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The aim of this work is to describe the computed tomographic (CT) anatomy in patients who underwent Nissen's fundoplication. Forty patients (mean age = 61 years) with peptic esophagitis (nine cases), refractory gastroesophageal reflux (11 cases), and hiatal hernia (20 cases) were studied. Examinations were performed by third-generation CT equipment, with patients in the prone position after the ingestion of gastrovison and barium paste. In 34 patients, the examination demonstrated anatomical variations related to surgery, that is, the presence of a soft tissue mass at the level of the distal third of the esophagus. In four patients, a functional incompetence of the fundoplication (three cases) and a recurrent hiatal hernia (one case) were demonstrated. Our results suggest a possible application for CT study in postoperative follow up of patients who undergo Nissen's fundoplication, complementary to endoscopy and functional exams.

Background: The "gold standard" and only accurate method for diagnosing Barrett's esophagus is by esophagogastroduodenoscopy with biopsy. We evaluated the ability of high-resolution endoluminal sonography (HRES) to detect the mucosal changes in Barrett's esophagus., Methods: Seventeen patients with documented Barrett's and 12 normal controls underwent endoscopy with HRES examination using a 20 MHz ultrasound transducer to evaluate for mucosal changes. HRES examinations were videotaped then reviewed by an unblinded investigator to identify criteria possibly diagnostic of Barrett's and then by a blinded investigator to test the validity of these criteria. Barrett's was diagnosed by HRES if the second hypoechoic layer appeared thicker than the first hyperechoic layer of the mucosa. Normal mucosa was defined as having a pencil-thin second hypoechoic layer on HRES. Measurements of the second hypoechoic layer were made using a computer and compared in patients with Barrett's and patients with normal esophagus., Results: All 17 patients with Barrett's were correctly identified by HRES (sensitivity 100%). Ten of 12 controls were correctly identified as normal (specificity 86%). There was good correlation between HRES and pathologic diagnoses (r 0.86). The second hypoechoic layer was significantly thicker in Barrett's patients than in normal controls (p < .001)., Conclusions: HRES is a sensitive new method for identifying Barrett's esophagus. However, dysplasia could not be identified by HRES in this study.

Objective: To evaluate the effect of the type of jejunal pouch (long or short) on reflux esophagitis after total gastrectomy., Methods: Two groups of patients who underwent jejunal pouch reconstruction (long pouch, n = 9; short pouch, n = 9) after total gastrectomy were compared, and each was also compared with a group of healthy control subjects (n = 9). Reflux symptoms were assessed using a reflux score questionnaire derived from Moran's graded reflux questionnaire. Scintigraphy was performed to evaluate quantitatively intestinoesophageal reflux and pouch emptying time (t75%)., Results: Heartburn was more common in the long pouch group than in the short pouch group (56 vs 11%, p < 0.05), and the reflux score was significantly higher in the long pouch group (mean score 3.0 vs 1.0, p < 0.01). The scintigraphic reflux index in the long pouch group, short pouch group, and control group was 9.57 +/- 5.52, 7.05 +/- 3.35, and 1.55 +/- 0.70, respectively. The reflux index in the entire group of patients was significantly higher than that in the control group (p < 0.005). In addition, t75% was significantly longer in the long pouch group (46.0 +/- 16.2 min) than in the short pouch group (21.1 +/- 15.39 min)., Conclusion: Our findings suggest that reconstruction with a short jejunal pouch is more effective than a long pouch in preventing reflux symptoms.

Background: Some patients with reflux esophagitis have solitary ulcers in the distal esophagus. This study was undertaken to characterize further the radiographic features of these ulcers and to determine whether or not they have a predisposition to develop on the posterior esophageal wall., Methods: Radiologic files and teaching files at our university hospital and affiliated Veterans Administration hospital revealed 29 patients with solitary reflux-induced ulcers. The radiographs were reviewed retrospectively to determine the size and location of the ulcers as well as the presence or absence of other findings., Results: Twenty ulcers (69%) were located on the posterior wall, five (17%) on the left or right lateral wall, and four (14%) on the anterior wall. All but two ulcers were located 1-4 cm from the gastroesophageal junction. All of the ulcers were less than 10 mm in width and 5 mm in depth. Other associated findings included hiatal hernias in 11 patients (38%), mucosal nodularity or granularity in 12 (41%), one or more tiny satellite ulcers in three (10%), esophageal intramural pseudodiverticula in three (10%), an inflammatory esophagogastric polyp in one (3%), and scarring or stricture formation in 12 (41%)., Conclusion: Our findings suggest that solitary reflux-induced ulcers tend to occur on the posterior wall of the distal esophagus near the gastroesophageal junction, producing characteristic radiographic findings. We postulate that affected individuals sleep primarily in the supine position, so that refluxed acid pools on the dependent or posterior esophageal wall, causing maximal injury in this location.

