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Acid reflux is a poor predictor of severity of esophageal mucosa injury
April 2000
AGAA477
2582
2584
PATHOPHYSIOLOGICAL FEATURES OF DECREASED VASCU· LARITY AROUND SQUAMOCOLUMNAR JUNCTION IN PATIENTS WITH ENDOSCOPY-NEGATIVE GASTROESOPHAGEAL REFLUX DISEASE. Jun-ichi Akiyama, Kei Matsueda, Shoda Ryosuke, Shigeru Yamato, Akira Muraoka, Masako Asayama, Hideya Yoshinaga, Hiroyuki Oka, Hitoshi Baba, Hiroko Yamashita, Naohiko Masaki, Shigeki Hayashi, IntI Med Ctr of Japan, Tokyo, Japan.
ACID· REFLUX IS A POOR PREDICTOR OF SEVERITY OF ESOPHAGEAL MUCOSA INJURY. Benjamin Avidan, Amnon Sonnenberg, Thomas G. Schnell, Stephen J. Sontag, VA Med Ctr - 11IF, Albuquerque, NM; VA Hosp, Hines, IL.
Background: Several randomized controlled studies have shown that treatment with proton pump inhibitor is beneficial to improve heartburn and quality of life in patients with endoscopy-negative reflux disease (ENRD). However, the majority of those patients have no evidence of increased acid reflux determined by pH monitoring, and the pH monitoring itself is considered to be of limited value to define the pathophysiology of ENRD. The current definition of acid reflux (such as % T with pH<4.0) in the pH monitoring could be inappropriate to detect and quantitate mild degree of acid reflux. On the other hand, the patients with ENRD may have an endoscopic finding of decreased vascularity around squamocolumnar junetion(DV around SCJ), but its clinical role in ENRD has not been well defined. Aims: The aim of this study was to evaluate the pathophysiological features of DV around SCJ in patients with ENRD. Subjects & Methods: We enrolled 24 consecutive patients with ENRD to our study during the last 2 years. Of 24 patients, 5 had normal vascularity around the SCJ (NV around SCJ) and 19 had DV around SCJ. The acid reflux was determined by utilizing either of the following five different criteria: namely pH<5.0, <4.0, <3.0, <2.0 and <1.0. After 24 hour pH monitoring, the amount of acid reflux was calculated with the each criterion, and their indices of reflux time ( %T) and acid reflux area (ARA) were compared. Moreover, biopsy specimens just above SCJ were obtained for histological diagnosis. Results: The amount of acid reflux was greater in DV around SCJ than in NY around SCJ, and statistical significance was noted with indices of % T and ARA with pH<3 (p=0.04, 0.01) and pH<2 (p=0.02, 0.02), but not by those with pH<5 (p=0.43, 0.12), pH<4 (p=O.l4, 0.06), or pH<1 (0.23,0.42). Histologically, basal cell hyperplasia and intraepithelial inflammatory cells were found in all patients, papillary elongation in 60% , and balloon cells in 90% of patients with DV around SCJ. Discussion & Conclusions: With utilizing new criteria of acid reflux (pH<3.0 or <2.0, which has 10 or 100 folds in H+ concentration than pH<4.0), the patients with decreased vascularity around SCI was proven to have excess of acid reflux as compared with NV around SCJ. The decreased vascularity around SCJ also reflected mild histological esophagitis. These findings suggest that decreased vascularity around SCJ indicates distinctive reflux esophagitis, and should be separated from ENRD.
