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Health care seeking in gastroesophageal reflux disease
A124
AGAABSTRACTS
• A N G I O T E N S I N II INHIBITS D U O D E N A L B I C A R B O N A T E SECRETION IN THE RAT BY A PERIPHERAL NEURAL SITE ACTION. B. Johansson. L.Chen*, M. Holm, A.Pettersson*, C.Jtnsson & L.Fiindriks Dept.of Physiology and *Clinical Pharmacology,University Of Gothenburg, Sweden Introductionl Bicarbonate secretion by the duodenal surface mucosa is considered to be of a groat importance for the defence against gastric acid. We have previously shown that a modest bleeding (=10% of the blood volume) decreases this secretion by use of a sympathoadrenergic mechanism (1). Administration of enalaprilate, an inhibitor of angiotensin converting enzyme, inferferes with such a hypovolemia-induced inhibition of the mucosal bicarbonate secretion (2). Apparantly, the presence of angiotensin II (Ang H) prolongates the sympathoadrenergic effect: The aim of the present study was to elucidate if the Ang II effect was exerted at a central or peripheral site. Methods: Experiments were performed on male, chloralose anesthetised, Sprague-Dawley rats and the mucosal bicarbonate secretion was measured by pH-stat titration technique ad modum Flemstrtm et al (3). The common bile duct was catheterized and the splanchnic nerves were cut on both sides and arranged for peripheral electrical stimulation. Results: All animals were pretreated with an ACE-inhibitor (enalaprilate, 0,7 mg/kg, i.v.) to block engogenous Ang H-production. Continuous bilateral splanchnic nerve stimulation (3 Hz, 5 ms, 5 V) raised arterial pressure and decreased transiendy duodenal bicarbonate secretion by 50%, the latter returning to base-line within 50 min. Exogenous Ang H (0,75 - 2,25~tg/kg h) slightly decreased basal bicarbonate secretion to a stable level. When Ang II was administered simultaneously with nerve stimulation, the neurally induced decrease in secretion was sustained. Conclusiom Ang H prolongates peripherally induced sympathoadrenergic inhibition of duodenal mucosal bicarbonate secretion, suggesting a primarily peripheral site of action. Reference~; 1. lSnson et al, Gastroenterology 96: 45-49, 1990 2. Holm et ai, IUPS XXIIIrd Congress, Glasgow, 1993 3. Flemstrtm et al, Am J Physiol 243: G348-G358, 1982
• COMPARISON OF SWALLOWING FUNCTION IN PARKINSON'S DISEASE (PD) AND PROGRESSIVE SUPRANUCLEAR PALSY (PSP). BT Johnston, JA Custell, A Colcher, RM Gideon, Q Li, DO Castell. Dept of Medicine, Graduate Hospital, Philadelphia, PA. Background: PSP is a diagnosis differentiated from ideopathic PD by its involvement of brain stem nuclei in addition to the nigrostriatal tract: Patients with PSP are believed to have a greater prevalence of swallowing difficulties. We compared swallowing function in patients with PSP and PD. Each 0 f 7 PSP patients was matched to a PD patient with the same duration of diagnosis to within 1 year. Modified barium swallow (MBS), esophageal manometry and UES/pharyngeal manometry were performed. Results: Patients did not differ in age (PSP:PD, mean age 69:63 years) or gender. Frequency of dysphagia on a scale of 1-7 (7--no dysphagia) did not differ' between the groups {PSP:PD, 3(2-7):4(3-7), median(range)}; nor did the duration of dysphagia (PSP:PD, 1(04):0.5(0-2) years). Only abnormalities in the oral phase of swallowing differentiated the 2 groups. The most frequent abnormalities were the same for both PSP and PD: diffuse esophageal spasm on esophageal manometry 2PSP:3PD, high UES residual pressures during relaxation on UES manometry 3PSP:4PD and pharyngeal pooling on MBS 3/6PSP:5/7PD. There was good correlation between the MBS score and the dysphagia scale for PSP (r=0.93, p<0.05) but not for PD (r=0.42, p=NS).The number of patients with abnormalities are shown in the table. LES Esobody LIES MBS-oral MBS-pharynx PSP (N=7) 3 4 5 4/6 4/6 PD (N=7) 1 4 6' 0/7* 5/7 * p<0.05 Conclusion:
Objective swallowing abnormalities are remarkably similar in PSP and PD, the only difference being in the oral phase of swallowing on MBS. Thus our data do not support the belief that PSP results in greater swallowing defects than PD. However, unlike PD, severity of dysphagia does correlate with the degree o f MBS abnormality which might help to explain the perception of increased swallowing difficulties in PSP.
