Gastroenterology

Gastroenterology

Volume 118, Issue 4, April 2000, Pages 688-695
Gastroenterology

Alimentary Tract
Increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention in reflux patients with hiatal hernia,☆☆

https://doi.org/10.1016/S0016-5085(00)70138-7Get rights and content

Abstract

Background & Aims: This study aimed to determine if hiatal hernia influences vulnerability to reflux and transient lower esophageal sphincter relaxation (tLESR) during gastric distention in patients with gastroesophageal reflux disease (GERD). Methods: Eight normal subjects and 15 patients with GERD were studied. A metal clip attached to the squamocolumnar junction (SCJ) was beneath the hiatus in all control subjects. Eight GERD patients with ≥1-cm SCJ-hiatus separation were considered hernia patients, and 7 with <1-cm separation were considered nonhernia patients. Manometry and esophageal pH were recorded for 30 minutes, after which the stomach was loaded with acid dextrose and the recording continued for 2 hours with intragastric air infusion of 15 mL/min. Results: Baseline reflux was comparable among groups. Gastric distention increased the frequency of reflux by the tLESR mechanism in all groups. Controls and nonhernia patients had median increases of 4.0 and 4.5 in tLESR frequency, respectively, and hernia patients had a median increase of 9.5/h. tLESR frequency was highly correlated with the SCJ-hiatus separation (r = 0.76; P < 0.001). Conclusions: Gastric air infusion was a potent stimulus for tLESR and reflux. The resultant tLESR frequency was directly proportional to the separation between the SCJ and hiatus, suggesting that the perturbed anatomy associated with hiatal hernia predisposed to eliciting tLESRs in patients with GERD.

GASTROENTEROLOGY 2000;118:688-695

Section snippets

Materials and methods

Intraluminal pressures from within the esophagus, EGJ, and stomach, along with distal esophageal pH, were recorded during gastric air distention in healthy subjects and in patients with GERD who had varying degrees of hiatal hernia. The protocol was approved by the Northwestern University Institutional Review Board, and informed consent was obtained from all subjects.

Effect of intragastric air infusion on gastroesophageal acid reflux

The number of acid reflux events and the corresponding esophageal acid exposure times among the 3 groups are shown in Table 1.

. Number of acid reflux events per hour and percent time with pH <4 among subject groups

Empty CellNo. of acid reflux events% Time with pH <4
Empty CellBaselineAir infusionBaselineAir infusion
Normal controls0 (0–2)4 (1.8–4.3)a0 (0–5.6)5.4 (3.1–10.4)a
Nonhernia patients0 (0–3)6 (6.4–10.6)a,b0 (0–4.9)14.6 (5.6–16.6)a,b
Hernia patients1 (0–7)12.8 (6.5–26.3)a,b,c1.8 (0–5.8)22.7 (14–24.8)a,b
aP < 0.05

Discussion

Many clinical studies have strongly argued for more than a chance association between GERD and hiatal hernia.1, 2, 3, 4, 5 On the other hand, physiological studies analyzing the mechanism by which gastroesophageal reflux events occur have identified LES hypotension and especially tLESR as the dominant mechanisms of reflux.10, 11, 12 Thus, the physiological relevance of the anatomic aberrations of the EGJ associated with hiatal hernia remains incompletely defined. The major finding of this study

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    Address requests for reprints to: Peter J. Kahrilas, M.D., Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Medical School, Searle Building, 10th Floor, Suite 541, 303 East Chicago Avenue, Chicago, Illinois 60611. e-mail: [email protected]; fax: (312) 908-6192.

    ☆☆

    Supported by grant RO1 DC00646 from the Public Health Service (to P.J.K.).

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