2583 CHRONIC COUGH AND GASTROESOPHAGEAL REFLUX • 5 YEAR FOLLOW UP AFTER LAPAROSCOPIC NISSEN FUNDO· PLICATION. Christopher J. Allen, Mehran Anvari, St Joseph's Hosp, Hamilton, ON, Canada; McMaster Univ, Hamilton, ON, Canada. Chronic cough is commonly associated with gastroesophageal reflux disease (GERD). Patients who do not respond to medical antireflux therapy may need surgery. We report results of a prospective consecutive case series of 640 patients who underwent laparoscopic Nissen fundoplication (LNF). Patients were assessed with esophageal motility and 24 hour pH recording, GERD symptom and cough scores, before, 6 months, 2 and 5 years after surgery. 462 of 588 (78%) eligible patients underwent 6 month evaluation, 256 of 492 (52%) 2 year and 77 of 157 (49%) 5 year evaluation. Of the 157 eligible 5 year patients 47 (30%) refused follow up, 30 (19%) had moved or could not be traced, and 3 had died of unrelated causes. Results: 26 % of the patients presented with respiratory symptoms. Their reflux profiles were identical to the GI patients, but more of them had cough (88% vs 54%) however their cough and GERD symptoms did equally well after surgery. We conclude that LNF gives excellent long term control of GERD. Cough is a common symptom in patients with GERD and in 75% of patients shows a long term improvement after antireflux surgery.
24hrpH (%pH,;4) LES Tone (mmHg) GERD Symptom Score Number with Cough (%) Cough Score Cough Improved (%) 'p < 0.0001
Preop mean (SEM)
6 months mean (SEM)
2years mean (SEM)
5years mean (SEM)
9.2 (0.4) 6.2(0.2) 343(06) 63% 9.0 (0.2)
13(0.1)" 19.2 (0.5)' 12.1 (0.6)' 35% 2.7 (0.2)' 86%
1.7 (0.3)' 17.1 (0.7)' 13.7 (0.9)' 44% 3.9(03)' 77%
1.0 (0.3)' 15.4 (1.3)' 14.1 (1.4)' 47% 4.7 (0.7)' 75%
Background and Aims: It is unknown which factors determine the severity of mucosal damage in gastroesophageal reflux disease (GERD). The aim of this study was to determine whether the amount of esophageal acid exposure could be used to predict the severity of mucosal injury in erosive reflux esophagitis. Methods: A total of 644 outpatients with symptomatic GERD underwent an esophagogastroduodenoscopy followed by esophageal manometry and 24-hour pH monitoring. GERD was graded according to the endoscopic severity of mucosal damage as follows: no erosions (n=314), single erosions (208), confluent erosions (69), esophageal ulcers (48), and strictures (5). A multiple linear regression was used to assess the joint influences of demographic characteristics, social habits, and various GERD parameters on the severity of esophageal injury. Results: No c1earcut association between the amount of acid reflux and the severity of esophagitis could be established. The individual parameters of esophageal pH monitoring, such as upright or supine acid contact time, frequency of all or only long reflux episodes, and an overall summary score of pH metry, revealed no or only weak correlations with the severity grade of erosive reflux esophagitis, the Pearson correlation coefficients ranged between r=0.06 and r=0.39. Similarly, the pressure of the lower esophageal sphincter was only slightly more decreased in patients with extensive erosive esophagitis as compared to subjects without esophageal erosions (I2.4:t9.3 vs. 13.3:t9.2 mmHg). In the multiple linear regression, the strongest influence on esophageal injury was exerted by the presence of hiatus hernia (t=7.63, p
