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Background With rising interest in gastroesophageal reflux disease, an evaluation of the importance of manometry (M) and 24-hour pH testing (pH) for decisions regarding these patients is appropriate. Methods Two gastroenterologists and two surgeons were presented with history and physical examination, endoscopy, histology, and esophagram data (“DATA”) from 100 patients and asked to make a treatment decision. After some time, either pH or M was added to DATA, and a further decision requested. Finally, DATA plus pH plus M was presented, and a decision was requested. Decisions were evaluated for changes in medical therapy, changes between medical and surgical therapy, and changes in type of surgery offered. Results Overall, 43% (173 of 400) of decisions were altered by the addition of both M and pH to DATA, with 28.5% (114 of 400) of decisions changed from medical therapy to surgery or vice versa by the addition of both tests to DATA. The addition of M alone changed decisions more often than pH alone especially with regard to the type of surgery offered (P Conclusions Together, M and pH alter clinical decisions and often alter the decision regarding surgery. Both tests appear important, but M more frequently alters overall management decisions and the type of surgery offered. Despite the need for cost containment, these clinical tools are essential to important decisions regarding the care of patients with gastroesophageal reflux disease.

Background This study defines the entity of the hypertensive lower esophageal sphincter (HLES) and its treatment, including surgical implications. Methods Esophageal manometry was performed on 1,300 patients. Of these, 53 (4%) had HLES with resting pressure >26.5 mm Hg, defined as the upper limit of normal resting LES pressure. Thirty-two of these patients had 24-hour esophageal pH studies. The response to treatment was assessed. Results Fourteen patients (26%) with HLES had achalasia. Of the remaining 39 (74%), 25 had an isolated HLES with normal esophageal body motility, 5 had a nonspecific esophageal motiliry disorders (NEMD), 4 were post-Nissen fundoplication, 3 had a nutcracker esophagus, and 2 had diffuse esophageal spasm (DES). Nineteen percent of HLES patients had gastroesophageal reflux on pH studies. Eighty-two percent of HLES patients responded well to symptom-directed medical therapy. Two patients with esophageal body dysmotility responded well to an esophageal myotomy with a partial fundoplication. Conclusions Patients with the HLES form a heterogeneous group. Gastroesophageal reflux in HLES patients is not uncommon. Patients with HLES respond well to medical therapy. Carefully selected patients require surgery.

Early results of laser-assisted balloon angioplasty (LABA) and peripheral directional atherectomy (PDA) are encouraging. The true value of these procedures has remained in doubt, however, because of the absence of data on long-term objective patency rates.From August 1988 through October 1993, LABA and PDA were performed on 151 limbs of 124 patients. Presenting symptoms were mild-to-severe claudication in 128 limbs (63 LABA, 65 PDA) and rest pain or necrosis in 23 (7 LABA, 16 PDA). Seventy-seven percent of the atherosclerotic lesions were localized in the iliofemoral tract (77% LABA, 76% PDA). Seventy limbs were treated with LABA and 81 with PDA.Initial hemodynamic and arteriographic success was achieved in 46 LABA limbs (66%) and 75 PDA limbs (93%) (P0.002). Mean follow-up was 16 +/- 2 months after LABA and 18 +/- 1 months after PDA. During this time, 32 failures were recorded in limbs treated with LABA, and 29 in limbs treated with PDA. The patency rate at 40 months was 23% in the LABA group and 45% in the PDA group (P0.005). Patency rates were not affected by the length or site of the arterial lesion or the runoff score.PDA had a better long-term patency rate than LABA, but long-term results were dismal with both techniques. PDA appears to have a limited role and LABA no role in the treatment of lower extremity occlusive disease.

The effects of the intravenous bolus administration of famotidine versus the administration of Mylanta II liquid every 2 hours on the pH of the gastric antrum, body, and fundus for 24 hours were compared in 10 critically ill patients admitted to the intensive care unit with isolated cranial trauma. Patients received 30 mL of Mylanta II every 2 hours via nasogastric tube for 24 hours, followed by administration of 20 mg of intravenous bolus famotidine every 12 hours for the subsequent 24-hour period. pH of the gastric antrum, body, and fundus was monitored continuously using a three antimony pH electrode/nasogastric tube assembly. Gastric pH data were analyzed for the percentage of time pH was less than 4 and median pH for the antrum, body, and fundus for each 24-hour period. The percentage of time pH was less than 4 was significantly less in the antrum and body of the stomach during famotidine therapy (8.9% +/- 3.6% and 24.9% +/- 6.9%, respectively) compared with Mylanta II (39.1% +/- 6.7% and 57.6% +/- 8.5%, respectively, both p0.005), but was not significantly different in the fundus (famotidine: 25.3% +/- 7.8%; Mylanta II: 28.3% +/- 6.5%). Median gastric pH for 24 hours was significantly greater in the antrum and body of the stomach during famotidine therapy (7.8 +/- 0.2 and 6.8 +/- 0.6, respectively) compared with Mylanta II (4.5 +/- 0.6 and 3.7 +/- 0.9, respectively, p0.005 and p0.01, respectively), but was not significantly different in the fundus (famotidine: 5.9 +/- 0.8; Mylanta II: 5.4 +/- 0.7). The data indicate that an intravenous bolus of famotidine every 12 hours is more effective than Mylanta II liquid every 2 hours administered via a nasogastric tube in maintaining gastric pH above 4 in critically ill patients. Famotidine produces a uniform increase in gastric pH throughout the stomach, whereas Mylanta II controls only proximal gastric pH, probably related to fundic pooling of antacid in the supine position.