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Tu1144 Impaired Bolus Transits of Esophageal Swallows May Play an Important Role in Eliciting Non-Cardiac Chest Pain: A Study Using High Resolution Impedence-Manometry Test
marker of gastroesophageal reflux, even if its relationship with the reflux pattern remains to be fully investigated. High resolution manometry (HRM) combined with multichannel impedance (MI) monitoring allows a more accurate and a simultaneous analysis of the reflux episodes and esophageal motility. Aim/Methods: To evaluate frequency and relationship between reflux pattern and esophageal pressures during TLESRs, 17 NERD patients, following a 3-week pharmacological washout, and 14 healthy volunteers (HV), matched for sex and BMI, without evidence of hiatal hernia, underwent combined HRM-MI in a sitting position, before and 60 min after, a solid-liquid meal (1500 Kcal). The diagnosis was confirmed by 24-hour pH-impedance test in all patients. A catheter with 36 solid state pressure sensors and 9 impedance measuring segments was used (MMS SOLAR HRIM, Enschede, The Netherlands). TLESRs, CCs and reflux events were defined according to standard criteria and agreement between at least 2 out of 3 investigators was required. Results: 2 HV not completing the test and 4 patients showing a very low LES baseline pressure were not analyzed. A total of 65 and 90 TLESRs were detected in HV and in patients. The frequency and duration (patients 15.2s vs HV 14.8s) of TLESRs did not differ between patients and HV (Table). However, TELSRs in patients were more likely to be associated with reflux and proximal extent. In patients, 96% of mixed (p<0.05) and 91% of proximal refluxes were associated with CCs (vs 71% and 63%, in HV). Conclusions: The frequency and duration of TLESRs are similar in NERD patients and HV. In contrast to commonly held current concepts, NERD patients show a significantly higher number of reflux episodes, and CCs and proximal reflux during TLESRs. These findings suggest that the mechanics of the gastrooesophageal junction during TLESRs in NERD favours reflux to a greater degree than in normal subjects, which may help to explain the occurrence of symptoms.
* p<0.05 vs healthy volunteers Tu1142 Tu1144 Central Obesity and Age Predict Cardia Mucosal Length in Healthy Volunteers: Evidence for an Acquired Entity Elaine V. Robertson, Mohammad H. Derakhshan, Angela A. Wirz, Yeong Yeh Lee, James J. Going, Scott Hanvey, Stuart Ballantyne, Kenneth E. McColl
Impaired Bolus Transits of Esophageal Swallows May Play an Important Role in Eliciting Non-Cardiac Chest Pain: A Study Using High Resolution Impedence-Manometry Test Jun Young Park, Jin Hee Lee, Yun Soo Hong, Jae J Kim, Jong Chul Rhee, Poong-Lyul Rhee
Background: Oesophageal adenocarcinoma is thought to arise from columnar metaplasia of distal oesophageal mucosa caused by gastro-oesophageal reflux. Obesity is a risk factor for this process. There is some evidence that ‘normal' cardia may be an acquired mucosa arising through the same pathway and predisposing to adenocarcinoma development at this site. The influence of obesity on the aetiology of cardia mucosa is unknown. Aim and Methods: The aim was to investigate the association between cardia mucosal length and BMI, intra-abdominal fat and subcutaneous fat in a normal healthy population. Sixty two H. pylori negative healthy volunteers (age 18-74 years) were recruited. BMI, waist circumference and gender were recorded. MRI (Phillips 1.5T) was performed for quantification of visceral and subcutaneous fat, calculated as an average of three axial planes (L2, L3 and L4). Upper GI endoscopy was performed with biopsies of the gastro-oesophageal junction using large capacity forceps with a jaw span of 8mm. Biopsies were taken in a cranio-caudal direction and targeted to include enough squamous mucosa to confirm position. Intraprocedure pathological feedback was available and two to three biopsies were taken to optimise accuracy. Junctional biopsies were assessed to determine cardia length, considered measurable provided there was consecutive squamous, cardia and oxyntic