2585 GASTRIC ACID SECRETION INCREASES WITH SEVERITY OF GASTRO-ESOPHAGEAL REFLUX IN CHILDREN. Abdul-Monem Badran, Nicolas Kalach, Patrick Jaffray, Said Hadji, PierreHenri Benhamou, Christophe Dupont, Hosp saint Vincent de Paul, Paris, France; Hosp cochin, Paris, France. Background: The demonstration of highly variable dosages of proton pump inhibitors (PPIs) to obtain similar effects on pH metric recordings underlines a variable impact of these drugs on gastric acid secretion. Considering their potentially wide and prolonged use in children suffering from gastroesophageal reflux (GER), it was decided to systematically evaluate gastric acid output in children with severe and long lasting GER in order to assess the need for anti-acid treatment. Patient and methods: The investigation was carried out in 29 children (17 males and 12 females, aged 8.4:t4.3 years) with prolonged (>18 months) clinical manifestations of GER. All underwent routine ambulatory 24-h esophageal pH-monitoring and gastric acid secretion measurement including gastric basal acid output (BAD), /-LmollKg/h, maximal acid output (MAO) and peak acid output (PAO) after pentagastrin (6 /-Lg/Kg) stimulation. Children with pyrosis or abdominal pain underwent upper fiber-endoscopy. In group A (moderate GER, n=9), patients had a normal ESPGHAN reflux index (pH<4 below 5.2% of total recording time) despite abnormal Euler and Byrne (Gastroenterology 1981; 80:957-61) scoring: total number of 24 h reflux episodes plus 4 times the number of reflux episodes above 5 minutes> 50. In group B (severe GER, n=16, among whom 4 with grade III oesophagitis), the reflux index was >5.2%. A control group consisted of 4 with gastritis routinely explored for gastric acid hyper-secretion. Written parental consent was obtained in all children. Results: The children with GER, esophageal pH (%) was significantly correlated with MAO and PAD, r 0.41, p=O.04 and r 0.45, p=0.02 respectively. Group B children exhibited significantly higher median BAD (70, 95%IC 47.56-143.25), MAO (468, IC 301.6-1149.8) and PAD (617, IC 509.9·806.4) than those of group A, BAD (24, IC 11.5-39.5), MAO (260, IC 223.7-329.3) and PAD (356, IC 302.3-431.4), p<0.05. In group B, the 4 children with severe esophagitis exhibited significant higher median BAD, MAO and PAD than the other 12 children from the same group, group A, and children with gastritis, p<0.05. Conclusion: II Children with severe GER hyper-secrete gastric acid; 21 Individual variations in gastric acid secretion probably account for variations in gastric acid inhibitors requirements; 31 Individual assessments of gastric acid secretion might be useful when deciding prolonged medical anti-acid treatment.
AGAA477
2582
2584
PATHOPHYSIOLOGICAL FEATURES OF DECREASED VASCU· LARITY AROUND SQUAMOCOLUMNAR JUNCTION IN PATIENTS WITH ENDOSCOPY-NEGATIVE GASTROESOPHAGEAL REFLUX DISEASE. Jun-ichi Akiyama, Kei Matsueda, Shoda Ryosuke, Shigeru Yamato, Akira Muraoka, Masako Asayama, Hideya Yoshinaga, Hiroyuki Oka, Hitoshi Baba, Hiroko Yamashita, Naohiko Masaki, Shigeki Hayashi, IntI Med Ctr of Japan, Tokyo, Japan.
ACID· REFLUX IS A POOR PREDICTOR OF SEVERITY OF ESOPHAGEAL MUCOSA INJURY. Benjamin Avidan, Amnon Sonnenberg, Thomas G. Schnell, Stephen J. Sontag, VA Med Ctr - 11IF, Albuquerque, NM; VA Hosp, Hines, IL.
