Evidence Of Esophagitis Research Articles

The Prevalence of Gastroesophageal Reflux in Patients with Paradoxical Vocal Fold Motion

Purpose: Paradoxical vocal fold motion (PVFM) is an inappropriate adduction of the true vocal folds, which causes airway obstruction and inspiratory stridor. PVFM may lead to wheezing and is often mistaken for asthma, and patients are treated with glucocorticoids and beta-agonists inappropriately. There is a body of evidence stating that irritation of the vocal folds may cause or exacerbate PVFM. One-third of PVFM patients have been shown to report GERD symptoms, but studies to evaluate PVFM patients with pH monitoring have all been small (<10 subjects). We studied patients with PVFM to determine the prevalence of GERD in this population as diagnosed by esophagogastroduodenoscopy (EGD) or 48-hour esophageal acid monitoring. Methods: Patients diagnosed with PVFM by flattened inspiratory loop on pulmonary function testing underwent EGD with BRAVO capsule placement at 6 cm proximal to SCJ. All patients abstained from acid suppression agents (PPI's, H2RA's) for 7 days prior to the EGD. 48 hours of pH monitoring was performed with the BRAVO capsule. Patients were considered to have a diagnosis of GERD if they had any evidence of erosive esophagitis on EGD or if they had a positive Johnston-Demeester (JD) score (>22) during the second 24-hour period of pH monitoring by BRAVO capsule. Results: 32 patients (20 females, mean age 42 + 16 yrs) with PVFM completed the study. 31% (10/32) of subjects had a positive JD score, 50% of which had significant combined upright and supine reflux. On EGD, 18.8% (6/32) had evidence of esophagitis. Two subjects with esophagitis had a normal JD score. In this study the prevalence of GERD in PVFM was 37.5% (12/32, 95% CI 21.1–56.3%). Of GERD positive subjects, 50% (6/12) had evidence of esophagitis and 50% had atypical or no symptoms of GERD. GERD pos and GERD neg groups were similar in mean age (43 + 16 yrs vs. 41 + 16 yrs, P= 0.708) and sex (female, 50% of GERD pos vs. 70% of GERD neg, P= 0.452). Conclusion: GERD prevalence in this study was 37.5%. This suggests a high prevalence of GERD in the PVFM population. Because of this, PVFM patients should be studied for GERD, especially since many are asymptomatic. This may also suggest that GERD plays a role in the pathogenesis of PVFM.

Eosinophilic Esophagitis Presenting with Dyspepsia and Anorexia

Purpose: Eosinophilic esophagitis (EoE) is characterized by an eosinophilic infiltration of the esophagus and is increasingly recognized as a cause of dysphagia and heartburn unresponsive to antireflux therapy. We report a case of eosinophilic esophagitis that presented without dysphagia, heartburn or endoscopic abnormalities to alert clinicians to the importance doing of esophageal biopsies in atypical presentations of EoE. Methods: A 19 yo college student presented with a 3 year history of anorexia and dyspepsia. Multiple foods and milk seemed to cause dyspepsia. However, his symptoms persisted despite avoiding milk and milk products. He had several episodes of minor hematemesis that led to an endoscopy at age 16 (by a different physician) showing only a small Mallory-Weiss tear and normal duodenal biopsies. Because of worsening symptoms and weight loss of ten pounds, he was referred for further evaluation. Family history was notable for mother with celiac sprue. A gastric emptying test was normal, LFTs and CBC were normal except for borderline eosinophilia; WBC = 7000/uL and 7.3% eosinophils (normal 0–7.0%). A full panel of celiac antibodies were negative except for an antigiadin IgG of 100.0 U/ml (normal <10.0 U/ml). A repeat endoscopy to assess for celiac sprue was normal except for slight gastric retention. Multiple biopsies were negative for celiac sprue and H. pylori. There was no eosinophilia in the duodenal or gastric biopsies. The esophagus was endoscopically normal without evidence of esophagitis, rings, or any other abnormalities. Biopsies from a normal appearing GE junction revealed a focal dense eosinophilic infiltration in the squamous epithelium (≥28 eosinophils per high powered field) consistent with EoE. The patient was started on fluticasone swallowed twice a day with resolution of all symptoms within a few weeks. Results: EoE is becoming more frequently diagnosed as a cause of dysphagia and heartburn and is predominantly considered in younger patients presenting with symptoms that are unresponsive to antireflux therapy or with endoscopic signs of EoE such as ringed esophagus. Diagnosis is by clinical features supported by esophageal biopsy with ≥15 eosinophils per HPF. Five biopsies (including proximal esophagus) have a sensitivity of 100%. Other bloodwork and endoscopic findings are neither sensitive nor specific. Conclusion: This case highlights the importance of esophageal biopsies in the diagnosis of EoE in atypical presentations. We suggest that clinicians consider the possibility of EoE in patients with prolonged, non-specific upper GI complaints and biopsy the esophagus even if the mucosa appears normal on endoscopy.

