Search PubMed⌕ Search

Biomedical subjects

D O Castell

Publications and source records attributed to D O Castell.

At least 163 records · Page 9Linked to original sources
PubMed1994

Frequency and site of gastroesophageal reflux in patients with chest symptoms. Studies using proximal and distal pH monitoring.

Prolonged ambulatory pH monitoring was performed on 89 patients with previous diagnosis of asthma (27 patients), chronic cough (28 patients), noncardiac chest pain (34 patients), and on 27 healthy control subjects. The extent of gastroesophageal reflux (GER) was determined using a catheter containing two antimony pH electrodes positioned 5 cm and 20 cm above the superior border of the manometrically determined lower esophageal sphincter. Reflux was defined as a drop in pH to < 4 in the distal esophagus. We compared both pH < 4 and pH < 5 as the beginning of reflux episodes for the proximal esophagus. Considering the confidence interval of 95% in healthy control subjects as a normality criterion, we found a prevalence of abnormal distal GER in 44% of asthmatics, 50% of patients with cough, and 53.8% of patients with noncardiac chest pain. Abnormal proximal acid exposure was found in 24% of asthmatics, 10.7% of patients with cough and 44.1% of patients with chest pain. Distal acid exposure was significantly longer than proximal esophageal acid exposure in all patient groups (p < 0.05). There were no differences in the evaluation of proximal GER comparing pH < 4 with pH < 5. The data also indicate a tendency toward upright, rather than supine acid exposure. These results support the use of 24-h pH monitoring in patients with chest complaints and indicate that GER may frequently be involved in the pathogenesis. They do not support the theory that proximal GER is a specific etiologic factor in chronic cough or asthma.

Asthma↗
PubMed1994

Chest pain of undetermined origin.

Chest pain of undetermined origin (CPUO) can be a diagnostic dilemma for both the primary care physician and subspecialist. This article focuses on the diagnostic tools used in the evaluation of CPUO, which include: prolonged ambulatory intraesophageal pH monitoring; esophageal manometry with provocative testing; ambulatory intraesophageal pressure monitoring; the role of radiology and endoscopy in the evaluation of chest pain; the role of psychological abnormalities and abnormal nociception in the pathogenesis of chest pain; and the clinical approach and treatment rationale for CPUO.

Barium Sulfate↗
PubMed1994

Approach to the patient with unexplained chest pain.

What are some take-home lessons on the syndrome of unexplained chest pain? Carefully exclude heart disease, which--unlike esophageally caused chest pain--may be life-threatening. Noncardiac chest pain is a common problem: at least 25% of chest pain patients in coronary care units or emergency rooms "rule out" for heart disease. It is a problem that has been vexing physicians for at least 100 years. The pain patterns in ischemic heart disease and in the unexplained pain syndromes, particularly reflux, may be identical. The mechanism may be an "irritable" esophagus, in which the visceral pain threshold is lowered. Look carefully for gastroesophageal reflux, and treat it aggressively. Finally, in all cases, try to establish a diagnosis if at all possible. When patients are told they don't have heart disease and no further workup is pursued, more than half of them continue to have significant morbidity from their chest pain, utilizing health care facilities and visiting doctors (34,35). Research over the past two decades has enlightened us about many patients with unexplained chest pain, but unfortunately we are still confused about many others, and for this group of patients a conservative therapeutic approach may be best.

Chest Pain↗
PubMed1994

Successful elimination of reflux symptoms does not insure adequate control of acid reflux in patients with Barrett's esophagus.

OBJECTIVE: Patients with Barrett's metaplasia of the esophagus often lack the appropriate amount of heartburn for their severity of gastroesophageal reflux. Therefore, we studied patients with Barrett's metaplasia by prolonged ambulatory pH monitoring after completely suppressing their heartburn symptoms to determine whether acid reflux was underestimated in symptom assessment. METHODS: Five patients with Barrett's esophagus, all of whom presented with heartburn, were treated with omeprazole (20-60 mg/day) until they were asymptomatic. Twenty-four-hour pH ambulatory monitoring was performed while they were on omeprazole. RESULTS: Four of five patients showed persistent abnormal gastroesophageal reflux after treatment with omeprazole. Two patients showed abnormally increased supine reflux and two patients had an abnormal increase in both supine and upright reflux. Only one patient had complete inhibition of the acid reflux by the omeprazole (20 mg b.i.d.). CONCLUSIONS: Treating the patient with Barrett's esophagus to the endpoint of eradication of heartburn does not insure adequate control of acid reflux. Prolonged ambulatory pH monitoring of the esophagus should be conducted to demonstrate that an adequate dose of omeprazole has been given, despite symptomatic improvement.

