Incidence of hiatus hernia and gastro-oesophageal reflux in 1030 prospective barium meal examinations in adult Nigerians

A prospective study to determine the incidence of hiatus hernia and gastro-oesophageal reflux in 1030 consecutive symptomatic adult Nigerian patients undergoing barium meal examination is reported. The results show a very low incidence of hiatus hernia (0-39%) and an equally low incidence of gastro-oesophageal reflux (2-2%) when compared with similar studies in Europe and America. There was a high incidence of duodenal ulcer (23-3%) and a low incidence of gastric ulcer (1-8%), the duodenal/gastric ulcer ratio of 12-1:1 being much higher than in Europe.     

Surgical treatment of paraesophageal hiatal hernia with total intrathoracic volvulus of the stomach

From 1971 to 1993, we operated 44 patients, 34 females and 10 males with a paraoesophageal hernia in which the entire stomach entered the thorax. Mean age of the patients was 70 years. Seventeen patients underwent emergency surgery for strangulated hernia leading to complete ghastric occlusion, gastric bleeding or necrosis (3 cases). Only 2 patients had a past history of gastro-oesophageal reflux. The following techniques were used: abdominal access in all cases, saccular resection, closure of the widened hiatus or of a left sided hernial hiatus, anterior gastropexy suturing the greater curvature to the abdominal on the left. Several patients were in precarious clinical situations and had to be treated under local or regional anaesthesia alone. Two patients had partial necrosis of the stomach and were treated by partial gastropexy. There were no deaths or major complications. Incomplete recurrence was noted in one patient 2 years after the initial procedure. In conclusion: 1) abdominal access is much preferable; 2) an antireflux procedure is only indicated when the patients have signs of gastro-oesophageal reflux; 3) most complications are not due to the hernia itself but to gastric volvulus. Consequently, simple reduction of the hernia followed by anterior gastroplexy under local anaesthesia can give excellent results in patients in precarious clinical situations and argues against major operation with general anaesthesia; 4) due to the gravity of paraesophageal hernia, a surgical solution is required as soon as diagnosis has been confirmed.     

Esophageal function after fundoplication (Nissen)

Manometric, pH-metric, radiological and histological examinations were performed in 15 of 18 consecutive patients with gastro-esophageal reflux before and after fundoplication. In 13 of these 15 patients, reflux symptoms largely or completely disappeared after the operation. In the successfully operated patients, the reflux provocation test markedly improved but lower esophageal sphincter pressure did not rise. Six successfully operated patients in whom hiatus hernia was present after the operation and 7 patients without hernia had similar esophageal function tests. Therefore, success of surgery does not depend on resting pressure and position of the lower esophageal sphincter.     

Home medical equipment suppliers: a critical home care partner. Interview by Sarah F Zarbock

Conventional management of gastroesophageal reflux (GER) and hiatus hernia in children affected with encephalopathy can deteriorate their pulmonary function, already compromised by their leaning position and their spine deformations. The results after laparoscopic surgery for GER in 6 encephalopathy children are reviewed; their ages ranged from 9 to 14 years, their accompanying diseases were: spastic tetraparesia, hydrocephalus, scoliosis, epilepsy and Reye's syndrome. The laparoscopy procedures followed the same surgical steps as open surgery; the surgical time was 3 to 5 hours; the average hospital stay was 3 days. Oral intake started 8 hours after surgery. The successful results of these first cases in this group of patients with neurologic anomalies, suggest that laparoscopic Nissen funduplication is the treatment of choice for GER and hiatus hernia.     

Hiatus hernia and the respiratory tract

Hoarseness, asthma, and bronchitis are common but sometimes obscure manifestations of gastroesophageal reflux, the etiology of when respiratory symptoms predominate. In 300 consecutive patients who underwent surgical correction for gastroesophageal reflux, 129 (43%) had major respiratory complaints. Group 1 patients (82, 64%) were those referred for respiratory problems alone. In Group 2 (patients referred because of peptic complaints), 47 had associated respiratory problems in various combinations, including an additional 10 patients who had bronchiectasis. Treatment with appropriate surgical resection, in addition to antireflux procedures, was carried out in these people. Noticeable relief of respiratory symptoms was obtained in 96 (74%) of the 129 patients; 30 were improved and 2 were unchanged. Recurrent hiatus hernia or esophagitis was documented in 21 (7%) of the 300 patients.     