Comparing Reconstruction With Ileocecal Graft to Jejunal Interposition Pouch After Total Gastrectomy in Rats

After total gastrectomy, the ileocecal graft may act as a reservoir and protect against reflux but give rise to transposition of the ileum and cause possible changes in bile acid metabolism and nutrition. This study compared the ileocecal graft and jejunal pouch. Male Wistar rats weighing 265 ± 22 g were submitted to sham operation (S), ileocecal interposition graft (IIG), and jejunal pouch interposition graft (JP) after total gastrectomy. Eight weeks later, the esophagus was examined for evidence of esophagitis. Nutritional biochemistry and weight profile were documented preoperatively and 8 weeks after surgery. The oral glucose tolerance test was performed. Thirty-three rats were operated on and 30 survived for 8 weeks. Esophagitis occurred in seven JP rats. Body weight was significantly higher in IIG than in JP rats (p <. 05). Normal glucose tolerance to intragastric glucose load was observed in sham and operated rats. JP rats had a significant decrease in serum albumin, glucose, transferrin, hemoglobin, iron, folate, and calcium, compared to sham (p <. 05). Cobalamine was significantly lower in IIG rats than in JP rats (p <. 05). In the IIG and JP groups, serum/hepatic total bile acid did not differ significantly from preoperative and sham values. In conclusion, the IIG interposition graft in rats prevented esophagitis, preserved nutrition, and did not interfere with enterohepatic total bile acid circulation.

Achalasia-like syndrome in systemic sclerosis

Two methods of quantifying oesophageal emptying for liquids have been used to assess the dysphagia of patients with systemic sclerosis: the oesophageal infusion scintiscan and the timed Gastrografin swallow. Upper gastrointestinal endoscopy and oesophageal manometry were also performed. Thirteen patients with oesophageal symptoms were studied. Eight had dysphagia, and all of these had endoscopies with no evidence of oesophagitis or stricture. Four of these eight subjects had gross delay of oesophageal emptying for fluids, and manometry showed absence of oesophageal peristalsis and incomplete relaxation of the lower oesophageal sphincter. This abnormality is similar to achalasia. Two of these four patients have benefited from pneumatic dilatation with improvement in their severe dysphagia. We believe that pneumatic dilatation should be considered in patients with systemic sclerosis and severe dysphagia where reflux oesophagitis is not apparent.

Paraoesophageal hernia repair with and without concomitant fundoplication.

There is currently no consensus as to whether an antireflux procedure should accompany surgical repair of paraoesophageal hernia. Forty consecutive patients with paraoesophageal hernia were studied. Surgery routinely included transabdominal hernia reduction, excision of the sac and crural repair. The addition of fundoplication was based on the presence of preoperative endoscopic evidence of oesophagitis. Twenty-three patients without endoscopic oesophagitis had no antireflux procedure whereas 17 with oesophagitis underwent concomitant antireflux surgery. Thirty-six patients were followed for 1-7 years. Patients without endoscopic oesophagitis had no postoperative reflux problems. All patients with oesophagitis who underwent fundoplication were improved or cured of reflux. The selection of patients for antireflux repair can satisfactorily be based on preoperative endoscopic findings.

