- Email: [email protected]
Use of simultaneous HRES and manometry to characterize the high pressure zone of the distal esophagus during the respiratory cycle
AJG – September, Suppl., 2001
Abstracts
ences between the 2 groups. Results are given in table. EGD influenced management in 39 pts (32%) with alarm symptoms and 15 pts (25%) with refractory HB (p ⫽ 0.47). EGD improved management in 41 pts (34%) with alarm symptoms compared to 9 pts (15%) with refractory HB (p ⫽ 0.02). EGD was more likely to improve management in males with alarm symptoms (55%) than females (26%), p ⫽ 007. Management decisions were similar between primary care vs GI pts and between Caucasians vs Af-Am. In pts with alarm symptoms, 20/41 pts (49%) on PPI had further testing compared to 14/81 pts (17%) not taking PPI, p ⫽ 0.001. Alarm Symptoms (N ⴝ 122 pts) EGD influencing management:
EGD improving management:
Post-EGD med decision different than pre-EGD New consultation obtained Additional tests ordered BE surveillance initiated Dilated for peptic stricture Esophagitis grade 3–4 * p ⫽ 0.004, ** p ⫽ 0.18
Refractory HB (N ⴝ 59 pts)
6 (5%)
1 (2%)
1 (1%) 34 (28%) 4 (3%)
2 (3%) 12 (20%) 1 (2%)
22* (18%) 26** (21%)
1 (2%) 7 (12%)
Conclusions: 1)Decisions regarding medications for GERD were similar with or without EGD. 2)EGD improved management decisions in patients with alarm symptoms, especially males.
68 Treatment of chest pain in patients with non-achalasia spastic esophageal motor disorders using botulinum toxin injection Sujata V. Pullela, MD1, Henry P. Parkman, MD1, Thomas D. Schiano, MD1, Michael J. Cassidy MD1, Sidney Cohen MD1, Robert S. Fisher MD1 and Larry S. Miller MD1*. 1Gastroenterology, Temple University Hospital, Philadelphia, Pennsylvania, United States. Purpose: To determine if botulinum toxin injection in the gastroesophageal junction improves symptoms in patients with non-GERD, non-achalasia esophageal motility disorders whose major complaint was chest pain. Methods: 29 (24 female & 5 male) non-cardiac chest pain patients were enrolled in this open labeled preliminary trial. The mean was 61 ⫹/⫺13 yrs with a (range from 39 to 87 yrs). Chest pain was the predominant symptom in all patients. Cardiac workup was negative for coronary artery disease. Esophageal manometry was diagnostic of a non-achalasia spastic esophageal motility disorder. Patient’s symptoms were unresponsive to a trial of high dose proton pump inhibitor. 100 units of botulinum toxin was injected in five circumferential injections of 20 units each at the GE junction. Symptoms were scored pre and one-month post botulinum toxin injection on a grade of (0 – 4) for chest pain, dysphagia, regurgitation and heartburn. A response to botulinum toxin was defined as a 50% reduction in the symptom score. The duration of response was defined as the time period, between the time of injection and the point in time at which the severity of the symptoms returned to the preinjection score. The total symptom score (TSS) was defined as the sum of the individual scores for chest pain, regurgitation and dysphagia. Results: 72% of the patients responded with at least a 50% reduction in symptoms. There was a 79% reduction in the mean chest pain score from a pre injection score of 3.7 to a post injection score of 0.78 (p ⬍ 0.0001). 48% had complete relief of chest pain, 19% had greater than or equal to a 75% reduction in chest pain and 33% had greater than or equal to a 50% reduction in chest pain. The mean duration of the response for chest pain in these patients was 7.3 ⫹/⫺ 4.1 months (range of 1 to 18 months). There was a significant reduction in the mean regurgitation score (78%) from 2.1 to 0.5 (p ⬍ 0.0001) and the mean dysphagia score (74%) from 2.1 to 0.5 (p ⬍ 0.0001) between the pre and post injection symptom scores. There was no increase and actually a decrease in the heartburn score (56%) from 1.5 to 0.7 (p ⬍ 0.06) after the injection. The mean TSS decreased by 77% from 7.9 to 1.8 (p ⬍ 0.0001).
