Saudi Journal of Gastroenterology
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Year : 1999  |  Volume : 5  |  Issue : 2  |  Page : 66-70
Frequency of endoscopic esophagitis in nutcracker patients with pathological 24-hour pH monitoring


Department of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia

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Date of Submission10-Jun-1998
Date of Acceptance26-Dec-1998
 

   Abstract 

Endoscopically, it was claimed that reflux esophagitis is less frequently seen in patients with tertiary contractions. The aim of this prospective study is to evaluate the frequency of endoscopic esophagitis in nutcracker patients with pathological 24-hour pH monitoring as compared to a matched group of patients with pathological prolonged ambulatory pH monitoring. The study included eight patients with nutcracker esophagus and pathological 24-hour pH monitoring (Group 1); mean (SD) age was 36.5 (10.6) years, mean (SD) LES pressure was 11 (2.9) mmhg and % total pH <4 was 11.5 (7), which were not statistically different from a matched control of 25 patients (Group 2). Patients with underlying definable systemic diseases were excluded from the study.. Three nutcracker esophagus and eight control showed evidence of endoscopic esophagitis (P value=0.9). Among group I, nutcracker patients with endoscopic esophagitis had a tendency towards a lower LES pressure (P=0.056) and a significantly greater % total pH <4 (P=0.04). % upright reflux (P=0.03) and total time pH <4 (P=0.003) than nutcracker without endoscopic oesophagitis. Moreover, nutcracker patients with endoscopic esophagitis had a significantly greater % total pH <4 and total time pH <4 than control group with endoscopic esophagitis with P value = 0.03 and 0.02, respectively. Conclusion: The frequency of endoscopic esophagitis is similar in nutcracker and a matched control with pathological 24-hour pH monitoring.

How to cite this article:
Al Amri SM. Frequency of endoscopic esophagitis in nutcracker patients with pathological 24-hour pH monitoring. Saudi J Gastroenterol 1999;5:66-70

How to cite this URL:
Al Amri SM. Frequency of endoscopic esophagitis in nutcracker patients with pathological 24-hour pH monitoring. Saudi J Gastroenterol [serial online] 1999 [cited 2020 Oct 22];5:66-70. Available from: https://www.saudijgastro.com/text.asp?1999/5/2/66/33512


The most common motor disorder detected in patients presenting with noncardiac chest pain is the "nutcracker esophagus" [1] . It is characterized by high amplitude contractions in the distal esophageal body [2] . The association between Gastroesophageal reflux disease (GERD) and nutcracker esophagus was described [3],[4],[5] . Furthermore, GERD was also reported in patients with nonpropulsive esophageal contractions using ambulatory pH monitoring [6] . Approximately 30-50% of patients with reflux symptom develop esophageal mucosal damage [7],[8] . Acid exposure of the lower esophagus has an important role in the pathogenesis of GERD and its frequency and esophageal acid clearance time are the - two factors that determine esophageal acid exposure time [9],[10] . In turn, this and the caustic potential of refluxed fluid determine the extent of esophageal mucosal damage [11],[12],[13] . Adequate esophageal body peristaltic waves are a critical determinant of esophageal acid clearance, whereas lower esophageal sphincter (LES) is an important barrier of acid reflux [9],[10] . Endoscopically, it was claimed that reflux esophagitis was less frequently seen in patients with tertiary contraction [6] . The aim of this prospective study is to evaluate the frequency of endoscopic esophagitis in a group of patients with pathological 24-hour pH monitoring and nutcracker esophagus, and to compare the results with a matched group of patients with abnormal pH monitoring but normal manometric study.


