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Biomedical subjects

D O Castell

Publications and source records attributed to D O Castell.

At least 271 records · Page 15Linked to original sources
PubMed1987

Long-term follow-up of symptomatic status of patients with noncardiac chest pain: is diagnosis of esophageal etiology helpful?

Questionnaires were sent to 119 patients with noncardiac chest pain, all of whom had previous detailed esophageal evaluations in which 63 were diagnosed as having pain from the esophagus. Mean follow-up period was 21.8 months. Patients diagnosed as having an esophageal etiology of their noncardiac chest pain usually continued to have recurrent pain. Furthermore, a specific diagnosis did not significantly increase the likelihood of pain resolution. However, patients who understood that the esophagus was the source of their pain were significantly less likely to feel disabled by their pain and to require continued physician evaluation. This finding was independent of any treatment program. This study emphasizes the importance of a careful evaluation of the esophagus as a potential source of pain and clearly communicating this information to the patient.

Cardiac Catheterization↗
PubMed1986

Computer analysis of human esophageal peristalsis and lower esophageal sphincter pressure. II. An interactive system for on-line data collection and analysis.

A computer program has been written to directly read and analyze esophageal manometric tracings on-line using low-cost off-the-shelf microcomputer hardware. The system consists of an Apple IIe microcomputer and an Interactive Microwave Inc. ADALAB Data Acquisition System with an AI13 fast A/D Multiplexer. The primary program is in BASIC with ASSEMBLY language subroutines for data collection. Data are collected through the voltage output of a Hewlett-Packard recorder at 30 points per second on four channels for lower esophageal sphincter pressures (LESP) and three channels for peristaltic waves. Computer-determined values for LESP and wave parameters showed excellent correlation with mean values as read by five individuals experienced in esophageal manometry.

Adult↗
PubMed1986

Graded esophageal balloon distention. A new provocative test for noncardiac chest pain.

The evaluation of suspected esophageal chest pain is frustrating because of difficulty in clearly implicating the esophagus. Balloon distention was considered as a new provocative test in the esophagus because it has been shown to safely produce pain in other hollow gastrointestinal organs. Studies were performed in 50 chest pain patients (mean age 50 years) with negative coronary arteriograms and 30 healthy volunteers (mean age 41 years). A polyvinyl balloon (length 30 mm; maximum diameter after 10 cc distention 25 mm) was positioned 10 cm above the lower esophageal sphincter and inflated with 1-cc increments of air to a total volume of 10 cc. Using a placebo-controlled design, pain response was recorded along with associated balloon volumes. Pain occurred in 28/50 (56%) patients and 6/30 (20%) volunteers (P less than 0.005). Symptoms were unassociated with ECG changes, and resolved immediately with decompression of the balloon. Most patients (24/28) experienced their typical chest pain at less than or equal to 8 cc distention, while all volunteers with pain noted it at greater than or equal to 9 cc distention. For this reason, 8 cc was considered a diagnostic cutoff. Chest pain patients were also studied with two other commonly used provocative tests: intraesophageal acid perfusion and intravenous edrophonium (80 micrograms/kg). These tests reproduced pain in only 12 (24%) patients. Positive balloon studies occurred in 11 of these patients and identified an additional 13 patients, thus increasing the diagnostic yield from 24% to 48%. Only one of 22 (4%) balloon-negative patients had a positive acid-perfusion or edrophonium test.

Acids↗
PubMed1986

Oral pirenzepine does not affect esophageal pressures in man.

Pirenzepine has been proposed to selectively inhibit gastric acid production. In contrast to classical anticholinergics, pirenzepine does not appear to produce systemic side effects or to strongly inhibit contractions in gastrointestinal tract smooth muscle. This study compares the effects of two doses of pirenzepine (25 and 50 mg per os) with a standard anticholinergic, propantheline, 30 mg per os, and with placebo on esophageal contraction pressures in 12 healthy volunteers in a random double-blind study sequence. No significant change in lower esophageal sphincter pressure (LESP) or in peristaltic pressures occurred with placebo or pirenzepine 25 or 50 mg. However, propantheline produced marked reduction in peristaltic contraction pressures and increased velocity (4 of 12 subjects had complete loss of peristalsis). LESP decrease was almost significant. Seven of 12 subjects experienced dry mouth after propantheline, but none after either dose of pirenzepine or placebo. This study indicates that, as opposed to a classical anticholinergic, pirenzepine does not adversely affect esophageal contraction pressures nor does it have anticholinergic side effects with the oral doses studied.