S23
Conclusions: Botulinum toxin injection at the GE junction leads to a significant symptomatic improvement in patients with spastic esophageal motility disorders whose major complaint is chest pain. (Funded by a generous grant from the ACG and Donald O. Castell) 69 Use of a pepsin assay in saliva and sputum to determine gastroesophageal reflux into the proximal esophagus, oral pharynx and lung Sunita Potluri, MD1, Alan Chang MD1, Robert MacNeal MD1, Christopher Manus MD1, Henry P. Parkman MD1, Matt Bromer MD1, Robert Fisher MD1, Thomas Neuman MD1, Friedrich Kueppers MD1 and Larry S. Miller MD1*. 1Gastroenterology and Pulmonary, Temple University Hospital, Philadelphia, PA, United States. Purpose: Proximal reflux of gastric contents can cause extraesophageal manifestations of gastroesophageal reflux desease (GERD) including cough, asthma and laryngitis. Pepsin is only found in gastric secretions, therefore pepsin in the oral pharynx or in pulmonary secretions originated in the stomach. The purpose of this study was to develop a noninvasive assay for pepsin in saliva and sputum which could be used to determine reflux of gastric contents into the proximal esophagus, oral pharynx and lungs and to correlate this assay with 24 hour ph monitoring. Methods: A pepsin assay was developed using digestion of fibrinogen. Patients with GERD type symptoms underwent 24 hour ph monitoring with a proximal ph probe. Patients collected sputum and saliva samples every 2 hours and whenever they had symptoms. These specimens were assayed for pepsin. Proximal reflux was defined as a ph ⬍ 4.0 for at least .4% of the study. Results: 16 patients underwent testing. 19 positive and 161 negative pepsin assays were collected. The mean minimum ph during a 30 min. interval of time at the time of the negative pepsin assays was 4.82 ⫹/⫺ 1.06. This was significantly greater than the mean minimum ph during a 30 min. time interval at the time of the positive pepsin assays (3.45 ⫹/⫺ 1.46) (p ⬍ .0007). 4 of 16 (25%) patients had positive pepsin assays. 12 of 16 (75%) of patients had negative pepsin assays. All patients with negative pepsin assays had no proximal reflux. 3 of 4 patients with positive pepsin assays had proximal reflux. The sensitivity and specificity of the pepsin assay compared to proximal reflux was found to be 100% and 92.3% respectively. The one patient with a false positive test actually had a short (⬍1 min.) episode of proximal reflux at exactly the time of the positive pepsin assay. By definition this patient did not have proximal reflux because of the short duration of the reflux event. However, if this reflux event was included as a proximal reflux event the pepsin assay would have been 100% sensitive and 100% specific. Conclusions: The pepsin assay, in saliva and sputum, is a noninvasive test with a very high sensitivity and specificity for the proximal reflux of gastric contents in patients with GERD and GERD related symptoms. We feel that this assay can be used to evaluate patients with extraintestinal manifestations of GERD such as chronic cough, asthma, and laringitis. In addition this assay has the potential to be used in patients who are being treated with acid suppressive therapy. 70 Use of simultaneous HRES and manometry to characterize the high pressure zone of the distal esophagus during the respiratory cycle Annapurna Korimilli1, Jose R. Carrasquillo 1, Chan C. Chung1, Frazad Nowrouzzadh1, Jasneet Gandehok1, Eric Choi1, Henry P. Parkman1, Robert Fisher1 and Larry S. Miller1*. 1Gastroenterology, Temple University Hospital, Philadelphia, PA, United States. Purpose: To use Simultaneous high resolution endoluminal sonography (HRES) and manometry to separate the high pressure zone (HPZ) of the distal esophagus into its two components, the extrinsic crural diaphragm and the intrinsic lower esophageal sphincter (LES) during various phases of the respiratory cycle.
