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Background: Gastric phasic activity (GPA) of 3/min is measured by impedance gastrography (IGG) in healthy adults after a meal. IGG was performed in infants with severe gastrointestinal diseases to see if the presence of disease could affect GPA.

A total of 45 patients have undergone an Inkwell esophagogastrostomy after resection of a benign esophageal stricture. Nineteen patients were available for a long-term follow-up study, showing evidence of gastroesophageal reflux in 16 patients. Due to the high incidence of reflux and subsequent morphologic changes, there was a not negligible late disability. The Inkwell esophagogastrostomy can no longer be recommended in the treatment of an underlying reflux-induced lesion, strictures included.

The purpose of this paper is to survey the basic principles in upper gastrointestinal motility. The upper GI-tract will be delineated as the esophagus, stomach, and duodenum. The biliary tract will be emphasized in a later presentation.For each of the organs the basic mechanisms will be considered, i.e. hormonal and neural regulation, influence of food intake, postural changes, and relation to age. An overall mention of the interdigestive variation will appear at the end.

In this study both pancreatic and bile duct sphincter pressures were measured on the same occasion by means of endoscopic manometry in 42 patients with long-standing upper abdominal pain. Nine (53%) of the 17 patients with abnormal sphincter function had a marked difference between the pancreatic duct sphincter pressure (PSOP) and the bile duct sphincter pressure (BSOP): 6 patients with a clinical diagnosis of biliary dyskinesia showed elevated BSOPs, whereas the PSOPs were normal. The reverse, an abnormal PSOP but normal or only a slightly elevated BSOP, was registered in the three patients with chronic pancreatitis. These findings indicate that a motor abnormality may be restricted to only one of the sphincters. Thus, when the sphincter of Oddi is investigated only from the pancreatic duct, manometry may either fail to show an abnormal BSOP in some patients with biliary dyskinesia, or it may falsely suggest this diagnosis in patients with unrecognized pancreatitis.

Resting common bile duct pressure and Oddi sphincter pressure were measured in 16 patients with common bile duct stones, 8 having in addition a juxta-ampullar diverticulum. Pressure measurements were performed with an infused catheter introduced through an endoscope under direct vision. No significant differences in fasting common bile duct pressures were observed between the two groups. The Oddi sphincter had a phasic activity, and the peak pressure was similar in both groups.

Using a high-fidelity recording system, simultaneous manometric measurements of the sphincter of Oddi and duodenum were performed in 6 dogs. The sphincter of Oddi was a high-pressure zone with superimposed phasic activity. The tracings were analyzed according to the distribution of the peak-to-peak contraction intervals (PPI), and a multimodal distribution was consistently found with a basal mode of 3.5 s. If not occurring at this interval, the PPI would be a multiple of this value. These findings suggest that slow-wave control activity is present in the canine sphincter of Oddi. The origin of this control is still unknown.

The histologic finding of basal-layer hyperplasia and papillosis as consequences of gastroesophageal reflux still constitute an area of controversy. Consequently, a prospective study of symptoms and endoscopy and biopsy interpretation was undertaken in 200 patients consecutively submitted to upper endoscopy, whereof 12 were excluded. Complete agreement among all three variables was found in half of the patients and harmony between two of the variables in one fourth. In the last fourth the outcome was positive in one variable only, equally distributed among the symptoms, endoscopy, and histology. It is concluded that histology is of considerable value in gastroesophageal reflux disease.

Parietal cell vagotomy (PCV) and the Hill antireflux procedure were used in 108 patients with reflux esophagitis. The addition of PCV provides better access to the cardia and ensures that more extensive vagotomy than intended does not occur. Furthermore, a reduction in the basal acid output (BAO) is preferable. In patients still symptomatic after surgery, the BAO was unchanged, while in those without postoperative symptoms a significant decrease in BAO was found (p < 0.01).