Are frequent short gastro-oesophageal reflux episodes the cause of symptoms in patients with non-ulcer dyspepsia responding to treatment with ranitidine?

BACKGROUND: Patients with non-ulcer dyspepsia (NUD) responding to treatment with H2-receptor antagonists have no clinically useful characteristics. This trial compares the gastro-oesophageal reflux pattern as measured by 24-h oesophageal pH monitoring in patients responding to ranitidine with that of non-responders. METHODS: Thirty-one patients with NUD were randomized to 6 weeks' double-blind alternating treatment with 150 mg ranitidine twice daily or placebo and classified as responders or non-responders. RESULTS: Pathologic gastro-oesophageal reflux was seen in 3 of the 13 responders and 4 of the 18 no-responders (NS). The responders had frequent short reflux episodes (< 1 min in duration). When 4 patients with > or = 5 reflux episodes longer than 5 min were excluded, the number of short reflux episodes (median) in responders and non-responders was 32 and 14, respectively. The difference is statistically significant (p = 0.025). There were no other differences between the groups. CONCLUSIONS: In this study patients with NUD responding to ranitidine were characterized by frequent short reflux episodes in the absence of numerous long reflux episodes.     

Gastro-oesophageal reflux associated with nocturnal gastric acid breakthrough on proton pump inhibitors

BACKGROUND: Nocturnal gastric acid breakthrough, defined as intragastric pH < 4 for more than 1 h in the overnight period, is observed in up to 70% of normal subjects on proton pump inhibitors taken twice daily. The frequency of this breakthrough in patients with gastro-oesophageal reflux and accompanying oesophageal reflux during this period has not been studied. AIM: To examine the frequency of nocturnal break-through and accompanying oesophageal acid exposure in patients with gastro-oesophageal reflux treated with proton pump inhibitors twice daily. METHODS: Prolonged ambulatory pH records from 76 patients on twice daily proton pump inhibitors between January 1991 and July 1997 were analysed for the presence of nocturnal gastric acid breakthrough and accompanying oesophageal pH < 4. Studies from 31 normal subjects on twice daily proton pump inhibitors constituted the control group. RESULTS: Nocturnal gastric acid breakthrough was seen in 70% of 61 patients with gastro-oesophageal reflux, 80% of 15 patients with Barrett's oesophagus and 67% of normal controls (P=N.S.). Oesophageal acid exposure was seen in 33% of gastro-oesophageal reflux patients, 50% of Barrett's oesophagus patients and 8% of normal controls (P < 0.03). No difference was found between patients taking omeprazole or lansoprazole. CONCLUSION: Nocturnal acid breakthrough is frequently seen on proton pump inhibitors twice daily and is often accompanied by oesophageal reflux. This has important implications for medical therapy in patients with severe gastro-oesophageal reflux and Barrett's oesophagus.     

Gastroesophageal reflux disease: pathophysiology, diagnosis and drug therapy

The principal mechanism leading to gastro-oesophageal reflux is an increased frequency of transient lower oesophageal sphincter relaxations; other factors are oesophageal hypersensitivity to gastric juice, hiatus hernia, and possible duodenal reflux. Patients with classical symptoms such as heartburn and regurgitation may be treated pharmaceutically combined with life style counselling. If the symptoms have not improved after 6 to 12 weeks, endoscopical examination is performed and, if necessary, 24-hour pH monitoring, barium radiographing and manometry. In the case of atypical symptoms such as dysphagia, laryngitis, asthma and chest pain, there is more reason to pursue diagnostic testing. In patients with dysphagia endoscopy is indicated to exclude malignancy. Drug treatment can be subdivided into antacids, H2 receptor antagonists, cytoprotective agents, prokinetics and proton pump inhibitors. In general practice a step-up approach to treatment is preferable, while for specialist treatment a stepdown approach is more (cost-)effective. Drawbacks of medical treatment are considerable frequency of recurrence of oesophagitis, persistence of regurgitation in 'volume refluxers' and controversial data on the possible development of (pre)malignant lesions of oesophagus and stomach. Surgical treatment is a good alternative for patients with persistent severe regurgitation during medical therapy and for young patients who prefer surgery to lifelong medication. Patients with Barrett's oesophagus should undergo regular endoscopic biopsy surveillance.     