Aged↗
PubMed1994

Intraesophageal balloon distention in the evaluation of sensory thresholds: studies on reproducibility and comparison of balloon composition.

OBJECTIVE: Graded intraesophageal balloon distention has been suggested as a provocative test in the assessment of undetermined chest pain. Balloon distention was used to determine pain threshold reproducibility for 20 normal individuals (mean age: 27 yr). METHODS: Balloons made of silicone and latex were each evaluated in 10 subjects, with the balloon located 10 cm above the lower esophageal sphincter. The balloons were sequentially inflated with 2-cc increments of air by a specially designed pump to a total volume of 2 cc above the level of pain for each subject. A random series of inflations was also used. Three sets of both sequential (S) and random (R) inflations were performed on 2 subsequent days. RESULTS: With the silicone balloon, the mean volume for pain threshold was 15 +/- 1.1 cc (+/- SE) for S and 15 +/- 1.2 cc for R inflations on day 1 and 15 +/- 1.5 cc and 15 +/- 1.5 cc on day 2. For the latex balloons, the mean volume for pain threshold was 17 +/- 1.4 cc for S and 17 +/- 1.4 cc for R inflations on day 1 and 17 +/- 1.6 cc and 18 +/- 1.9 cc on day 2. CONCLUSION: From these studies, we conclude that pain thresholds to esophageal balloon distention are reproducible with same or subsequent day testing. Similar effects occur with either silicone or latex balloons. In vitro studies on the inflation characteristics of the balloons indicate that the latex balloon inflates in a more even, linear manner, which makes this balloon more practical for evaluating pain thresholds in terms of air volume inflations.

Adult↗
PubMed1994

Approach to patients with oropharyngeal dysphagia.

Oropharyngeal dysphagia is a difficult clinical problem that is commonly found in patients with diffuse neurological or local laryngeal disorders. Gastroenterologists are frequently consulted regarding management of these patients. Diagnosis of specific pathophysiology is best accomplished with a combined approach, including barium video radiography and solid-state manometry. Therapy includes specific modalities where appropriate and mechanical manipulations aimed at prevention of aspiration, in consultation with a speech language pathologist.

Deglutition Disorders↗
PubMed1994

Manometric determination of esophageal length.

OBJECTIVE: Two hundred and fifty-two esophageal manometric studies were reviewed retrospectively to determine the length of esophagus and its relationship to disease, sex, height, and weight. METHODS: For all studies, solid state intraluminal transducers were used, with patients in the supine position. Esophageal length was defined as the difference between the high pressure zone of the upper esophageal sphincter and proximal margin of the lower esophageal sphincter. The mean length of the esophagus was 22.9 +/- 0.2 cm (+/- SEM) in all patients and volunteers (excluding those with achalasia). RESULTS: The 40 patients with achalasia had a significantly (p < 0.05) longer mean esophageal length (24.5 +/- 0.5 cm) than normal volunteers or other patient groups with scleroderma, GERD, chest pain, and dysphagia. Excluding patients with achalasia, 96 males had a significantly (p < 0.05) longer mean esophageal length (23.6 +/- 0.3 cm) than 116 females (22.4 +/- 0.3 cm). A normal distribution of esophageal length was demonstrated in all subjects (excluding those with achalasia). Esophageal length showed poor correlation with either height (r2 = 0.15) or body weight (r2 = 0.003). CONCLUSION: esophageal length showed considerable intersubject variation. Patients with achalasia had a longer esophagus consistent with esophageal dilation. Males had a longer esophagus than females. Esophageal length did not correlate with either height or weight.

Adolescent↗
PubMed1994

Manometric analysis of the pharyngo-esophageal segment.