Sphincter of Oddi manometry was performed in three anesthetized dogs, using different measuring catheter diameters, ranging from 1.0 to 1.9 mm. No differences were seen either in sphincter of Oddi wave amplitude, frequency, and base-line pressure or in common bile duct pressure measured after cannulation during 20 min with catheters of 1.0 and 1.3 mm. However, significant disturbances of these variables were present when the measuring catheter diameter was 1.6 and 1.9 mm. It is concluded that the diameter of the recording catheter is of crucial importance in sphincter of Oddi manometry. In dogs with a body weight of 30-40 kg, the outer diameter should not exceed 1.3 mm.

The efficacy of sucralfate in the treatment of patients with dyspepsia and macroscopic signs of gastritis was assessed in a double-blind, placebo-controlled study. Treatment was 2 g sucralfate or placebo taken 1/2 h before breakfast and at bedtime. Clinical and endoscopic examinations were performed after 6 weeks' treatment, and if mucosal changes and/or symptoms persisted, medication was continued for another 6 weeks. Cumulative healing rates at 6 and 12 weeks were 43% (13 of 30) and 62% (18 of 29) in the sucralfate group verus 37% (11 of 30) and 62% (18 of 29) in the placebo group. Corresponding rates for symptomatic improvement were 80% and 83% for those receiving sucralfate and 73% and 79% for placebo-treated patients. None of the differences between sucralfate and placebo were significant, and sucralfate does not seem to be superior to placebo in the treatment of macroscopic gastritis.

Basal and food-stimulated motility patterns were studied in seven patients with distal duodenal anomalies (DDA) and in seven controls. A discordant pressure pattern and a significantly higher frequency of pressure waves was observed in DDA both in the basal state and after food intake in comparison to controls. It is concluded that the shape of the duodenal loop can influence basal and food-stimulated motility patterns in the duodenum, and thereby probably also the transport mechanism through the duodenal loop.

Sixty two patients with a clinical suspicion of biliary dyskinesia were investigated with endoscopic manometry of the sphincter of Oddi before and after intravenous injection of cholecystokinin or ceruletide. In 52 patients injection was followed by decreased pressure in the sphincter of Oddi; 43 of these had normal prestimulatory values (group I), while the values were raised in the other nine patients (group II). A paradoxical response to intravenous injection was observed in 10 women (group III): increased baseline sphincteric pressure occurred in eight and increase in the amplitude of phasic contractions in four patients. The prestimulatory sphincteric pressure was raised in five and normal in the remaining patients. Eight patients were treated with papillotomy (seven) or balloon dilatation of the sphincter (one). They experienced relief of pain during a follow up period of 11-16 months. Intravenous injection of cholecystokinin or ceruletide may disclose a special type of biliary dyskinesia even in patients with normal prestimulatory manometric findings. Hormone injection increases the diagnostic yield of endoscopic manometry in patients suspected of biliary dyskinesia.

In a prospective study a barium examination combined with food stimulation was compared with the acid reflux test in 30 consecutive patients with symptoms of gastro-oesophageal reflux. Both methods were further compared with endoscopy and histology. Gastro-oesophageal reflux could be demonstrated by the radiologic examination in 22 patients and by the acid reflux test in 23 patients. By combining the two methods gastro-oesophageal reflux could be demonstrated in 27 patients. Comparing the two methods with symptoms, endoscopy, and histology they seemed to be of equal value. Accordingly, a food-stimulated barium examination is recommended as the first method for demonstrating gastro-oesophageal reflux because it is simple and well-tolerated by the patient. References

Bei 200 Patienten wurden endoskopische Sphincter Oddi Manometrien durchgefuhrt. Erhohte Druckwerte fanden sich bei Patienten mit einem sogenannten Postcholecystektomie-Syndrom. Die endoskopische — Sphincterotomie neutralisierte das choledochoduodenale Druckgefalle und reduzierte phasische Kontraktionen. Verapamil beeinfluste die Motilitat des Sphincter Oddi nicht. 6 Patienten mit Gallengangsdyskinesie wurden sphincterotomiert. 5 waren beschwerdefrei, ein Patient leidet noch unter leichten Symptomen, ein Patient leidet unter denselben Symptomen wie vor dem Eingriff. Mit einer Sphincterotomie kann man diesen Patienten helfen.