Heartburn. The role of radiology

There is currently controversy as to the importance of the radiologic demonstration of a hiatal hernia, reflux, or both as the explanation of heartburn. It is clear, however, that clinical-radiologic correlation requires additional observations such as the straightness of the potential path for reflux, the presence of a contractile esophagogastric region, the degree of extrinsic compression of the cuff of the stomach within the hiatus, the size of the hernia, and the peristaltic activity of the body of the esophagus. Vigorous or water-swallowing maneuvers to demonstrate reflux are unreliable in individual cases. Of importance is the concept that the so-called patulous cardia, or effaced abdominal esophagus or widened or absent "submerged segment," is a variety of sliding hiatal hernia that is often neglected radiologically but may be of considerable clinical significance.     

Research of non-specific hyperreactivity of upper airways in subjects with gastro-esophageal reflux (G.E.R.): preliminary reports

An association between asthma and gastro-esophageal reflux (GER) is well recognized but the underlying mechanism is still unclear. The authors suggest that could exist an association between GER and upper airways hyperreactivity and this association could represents the mechanism underlying the lower esophageal sphincter releasing, that determine the reflux. In fact they suppose that, the noxious injury of acid reflux follows a course that could be: pharynx-->larynx-->bronchi-->1/3 inferior of the esophagus-->reflux. From these presuppositions the authors carried out a study on the possible relationship between GER and non-specific hyperreactivity of upper airways on 14 subjects, divided in 2 groups: 10 subjects with functional GER, 4 subjects suffering from GER caused by hiatus hernia as control group. All patients had a thorough medical history, ENT examination with rigid and flexible endoscope, anterior Rhinomanometry (RRM), skin-test for inhalant and alimentary allergens, RAST, audiometric exam, non-specific nasal provocation test (NSNPT) with histamine, using as control the number of sneezes. From a through analysis of objective examination and from the results of the NSNPT with histamine resulted that all subjects with functional GER were rhinopathics. In all tests both in vivo (Skin-test) and in vitro(RAST) for the most common allergens (pollens-inhalant-mycophites-alimentary) the results were negative. The authors also found an involvement of paranasal sinuses that raised: 91% in the patients with recurrents phlogosis due to non specific nasal hyperreactivity; 40.9% in the allergic subjects (20% in the Graminacee +; 32% in the Parietaria O. +; 76% in the Dermatophagoides Pt. +; others 4%); 100% in the ASA-intolerance subjects. The NSNSPT with histamine showed in the group with functional GER a hyperreactivity with sneezes in 6/10 subjects, and 1/4 subjects of the group with GER with hiatus hernia. The RRM variations showed an unilateral nasal hyperreactivity in 6/10, bilateral in 3/10 subjects of the group with functional GER. In the group with GER with hiatus hernia only 1/4 subject showed reliable unilateral RRM variation. From the analysis of data resulted that subjects with functional GER showed a completely involvement of the upper airways and not only of the pharynx and larynx, caused by non specific hyperreactivity at the NSNPT with histamine, associated with a chronic pathology.     

The 100th birthday of Rudolf Nissen

Rudolf Nissen was born in Neisse, Schlesien, 9 September 1896. From 1921 to 1933 he was the favorite pupil of Ferdinand Sauerbruch in Munich and Berlin. 1930 he became professor of surgery at the Charité. The assumption of power by the Nazi-regime forced Nissen to resign his position and end his career in Germany. He took over the surgical chair in Istanbul, Turkey. Emigrating in 1939 to the USA, he held surgical positions in hospitals at New York and accepted in 1952 the chair of Surgery at the University of Basel, Switzerland. Nissen died in Riehen/ Basel on 22 January 1981. Nissen was a critical observant clinician, an efficient and popular physician, a teacher and a speaker. Of historical significance are pioneering works in thoracic surgery, the first successful pneumectomy in man, the classical works about the treatment of gastro-oesophageal reflux disease and hiatus hernia. The Nissen-Rossetti type of fundoplication has remained the standard procedure in Europe and the USA.     

Is functional dyspepsia largely explained by gastro-oesophageal reflux disease?