   Patients and Methods Top


Over a 2-year period (January 1995 to December 1996), 11 consecutive patients (seven females) fulfilled the criteria of nutcracker esophagus: normally propagating high amplitude contractions in excess of 180 mmHg at 2 and/or 7 cm above the lower esophageal sphincter. All patients were diagnosed at King Khalid University Hospital, Riyadh. The main indications for esophageal manometry were heartburn, regurgitation, chest pain and dysphagia. 24-hour pH monitoring demonstrated pathological GERD in eight patients (six females) which constituted group I. Control group 25 patients (Group 2) were selected as a control group. They were of similar age, sex, LES pressure and magnitude of pathological reflux to group I. These were seen during the same period and presented with a similar symptomatology. Patients with underlying definable systemic diseases e.g progressive systemic sclerosis, Systemic lupus erythematosus, diabetes mellitus or using acid suppressing agents, were excluded. All patients and control groups underwent upper gastrointestinal endoscopy for visible evidence of GERD, namely, erosions, ulcerations or both.


   Esophageal Motility Study Top


The study was performed in fasted patients in supine position using eightlumen polyvinyl catheter (outer diameter is 4.5 mm; internal diameter is 0.8 mm; ESM 3R, Arndorfer Medical Specialties). The distal four openings were spaced 1 cm apart at 90° angle, while the proximal four openings were spaced at 5 cm distant at 90° angle. The catheter was connected to external pressure transducers (Novadome MX 860 medex Rossenda, England). The catheter was continuously perfused with distilled water at a rate of 0.5 ml/min by a law­compliance pneumohydraulic capillary infusion system (Arndorfer Medical Specialties). The catheter assembly was passed through the nose till all recording orifices were in the stomach. The station pull-through of the lower esophageal sphincter (LES) was performed at 1 cm intervals. The LES pressure recorded for each patient represented the calculated average of four individual pressure readings (distal ports), measured at end­expiratory variation to the mean gastric baseline pressure. Esophageal body recordings were performed by positioning the four proximal ports 2, 7, 12 and 17 cm above the LES. At least, 10 wet swallows (10 ml water) were administered, separated by 30-seconds. The amplitude of pressure wave was measured from the mean intraesophageal baseline pressure to the peak of the wave.


   Ambulatory 24-Hour pH Monitoring Top


In an overnight fasting patient, an antinomy pH probe with an outer diameter of 2.1 mm, was positioned 5 cm above the upper border of the LES and a reference electrode was attached to the anterior chest wall. Both electrodes were connected to a recording device (Synectics Medical, Inc., Irving Tx). pH electrode was calibrated using buffers of pH one and 7. Patients were instructed to keep records of their upright and supine positions. The pH tracing were analyzed by a commercial computer software program and reviewed by the author. Reflux disease was considered pathological if any of the following criteria were exceeded: 1) total time with pH < 4 (normal < 5,5%); 2) upright with pH <4 (Normal <8.2%); 3) % supine with pH <4 (normal <3%) [7] . All data reported as mean (SD). Student t-test, chisquare and fisher exact test were used for statistical analysis. Statistical significance was defined as P value less than 0.05.


   Results Top


This study included eight nutcracker patients. Two males and six females with a mean age of 36.5 (10.6) years range 25-60 years, mean LES pressure 11 (2.9) mmHg, and range 7-15 mmHg [Table - 1]. All patients had abnormal 24-hour pH monitoring; mean % total pH <4 and range were 11.5 (7) and 3.7-22, respectively.

Control group was similar to nutcracker patients regarding age mean 35.9 (9.5) years, sex distribution, and mean LES pressure 10.2 (2.4) iiuiiHg. Similarly, all control patients had pathological 24-hour pH monitoring; mean % total pH <4% and range were 11.5 (6.2) and 3.7­29.2, respectively. Nutcracker group had significantly higher amplitude mean of 202 (11) linnHg compared to control, mean 82.6 (31.7) mmHg, (p=0.0001). Grade H reflux esophagitis was diagnosed endoscopically in three nutcracker patients and eight control patients (seven grade 2 and one grade 3) (P=0.9) [Table - 1]. [Table - 2] compares nutcracker with and without endoscopic esophagitis. %total 24-hour pH <4, upright reflux, number of reflux lasting more than 5 minutes and total time pH <4 were significantly higher in patients with evidence of endoscopic esophagitis giving P value of 0.04, 0.03, 0.02, 0.003, respectively. However, the mean LES pressure between the two groups failed to reach statistical significance (8.67 vs 12.6 P=0.056).

