PRESSURES OR VOLUMES IN GASTROESOPHAGEAL REFLUX DISEASE: WHICH IS MOST IMPORTANT?
One hundred twenty patients with abnormal 24‐h pH monitoring studies were seen in the 2‐yr period from 1986 to 1988. Eighty‐five subsequently had upper endoscopy, esophageal manometry, and gastric analysis (BAO, MAO). Ten were excluded for previous gastric surgery, leaving 75 patients who were evaluated in an attempt to answer the following questions: 1) Is a gastric hypersecretory state (defined as BAO > 5 mmol/h, MAO > 30 mmol/h) associated with gastroesophageal reflux disease? 2) If so, is the hypersecretory state more prevalent than a mechanically defective sphincter (defined as LESP < 6 mm Hg, length < 2.0 cm, abdominal length < 1.0 cm; based on 50 normal controls)? 3) Is hypersecretion associated with increased esophageal acid exposure time and/or reflux complications, compared with normal secretors? Are complications higher with hypersecretion than with a mechanically defective sphincter? 4) Is there a relationship between the gastric secretory state and adequacy of the LES? In an extremely well done study, the authors found the following: 28% bad high BAO and MAO‐defined hypersecretors. Forty percent and 49%, respectively, bad either an elevated BAO or MAO. Duodenal ulcer was found in only 8% of hypersecretors. Mechanically defective sphincter was found in 72%, significantly higher (p < 0.01 by x 2 ) than gastric hypersecretion. Twenty‐four‐hour acid exposure and incidence of reflux complications were similar in hyper‐ and normal secretors (24‐b pH score 37.6 vs 34.2, complications 65% vs 62%). Twenty‐eight (37%) bad endoscopic esophagitis, seven (10%) stricture, and 13 (17%) Barrett's esophagus. The three complications studied showed rates similar in patients with mechanically defective lower sphincters compared with hypersecretors (78 vs 62%, p > 0.05). Esophageal stricture and/or Barrett's esophagus were seen only if the sphincter was mechanically defective. Neither was seen with gastric hypersecretion and a normal LES. Complication rates were high in patients with a mechanically defective sphincter independent of gastric secretory state (82 v* 11%., p > 0.05). Patients with a normal LES and hypersecretion appeared to have more frequent esophagitis than normal secretors with a normal LES (35% vs 18%, p value not given). Copyright © 1990, Wiley Blackwell. All rights reserved
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