Biomedical subjects
Publications and source records attributed to D O Castell.
A variety of esophageal abnormalities produce the symptoms of heartburn, dysphagia, and/or chest pain in the elderly. Most such diseases also occur in younger patients, but some disorders are unique to the elderly or occur with increased frequency. Diagnostic and therapeutic approaches are discussed.
We report the results of a randomized prospective study comparing a standard bougie rubber balloon dilator [Brown-McHardy (BMH)] and a newer polyethylene dilator passed over a guide wire [Microvasive Rigiflex (MVR)]. Twenty achalasia patients (15M, 5F, mean age 45.4 yr) considered candidates for either dilator were randomized. Symptom assessment, body weight, and upright radionuclide solid esophageal emptying study were measured before and 6 months after pneumatic dilatation. All dilatations were performed by one of three experienced gastroenterologists under fluoroscopic guidance. Overall success occurred with 10/10 BMH and 7/10 MVR. One patient not improved with MVR had myotomy; the other two were successfully treated by BMH. No complications occurred with either dilator.
Acute reflux esophagitis in man is characterized histologically by infiltrates of segmented leukocytes, epithelial proliferation, and ulcers. Our feline model, which includes each of these features, is produced by the infusion of 0.1 N HCl at a rate of 1 ml per min into the distal esophagus of adult cats for varying periods of time. Our histologic scoring system includes both the intensity and the distribution of four morphologic features, namely basal cell hyperplasia (BCH), intraepithelial segmented leukocytes (IEL), subepithelial leukocytes (SEL), and ulcers. Each of these four categories are scored from 0 to 4, with a potential score of 16. We evaluated the effects of duration of acid exposure by infusing cats with HCl for 5 min (N = 4), 15 min (N = 12), 20 min (N = 12), and 30 min (N = 6), followed by autopsy 24 h later. Mean scores (+/- SE) were as follows: 5 min, 3.0 (+/- 1.7); 15 min, 9.0 (+/- 1.0); 20 min, 11.17 (+/- 1.06); 30 min, 15.17 (+/- 0.54). Differences between 5 and 15 min, 15 and 30 min, and 20 and 30 min were significant (P less than 0.05). Basal cell hyperplasia appeared to be the most sensitive marker of acid injury; ulcers denoted severe injury associated with longer exposure periods. Although an occasional eosinophil was seen, the majority of the segmented leukocytes were neutrophils. We also studied healing histologically by examining cats at 1 d (N = 6), 2 d (N = 6), 3 d (N = 11), and 4 d (N = 6) after a 30 min exposure to HCl.(ABSTRACT TRUNCATED AT 250 WORDS)
Failure to obtain preoperative esophageal manometry in patients being considered for antireflux surgery can result in immediate persistent postoperative dysphagia due to a missed diagnosis of achalasia. We describe the clinical assessment and management of a case of delayed postoperative dysphagia due to a "slipped" fundoplication, which is contrasted with three patients with immediate postoperative dysphagia due to a missed diagnosis of achalasia. Surgical revision was required to correct the "slipped" fundoplication, and pneumatic dilatation was successfully used in two of three cases of achalasia complicated by fundoplication. Careful preoperative esophageal evaluation with manometry is essential to rule out the presence of a primary esophageal motor disorder.
Recent improvements in manometric catheters have made measurement of pharyngeal (P) and upper esophageal sphincter (UES) swallowing mechanics more reliable. Few studies have attempted to evaluate the effect of normal aging on P and UES mechanics. Pharyngeal and upper esophageal sphincter dynamics were studied in 10 healthy elderly adults (age greater than 60; range 62-79 yr) and 10 younger adults (age less than 60; range 24-59 yr). A solid-state intraluminal transducer system was used with a proximal unidirectional Konigsberg microtransducer and a circumferential (sphincter) transducer located 5 cm distally. Mean resting UES pressure was significantly (p less than 0.05) lower in the elderly than in the younger subjects (52 +/- 5 vs 72 +/- 6 (SE)) mm Hg. A significant inverse relation (R = -0.54; p less than 0.02) was found between age and resting UES pressure. Time from peak of pharyngeal contraction to UES nadir was significantly (p less than 0.05) shortened in the healthy elderly vs younger controls (10 +/- 30 vs 90 +/- 20 ms) during dry swallows. Our studies indicate that aging is associated with lower resting UES pressure and delayed UES relaxation, relative to the pharyngeal peak.
