Integrated ambulatory foregut monitoring in patients with functional foregut disorders.
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Ambulatory Care↗
Biomedical subjects
T R DeMeester
Publications and source records attributed to T R DeMeester.
Elevated serum gastrin levels in patients with gastric cancer.
Elevated plasma gastrin levels have been found in patients with colorectal cancer. We measured fasting serum gastrin levels in control subjects (n = 12), patients with gastric cancer (n = 43), and patients with carcinoma of the esophagus (n = 55). Serum gastrin levels were significantly higher in patients with gastric cancer compared to normal controls (P less than 0.005) and those with esophageal cancer (P less than 0.05). This information may add to our understanding of the pathogenesis of gastric cancer.
Carcinoma, Squamous Cell↗
Etiology and importance of alkaline esophageal reflux.
While an alkaline component to esophageal reflux disease is known to be present, little is known about its etiology and harmful effects. Simultaneous gastric and esophageal 24-hour pH monitoring was performed in 81 patients with foregut symptoms. The presence of a mechanically defective lower esophageal sphincter was determined by manometry and duodenogastric reflux by computer-assisted discriminant analysis of the gastric pH record. Heartburn, dysphagia, and regurgitation occurred more frequently in those with a mechanically defective sphincter (p < 0.05) and epigastric pain in those with duodenogastric reflux (p < 0.05). Esophagitis was more common and severe in those with a mechanically defective sphincter (p < 0.05). In these patients, the percentage of time over 24 hours that the esophageal pH was less than 4 was 40.5% in patients without duodenogastric reflux but only 10.2% in those with duodenogastric reflux (p < 0.005), suggesting acid damage in the former and alkaline damage in the latter. To establish the origin of the esophageal alkaline exposure, episodes of elevated fasting gastric pH greater than 4 lasting longer than 1 minute were searched for and identified in 45 patients. Esophageal pH tracings were compared for 30 minutes before and after these events. The esophageal pH was higher following these episodes in duodenogastric reflux patients (p < 0.05), suggesting a gastroduodenal origin of the esophageal alkalinization. This study shows that esophageal damage may be due to acid or alkaline reflux. The alkaline component of gastroesophageal reflux is important and should be considered in the evaluation of patients with foregut symptoms so that appropriate medical or surgical therapy can be instituted.
Esophagitis, Peptic↗
Cystic and bullous lung disease.
One of the most difficult problems facing clinicians is the evaluation and management of patients with dyspnea whose chest roentgenogram shows single or multiple large cystic spaces. This is made more difficult when underlying lung disease is present. The dilemma focuses on whether the obliteration or removal of the cystic areas will benefit or cause further deterioration of the patient's condition. The pathophysiology of the problem is not completely understood, but accumulated clinical experience has shown that surgical therapy can be beneficial but requires proper patient selection.
Humans↗
Computerized identification of pathologic duodenogastric reflux using 24-hour gastric pH monitoring.
Duodenogastric reflux is a naturally occurring sporadic event, the incidence, occurrence, and detrimental effects of which have been difficult to assess. The reliability of 24-hour gastric pH monitoring to detect duodenogastric reflux was studied. Central to the use of pH monitoring for this purpose is confidence in its ability to measure and display pH data in a way that reflects changes in the gastric pH environment with sufficient sensitivity. To test this the gastric pH of 10 dogs was measured in the fasting state, after feeding, and after pentagastrin stimulation. The antrum was more alkaline in the fasting state (p less than 0.01) and the display of data by frequency distribution graph was sensitive enough to reflect induced pH changes. To test the consistency of gastric pH at a given position, simultaneous 24-hour gastric monitoring was performed in 12 normal subjects with two probes placed at either 5 or 10 cm below the lower esophageal sphincter. Only at the 5-cm position did the two probes read within 1 pH unit of each other more than 90% of the time. Based on these principles, gastric pH monitoring was performed 5 cm below the lower esophageal sphincter in 30 normal subjects and 11 patients, fulfilling Ritchie's clinical criteria for pathologic duodenogastric reflux. The data obtained was arranged into 71 variables and subjected to discriminant analysis. Sixteen variables were identified, each with a corresponding coefficient to be used as a multiplier to derive a score. A score of more than +2.2 indicated a high probability of pathologic duodenogastric reflux. The test was applied to a validation population consisting of 10 additional normal subjects and 10 patients meeting Ritchie's criteria. All normal subjects had a normal score and all but one (90%) of the patients had an abnormal score. When compared to O-diisopropyl iminodiacetic acid (DISIDA) scintigraphy in another group of 22 normal subjects and 60 patients, 24-hour gastric pH monitoring was superior in the detection of pathologic duodenogastric reflux. The study shows how the application of computer technology can be used to diagnose pathologic duodenogastric reflux in patients with complex foregut complaints.