Background: Esophageal strictures due to gastroesophageal reflux disease are often resistant to medical therapy and require repeated dilation procedures. Our aim was to compare the efficacy of therapy with omeprazole (20 mg/day) to ranitidine (150 mg twice daily) in the treatment of chronic esophageal strictures., Methods: Thirty-three patients with chronic esophageal stricture disease (mean length of prior treatment, 50.9 months) were entered into a randomized blinded trial. The majority (88%) of the patients had received multiple prior esophageal dilations (mean, 7.9 per patient). Endoscopy and barium esophagograms were performed initially and at the end of 10 months. Symptoms were considered every 2 months and dilations performed as needed. The patient groups were equivalent., Results: One patient in each group was subsequently lost to follow-up. No significant differences were seen in symptom improvement or need of dilation. At the final endoscopy, 8 of 17 (47%) patients receiving ranitidine had residual erosions or ulceration, compared with 1 of 14 (7%) patients receiving omeprazole (p >0.2). All patients receiving ranitidine had persistent strictures, whereas 8 of 14 (57.1%) patients receiving omeprazole had radiographic and endoscopic resolution of their strictures (p <0.004)., Conclusion: These data further emphasize the need for vigorously treating esophagitis in patients with acid peptic strictures.

Rationale and Objectives: The purpose of this retrospective study was to investigate any association between the classic radiographic findings of nonerosive gastritis on the upper gastrointestinal (GI) series (antral nodularity, fold thickening, and narrowing) and histologically proven gastritis secondary to Helicobacter pylori., Methods: The authors reviewed the histopathologic results of 31 patients who had upper GI barium examinations with the findings listed above who presented with dyspepsia. These patients were compared with 30 dyspeptic patients who had radiographically normal antrums., Results: Twenty (64.5%) patients had chronic active gastritis and tested positive for H pylori organism, 5 (16.1%) were normal, 5 (16.1%) had inflammation but were negative for H pylori, and 1 (3.2%) had an insufficient amount of tissue. The barium upper GI series was 66.7% sensitive and 69.4% specific for chronic active gastritis secondary to H pylori (P = 0.0002 Fisher's exact test), with a positive predictive value of 64.5% and a negative predictive value of 83.3%., Conclusions: The differential diagnosis for antral nodularity, fold thickening, and narrowing is extensive. However, because of the common histopathologic diagnosis of chronic active gastritis secondary to H pylori in patients with these radiographic findings, the radiologist must remember to include this infectious cause of gastritis in the interpretive report. If the antrum is normal on the upper GI series, other causes should be considered.

Objective: The objective of this study was to compare the cost of achieving a unit of clinical success for treatment of reflux oesophagitis with either ranitidine or omeprazole., Methods: After randomisation 430 patients with reflux oesophagitis (grade 2 or 3) were assigned to receive omeprazole 20 mg or ranitidine 150 b.i.d. for 8 weeks. Patients were given diary cards to assess their symptoms every day, and record every two weeks a life satisfaction index. Patients were seen after 4 and 8 weeks for symptoms assessment and repeat endoscopy at 8 weeks. The perspective of the analysis was that of the payer. The costs of medical care were based in French drug costs currently advertised, payment for physician and actual mean payment for upper GI endoscopy., Results: The healing rates at 8 weeks in the omeprazole group and the ranitidine group were 93 and 67.5% respectively. After 8 weeks of treatment, life satisfaction was good in 81 and 53.6% and the relief of pain was 86,6 and 69,5% respectively. For each effectiveness criteria, omeprazole was more cost effective than ranitidine: cost per healed patient (2,338 F vs 2,744 F), cost per asymptomatic patient (2,510 F vs 2,964 F), cost per patient with a good or very good life satisfaction index (2,687 F vs 3,456 F). This advantage remained independent of the oesophagitis initial severity. The sensitivity analysis showed that the results were unsensitive to the variations of the efficacy variables in their confidence interval., Conclusions: This cost-effectiveness analysis suggests that in the treatment of reflux oesophagitis, the strategy with the more effective treatment is more cost-effective.

We prospectively compared the efficacy of polyvinyl bougies (Savary type) passed over a guide wire and through-the-scope balloons for the dilation of peptic esophageal strictures in a randomized study. Thirty-four patients, 17 in each treatment arm, were studied. At entry, dysphagia was assessed according to a six-point scale (0, unable to swallow; 5, normal). The end-point for dilation was to size 45F or 15 mm. Discomfort during the procedure was graded on a four-point scale (0, no discomfort; 1, mild; 2, moderate; 3, severe discomfort). Follow-up visits were at 1 week, 1 month, 3 months, and every 3 months thereafter for 2 years. At the 1-week visit, the size of esophageal lumen was measured by 8-, 10-, and 12-mm pills. Both devices effectively relieved dysphagia. By life-table analysis, stricture recurrence during the first year of follow-up was similar in both groups, but during the second year, the risk of recurrence was significantly lower in patients whose strictures were dilated with balloons. Other advantages of balloons included the need for fewer treatment sessions to achieve the defined end-diameter for dilation (1.1 + 0.1 versus 1.7 + 0.2, p < .05), and less procedural discomfort (p < .05). The differences in luminal size after dilation, measured by the barium pill test, were not significant. Ability to pass the 12-mm pill and absence of dysphagia were correlated. Our results indicate that both devices are effective in relieving dysphagia, but balloons may have a long-term advantage.