We compared lower esophageal sphincter (LES) pressures to parameters of acid reflux measured during 24-h pH monitoring in 81 patients being evaluated for possible reflux disease. Mid-respiratory LES pressures were significantly higher (p less than 0.05) in patients with normal amounts of reflux than in those with abnormal reflux. This difference did not occur with LES pressure measured by end-expiratory station pull-through (SPT) or rapid pull-through (RPT). There was no significant difference in total length or intra-abdominal portion of LES between the two groups. However, the product of LES pressure and total LES length was greater (p less than 0.05) for patients with normal reflux than for these with abnormal reflux. No difference was noted in the percentage of abnormal contractions in the distal esophagus between groups. These studies support the following conclusions: 1) LES pressure may be a more important protective mechanism against reflux than LES length. 2) Mid-respiratory SPT technique appears to identify the LES antireflux barrier better than either end-expiratory SPT or RPT techniques. 3) Acid exposure time seems to be a better measure of gastroesophageal reflux than the number of reflux episodes.
PURPOSE: To evaluate the importance of esophageal abnormalities as a potential cause of recurrent noncardiac chest pain. DATA IDENTIFICATION: We discuss the rapidly evolving new knowledge in this field after analyzing the literature in English published since 1979. STUDY SELECTION: We reviewed 117 articles on recurring chest pain and paid specific attention to the following nine controversial issues: the potential mechanisms of esophageal pain, the differentiation of cardiac and esophageal causes, the evaluation of new esophageal motility disorders, the use of esophageal tests in evaluating noncardiac chest pain, the usefulness of techniques for prolonged monitoring of intraesophageal pressure and pH, the relation of psychologic abnormalities to esophageal motility disorders, the possible mechanisms for decreased visceral pain thresholds in these patients, the relation of esophageal chest pain to the irritable bowel syndrome, and the appropriate therapies for these patients. RESULTS OF DATA SYNTHESIS: Through our review of the literature, we identified areas of concordance and disagreement. These areas are discussed and an overall perspective is provided. CONCLUSIONS: Continuing attempts to develop rational diagnostic and therapeutic approaches to patients with noncardiac chest pain should include a multidisciplinary approach involving basic scientists, gastroenterologists, psychologists, and other clinical experts in the field of pain research.
We performed an experiment in dogs in order to assess the accuracy of an intraesophageal pH probe and to examine possible mechanisms for any lack of accuracy. Two pH probes were placed in the esophagus of supine anesthetized dogs and acid was infused in small serial volumes from an infusion tube placed at the gastroesophageal junction. Two general patterns of pH probe responses were seen: (1) neither probe recorded a fall in pH with acid infusion, and (2) both probes recorded a fall in pH, but in a nonsynchronous manner. Changing the relationship of the tips of the probes with respect to the adjacent mucosa caused a fall in the pH recorded by each probe to the pH of the intraesophageal infusate. This and other evidence seen in the pH tracings suggest that mucosal abutment of the probe tips causes a falsely negative pH recording and raises the question of whether such a phenomenon occurs in human studies.
