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Autonomic function in patients with achalasia and nutcracker oesophagus
A244
AGA ABSTRACTS
GASTROENTEROLOGY, VOl. 108, NO. 4
O AUTONOMIC FUNCTION IN PATIENTS WITH ACHALASIA AND NUTCRACKER OESOPHAGUS. N Trudqill, F Hussain, L Smith, S Harris, Q Cook, S Riley. Oesophageal Laboratory, Northern General Hospital, Sheffield, UK.
LAPAROSCOPIC ANTIREFLUX SURGERY IN THE ELDERLY. TL Trus, JG Hunter, SJ Mauren, EM Katz, JP Waring, WS Laycock, JM Wo, GD Branum. Depts of Digestive Diseases and Surgery, Emory University, Atlanta, GA.
Although previous studies of autonomic function in patients with aehalasia have yielded conflicting results, Auer et al. have recently reported clear evidence of pupillary and cardiovascular reflex abnormalities (AGA 1994:A-481). We have therefore studied non-gastrointestinal autonomic function in patients with established achalasia, a disease control group, nutcracker oesophagus, and age- and sex-matched healthy volunteers.
Introduction: Laparoscopic antireflux surgery (LAS) is advocated as an alternative in young patients with chronic gastroesophageal reflux disease (GERD) because of long term requirements for medical therapy and associated costs. However, many elderly patients who are otherwise healthy, have similar concerns. Aim: To evaluate the safety and efficacy of LAS in the elderly. Methods: 201 patients have had LAS in our hospital, 26 of whom are over age 65. Symptoms of heartburn, chest pain, regurgitation and dysphagia were scored from 0 (none) to 4 (severe) before and after surgery. Ambulatory pH monitoring was done before and after surgery. A reflux episode was defined as a drop in pH < 4.0. Symptom scores were compared with Chi square analysis, and pH results were compared with the Mann Whitney test: Results: The elderly patients had significantly h!gher preoperative ASA scores (mean 2.4 vs 2.0) (p=0.02) but otherwise there were no statistically significant differences in preoperative symptom .scores or pH results. Both groups demonstrated postoperative improvement in subjective and objective measurements of gastroesophageal reflux. There was no mortality in either group and there was no difference in length of hospital stay of the two groups. There were no statistically significant differences in postoperative symptom scores or pH results between the two groups. All 13 elderly patients followed for greater than one year claim they would have the surgery again. Conclusion: Laparoscopic antireflux surgery is a safe and effective treatment of GERD in the elderly.
Seventeen patients with achalasia [ii male, age 39 (25 to 61) years], Ii patients with nutcracker oesophagus [6 male, age 51 (39 to 59) years] and 20 matched controls underwent a battery of tests including: Valsalva ratio, 30:15 ratio, IE ratio, systolic blood pressure response to standingi diastolic blood pressure response to handgrip, lying and standing spectral analysis and pupil cycle time estimation. Autonomic function in patients with achalasia was not significantly different from healthy volunteers whereas patients with nutcracker oesophagus were abnormal. Pupil cycle length was significantly prolonged [1.23 (0.98 to 1.77) seconds versus 1.05 (0.89 to 1.29) seconds, p=0.02], a blood pressure drop was apparent on standing [-6(-15 to + 5)mm/Hg versus +4 (-12 to +10)mm/Hg, p=0.06] and the diastolic response to handgrip was attenuated [7(2 to 28)mm/Hg versus 20 (Ii to 45)mm/Hg, p=0.07] Autonomic dysfunction is a feature of nutcracker oesophagus but not achalasia. The abnormality is diffuse affecting both cardiovascular and pupillary reflexes, (Funded in part by Astra UK).