[Table - 3] compares nutcracker with evidence of endoscopic esophagitis (n=3) and control patients with endoscopic esophagitis (n=8). Nutcrackers had a significantly greater amplitude (P=0.005), % total pH <4 (P=0.03) and total time pH <4 (P=0.02) than control patients with endoscopic esophagitis. However, the mean LES pressure was almost identical in both groups.


   Discussion Top


Nutcracker esophagus is the most frequent abnormality detected during stationery esophageal manometry in patients presenting with non-cardiac chest pain [1],[14] . De Meester was the first to demonstrate acid reflux among patients presenting with non-cardiac chest pain [15] . Achem et al recently evaluated the role of gastroesophageal reflux among patients with nutcracker esophagus using ambulatory pH monitoring, 65% of patients had pathological reflux [3] . Upper gastrointestinal endoscopy however revealed evidence of esophagitis in one patient only. Triadafilopoulos and Castillo examined the prevalence of gastroesophageal reflux quantified by ambulatory 24-hour pH monitoring in 35 patients with non­propulsive esophageal contractions. Esophageal manometry showed nutcracker esophagus in eight patients, five (62.5%) of them suffered from GERD. Moreover, upper gastrointestinal endoscopy revealed erosive esophagitis in three patients; one patient was diagnosed manometrically to have nutcracker esophagus [6] . This is the first preliminary study reporting the frequency of endoscopic esophagitis in nutcracker patients known to have GERD and comparing the results to a matched control group.

The two groups were matched regarding age, sex, LES pressure, magnitude of reflux, total, as well as supine and upright pH. The nutcracker group however, differed in that they had significantly greater amplitude (P<0.0001). This study demonstrated a similar frequency rate of endoscopic esophagitis among the two groups namely; 37.5% vs 47% (P=0.9). This is similar to that reported in patients with symptomatic gastroesophageal reflux [7],[8],[16] . The two groups did not demonstrate any significant peristaltic dysfunction and had a similar esophageal clearance as measured by the number of reflux episodes lasting more than 5 minutes [16],[17]. No similar study looked into the frequency of endoscopic esophagitis in nutcracker. However, data from Achem et al study showed endoscopic esophagitis in one (5%) patient out of 20 nutcrackers [3] . Furthermore, of eight nutcracker patients studied by Triadafilopoulos and Castillo, endoscopic esophagitis was seen in one [6] .

Analysis of the 24-hour pH and esophageal manometry demonstrated that nutcracker patients with endoscopic esophagitis constituted a more severely affected group with tendency toward a lower LES pressure and significantly greater acid exposure in term of % total pH <4, % upright, more episodes of acid reflux greater than 5 minutes and total exposure time than nutcracker without endoscopic esophagitis (P=0.056, 0.04, 0.039, 0.02 and 0.003, respectively). A similar observation has been made in two groups of patients with and without esophagitis [16] . Moreover, this study demonstrated that nutcracker patients with endoscopic esophagitis had significantly greater total pH <4 and longer total time pH <4 than control patient with endoscopic esophagitis (P=0.03, 0.02, respectively).

In conclusion: This preliminary study demonstrated a similar frequency rate of endoscopic esophagitis in nutcracker and control patients. Nutcracker with endoscopic esophagitis constituted a group of patients with greater magnitude of acid reflux compared to either nutcracker without endoscopic esophagitis or control patients with endoscopic esophagitis.

