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Biomedical subjects

D O Castell

Publications and source records attributed to D O Castell.

At least 145 records · Page 8Linked to original sources
PubMed1995

Gastroesophageal reflux laryngitis resistant to omeprazole therapy.

Gastroesophageal reflux disease (GERD) is known to cause a variety of symptoms that lead a patient to seek otolaryngologic care. New advances in the treatment of GERD have enabled otolaryngologists to eliminate most of the signs and symptoms caused by acid reflux. Omeprazole, the most recent pharmacologic advancement, has been reported to be universally successful in controlling acid release from the stomach of patients with GERD. This report describes a series of patients with GERD for whom high-dose omeprazole therapy was not successful in completely reducing gastric acid levels of GERD symptomatology.

Adult↗
PubMed1995

Intra-oesophageal balloon distension and oesophageal sensation in humans.

Intra-oesophageal balloon distension is a recognized stimulus for the assessment of oesophageal motor and sensory responses. It is increasingly being adopted by oesophageal laboratories, especially for the investigation of unexplained chest pain. The purpose of this paper is to review current knowledge concerning intra-oesophageal balloon distension. Perception of balloon distension is dependent upon demographic variables such as age, height and sex. Even when these are controlled for, patient groups are more sensitive to the stimulus than are healthy controls. This is true for patients with dysphagia and irritable bowel syndrome as well as those with unexplained chest pain. The role of intra-oesophageal balloon distension in determining oesophageal visceral hypersensitivity is outlined. In the investigation of unexplained chest pain, it may double the diagnostic yield of either acid perfusion or edrophonium provocation testing. Intra-oesophageal balloon distension has the potential to assess the response to therapy in patients with unexplained chest pain and has also been used in conjunction with cerebral evoked potential measurements to identify the afferent pathways involved. This technique provides another diagnostic tool that can readily be used in any oesophageal laboratory.

Catheterization↗
PubMed1995

Swallowing and esophageal function in Parkinson's disease.

Dysphagia and drooling of saliva are frequent symptoms in Parkinson's disease (PD), occurring in one-half and three-quarters of all patients, respectively. Aspiration related to swallowing is a major cause of morbidity and mortality in PD. Defects in oral, pharyngeal, and esophageal phases of swallowing have been documented in patients with PD, and these defects precede symptoms. This paper reviews the current knowledge concerning swallowing abnormalities in PD. The pathogenesis of dysphagia and drooling of saliva is multifactorial, involving cognitive and psychological changes in addition to abnormalities of the extrapyramidal and autonomic nervous systems. Videofluoroscopic imaging of the upper esophageal sphincter and pharynx during mastication and swallowing has been the basis of our understanding of the mechanical malfunction present in patients with PD. Manometric abnormalities of the esophageal body and lower esophageal sphincter have also been documented. The use of combined manofluoroscopy to examine the upper esophageal sphincter and pharynx in PD offers great promise both in understanding the defects and directing therapy. Voluntary airway protection techniques may reduce aspiration, but they need to be tested in a clinical study. Such maneuvers may reduce the morbidity seen in PD.

Deglutition↗
PubMed1995

The effect of nasogastric intubation on gastroesophageal reflux: a comparison of different tube sizes.

OBJECTIVE: Previous reports have revealed conflicting conclusions about whether tubes placed across the esophagogastric junction (EGJ) have promoted reflux and whether there is potential for subsequent esophageal mucosal damage. The purpose of this study was to examine whether commonly used tubes (diameters: 2.1 mm, antimony pH probe and 3.8 mm, nasogastric tube) promote reflux under typical inpatient conditions. METHODS: Eight asymptomatic volunteers (five male, mean age 27.6 yr) underwent three sessions, each lasting 6 hours postprandially, while supine with the head elevated 20 degrees. In randomized order, the subjects had either a 2.1-mm tube, 3.8-mm tube, and 2.1-mm tube together or no tube across the EGJ. The subjects were fed 500 ml of Ensure Plus at the beginning of the study. Reflux was measured by a pH probe placed 5 cm above the lower esophageal sphincter. The number of reflux episodes, number of reflux episodes more than 5 minutes, longest reflux episode, time esophageal pH was less than 4, and percentage total time pH was less than 4 were evaluated. RESULTS: Over the 6 hours, no abnormal reflux was shown with either tube size across the EGJ. CONCLUSIONS: Over a 6-h period, a tube (pH probe alone or combined with nasogastric tube) across the EGJ does not promote an increase in the amount of postprandial supine gastroesophageal reflux in normal volunteers.

