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Ineffective esophageal motility (IEM) increases reflux in nonerosive reflux disease (NERD) patients?
S28
Abstracts
esophageal manifestations of GERD include hoarseness, cough, asthma or exacerbation of asthma, and symptoms of aspiration. Dysphagia is a sign of complicated reflux disease. The purpose of this study was to determine the prevalence of extra– esophageal manifestations and dysphasia in pregnancy. Methods: Patients receiving prenatal care at a hospital clinic and patients presenting to the labor and delivery unit at various stages of pregnancy were asked to complete a questionnaire regarding the extra– esophageal manifestations of GERD and dysphagia during the current pregnancy, prior to pregnancy, and during previous pregnancies. The information provided was used to determine the prevalence of these symptoms in pregnancy in the population studied. Results: Over a period of 7 months, 118 patients completed the questionnaire. Twenty–two patient (18.6%) reported at least one of the symptoms or conditions associated with atypical presentations of GERD, and 15 patients (12.7 %) reported two or more. Chronic cough and choking sensation were the most common symptoms with 11.0% and 10.2% positive responses, respectively. Hoarseness of voice was found in 8.0% of patients, and 5.9% reported difficulty swallowing. Four patients (3.4%) reported treatment for asthma during the current pregnancy.This probably represents a separate pulmonary process unrelated to GERD.All four were diagnosed with asthma prior to the current pregnancy. Five of the 22 patients who reported one or more symptom were diagnosed with GERD or reflux during their current pregnancy. Four of the five patients who were diagnosed with GERD were treated with medications including antacids, H2–receptor blockers, and metoclopramide. Conclusions: Gastroesophageal reflux is a common condition in pregnancy. Studies in the past of reflux in pregnancy have excluded the extraesophageal symptoms. This study indicates there may be a high prevalence of extra– esophageal symptoms of GERD in pregnancy, and that this condition may be under–recognized and under–treated in pregnancy. An increased awareness of these symptoms should aid in the diagnosis and treatment of this condition.
83 WILL SURVEILLANCE IMPACT LONG–TERM SURVIVAL IN BARRETT’S ESOPHAGUS? Gary De La Pena, M.D., Rakesh Nanda, M.D.* and Francisco C. Ramirez, M.D. Gastroenterology, Carl T. Hayden VA Medical Center, Phoenix, AZ. Background: Barrett’s esophagus has an increased risk of adenocarcinoma. However, only 6,600 new cases of cancer per year are diagnosed. The value of surveillance programs is still unproven and patients most likely die of unrelated causes. Aim: Perform a chart review to determine causes of mortality in Barrett’s patients. Methods: Setting: VA endscopy unit. Study Period: 1988 –2002. Methods: A list of patients with confirmed intestinal metaplasia was retrieved from the gi database. Patient Age was recorded as was the cause of death. A qualitative comparison to mortality in the US population was made. Results: 205 patients had confirmationof Barrett’s. Two developed adenocarcinoma. One elected for curative esophagectomy. The other eventually died of metastatic disease. 175 patients remain (mean age 66.7 years, std dev. 11.4 y). 30 patients died with only a single patient dying of esophageal carcinoma. Causes of death are listed below. Mean age at the time of death was not significantly different than the life expectancy of the general male population – 69.1 years (SD 11.2y, SEM 2.02y) versus 73 years. Summary: In this group 97% of patients died from causes unrelated to esophageal cancer. Despite the relative increase in cancer risk, Barrett’s esophagus has minimal if any impact on longevity as most patients will die from more common causes of mortality.
AJG – Vol. 97, No. 9, Suppl., 2002
Top Ten Causes of Mortality Barrett’s Patients Cause of Death
General US Population Cause of Death
Percentage
Heart disease Malignant neoplasm CVA COPD Accidents Diabetes Pneumonia/FLU Alzheimer’s disease Renal failure Sepsis
30.3% 23% 7% 5% 4% 2.9% 2.4% 1.9% 1.5% 1.3%
Number, %
Non–esophageal malignancy Heart disease Pneumonia Hematologic disorder Sepsis CVA COPD Esophageal CA Pulmonary embolus Suicide
8/30 7/30 4/30 3/30 3/30 1/30 1/30 1/30 1/30 1/30
27% 24% 13% 10% 10% 3% 3% 3% 3% 3%
Conclusions: Because most patients will die of non– esophageal causes, surveillance endoscopy for Barrett’s esophagus will likely have minimal impact on long–term mortality.