Administration, Oral↗
PubMed1986

Abnormal sensory perception in patients with esophageal chest pain.

Many cases of recurrent noncardiac chest pain are considered to be of esophageal origin. The mechanism of this pain is poorly understood and only rarely appears related to abnormal esophageal contractions observed during manometry. We studied the response to intraesophageal balloon distention in 30 patients with noncardiac chest pain (mean age 52 yr) and 30 controls (mean age 41 yr). A polyvinyl balloon (length 30 mm; maximum diameter after 10-ml distention, 25 mm) was positioned 10 cm above the lower esophageal sphincter and inflated with progressively larger volumes of air (each increase = 1 ml). Chest pain was correlated with balloon volumes and pressures, esophageal contractions 5 cm above the balloon, and electrocardiogram changes. Results were as follows: 18 of 30 (60%) patients and 6 of 30 (20%) controls (p less than 0.005) experienced chest pain. Electrocardiogram changes of ischemia were not seen. Neither balloon pressures nor esophageal contractions above the balloon differed significantly during pain in the controls or patients. As assessed by pressure-volume curves, esophageal tone was also similar in all subjects regardless of pain production. Patients were more sensitive to smaller volumes of balloon distention; 15 of 18 patients had chest pain at less than or equal to 8 ml volume while controls only noted chest pain at greater than or equal to 9 ml volume. We therefore arrived at the following conclusions: esophageal balloon distention may provide a nonpharmacologic provocative test for esophageal chest pain; and the mechanism of chest pain in these patients may be related to lower pain threshold to balloon distention, which is independent of esophageal contractions.

Adult↗
PubMed1986

Apparent complete lower esophageal sphincter relaxation in achalasia.

Seven of 23 patients (30%) seen in 2 yr with clinical and radiologic manifestations of achalasia underwent esophageal manometry demonstrating aperistalsis but apparent complete lower esophageal sphincter (LES) relaxation. Detailed clinical and laboratory evaluation suggests these patients may represent an early stage of achalasia. Duration of dysphagia and weight loss were significantly less (p less than 0.05), whereas LES pressure was similar in the 7 patients compared with the 16 more traditional achalasia patients. Isotope retention during radionuclide esophageal solid-emptying studies showed intermediate delay in emptying between normal subjects and achalasia patients. The duration of LES relaxation in this group was significantly shorter (p less than 0.01) than in normal subjects. Although complete, sphincter relaxation in these patients is functionally inadequate and may be the result of this shortened duration. The small size of standard manometry catheters may also contribute to this confusing finding. Apparent complete LES relaxation may be seen during manometry in achalasia and should not exclude its diagnosis.

Adult↗
PubMed1986

Evaluation of the Angelchik antireflux prosthesis using a model for esophageal reflux in rhesus monkeys.

Minimal data are available about the Angelchik antireflux prosthesis although it has been inserted in more than 14,000 patients. The present animal study was designed to evaluate the effectiveness and mechanism of action of this prosthesis. A reproducible model of esophageal reflux in primates was created using a double myotomy. Lower esophageal sphincter (LES) pressure and reflux score were improved significantly in animals by insertion of an Angelchik antireflux prosthesis, a modified antireflux prosthesis, or a Nissen fundoplication. Manometrically determined LES length was increased after insertion of an Angelchik antireflux prosthesis but not by a Nissen fundoplication or sham operation. Complications after insertion of the modified prosthesis included intraluminal erosion, fibrous stricture, and slippage of the device over the stomach.

Animals↗
PubMed1986

Muscle anatomy of the human esophagus.

