Distension during gastroesophageal reflux: effects of acid inhibition and correlation with symptoms

Abstract

We studied spontaneous gastroesophageal reflux (GER)-induced esophageal distension using ultrasound imaging and its role in the genesis of esophageal symptoms before and during esomeprazole therapy. Ten controls and 10 GER disease (GERD) patients were studied by combined impedance, esophageal pH, manometry, and ultrasonography before and during esomeprazole therapy. Physiological data and symptoms were recorded for 2 h following a standardized meal. From ultrasound images, the esophageal cross-sectional area (CSA) at the peak of GER-induced distension was determined and compared between controls vs. patients, symptomatic vs. asymptomatic GER episodes, and before vs. during esomeprazole in GERD patients. The mean lumen CSA is greater in the patients than controls (271 +/- 71 mm(2) vs. 163 +/- 56 mm(2), P = 0.001) but not different among asymptomatic reflux episodes, and those associated with regurgitation (290 +/- 110 mm(2)) or heartburn (271 +/- 67 mm(2)). Eight chest pain episodes associated with reflux revealed a tendency toward larger mean esophageal distension (459 +/- 40 mm(2)) compared with asymptomatic reflux (268 +/- 70 mm(2), P = 0.058). Following esomeprazole treatment, most GER episodes were nonacidic and asymptomatic except in two patients in whom cyclical reflux was associated with large esophageal distensions. Esomeprazole did not alter the lumen CSA during GER. Esophageal distension is greater in the GERD subjects compared with controls; however, it is unlikely that the GER-induced distension of the esophagus plays a significant role in the genesis of heartburn sensation. Esomeprazole therapy does not alter the GER-induced distension of the esophagus.

Liquid in the gastroesophageal segment promotes reflux, but compliance does not: a mathematical modeling study

“…A recent study by Schiffner et al (48,49) has shown that, in GERD patients without an obvious HH, the higher level of distension observed after opening could be traced back to an abnormally high radius to the circular muscle in the resting state and that, during opening, the muscularis continues to distend abnormally. When fully open, the difference was ϳ2.1 mm, consistent with a 2.5-mm difference between a normal and HH group at maximum mechanical distension of the GES and a 2.1-mm difference at maximum opening during reflux between a normal and GERD group as measured by other investigators (43,54). However, Schiffner et al (48,49) found that, in the resting state, the average radius to the inner surface of the circular muscle was ϳ1.2 mm greater in the GERD group compared with that in normal controls.…”

“…3-5 indicate that the existence of abnormally high levels of liquid within the GES, perhaps associated with an abnormality in the anatomy of the GES, is a controlling element that distinguishes normal opening from pathological opening and reflux. Studies comparing GERD groups with controls have shown that, when the relaxed sphincter is opened, the opening diameter of the hiatus is higher in the GERD groups (43,54). A recent study by Schiffner et al (48,49) has shown that, in GERD patients without an obvious HH, the higher level of distension observed after opening could be traced back to an abnormally high radius to the circular muscle in the resting state and that, during opening, the muscularis continues to distend abnormally.…”

“…Abnormal distension is a natural consequence, for example, of hiatal hernia (HH) but, based on recent studies, may be a general feature of GERD (43,48,49,54). A recent study has concluded that the sphincter components include an overlapping intrinsic and extrinsic component, as well as a third component at the gastro-cardiac junction (6), and has suggested that this third component may be absent in HH (25).…”

“…However, these distinguishing characteristics could be studied only after reflux had occurred. Sphincter compliance, for example, was identified as a potentially distinguishing characteristic between normal controls and gastroesophageal reflux disease (GERD) patients by the maximum distension of the GES during deglutitive inhibition (43,49) and during reflux (54).…”

Assessment of the Acute Effects of Carbonated Beverage Consumption on Symptoms and Objective Markers of Gastric Reflux

“…The average concentration of pepsin in gastric juice has previously been suggested to be approximately 0.5 mg/mL [30]. Reflux volumes could be virtually zero (e.g., aerosolised fluid brought up with a belch) or up to around 5.0 mL outside of mass regurgitation events [31]. There is approximately 0.8 mL of saliva/moisture in the oral cavity at any one time [32], which might dilute very low volume reflux events and therefore reduce [pepsin] saliva below a detectable limit.…”