S24
Abstracts
Methods: 6 normal subjects ages between 22 to 29 years, underwent simultaneous ultrasound manometry using a 20 Mhz ultrasound transducer attached to a water perfused manometry system. The catheter was placed transnasally into the stomach and a pulling machine was used to pull the catheter through the HPZ at a constant velocity of 0.5 cm/sec during various phases of the respiratory cycle (full inspiration (FI), full expiration (FE), tidal inspiration (TI), and tidal expiration (TE)). Results: The peak pressure always corresponds to an overlap of the crural diaphragm with the LES. Full inspiration increased the peak pressure generated by 25% over full expiration. The initial distal rise in the pressure at the HPZ corresponded to imaging of the crural diaphragm rather than the imaging of the LES and contributed to a total of 46%, 40%, 36%, and 40% in FI, FE, TI, and TE respectively of the total pressure generated. The length of the entire crural diaphragm from the beginning of left crura to the end of the right crura remained constant (2.94 ⫾ 0.12) during the various respiratory maneuvers as was expected, but the position of the peak pressure with respect to the beginning and end of the crural diaphragm shifting during the various phases of the respiratory cycle. Conclusions: The peak pressure corresponds to an overlap of the crural diaphragm and the intrinsic LES. The HPZ can be separated into its two components the extrinsic crural diaphragm and the intrinsic LES using simultaneous ultrasound manometry. The initial distal rise in the pressure at the HPZ is due to the crural diaphragm. The crural diaphragm alone accounts for a significant portion of the peak pressure during various phases of the respiratory cycle 46%, 40%, 36%, and 40% during FI, FE, TI, and TE. The position of the peak pressure with respect to the crural diaphragm varies during the various phases of the respiratory cycle. (Funded by generous grants from Janssen and the NIH RO1 DK5950001) 71 Assessment of effectiveness of different dosage regimens of pantoprazole in the treatment of mild erosive esofhagitis Luciana D Moretzsohn MD, Eliza M Brito MD, Margareth SF Reis MD, Luiz GV Coelho MD and Luiz P Castro MD*. 1Gastroenterology, University Hospital, Belo Horizonte, Minas Gerais, Brazil. Purpose: The aim of this study is to compare the effectiveness of two different pantoprazole dosage regimens (20 and 40 mg/day), in controlling symptoms and healing oesophageal lesions of patients with mild erosive oesophagitis. Methods: Fifty-seven patients with endoscopically confirmed mild erosive oesophagitis characterised as non-confluent erosions in the distal oesophagus, were randomly to be treated either with pantoprazole 20 mg/day (group I, 28 patients) or 40 mg/day (group II, 29 patients) over a period of four weeks. After treatment completion, the patients were assessed for clinical and endoscopic outcome, i.e., absence of erosions in distal oesophagus and improvement of GORD symptoms. Results: At the end of the treatment, 73.1% of the patients in group I and 85.7% of the patients in group II had endocopic improvement. We also observed, that 88.5% of the patients in group I and 92.9% of the patients in group II had complete elimination of heartburn and regurgitation. Conclusions: Pantoprazole dosage regimens of 20 mg/day and 40 mg/day provide equivalent effectiveness in controlling symptoms and healing oesophageal lesions of mild oesophagitis. 72 Clinical utility of gastrointestinal rating scale to identify refractory symptom control of patients receiving proton pump inhibitors for chronic GERD Anthony P MorrealeVA*, Melissa DeLattreVA, Brian K PlowmanVA and Monica SchaeferVA. 1Pharmacy, VA San Diego Healthcare System, San Diego, CA, United States; 2Pharmacy, VA San Diego Healthcare System, San Diego, CA, United States; 3Pharmacy, VA San Diego Healthcare System, San Diego, CA, United States; and 4Pharmacy, VA San Diego Healthcare System, San Diego, CA, United States.