• RESULTS OF LAPAROSCOPIC ANTIREFLUX SURGERY IN PATIENTS WITH PREDOMINANT UPRIGHT REFLUX. TL Trus, SJ Mauren, EM Katz, WS Laycock, JM W0, JG Hunter, JP Waring, GD Branum. Depts. of Digestive Diseases and Surgery, Emory University, Atlanta GA. Introduction: Laparoscopic antireflux surgery (LAS) is an effective treatment of gastroesophageal reflux disease (GERD). Upright refluxers represent a special group of patients whose pathophysiology is thought to be related to frequent transient lower esophageal sphincter relaxation with an otherwise competent sphincter. It is unknown if antireflux surgery would be helpful in this group. Aim: To compare results of LAS in upright reflux patients with a control group of age and sex matched reflux patients. Methods: Of 200 patients who underwent LAS, 28 (14%) had predominantly upright reflux (UR)(supine time p H < 4 , <1%). They were compared to 56 controls (C). Symptoms of heartburn, chest pain, regurgitation and dysphagia were scored from 0 (none) to 4 (severe) before and after surgery. Ambulatory pH monitoring was done before and after surgery. A reflux episode was defined as a drop in pH < 4.0. Symptom scores were compared with Chi square analysis, and pH results were compared with the Mann Whitney test. 21 of the UR patients have been followed for 6 weeks, and 10 have been followed for over 1 year. Results: There were no differences between the two groups with respect to upright reflux time, age, gender or pre-op symptom scores. Statistically significant pre-op differences were seen in supine time (0.35% vs 19.9%, p=0.0001) and total reflux time (9.3% vs 20.0%, p=0.0006). Both groups experienced significant improvements in symptom scores and reflux time by ambulatory pH monitoring. There are no significant differences in any symptom score or pH parameter between the two groups at follow up. Conclusion: LAS is an effective treatment for patients with predominant upright gastroesophageal reflux.
AMMONIA INDUCES GASTRIC CELL APOPTOSIS: POSSIBLE IMPLICATION TO HELICOBACTER-RELATED GASTRIC MUCOSAL ATROPHY. S.Tsnii, S.Kawano, Y.Takei, M.Tsujii, I.Kobayashi, K.Nagano, H.Fusamoto and T.Kamada, The 1st Dept. of Meal., Osaka Univ. Sch. of Med., Suita, Japan. Background and Aims: Although we have demonstrated that ammonia induces gastric atrophy (Dig.Dis.Sci. 36: 33-38, 1991), t h e mechanism for this atrophy have not been unknown. Since gastric mucosal cell proliferation increases after its ingestion (Gastroenterot. 104:796-801,1993), ammonia may accelerate cell death after proliferation. Here, we examined whether ammonia induces programmed cell death (apoptosis) in a gastric mucosal cell-line. Matedals and Methods: RGM1 (Matsui and Ohno, 1989, RCB-0876 at Riken Cell Bank, Tsukuba), a M-line established from rat gastric mucosal epithelium, was grown on collagen-ceated chamber slides and plastic dishes with DMEM/Ham's F-12 medium supplemented with 20% fetal calf serum (D/F(20)). The confluent cells were incubated with D/F(20) containing 0-100raM ammonia for 0-24 hours, Apoptotic cells with DNA-fragmentation were stained by TdT-uridine nick-end labeling (TUNEL, J. Cell Biol. 119:493, 1992). Results: Incubation of RGM1 cells with ammonia (0-30ruled increased the number of TUNEL-positive apoptotic cells in a dose-dependent and time-dependant manner. This process was followed by crescent-shaped condensation of the cell nuclei. At the concentration of 100 raM, ammonia did not develop apoptosis on RGM1 within 6 hrs. Discussion and conclusion: We have reported that ammonia induces gastric mucosal atrophy which is characterized by increased cell proliferation, accelerated cell migration and loss of mucosal gland length. We have also noted nuclear condensation of gastric mucosal epithelial cells in rats ingesting ammonia. Apoptosis is a type of cell death accompanied with DNA-fragmentation, nuclear condensation and development of apoptotic body. The present results demonstrate that ammonia induces apoptosis which may result in gastric mucosal atrophy.