Endoscopic ultrasonography of the lower esophagus was performed in 25 patients with reflux esophagitis and 13 age-matched controls. Thickening of the esophageal wall and abnormalities of its architecture were detected. As these morphological changes became more extensive, the lower esophageal sphincter pressure and the decrease of sphincter pressure on relaxation were both progressively reduced. There was a significant correlation between morphological abnormalities and lower esophageal function. Our results suggest that inflammatory damage to the muscle layer of the lower esophagus may impair lower esophageal sphincter function further, especially in patients with advanced esophagitis.

Precise staging of reflux esophagitis is very important for therapeutic decisions; in fact, chronic gastroesophageal reflux may cause transmural inflammation that leads to fibrosis with loss of esophageal wall compliance. In reflux esophagitis, endoscopic stating is limited to mucosal injury, while endoscopic ultrasonography (EUS) is able to visualize changes in the layer structure and localized or diffuse thickenings of the esophageal wall. In order to evaluate the usefulness of EUS in reflux esophagitis, a prospective study of 31 patients and ten normal subjects was performed. Endoscopic reflux esophagitis was staged as: E1 (erythema, n = 7), E2 (erosions, n = 13), E3 (ulcers, n = 11). EUS findings were recorded and evaluated at five different levels, starting from the gastroesophageal junction, using a quantitative method, the center line method. With this method, the sectorial and mean thickness, and area were calculated for each level. There was a significant difference between patients with reflux esophagitis and normal subjects in our study. E3 patients showed a significant upward involvement of the wall far from the visible lesions. Mild esophagitis may also cause esophageal wall thickening, involving even the entire wall. There was no correlation between the onset time of symptoms and the degree of thickening. In conclusion, EUS seems to be an important supplement to endoscopy in staging reflux esophagitis, as the progression of the inflammation is not related to the endoscopic findings.

Although antireflux surgery offers very good results and patient's satisfaction, the referral rate to the surgeon remains very low. We present our experience with a less-invasive procedure that would result in minimal pain and very rapid return to normal activities and thus might lead to earlier referral. Fifty-nine patients with documented reflux esophagitis were treated. There were 31 females and 28 males whose age ranged from 27 to 69 years and whose weight varied between 140 and 280 lbs. Pre-op work-up included endoscopy, barium swallow, manometry, and 24-h pH studies. There was no mortality and morbidity was minimal; hospital stay was 2-3 days. Ten patients were lost to follow-up; all the remaining patients are completely asymptomatic, and the patients who had their pre-op work-up repeated showed normal results. Laparoscopic fundoplication seems to be as efficient and safe as the open procedure.

Background: pH monitoring of the distal esophagus has proved both sensitive and specific in the detection of reflux but has several limitations due to changes over time in esophageal pH and possibility of alkaline reflux. Simultaneous ultrasonographic monitoring can be helpful when interpreting the results., Population and Methods: One thousand infants (80% under 1 year of age) were examined: 500 suffered from vomiting (310 patients), life-threatening events (65 patients) or repeated respiratory diseases (125 patients). Five hundred infants were controls (320 asymptomatic and 180 sibs of patients with SIDS). pHmonitoring and ultrasonography were performed before and after ingestion of milk by vomiting patients and after administration of orange juice in the other symptomatic patients. Control patients were given milk when asymptomatic or orange juice when they belonged to a SIDS sibship., Results: Ultrasonography permitted to interpret the different phases of the pH curves according to the age of patients, the meals and their nature, the events associated with temporary increase in abdominal pressure, the gravity. pH monitoring was able to recognize 1589 acid reflux but failed to recognize 2091 reflux episodes., Conclusions: While pHmonitoring is helpful to demonstrate a relationship between the reflux and such events as apnea, bradycardia, cough, ultrasonography defines a risk based on specificity of reflux and laryngeal or esophageal dysfunction.

