History Of Reflux Symptoms Research Articles

S3543 Esophageal Parakeratosis? You GERD Be Kidding!

INTRODUCTION: Esophageal parakeratosis is an atypical finding on histology with limited data available. On microscopy it is characterized by superficial, compact squamous epithelium with retained pyknotic nuclei. References describe parakeratosis in various clinical settings such as candidiasis, vitamin B12 and zinc deficiencies, esophageal lichen planus and ethanol exposure in adults. To our knowledge, based on a PubMed Search, this condition has never been reported in children. We describe a child with esophageal parakeratosis with history of reflux symptoms and recent coin ingestion. CASE DESCRIPTION/METHODS: An 8-year-old boy with a history of regurgitation presented to the emergency room with dysphagia after swallowing a penny earlier that day. Chest X-ray revealed a discoid metallic foreign body lodged in the mid esophagus. During upper endoscopy the coin was located in the mid esophagus and retrieved easily. There was an erosion at the site of the penny lodgment and furrowing of the distal esophagus. Biopsies were obtained from the distal esophagus and mid esophagus, distal to the site of coin lodgment. On histological examination of the mid esophageal biopsies, there was mild reactive esophageal squamous mucosa with focal superficial erosion, focal parakeratosis, mild mixed inflammation and vascular congestion without evidence of eosinophilic esophagitis. Based on the pathology, he was diagnosed with gastroesophageal reflux disease (GERD) esophagitis. He was treated with a proton pump inhibitor for 3 months with clinical resolution of reflux symptoms. A 3-month follow-up endoscopy revealed mild edematous mucosa in the distal esophagus without furrowing, ulcers or erythema. Histopathology of the proximal and distal esophagus revealed persistence of minimal reactive esophageal mucosa, with vascular congestion and minimal chronic inflammation but with no parakeratosis. DISCUSSION: Esophageal parakeratosis is often a non-specific histological finding. Based on the clinical history, the resolution of esophageal parakeratosis on repeat biopsy in an area distal to the coin lodgment, along with subtle findings of esophagitis after PPI therapy, led us to believe that the parakeratosis was a manifestation of GERD. It is unlikely that these changes are secondary to a blunt foreign body (coin) reaction in such a short window of time. Clinicians should be aware that esophageal parakeratosis may be associated with GERD.

Waist belt and central obesity cause partial hiatus hernia and short-segment acid reflux in asymptomatic volunteers

ObjectiveThere is a high incidence of inflammation and metaplasia at the gastro-oesophageal junction (GOJ) in asymptomatic volunteers. Additionally, the majority of patients with GOJ adenocarcinomas have no history of reflux...

Ultrasonographic study of antral motility in patients with Barrett's oesophagus and erosive oesophagitis

Background: Antral contractility and antroduodenal motility are major physiologic determinants of gastric emptying (GE). Delayed GE has been demonstrated in patients with reflux disease. In our previous study, using ultrasonography, we have investigated the role of the proximal stomach in the GE of patients with erosive oesophagitis (EO) or with Barrett's oesophagus (BO). The aim of the present study was the assessment of the antral contractility and its role in GE in these two subsets of patients with reflux disease. Patients and methods: Twenty-one patients BO, 17 patients with moderate EO (10 LA-A; 7 LA-B), and 19 control persons (CP) without history of reflux symptoms or dyspepsia were enrolled into the study. After an overnight fast the subjects ingested 500ml of a low calorie content semisolid test meal. The GE was characterized by the reduction of the residual gastric content calculated from the change of cross-sectional areas determined at predefined time points over a period of 240min after ingestion of the test meal. The frequency of antral contractions was counted for 3min at each time point. The amplitude of contractions was calculated from the maximal reduction of the antral area for each contraction. The motility index (MI) was expressed as the multiplication of the mean amplitude and frequency of the contractions. Results: GE was significantly slower in patients with BO and EO than in CP. In patients with BO a significant decrease of the MI was observed in the first 90 minutes of the study, whereas significant reduction of MI occurred only in the first 45 minutes in patients with EO. A negative correlation was observed between the GE and MI in the first 45min of the study in both groups of patients with reflux disease. Conclusions: Impaired antral motility and delayed GE are demonstrated in patients with BO and EO. Antral dysmotility was more pronounced in patients with BO. A possible role of increased biliary reflux in patients with BO warrants further investigation.

P0971 INCIDENCE OF INFANTILE AND FAMILIAL GER IN CHILDREN WITH GASTROESOPHAGEAL REFLUX DISEASE(GERD)

