome of the acid-clearing test reflects both the transporting capacity of the esophageal muscles and the production of saliva. The precision of the acid-clearing test is not satisfactory, which makes it unsuitable for use in individual cases. It seems, however, well fitted for evaluation of esophageal acid clearing in larger samples.

Benign esophageal strictures with a diameter of less than 10 mm were dilated by balloon catheter in 15 patients. Liquid esophageal transit scintigraphy was performed before, the day after, and 3 weeks following dilatation. Before treatment the mean esophageal transit was 38 s (range, 8.0-120). The day after dilatation the mean transit time was 20 s (range, 7.5-120), which differed significantly (p less than 0.01) from the pretreatment value. At the 3 weeks check-up, the mean transit time was 16 s (range, 4.5-120), which did not differ (NS) from the result obtained the day after treatment. Thus, esophageal liquid transit improves rapidly and lasts for at least 3 weeks. Improvement in esophageal liquid transit did not always accord with the clinical outcome after dilatation, which was significantly (p less than 0.05) related to the postdilatation stricture width as measured radiographically.

The purpose of this study was to evaluate the physiological transit pattern of a compact bolus through the oesophagus in normal subjects. A standard gelatine bolus labelled with 99mTechnetium pertechnetate was swallowed in the erect and the supine positions and traced by a gamma-camera in 20 subjects. In the erect position, the mean overall transit time was 5.5 +/- 1.1 s (SD) which differed significantly (P less than 0.001) from the longer mean overall transit time of 6.9 +/- 1.4 s (SD) in the supine position. The transit patterns differed between erect and supine positions. In the erect position, the bolus travelled at a constant velocity until the most distal part of the oesophagus where a slight retardation of the velocity occurred, whilst in the supine position, a uniform retardation of the velocity was seen which was slightly accentuated in the most distal part. The present data provide a basis for the evaluation of studies on the bolus transport in patients with suspected oesophageal dysfunction.

Oesophageal emptying was studied with scintigraphy, radiography, and the acid clearing test (ACT) in 18 patients reporting dysphagia and previously operated on with fundoplication. Radiography with contrast medium, isodense with water, revealed abnormalities in either motility or emptying capacity in 39% (7/18). A A barium meal showed abnormalities--that is, a tight repair, disruption of the fundoplication, or recurrence of the hernia--in 56% (10/18). The ACT was prolonged in 40% (6/15) of the patients. Pathological findings at scintigraphy with a solid bolus were found in 67% (12/18). Even if scintigraphy with a solid bolus is the method that identifies the highest number of patients with impaired oesophageal function among the tests used, it cannot differentiate between functional and anatomical disorders. A barium meal examination is the method of choice when an anatomical disorder is suspected.

Esophageal function and anatomy were investigated with manometry, acid perfusion test, acid clearing test, and x-ray in 11 patients with primary Sjögren's syndrome (SS) and in 11 with secondary SS. The manometric investigation revealed minor motor differences in the SS patients as compared to 16 controls, ie, shorter peristaltic contraction time of the whole esophagus, and faster peristaltic velocity preferably in the distal part of the esophagus, while the results from the reflux tests did not differ between patients and controls. Radiographic examination revealed upper esophageal webs in 10% (2/20), and hiatal hernia in 25% (5/20). The dysphagia as reported by 73% of the patients cannot be explained by webs or impaired motor function and is regarded to be secondary to lack of saliva, making the solid bolus passage difficult.

Fifty consecutive patients with different esophageal symptoms were investigated with esophageal endoscopy, transit scintigraphy, and gastroesophageal (GE) scintigraphy with extra-abdominal compression. Scintigraphic findings were abnormal in 27 of those 31 patients (87%) who were classified as abnormal at endoscopy. A prolonged transit time was the commonest finding, but hiatal hernia and GE reflux were also found. However, the scintigraphic procedure showed abnormalities in 6 of 19 (31%) who were classified as normal at endoscopy. Esophageal scintigraphy is recommended as a screening test before endoscopy is decided on.

In patients with asthma who do not respond to conventional therapy, esophageal dysfunction should be considered. The treatment of esophageal dysfunction has an improving effect on both the esophageal and the bronchial symptoms in these cases.

To evaluate the mean transit time of a solid bolus in 17 patients with prolonged acid clearing, a scintigraphic non-invasive technique was used. Sticking of the bolus in the middle third of the oesophagus was a common feature in these patients as compared with normals. Thus, the deteriorated transport pattern of a solid bolus in patients with prolonged acid clearing is not acidification-dependent. The catheter-intubated oesophagus showed a significantly (p less than 0.01) lower tendency for sticking as compared with prior intubation, whereas acidification of the oesophagus increased the sticking tendency significantly (p less than 0.01) as compared with the intubated oesophagus without acid. The evaluation of mean transit times was of no value because of the frequency of sticking. The fact that intubation improves the passage must be kept in mind when studies of solid bolus are performed in intubated patients.