Prospective study of the Angelchik anti-reflux prosthesis.

Fifty patients with medically refractory gastro-oesophageal reflux were treated by the insertion of an Angelchik anti-reflux prosthesis. All patients had a pre-operative upper gastrointestinal endoscopy, 32 were investigated with 15 h overnight oesophageal pH studies combined with oesophageal bile sampling and 20 underwent oesophageal manometric studies. At pre-operative endoscopy 45 patients had evidence of oesophagitis and the 5 who did not had pathological reflux demonstrated on overnight pH testing. Postoperatively the main clinical problem was dysphagia which appeared to settle with time but left one-third of patients with mild dysphagia at the end of 12 months. A further 12 per cent had residual moderate to severe dysphagia which required the removal of the prosthesis in five patients (10 per cent). In only one patient was the dysphagia due to prosthetic migration and this was the first patient in the series. Subsequently, we have had no problems with prosthetic migration, disruption, or erosion into the oesophagus. The overnight pH studies confirmed the efficacy of the prosthesis in preventing reflux which correlated with symptomatic improvement. We conclude that, while the Angelchik anti-reflux prosthesis is an effective device, it has a disturbingly high incidence of postoperative dysphagia though this appears to settle with time, leaving around 10 per cent of patients with severe dysphagia which will necessitate removal of the prosthesis and one-third with mild dysphagia which may settle with the further passage of time.

Haematemesis in infantile hypertrophic pyloric stenosis: the source of the bleeding.

Thirteen infants with haematemesis associated with hypertrophic pyloric stenosis were investigated in order to elucidate the source of bleeding. All 13 patients showed endoscopic evidence of oesophagitis, moderate in 4 and severe in 9. No significant gastric mucosal lesion was found. It was concluded that the site of the haemorrhage was the oesophageal mucosa in all 13 infants. Eleven of the patients experienced troublesome postoperative vomiting.

Symptom index as a marker of gastro-oesophageal reflux disease.

Forty per cent of patients with heartburn may have no evidence of oesophagitis or of abnormal oesophageal acid exposure. The symptom index correlates symptoms that occur during pH monitoring with episodes of acid reflux, being the number of symptoms during reflux divided by the total number occurring during monitoring. This index was assessed in 61 patients with heartburn. In 39 patients with endoscopic evidence of oesophagitis or abnormal acid exposure times on pH monitoring, the symptom index had a sensitivity of 90 per cent. Of the 22 patients with no objective abnormality, the index was > or = 50 per cent in five (23 per cent) whose symptoms were presumably due to acid reflux despite results of other investigations being normal, suggesting an acid-sensitive oesophagus. The symptom index is a useful additional measure in the investigation of patients with suspected gastro-oesophageal reflux disease.

American Gastroenterological Association Medical Position Statement: Evaluation of Dyspepsia

American Gastroenterological Association Medical Position Statement: Evaluation of Dyspepsia

Evaluation of Chronic Gastrointestinal Symptoms following Persian Gulf War Exposure

This was a prospective study performed in a Department of Veterans Affairs Medical Center. The aim of this study was to use endoscopic and histological examinations to determine the potential diagnostic origins of chronic gastrointestinal symptoms among patients who were part of the deployment of troops to the Persian Gulf after August 1990. Twenty-four (8%) male patients (mean age, 42 years) of 308 patients in the Persian Gulf War Registry agreed to undergo endoscopic examination of chronic symptoms, including heartburn (29%), dyspepsia (33%), dysphagia (8%), diarrhea (63%), Hemoccult-positive stool (21%), and rectal bleeding (17%). There were 17 upper endoscopies, 18 colonoscopies, and 4 flexible sigmoidoscopies performed, all with biopsies. Five (33%) of 15 patients had positive serological findings for Helicobacter pylori. With upper endoscopy, major findings included esophagitis (12%), Schatzki's ring (12%), hiatal hernia (47%), antral erythema (59%), and duodenal erythema (29%). With lower endoscopy, major findings included ileitis (5%), lymphoid hyperplasia (9%), polyps (27%), diverticulosis (23%), and hemorrhoids (23%). Major histopathological findings included microscopic esophagitis (24%), gastritis with H. pylori (35%), gastritis without H. pylori (18%), Crohn's disease (5%), tubular adenoma (5%), hyperplastic polyps (18%), and melanosis coli (5%). Most patients with chronic heartburn or dyspepsia have evidence of esophagitis or H. pylori. Individuals with these chronic symptoms should undergo evaluation.