We studied the esophageal musculature of 11 cadavers to assess the distribution of striated and smooth muscle. The lower 54-62% of the esophagus was found to be exclusively smooth muscle, the proximal 4.1-5.6% to be exclusively striated, and the remainder to be mixed. The area in which striated and smooth muscle portions were approximately equal, the 50/50 point, was found to be 4.7 +/- 0.6 cm from the proximal portion of the cricopharyngeus muscle. This point corresponds to the previously described physiologic low pressure zone in the proximal esophagus.

Adult↗
PubMed1986

Ambulatory 24-hour esophageal pH monitoring. Technology searching for a clinical application.

The development of commercially available ambulatory 24 hour pH monitoring systems has expanded the potential use of this technique. In this article the use of these instruments is reviewed and direct comparisons between different techniques are made. Both the transnasal pH probes and the telemetric capsule have potential advantages and disadvantages for both the physician and the patient. Problems with the interpretation of pH recordings are discussed. A symptom index is developed in an attempt to provide a numerical assessment of the direct association between reflux events and symptoms in each individual patient.

Ambulatory Care↗
PubMed1986

Effectiveness of foaming antacid in relieving induced heartburn.

A double-blind, placebo-controlled, randomized crossover study was made of 60 patients with chronic heartburn to test the efficacy of foaming antacid in promoting symptom relief. Heartburn was induced by a meal consisting of chili, black coffee, and a spicy tomato drink mix. Of the 60 patients, 40 (67%) had relief within 15 minutes after taking foaming antacid tablets as compared to only 17 (28%) after taking a placebo. The difference in response was significant (P less than .05). Foaming antacid appears to be an effective therapy for acute postprandial heartburn.

Adolescent↗
PubMed1986

Histamine H2-receptor involvement in the regulation of gastric emptying.

The effect of cimetidine on gastric emptying and gastric secretion was evaluated in eight chair-adapted rhesus monkeys. A dye-dilution technique was used to simultaneously determine gastric emptying, gastric secretion of water and hydrogen ion (H+), and intragastric volume and H+ concentration. A continuous intravenous infusion of either saline (control) or cimetidine (4 mg X kg-1 X h-1) was administered during a 40-min fasting steady state and following intragastric instillation of 100 ml of water. During fasting, administration of cimetidine abolished H+ secretion and significantly decreased fractional emptying rate and water secretion (P less than 0.05). After the water load, cimetidine also suppressed H+ secretion and reduced fractional emptying and water secretion compared with control (P less than 0.05). Increasing HCl concentration of the test solution to 50 mM significantly decreased fractional emptying both during saline and further suppressed emptying during cimetidine infusion (P less than 0.05). In conclusion, cimetidine significantly decreased gastric emptying during fasting and following a liquid load. Restoring intragastric acidity to physiological levels removed the effect of gastric acid suppression on emptying and unmasked the full potential for cimetidine to decrease gastric emptying, possibily through an effect on gastric smooth muscle.

Animals↗
PubMed1986

Radiologic and manometric correlation in "nutcracker esophagus".

"Nutcracker esophagus" is a newly described esophageal motor disorder seen in some patients with chest pain and/or dysphagia and characterized manometrically by normal primary peristalsis with distal contractions of high amplitude. The radiographic and manometric examinations in 20 patients with nutcracker esophagus were correlated. Normal primary peristalsis was observed radiographically in 16 patients, and a nonspecific motor disorder was diagnosed in the remaining four patients. Mild-to-severe nonspecific tertiary activity was seen in about half of the patients, esophageal wall thickness was normal. It is concluded that nutcracker esophagus is primarily a manometric diagnosis made in the appropriate clinical setting, and that the radiographic findings are normal or nonspecific.

Adult↗
PubMed1986

Pirenzepine and propantheline effects on esophageal pressure responses to bethanechol.