Animals↗
Three-dimensional imaging of the lower esophageal sphincter in gastroesophageal reflux disease.
The resistance of the lower esophageal sphincter to reflux of gastric juice is determined by the integrated effects of radial pressures exerted over the entire length of the sphincter. This can be quantitated by three-dimensional computerized imaging of sphincter pressures obtained by a pullback of radially oriented pressure transducers and by calculating the volume of this image, in other words, the sphincter pressure vector volume. Validation studies showed that sphincter imaging based on a stepwise pullback of a catheter with four or eight radial side holes is superior to a rapid motorized pullback. Compared with 50 healthy volunteers, the total and abdominal sphincter pressure vector volume was lower in 150 patients with increased esophageal acid exposure (p less than 0.001) and decreased with increasing esophageal mucosal damage (p less than 0.01). Calculation of the sphincter pressure vector volume was superior to standard techniques in identifying a mechanically defective sphincter as the cause of increased esophageal acid exposure, particularly in patients without mucosal damage. The Nissen and Belsey fundoplication increased the total and intra-abdominal sphincter pressure vector volume (p less than 0.001) and normalized the three-dimensional sphincter image. Failure to do so was associated with recurrent or persistent reflux. These data indicate that three-dimensional imaging of the lower esophageal sphincter improves the identification of patients who would benefit from an antireflux procedure. Analysis of the three-dimensional sphincter pressure profile should become the standard for evaluation of the lower esophageal sphincter.
Adult↗
Surgical treatment of esophageal carcinoma.
The view of surgical treatment of esophageal carcinoma is pessimistic. This is so because (1) most patients present late in the disease and are beyond the benefits of surgical therapy for cure, (2) resection is associated with a high operative mortality, and (3) the poor 5-year survival rates for surgical resection cited in the literature are poor, although these rates may include procedures done for palliation and not for survival. Early disease is potentially curable. With a better understanding of the biology of the tumor and with improved staging techniques, patients who are able to undergo an en bloc resection designed for cure according to the classic principles of surgical oncology are selected. Five-year survival rates for curative en bloc resections range from 40% to 50%. For patients unable to undergo a curative resection, esophagectomy with esophagogastrostomy offers the best palliation. Transhiatal esophagectomy performed through an abdominal and cervical incision is an appropriate palliative procedure for tumors located in the lower third and cervical portions of the esophagus. The standard esophagectomy using a right thoracotomy is the preferred technique for a palliative resection of tumors located in the upper and midthoracic esophagus. Unresectable tumors may be palliated by intubation and, in some specific situations, surgical bypass.
Adult↗
Ambulatory 24-hour esophageal manometry in the evaluation of esophageal motor disorders and noncardiac chest pain.
Standard manometry is currently considered the gold standard for the classification of esophageal motor disorders. We compared the new technique of ambulatory 24-hour esophageal motility monitoring to standard manometry in 108 patients thought to have a primary esophageal motor disorder, assessed the esophageal motor pattern associated with spontaneous noncardiac chest pain, and studied the effect of long esophageal myotomy on circadian esophageal motor function. Standard manometry was found to frequently overestimate and underestimate the severity of esophageal motor abnormalities as compared to 24-hour monitoring. Ambulatory manometry showed a direct correlation of abnormal esophageal motor activity with episodes of noncardiac chest pain in 13 of 26 patients who experienced the symptom during the monitoring period. The abnormal motor activity immediately preceding the pain episodes in these patients was characterized by an increased frequency of simultaneous, double and triple-peaked, high amplitude, and long duration contractions (p less than 0.01). Long esophageal myotomy markedly reduced or eliminated the ability of the esophagus to produce these abnormal contractions (p less than 0.01). These data suggest that ambulatory esophageal motility monitoring allows more precise classification of esophageal motor disorders than standard manometry and identifies abnormal esophageal motor activity associated with noncardiac chest pain that can be abated by long esophageal myotomy.
Adult↗
The current management of gastroesophageal reflux.
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Gastric Fundus↗
Invited letter concerning: peptic esophageal stricture.
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Anastomosis, Roux-en-Y↗
Clinical use of 24-hour gastric pH monitoring vs o-diisopropyl iminodiacetic acid (DISIDA) scanning in the diagnosis of pathologic duodenogastric reflux.