Abnormal acid reflux in asthmatic patients in a region with low GERD prevalence

A high prevalence of gastroesophageal reflux disease (GERD) in asthmatic patients has been reported from North America and Europe. However, only a few data from Asia are available. This study evaluated the incidence of abnormal gastroesophageal reflux (GER) in asthmatic patients in Taiwan. Fifty-six consecutive ambulatory patients with clinically stable asthma (41 men and 15 women; age, 57.7 +/- 12.4 years; range, 24 to 74 years) were evaluated prospectively. All patients underwent esophagogastroduodenoscopy, esophageal manometry, and 24-h esophageal pH monitoring. Twenty-nine patients (51.8%) had abnormal GER, as defined by 24-h esophageal pH monitoring. There were 42 patients without endoscopic evidence of esophagitis, 10 patients with Los Angeles (LA) grade A esophagitis, and 4 patients with LA grade B esophagitis. The esophageal motility function studies revealed 21 patients with normal esophageal motility, 23 patients with ineffective esophageal motility (IEM), and 12 patients with nonspecific esophageal motility disorders other than IEM. Although the lower esophageal sphincter (LES) basal pressure was higher in the patients without GER, the difference was not statistically significant. Abnormal GER seems to be a clinically significant problem in asthmatic patients in Taiwan. The most common esophageal motility dysfunction is IEM. However, the status of Helicobacter pylori infection plays no role in abnormal GER.

Noctural Asthma: Role of Nocturnal Gastroesophageal Reflux

Gastroesophageal reflux (GER) is common in those with asthma, with 77% of asthmatics complaining of heartburn, with 41% experiencing reflux-associated respiratory symptoms. Likewise, 24% of those with asthma that is difficult to control have “clinically silent” GER. There are no studies examining nocturnal reflux symptoms in asthmatics. Esophageal dysmotility is also common, and abnormal esophageal acid contact times on 24h esophageal pH tests were found in 82% of asthmatics examined consecutively. Most asthmatics with GER also have abnormal esophageal acid contact times while in the supine position, reflecting sleep time. Endoscopic evidence of esophagitis was found in 43% of asthmatics. Two mechanisms of bronchoconstriction induced by esophageal acid have been proposed: a vagally mediated reflex, by which esophageal acid in the distal esophagus causes reflex bronchoconstriction, and microaspiration. Although there is conflicting evidence, distal esophageal acid causes a decrease in peak expiratory flow rates, an increase in respiratory resistance, and an increase in minute ventilation. If microaspiration is present, there is further augmentation of this airway response. Although only a few studies have been performed in those with nocturnal asthma with GER, one study in a pediatric population showed that esophageal acid infusions caused more airway responses at 04:00 than at 24:00. Also, asthmatic children with nocturnal asthma symptoms have a higher re-flux score, with a positive correlation between reflux score and nighttime-associated wheezing. Despite these findings in children, a study performed in sleeping adults with nocturnal asthma noted no alterations in airflow resistance with esophageal acid, concluding that GER contributed little to the nocturnal worsening of asthma. There are also gastroesophageal circadian issues that may influence GER in asthmatics. Gastric acid secretion peaks at approximately 21:00, and gastric emptying is delayed when a meal is given at 20:00 versus 08:00. Esophageal acid clearance is delayed significantly during sleep, and acid clearance occurs during arousals. Upper esophageal sphincter (UES) pressure also decreases with sleep onset, which may predispose to microaspiration. Further research is needed to clarify what role nocturnal reflux has on nocturnal asthma and airway inflammation and whether circadian rhythm factors alter airway responses to esophageal acid.