Manometry of the pharyngo-esophageal segment can be a valuable tool in the investigation of pharyngeal dysphagia. Advances in technology have overcome previous equipment shortcomings and now allow accurate measurements of such factors as the rapid response rate of the striated muscle and asymmetry of the upper esophageal sphincter. Close attention to technique can overcome difficulties with movement artifacts encountered during deglutition. There are an increasing number of reports in the literature of manometric studies of normal swallow function as well as of patients with oropharyngeal dysphagia.

Deglutition Disorders↗
PubMed1993

Cerebral evoked potentials. A method of quantification of central nervous system response to esophageal pain.

Cerebral evoked potentials (EPs) represent a new technique for the evaluation of afferent outflow from the gastrointestinal tract. We compared EPs obtained with distension of the distal and proximal esophagus. Responses were recorded with the balloon 5 cm proximal to the lower esophageal sphincter and 3 cm distal to the upper esophageal sphincter. Balloon stimulation resulted in cortical responses recorded by midline scalp electrodes (CZ', PZ, and OZ by the International 10-20 system) in normal volunteers. EP responses consisted of two negative (N1, N2) and one positive (P1) deflections. The proximal esophageal latency of N1 was shorter in all three leads. The latency to P1 was shorter with proximal stimulation in lead CZ' only, and N2 latencies were not different. Amplitudes expressed as the difference between N1 and P1, and P1 and N2 were not different. When two sets of potentials several minutes apart from the proximal position were compared, a decrease in amplitude with the second set of stimulations was noted. Esophageal EP recording is a new technique that may provide information about the integrity and function of the sensory innervation of the esophagus.

Adult↗
PubMed1993

Does diet affect values obtained during prolonged ambulatory pressure monitoring.

With the development of a portable high-capacity data-recording device and fully automated computer analysis, it is now possible to monitor esophageal motility in an ambulatory outpatient setting and over a complete circadian cycle. However, limited data are available on the characteristics and pattern of esophageal motility in healthy subjects, particularly the effects of meals. We studied the effect of food types (liquid vs solid) and standardized vs nonstandardized diet on 17 healthy volunteers with a probe combining three miniature pressure transducers 5 cm apart. All subjects followed the same diet regimen: a standardized breakfast, strict liquid lunch, and no restriction for composition and quantity of dinner. The characteristics of contraction events (amplitude, duration, velocity, slope, area under curve) and their propagation types (peristaltic, simultaneous, segmental, retrograde) were analyzed and compared to supine and interprandial periods. The contraction characteristics and the propagation pattern were identical for the three types of meals. In comparison with the interprandial and supine periods, the three types of meals showed higher percent peristaltic contractions and smaller percent simultaneous contractions. The individual contraction characteristics were, however, not significantly different. Higher percentages of simultaneous, retrograde, and segmental contractions were found during the supine period than either the perprandial or interprandial periods. This study indicates that characteristics of esophageal contractions and propagation pattern are similar for meals of different composition and quantity. In comparison with interprandial and supine periods, the meals are always characterized predominantly by peristaltic contractions. Thus, standardization of meals during prolonged ambulatory pressure monitoring is not required.

Adult↗
PubMed1993

Manometric evaluation of the pharynx.

Over the past few years, studies of manometric techniques have improved our ability to accurately assess pharyngeal pressure events during swallowing. Solid-state transducers, circumferentially recording transducers, and on-line computer interpretation allow quantitative measurements. Studies in normal subjects will permit better recognition of pathologic states.

Deglutition↗
PubMed1993

Effect of head position on the dynamics of the upper esophageal sphincter and pharynx.

Due to limitations in available technology it has been difficult to obtain data on upper esophageal sphincter (UES) and pharyngeal (P) function under varying physiologic conditions. We used a manometry system with solid-state intraluminal transducers, including a circumferential sphincter transducer, and computer analysis to measure pressure changes in UES and P during wet (5 ml H2O) swallows as the head was moved through a 75 degree arc in nine normal volunteers. UES residual pressure increased markedly and duration of UES relaxation decreased with increasing head extension. Similar decreases were also seen with time between P peak and both UES nadir and UES end. There were no changes in either pharyngeal peak pressures or the duration of the pharyngeal contraction. Head extension produces major changes in UES relaxation and UES/P coordination. These effects may be clinically important when feeding neurologically impaired patients.