Gastric emptying time of a solid meal was estimated on X-ray in 7 patients with a normal duodenal loop, 7 patients with a proximal duodenal anomaly, and 12 patients with a distal duodenal anomaly. A determination coefficient between gastric emptying time and duration of serum gastrin increase was calculated. The food-stimulated serum gastrin secretory pattern was studied in 9 patients with a normal duodenal loop, 6 with a proximal duodenal anomaly, and 13 with a distal duodenal anomaly. The various groups presented significantly different gastric emptying times; thus patients with normal duodenal loop had a mean gastric emptying time of 6 h, patients with proximal duodenal anomalies ahd a mean gastric emptying time of 4.5 h, and patients with distal duodenal anomalies had a mean gastric emptying time of 9 h. Gastric emptying time and duration of increased serum gastrin secretion was positively correlated (R2 = 0.89). The food-stimulated serum gastric secretory pattern was equal in patients with proximal duodenal anomalies and those with distal duodenal anomalies and furthermore, reached significantly higher serum gastrin concentrations than in patients with a normal duodenal loop.

Antroduodenal motility was studied before, during, and after food intake in patients with X-ray-negative dyspepsia and abnormal duodenal loop and in normals. No differences were observed between X-ray-negative dyspepsia and a proximally located abnormal duodenal loop. Patients with a distal duodenal anomaly had significantly higher food-stimulated duodenal activity than any of the other groups studied, whereas no differences were observed in antral motility.

Pressures in the Oddi sphincter and common bile duct were determined before, immediately after and several weeks after endoscopic papillotomy. Fifteen patients were included in the study. Significant decreases in Oddi sphincter and common bile duct pressures were found and the decrease in Oddi sphincter pressure was to some extent dependent upon the length of the papillotomy.

The gastroesophageal sphincter pressure (GESP) was studied before, during, and after food intake in nine patients with abnormal duodenal loop (AD), six patients with a normal duodenum (controls), and seven healthy volunteers. In normal and control subjects a significant increase in GESP was observed during food intake, in contrast to a significant decrease in patients with AD. This may explain why patients with AD often develop symptoms when eating.

In a prospective study, 26 patients with symptoms of reflux oesophagitis underwent a barium examination for gastro-oesophageal reflux after food stimulation, and endoscopy with biopsy from different levels of the oesophagus. Radiologic grading of the gastro-oesophageal reflux depending on the height of the reflux into the oesophagus was performed, and this was correlated to the microscopic appearance at different levels in the oesophagus. Complete agreement between the radiologic grading and the histology was found in 69 per cent of the cases, and when ***gastro-oesophageal reflux was demonstrated the agreement was 75 per cent. Accordingly, the results showed a good accordance between the two variants, indicating that the height of the reflux during the food stimulated test may be truly indicative of the reflux height under non-test conditions.

Resting common bile duct, main pancreatic duct, and resting Oddi sphincter pressures were measured in controls and in patients with gallstones, previous cholecystectomy, common bile duct stones, hepatic duct cancer, and chronic pancreatitis. No significant differences in resting common bile duct pressures were observed in controls compared with the other groups. No significant differences in resting intrapancreatic duct pressure were observed in controls compared with patients with various biliary diseases. Resting intrapancreatic duct pressure was two to three times greater than the common bile duct pressure in all patients. No motor activity was found in either of the ducts. Only passive transmission of changes in intraabdominal pressures was demonstrated. No correlation between diameter of the ducts and intraluminal pressure was observed. The injection of a known volume of normal saline or contrast medium was associated with abrupt increase in intraluminal pressure, and in some patients typically biliary cholics were produced. Oddi sphincter pressure caused a phasic activity composed of contractions and relaxations in all patients. Peak Oddi sphincter pressure was approximately 100 mm Hg above the duodenal pressure, and no significant differences were seen in controls compared with any other group (P > 0.4). The results of this study show that a unique high pressure zone with sphincter characteristics exists at the level of the choledochoduodenal and pancreaticoduodenal junction, and that it is independent of duodenal dynamics. This sphincter creates a gradient between the bile or pancreatic ducts and the duodenum, and probably prevents reflux of duodenal content into these ducts.