GASTROENTEROLOGY, VoI. IO8, No. 4
• COMBINED VIDEOMANOMETRY IDENTIFIES DISTINCT ABNORMALITIES IN PATIENTS WITH PHARYNGEAL RETENTION, BT Johnston, JA Caste,, R Olsson, O Ekberg, DO Castell. Dept of Medicine, Graduate Hospital, Philadelphia, PA and Dept of Diagnostic Radiology, University Hospital MAS, Malmoa, Sweden. BACKGROUND: Retention of barium within the pharynx after swallowing is a recognized risk factor for tracheal aspiration. AIM: To assess the function of the upper esophageal sphincter (UES) and pharynx in patients with pharyngeal retention. PATIENTS AND METHODS: 26 patients with dysphagia (14 with pharyngeal retention (RETN)and 12 with no retention (NRETN) underwent manometry performed with simultaneous barium swallow, allowing direct comparison of pressure recordings with movement of the bolus through the pharynx. RESULTS: Patient groups did not differ in age (RETN : NRETN, both mean age 56 years) or gender. UES opening diameter was lower in the RETN group (7.7 vs. 10.3ram, p<0.005) as was laryngeal elevation (17.1 vs. 23.8mm, p<0.005). Resting UES pressure was lower in the RETN group (42.7 vs. 54mmHg, p<0.05). Degree of relaxation in response to swallowing was normal (residual pressure, 6A vs. 5.6mmHg) but of shorter duration in patients with retention (374ms vs. 603ms, p<0.005). There were no differences in manometric measurements of the tongue base or pharyngeal contractions. There were no correlations between the 2 abnormal radiologic and 2 abnormal manometric variables suggesting that they are recognizing distinct abnormalities in patients with retention. CONCLUSION: Pharyngeal retention is associated with both radiologic and manometric abnormalities which appear distinct. This suggests that use of b o t h modalities or a combined approach is important in the assessment of the dysphagic patient.
•
HEALTH CARE SEEKING IN GASTROESOPHAGEAL REFLUX D I S E A S E . BT Johnston, J Gunning and SA Lewis. Depts of Medicine and
Mental Health, Queen's University of Balfust, UK Aim: To ascertain if patients who seek medical help because ofhearthum have
different psychological or social characteristics than those who do not consult a doctor. Studies among IBS patients have demonstrated that such differenees influence presentation in that disease. Patients and methods: 217 patients were recruited to this study: 138 presenting to a hospital doctor for the first time with hearthum (PTS), 39 subjects experiencing frequent heartburn who had never consulted a doctor (COMM) and 40 matched healthy controls (NORM). Four established questionnaires were USed: State-trait anxiety index, Crown-Crisp experiential index, hassles scale and the interview schedule for social interaction. The Bonfcrroni calculation was applied to correct for multiple comparisons. Results: PTS experienced more severe heartburn than COMM and this was controlled for in the analysis ofpsychologienl factors. COMM did not differ in any way from NORM. PTS experienced lower levels of both State and Trait anxiety than NORM but did not differ from COMM. PTS had greater Phobia, Obsessionality and Somatization than both COMM and NORM. PTS reported more daily Hassles than NORM but the Hassle intensity was lower than both COMM and NORM. PTS bad less available social support than NORM while COMM had hitcher levels of close social support than PTS, Mean trait state phobia obsess somat bass hass avail adeq scores freq ave SS SS Norm 47 46 3.4 5.1 3.4 19 2.3 4.3 6.3 Comm 44 46 3.0 5.2 4.2 17 2.3 4.3 7.8 Pts 41 40 5.2 7.9 7.7 24 1.5 3.5 6.5 n
n
c,n
c,n
c,n
c
c,n
n
c
n=PTS v. NORM,ire0.05; c=FTSv. COMM,p<0.05; SS=seeialsuppert Conclusion: In addition to hearthum severity, them are other factors which influence the seeking of health care. From this study, those who seek medical attention because of heartburn are more aware of minor daily hassles and have psychological traits indicative of oversensitivity to and preoccupation with minor ailments. Good social support among COMM may have a protective effect, obviating the desire for medical attention.