Adult↗
PubMed1993

Modern solid state computerized manometry of the pharyngoesophageal segment.

There has been renewed interest in the use of manometry of the pharyngoesophageal segment in the investigation of pharyngeal dysphagia. Advances in technology have alleviated previous difficulties presented by factors such as the rapid response rate of the striated muscle and asymmetry of the upper esophageal sphincter. Close attention to technique can overcome difficulties with movement artifacts encountered during deglutition. Manometry is being used to study normal swallow function and the effects of physiologic changes. There are also increasing numbers of reports in the literature of manometric studies in patients with oropharyngeal dysphagia. This technique provides information on pressure changes and augments that information obtained from a barium swallow.

Deglutition↗
PubMed1993

Endoluminal ultrasonography of the distal esophagus in systemic sclerosis.

BACKGROUND: The aim of this study is to apply high-resolution endoluminal sonography (HRES) to the study of the esophageal disease in systemic sclerosis (SSc). METHODS: An HRES transducer was used to image the esophagus. Autopsy specimens of normal and SSc esophagi were imaged to define a hyperechoic abnormality in the normally hypoechoic muscularis propria. The presence or absence of this hyperechoic abnormality of the esophagus in SSc patients was compared with sonographic findings in normal volunteers. The degree of the hyperechoic abnormality was correlated with the results of functional esophageal studies including esophageal motility, lower esophageal sphincter pressure, and 24-hour pH monitoring in SSc patients. RESULTS: A hyperechoic abnormality in the normally hypoechoic muscularis propria on HRES seemed to correspond with the presence of fibrosis on histological sections from the distal esophagus in SSc autopsy specimens. A significant difference was found in the presence of this hyperechoic abnormality in patients with SSc when compared with normal controls (P < 0.001). Finally, there were strong positive correlations between the degree of this hyperechoic abnormality and esophageal manometric abnormalities (r = 0.89; P < 0.001) and supine (r = 0.74; P < 0.01) and total (r = 0.70; P < 0.02) acid reflux on 24-hour pH monitoring. CONCLUSIONS: HRES is a sensitive new method to determine the presence or absence of hyperechoic abnormalities in the muscularis propria and to predict functional abnormalities of the esophagus in patients with SSc.

Adult↗
PubMed1993

Salivary stimulation mimics esophageal exposure to refluxed duodenal contents.

It has been suggested that shifts in gastric and esophageal pH can be used to estimate the reflux of injurious alkaline material, particularly bile, into the esophagus. We sought to evaluate the contribution of swallowed saliva to alkalinization of both the stomach and esophagus in 10 normal volunteers, by performing combined gastric and esophageal pH monitoring before, during, and after salivary stimulation. The intraesophageal pH universally increased during salivary stimulation, whereas the intragastric pH was noted to increase in six of 10 subjects. In four of these six, the pattern of simultaneous increases in esophageal and gastric pH mimicked and could be mistaken for episodes of "alkaline reflux." We conclude that the diagnosis of reflux of duodenal contents into the esophagus by pH monitoring may be compromised by false-positive results related to swallowed saliva.

Adult↗
PubMed1993

Normal and abnormal proximal esophageal acid exposure: results of ambulatory dual-probe pH monitoring.

Ambulatory esophageal pH monitoring was performed in 26 normal volunteers, 20 patients with normal distal acid exposure, and 23 patients with abnormal distal acid exposure in an attempt to define normal values for proximal esophageal acid exposure using a standardized technique. We used a dual pH sensor with antimony electrodes spaced at 15 cm. The distal electrode was placed manometrically at 5 cm above the lower esophageal sphincter. Proximal electrode thus was located below the upper esophageal sphincter in the esophageal inlet. The patients underwent 24-h ambulatory pH monitoring and were told to pursue normal daily activities. The percentage of acid exposure time and number of episodes per 24 h at both pH < 4.0 and 5.0 were measured for the total, upright, and supine periods. Since the pH values were not normally distributed, the medians and 95th percentiles were used to define normal values. Minimal acid exposure occurred in the proximal esophagus (< 1% total; 0% supine) in volunteers and patients with normal distal reflux. Patients with abnormal distal acid exposure had significantly greater proximal reflux.

Adult↗