The gastroesophageal sphincter pressure (GESP) was studied before, during, and after food intake in 9 reflux esophagitis patients and 11 healthy controls. A significant decrease in GESP was observed 5, 10, and 30 min after the beginning of the meal in reflux esophagitis patients, contrasting with an increase during food intake in the control group. In the supine position GESP was significantly lower than in the sitting position in esophagitis patients, contrasting with a significantly higher GESP in the supine position in the control group. These results may explain why patients with gastroesophageal reflux often develop their symptoms during food intake and in the supine position.

Acute biliary manometry was performed in 10 dogs during operation. The sphincter of Oddi was a high-pressure zone with phasic activity. No active contractions were observed either in the common bile duct or in the gallbladder. Electrostimulation of the right and left thoracic vagal branches increased bile flow, decreased the activity of the sphincter of Oddi and gallbladder pressure. Stimulation of the right vagus gave a more complex response as the initial inhibition of the activity of the sphincter of Oddi was followed by an increased motor activity. Intra-arterial cholecystokinin injection increased bile flow, inhibited the activity of the sphincter of Oddi, whereas gallbladder pressure remained unchanged.

Smooth-muscle specimens from the lower esophagus of nine patients operated on for esophageal achalasia were examined with routine hematoxylin-eosin staining. This procedure revealed only a few eosinophils in or between the external smooth-muscle layers. Using specific immunohistochemical methods for the detection of the eosinophil cationic protein (ECP), however, varying degrees of eosinophil infiltration and extracellular deposit of ECP were disclosed in the achalasia specimens. The ECP also reacted with the monoclonal antibody, EG2, indicating secretion of the cytotoxic ECP. Few or no eosinophils were seen in the muscularis externa in specimens from six control patients without esophageal disease. In two controls many eosinophils were observed in the muscularis externa. However, no extracellular ECP was detected and very few eosinophils reacted with the monoclonal antibody (EG2), suggesting that these eosinophils were not activated. Depletion or total absence of peptidergic innervation was seen in all achalasia specimens but not in controls. Since the eosinophil cationic protein (ECP), in its activated form, is cytotoxic, we propose a pathogenic role of the eosinophil infiltration in achalasia.

In 73 patients the occurrence of dyspeptic symptoms were correlated with the presence of a normal duodenal loop (29 patients) and an abnormal duodenal loop (44 patients). An abnormal duodenal loop was associated with a significantly higher incidence of symptoms provoked by meals, vomiting, regurgitation, heartburn, and the irritable bowel syndrome.

The incidence of severe duodenal anomalies (MD) has been investigated in 458 patients submitted to barium meal examination and in 176 subjects comprising various clinical subgroups. The incidence of MD in patients submitted to barium meal examination was 11.6%. The incidence of MD in 25 normals was 4%, which was not significantly different from the incidence (10%) of MD in patients with gastroesophageal reflux symptoms. Compared with in normals, MD occurred with a significantly higher incidence in 45 patients with X-ray-negative dyspepsia (24%), in 36 patients with the irritable bowel syndrome (44%), and in 37 patients with asthma (38%). It is concluded that demonstration of MD in a patient is only indicative of a possible disorder.

Gastroesophageal reflux was investigated in 80 patients with duodenal ulcer by analysis of symptomatology and the acid reflux test. Resting gastroesophageal sphincter pressure (GESP) and postvagotomy reduction in basal and pentagastrin stimulated gastric acid secretion were also studied. Reflux symptoms were present in 40% of the patients, and this incidence was significantly reduced two months after vagotomy. In patients studied late after operation reflux symptoms were still less frequent than before operation, but not significant. After vagotomy, no significant changes in the fasting GESP or in gastroesophageal reflux as determined by the pH glass electrode were demonstrated. Thus, the decrease in reflux symptoms may be explained by the significant reduction in gastric acid secretion. Denervation of the cardia and the lower esophagus does not influence GESP or gastroesophageal reflux.