Schatzki ring in children and young adults: clinical and radiologic findings.

The Schatzki ring is a well-known clinical and radiologic entity in adults, but is thought to be rare in childhood. Objective. To review the clinical presentations and radiologic findings of children and young adults with Schatzki rings. A retrospective review of all barium swallow examinations done between 1990 and 1996 revealed 20 patients with Schatzki rings. The most frequent presenting symptoms of these patients were progressive dysphagia with solid food and acute food impaction. Radiographic findings of Schatzki rings were typical in all cases. Twelve patients had endoscopy and all had evidence of esophagitis. Schatzki rings are not rare in childhood. The patients are symptomatic, presenting with either progressive dysphagia with solids or acute food impaction. A thorough evaluation of the distal esophagus should be performed in patients with a suggestive clinical history.

Noninvasive diagnosis of gastroesophageal inflammation using dipyridamole thallium-201 tomography

Objective: Esophagitis, a complication of GERD, and gastric erosions are common findings in dyspeptic patients. Unfortunately, these findings cannot be predicted based on symptoms alone and require endoscopy for an accurate diagnosis. Noninvasive diagnosis of other gastrointestinal pathology by radiopharmaceuticals (GA 67, Tc 99m pertechnetate) has previously been studied. We hypothesized that endoscopically documented esophagitis and/or gastric erosions could also be detected by using dipyridamole thallium-201 imaging and, if they were of sufficient accuracy, could serve as a useful, noninvasive screening test for esophagitis and/or gastric erosions. Methods: A pilot study was undertaken in 12 patients undergoing endoscopy for symptoms of GERD or dyspepsia. Esophagitis was defined as the presence of either erosions or ulceration and gastric erosions were defined as discrete mucosal breaks measuring ≥1 mm. Dipyridamole thallium-201 imaging was performed the following day on all 12 patients. A standard dose of dipyridamole (0.56 mg/kg) was infused over 4 min, followed by a 3-mCi dose of thallium-201. Initial stress tomographic images and reinjection (1 mCi) resting tomographic images 3–4 h later were obtained using a gamma camera. Tomographic images were read blinded to the endoscopy results. Thallium-201 uptake was graded on a 0–3+ scale using the liver uptake as the internal comparative standard (2+ = uptake equal to the liver). Abnormal thallium uptake was defined as ≥2+ in the area of the esophagus or stomach. Results: Seven women and five men (mean age 41 yr, range 25–60 yr) were studied. Eight patients were taking histamine-2 receptor antagonists and none were on proton pump inhibitors, or promotility agents. All five patients with endoscopic esophagitis had a positive thallium-201 tomographic image. Seven patients had no evidence of esophagitis, and three had positive thallium-201 tomograms. Dipyridamole thallium-201 imaging sensitivity, specificity, and positive and negative predictive values for esophagitis were 100%, 57%, 63%, and 100%, respectively. All three patients with gastric erosions had positive thallium-201 tomograms. Six of nine patients without gastric erosions had positive tomograms. The sensitivity, specificity, and positive and negative predictive values of DT 201 gastric erosions were 100%, 33%, 33%, and 100%, respectively. Conclusions: Dipyridamole thallium-201 tomographic imaging has good sensitivity (100%) in detecting esophagogastric mucosal erosions, but its poor specificity (33–57%) results in an unacceptable accuracy as a screening test. Additionally, the cost of radiopharmaceuticals requires that sensitivity and specificity be at least equal to that of endoscopy for this test to be clinically valuable as a screening test. However, a noninvasive test for these diseases is inherently appealing, and further research in this area seems to be warranted.

Noninvasive diagnosis of gastroesophageal inflammation using dipyridamole thallium-201 tomography.