We conducted a randomized prospective study with extended intraesophageal pH monitoring on two consecutive nights to test the hypothesis that a waterbed (WB) might increase recumbent acid exposure compared to a regular bed (RB). We studied 10 controls (mean age 29 years; five males, five females) with no history of reflux symptoms more than two times per month. We also studied 10 reflux patients (mean age 42 years; seven males, three females) with symptoms at least five days a week and documented recumbent reflux, with or without upright reflux, by previous 24 hr pH study. A standard meal (56% fat) was provided at 6 PM. After randomization, the subjects and patients slept on the assigned bed (WB or RB) in one nearby hotel. The pH probe was removed the next morning at 8 AM. On the same day, the pH probe was inserted at 4 PM and the routine was repeated with use of the other bed. No significant difference (P greater than 0.05; paired t test) was found between the regular bed and waterbed in any measurement of recumbent reflux. Our study does not support the hypothesis that greater recumbent reflux may occur when sleeping flat on a waterbed compared to a regular bed. It does not, however, absolutely refute the possible association of waterbed use with esophagitis, since elevation of the head of a waterbed is not possible.
Little is known about the accuracy of intraesophageal pH monitoring, ie, do false negatives occur? This study was designed based on the assumption that if two pH probes are placed equidistant from a distal acid source, and the probes measure different values, then one probe might miss acid if it were there alone. We performed 24-hr intraesophageal pH monitoring in 10 patients with gastroesophageal reflux disease, simultaneously placing two pediatric pH probes (probes A and B) 5 cm proximal to the LES in such close proximity that one would expect only small differences in the acid exposure measured by the probes. However, the amount of acid exposure measured by probes A and B differed greatly in some instances. Individual probe performance does not alone account for these differences, since, when pH recordings were reviewed, one probe was as likely to miss acid exposure as the other. These differences would result in a change in the clinical diagnosis in two of 10 patients. Variability in the number of episodes was great and occurred even when there was concordance in percent acid exposure. These data raise questions about the absolute accuracy of the pH probe as the gold standard in the measurement of gastroesophageal reflux.
We compared the clinical, radiographic, and manometric findings in 10 patients with atypical achalasia showing complete lower esophageal sphincter (LES) relaxation to 39 patients with classic achalasia (i.e., incomplete LES relaxation). Those with atypical achalasia were younger (46.1 vs 60.6 years), had dysphagia of shorter duration (18.7 vs 45.7 mos), had lost less weight (8.2 vs 21.5 lbs), and had less esophageal dilatation (2.8 vs 3.9 cm). However, the mean LES pressures (34.5 vs 37.7 mmHg) and the esophagogastric junction calibers (4.5 vs 4.8 mm) were similar. Radionuclide esophageal emptying studies were done in 15 patients (6 with atypical achalasia; 9 with classic achalasia) and were abnormal in all. Most patients in both groups (90 and 92%) responded well to pneumatic dilatation. We conclude that achalasia with apparent LES relaxation may represent an early form of this motor disorder and that the radiographic findings remain characteristic except for less dilatation of the esophagus.
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Achalasia presenting as an acute airway obstruction is a rarely reported phenomenon. The pathophysiology of this dramatic complication of achalasia remains an enigma. Our patient with achalasia presented with an acute airway compromise necessitating emergent endotracheal intubation. We review the available literature on this interesting yet rare complication of achalasia. We also add some information to help elucidate the possible pathophysiologic mechanism of this emergency, proposing that specific upper esophageal sphincter manometry may indicate abnormality of the "belch reflex."
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At least 13% of the US adult population have chronic heartburn, and unknown percentages of others have related symptoms of gastroesophageal reflux disease. Studies show that most people with symptoms of reflux self-medicate and do not seek medical advice. Also, they fail to mention these symptoms when visiting their physician for other conditions. Therefore, the importance of thorough history taking cannot be overstated, and it may be prudent for primary care physicians to question all patients routinely about reflux symptoms.