84 INEFFECTIVE ESOPHAGEAL MOTILITY (IEM) INCREASES REFLUX IN NONEROSIVE REFLUX DISEASE (NERD) PATIENTS? Luiz J. Abrahao Junior, M.D.,M.Ph.*, Eponina O. Lemme, M.D.,Ph.D., Beatriz B. Carvalho, M.D., Gerson R. Domingues, M.D.,M.Ph. and Eduardo Nigri, M.D. Laboratorio de Motilidade Esofagiana – Servico de Gastroenterologia, Hospital Universitario Clementino Fraga Filho Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil. Purpose: IEM is a hipocontratile motor disorder defined as low amplitude (⬍30 mmHg) or nontransmitted contractions in esophageal body in more than 20% of wet swallows (Leite et al, Dig Dis Sci 1997;42: 1859 – 65) and it has recently been associated with prolonged supine acid exposure time and prolonged bolus transport time . We evaluated if IEM increase reflux in NERD patients in relation to those with normal manometry. Methods: 1560 esophageal pH monitorings (pHM) were carried out in ambulatory setting in the last 10 years (MKII or III, Synectics, antimony electrodes, distal sensor positioned 5 cm over LES previously located by manometry). Patients with typical GERD symptoms (heartburn), without erosive esophagitis (NERD), abnormal pHM (% total time {TT} pH ⬍4 ⬎ 4,5 % , IEM or normal manometry were selected. Statistical tests included Chi–square and Kruskal–Wallis test, and p value of 0.05 was required for statistical significance . Results: 141 patients met inclusion criteria, 79 patients (55%) with IEM, (62%females, 38% males, mean age 50 years) and 62 (45%) with normal esophageal manometry (females 60%, 40% males, mean age 49 years ). In Table 1 are the values obtained by pHM (number of episodes, % total time, % upright time and %supine time) in patients with IEM and normal manometry. % of supine time was higher in patients with IEM than in normal manometry patients (p⫽0.05) , what was not observed for % total time and in upright position. Table 1. Abnormal reflux in NERD patients with IEM and normal manometry TOTAL (141)
Number of episodes
Total time (%)
Upright time (%)
Supine time (%)
IEM (n ⫽ 79) NORMAL (n ⫽ 62) p value*
53.6 ⫹ 32.7 51.0 ⫹ 25.9 0.92
10.6 ⫹ 8.8 9.7 ⫹ 6.8 0.48
10.6 ⫹ 10.9 10.7 ⫹ 7.3 0.38
10.4 ⫹ 12.8 7.0 ⫹ 9.2 0.05
* Kruskal–Wallis.
Conclusions: Ineffective esophageal motility in patients with typical reflux symptoms and nonerosive gastroesophageal disease is related to a prolonged supine exposure time when compared to patients with normal manometry.
Abstracts
esophageal manifestations of GERD include hoarseness, cough, asthma or exacerbation of asthma, and symptoms of aspiration. Dysphagia is a sign of complicated reflux disease. The purpose of this study was to determine the prevalence of extra– esophageal manifestations and dysphasia in pregnancy. Methods: Patients receiving prenatal care at a hospital clinic and patients presenting to the labor and delivery unit at various stages of pregnancy were asked to complete a questionnaire regarding the extra– esophageal manifestations of GERD and dysphagia during the current pregnancy, prior to pregnancy, and during previous pregnancies. The information provided was used to determine the prevalence of these symptoms in pregnancy in the population studied. Results: Over a period of 7 months, 118 patients completed the questionnaire. Twenty–two patient (18.6%) reported at least one of the symptoms or conditions associated with atypical presentations of GERD, and 15 patients (12.7 %) reported two or more. Chronic cough and choking sensation were the most common symptoms with 11.0% and 10.2% positive responses, respectively. Hoarseness of voice was found in 8.0% of patients, and 5.9% reported difficulty swallowing. Four patients (3.4%) reported treatment for asthma during the current pregnancy.This probably represents a separate pulmonary process unrelated to GERD.All four were diagnosed with asthma prior to the current pregnancy. Five of the 22 patients who reported one or more symptom were diagnosed with GERD or reflux during their current pregnancy. Four of the five patients who were diagnosed with GERD were treated with medications including antacids, H2–receptor blockers, and metoclopramide. Conclusions: Gastroesophageal reflux is a common condition in pregnancy. Studies in the past of reflux in pregnancy have excluded the extraesophageal symptoms. This study indicates there may be a high prevalence of extra– esophageal symptoms of GERD in pregnancy, and that this condition may be under–recognized and under–treated in pregnancy. An increased awareness of these symptoms should aid in the diagnosis and treatment of this condition.