AGAABSTRACTS
• A N G I O T E N S I N II INHIBITS D U O D E N A L B I C A R B O N A T E SECRETION IN THE RAT BY A PERIPHERAL NEURAL SITE ACTION. B. Johansson. L.Chen*, M. Holm, A.Pettersson*, C.Jtnsson & L.Fiindriks Dept.of Physiology and *Clinical Pharmacology,University Of Gothenburg, Sweden Introductionl Bicarbonate secretion by the duodenal surface mucosa is considered to be of a groat importance for the defence against gastric acid. We have previously shown that a modest bleeding (=10% of the blood volume) decreases this secretion by use of a sympathoadrenergic mechanism (1). Administration of enalaprilate, an inhibitor of angiotensin converting enzyme, inferferes with such a hypovolemia-induced inhibition of the mucosal bicarbonate secretion (2). Apparantly, the presence of angiotensin II (Ang H) prolongates the sympathoadrenergic effect: The aim of the present study was to elucidate if the Ang II effect was exerted at a central or peripheral site. Methods: Experiments were performed on male, chloralose anesthetised, Sprague-Dawley rats and the mucosal bicarbonate secretion was measured by pH-stat titration technique ad modum Flemstrtm et al (3). The common bile duct was catheterized and the splanchnic nerves were cut on both sides and arranged for peripheral electrical stimulation. Results: All animals were pretreated with an ACE-inhibitor (enalaprilate, 0,7 mg/kg, i.v.) to block engogenous Ang H-production. Continuous bilateral splanchnic nerve stimulation (3 Hz, 5 ms, 5 V) raised arterial pressure and decreased transiendy duodenal bicarbonate secretion by 50%, the latter returning to base-line within 50 min. Exogenous Ang H (0,75 - 2,25~tg/kg h) slightly decreased basal bicarbonate secretion to a stable level. When Ang II was administered simultaneously with nerve stimulation, the neurally induced decrease in secretion was sustained. Conclusiom Ang H prolongates peripherally induced sympathoadrenergic inhibition of duodenal mucosal bicarbonate secretion, suggesting a primarily peripheral site of action. Reference~; 1. lSnson et al, Gastroenterology 96: 45-49, 1990 2. Holm et ai, IUPS XXIIIrd Congress, Glasgow, 1993 3. Flemstrtm et al, Am J Physiol 243: G348-G358, 1982
• COMPARISON OF SWALLOWING FUNCTION IN PARKINSON'S DISEASE (PD) AND PROGRESSIVE SUPRANUCLEAR PALSY (PSP). BT Johnston, JA Custell, A Colcher, RM Gideon, Q Li, DO Castell. Dept of Medicine, Graduate Hospital, Philadelphia, PA. Background: PSP is a diagnosis differentiated from ideopathic PD by its involvement of brain stem nuclei in addition to the nigrostriatal tract: Patients with PSP are believed to have a greater prevalence of swallowing difficulties. We compared swallowing function in patients with PSP and PD. Each 0 f 7 PSP patients was matched to a PD patient with the same duration of diagnosis to within 1 year. Modified barium swallow (MBS), esophageal manometry and UES/pharyngeal manometry were performed. Results: Patients did not differ in age (PSP:PD, mean age 69:63 years) or gender. Frequency of dysphagia on a scale of 1-7 (7--no dysphagia) did not differ' between the groups {PSP:PD, 3(2-7):4(3-7), median(range)}; nor did the duration of dysphagia (PSP:PD, 1(04):0.5(0-2) years). Only abnormalities in the oral phase of swallowing differentiated the 2 groups. The most frequent abnormalities were the same for both PSP and PD: diffuse esophageal spasm on esophageal manometry 2PSP:3PD, high UES residual pressures during relaxation on UES manometry 3PSP:4PD and pharyngeal pooling on MBS 3/6PSP:5/7PD. There was good correlation between the MBS score and the dysphagia scale for PSP (r=0.93, p<0.05) but not for PD (r=0.42, p=NS).The number of patients with abnormalities are shown in the table. LES Esobody LIES MBS-oral MBS-pharynx PSP (N=7) 3 4 5 4/6 4/6 PD (N=7) 1 4 6' 0/7* 5/7 * p<0.05 Conclusion:
Objective swallowing abnormalities are remarkably similar in PSP and PD, the only difference being in the oral phase of swallowing on MBS. Thus our data do not support the belief that PSP results in greater swallowing defects than PD. However, unlike PD, severity of dysphagia does correlate with the degree o f MBS abnormality which might help to explain the perception of increased swallowing difficulties in PSP.