Objectives: The symptoms and mucosal damage that occur in gastroesophageal reflux disease (GERD) may be a consequence of either an increased frequency of reflux events or of a prolonged process of esophageal acid clearance. Acid clearance is dependent both upon effective esophageal emptying of luminal fluid and on normal salivary function to titrate residual acid to neutrality. This investigation examined the efficacy of esophageal emptying in a large group of GERD patients., Methods: Barium swallow examinations were done to categorize and quantify esophageal emptying dysfunction in 67 consecutive patients with reflux disease, compared with 85 patient asymptomatic controls. Quantitative fluoroscopic estimates of esophageal residua were compared with scintigraphic quantification in 14 controls and 20 GERD patients., Results: There was progressive impairment of esophageal emptying in the reflux patients without esophagitis compared with the controls, and it was even greater in patients with endoscopically evident esophagitis compared with reflux patients without esophagitis. Good correlation existed between the fluoroscopic and scintigraphic assessment of esophageal emptying., Conclusions: These findings support the hypothesis that impaired esophageal emptying is an important determinant in the development of esophagitis among reflux patients. The dominant site of impaired emptying in the reflux patients was the phrenic ampulla as opposed to the tubular esophagus, suggesting a pathophysiological contribution of hiatus hernia.

While oesophageal obstacles are responsible for regurgitation or aspiration in neonates and infants, older children present with dysphagia. Before any investigation, a buccopharyngeal infection must first be eliminated clinically. In the absence of fever, the ingestion of a foreign body or caustic substances must be considered, either in an acute context, or in a chronic context related to cicatricial stenosis. Tumour or congenital lesions are less common, whether intrinsic (stenosis, fistulas, duplications), or extrinsic (vascular malformations, mediastinal tumours). Radiological investigation is based on simple techniques: chest X-ray and barium swallow are usually sufficient to establish the aetiological diagnosis.

Gastric volvulus may present acutely with Borchardt's triad or with chronic vague abdominal symptoms. Predisposing factors include lax ligaments, bands, adhesions, paraesophageal diaphragmatic hiatus hernia, and eventration of the diaphragm. The goals of surgery are to detorse the stomach, correct conditions associated with volvulus and prevent a recurrence. Anterior gastropexy with or without colon displacement is mandatory. Gastric resection may be required for strangulation and necrosis.

We evaluated the relationship between gastroesophageal scintigraphy, endoscopy, and biopsy in 48 gastrectomy patients (33 with reflux and 15 without reflux symptoms). Endoscopic esophagitis was demonstrated in 78.8% of the patients with reflux symptoms, histological esophagitis was found in 72.2% of them, and scintigraphic reflux was found in 81.8%. Either endoscopic or histological esophagitis was recognized in 93.7% of the patients with reflux symptoms, while either scintigraphic reflux or endoscopic esophagitis was demonstrated in 97.0%. Scintigraphic reflux was significantly more common in patients with histological esophagitis than in those without it (92.9% vs. 40%, p < 0.01). In addition, it was found in 74.2% of patients with and 64.7% of patients without endoscopic esophagitis. The reflux index tended to increase as the grades of esophagitis increased; there was an approximate relationship between the two parameters. Our study suggested that scintigraphy reflects histological esophagitis rather than endoscopic esophagitis, and that there was an approximate relationship between the reflux index and the endoscopic grade of esophagitis. In addition, performance of scintigraphy and endoscopy combined with esophageal biopsy increased the diagnostic yield in gastrectomy patients with reflux symptoms.

We used scintigraphy to detect and quantify gastro-esophageal reflux, and determined the sensitivity of this method for identifying patients with clinical symptoms and/or endoscopic evidence of reflux. Thirty gastrectomy patients with heartburn and regurgitation, and 8 healthy controls were studied. The gastro-esophageal reflux index, calculated from imaging data, correlated significantly with the symptom score of the subjects, and the index was significantly larger in the symptomatic patients group (7.07 +/- 1.21) than in the healthy control group (1.54 +/- 0.22) (p < 0.001). Our study suggests that scintiscanning is capable of detecting gastro-esophageal reflux accurately, rapidly, noninvasively, and with a high degree of sensitivity. In addition, scintiscanning can be employed to quantify reflux in gastrectomy patients.

In an attempt to ascertain radiologic efficacy in patients with evidence of gastroesophageal reflux disease (GERD) at pH testing, radiographic findings were correlated with pH values obtained with an esophageal monitor worn for a 24-hour period in 112 patients. Fifteen (30%) of 50 patients with abnormal pH test results had esophagitis diagnosed radiographically, compared with six (10%) of 62 with normal pH test results (P < .05). The severity of abnormal pH monitoring results was classified but did not correlate significantly with the prevalence of esophagitis diagnosed radiographically. Hiatal hernia was also more common (80% vs 60%) in patients with abnormal pH test results (40 of 50 patients) than in those with normal results (37 of 62 patients) (P < .05). Pharyngeal, laryngeal, and pulmonary symptoms were common indications for evaluation, and 14 of 27 (52%) patients with hoarseness had an abnormal pH tracing. Only a minority of patients with evidence of GERD as defined by abnormal pH test results had reflux esophagitis diagnosed radiographically.