Functional dyspepsia is a chronic disorder of unknown aetiology. The lack of endoscopic abnormalities in patients with this disorder has led many physicians to believe that gastro-oesophageal reflux disease may be responsible for most symptoms. Our group has addressed this issue, by pathophysiological studies in a large cohort of Dundee patients with persistent dyspeptic symptoms. Peptic ulcer and gallstones were excluded in all patients by appropriate tests. Ambulatory pH monitoring showed oesophageal acid reflux that lay above the conventional diagnostic threshold in approximately 20% of patients. This subset was diagnosed as having gastro-oesophageal reflux disease. In the remainder, moderate or severe reflux-like symptoms were reported by approximately 44% patients, who were categorized as reflux-like functional dyspepsia. Reflux symptoms were mild or absent in 36% patients, who were categorized as non-reflux-like dyspepsia. While oesophageal pH profiles lay within the conventional normal range in both of these functional dyspepsia subgroups, patients with reflux-like functional dyspepsia had significantly greater acid exposure values, including total oesophageal acid exposure time, percentage time at a pH of less than 4.0, DeMeester scores and pain reflux event correlation. Hence patients with reflux-like functional dyspepsia have oesophageal acid exposure that lies below the diagnostic threshold for gastro-oesophageal reflux disease but exceeds that of patients with non-reflux dyspepsia. The high pain/reflux event correlation in reflux-like functional dyspepsia suggests that subthreshold oesophageal acid exposure may be associated with troublesome reflux symptoms.     

A message from the Texas Bureau of Radiation Control

A new anti-reflux procedure, cardiac oblique invagination, was designed. Having succeeded in animal experiment, we performed this procedure clinically. Sixteen patients with sliding hiatus hernia and one with paraesophageal hernia were operated on. Reflux symptoms disappeared postoperatively. Esophageal manometric study showed that the pressure of HPZ elevated and no abnormal reflux was found by 24-hour esophageal pH monitoring. The effectiveness of this method was assumed that the abdominal segment of the esophagus, His angle, and cardiac rosette were well established and, also, this procedure fitted in with LaPlace's law. The method was simple, transabdominal, easy to teach, and it provided excellent short-term result.     

Three-dimensional ultrasound evaluation of fetal tooth germs

Thirty children have had percutaneous endoscopic gastrostomy (PEG) inserted for feeding purposes. During a follow-up period of 5-45 months (mean 24 months), complications were recorded in 13 patients. Some patients had more than one complication. Complications included colocutaneous fistula, gastro-oesophageal reflux, wound infection, granulation tissue formation, tube leakage, tube blockage and bleeding. The authors present a retrospective review of the results and discuss the management of these complications.     

Prosthetic reinforcement of posterior cruroplasty during laparoscopic hiatal herniorrhaphy

Symptomatic gastroesophageal reflux after Nissen fundoplication may occur if the wrap herniates into the thorax. In an attempt to prevent recurrent hiatal hernia we employed polytetrafluoroethylene (PTFE) mesh reinforcement of posterior cruroplasty during laparoscopic Nissen fundoplication and hiatal herniorrhaphy. Three patients with symptomatic gastroesophageal reflux and a large (>==8 cm) hiatal defect underwent laparoscopic posterior cruroplasty and Nissen fundoplication. The cruroplasty was reinforced with a PTFE onlay. No perioperative complications occurred, and in follow-up (<==11 months) the patients are doing well. When repairing a large defect of the esophageal hiatus during fundoplication, the surgeon may consider reinforcement of the repair with PTFE mesh.     

High prevalence of ciprofloxacin resistance amongst strains of Neisseria gonorrhoeae isolated from commercial sex workers in Bangladesh

We have evaluated if breathing spontaneously via a laryngeal mask airway is associated with a higher risk of gastro-oesophageal reflux compared with positive pressure ventilation via a laryngeal mask airway in 40 patients undergoing day-case gynaecological laparoscopy. Patients were allocated randomly to receive either positive pressure ventilation or breathe spontaneously via a laryngeal mask airway. Using continuous oesophageal pH monitoring, three patients in the ventilated group and one in the spontaneous breathing group had gastrooesophageal reflux (P = 0.29). We found no evidence to suggest that breathing spontaneously via a laryngeal mask airway increased the risk of gastro-oesophageal reflux compared with positive pressure ventilation in this group of patients.     

