Gastroenterology

Gastroenterology

Volume 125, Issue 4, October 2003, Pages 1018-1024
Gastroenterology

Clinical-alimentary tract
Esophagogastric junction opening during relaxation distinguishes nonhernia reflux patients, hernia patients, and normal subjects

https://doi.org/10.1016/S0016-5085(03)01210-1Get rights and content

Abstract

Background & Aims: Flow across the esophagogastric junction (EGJ) is strongly related to opening dimensions. This study aimed to determine whether opening of the relaxed EGJ was altered in patients with gastroesophageal reflux disease (GERD). Methods: Seven normal subjects (NL), 9 GERD patients without hiatus hernia (NHH), and 7 with hiatus hernia (HH) were studied. Cross-sectional area (CSA) of the relaxed EGJ was measured during low-pressure distention using a modified barostat technique that resulted in filling a compliant bag straddling the EGJ with renograffin to the set pressure. Swallows were imaged fluoroscopically at distensive pressures of 2–12 mm Hg. The diameter of the narrowest point of the EGJ in PA and lateral projections was measured from digitized images. CSA was determined as a function of intrabag pressure. Results: The minimal EGJ opening aperture occurred at the diaphragmatic hiatus in all subjects. At pressures ≤0 mm Hg, EGJ opening was observed only in HH patients, making it plausible for these patients to reflux during deglutitive relaxation. At pressures >0 mm Hg, there were significant increases in EGJ CSA both for HH and NHH compared with NL (P < 0.001) and for HH compared with NHH (P < 0.005). This difference may explain the diminished air/water discrimination seen during transient lower esophageal sphincter (LES) relaxation-associated reflux in GERD patients. Conclusions: Anatomic degradation of the EGJ distinguishes GERD patients from normal subjects, and these changes may impact on both the observed mechanisms of reflux and the constituents of reflux during transient LES relaxation. Therapy focused on EGJ compliance may benefit GERD patients.

Section snippets

Subjects

Seven NL (4 males, 23–33 years old) without reflux symptoms, 7 patients with GERD and HH (5 males, 28–53 years old), and 9 GERD patients without HH (NHH) (5 males, 24–48 years old) were studied. The patients were enrolled from the gastrointestinal diagnostic laboratory at Northwestern Memorial Hospital. Patients were classified as HH or NHH based on recent upper endoscopy results (performed by P.J.K. or J.E.P.). The endoscopic criterion for HH was that the position of the squamocolumnar

Manometric measures of EGJ function

Manometric data for each group are shown in Table 2. Using ANOVA, no significant difference existed in mean basal LES pressure among the 3 groups. However, an unpaired t test revealed a significant difference in LES pressure between NL and HH patients (P < 0.005). Neither ANOVA nor an unpaired t test revealed any significant differences in LES relaxation pressure or intragastric pressure among the 3 subject groups.

EGJ opening during low-pressure distention

The smallest EGJ opening aperture during deglutitive relaxation occurred at the

Discussion

The central hypothesis leading to this report was that mechanical alterations of the EGJ might underlie differences in both the volume and the constituents of reflux in GERD patients with or without hiatus hernia. The major findings of the paper were that (1), at distention pressures greater than intragastric pressure, the relaxed EGJ opened incrementally wider in HH patients compared with NHH patients and in NHH patients compared with NL subjects, and (2) at distention pressures greater than

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    Citation Excerpt :

    The interplay between HH and increased EGJ compliance is another mechanism. Pandolfino and colleagues43 measured EGJ compliance using a hydrostat applying the law of Laplace to calculate the EGJ cross-sectional area (CSA) based on the known intrabag pressure and the degree of EGJ opening using fluoroscopy. EGJ opening occurred at pressures of less than 0 mm Hg only in subjects with GERD with HH compared with those without HH and controls.

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Supported by grants RO1 DC00646 (to P.J.K.) from the Public Health Service and K23 DK62170-01 (to J.E.P.).

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