The purpose of this study is to determine if frequent reflux events from an incompetent LES or poor clearance from decreased peristalsis is the predominant abnormality in PSS patients with severe reflux esophagitis. Seven patients with both classic manometric findings of PSS and endoscopic findings of esophageal ulcerations and/or Barrett's esophagus were compared to nine patients with similar endoscopic findings but with no evidence of a connective tissue disorder. All patients underwent simultaneous intraesophageal pH monitoring and scintigraphy for a total of 40 min after a radiolabeled meal. Four of the PSS patients and all the non-PSS patients had simultaneous manometry. We found that PSS patients had significantly fewer reflux events (P less than 0.01), but the reflux events had significantly longer duration (P less than 0.01) compared to patients with similar severity of esophagitis and no connective tissue disease. We conclude that decreased smooth muscle peristalsis appears to be the primary contributor to acid exposure and esophageal injury in PSS.

Of 15 patients operated on for achalasia in the Department of General and Abdominal Surgery at the University of Mainz between September 1985 and April 1990, 14 were followed-up. All the patients had received an extramucous myotomy combined with Dor's semifundoplication; in twelve, one or more preoperative balloon dilatations had been performed. The results are reported in this study. The average age of the patients was 55.3 years (18 to 76 years), and the average follow-up period 21 months (six to 53 months). No postoperative complications were seen in any of the case. All patients reported appreciable improvements in their symptoms, six being completely symptom-free. Occasional dysphagia was reported in six cases, one patient had occasional, another frequent, nocturnal heartburn, which however had already presented preoperatively. In all seven cases submitted to postoperative radiological examination, the diameter of the esophagogastric junction was increased, and the diameter of the middle-third of the esophagus decreased. No gastroesophageal reflux or signs of inflammation were seen in any of the cases. The low complication rate and the high success rate despite prior balloon dilatation or bougienage support the use of Heller's operation combined with Dor's semifundoplication for the surgical treatment of achalasia after failed balloon dilatation.

Twelve patients presenting with symptomatic esophagitis associated with hiatal hernia and gastroesophageal reflux underwent operative management under laparoscopic guidance. The antireflux procedure employed was the Nissen fundoplication. The authors completed the operation laparoscopically in nine patients. Postoperatively, patients were evaluated with repeat fiberoptic endoscopy, esophageal manometry, and barium contrast studies. Postoperative results were considered excellent on the basis of these studies and complete control of symptoms. The mortality rate was 0%. The only major operative complication was a pneumonia that occurred in one patient. At 1 month follow-up, six patients were totally asymptomatic. The authors conclude that laparoscopic treatment of gastroesophageal reflux associated with a hiatal hernia is feasible by a procedure that has already proven its value during open surgery.

To compare reflux events detected by intraesophageal pH monitoring with that of scintigraphy, we simultaneously performed both techniques along with esophageal manometry in nine patients with severe reflux esophagitis. Two hundred eighteen reflux events were detected in the recumbent posture after a meal during a 40-min interval. Both techniques simultaneously detected only 23% of all reflux events. Scintigraphy alone detected 61% of all reflux events as opposed to 16% for pH monitoring. Of those reflux events diagnosed only by scintigraphy, more occurred while the intraesophageal pH was less than 4 (ie, during an acid-clearing interval) than while the intraesophageal pH was greater than 4 (ie, when intragastric contents were neutralized by the meal). Most reflux events occurred during periods of stable, but low LES pressure. While reflux events diagnosed by scintigraphy significantly decreased during the second of two 20-min postprandial intervals, those by pH monitoring tended to increase. That simultaneous scintigraphy and pH monitoring agreed on less than 1/3 of all reflux events not only underscores the fact that both techniques measured different physical components of the esophageal refluxate (ie, volume vs acid concentration, respectively), but also were influenced by different physiologic events such as the ingestion of a meal, gastric emptying, and esophageal acid clearance.

This article presents a pattern approach for diagnosing esophagitis at double-contrast esophagography. In patients with nodular elevations of the mucosa, discrete plaques should suggest Candida esophagitis, whereas poorly defined nodules should suggest reflux esophagitis and a distinctive reticular pattern of the mucosa should suggest Barrett esophagus, particularly if adjacent to the distal aspect of a high stricture. In patients with ulceration, one or more shallow ulcers at or near the gastroesophageal junction should suggest reflux esophagitis, whereas discrete, superficial ulcers in the midesophagus should suggest herpes or drug-induced esophagitis, depending on the clinical setting. In contrast, one or more giant, relatively flat ulcers should suggest cytomegalovirus esophagitis, particularly in patients with acquired immunodeficiency syndrome. Finally, thickened longitudinal folds may be caused by esophagitis, varices, or, rarely, "varicoid" carcinoma, but these conditions usually can be differentiated on radiologic grounds. By carefully analyzing the appearance and location of nodules, plaques, ulcers, or abnormal folds in the esophagus, one can usually suggest a cause of the disease.