Adult↗
PubMed1995

Control of gastric acid with high dose H2-receptor antagonists after omeprazole failure: report of two cases.

Successful omeprazole therapy in patients with symptomatic gastroesophageal reflux (GER) refractory to treatment with H2-receptor antagonists has often been reported. In contrast, successful treatment of GER by H2-receptor antagonists in patients resistant to the acid-suppressing effects of omeprazole is rarely reported. We describe two patients who demonstrated therapeutic responses to high dose H2-receptor antagonists after high dose omeprazole failed to suppress gastric acidity and GER.

Adult↗
PubMed1995

Evidence of gender differences in esophageal pain threshold.

OBJECTIVE: To compare esophageal sensation thresholds between healthy males and females. METHODS: We used esophageal balloon distention to compare sensory thresholds between nine male and 10 female volunteers with a latex balloon (length 3 cm) positioned 5 cm proximal to the lower esophageal sphincter. Subjects indicated feeling: 0 (no sensation), 1 (aware of balloon but no discomfort), 2 (pain or discomfort) during rapid (170 cc/s) or slow (0.7 cc/s) balloon inflation rates as the balloon was inflated with increasing volumes of 2 cc. Females were studied on two separate occasions, days 5-7 and days 20-22 of their menstrual cycles, with day 1 being the first day of menses. RESULTS: Females had a significantly lower pain threshold and a trend toward lower awareness level. No significant differences in sensory perception were found between the two phases of the female cycle. Poor correlation (r = 0.35 in rapid, r = 0.4 in slow inflation) was found between subject height and balloon volume at perception of pain. CONCLUSION: Healthy females demonstrate a lower threshold to esophageal pain induced by balloon distention than healthy males. This difference is not explained by hormonal changes during normal menstrual cycle or by body size. This observation may explain in part the observed preponderance of females with unexplained chest pain of possible esophageal origin.

Adult↗
PubMed1995

Hypertensive lower esophageal sphincter pressures and gastroesophageal reflux: an apparent paradox that is not unusual.

UNLABELLED: The association of a hypertensive lower esophageal sphincter pressure (LESP) with significant gastroesophageal reflux (GER) has always seemed paradoxical because of the original association of a hypotensive sphincter with reflux. OBJECTIVES AND METHODS: In this study, the manometric and ambulatory pH studies of a group of consecutive patients evaluated over a 3-yr period were reviewed to identify and characterize patients with a hypertensive LESP and abnormal GER as defined by increased acid exposure in the distal esophagus as measured on ambulatory pH monitoring. RESULTS: Eighteen such patients were identified, which represented 5.2% of all patients with abnormal GER and 23.4% of all patients with a hypertensive LESP. Heartburn (nine patients) and chest pain (nine patients) represented the dominant symptoms. LESP ranged from 47 to 73 mm Hg. Incomplete LES relaxation in response to swallow was found in nine out of 18 patients. Intact peristalsis was found in all patients, and seven patients had a nutcracker esophagus. Patients showed a wide range of abnormal distal esophageal acid exposure times with only slightly abnormal recumbent or upright reflux times to greater than 25% pH less than 4 total (although most patients had mild reflux with 17 out of 18 patients having total distal esophageal acid exposure less than 10%). There was no correlation between LESP and total % pH less than 4 (r = 0.11). Of 16 patients, 12 responded to antireflux treatment, including the three patients who required fundoplication. The four patients who did not respond to treatment had poor correlation of reflux episodes to symptoms on pH monitoring, had markedly elevated LESPs, and did not present with heartburn. CONCLUSIONS: The association of a hypertensive LESP and abnormal GER is not uncommon. When abnormal GER does occur in these patients, it tends to be mild but can be clinically important and respond to antireflux treatments. We recommend that patients with a hypertensive LESP and/or nutcracker esophagus who present with heartburn or chest pain should undergo ambulatory pH monitoring to evaluate the possibility of GER disease.