This study evaluates the endoscopic manometric findings within the sphincter of Oddi (SO) in nine healthy volunteers premedicated with atropine 1 h before and with diazepam during the investigation. We measured the bile duct sphincter in seven persons and the pancreatic duct sphincter in two. A hydraulic capillary infusion system and a triple-lumen catheter were used. In all the SO was identified as a zone (median length, 8 mm) with elevated base-line pressure and superimposed phasic activity. Median values for amplitude was 102.9 mm Hg; base-line pressure, 10 mm Hg; wave duration, 4.8 sec; and frequency, 2.6/min. Most waves propagated antegrade or simultaneously, and in no individual were more than one third of the waves retrograde. When peak-to-peak intervals were analyzed in one volunteer with prolonged manometry, a basal mode of 6 sec or an even multiple of this value was disclosed, indicating that the SO is paced.

In seven patients operated on with cholecystectomy for simple gallstones, sphincter of Oddi manometry was performed during surgery. The sphincter was localized as a zone with elevated base-line pressure and phasic contractile activity. Mean value of the amplitude was 90 mm Hg; wave duration, 4 sec; frequency, 5/min; and base-line pressure, 10 mm Hg. No activity was seen in the antrum or duodenum. The plotting of peak-to-peak intervals in a histogram showed that these were evenly distributed around 6 sec or at integrated multiples of this value. This indicates that the sphincter of Oddi is paced. The origin of the pacing is not yet established.

Previous anatomical studies have described a distinct sphincteric structure at the entrance of the common bile and pancreatic ducts in the duodenum. However, from an anatomical point of view, the pancreatic duct sphincter is only present in one third of human specimens. The purpose of the present study was therefore to investigate whether sphincteric activity could be demonstrated in patients in whom the common bile duct sphincter was completely transsected during endoscopic sphincterotomy. Twelve patients had a complete bile duct sphincterotomy because of sphincter of Oddi dyskinesia. The sphincterotomy was checked manometrically in all, and neutralization of the choledochoduodenal gradient recognized. In all patients a distinct pancreatic sphincteric zone with base-line elevation and superimposed phasic activity was demonstrated. In six patients the pancreatic duct sphincter was studied before and after bile duct sphincterotomy, and, although a definite sphincter zone still was present in the pancreatic duct, a reduction in phasic wave amplitude was observed. A similar decreased base-line and pancreatic duct pressure was observed, although not statistically significant.

Gastritis has a wide spectre of definition modalities. Most previous studies have compared symptomatology with histologic gastritis with negative results. We believe that this may be due to inadequate definition criteria and emphasize this point by comparing gastroesophageal reflux with duodenogastric reflux. A prospective randomized trial has been conducted for half a year comparing Sucralfate with a placebo in patients with symptomatological and macroscopical gastritis. Although approximately one hundred patients met the endoscopic criteria, the vast majority could not be included due to well-defined interfering diseases, and thus the material is still too sparse to give any indication of the influence of Sucralfate on endoscopic gastritis, although the preliminary overall results seem promising.

Outcomes after redo fundoplication (RF) in recurrent gastroesophageal reflux disease (GERD) are debatable, and they may include lower success rates with higher postoperative morbidity and mortality than outcomes after primary fundoplication (PF). However, data from large, nationwide studies are not available. Accordingly, the aim of the present study was to evaluate nationwide Danish data on RF in a nine-year period. Data in the period from 1997 through 2005 were extracted from the National Patient Register. The following information was procured: frequency of RF, rate of conversion to open surgery, rate of complications requiring reoperation, and 30-day mortality. Data for RF were compared to PF. A total of 2589 fundoplications were performed in 2465 patients. Thus, 113 patients underwent a total of 124 RF (RF rate = 5.0%). Most RF (84.7%) were performed at high-volume departments. Patients who underwent RF were converted to open surgery more often (16.1% vs. 6.1% in PF) (P