Scintigraphic technique was used to study esophageal transport of a solid bolus in 16 patients with dysphagia but with normal manometry, and negative acid perfusion tests, acid clearing tests, and pH reflux tests. Radiology performed on 14 of the 16 patients showed no evidence of organic lesions. Half the patients had abnormal findings at scintigraphy, with either bolus retention in the upper part of the esophagus or prolonged transit time as compared to a group of 20 asymptomatic subjects. Scintigraphy can be regarded as a valuable complement in the objective documentation of dysphagia when other diagnostic methods fail.

The frequency of different kinds of oesophageal dysfunction (OD) as shown by manometry and acid perfusion test was investigated in a 55-year-old general population. OD was found in 34 +/- 8% (95% confidence interval). Seventeen per cent had signs of dysmotility, 14% of hiatal hernia, 6% of lower oesophageal sphincter (LES) hypotension, 5% had a positive acid perfusion test and 13% had more than one kind of OD. Symptoms of gastro-oesophageal reflux and chest symptoms were significantly more common in OD subjects than in subjects with normal oesophageal function. The oesophageal function tests had a capability in detecting 66% of subjects in the general population with heartburn or acid regurgitation, whereas they had a poor capability in detecting subjects with other oesophageal related symptoms. This investigation can therefore not answer the question whether our criteria for OD is clinically relevant or not. Irrespective of this, it is important to know the frequency of OD in the general population if the relevance of the OD frequency in hospital patient materials is to be evaluated.

Oesophageal motility was studied in 59 patients before and again after prolonged acid perfusion. In group 1 (n = 16), who were asymptomatic during the acid perfusion, no significant motility differences were obtained by perfusion. In group 2 (n = 18), who had heartburn, and in group 3 (n = 25), who had angina-like chest pain during acid perfusion, significant (p less than 0.01-0.001) changes of motility were seen: these included higher peristaltic amplitude, longer contraction duration, and slower peristaltic velocity. In addition, patients in group 3 showed a decrease (p less than 0.01) of peristaltic propagation and had secondary wave activity more often (p less than 0.01) during acid perfusion. Significantly (p less than 0.01) more patients in group 3 showed secondary wave activity after acid perfusion than in group 2. Pretest motility investigation did not separate the two acid-sensitive groups from the acid-unsensitive one, whereas the investigation of the lower oesophageal sphincter (LOS) did. Thus, LOS incompetence was significantly (p less than 0.01) commoner in the two symptomatic groups than in the asymptomatic group. We suggest that the motility changes observed during acid perfusion are secondary to increased sensory stimulation from the oesophagus but are not the cause of the symptoms. However, nervous reflex reactions from other chest organs, such as the heart, may also explain the results.

Fifteen patients with the combination of bronchial asthma and symptoms of gastro-esophageal reflux reproduced at endo-oesophageal acid perfusion (group 1) were investigated to detect bronchial obstruction, reflexly elicited from the distal oesophagus. Five patients with bronchial asthma but without symptoms of gastro-oesophageal reflux (group 2) and five patients with symptoms of gastro-oesophageal reflux but without respiratory symptoms (group 3) served as controls. The vital capacity (VC), the slope of the alveolar plateau (delta N2) and the closing volume (CV) were measured with the single breath nitrogen test before and after acid perfusion of the oesophagus, and again after antacid and glucose perfusion of the oesophagus. In group 1 a significant decrease of VC by 0.21 (P less than 0.001) and a significant increase of delta N2 by 0.9% (P less than 0.05) was seen while no change in CV was found. There was no change after acid perfusion in groups 2 or 3. After glucose and antacid the VC increased significantly in group 1 while no significant change was seen in delta N2 or CV. These findings were taken as indirect evidence of bronchial obstruction induced by the acid infusion. Since the changes were provoked in the sitting position and only in asthmatics with a positive acid perfusion test and since no patient complained of acid taste in the mouth it is unlikely that the bronchial obstruction was due to aspiration. A neural oesophago-bronchial reflex mechanism is suggested.

Sixty-two patients with both bronchial asthma and oesophageal dysfunction (OD) were randomized into an OD treatment group and a control group. Patients in the treatment group were given advice and medication for their OD. No changes were made in their existing asthma therapy. Patients in the control group were told that there was a suspicion of OD which should be rechecked in 2 months. After 2 months the patients of the treatment group reported alleviation of their oesophageal and bronchial symptoms significantly more frequently than patients of the control group. Fewer signs of OD were found after treatment than before. Lung function tests did not differ between the group treated for 2 months and the control group but there was a significant reduction in consumption of beta-adrenergic stimulating drugs in the treatment group compared with the control group. In conclusion, treatment of OD improves not only oesophageal symptoms but also respiratory symptoms in asthmatic patients. OD should therefore be looked for in patients with bronchial asthma and treated whenever found.