AJG – Vol. 96, No. 9, Suppl., 2001
Purpose: Cross-sectional survey study to estimate patient perceptions of symptom control and utilizing the Gastrointestinal Symptom Rating Scale (GSRS) to test for correlation of survey instument to patient perceptions of disease control. Methods: An unblinded, self-administered questionnaire, including the GSRS, was mailed to 300 patients who were currently receiving GERD maintenance therapy with a PPI. Patients were surveyed regarding the duration and severity of symptoms, dosing of medication, contributing lifestyle factors and debilitation of disease. A secondary use for this data will be to correlate to risk of complications utilizing population analysis. Results: 135 usable questionnaires were returned. Only 68% of patients perceived their symptoms to be controlled. In the patients who perceived symptom to not be controlled (32%) there was good correlation of the GSRS with patient perceptions, frequency, severity, and GSRS domain scores. GSRS total scores and sub scores were consistently higher, indicating more discomfort, in the non-controlled group vs. the controlled group despite demographics being similar. Indigestion and reflux sub scores were highest in the non-controlled patients. Conclusions: The GSRS correlated well with patient perceptions of symptom control. Patients who were not controlled had similar clinical demographics and doses of PPIs as those uncontrolled and a significant proportion (⬎33%) of the population is uncontrolled and is at high risk for complications. 73 Altered esophageal sensory and biomechanical properties in GERD Ranjit Mudipalli, MD; Satish Rao, MD; FACG, Xing Zhao, MD; James Maher, MD. University of Iowa, Iowa City, IA. Background: The biomechanical and sensory properties of the esophagus in patients with GERD is incompletely known. Abnormal neuromuscular dysfunction may play a role in the pathogenesis of GERD. Aim: To characterize the biomechanical and sensory properties of the esophagus in GERD. Methods: Graded balloon distensions were performed at 10 cm above LES using impedance planimetry in 31 patients with refractory GERD, (M/F ⫽ 15/16; mean age-43 years) who were referred for fundoplication and in 26 (M/F ⫽ 12/14; mean age ⫽ 36years) matched controls. None had a stricture. Results: Balloon distention reproduced chest pain in 15 patients (48%) and heartburn in 3 others (10%) at distention pressures ⱕ50 cm H2O. Overall patients had lower thresholds for sensory perception and pain when compared to controls (p ⬍ 0.05). In patients, the cross sectional area and circumferential wall tension was higher (p ⬍ 0.05) and, the tension straincurve shifted significantly (p ⬍ 0.005) to the left. Conclusions: In patients with refractory GERD, the lumen is larger and the wall tension is higher. About 60% had a hypersensitive esophagus. The larger lumen and stiffer esophageal wall may cause pooling of acid. This increased acid exposure may sensitize the nociceptors and cause hypersensitivity and lead to refractory GERD symptoms. Table. Biomechanical Properties in GERD (G) and Controls (C) Distention (cm H2O) CSA(mm2) Tension (mm/cmH2O) Strain
G 10
C 10
G 20
C 20
G 30
C 30
G 40
C 40
235 99 0.4
146 67 0.8
384 211 0.8
246 174 1.4
504 412 1.1
351 314 1.9
626 555 1.3
457 477 2.3
74 Are sensory and biomechanical properties different in Barrett’s vs. non Barrett’s GERD? Ranjit Mudipalli, MD; Xing Zhao, MD; James Maher, MD; Satish Rao, MD; FACG. University of Iowa, Iowa City, IA. Background: The biomechanical and sensory properties of the esophagus in patients with Barrett’s esophagus and GERD are not known. Abnormal
Abstracts
ences between the 2 groups. Results are given in table. EGD influenced management in 39 pts (32%) with alarm symptoms and 15 pts (25%) with refractory HB (p ⫽ 0.47). EGD improved management in 41 pts (34%) with alarm symptoms compared to 9 pts (15%) with refractory HB (p ⫽ 0.02). EGD was more likely to improve management in males with alarm symptoms (55%) than females (26%), p ⫽ 007. Management decisions were similar between primary care vs GI pts and between Caucasians vs Af-Am. In pts with alarm symptoms, 20/41 pts (49%) on PPI had further testing compared to 14/81 pts (17%) not taking PPI, p ⫽ 0.001. Alarm Symptoms (N ⴝ 122 pts) EGD influencing management:
EGD improving management:
Post-EGD med decision different than pre-EGD New consultation obtained Additional tests ordered BE surveillance initiated Dilated for peptic stricture Esophagitis grade 3–4 * p ⫽ 0.004, ** p ⫽ 0.18
Refractory HB (N ⴝ 59 pts)
6 (5%)
1 (2%)
1 (1%) 34 (28%) 4 (3%)
2 (3%) 12 (20%) 1 (2%)
22* (18%) 26** (21%)
1 (2%) 7 (12%)
Conclusions: 1)Decisions regarding medications for GERD were similar with or without EGD. 2)EGD improved management decisions in patients with alarm symptoms, especially males.