After resection of a cardia carcinoma a gastric obstruction was observed. Because of a severe esophagitis the planned operation could not be performed. In the following a method of palliative treatment of pyloric dysfunction is described. Under fluoroscopic control a stiff balloon catheter was introduced into the stomach. Under endoscopic control a guide wire fitting the central lumen of the balloon catheter was passed into the pylorus by use of a biopsy forceps. Under endoscopic and fluoroscopic control the guide wire was positioned in the duodenum. Than the balloon catheter was passed through the pylorus both, under endoscopic and fluoroscopic control and inflated. No complication was observed. After dilatation of pylorus the patient was able to take food as usual. In the following weeks the esophagitis was treated and the pyloroplasty was performed successfully.

A method is presented which combines gastro-oesophageal reflux quantification and oesophageal transit measurement so as to differentiate true reflux from residual oesophageal activity. A group of 33 subjects with gastro-oesophagitis reflux symptoms and endoscopically confirmed reflux oesophagitis and a group of 21 asymptomatic subjects with normal oesophageal, gastric and duodenal endoscopic findings were examined. The subjects were given 37 MBq 99mTc-Sn-colloid in saline orally and then scintiscanned dynamically. The gastro-oesophageal quantification was done after transit measurement and after the oesophageal time activity (to detect residual oesophageal activity) reached its minimum. The difference in the reflux indices between the two groups was highly significant. In low-grade oesophagitis measured reflux was lower than in higher grades of disease. Only 4.7% false-positive results were observed with a specificity of 95%, indicating that this method may be superior to methods published earlier.

The influence of Cisapride on food-stimulated gastro-oesophageal reflux mechanisms was studied in a double-blind cross-over investigation in 24 consecutive patients selected by endoscopy, 12 with microscopical evidence of gastro-oesophageal reflux and 12 with additional macroscopic oesophagitis. 63% had food-stimulated gastro-oesophageal reflux, and Cisapride significantly reduced the tendency to gastro-oesophageal reflux and mucosal contact time between gastric content and the oesophageal mucosa in 73% of these patients. It is concluded that Cisapride could be valuable in the treatment of gastro-oesophageal reflux.

Histological biopsy and radionucleotide scintigraphy (RNS) were carried out in 39 patients with symptoms and esophagoscopy evidence of gastroesophageal reflux disease. The detective rates were 74% and 79% respectively. The mechanism were discussed. There was no correlation between histological changes, RNS and clinical TCM types based on the theory of TCM.

We report a patient with acquired "double cardia" (esophagogastric fistula). She was a 76-year-old farmer's widow with severe kyphosis. She presented with postprandial heartburn one month after the initiation of nifedipine and isosorbide dinitrate. Radiologic and endoscopic examinations revealed an esophagogastric fistula, short esophagus with hiatal hernia, Barrett's esophagus with reflux esophagitis, and ulcer. This case shows that repeated reflux esophagitis and esophageal ulcer, complicated with short esophagus and hiatal hernia, can predispose to the formation of esophagogastric fistula.

A review of 26 cases of columnar-lined (Barrett's) esophagus suggests that this lesion is more common than generally appreciated, usually arising consequent to reflux esophagitis. The radiologically detectable lesions frequently do not support the idea that Barrett's esophagus presents only with high esophageal ulcer and/or stricture. Hiatal hernia, gastroesophageal reflux, stricture, ulcers, and even minor mucosal abnormalities may be present alone or in combination, and may be variably located.

A simple method for obtaining double-contrast views of the oesophagus as part of the routine double contrast examination of the upper gastrointestinal tract using high-density low-viscosity barium is described. The typical radiological changes of early peptic oesophagitis (confirmed by endoscopy) which can be readily demonstrated with this technique are illustrated as an example of its practical value. These consist of 'smudged' or 'cobble-stone' mucosa with thickened and distorted longitudinal folds. Superficial erosions and deep ulcers may also be seen. It is suggested that endoscopic confirmation of these characteristic radiological signs of peptic oesophagitis is unnecessary.

We reviewed the radiographic findings in thirty patients with columnar-lined (Barrett's) esophageal mucosa. Gastroesophageal reflux was observed in 90%, hiatal hernia in 83%, stricture in 80% and esophageal ulceration in 33%. Superficial nodular mucosal changes were detected on 50% of the air contrast esophagrams. Prominence of this pattern may be associated with dysplastic or early malignant change. In addition, four conditions associated with secondary lower esophageal sphincter incompetence were identified in our patient group. These were scleroderma, previous myotomy for achalasia, previous gastric surgery and long-term indwelling nasogastric tubes.