mucosal types present. Non-parametric correlations were examined between BMI, waist circumference and cardia length as well as between fat distribution quantified by MRI and cardia length. Regression analysis (Stepwise method) incorporating age, BMI, waist circumference and MRI total fat was used to determine predictors of cardia length Results: Thirty-seven of sixty two volunteers had at least one junctional biopsy including squamous, cardia and oxyntic mucosa; median total length 6.5mm (IQR 1.6). Median cardia mucosal length was 2.5mm (IQR 1.5mm). Length of cardia mucosa increased with age (R=0.457, P=0.004) and with waist circumference (R= 0.466, P=0.004). A correlation was also seen with intra-abdominal fat (R=0.374, P=0.027) and total fat measured by MRI (R= 0.389, P=0.021) but not with subcutaneous fat (P=0.091). There was no significant correlation with BMI. On regression analysis the independent predictors of cardia mucosa length were waist circumference (Standardised coefficient 0.342, P=0.035) and age (Standardised coefficient 0.322, P=0.046). Intestinal metaplasia at the cardia was seen in only four of sixty-two volunteers. Conclusions: These findings suggest that cardia mucosa may be acquired with increasing age through a process of distal squamous columnar metaplasia accelerated by central obesity. A possible mechanism is opening of the distal portion of the lower oesophageal sphincter and short segment acid reflux.
Background: Gastroesophageal reflux disease (GERD) related non-cardiac chest pain (NCCP) showed a good response of proton pump inhibitor (PPI), but non-GERD related NCCP has a little effect of PPI therapy. Therefore the presence or absence of GERD is not a good indicator of management in NCCP patients. Aims: We aimed to explore the new mechanisms of NCCP by high resolution impedence-manometry (HRiM) test and evaluate the role of impaired esophageal bolus transit in NCCP patients. Methods: A total of 107 consecutive patients with NCCP were evaluated at the Samsung Medical Center, Seoul, Korea, from June 2009 to May 2011. They were performed the HRiM, impedence-pH monitoring test, and upper GI endoscopy. All patients were divided to two groups: normal bolus transit group was defined as ≥ 70% liquid swallows with complete bolus transit. And impaired bolus transit group was defined as > 30% liquid swallows with incomplete bolus transit. Results: There was no difference in mean age, sex ratio, and underlying body mass index between the normal bolus transit group (n=30) and impaired bolus transit group (n=77). The prevalence of GERD was not significantly different in both groups (13% in normal bolus transit group vs. 18% in impaired bolus transit group, p=0.38). The percentage time of intra-esophageal pH of < 4 was 2.4% in normal bolus transit group and 1.7% in impaired bolus transit group, which was no statistically significant difference. Using HRiM, contractile front velocity (CFV), distal contractile integral (DCI), distance (transitional zone), and integrated relaxation pressure (IRP) were measured in both groups. CFV of normal bolus transit group was slightly lower than ones of impaired bolus transit group (mean 5.2±2.6 cm/sec vs. 6.5± 5.4 cm/sec, respectively, p< 0.0001). The mean value of DCI was 1742.4±2253.8 mmHg-cm-sec in normal bolus transit group and 1222.6±1206.9 mmHg-cm-sec in impaired bolus transit group, which was lower than those of normal bolus transit group (p<0.0001). Distance and IRP were no significant difference in both groups. Thirteen (43%) patients of normal bolus transit group showed a normal peristalsis and 12 (40%) patients presented a peristaltic dysfunction. However, a total 56 (73%) patients of impaired bolus transit group showed a peristaltic dysfunction and only 11(14%) patients presented a normal esophageal peristalsis. Conclusion: Many NCCP patients showed an impaired bolus transit in esophageal HRiM and they combined with a more esophageal peristaltic dysfunction than those which bolus transits were complete. Impaired bolus transit of esophageal swallows may affects in elucidating NCCPs regardless of presence or absence of GERD.