Adult↗
PubMed1994

Pulmonary function and gastroesophageal reflux in systemic sclerosis.

OBJECTIVE: To determine the relations among esophageal dysfunction, gastroesophageal reflux, and lung involvement in patients with systemic sclerosis. DESIGN: Retrospective review of esophageal motility, esophageal pH, and pulmonary function data. SETTING: University hospital outpatient clinic and community. PATIENTS: 39 consecutively referred patients who were grouped according to the presence or absence of abnormal distal (pH < 4.0 for > 5% of the 24-hour monitoring period) or proximal (pH < 4.0 for > 1% of the 24-hour period) gastroesophageal acid reflux. Patients were also grouped according to the presence or absence of distal esophageal peristalsis. MEASUREMENTS: Esophageal manometry, dual-probe (distal and proximal) esophageal 24-hour pH measurements, and pulmonary function studies (forced vital capacity, forced expiratory volume at 1 second, total lung capacity, and single-breath carbon monoxide diffusing capacity [DLco]). RESULTS: The mean total lung capacity (values as percentage predicted) was 87.1% +/- 11.2% (SD) for patients with abnormal proximal reflux and 77.8% +/- 21.6% for patients with normal proximal reflux (difference, 9.3%; 95% CI, -1.4% to 20.0%). The mean forced vital capacity for these patients was 91.1% +/- 12.4% and 85.4% +/- 25.6%, respectively (difference, 5.7%; CI, -6.9% to 18.1%). The mean total lung capacity was 83.8% +/- 15.4% for patients with abnormal distal reflux and 77.9% +/- 22.7% for patients with normal distal reflux (difference, 5.9%; CI, -7.6% to 19.4%). Among potential confounders of pulmonary measures, only smoking was related to decreased pulmonary function (smoking related to decreased DLco P < 0.01). Smoking was more common in patients with abnormal distal reflux than in those with normal distal reflux (65% compared with 25%, P = 0.03). After adjusting for smoking, the difference in mean DLco between patients with abnormal compared with normal distal reflux was 7.19% (Cl, -8.5% to 22.9%). CONCLUSION: Important measures of lung volume indicative of interstitial lung disease (total lung capacity, forced vital capacity) do not appear to be related to abnormal gastroesophageal acid reflux in patients with systemic sclerosis.

Esophagus↗
PubMed1994

Exclusion of meal periods from ambulatory 24-hour pH monitoring may improve diagnosis of esophageal acid reflux.

Distal esophageal pH less than 4 is frequently seen during meal ingestion in 24-hr ambulatory pH monitoring for the diagnosis of gastroesophageal reflux disease (GERD). The characteristics of this meal-related apparent reflux without diet restriction was evaluated. Data from normal volunteers (N = 21) and consecutive patients (N = 66) referred with heartburn and/or chest pain were studied with ambulatory pH monitoring. The median percent times pH < 4 in the distal esophagus were significantly greater in symptomatic patients than controls for total 24-hr, upright, and supine periods, and postprandial periods of 30, 60, 90, 120, and 150 min (P values of 0.007-0.03). However, the median percent time pH < 4 during the meal periods was the same for patients (4.4%) and for controls (6.6%) with P = 0.23. Excluding the meal periods from analysis resulted in greater separation between controls and patients with abnormal acid exposure when compared to the conventional method. Patients should maintain their usual routine without diet restriction during 24-hr ambulatory pH studies in the clinical setting. Furthermore, exclusion of meal periods can eliminate meal-time pH variabilities without affecting postprandial acid exposure and improve the diagnosis of GERD.

Adult↗
PubMed1994

Current diagnosis and treatment of gastroesophageal reflux disease.