AIM: Sensitization most likely plays an important role in chronic pain disorders, and such sensitization can be mimicked by experimental acid perfusion of the esophagus. The current study systematically investigated the sensory and motor responses of the esophagus to controlled mechanical stimuli before and after sensitization. METHODS: Thirty healthy subjects were included. Distension of the distal esophagus with a balloon was performed before and after perfusion with 0.1 mol/L hydrochloric acid for 30 min. An impedance planimetry system was used to measure cross-sectional area, volume, pressure, and tension during the distensions. A new model allowed evaluation of the phasic contractions by the tension during contractions as a function of the initial muscle length before the contraction (comparable to the Frank-Starling law for the heart). Length-tension diagrams were used to evaluate the muscle tone before and after relaxation of the smooth muscle with butylscopolamine. RESULTS: The sensitization resulted in allodynia and hyperalgesia to the distension volumes, and the degree of sensitization was related to the infused volume of acid. Furthermore, a nearly 50% increase in the evoked referred pain was seen after sensitization. The mechanical analysis demonstrated hyper-reactivity of the esophagus following acid perfusion, with an increased number and force of the phasic contractions, but the muscle tone did not change. CONCLUSION: Acid perfusion of the esophagus sensitizes the sensory pathways and facilitates secondary contractions. The new model can be used to study abnormal sensory-motor mechanisms in visceral organs.

Udgivelsesdato: 1990-Mar Isolated smooth muscle strips from the human esophagus representing both the longitudinal and circular layers of the esophagogastric junction and the esophageal body were prepared. The strips were mounted in organ baths, and resting length was defined. By repeatedly increasing the length of the strips with 20% of resting length and recording values of resting and active tensions, length-tension relations for each muscle type were constructed. Only circular strips from the esophagogastric junction developed active, resting tension, disclosed by replacing the normal Ca2(+)-containing Krebs solution with Ca2(+)-free medium. Carbachol (10(-6) M) was used for submaximal activation of the contractile apparatus. At lengths between 180 and 260% of resting length, all strips reached optimum length (LO) where further elongation gave no further increase in active tension development. Repeated stimulations with carbachol was possible at a length of 200% of LO without affecting reproducibility. Determination of different collagen components revealed no differences between muscle types.

BACKGROUND AND AIMS Abdominal pain provoked by acute gastrointestinal disease may increase the sensitivity in the referred somatic pain area. The aim of this study was to examine sensory changes in the referred pain area during acute appendicitis. SUBJECTS Twenty patients with clinical symptoms of appendicitis were included; 16 of these had appendicitis confirmed at operation. Ten healthy volunteers served as controls. METHODS In patients with symptoms of appendicitis, somatic sensitivity was assessed using different stimuli presented in the area of referred pain and in a comparable non-painful area at the contralateral site of the abdomen. In healthy control subjects, the same stimuli were presented to McBurney's point and at a similar area on the left abdomen. The rating to pinprick was determined using a Von Frey hair. The rating to thermal stimuli was tested by warm and cold metal rollers. A constant current stimulator was used to measure the sensation and pain-detection threshold to single and repeated electrical stimuli. The pressure pain threshold was determined by an electronic pressure algometer. RESULTS Patients (n = 16) with verified appendicitis showed increased ratings to pinprick (50%, P < 0.05) and thermal stimuli (56%, P < 0.05) in the referred pain area. There was a reduction in pain thresholds to single electrical (4.3 v. 8.4 mA, P = 0.001), repeated electrical (3.5 v. 4.6 mA, P = 0.005) and pressure (89 v. 243 kPa, P < 0.001) stimuli in the referred pain area versus the control area. In the control group, no difference was observed between the two areas. The pain thresholds for electrical and pressure stimuli were lower in the referred pain area in patients compared with the same area in controls (P < 0.001). CONCLUSION Somatosensory hyperalgesia to experimental stimuli was observed in acute appendicitis. We believe that viscerosomatic convergence mechanisms and central nervous system hyperexcitability explain these findings.