Background: Several randomized controlled studies have shown that treatment with proton pump inhibitor is beneficial to improve heartburn and quality of life in patients with endoscopy-negative reflux disease (ENRD). However, the majority of those patients have no evidence of increased acid reflux determined by pH monitoring, and the pH monitoring itself is considered to be of limited value to define the pathophysiology of ENRD. The current definition of acid reflux (such as % T with pH<4.0) in the pH monitoring could be inappropriate to detect and quantitate mild degree of acid reflux. On the other hand, the patients with ENRD may have an endoscopic finding of decreased vascularity around squamocolumnar junetion(DV around SCJ), but its clinical role in ENRD has not been well defined. Aims: The aim of this study was to evaluate the pathophysiological features of DV around SCJ in patients with ENRD. Subjects & Methods: We enrolled 24 consecutive patients with ENRD to our study during the last 2 years. Of 24 patients, 5 had normal vascularity around the SCJ (NV around SCJ) and 19 had DV around SCJ. The acid reflux was determined by utilizing either of the following five different criteria: namely pH<5.0, <4.0, <3.0, <2.0 and <1.0. After 24 hour pH monitoring, the amount of acid reflux was calculated with the each criterion, and their indices of reflux time ( %T) and acid reflux area (ARA) were compared. Moreover, biopsy specimens just above SCJ were obtained for histological diagnosis. Results: The amount of acid reflux was greater in DV around SCJ than in NY around SCJ, and statistical significance was noted with indices of % T and ARA with pH<3 (p=0.04, 0.01) and pH<2 (p=0.02, 0.02), but not by those with pH<5 (p=0.43, 0.12), pH<4 (p=O.l4, 0.06), or pH<1 (0.23,0.42). Histologically, basal cell hyperplasia and intraepithelial inflammatory cells were found in all patients, papillary elongation in 60% , and balloon cells in 90% of patients with DV around SCJ. Discussion & Conclusions: With utilizing new criteria of acid reflux (pH<3.0 or <2.0, which has 10 or 100 folds in H+ concentration than pH<4.0), the patients with decreased vascularity around SCI was proven to have excess of acid reflux as compared with NV around SCJ. The decreased vascularity around SCJ also reflected mild histological esophagitis. These findings suggest that decreased vascularity around SCJ indicates distinctive reflux esophagitis, and should be separated from ENRD.
2583 CHRONIC COUGH AND GASTROESOPHAGEAL REFLUX • 5 YEAR FOLLOW UP AFTER LAPAROSCOPIC NISSEN FUNDO· PLICATION. Christopher J. Allen, Mehran Anvari, St Joseph's Hosp, Hamilton, ON, Canada; McMaster Univ, Hamilton, ON, Canada. Chronic cough is commonly associated with gastroesophageal reflux disease (GERD). Patients who do not respond to medical antireflux therapy may need surgery. We report results of a prospective consecutive case series of 640 patients who underwent laparoscopic Nissen fundoplication (LNF). Patients were assessed with esophageal motility and 24 hour pH recording, GERD symptom and cough scores, before, 6 months, 2 and 5 years after surgery. 462 of 588 (78%) eligible patients underwent 6 month evaluation, 256 of 492 (52%) 2 year and 77 of 157 (49%) 5 year evaluation. Of the 157 eligible 5 year patients 47 (30%) refused follow up, 30 (19%) had moved or could not be traced, and 3 had died of unrelated causes. Results: 26 % of the patients presented with respiratory symptoms. Their reflux profiles were identical to the GI patients, but more of them had cough (88% vs 54%) however their cough and GERD symptoms did equally well after surgery. We conclude that LNF gives excellent long term control of GERD. Cough is a common symptom in patients with GERD and in 75% of patients shows a long term improvement after antireflux surgery.