68 Treatment of chest pain in patients with non-achalasia spastic esophageal motor disorders using botulinum toxin injection Sujata V. Pullela, MD1, Henry P. Parkman, MD1, Thomas D. Schiano, MD1, Michael J. Cassidy MD1, Sidney Cohen MD1, Robert S. Fisher MD1 and Larry S. Miller MD1*. 1Gastroenterology, Temple University Hospital, Philadelphia, Pennsylvania, United States. Purpose: To determine if botulinum toxin injection in the gastroesophageal junction improves symptoms in patients with non-GERD, non-achalasia esophageal motility disorders whose major complaint was chest pain. Methods: 29 (24 female & 5 male) non-cardiac chest pain patients were enrolled in this open labeled preliminary trial. The mean was 61 ⫹/⫺13 yrs with a (range from 39 to 87 yrs). Chest pain was the predominant symptom in all patients. Cardiac workup was negative for coronary artery disease. Esophageal manometry was diagnostic of a non-achalasia spastic esophageal motility disorder. Patient’s symptoms were unresponsive to a trial of high dose proton pump inhibitor. 100 units of botulinum toxin was injected in five circumferential injections of 20 units each at the GE junction. Symptoms were scored pre and one-month post botulinum toxin injection on a grade of (0 – 4) for chest pain, dysphagia, regurgitation and heartburn. A response to botulinum toxin was defined as a 50% reduction in the symptom score. The duration of response was defined as the time period, between the time of injection and the point in time at which the severity of the symptoms returned to the preinjection score. The total symptom score (TSS) was defined as the sum of the individual scores for chest pain, regurgitation and dysphagia. Results: 72% of the patients responded with at least a 50% reduction in symptoms. There was a 79% reduction in the mean chest pain score from a pre injection score of 3.7 to a post injection score of 0.78 (p ⬍ 0.0001). 48% had complete relief of chest pain, 19% had greater than or equal to a 75% reduction in chest pain and 33% had greater than or equal to a 50% reduction in chest pain. The mean duration of the response for chest pain in these patients was 7.3 ⫹/⫺ 4.1 months (range of 1 to 18 months). There was a significant reduction in the mean regurgitation score (78%) from 2.1 to 0.5 (p ⬍ 0.0001) and the mean dysphagia score (74%) from 2.1 to 0.5 (p ⬍ 0.0001) between the pre and post injection symptom scores. There was no increase and actually a decrease in the heartburn score (56%) from 1.5 to 0.7 (p ⬍ 0.06) after the injection. The mean TSS decreased by 77% from 7.9 to 1.8 (p ⬍ 0.0001).
S23
Conclusions: Botulinum toxin injection at the GE junction leads to a significant symptomatic improvement in patients with spastic esophageal motility disorders whose major complaint is chest pain. (Funded by a generous grant from the ACG and Donald O. Castell) 69 Use of a pepsin assay in saliva and sputum to determine gastroesophageal reflux into the proximal esophagus, oral pharynx and lung Sunita Potluri, MD1, Alan Chang MD1, Robert MacNeal MD1, Christopher Manus MD1, Henry P. Parkman MD1, Matt Bromer MD1, Robert Fisher MD1, Thomas Neuman MD1, Friedrich Kueppers MD1 and Larry S. Miller MD1*. 1Gastroenterology and Pulmonary, Temple University Hospital, Philadelphia, PA, United States. Purpose: Proximal reflux of gastric contents can cause extraesophageal manifestations of gastroesophageal reflux desease (GERD) including cough, asthma and laryngitis. Pepsin is only found in gastric secretions, therefore pepsin in the oral pharynx or in pulmonary secretions originated in the stomach. The purpose of this study was to develop a noninvasive assay for pepsin in saliva and sputum which could be used to determine reflux of gastric contents into the proximal esophagus, oral pharynx and lungs and to correlate this assay with 24 hour ph monitoring. Methods: A pepsin assay was developed using digestion of fibrinogen. Patients with GERD type symptoms underwent 24 hour ph monitoring with a proximal ph probe. Patients collected sputum and saliva samples every 2 hours and whenever they had symptoms. These specimens were assayed for pepsin. Proximal reflux was defined as a ph ⬍ 4.0 for at least .4% of the study. Results: 16 patients underwent testing. 19 positive and 161 negative pepsin assays were collected. The mean minimum ph during a 30 min. interval of time at the time of the negative pepsin assays was 4.82 ⫹/⫺ 1.06. This was significantly greater than the mean minimum ph during a 30 min. time interval at the time of the positive pepsin assays (3.45 ⫹/⫺ 1.46) (p ⬍ .0007). 4 of 16 (25%) patients had positive pepsin assays. 12 of 16 (75%) of patients had negative pepsin assays. All patients with negative pepsin assays had no proximal reflux. 