The efficacy of o-diisopropyl iminodiacetic acid (DISIDA) scanning was compared with that of computerized analysis of 24-hour gastric pH monitoring to diagnose excessive duodenogastric reflux in 22 normal volunteers and 106 consecutive patients with foregut symptoms. DISIDA scanning had a false-positive rate of 18% in the normal volunteers. Gastric pH monitoring showed an increasing prevalence of duodenogastric reflux in patients with increasing clinical evidence of this condition, which was not seen with DISIDA scanning. Both DISIDA scanning and gastric pH monitoring identified duodenogastric reflux in most patients who had had previous pyloroplasty or antrectomy. Only gastric pH monitoring, however, showed a significantly increased prevalence of duodenogastric reflux in symptomatic patients after previous cholecystectomy compared with those who had not undergone previous surgery. These data suggest that 24-hour gastric pH monitoring is superior to DISIDA scanning in identifying duodenogastric reflux as a cause of foregut symptoms.
Adolescent↗
A new technique to define and clarify esophageal motor disorders.
Ambulatory 24-hour esophageal manometry was applied to analyze motility in 12 normal subjects and 9 patients with chest pain and dysphagia caused by diffuse esophageal spasm (DES). Pain episodes characterized by nonperistaltic activity occurred in 7 of 9 patients. A score based on 10 variables of the motility pattern differentiated patients from normal subjects and quantitated the severity of the disorder. Ambulatory motility monitoring was prospectively performed in 8 normal subjects and 37 patients: 8 with DES, 13 with hypertensive contractions, and 16 with a nonspecific disorder on standard manometry. The score was positive in 6 of 8 patients with DES and negative in all normal subjects (accuracy 87 percent). Nine of the 13 patients with hypertensive contractions (70 percent) and 6 of 16 with nonspecific disorders (38 percent) had a pathologic score reflecting a dysmotility as severe as DES. Ambulatory esophageal manometry is a more physiologic way to identify a motor disorder than standard manometry and has the potential to improve selection of patients for a surgical myotomy.
Adult↗
Chronic respiratory symptoms and occult gastroesophageal reflux. A prospective clinical study and results of surgical therapy.
Seventy-seven patients with a primary complaint of persistent cough, wheezing, and/or recurrent pneumonia were evaluated for the presence of occult gastroesophageal reflux disease. Fifty-four patients (70%) had increased esophageal acid exposure on 24-hour pH monitoring of the distal esophagus. In 28% of these patients the respiratory symptoms were thought to be due to aspiration because they occurred during or within 3 minutes after a reflux episode. In the other patients, the respiratory symptoms were either induced by or were unrelated to reflux episodes. The number of respiratory symptoms reported by the patients with increased esophageal acid exposure was directly related to the presence of a nonspecific esophageal motility abnormality (p less than 0.05). This suggested that a motility disorder contributes to aspiration by promoting the aboral flow of refluxed gastric juice. Seventeen patients with increased esophageal acid exposure had an antireflux operation to relieve their respiratory complaints. Patients whose respiratory symptoms induced reflux episodes were not helped by the procedure. Of the other patients, symptoms were abolished by the procedure only in those with normal esophageal motility. It is concluded that the majority of patients suffering from chronic unexplained respiratory symptoms have occult gastroesophageal reflux disease, but only a minority of them are helped by surgery. Carefully performed esophageal function studies are needed to select those patients who will benefit from a surgical antireflux procedure.
Adult↗
The cause of dysphagia in uncomplicated sliding hiatal hernia and its relief by hiatal herniorrhaphy. A roentgenographic, manometric, and clinical study.
Patients with an uncomplicated sliding hiatal hernia frequently experience dysphagia. The present study shows, using video barium contrast esophagograms, that the cause of dysphagia in 60% of these patients is an obstruction to the passage of the swallowed bolus by diaphragmatic impingement on the herniated stomach. Manometrically this was reflected by a double-hump high pressure zone (HPZ) at the gastroesophageal junction, and specifically to the length and amplitude of the distal HPZ and the length of the intervening segment between the two HPZs. The former represents the degree of the diaphragmatic impingement on the herniated stomach and the latter the size of the supradiaphragmatic herniated stomach. Surgical reduction of the hernia resulted in relief of dysphagia in 91% of the patients.
Barium Sulfate↗
Surgical therapy in Barrett's esophagus.