83 WILL SURVEILLANCE IMPACT LONG–TERM SURVIVAL IN BARRETT’S ESOPHAGUS? Gary De La Pena, M.D., Rakesh Nanda, M.D.* and Francisco C. Ramirez, M.D. Gastroenterology, Carl T. Hayden VA Medical Center, Phoenix, AZ. Background: Barrett’s esophagus has an increased risk of adenocarcinoma. However, only 6,600 new cases of cancer per year are diagnosed. The value of surveillance programs is still unproven and patients most likely die of unrelated causes. Aim: Perform a chart review to determine causes of mortality in Barrett’s patients. Methods: Setting: VA endscopy unit. Study Period: 1988 –2002. Methods: A list of patients with confirmed intestinal metaplasia was retrieved from the gi database. Patient Age was recorded as was the cause of death. A qualitative comparison to mortality in the US population was made. Results: 205 patients had confirmationof Barrett’s. Two developed adenocarcinoma. One elected for curative esophagectomy. The other eventually died of metastatic disease. 175 patients remain (mean age 66.7 years, std dev. 11.4 y). 30 patients died with only a single patient dying of esophageal carcinoma. Causes of death are listed below. Mean age at the time of death was not significantly different than the life expectancy of the general male population – 69.1 years (SD 11.2y, SEM 2.02y) versus 73 years. Summary: In this group 97% of patients died from causes unrelated to esophageal cancer. Despite the relative increase in cancer risk, Barrett’s esophagus has minimal if any impact on longevity as most patients will die from more common causes of mortality.
AJG – Vol. 97, No. 9, Suppl., 2002
Top Ten Causes of Mortality Barrett’s Patients Cause of Death
General US Population Cause of Death
Percentage
Heart disease Malignant neoplasm CVA COPD Accidents Diabetes Pneumonia/FLU Alzheimer’s disease Renal failure Sepsis
30.3% 23% 7% 5% 4% 2.9% 2.4% 1.9% 1.5% 1.3%
Number, %
Non–esophageal malignancy Heart disease Pneumonia Hematologic disorder Sepsis CVA COPD Esophageal CA Pulmonary embolus Suicide
8/30 7/30 4/30 3/30 3/30 1/30 1/30 1/30 1/30 1/30
27% 24% 13% 10% 10% 3% 3% 3% 3% 3%
Conclusions: Because most patients will die of non– esophageal causes, surveillance endoscopy for Barrett’s esophagus will likely have minimal impact on long–term mortality.
84 INEFFECTIVE ESOPHAGEAL MOTILITY (IEM) INCREASES REFLUX IN NONEROSIVE REFLUX DISEASE (NERD) PATIENTS? Luiz J. Abrahao Junior, M.D.,M.Ph.*, Eponina O. Lemme, M.D.,Ph.D., Beatriz B. Carvalho, M.D., Gerson R. Domingues, M.D.,M.Ph. and Eduardo Nigri, M.D. Laboratorio de Motilidade Esofagiana – Servico de Gastroenterologia, Hospital Universitario Clementino Fraga Filho Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil. Purpose: IEM is a hipocontratile motor disorder defined as low amplitude (⬍30 mmHg) or nontransmitted contractions in esophageal body in more than 20% of wet swallows (Leite et al, Dig Dis Sci 1997;42: 1859 – 65) and it has recently been associated with prolonged supine acid exposure time and prolonged bolus transport time . We evaluated if IEM increase reflux in NERD patients in relation to those with normal manometry. Methods: 1560 esophageal pH monitorings (pHM) were carried out in ambulatory setting in the last 10 years (MKII or III, Synectics, antimony electrodes, distal sensor positioned 5 cm over LES previously located by manometry). Patients with typical GERD symptoms (heartburn), without erosive esophagitis (NERD), abnormal pHM (% total time {TT} pH ⬍4 ⬎ 4,5 % , IEM or normal manometry were selected. Statistical tests included Chi–square and Kruskal–Wallis test, and p value of 0.05 was required for statistical significance . Results: 141 patients met inclusion criteria, 79 patients (55%) with IEM, (62%females, 38% males, mean age 50 years) and 62 (45%) with normal esophageal manometry (females 60%, 40% males, mean age 49 years ). In Table 1 are the values obtained by pHM (number of episodes, % total time, % upright time and %supine time) in patients with IEM and normal manometry. % of supine time was higher in patients with IEM than in normal manometry patients (p⫽0.05) , what was not observed for % total time and in upright position. Table 1. Abnormal reflux in NERD patients with IEM and normal manometry TOTAL (141)
Number of episodes
Total time (%)
Upright time (%)
Supine time (%)
IEM (n ⫽ 79) NORMAL (n ⫽ 62) p value*
53.6 ⫹ 32.7 51.0 ⫹ 25.9 0.92
10.6 ⫹ 8.8 9.7 ⫹ 6.8 0.48
10.6 ⫹ 10.9 10.7 ⫹ 7.3 0.38
10.4 ⫹ 12.8 7.0 ⫹ 9.2 0.05
* Kruskal–Wallis.
Conclusions: Ineffective esophageal motility in patients with typical reflux symptoms and nonerosive gastroesophageal disease is related to a prolonged supine exposure time when compared to patients with normal manometry.