Tu1143
Tu1145
Increased Frequency of Reflux Episodes and of Common Cavity Phenomenon in NERD Patients Than in Asymptomatic Volunteers: A Combined Impedance and High Resolution Manometry Study Mentore Ribolsi, Sara Emerenziani, Paola Balestrieri, Maria Chiara Addarii, Richard H. Holloway, Michele Cicala
Overweight and Obesity in Primary Care Patients With Functional Dyspepsia Compared With Gastroesophageal Reflux Disease Nimish B. Vakil, John Dent, Börje Wernersson, Lis Ohlsson Introduction. Gastroesophageal reflux disease (GERD) has been associated with increasing weight and obesity. In tertiary care settings, functional dyspepsia (FD) has been associated with weight loss. Patients with FD often have background symptoms of heartburn and regurgitation. The aim of this study was to compare the distribution of body mass indices (BMIs) in patients with GERD or FD. Methods. Primary care patients (N=335) were studied in north-western Europe and Canada. Patients were included if they had not taken a proton
Background: Although transient LES relaxations (TLESRs) are the major mechanism of gastroesophageal reflux in GERD, the frequency of TLESRs and of reflux episodes during TLESRs detected at conventional manometry are reported to be similar in GERD patients and asymptomatic subjects. The manometric phenomenon of common cavity (CC) is a
S-757
AGA Abstracts
AGA Abstracts
aim of this study was to evaluate the effect of sleeve gastrectomy on gastroesophageal reflux in obese patients with and without preoperatory reflux. METHODS. An observational and prospective study was conducted among patients who underwent SG according to the following inclusion criteria: age 18 to 60 years, and body mass index ≥ 40 Kg/m2 o ≥ 35 Kg/m2 with comorbidities. Patients with previous bariatric surgery or major comorbidities were excluded. Patients were evaluated with upper endoscopy, standard esophageal perfusion manometry (Medtronics®) and 24 hour ambulatory pH-impedance recording (Sandhill®) before and after 6 months of surgery. Hiatal hernia (HH) was documented preoperatively, and repaired upon surgery. Descriptive and comparative statistics were performed with McNemar and Wilcoxon tests. RESULTS. 14 patients were included, (11 female and 3 male), with mean age of 36.5 ± 9.8 years; Only 28.5% (n = 4) were found to have erosive esophagitis preoperatively (grade A = 2, grade B = 2) and 42.8% had it postoperatively (grade A = 2, grade B = 3 grade C = 1) p = NS; only 4 had preoperative HH (28.5%) and were corrected during surgery. On regard of GERD, 42.9% (n = 6) of patients had symptoms preoperatively, but only 7% (n = 1) remained symptomatic after surgery. Weight, manometry results and 24 hour pH-impedance comparisons are show in table 1. CONCLUSIONS. After SG procedure, patients with preoperative GERD improved symptomatically. In contrast after six months, endoscopic findings were the same or more severe. After operation, patients presented a similar amount of acid reflux but had more episodes of non-acid reflux, suggesting nonacidic reflux increases after SG. Our preliminary results suggest that patients considered to SG should be evaluated preoperatively for GERD, and if detected, an alternative bariatric procedure might be proposed.