Esophagitis, a complication of GERD, and gastric erosions are common findings in dyspeptic patients. Unfortunately, these findings cannot be predicted based on symptoms alone and require endoscopy for an accurate diagnosis. Noninvasive diagnosis of other gastrointestinal pathology by radiopharmaceuticals (GA 67, Tc 99m pertechnetate) has previously been studied. We hypothesized that endoscopically documented esophagitis and/or gastric erosions could also be detected by using dipyridamole thallium-201 imaging and, if they were of sufficient accuracy, could serve as a useful, noninvasive screening test for esophagitis and/or gastric erosions. A pilot study was undertaken in 12 patients undergoing endoscopy for symptoms of GERD or dyspepsia. Esophagitis was defined as the presence of either erosions or ulceration and gastric erosions were defined as discrete mucosal breaks measuring > or = 1 mm. Dipyridamole thallium-201 imaging was performed the following day on all 12 patients. A standard dose of dipyridamole (0.56 mg/kg) was infused over 4 min, followed by a 3-mCi dose of thallium-201. Initial stress tomographic images and reinjection (1 mCi) resting tomographic images 3-4 h later were obtained using a gamma camera. Tomographic images were read blinded to the endoscopy results. Thallium-201 uptake was graded on a 0-3+ scale using the liver uptake as the internal comparative standard (2+ = uptake equal to the liver). Abnormal thallium uptake was defined as > or = 2+ in the area of the esophagus or stomach. Seven women and five men (mean age 41 yr, range 25-60 yr) were studied. Eight patients were taking histamine-2 receptor antagonists and none were on proton pump inhibitors, or promotility agents. All five patients with endoscopic esophagitis had a positive thallium-201 tomographic image. Seven patients had no evidence of esophagitis, and three had positive thallium-201 tomograms. Dipyridamole thallium-201 imaging sensitivity, specificity, and positive and negative predictive values for esophagitis were 100%, 57%, 63%, and 100%, respectively. All three patients with gastric erosions had positive thallium-201 tomograms. Six of nine patients without gastric erosions had positive tomograms. The sensitivity, specificity, and positive and negative predictive values of DT 201 gastric erosions were 100%, 33%, 33%, and 100%, respectively. Dipyridamole thallium-201 tomographic imaging has good sensitivity (100%) in detecting esophagogastric mucosal erosions, but its poor specificity (33-57%) results in an unacceptable accuracy as a screening test. Additionally, the cost of radiopharmaceuticals requires that sensitivity and specificity be at least equal to that of endoscopy for this test to be clinically valuable as a screening test. However, a noninvasive test for these diseases is inherently appealing, and further research in this area seems to be warranted.

Gastroesophageal physiology after stapled gastroesophagostomy in dogs

A stapled vertical gastroesophagostomy (VGE) has been proposed for benign esophageal stricture. The VGE involves performing an anastomosis using a linear cutting stapler inserted via a gastrotomy (one limb in the esophagus, the other in the proximal fundus). In phase I of the study, a 50-mm VGE was performed in 13 dogs; 7 received an additional fundoplication. Endoscopy with pinch biopsies, esophageal manometry, and 4-hour ambulatory pH recordings were performed in each dog prior to and 1 month after VGE. The only difference between groups postoperatively was a higher lower esophageal sphincter pressure in the group with the added fundoplication. The incidence of histologic esophagitis was low in both groups. In phase II of the study, a VGE was performed in six dogs using a 75-mm linear cutting stapler, accompanied by fundoplication in each dog. These dogs were then followed for 6 months to more completely assess the long-term risk of developing reflux esophagitis. At necropsy, no gross or histologic evidence of esophagitis was found. The performance of a VGE through the lower esophageal sphincter in normal dogs does not result in significant reflux esophagitis. VGE may be an alternative to resection for esophageal stricture.

Natural history of gastro-oesophageal reflux disease without oesophagitis.