Prevalence of metaplasia at the gastro-oesophageal junction

Specialised columnar epithelium (SCE), a form of intestinal metaplasia usually found in Barrett's oesophagus, cannot be distinguished endoscopically from normal gastric epithelium. Endoscopists seldom obtain biopsy specimens from a normal-appearing gastro-oesophageal junction, and therefore short segments of SCE in this region may go unrecognised. We studied patients who had short segments of SCE at the gastro-oesophageal junction. All patients scheduled for elective endoscopic examinations in our general endoscopy unit, irrespective of indication, were questioned for symptoms of gastro-oesophageal reflux disease. At endoscopy, severity of oesophagitis was graded, and biopsy specimens obtained from the squamocolumnar junction, irrespective of its appearance or location in the oesophagus. Among 142 patients without endoscopically apparent Barrett's oesophagus, 26 (18%) were found to have SCE. All patients with SCE were white, and the male/female ratio was 1.9. In contrast, non-whites accounted for 14% of the 114 patients without SCE and the male/female ratio was 0.8. The groups did not differ significantly in the frequency of symptoms and endoscopic signs of gastrooesophageal reflux. We conclude that adults frequently have unrecognised segments of SCE at the gastro-oesophageal junction; this may underlie the rising frequency of cancer of the gastrooesophageal junction in the USA and Europe.     

Lower esophageal sphincter function in children with and without gastroesophageal reflux

Resting lower esophageal sphincter (LES) pressure was assessed in infants and children 2 weeks to 12 years of age. There were 62 control subjects and 35 patients with reproducible gastroesophageal reflux (GER) determined radiologically. In control subjects without GER: (1) LES pressure was well developed by 2 weeks of age; (2) in children less than 1 year of age, mean LES pressure (43.3 +/- 2.4 mm Hg) was significantly greater than mean LES pressure (30.6 +/- 2.3 mm Hg) children older than 1 year of age; (3) LES sphincter length increased with age; and (4) bethanechol 0.1 mg per kg subcutaneously caused a rise in LES pressure that increased in magnitude as LES resting pressures increased. In patients with GER: (1) only 16 or 35 children had LES pressures below the normal range for their appropriate age group; (2) LES length was shorter than control values in children beyond 6 months of age; (3) GER usually occurred in the absence of hiatus hernia; (4) clinical improvement was common and in patients with low LES pressure was associated with a rise in LES pressures to normal, even in the presenece of hiatus hernia; and (5) bethanechol caused a change and an absolute rise in LES pressure that were not significantly different from those observed in controls. These results indicate that in infants and children low LES pressure is not the sole determinant of GER, and that pharmacological stimulation of the Les could prove to be a useful adjunct to the medical management of GER.     

Effects of barium on stimulus-induced changes in [K+]o and field potentials in dentate gyrus and area CA1 of human epileptic hippocampus

Congenital para-oesophageal hiatal hernia (PEHH) is a rare problem in infancy, however, it constitutes a clinical entity that mandates surgical repair once the diagnosis is made. In the paediatric age group, acquired PEHH has been described as a major complication in a number of patients who were treated surgically for gastro-oesophageal reflux (GER) by Nissen fundoplication. PEHH is a frequently encountered condition in elderly patients; it accounts for 5% of diaphragmatic hiatal hernias. In both paediatric and adult patients PEHH, whether congenital or acquired in origin, is usually associated with potentially lethal complications such as gastric volvulus, incarceration, and perforation. In clinical practice true PEHH is extremely rare. The term has been expanded to include large gastric hiatal hernias where most of the stomach and the gastro-oesophageal junction are in the chest. Six infants with congenital PEHH are presented, together with an attempt to understand its possible aetiology and a review of its current surgical management.     

Oesophageal function in patiensts with angina (author's transl)

Oesophageal functions were measured in 18 patients with angina, 13 healthy volunteers and 29 age-matched patients with reflux disease. Acid clearance was as abnormal in angina patients (88 +/- 46 swallows) as in those with reflux disease (97 +/- 45). The pressure in the lower oesophageal sphincter was low in patients with angina (13 +/- 8 mm Hg). The incidence of hiatal hernia, subjective symptoms during acidification of the oesophagus and results of the reflux provocation test were similar in patients with angina pectoris and healthy controls.