In this prospective, blind study we compare the diagnostic results of endoscopy with a biphasic radiologic examination with drug-induced hypotony in gastric malignancy, peptic ulcer, and reflux esophagitis. Two hundred fourteen patients underwent both examinations within a week. Both disciplines detected seven malignant tumors. Twenty-three peptic ulcers were found by both; in addition, each diagnosed another ulcer. Fourteen ulcer scars were diagnosed by both; endoscopy demonstrated 10 additional scars and radiology 1. The radiologic examination detected 7 of the 37 cases of endoscopically diagnosed cases of mild reflux esophagitis, 4 of the 7 moderate cases, and 7 of 8 severe ones. A state-of-the-art radiologic examination represents an adequate initial examination in the dyspeptic patient. If the complaints suggest reflux esophagitis, the clinician has to choose between treatment and endoscopy.

Eleven patients who required reoperation for persistent or recurrent symptoms after esophagomyotomy are reported on. Failure of the original operation was attributed to inadequate myotomy in three, healed myotomy in four, and reflux esophagitis in four. The myotomy was extended or a new myotomy created in the first two categories of patients. Three of the four patients with reflux esophagitis were treated by antrectomy and Roux-en-Y esophagojejunostomy; one of these also required concomitant exision of the esophagogastric junction because of stricture. The fourth patient with esophagitis ultimately required colonic interposition for relief of symptoms. Ten of the eleven patients were improved after reoperation, but results were less good than those achieved by a properly performed primary esophagomyotomy. This -re-emphasizes the need for attention to the technical details of esophagomyotomy if good results are to be achieved.

Out of 5000 consecutive double-contrast examinations of the esophagus, 50 cases presented a diffuse finely granular or nodular appearance of the mucosa. Endoscopy was subsequently performed in 38 cases and biopsy in the majority of these. In 23 of the 38 verified cases the diagnosis was reflux esophagitis. In the other 15 cases the diagnoses were: candidal esophagitis (4), leukoplakia (2), glycogenic acanthosis (1), and diffuse leiomyomatosis (1). A normal mucosa was demonstrated in 7 cases. Our study indicates that a radiologically granular or nodular appearance of the esophageal mucosa often indicates reflux esophagitis and less commonly identifies diffuse lesions of variable origin.

A prospective radiologic-endoscopic study of the esophagogastric region in 266 patients, including 206 normals and 60 with esophagitis, is reported. The endoscopic classification grading severity of esophagitis was grade 1 -- normal; grades 2, 3, and 4 -- mild, moderate, and severe esophagitis, respectively. Radiology detected 22% of patients with mild esophagitis, 83% with moderate esophagitis, and 95% with severe esophagitis. Although hiatal hernia was present in 40% of normals and 89% with esophagitis, absence of radiographic hiatal hernia excluded esophagitis with 95% accuracy. The implications of this study regarding the role of radiology in evaluating patients with suspected reflux esophagitis are discussed.

Initially, scintigraphy was established as a valid method for detecting and quantitating enterogastric reflux. A new, tubeless technique for the measurement of enterogastric reflux was developed. 99mTc bound to [(2,6 dimethylphenylcarbamoylmethyl) iminodiacetic acid] (5 mCi) was administered intravenously to visualize the liver and biliary tract. One hour later, a standard liquid meal labeled with 111In bound to diethylene-triamine penta-acetic acid (250 microCi) was given. The 99mTc and 111In activities were recorded simultaneously for 1-min periods at 15-min intervals for 2 hr over liver, gallbladder, and gastric areas of interest. Enterogastric reflux indices were determined. Ten normal subjects and 13 patients with vagotomy, hemigastrectomy, and Bilroth II gastrojejunostomy were evaluated. The enterogastric reflux index in asymptomatic postsurgical patients was increased significantly to 24.6 +/- 4.7 compared with 8.2 +/- 6.0 (P less than 0.01) in normal subjects. In postsurgical patients with the syndrome of alkaline gastritis, the enterogastric reflux index was increased significantly to 86.3 +/- 7.1 (P less than 0.01) compared with asymptomatic postsurgical patients.

In the two years 1974--1976, the radiographic diagnosis of peptic ulcer of the oesophagus was made in 14 patients. All these patients showed oesphagogastric reflux at fluoroscopy, 13 had an axial hiatus hernia. The ulcer lay at the oesophagogastric junction in 13 patients, in one patient it was located 5 cm. above the cardia. Endoscopy was performed in 11 patients and confirmed the X-ray diagnosis. The authors believe the best technique for this purpose to be "hypotonic oesophogography" and that this is essential for the differential diagnosis between benign and malignant ulcers.