AGA ABSTRACTS
GASTROENTEROLOGY, VOl. 108, NO. 4
O AUTONOMIC FUNCTION IN PATIENTS WITH ACHALASIA AND NUTCRACKER OESOPHAGUS. N Trudqill, F Hussain, L Smith, S Harris, Q Cook, S Riley. Oesophageal Laboratory, Northern General Hospital, Sheffield, UK.
LAPAROSCOPIC ANTIREFLUX SURGERY IN THE ELDERLY. TL Trus, JG Hunter, SJ Mauren, EM Katz, JP Waring, WS Laycock, JM Wo, GD Branum. Depts of Digestive Diseases and Surgery, Emory University, Atlanta, GA.
Although previous studies of autonomic function in patients with aehalasia have yielded conflicting results, Auer et al. have recently reported clear evidence of pupillary and cardiovascular reflex abnormalities (AGA 1994:A-481). We have therefore studied non-gastrointestinal autonomic function in patients with established achalasia, a disease control group, nutcracker oesophagus, and age- and sex-matched healthy volunteers.
Introduction: Laparoscopic antireflux surgery (LAS) is advocated as an alternative in young patients with chronic gastroesophageal reflux disease (GERD) because of long term requirements for medical therapy and associated costs. However, many elderly patients who are otherwise healthy, have similar concerns. Aim: To evaluate the safety and efficacy of LAS in the elderly. Methods: 201 patients have had LAS in our hospital, 26 of whom are over age 65. Symptoms of heartburn, chest pain, regurgitation and dysphagia were scored from 0 (none) to 4 (severe) before and after surgery. Ambulatory pH monitoring was done before and after surgery. A reflux episode was defined as a drop in pH < 4.0. Symptom scores were compared with Chi square analysis, and pH results were compared with the Mann Whitney test: Results: The elderly patients had significantly h!gher preoperative ASA scores (mean 2.4 vs 2.0) (p=0.02) but otherwise there were no statistically significant differences in preoperative symptom .scores or pH results. Both groups demonstrated postoperative improvement in subjective and objective measurements of gastroesophageal reflux. There was no mortality in either group and there was no difference in length of hospital stay of the two groups. There were no statistically significant differences in postoperative symptom scores or pH results between the two groups. All 13 elderly patients followed for greater than one year claim they would have the surgery again. Conclusion: Laparoscopic antireflux surgery is a safe and effective treatment of GERD in the elderly.
Seventeen patients with achalasia [ii male, age 39 (25 to 61) years], Ii patients with nutcracker oesophagus [6 male, age 51 (39 to 59) years] and 20 matched controls underwent a battery of tests including: Valsalva ratio, 30:15 ratio, IE ratio, systolic blood pressure response to standingi diastolic blood pressure response to handgrip, lying and standing spectral analysis and pupil cycle time estimation. Autonomic function in patients with achalasia was not significantly different from healthy volunteers whereas patients with nutcracker oesophagus were abnormal. Pupil cycle length was significantly prolonged [1.23 (0.98 to 1.77) seconds versus 1.05 (0.89 to 1.29) seconds, p=0.02], a blood pressure drop was apparent on standing [-6(-15 to + 5)mm/Hg versus +4 (-12 to +10)mm/Hg, p=0.06] and the diastolic response to handgrip was attenuated [7(2 to 28)mm/Hg versus 20 (Ii to 45)mm/Hg, p=0.07] Autonomic dysfunction is a feature of nutcracker oesophagus but not achalasia. The abnormality is diffuse affecting both cardiovascular and pupillary reflexes, (Funded in part by Astra UK).