3 of 4 patients with positive pepsin assays had proximal reflux. The sensitivity and specificity of the pepsin assay compared to proximal reflux was found to be 100% and 92.3% respectively. The one patient with a false positive test actually had a short (⬍1 min.) episode of proximal reflux at exactly the time of the positive pepsin assay. By definition this patient did not have proximal reflux because of the short duration of the reflux event. However, if this reflux event was included as a proximal reflux event the pepsin assay would have been 100% sensitive and 100% specific. Conclusions: The pepsin assay, in saliva and sputum, is a noninvasive test with a very high sensitivity and specificity for the proximal reflux of gastric contents in patients with GERD and GERD related symptoms. We feel that this assay can be used to evaluate patients with extraintestinal manifestations of GERD such as chronic cough, asthma, and laringitis. In addition this assay has the potential to be used in patients who are being treated with acid suppressive therapy. 70 Use of simultaneous HRES and manometry to characterize the high pressure zone of the distal esophagus during the respiratory cycle Annapurna Korimilli1, Jose R. Carrasquillo 1, Chan C. Chung1, Frazad Nowrouzzadh1, Jasneet Gandehok1, Eric Choi1, Henry P. Parkman1, Robert Fisher1 and Larry S. Miller1*. 1Gastroenterology, Temple University Hospital, Philadelphia, PA, United States. Purpose: To use Simultaneous high resolution endoluminal sonography (HRES) and manometry to separate the high pressure zone (HPZ) of the distal esophagus into its two components, the extrinsic crural diaphragm and the intrinsic lower esophageal sphincter (LES) during various phases of the respiratory cycle.
S24
Abstracts
Methods: 6 normal subjects ages between 22 to 29 years, underwent simultaneous ultrasound manometry using a 20 Mhz ultrasound transducer attached to a water perfused manometry system. The catheter was placed transnasally into the stomach and a pulling machine was used to pull the catheter through the HPZ at a constant velocity of 0.5 cm/sec during various phases of the respiratory cycle (full inspiration (FI), full expiration (FE), tidal inspiration (TI), and tidal expiration (TE)). Results: The peak pressure always corresponds to an overlap of the crural diaphragm with the LES. Full inspiration increased the peak pressure generated by 25% over full expiration. The initial distal rise in the pressure at the HPZ corresponded to imaging of the crural diaphragm rather than the imaging of the LES and contributed to a total of 46%, 40%, 36%, and 40% in FI, FE, TI, and TE respectively of the total pressure generated. The length of the entire crural diaphragm from the beginning of left crura to the end of the right crura remained constant (2.94 ⫾ 0.12) during the various respiratory maneuvers as was expected, but the position of the peak pressure with respect to the beginning and end of the crural diaphragm shifting during the various phases of the respiratory cycle. Conclusions: The peak pressure corresponds to an overlap of the crural diaphragm and the intrinsic LES. The HPZ can be separated into its two components the extrinsic crural diaphragm and the intrinsic LES using simultaneous ultrasound manometry. The initial distal rise in the pressure at the HPZ is due to the crural diaphragm. The crural diaphragm alone accounts for a significant portion of the peak pressure during various phases of the respiratory cycle 46%, 40%, 36%, and 40% during FI, FE, TI, and TE. The position of the peak pressure with respect to the crural diaphragm varies during the various phases of the respiratory cycle. (Funded by generous grants from Janssen and the NIH RO1 DK5950001) 71 Assessment of effectiveness of different dosage regimens of pantoprazole in the treatment of mild erosive esofhagitis Luciana D Moretzsohn MD, Eliza M Brito MD, Margareth SF Reis MD, Luiz GV Coelho MD and Luiz P Castro MD*. 1Gastroenterology, University Hospital, Belo Horizonte, Minas Gerais, Brazil. Purpose: The aim of this study is to compare the effectiveness of two different pantoprazole dosage regimens (20 and 40 mg/day), in controlling symptoms and healing oesophageal lesions of patients with mild erosive oesophagitis. Methods: Fifty-seven patients with endoscopically confirmed mild erosive oesophagitis characterised as non-confluent erosions in the distal oesophagus, were randomly to be treated either with pantoprazole 20 mg/day (group I, 28 patients) or 40 mg/day (group II, 29 patients) over a period of four weeks. After treatment completion, the patients were assessed for clinical and endoscopic outcome, i.e., absence of erosions in distal oesophagus and improvement of GORD symptoms. Results: At the end of the treatment, 73.1% of the patients in group I and 85.7% of the patients in group II had endocopic improvement. We also observed, that 88.5% of the patients in group I and 92.9% of the patients in group II had complete elimination of heartburn and regurgitation. Conclusions: Pantoprazole dosage regimens of 20 mg/day and 40 mg/day provide equivalent effectiveness in controlling symptoms and healing oesophageal lesions of mild oesophagitis. 72 Clinical utility of gastrointestinal rating scale to identify refractory symptom control of patients receiving proton pump inhibitors for chronic GERD Anthony P MorrealeVA*, Melissa DeLattreVA, Brian K PlowmanVA and Monica SchaeferVA. 1Pharmacy, VA San Diego Healthcare System, San Diego, CA, United States; 2Pharmacy, VA San Diego Healthcare System, San Diego, CA, United States; 3Pharmacy, VA San Diego Healthcare System, San Diego, CA, United States; and 4Pharmacy, VA San Diego Healthcare System, San Diego, CA, United States.