Pirenzepine is an antisecretory anticholinergic type drug that has recently been shown to be relatively free of usual anticholinergic side effects on esophageal smooth muscle. It has also been suggested that this drug might release some of the inhibitory control of the esophagus and allow increased muscle contractions. To test this hypothesis, we compared the response of the lower esophageal sphincter (LES) and esophageal peristaltic contractions to bethanechol in 12 healthy controls after background oral doses of placebo, pirenzepine (50 mg), and propantheline (30 mg). After baseline placebo, bethanechol (40 micrograms/kg subcutaneously) produced the expected significant increases in LES pressure and amplitude of peristaltic contractions. Maximal increases were 51.9 +/- 14.9 and 29.5 +/- 7.0%, respectively. Also as expected, propantheline inhibited the cholinergic stimulation from bethanechol, allowing only a 10.1 +/- 13.6% increase in LES pressure and a decrease in peristaltic contraction amplitudes (-44.1 +/- 5.0%) after bethanechol. After background pirenzepine, the responses to bethanechol were intermediate between the other two drugs. A significant increase (44.2 +/- 16.4%) in LES pressure occurred after bethanechol while no significant changes (6.9 +/- 5.8%) were noted in peristaltic amplitudes with this drug. Typical side effects of dry mouth were noted in six of the 12 subjects with propantheline and in only three subjects after pirenzepine. These studies once again confirm the absence of usual anticholinergic side effects with oral pirenzepine compared to oral propantheline in the doses studied. We could find no evidence for a release of cholinergic inhibition after pirenzepine administration.

Adult↗
PubMed1986

Future medical therapy of reflux esophagitis.

In recent years, many new systemic medications have been developed as potential therapies for the patient with chronic GER and esophagitis. Despite these therapeutic advances, large numbers of GER patients continue to have chronic symptoms or unresolved complications. To some degree, this may relate to uncertainties regarding the pathogenesis of GER and its complications; i.e., is it primarily due to acid/pepsin injury or to primary motility disorders in the esophagus. Many new therapies are currently being developed, particularly those with the potential ability to enhance esophageal contractions--the prokinetic drugs. The main potential therapies of GER are discussed, including possible new acid suppression therapies, new anticholinergic drugs, new prokinetic drugs, and medications that might enhance the mucosal barrier. In addition, the more complex questions of effectiveness of chronic medical versus surgical therapy, and the use of combined medical therapies, are discussed.

Animals↗
PubMed1986

Abnormal esophageal pressures in reflux esophagitis: cause or effect?

Thirteen patients with gastroesophageal reflux disease underwent esophageal manometric evaluation during acute exacerbations and disease remission to evaluate lower esophageal sphincter and peristaltic pressure in response to treatment. No change was noted in lower esophageal sphincter pressure (15.2 +/- 2.6 mg versus 14.3 +/- 1.8 mm Hg) or peristaltic pressure (64.1 +/- 6.9 versus 62.1 +/- 7/8 mm Hg) with remission while both lower esophageal sphincter pressure and distal amplitude were lower in reflux patients than controls (p less than 0.05). Short-term treatment resulting in endoscopic and symptom improvement of gastroesophageal reflux disease does not appear to improve lower esophageal sphincter and peristaltic pressure.

Adult↗
PubMed1985

Are esophageal motility abnormalities produced during the intraesophageal acid perfusion test?

Many years ago, it was proposed that the symptoms of heartburn correlated more closely with acid-induced esophageal motility abnormalities than with the presence of inflammation. This concept, however, has not been evaluated by modern manometric techniques. We monitored intraesophageal pressures during acid perfusion (O.1N hydrochloric acid) in 17 reflux patients with gross esophagitis and positive pain response and 17 age-matched controls. Using a low-compliance infusion system, amplitude, duration, velocity, and the presence of simultaneous and repetitive contractions in the body of the esophagus were evaluated. Amplitude did not change in either group. Duration did increase significantly during acid perfusion in reflux patients, but not in controls. Mean duration between groups, however, was similar before and during acid perfusion. No simultaneous contractions were observed, while three patients and two controls had repetitive contractions. A significant decrease in velocity was observed in both groups during acid perfusion. These studies indicate that acid-induced motor abnormalities are neither a common accompaniment nor necessary for the production of acid-induced pain in the esophagus.

Adult↗