* p<0.05 vs healthy volunteers Tu1142 Tu1144 Central Obesity and Age Predict Cardia Mucosal Length in Healthy Volunteers: Evidence for an Acquired Entity Elaine V. Robertson, Mohammad H. Derakhshan, Angela A. Wirz, Yeong Yeh Lee, James J. Going, Scott Hanvey, Stuart Ballantyne, Kenneth E. McColl
Impaired Bolus Transits of Esophageal Swallows May Play an Important Role in Eliciting Non-Cardiac Chest Pain: A Study Using High Resolution Impedence-Manometry Test Jun Young Park, Jin Hee Lee, Yun Soo Hong, Jae J Kim, Jong Chul Rhee, Poong-Lyul Rhee
Background: Oesophageal adenocarcinoma is thought to arise from columnar metaplasia of distal oesophageal mucosa caused by gastro-oesophageal reflux. Obesity is a risk factor for this process. There is some evidence that ‘normal' cardia may be an acquired mucosa arising through the same pathway and predisposing to adenocarcinoma development at this site. The influence of obesity on the aetiology of cardia mucosa is unknown. Aim and Methods: The aim was to investigate the association between cardia mucosal length and BMI, intra-abdominal fat and subcutaneous fat in a normal healthy population. Sixty two H. pylori negative healthy volunteers (age 18-74 years) were recruited. BMI, waist circumference and gender were recorded. MRI (Phillips 1.5T) was performed for quantification of visceral and subcutaneous fat, calculated as an average of three axial planes (L2, L3 and L4). Upper GI endoscopy was performed with biopsies of the gastro-oesophageal junction using large capacity forceps with a jaw span of 8mm. Biopsies were taken in a cranio-caudal direction and targeted to include enough squamous mucosa to confirm position. Intraprocedure pathological feedback was available and two to three biopsies were taken to optimise accuracy. Junctional biopsies were assessed to determine cardia length, considered measurable provided there was consecutive squamous, cardia and oxyntic mucosal types present. Non-parametric correlations were examined between BMI, waist circumference and cardia length as well as between fat distribution quantified by MRI and cardia length. Regression analysis (Stepwise method) incorporating age, BMI, waist circumference and MRI total fat was used to determine predictors of cardia length Results: Thirty-seven of sixty two volunteers had at least one junctional biopsy including squamous, cardia and oxyntic mucosa; median total length 6.5mm (IQR 1.6). Median cardia mucosal length was 2.5mm (IQR 1.5mm). Length of cardia mucosa increased with age (R=0.457, P=0.004) and with waist circumference (R= 0.466, P=0.004). A correlation was also seen with intra-abdominal fat (R=0.374, P=0.027) and total fat measured by MRI (R= 0.389, P=0.021) but not with subcutaneous fat (P=0.091). There was no significant correlation with BMI. On regression analysis the independent predictors of cardia mucosa length were waist circumference (Standardised coefficient 0.342, P=0.035) and age (Standardised coefficient 0.322, P=0.046). Intestinal metaplasia at the cardia was seen in only four of sixty-two volunteers. Conclusions: These findings suggest that cardia mucosa may be acquired with increasing age through a process of distal squamous columnar metaplasia accelerated by central obesity. A possible mechanism is opening of the distal portion of the lower oesophageal sphincter and short segment acid reflux.
Background: Gastroesophageal reflux disease (GERD) related non-cardiac chest pain (NCCP) showed a good response of proton pump inhibitor (PPI), but non-GERD related NCCP has a little effect of PPI therapy. Therefore the presence or absence of GERD is not a good indicator of management in NCCP patients. Aims: We aimed to explore the new mechanisms of NCCP by high resolution impedence-manometry (HRiM) test and evaluate the role of impaired esophageal bolus transit in NCCP patients. Methods: A total of 107 consecutive patients with NCCP were evaluated at the Samsung Medical Center, Seoul, Korea, from June 2009 to May 2011. They were performed the HRiM, impedence-pH monitoring test, and upper GI endoscopy. All patients were divided to two groups: normal bolus transit group was defined as ≥ 70% liquid swallows with complete bolus transit. And impaired bolus transit group was defined as > 30% liquid swallows with incomplete bolus transit. Results: There was no difference in mean age, sex ratio, and underlying body mass index between the normal bolus transit group (n=30) and impaired bolus transit group (n=77). The prevalence of GERD was not significantly different in both groups (13% in normal bolus transit group vs. 18% in impaired bolus transit group, p=0.38). The percentage time of intra-esophageal pH of < 4 was 2.4% in normal bolus transit group and 1.7% in impaired bolus transit group, which was no statistically significant difference. Using HRiM, contractile front velocity (CFV), distal contractile integral (DCI), distance (transitional zone), and integrated relaxation pressure (IRP) were measured in both groups. CFV of normal bolus transit group was slightly lower than ones of impaired bolus transit group (mean 5.2±2.6 cm/sec vs. 6.5± 5.4 cm/sec, respectively, p< 0.0001). The mean value of DCI was 1742.4±2253.8 mmHg-cm-sec in normal bolus transit group and 1222.6±1206.9 mmHg-cm-sec in impaired bolus transit group, which was lower than those of normal bolus transit group (p<0.0001). Distance and IRP were no significant difference in both groups. Thirteen (43%) patients of normal bolus transit group showed a normal peristalsis and 12 (40%) patients presented a peristaltic dysfunction. However, a total 56 (73%) patients of impaired bolus transit group showed a peristaltic dysfunction and only 11(14%) patients presented a normal esophageal peristalsis. Conclusion: Many NCCP patients showed an impaired bolus transit in esophageal HRiM and they combined with a more esophageal peristaltic dysfunction than those which bolus transits were complete. Impaired bolus transit of esophageal swallows may affects in elucidating NCCPs regardless of presence or absence of GERD.