AJG – Vol. 96, No. 9, Suppl., 2001
Purpose: Cross-sectional survey study to estimate patient perceptions of symptom control and utilizing the Gastrointestinal Symptom Rating Scale (GSRS) to test for correlation of survey instument to patient perceptions of disease control. Methods: An unblinded, self-administered questionnaire, including the GSRS, was mailed to 300 patients who were currently receiving GERD maintenance therapy with a PPI. Patients were surveyed regarding the duration and severity of symptoms, dosing of medication, contributing lifestyle factors and debilitation of disease. A secondary use for this data will be to correlate to risk of complications utilizing population analysis. Results: 135 usable questionnaires were returned. Only 68% of patients perceived their symptoms to be controlled. In the patients who perceived symptom to not be controlled (32%) there was good correlation of the GSRS with patient perceptions, frequency, severity, and GSRS domain scores. GSRS total scores and sub scores were consistently higher, indicating more discomfort, in the non-controlled group vs. the controlled group despite demographics being similar. Indigestion and reflux sub scores were highest in the non-controlled patients. Conclusions: The GSRS correlated well with patient perceptions of symptom control. Patients who were not controlled had similar clinical demographics and doses of PPIs as those uncontrolled and a significant proportion (⬎33%) of the population is uncontrolled and is at high risk for complications. 73 Altered esophageal sensory and biomechanical properties in GERD Ranjit Mudipalli, MD; Satish Rao, MD; FACG, Xing Zhao, MD; James Maher, MD. University of Iowa, Iowa City, IA. Background: The biomechanical and sensory properties of the esophagus in patients with GERD is incompletely known. Abnormal neuromuscular dysfunction may play a role in the pathogenesis of GERD. Aim: To characterize the biomechanical and sensory properties of the esophagus in GERD. Methods: Graded balloon distensions were performed at 10 cm above LES using impedance planimetry in 31 patients with refractory GERD, (M/F ⫽ 15/16; mean age-43 years) who were referred for fundoplication and in 26 (M/F ⫽ 12/14; mean age ⫽ 36years) matched controls. None had a stricture. Results: Balloon distention reproduced chest pain in 15 patients (48%) and heartburn in 3 others (10%) at distention pressures ⱕ50 cm H2O. Overall patients had lower thresholds for sensory perception and pain when compared to controls (p ⬍ 0.05). In patients, the cross sectional area and circumferential wall tension was higher (p ⬍ 0.05) and, the tension straincurve shifted significantly (p ⬍ 0.005) to the left. Conclusions: In patients with refractory GERD, the lumen is larger and the wall tension is higher. About 60% had a hypersensitive esophagus. The larger lumen and stiffer esophageal wall may cause pooling of acid. This increased acid exposure may sensitize the nociceptors and cause hypersensitivity and lead to refractory GERD symptoms. Table. Biomechanical Properties in GERD (G) and Controls (C) Distention (cm H2O) CSA(mm2) Tension (mm/cmH2O) Strain
G 10
C 10
G 20
C 20
G 30
C 30
G 40
C 40
235 99 0.4
146 67 0.8
384 211 0.8
246 174 1.4
504 412 1.1
351 314 1.9
626 555 1.3
457 477 2.3
74 Are sensory and biomechanical properties different in Barrett’s vs. non Barrett’s GERD? Ranjit Mudipalli, MD; Xing Zhao, MD; James Maher, MD; Satish Rao, MD; FACG. University of Iowa, Iowa City, IA. Background: The biomechanical and sensory properties of the esophagus in patients with Barrett’s esophagus and GERD are not known. Abnormal