The reason why patients with isolated supine reflux do not reflux in the upright position and patients with isolated upright reflux do not reflux in the supine position is unknown. Our objective was to determine the characteristics of the crura, lower esophageal sphincter, crura-sphincter dynamics, and esophageal body on manometry, endoscopy, and X-ray in patients with isolated upright and isolated supine reflux. Eighty consecutive patients with isolated upright reflux were compared with 82 consecutive patients with isolated supine reflux. Manometrically there was no difference in lower esophageal sphincter characteristics and esophageal contractions between the two groups. The prevalence of a hiatal hernia on manometry was similar between upright and supine refluxers (88% vs 88%). Upright refluxers had shorter hiatal hernias [median (interquartile range) 1.1 (0.65-1.8) vs 1.2 (1-2.3), P < 0.046)]. The median crural pressure, crura-sphincter pressure gradient, and crura-sphincter pressure ratio in upright refluxers was 14.96 (9.5-21.27), 3.28 (1.7-12.2), and 1.33 (0.87-2.8) mm Hg, respectively. These values were significantly higher (P < 0.001) in supine refluxers at 21.43 (16.6-29.9), 10.66 (4.3-19.7), and 2.1 (1.3-4.2) mm Hg, respectively. We conclude that the significantly higher crural pressure in patients with supine reflux acts as a mechanical ring and as a physiologic protector against the unfolding of the sphincter in the postprandial and upright periods. Higher crura-sphincter pressure gradient and larger-size hiatal hernias in patients with supine reflux results in pressurization of the hernia sac and subsequent reflux when these patients are in a supine position.
The Bravo capsule allows monitoring of esophageal acid exposure over a two-day period. Experience has shown that 24–32% of patients will have abnormal esophageal acid exposure detected on only one of the 2 days monitored. This variation has been explained by the effect of endoscopy and sedation. The aim of this study was to assess the day-to-day discrepancy following transnasal placement of the Bravo capsule without endoscopy or sedation and to determine factors related to this variability. Bravo pH monitoring was performed by transnasal placement of the capsule in 310 patients. Patients were divided into groups based on the composite pH score: both days normal, both days abnormal and only one of the 2 days abnormal. Lower esophageal sphincter (LES) characteristics were compared between groups. Of the 310 patients evaluated, 60 (19%) showed a discrepancy between the 2 days. A total of 127 patients had a normal pH score on both days and 123 had an abnormal pH score on both days. Of the 60 patients with a discrepancy, 27 were abnormal the first day and 33 (55%) were abnormal the second day. Patients with abnormal esophageal acid exposure on both days had higher degrees of esophageal acid exposure and were more likely to have a defective LES compared to those with an abnormal score on only one day (35 vs. 83%, p = 0.027). Patients with a discrepancy between days of Bravo pH monitoring have lower esophageal acid exposure. Variability between the 2 days represents early deterioration of the gastroesophageal barrier and indicates less advanced reflux disease.
21015 Background: We previously showed that free DNA is present in blood of normal subjects and that the plasma DNA level is higher in patients with esophageal cancer compared to normal subjects. These observations suggest that the plasma DNA level may be a useful molecular marker in the diagnosis of esophageal cancer. We hypothesize that lymphatic and hematogenous spread may result in different plasma DNA levels despite both representing advanced disease. Our aim was to measure and compare plasma DNA levels in normal subjects, patients with localized esophageal cancer, patients with lymph node metastases, and patients with hematogenous spread to solid organs (systemic metastases). Methods: Plasma DNA was measured using PCR in 44 normal subjects, 25 patients with localized esophageal cancer (T1–3, N0, M0), 18 patients with lymph node metastases, and 7 patients with systemic metastases. Results: The 95th percentile of plasma DNA level in normal subjects was 19 ng/ml. The median plasma DNA levels were higher in all 3 groups of patients with esophageal cancer compared to control subjects. While there was no difference between the plasma DNA level in patients with localized esophageal cancer and those with lymph node metastases (median of 5 nodes involved, range: 1–31), patients with systemic metastases had a significantly higher level of plasma DNA compared to patients with lymph node metastases and those with localized esophageal cancer. Conclusion: Plasma DNA levels are elevated in patients with esophageal cancer, whether localized or associated with lymph node metastases. In patients with systemic metastases, a significant additional increase in the plasma DNA level occurs. This suggests that measuring the plasma DNA level is a useful molecular diagnostic tool for detection of disseminated esophageal cancer. [Table: see text] No significant financial relationships to disclose.