This retrospective study was undertaken to characterise the clinical course and reflux pattern of patients with gastro-oesophageal reflux without evidence of oesophagitis. We investigated 33 patients (12 women, 21 men; mean age 36 years) with typical symptoms, a negative oesophagoscopy, and a 24 hour oesophageal pH-metry indicative of pathological gastro-oesophageal reflux. All patients received antacids or prokinetic drugs or both for three to six months. Nineteen of 33 patients still had symptoms at the end of treatment, of whom five had developed erosive changes of the oesophageal mucosa. The other 14 discontinued treatment and remained asymptomatic during a six month follow up period. Comparison of the pretreatment pH-metry data of the 19 symptomatic patients and the 14 asymptomatic patients showed no differences in the pattern of gastro-oesophageal reflux in the two groups. We conclude that in a substantial proportion of patients with pathological reflux without oesophagitis symptoms may persist and mucosal lesions may develop during conventional treatment without any apparent change in the reflux. Patients who developed endoscopic oesophagitis did not have a more severe pretreatment pattern of gastro-oesophageal reflux when compared with those who did not develop oesophageal mucosal damage.

Endoscopic Removal of Inflammatory Esophagogastric Polyps in Children

Two adolescent patients with inflammatory esophagogastric polyps (IEPs) are presented. In each case, the patients complained of chest pain and dysphagia. In one patient, there was no histological evidence of esophagitis in association with the IEPs. Their clinical course suggests that the presentation of IEPs in adolescents is indistinguishable from and may result in secondary gastroesophageal reflux and esophagitis. In each case, endoscopic polypectomy was utilized effectively as the mode of therapy.

Utility of upper endoscopy in the evaluation of noncardiac chest pain

The diagnostic yield of esophagogastroduodenoscopy, esophageal manometry, and Bernstein testing was assessed in 100 consecutive patients being evaluated for non-cardiac chest pain. Manometric studies revealed the nutcracker esophagus in 21 patients; non-specific esophageal motility disorders in 19 patients; a hypertensive lower esophageal sphincter in 4 patients; diffuse esophageal spasm in 2 patients; and normal motility in 54 patients. Endoscopy was normal in 38 patients; but revealed grades II to IV esophagitis in 24 patients; gastritis and/or duodenitis in 18 patients; a sliding hiatal hernia without evidence of esophagitis in 14 patients; and gastric or duodenal ulcers in 6 patients. Twenty-five individuals were found to have normal manometric studies in combination with a negative Bernstein test. Among these 25 patients, however, 7 patients had esophagitis (grade II or higher); 6 patients had gastritis and/or duodenitis; five patients had a sliding hiatal hernia without esophagitis; 1 patient had peptic ulcer disease; and only 6 patients had a normal endoscopic exam. Our results indicate that endoscopy can identify a significant number of patients with acid-peptic disease who present with non-cardiac chest pain, that would not have been otherwise diagnosed by esophageal manometry or Bernstein testing alone or in combination.

Barrett's esophagus in children and young adults

Since few data are available on epidemiologic features of Barrett's esophagus in young persons, we reviewed the case records of patients undergoing esophageal biopsies at Children's Hospital, Boston, from 1982 through 1986. There were 1423 esophageal biopsies obtained from 1173 patients, and histological evidence of esophagitis was present in 397 cases; Barrett's epithelium was diagnosed in 10 patients (0.9% of total and 2.5% of esophagitis cases). Specialized columnar epithelium was present in seven of these 10 patients. The mean age of those with Barrett's epithelium was 19.0 +/- 7.9 years (range 3.7-27 years) compared to 8.7 +/- 6.7 years (range 4 days to 31 years) for all patients biopsied (P less than 0.0001); 80% (8/10) of the Barrett's cases were male compared to 54% of all cases. The relative importance of the possible risk factors was assessed by comparing the 10 patients with Barrett's with the 541 patients that had esophageal biopsies in calendar years 1984-1985. Mental retardation, a risk factor not previously described for young persons with Barrett's esophagitis, was present in 70% (7/10) of the Barrett's patients but in only 15% of all patients biopsied (P less than 0.0002). The frequency of mental retardation was also higher, but not significantly so (P greater than 0.07), in patients with biopsies that were positive for esophagitis (19%) than in those with normal biopsies (14%). No significant differences were found between the Barrett's group and all patients biopsied in regards to racial origin, prior stricture, or fundoplication.