Introduction: Gastroesophageal reflux disease (GERD) is being increasingly recognized in children. When children are diagnosed with GERD, parents frequently comment about other affected family members, or that the child had it as an infant. Methods: We performed a prospective study to evaluate family history of other relatives with GERD, infantile history of GER symptoms such as spitting, vomiting, crying, arching, etc. in children > 5 years in age who were diagnosed to have GERD at endoscopy. We also attempted to determine any correlation of their current GERD symptoms (abdominal pain, vomiting, heartburn, etc.) with their endoscopic grade of esophagitis per Savary Miller’s criteria. Most of the above data were extracted from an IRB approved questionnaire developed to evaluate quality of life issues in children with GERD and their parents. Current symptoms, history of reflux symptoms in infancy and family history data were reviewed. Endoscopic grade of esophagitis at the time of procedure was noted.Data analysis was completed using SAS software. Univariate frequency distributions were generated for the family history, GER in infancy, and severity of symptoms variables and correlations generated to examine relationships between the severity of symptoms and the grade of esophagitis. Results: Completed questionnaires were available for 54 children between the ages of 6–17 years (mean age 10.3 (SD=3.3) years, 17 M, 37 F). History of GER in infancy was identified in 21 (39 %) of patients. Of these 24% were managed conservatively by feeding modification and 76% needed medications in infancy. Furthermore, 24% of this group had been continuously on pharmacotherapy since infancy. A family history of reflux was detected in 42% of patients. It was present in one or both parents in 45%, in grandparents-36%, in both parents and grandparents-9% and other relatives in 9% of patients. There were no significant differences in gender frequencies for either parents or grandparents. Endoscopically, 83% of patients had Grade I esophagitis and 17% had Grade II. The correlations between the severity of symptoms and grade of esophagitis was not significant. Conclusion: There appears to be a history of GER symptoms in infancy in 39% of the patients >5 years of age diagnosed with GER. A strong family history in a parent or grandparent was also seen in 42% of this cohort. There was no correlation between endoscopic grade of esophagitis with symptoms. Further studies are needed to confirm these findings and seem to have implications for persuing possible genetic linkage.

Incidence of Infantile and Familial GER in Children with Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease (GERD) is being increasingly recognized in children. When children are diagnosed with GERD, parents frequently comment about affected family members, or that the child had it as an infant. We performed a prospective study to evaluate family history of other relatives with GERD, infantile history of GER symptoms such as spitting, vomiting, crying, arching, etc. in children >5 years in age who were diagnosed to have GERD at endoscopy. We also attempted to determine any correlation of their current GER symptoms (abdominal pain, vomiting, heartburn, etc.) with their endoscopic grade of esophagitis per Savary Miller's criteria. Most of the above data were extracted from an IRB approved questionnaire developed to evaluate quality of life issues in children with GERD and their parents. Current symptoms, history of reflux symptoms in infancy and family history data were reviewed. Endoscopic grade of esophagitis at the time of procedure was noted. Statistical Analysis Data analysis was completed using SAS software. Univariate frequency distributions were generated for the family history, GER in infancy, and severity of symptoms variables and correlations generated to examine relationships between the severity of symptoms and the grade of esophagitis. Results Completed questionnaires were available for 54 children between the ages of 6-17 yrs (mean age 10.3 (SD=3.3) years, 17 M, 37 F). History of GER in infancy was identified in 21 (39%) of patients. Of these 24% were managed conservatively by feeding modification and 76% needed medications in infancy. Furthermore, 24% of this group had been continuously on pharmacotherapy since infancy. A family history of reflux was detected in 42% of patients. It was present in one or both parents in 45%, in grandparents 36%, in both parents and grandparents 9% and other relatives in 9% of patients. There were no significant differences in gender frequencies for either parents or grandparents. Endoscopically, 83% of patients had Gr I esophagitis and 17% had Gr II. The correlations between the severity of symptoms and grade of esophagitis was not significant. Conclusions There appears to be a history of GER symptoms in infancy in 39% of the pts >5 years of age diagnosed with GER. A strong family history in a parent or grandparent was also seen in 42% of this cohort. There was no correlation between endoscopic grade of esophagitis with symptoms. Further studies are needed to confirm these findings and seem to have implications for persuing possible genetic linkage.

Intestinal metaplasia of the esophagus or esophagogastric junction: evidence of distinct clinical, pathologic, and histochemical staining features.

Our purpose was to evaluate the clinical, histologic, and histochemical staining characteristics of intestinal metaplasia (IM) at an endoscopically normal-appearing esophagogastric junction (IM-EGJ) compared with IM in a columnar-lined esophagus (IM-CLE). A prospective study included 253 patients referred for elective upper gastrointestinal endoscopy. Biopsy specimens were obtained from 2 cm above and immediately distal to the squamocolumnar junction, the gastric corpus, and the antrum. Any red mucosa above the EGJ was sampled. IM-CLE (prevalence, 5.5%) typically occurred in white male smokers with a long history of reflux symptoms. IM-EGJ (prevalence, 9.1%) was associated with corpus and antrum gastritis and with IM at these sites. IM-CLE usually (13/14 [93%]) was the incomplete type IM, whereas only 12 (52%) of 23 patients in the IM-EGJ group had incomplete IM. IM-EGJ and IM-CLE should be considered as separate entities. Further research is needed to evaluate whether neoplastic progression of IM-EGJ is related to its mucin profile.

Adenocarcinoma of the esophagus and Barrett's esophagus: a population-based study.