Seventy-six patients with Barrett's esophagus were cared for during a 10-year period. Fifty-six patients (74%) presented with complications of the disease. There were 20 strictures, 7 giant ulcers, 11 cases of dysplasia, and 29 patients with carcinoma. In patients with benign disease, 93% had mechanically defective sphincters and 83% had peristaltic failure of the lower esophageal body. Esophageal pH monitoring showed excessive esophageal exposure to pH less than 4 in 93% and excessive exposure to pH more than 7 in 34% of the patients tested. Ninety-three per cent of patients with excessive alkaline exposure had complications, compared to only 44% with normal alkaline exposure (p less than 0.01). Gastric pH monitoring, serum gastrin levels, and gastric acid analysis supported a duodenal source for the alkaline exposure. Antireflux surgery was performed using Nissen fundoplication in 30, Belsey partial fundoplication in 3, and Collis-Belsey gastroplasty in 2. Six required resection with colon interposition. Good symptomatic control was achieved in 77% after antireflux surgery. Four patients had symptoms and signs of duodenogastric reflux; three required a bile diversion procedure. Fifteen patients had an en bloc curative resection with colon interposition. One patient with high-grade dysplasia on biopsy was found to have intramucosal carcinoma after simple esophagectomy. Five tumors were intramucosal, seven were intramural, and four were transmural. Lymph node involvement occurred only in the latter two. Actuarial survival 5 years after curative resection was 53%. Median survival time for patients after palliative resection or no resection was 12 months. Study of en bloc specimens indicated that extent of resection should be adapted to extent of disease: esophagectomy for intramucosal disease, en bloc esophagectomy with splenic preservation for intramural and transmural disease. Serum CEA was useful in detecting recurrent disease after surgery when the primary tumor stained positively for CEA.
Adenocarcinoma↗
Intragastric pH pattern analysis in patients with duodenogastric reflux.
The intention of the present study was to apply 24-hour intragastric pH monitoring as a diagnostic tool for the detection of pathologic duodenogastric reflux. Therefore, an evaluation system was developed which is able to recognize and quantify specific intraluminal gastric pH patterns regarding their specificity for the disease. pH parameters, stored during 24 h and processed, according to the evaluation system, were obtained for a healthy control population (n = 30) and for patients with pathologic duodenogastric reflux (n = 11). These data were subjected to computerized discriminant analysis to identify pH changes with a high probability of resulting from pathologic duodenogastric reflux. The computer analysis identified 16 discriminating pH parameters to separate a physiologic pH pattern from a 24-hour intragastric pH pattern with a high probability of being associated with pathologic duodenogastric reflux.
Adult↗
Influence of dissolution rate and pH of oral medications on drug-induced esophageal injury.
The in vitro dissolution time and pH were measured for 16 drug products in capsule or tablet form representative of oral medications known to cause esophageal injury. The test drugs included Vibramycin, Minocin, quinidine sulfate, Cleocin HCl, Indocin, Tolectin 200, ferrous sulfate, vitamin C, aspirin, Procardia, phenobarbital, Dilantin, Butazolidin, Noctec, K-Dur, and Quinaglute. Artificial saliva (10 mL) was placed in a small beaker along with a pH probe connected to a digital display pH meter and a strip-chart recorder. The salivary pH was measured at baseline and continuously during the dissolution of each test medication and the time taken for complete dissolution was recorded. This experiment was repeated six times for each drug. Baseline and final dissolution pH were compared statistically for differences using the Wilcoxon matched-pairs signed-ranks test. Significance was established at the 0.05 level. Only three medications tested (vitamin C, aspirin, and Dilantin) produced a dissolution pH outside the range of physiological esophageal pH values. Although the majority of the test drugs significantly altered the baseline pH, the final dissolution pH did not fall outside the physiologic range. Nine of the 16 test drugs dissolved completely within 10 minutes, whereas the remaining 7 drugs took 30 minutes or longer (up to 24 hours) to dissolve. We conclude that the dissolution pH of potentially caustic medications does not appear to be a primary mechanism of drug-induced esophageal injury, whereas a rapid dissolution rate may play an important role in the pathogenesis of the lesion.
Administration, Oral↗
Surgical approach to non-small cell lung cancer stage I and II.
No patient with a potentially curable lung cancer should be denied the opportunity for a curative resection. Solitary pulmonary nodules should be approached as though they were malignant until proven otherwise, either by definitive histologic or extremely convincing circumstantial clinical evidence. Consequently, thoracotomy should be performed, assuming that the patient is physiologically able, if cancer cannot be definitely excluded. The evaluation of patients with synchronous lung nodules is complex owing to the possible causes of the two nodules but should be pursued because of its important effect on therapeutic outcome. The major factor influencing survival is the extent of the tumor at the time of resection. When metastatic lymph nodes are found at the time of surgery, regardless of the location, the survival rate is significantly lower. Lobectomy for patients with stage I disease is usually sufficient treatment, but when the tumor is large (exceeding 4 cm) or centrally located or when hilar lymph nodes are involved, a pneumonectomy must be considered in order to eradicate local disease. Those patients with N1 disease can obtain improved survival when resection is combined with adjuvant radiation and chemotherapy.
Biopsy↗