 
   References Top

1.Freidin N, Mittal RK, Traube M, et al. Seegmental High Amplitude Peristaltic Contractions in the Distal Esophagus. Am J Gastroenterol. 1989;84:619-23.  Back to cited text no. 1    
2.Dalton CB, Castell DO and Ritcher JE. The Changing Faces of the Nutcracker Esophagus. Am J Gastroenterol. 1988;83:623-8.  Back to cited text no. 2    
3.Achem SR, Kolts BE, Wears R, et al. Chest Pain Associated with Nutcracker Esophagus: A preliminary study of the role of gastroesophageal reflux. Am J Gastroenterol. 1993;88:187-92.  Back to cited text no. 3    
4.Katzka DA, Sidhu M and Castell DO. Hypertensive Lower Esophageal Sphincter Pressures and Gastroesophageal Reflux: An Apparent Paradox that is not Unusual. Am J Gastroenterol. 1995;90:280-4.  Back to cited text no. 4    
5.Hewson EG, Dalton CB and Ritcher JE. Comparison of Eophageal Manometry, Provocative Testing, and Ambulatory Monitoring in Patients with unexplained Chest Pain. Dig Dis Scie. 1990;35:302-9.  Back to cited text no. 5    
6.Triadifilopoulos G and Catillo T. Nonpropulsive Esophageal Contractions and Gastroesophageal Reflux. Am J Gastroenterol. 1991;86:153-9.  Back to cited text no. 6    
7.Ritcher JE, Castell DO. Gastroesophageal reflux: pathogenesis, diagnosis and therapy. Ann Intern Med. 1982;97:93-103.  Back to cited text no. 7    
8.Robinson MG, Orr WC, McCallum R, et al. Do endoscopic findings influence response to h2 antagonist therapy for gastroesophageal reflux disease ? Am J Gastroenterol. 19887;82:519-22.  Back to cited text no. 8    
9.Kahrilas PJ, Dodds WJ, Hogan WJ, et al. A. Esophageal Peristaltic Dysfunction in Peptic Esophagitis. Gastroenterol. 1986;91:897-904.  Back to cited text no. 9    
10.Gill RC, Bowes KL, Murphy PD, et al. Esophageal Motor Abnormalities in Gastroesophageal Reflux and the Effects of Fundoplication. Gastroenterology. 1986;91:364-9.  Back to cited text no. 10    
11.DeMeester TR, Johnson LF, Joseph FJ, et al. Patterns of gastroesophageal reflux in health and disease. Ann Surg. 1976;184:459-70.  Back to cited text no. 11    
12.Goldberg HI, Dodds WJ, Gee S, et al. Role of acid and pepsin in acute experimental esophagitis. Gastroenterol 1969;56:223-30.  Back to cited text no. 12    
13.Johnson LF. 24-hour pH monitoring in the study of gastroesophageal reflux. J Clin Gastroenterol. 1980;2:387-99.  Back to cited text no. 13    
14.Achem SR, Kolts BE and Burton L. Segmental versus Diffuse Nutcracker Esophagus: An intermittent motility pattern. Am J Gastroenterol 1993;88:847-51.  Back to cited text no. 14    
15.DeMeester TR, O'Sullivan GC, Bermudez G, et al. Esophageal function in patients with angina-type chest pain and normal coronary angiograms. An Surg. 1982;196:488-98.  Back to cited text no. 15    
16.Rokkas T and Sladen GE. Ambulatory Esophageal pH Recording in Gastroesophageal Reflux: Relevance to the Development of Esophagitis. Am J Gastroenterol. 1988;83:629-32.  Back to cited text no. 16    
17.Little AG, DeMeester TR, Kirchner PT, et al. Pathogenesis of esophagitis in patients with gastroesophageal reflux. Surgery 1980;88:101-7.  Back to cited text no. 17  [PUBMED]  

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Correspondence Address:
Saleh Mohsen Al Amri
Department of Medicine (38), King Khalid University Hospital, P.O. Box 2925, Riyadh 11461
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864746

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