OBJECTIVE: To review recent advances in the diagnosis and treatment of gastroesophageal reflux disease (GERD). MATERIAL AND METHODS: Original English language reports were obtained through a Medline search of the National Library of Medicine up to and including 1993. The reference lists of all original reports and review articles were searched to locate any further material. In the evaluation of therapeutic efficacy, randomized studies were preferentially considered; greatest priority was given to double-blind, placebo-controlled trials. Abstracts, nonrandomized trials, and non-English language publications were considered only when other data were unavailable. RESULTS: Information obtained from histories and physical examinations suggests that GERD occurs in many patients. Evaluation of mucosal injury with use of either endoscopy or air contrast barium radiography is an important early step in the diagnosis of GERD. Endoscopy obtains tissue for histologic study, especially in Barrett's esophagus. Prolonged esophageal pH monitoring is the most useful determinant of the presence and amount of reflux of acid. Patients with GERD should be counseled on lifestyle modification and the use of antacids and antirefluxants. Histamine type 2 receptor antagonists provide symptomatic relief in 32 to 82% of patients with GERD and resolution of verified esophagitis in 0 to 82%. Responses with omeprazole therapy are higher; symptomatic responses were noted in 62 to 94% of patients, and healing of esophagitis occurred in 71 to 96%. Promotility agents and surgical therapy have a role in selected patients. CONCLUSION: GERD is a chronic disorder that often necessitates individualized lifelong therapy. Many questions remain to be answered about the cost-effectiveness of both diagnostic tests and therapy for GERD.

Gastroesophageal Reflux↗
PubMed1994

Body position affects recumbent postprandial reflux.

There is a lack of consensus as to whether there is a difference in the amount of gastroesophageal reflux when lying with the right versus the left side down. In an attempt to answer this question we conducted a two-part study. The first consisted of a questionnaire distributed to 103 gastroenterologists with a special interest in the esophagus. The second was a randomized study in 20 normal subjects given a high-fat meal to induce reflux. Postprandial reflux was monitored by esophageal pH testing for 4 h after random assignment to either the left or right lateral decubitus position (left or right side down) on different days. Of the 87 gastroenterologists responding to our survey, 45 were uncertain as to which position was associated with worse reflux. Among the 42 who did specify, 27 (64%) favored the right lateral decubitus position as associated with more reflux symptoms. The direct comparison of the two positions demonstrated that the total amount of reflux time was significantly (p < 0.05) greater with subjects in the right decubitus position (231 min) than in the left (117 min). Although total episodes of reflux were greater when lying on the right side (227), compared with the left (198), the difference was not significant. In addition, average overall acid clearance was significantly (p < 0.001) prolonged with right side down (0.77 +/- 0.14 min/episode) compared with left side down (0.29 +/- 0.08 min/episode).

Adult↗
PubMed1994

Stimulation of esophageal mechanoreceptors is dependent on rate and duration of distension.

We randomly compared rapid (170 ml/s) and slow (0.7 ml/s) rates of balloon distension in 19 volunteers (9 male, 10 female) using a latex balloon (length 3 cm) positioned 5 cm proximal to the lower esophageal sphincter. The balloon was inflated/deflated (1-s dwell; 5- to 10-s interval) with increasing 2-ml volumes during rapid inflation studies and progressively distended during slow inflation studies while subjects blindly indicated feeling, rated as follows: 0 (no sensation); 1 (aware of balloon, but no discomfort); 2 (pain or discomfort). In a second set of studies, the balloon was left inflated for 60 s at a volume 2 ml below that producing sensation 1, and time until a change in sensation was recorded. This was repeated at a volume 2 ml below that producing sensation 2. Mean volume to sensation 1 with slow inflation was 14.6 +/- 1.2 ml (SE) and with rapid inflation was 8.5 +/- 0.8 ml (P < 0.001). Mean volume to sensation 2 with slow inflation was 23.7 +/- 1.0 ml and with rapid inflation was 17.4 +/- 1.0 ml (P < 0.001). With sustained (60 s) inflation, most subjects noted increasing sensation, independent of initial inflation rate. We conclude that distal esophageal sensory perception (both awareness and discomfort) is dependent on rate of stimulation of mechanoreceptors. A sustained distension stimulus appears to recruit additional receptors and increase the level of sensory awareness.

Adult↗