• RESULTS OF LAPAROSCOPIC ANTIREFLUX SURGERY IN PATIENTS WITH PREDOMINANT UPRIGHT REFLUX. TL Trus, SJ Mauren, EM Katz, WS Laycock, JM W0, JG Hunter, JP Waring, GD Branum. Depts. of Digestive Diseases and Surgery, Emory University, Atlanta GA. Introduction: Laparoscopic antireflux surgery (LAS) is an effective treatment of gastroesophageal reflux disease (GERD). Upright refluxers represent a special group of patients whose pathophysiology is thought to be related to frequent transient lower esophageal sphincter relaxation with an otherwise competent sphincter. It is unknown if antireflux surgery would be helpful in this group. Aim: To compare results of LAS in upright reflux patients with a control group of age and sex matched reflux patients. Methods: Of 200 patients who underwent LAS, 28 (14%) had predominantly upright reflux (UR)(supine time p H < 4 , <1%). They were compared to 56 controls (C). Symptoms of heartburn, chest pain, regurgitation and dysphagia were scored from 0 (none) to 4 (severe) before and after surgery. Ambulatory pH monitoring was done before and after surgery. A reflux episode was defined as a drop in pH < 4.0. Symptom scores were compared with Chi square analysis, and pH results were compared with the Mann Whitney test. 21 of the UR patients have been followed for 6 weeks, and 10 have been followed for over 1 year. Results: There were no differences between the two groups with respect to upright reflux time, age, gender or pre-op symptom scores. Statistically significant pre-op differences were seen in supine time (0.35% vs 19.9%, p=0.0001) and total reflux time (9.3% vs 20.0%, p=0.0006). Both groups experienced significant improvements in symptom scores and reflux time by ambulatory pH monitoring. There are no significant differences in any symptom score or pH parameter between the two groups at follow up. Conclusion: LAS is an effective treatment for patients with predominant upright gastroesophageal reflux.
AMMONIA INDUCES GASTRIC CELL APOPTOSIS: POSSIBLE IMPLICATION TO HELICOBACTER-RELATED GASTRIC MUCOSAL ATROPHY. S.Tsnii, S.Kawano, Y.Takei, M.Tsujii, I.Kobayashi, K.Nagano, H.Fusamoto and T.Kamada, The 1st Dept. of Meal., Osaka Univ. Sch. of Med., Suita, Japan. Background and Aims: Although we have demonstrated that ammonia induces gastric atrophy (Dig.Dis.Sci. 36: 33-38, 1991), t h e mechanism for this atrophy have not been unknown. Since gastric mucosal cell proliferation increases after its ingestion (Gastroenterot. 104:796-801,1993), ammonia may accelerate cell death after proliferation. Here, we examined whether ammonia induces programmed cell death (apoptosis) in a gastric mucosal cell-line. Matedals and Methods: RGM1 (Matsui and Ohno, 1989, RCB-0876 at Riken Cell Bank, Tsukuba), a M-line established from rat gastric mucosal epithelium, was grown on collagen-ceated chamber slides and plastic dishes with DMEM/Ham's F-12 medium supplemented with 20% fetal calf serum (D/F(20)). The confluent cells were incubated with D/F(20) containing 0-100raM ammonia for 0-24 hours, Apoptotic cells with DNA-fragmentation were stained by TdT-uridine nick-end labeling (TUNEL, J. Cell Biol. 119:493, 1992). Results: Incubation of RGM1 cells with ammonia (0-30ruled increased the number of TUNEL-positive apoptotic cells in a dose-dependent and time-dependant manner. This process was followed by crescent-shaped condensation of the cell nuclei. At the concentration of 100 raM, ammonia did not develop apoptosis on RGM1 within 6 hrs. Discussion and conclusion: We have reported that ammonia induces gastric mucosal atrophy which is characterized by increased cell proliferation, accelerated cell migration and loss of mucosal gland length. We have also noted nuclear condensation of gastric mucosal epithelial cells in rats ingesting ammonia. Apoptosis is a type of cell death accompanied with DNA-fragmentation, nuclear condensation and development of apoptotic body. The present results demonstrate that ammonia induces apoptosis which may result in gastric mucosal atrophy.