The hypertensive lower esophageal sphincter (LES) (mean LES pressure greater than 45 mm Hg; LES relaxation greater than 75%; normal peristalsis) is a poorly characterized motility disorder associated with chest pain and dysphagia. Therefore, we carried out a multidisciplinary study to assess esophageal pressures and function in 15 symptomatic hypertensive LES patients (3 men, 12 women; mean age, 53 years). On-line computer analysis showed a significant (p less than 0.05) increase in LES pressure (55.5 versus 14.9 mm Hg) and residual pressure (6.8 versus 1.1 mm Hg) as well as a decrease in percentage of LES relaxation (87 versus 93%) in patients compared with age-matched controls. All patients had normal peristalsis but 7 of 15 had nutcracker esophagus (mean distal amplitude, 216 mm Hg). No patient had evidence of impaired liquid transport on barium esophagram. The emptying of solids as assessed by radionuclide scans was normal in 14 of 15 patients. Of the 12 patients who completed both psychological inventories, nine had elevated scores on scales assessing anxiety and somatization. The heterogenous nature of this disorder is illustrated by a patient with a changeable narrowing in the distal esophagus associated with the transient impaction of a marshmallow. Dysphagia but not chest pain improved after pneumatic dilatation. We conclude that the hypertensive LES is a heterogenous disorder. Despite abnormal LES parameters, most patients have normal esophageal function, and frequent psychological abnormalities may contribute to their report of symptoms. A minority have abnormal esophageal transit.
Using 24 hour pH monitoring as a reference standard, the usefulness of the acid perfusion (AP) test in predicting gastro-oesophageal reflux disease (GORD) was assessed in 71 non-cardiac chest pain (NCCP) patients and 23 endoscopic oesophagitis patients. Of the 71 NCCP patients, 35 had a positive AP test (of whom 20 had an abnormal 24 hour pH) and 36 had a negative AP test (of whom 14 had an abnormal 24 hour pH study). Thus, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the AP test in this group was 59%, 59%, 57%, and 61%, respectively. The corresponding values in the oesophagitis group were 85%, 67%, 94%, and 40%. In the NCCP group when heartburn alone was used as the positive criterion the PPV rose to 74%. When chest pain with or without heartburn was used, however, the PPV dropped to 38%. A 'symptom index' was used to define the number of chest pain episodes that were caused by acid reflux. Only 48% of AP test positive patients had demonstrable acid mediated chest pain. In the NCCP population with a normal oesophageal examination (1) AP test reproduction of chest pain is poorly predictive of GORD; (2) AP test reproduction of heartburn is more predictive of GORD but does not ensure that the chest pain is caused by GORD; (3) a negative AP test does not exclude GORD and (4) only 48% of AP test positive patients have demonstrable acid mediated chest pain. The ambulatory 24 hour pH test may have rendered the AP test obsolete in the assessment of GORD as the cause of NCCP.
Ambulatory oesophageal motility/pH monitoring permits accurate detection of oesophageal events during spontaneous chest pain episodes. Opinions differ, however, about the methods to review the extensive motility data and the definition of abnormal motility changes. We studied 30 patients (18 women, age 46 years) with suspected oesophageal chest pain using a portable recording system attached to a 4.5 mm catheter with pressure transducers 3 and 8 cm and pH probe 5 cm above the lower oesophageal sphincter (LOS). An event marker was triggered by the patient for chest pain. In the patient's diary, pain was recorded on a scale of increasing severity 1-10. Two methods of analysis were used to assess 24 hour motility data. The 24 hour technique sampled five minute asymptomatic baselines throughout the study to define the patient's normal range of oesophageal motility. The second technique used only the 10 minute period immediately before each chest pain episode as the asymptomatic baseline. Chest pain episodes were defined as abnormal if associated with pH less than 4 or motility changes not present during the asymptomatic baseline analysis: 135 chest pain episodes were recorded. The method of motility analysis significantly (p less than 0.01) changed the number of chest pain episodes associated with abnormal motility: 24 hour technique - 14 episodes (10%) versus a 2.5-fold increase with the 10 minute baseline technique - 33 episodes (24%). Acid related pain episodes were similar in both groups - 13%. The majority of chest pain episodes had no association with abnormal motility or acid reflux. Increasing chest pain severity was inversely correlated with the presence of abnormal oesophageal events. We conclude that limited analysis of 24 hour motility data may over diagnose motility related chest pain events and lead to inappropriate medical or surgical therapy.