We described incidence rates of esophageal adenocarcinoma in Denmark in a 20-yr period and determined the proportion of patients diagnosed with esophageal adenocarcinoma who had a previous diagnosis of Barrett's esophagus, making them potential candidates for endoscopic surveillance. Rates of esophageal and gastric cancers were collected from the Danish Cancer registry for the period 1970-1991. The registry was used to identify all cases of esophageal adenocarcinoma in the period 1987-1992. Medical records were retrieved and details concerning previous diagnosis of reflux disease and Barrett's esophagus were recorded. The age- and gender-adjusted incidence of esophageal adenocarcinoma increased eightfold, from 0.3/10(5)/yr in 1970 to 2.3/10(5)/yr in 1990. This increase could not be explained by changes in classification or diagnostic routines. Medical data were retrieved for 524 of the 578 cases of esophageal adenocarcinoma reported during the period 1987-1992. A history of reflux symptoms or a diagnosis compatible with reflux was reported in 113 of 524 patients. A total of 119 patients (23%) had previously been investigated for dyspepsia or reflux symptoms, most often by endoscopy. A previous diagnosis of Barrett's esophagus was found in only 1.3% of the cancer patients. The rate of esophageal adenocarcinoma in Denmark has increased eightfold over a 20-yr period, and this increase is not explained by changes in classification or diagnostic routines. More than 98% of esophageal adenocarcinomas were found in patients who could not have entered endoscopic surveillance, as Barrett's esophagus had not been diagnosed before the cancer diagnosis. Endoscopic surveillance to detect dysplasia may be an option for the individual patient with Barrett's esophagus, but these screening programs are not likely to reduce the death rate from esophageal adenocarcinomas in the general population.

Adenocarcinoma of the esophagus and Barrett’s esophagus: a population-based study

Objective: We described incidence rates of esophageal adenocarcinoma in Denmark in a 20-yr period and determined the proportion of patients diagnosed with esophageal adenocarcinoma who had a previous diagnosis of Barrett’s esophagus, making them potential candidates for endoscopic surveillance. Methods: Rates of esophageal and gastric cancers were collected from the Danish Cancer registry for the period 1970–1991. The registry was used to identify all cases of esophageal adenocarcinoma in the period 1987–1992. Medical records were retrieved and details concerning previous diagnosis of reflux disease and Barrett’s esophagus were recorded. Results: The age- and gender-adjusted incidence of esophageal adenocarcinoma increased eightfold, from 0.3/10 5/yr in 1970 to 2.3/10 5/yr in 1990. This increase could not be explained by changes in classification or diagnostic routines. Medical data were retrieved for 524 of the 578 cases of esophageal adenocarcinoma reported during the period 1987–1992. A history of reflux symptoms or a diagnosis compatible with reflux was reported in 113 of 524 patients. A total of 119 patients (23%) had previously been investigated for dyspepsia or reflux symptoms, most often by endoscopy. A previous diagnosis of Barrett’s esophagus was found in only 1.3% of the cancer patients. Conclusions: The rate of esophageal adenocarcinoma in Denmark has increased eightfold over a 20-yr period, and this increase is not explained by changes in classification or diagnostic routines. More than 98% of esophageal adenocarcinomas were found in patients who could not have entered endoscopic surveillance, as Barrett’s esophagus had not been diagnosed before the cancer diagnosis. Endoscopic surveillance to detect dysplasia may be an option for the individual patient with Barrett’s esophagus, but these screening programs are not likely to reduce the death rate from esophageal adenocarcinomas in the general population.

The Clinical Control of Red Cell Loss in Burns

<h3>Objective</h3> There is a high incidence of inflammation and metaplasia at the gastro-oesophageal junction (GOJ) in asymptomatic volunteers. Additionally, the majority of patients with GOJ adenocarcinomas have no history of reflux symptoms. We report the effects of waist belt and increased waist circumference (WC) on the physiology of the GOJ in asymptomatic volunteers. <h3>Design</h3> 12 subjects with normal and 12 with increased WC, matched for age and gender were examined fasted and following a meal and with waist belts on and off. A magnet was clipped to the squamo-columnar junction (SCJ). Combined assembly of magnet-locator probe, 12-channel pH catheter and 36-channel manometer was passed. <h3>Results</h3> The waist belt and increased WC were each associated with proximal displacement of SCJ within the diaphragmatic hiatus (relative to upper border of lower oesophageal sphincter (LOS), peak LOS pressure point and pressure inversion point, and PIP (all p&lt;0.05). The magnitude of proximal migration of SCJ during transient LOS relaxations was reduced by 1.6–2.6 cm with belt on versus off (p=0.01) and in obese versus non-obese (p=0.04), consistent with its resting position being already proximally displaced. The waist belt, but not increased WC, was associated with increased LOS pressure (vs intragastric pressure) and movement of pH transition point closer to SCJ. At 5 cm above upper border LOS, the mean % time pH &lt;4 was &lt;4% in all studied groups. Acid exposure 0.5–1.5 cm above SCJ was increased, with versus without, belt (p=0.02) and was most marked in obese subjects with belt. <h3>Conclusions</h3> Our findings indicate that in asymptomatic volunteers, waist belt and central obesity cause partial hiatus herniation and short-segment acid reflux. This provides a plausible explanation for the high incidence of inflammation and metaplasia and occurrence of neoplasia at the GOJ in subjects without a history of reflux symptoms.