GASTROENTEROLOGY, VoI. IO8, No. 4
• COMBINED VIDEOMANOMETRY IDENTIFIES DISTINCT ABNORMALITIES IN PATIENTS WITH PHARYNGEAL RETENTION, BT Johnston, JA Caste,, R Olsson, O Ekberg, DO Castell. Dept of Medicine, Graduate Hospital, Philadelphia, PA and Dept of Diagnostic Radiology, University Hospital MAS, Malmoa, Sweden. BACKGROUND: Retention of barium within the pharynx after swallowing is a recognized risk factor for tracheal aspiration. AIM: To assess the function of the upper esophageal sphincter (UES) and pharynx in patients with pharyngeal retention. PATIENTS AND METHODS: 26 patients with dysphagia (14 with pharyngeal retention (RETN)and 12 with no retention (NRETN) underwent manometry performed with simultaneous barium swallow, allowing direct comparison of pressure recordings with movement of the bolus through the pharynx. RESULTS: Patient groups did not differ in age (RETN : NRETN, both mean age 56 years) or gender. UES opening diameter was lower in the RETN group (7.7 vs. 10.3ram, p<0.005) as was laryngeal elevation (17.1 vs. 23.8mm, p<0.005). Resting UES pressure was lower in the RETN group (42.7 vs. 54mmHg, p<0.05). Degree of relaxation in response to swallowing was normal (residual pressure, 6A vs. 5.6mmHg) but of shorter duration in patients with retention (374ms vs. 603ms, p<0.005). There were no differences in manometric measurements of the tongue base or pharyngeal contractions. There were no correlations between the 2 abnormal radiologic and 2 abnormal manometric variables suggesting that they are recognizing distinct abnormalities in patients with retention. CONCLUSION: Pharyngeal retention is associated with both radiologic and manometric abnormalities which appear distinct. This suggests that use of b o t h modalities or a combined approach is important in the assessment of the dysphagic patient.
•
HEALTH CARE SEEKING IN GASTROESOPHAGEAL REFLUX D I S E A S E . BT Johnston, J Gunning and SA Lewis. Depts of Medicine and
Mental Health, Queen's University of Balfust, UK Aim: To ascertain if patients who seek medical help because ofhearthum have
different psychological or social characteristics than those who do not consult a doctor. Studies among IBS patients have demonstrated that such differenees influence presentation in that disease. Patients and methods: 217 patients were recruited to this study: 138 presenting to a hospital doctor for the first time with hearthum (PTS), 39 subjects experiencing frequent heartburn who had never consulted a doctor (COMM) and 40 matched healthy controls (NORM). Four established questionnaires were USed: State-trait anxiety index, Crown-Crisp experiential index, hassles scale and the interview schedule for social interaction. The Bonfcrroni calculation was applied to correct for multiple comparisons. Results: PTS experienced more severe heartburn than COMM and this was controlled for in the analysis ofpsychologienl factors. COMM did not differ in any way from NORM. PTS experienced lower levels of both State and Trait anxiety than NORM but did not differ from COMM. PTS had greater Phobia, Obsessionality and Somatization than both COMM and NORM. PTS reported more daily Hassles than NORM but the Hassle intensity was lower than both COMM and NORM. PTS bad less available social support than NORM while COMM had hitcher levels of close social support than PTS, Mean trait state phobia obsess somat bass hass avail adeq scores freq ave SS SS Norm 47 46 3.4 5.1 3.4 19 2.3 4.3 6.3 Comm 44 46 3.0 5.2 4.2 17 2.3 4.3 7.8 Pts 41 40 5.2 7.9 7.7 24 1.5 3.5 6.5 n
n
c,n
c,n
c,n
c
c,n
n
c
n=PTS v. NORM,ire0.05; c=FTSv. COMM,p<0.05; SS=seeialsuppert Conclusion: In addition to hearthum severity, them are other factors which influence the seeking of health care. From this study, those who seek medical attention because of heartburn are more aware of minor daily hassles and have psychological traits indicative of oversensitivity to and preoccupation with minor ailments. Good social support among COMM may have a protective effect, obviating the desire for medical attention.