Tu1143
Tu1145
Increased Frequency of Reflux Episodes and of Common Cavity Phenomenon in NERD Patients Than in Asymptomatic Volunteers: A Combined Impedance and High Resolution Manometry Study Mentore Ribolsi, Sara Emerenziani, Paola Balestrieri, Maria Chiara Addarii, Richard H. Holloway, Michele Cicala
Overweight and Obesity in Primary Care Patients With Functional Dyspepsia Compared With Gastroesophageal Reflux Disease Nimish B. Vakil, John Dent, Börje Wernersson, Lis Ohlsson Introduction. Gastroesophageal reflux disease (GERD) has been associated with increasing weight and obesity. In tertiary care settings, functional dyspepsia (FD) has been associated with weight loss. Patients with FD often have background symptoms of heartburn and regurgitation. The aim of this study was to compare the distribution of body mass indices (BMIs) in patients with GERD or FD. Methods. Primary care patients (N=335) were studied in north-western Europe and Canada. Patients were included if they had not taken a proton
Background: Although transient LES relaxations (TLESRs) are the major mechanism of gastroesophageal reflux in GERD, the frequency of TLESRs and of reflux episodes during TLESRs detected at conventional manometry are reported to be similar in GERD patients and asymptomatic subjects. The manometric phenomenon of common cavity (CC) is a
S-757
AGA Abstracts
AGA Abstracts
aim of this study was to evaluate the effect of sleeve gastrectomy on gastroesophageal reflux in obese patients with and without preoperatory reflux. METHODS. An observational and prospective study was conducted among patients who underwent SG according to the following inclusion criteria: age 18 to 60 years, and body mass index ≥ 40 Kg/m2 o ≥ 35 Kg/m2 with comorbidities. Patients with previous bariatric surgery or major comorbidities were excluded. Patients were evaluated with upper endoscopy, standard esophageal perfusion manometry (Medtronics®) and 24 hour ambulatory pH-impedance recording (Sandhill®) before and after 6 months of surgery. Hiatal hernia (HH) was documented preoperatively, and repaired upon surgery. Descriptive and comparative statistics were performed with McNemar and Wilcoxon tests. RESULTS. 14 patients were included, (11 female and 3 male), with mean age of 36.5 ± 9.8 years; Only 28.5% (n = 4) were found to have erosive esophagitis preoperatively (grade A = 2, grade B = 2) and 42.8% had it postoperatively (grade A = 2, grade B = 3 grade C = 1) p = NS; only 4 had preoperative HH (28.5%) and were corrected during surgery. On regard of GERD, 42.9% (n = 6) of patients had symptoms preoperatively, but only 7% (n = 1) remained symptomatic after surgery. Weight, manometry results and 24 hour pH-impedance comparisons are show in table 1. CONCLUSIONS. After SG procedure, patients with preoperative GERD improved symptomatically. In contrast after six months, endoscopic findings were the same or more severe. After operation, patients presented a similar amount of acid reflux but had more episodes of non-acid reflux, suggesting nonacidic reflux increases after SG. Our preliminary results suggest that patients considered to SG should be evaluated preoperatively for GERD, and if detected, an alternative bariatric procedure might be proposed.