Introduction: Gastroesophageal reflux occurs twice as much during transient lower esophageal sphincter relaxations (TLESR) in GERD patients compared to healthy volunteers (HV). Our aim was to assess whether the localisation of the postprandial acid pocket and its interaction with a hiatal hernia (HH) play a role in the occurrence of acidic reflux during TLESRs.
Methods: 10 HV and 22 GERD patients (12 with HH<3cm (s-HH), 10 with HH≥3cm (l-HH)) were studied. The squamocolumnar junction and diaphragmatic impression were marked with a radio-labelled clip. To visualize the acid pocket, 99mTc-pertechnetate was injected iv and images were acquired up to 2hrs postprandial. Concurrently, combined manometry/impedance and 4-channel pH-metry were performed, with pH pull-through at multiple time-points.
Results: The rate of TLESRs and the % associated with reflux was comparable between all groups. However, acidic reflux was significantly increased in patients, especially in l-HH patients. Acid pocket length was significantly enlarged in patients. Moreover, immediately before a TLESR, the acid pocket was more frequently located within the hiatus or above the diaphragm in GERD patients (s-HH: 54%, l-HH: 77%) compared to HV (22% of TLESRs). Acidic reflux was significantly increased when the acid pocket was located above the diaphragm in all groups compared to a subdiaphragmatic localization.
Conclusion: The position of the acid pocket is largely determined by the presence of a HH. Entrapment of the pocket above the diaphragm, especially in l-HH patients, is a major risk factor underlying the increased occurrence of acidic reflux during a TLESR in GERD patients.
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