24hrpH (%pH,;4) LES Tone (mmHg) GERD Symptom Score Number with Cough (%) Cough Score Cough Improved (%) 'p < 0.0001
Preop mean (SEM)
6 months mean (SEM)
2years mean (SEM)
5years mean (SEM)
9.2 (0.4) 6.2(0.2) 343(06) 63% 9.0 (0.2)
13(0.1)" 19.2 (0.5)' 12.1 (0.6)' 35% 2.7 (0.2)' 86%
1.7 (0.3)' 17.1 (0.7)' 13.7 (0.9)' 44% 3.9(03)' 77%
1.0 (0.3)' 15.4 (1.3)' 14.1 (1.4)' 47% 4.7 (0.7)' 75%
Background and Aims: It is unknown which factors determine the severity of mucosal damage in gastroesophageal reflux disease (GERD). The aim of this study was to determine whether the amount of esophageal acid exposure could be used to predict the severity of mucosal injury in erosive reflux esophagitis. Methods: A total of 644 outpatients with symptomatic GERD underwent an esophagogastroduodenoscopy followed by esophageal manometry and 24-hour pH monitoring. GERD was graded according to the endoscopic severity of mucosal damage as follows: no erosions (n=314), single erosions (208), confluent erosions (69), esophageal ulcers (48), and strictures (5). A multiple linear regression was used to assess the joint influences of demographic characteristics, social habits, and various GERD parameters on the severity of esophageal injury. Results: No c1earcut association between the amount of acid reflux and the severity of esophagitis could be established. The individual parameters of esophageal pH monitoring, such as upright or supine acid contact time, frequency of all or only long reflux episodes, and an overall summary score of pH metry, revealed no or only weak correlations with the severity grade of erosive reflux esophagitis, the Pearson correlation coefficients ranged between r=0.06 and r=0.39. Similarly, the pressure of the lower esophageal sphincter was only slightly more decreased in patients with extensive erosive esophagitis as compared to subjects without esophageal erosions (I2.4:t9.3 vs. 13.3:t9.2 mmHg). In the multiple linear regression, the strongest influence on esophageal injury was exerted by the presence of hiatus hernia (t=7.63, p
2585 GASTRIC ACID SECRETION INCREASES WITH SEVERITY OF GASTRO-ESOPHAGEAL REFLUX IN CHILDREN. Abdul-Monem Badran, Nicolas Kalach, Patrick Jaffray, Said Hadji, PierreHenri Benhamou, Christophe Dupont, Hosp saint Vincent de Paul, Paris, France; Hosp cochin, Paris, France. Background: The demonstration of highly variable dosages of proton pump inhibitors (PPIs) to obtain similar effects on pH metric recordings underlines a variable impact of these drugs on gastric acid secretion. Considering their potentially wide and prolonged use in children suffering from gastroesophageal reflux (GER), it was decided to systematically evaluate gastric acid output in children with severe and long lasting GER in order to assess the need for anti-acid treatment. Patient and methods: The investigation was carried out in 29 children (17 males and 12 females, aged 8.4:t4.3 years) with prolonged (>18 months) clinical manifestations of GER. All underwent routine ambulatory 24-h esophageal pH-monitoring and gastric acid secretion measurement including gastric basal acid output (BAD), /-LmollKg/h, maximal acid output (MAO) and peak acid output (PAO) after pentagastrin (6 /-Lg/Kg) stimulation. Children with pyrosis or abdominal pain underwent upper fiber-endoscopy. In group A (moderate GER, n=9), patients had a normal ESPGHAN reflux index (pH<4 below 5.2% of total recording time) despite abnormal Euler and Byrne (Gastroenterology 1981; 80:957-61) scoring: total number of 24 h reflux episodes plus 4 times the number of reflux episodes above 5 minutes> 50. In group B (severe GER, n=16, among whom 4 with grade III oesophagitis), the reflux index was >5.2%. A control group consisted of 4 with gastritis routinely explored for gastric acid hyper-secretion. Written parental consent was obtained in all children. Results: The children with GER, esophageal pH (%) was significantly correlated with MAO and PAD, r 0.41, p=O.04 and r 0.45, p=0.02 respectively. Group B children exhibited significantly higher median BAD (70, 95%IC 47.56-143.25), MAO (468, IC 301.6-1149.8) and PAD (617, IC 509.9·806.4) than those of group A, BAD (24, IC 11.5-39.5), MAO (260, IC 223.7-329.3) and PAD (356, IC 302.3-431.4), p<0.05. In group B, the 4 children with severe esophagitis exhibited significant higher median BAD, MAO and PAD than the other 12 children from the same group, group A, and children with gastritis, p<0.05. Conclusion: II Children with severe GER hyper-secrete gastric acid; 21 Individual variations in gastric acid secretion probably account for variations in gastric acid inhibitors requirements; 31 Individual assessments of gastric acid secretion might be useful when deciding prolonged medical anti-acid treatment.