Barrett's esophagus was diagnosed in 26 men in a five-year period by demonstrating esophageal specialized columnar epithelium in target biopsies obtained at endoscopy or in peroral suction biopsies of the esophageal mucosa. The clinical, radiologic and manometric features of these patients were reviewed retrospectively. Esophageal lesions associated with this epithelium included distal and midesophageal strictures and ulcers, alone or in combination, or simply esophagitis. One patient had an associated adenocarcinoma. Twenty of 26 (77%) had heartburn or regurgitation, 16 (62%) had easily elicited reflux of barium while supine and 16 of 17 tested had lower esophageal sphincter pressure in the incompetent range. Ninety-six percent had one or more of these parameters positive. This series demonstrates a wide spectrum of esophageal lesions in Barrett's esophagus, and supports the concept that this lesion occurs as a consequence of gastroesophageal reflux and erosive esophagitis. The case of adenocarcinoma in this series adds to the concern that the columnar lined lower esophagus may be a premalignant lesion.

Motor function disturbances (MFD) of the esophagus occur in the majority (90%) of patients with systemic sclerosis. We have tested the diagnostic value of esophagus scintigraphy in 20 patients with systemic sclerosis (12 CREST and 8 with diffuse form) and 18 controls (11 normals and 7 with pyrosis and/or regurgitation), in order to establish sensitivity, specificity, effects of body posture, and use of a liquid or solid meal in the evaluation of MFD of the esophagus. The patients drank 4 ml of fruit juice marked with 500 microCi of 99mTc-sulfur-colloid and afterwards 10 g of an equally marked and scrambled egg. Pictures were made with a Gamma-Camera until 180 s. Radioactivity was plotted against time and separately analysed for the upper, middle and distal esophagus. 65% of the systemic sclerosis patients had dysphagia and 70% had abnormal barium meal transit in the esophagus. The scintigrams were altered in all the patients with systemic sclerosis (p less than 0.001). Sensitivity using fluids was 95%, and specificity was 89%; with solid food 100% and 50%, respectively. Tests done in the upright position showed a better clearance of the esophagus in patients with systemic sclerosis and control patients, with loss of sensitivity. The qualitative analysis yielded little benefit to the reported results. The quantitative analysis under use of 2 indices (total transit time and clearance rate) permitted a clear distinction among patients and control individuals with and without upper digestive symptoms in the first 15 s of the test. The esophagus scintigraphy is a simple, quantitative and very sensitive method for the diagnosis of MFD of the esophagus in patients with systemic sclerosis.

The major advance in the radiographic detection of peptic ulcers and their sequelae in the past decade has been the utilization of air-barium double-contrast studies of the esophagus, stomach, and duodenum. In many reported series, a decrease in the error rate, from 20-50% using single-contrast radiography, to 10-20% using double-contrast or combination single- and double-contrast radiographic techniques, has been noted. Double-contrast radiography has had a particularly great impact in the diagnosis of duodenal, gastric, and esophageal erosions. These shallow, superficial changes are not detected with single-contrast radiography. False-negative radiographic diagnoses still occur with double-contrast techniques because of (1) erosions too small to detect, (2) ulcers obscured by enlarged folds or a deformed duodenal bulb, and (3) poor mucosal coating and increased secretions. False-positive diagnoses occasionally occur because of precipitation or trapping of barium between gastric and duodenal folds. The improvements in overall radiographic diagnosis using a double-contrast technique indicate that this technique should be employed whenever possible for the evaluation of peptic ulcer disease.

Radionuclide esophageal scintigraphy is a sensitive test of esophageal function, but its usefulness is not well documented in Barrett esophagus. This technique was prospectively studied in 27 patients with histologically proved Barrett esophagus and 17 patients with biopsy-confirmed reflux esophagitis. The esophageal transit time and percentage of emptying were calculated. The only quantitative parameter of radionuclide esophageal scintigraphy to show a significant difference between the two conditions was the percentage of emptying, which was abnormal in 48% of patients with Barrett esophagus versus 31% of patients with reflux esophagitis. In the latter group, the mean percentage of emptying approached normal (89.5%), while in the former group it was decreased to 82.1% (P less than .05). Neither emptying parameter correlated with length of Barrett esophagus. These data support the hypothesis of inherent esophageal dysmotility in Barrett esophagus. Half of the patients with this condition have impaired esophageal clearance and may benefit from drug therapy.

We undertook a prospective study comparing the sensitivities of double-contrast and tube esophagography in 34 patients with gastroesophageal reflux and compared our findings with those at endoscopy. Neither test detected changes accurately in mild inflammation; however, they both became more sensitive as the severity of esophagitis increased. The sensitivity of both tests increased from 0% in grade 2 to 86% in grade 4 esophagitis. The tube esophagogram demonstrated inflammatory changes better than the double-contrast esophagogram in only 18% of the 34 patients, all with grade 3 or 4 esophagitis, despite the elimination of the barium pool in the distal esophagus and improved distension of the esophagogastric junction. Endoscopy is still the most reliable means of diagnosing and grading esophagitis.