Pharmacological analysis of stimulation action of histamine on gastric secretion

Abstract

Aim: To define the clinical presentation, motility characteristics, and prevalence and patterns of gastroesophageal reflux in patients with hypertensive lower esophageal sphincter (HTLES). Methods: HTLES was defined by a resting LES pressure measured at the respiratory inversion point on stationary manometry of > 26 mmHg (95'h percentile of normals). 100 consecutive patients (80 F, mean age 54.7 yrs, range 23-89 yrs) with HTLES were investigated at this institution between September 1996 and October 1999. Patients with HTLES represented ~7% of all patients investigated by motility examination during this period. Patients with another esophageal motility disorder or a history of foregut surgery were excluded. Results: The most common symptoms in HTLES patients were regurgitation (75%), heartburn (71%), dysphagia (71%), and chest pain (49%). 73 patients underwent 24 hour pH monitoring, of whom 26% had increased distal esophageal acid exposure. 48% of patients had moderately severe or severe dysphagia. Nutcracker esophagus was present in 23 patients. The intrabolus pressure, measured 5cm above the LES, was significantly higher in patients with HTLES compared to normal volunteers (P<O.OOOI). The residual pressure measured during LES relaxation in response to a 5 mL water swallow was also significantly higher than in normal individuals (P<O.OOOI). There were no significant associations between any of the relaxation parameters studied (residual pressure, nadir pressure, duration of relaxation, time to residual pressure) and either the presence or severity of any symptoms, or the presence of GERD. Comparison of HTLES patients with normal relaxation (n=38) with those with incomplete relaxation (n=62), using the previousl~ determined normal upper limit for the residual relaxation pressure (95' percentile value for normal volunteers; 7.5 mmHg), found no differences between the two groups for any symptoms. Compared to a cohort of patients with GERD but no HTLES (n=300), patients with HTLES and GERO had significantly lower total (P=O.004) and supine (P=0.02) period distal esophageal acid exposure. Conclusions: Patients with HTLES frequently present with typical reflux symptoms and approximately one quarter of them have objective GERD on pH monitoring. Moderately severe or severe dysphagia is common. Patients with HTLES have significantly elevated intrabolus and residual relaxation pressures, but neither these nor any other manometric measurements are significantly associated with the presence of any symptoms or with the diagnosis of GERD.