Most GERD symptoms are not due to acid reflux in patients with very low 24–hour acid contact times
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Purpose: A 29 –year– old female was admitted to the hospital for emergent evaluation of hematemesis. She was in her usual state of good health until three weeks prior to this admission when she developed fluid filled lesions on her neck and arms. A dermatologic evaluation that included a skin biopsy at another hospital was consistent with Bullous Pemphigoid. One week prior to her admission she detected a bullous lesion on the left buccal mucosa and began to experience mild dysphagia to solids. She reported no corrosive ingestions, was on no medications, and did not have a history of reflux. On admission she had a hematocrit of 27.6% and an activated partial thromboplastin time (aPTT) of 75 seconds (normal range 30.3– 43.5). After fluid resuscitation, an emer- gent esophagastroduodenoscopy revealed fresh heme oozing in a denuded esophageal mucosa with bullous lesions, and multiple casts of varying lengths throughout the esophagus (fig. 1). The elevated aPTT persisted despite fresh frozen plasma administration and the hematocrit dropped to 20.1%. Coagulation studies revealed a Factor VIII level of 1% (normal 65–150). A time– dependent inhibitor was demonstrated by activated par- tial thromboplastin time mixing studies. The patient was treated with activated factor VIII, aminocaproic acid, prednisone, and cyclophosphamide with resultant stabilization of the he- matocrit. Esophagitis Dessicans Superficialis (EDS) refers to the sloughing of the esophageal mucosa with the production of casts. It has been described in individuals with Pemphigus Vulgaris, as well as Bullous Pemphigoid. The development of a factor VIII inhibitor (acquired hemophilia A) has been reported in individuals with the previously mentioned skin conditions, but never in conjunction with EDS. 45 MOST GERD SYMPTOMS ARE NOT DUE TO ACID REFLUX IN PATIENTS WITH VERY LOW 24 –HOUR ACID CONTACT TIMES Bryan Green, M.D., Judy Smith, R.N. and J. Barry OConnor, M.D.*. Department of Medicine, GI Division, Duke University Medical Center, Durham, NC. Purpose: Not all symptoms potentially attributable to GERD are due to acid reflux. Ambulatory esophageal 24 – hour pH testing provides informa- tion on total acid contact time and symptom index (SI; % of symptoms associated with concomitant reflux). The aim of this study was to compare the relationship between total acid contact time and the SI in two groups: patients with very low vs. very high total acid contact times. Methods: We retrospectively reviewed 973 consecutive 24 – hour pH stud- ies performed at a U.S. tertiary referral center from 1997 to 2001. Exclu- sions: taking PPIs, had antireflux surgery or lung transplantation. The 49 patients with the lowest and the 49 patients with the highest total acid contact times were compared. SI was determined in each group for heart- burn, regurgitation, cough, chest pain, nausea and for all these symptoms combined. Scores on the hospital anxiety and depression screening ques- tionnaire (HAD) were recorded in a subset. Results: The low reflux group was significantly younger (median 50 vs 54 yrs, p0.026) and more predominantly female (78% vs 47%, p0.002) than the high reflux group. Low refluxers were 73% white, 14% black, not significantly different from the high refluxers. The median SI was signif- icantly lower in the low reflux group versus the high reflux group for all symptoms (Table). Median HAD scores were similar in both groups (anx- iety subscale 4.9 vs 5; p0.961 and depression subscale 2 vs 3; p0.239). Comparison of Low and High reflux groups Total acid contact time % Heart- burn SI Regurgi- tation SI Cough SI Chest pain SI Nausea SI SI for all symptoms combined Low reflux group 0.6% 0 0.2 0 0 0 0.12 High reflux group 26.4% 1 1 0.55 0.75 1 0.86 All values expresssed as median, p 0.05 for all comparisons, SI symptom index. Conclusions: In patients with very low acid contact times, only 12% of symptoms are associated with acid reflux, compared with 86% in patients with very high acid contact times. These differences apply to both typical and atypical reflux symptoms. Younger females are over–represented in the in the very low reflux, low SI group. Neither anxiety nor depression are associated with the observed differences in SI. 46 THE IMPACT OF PRE–OPERATIVE EVALUATION ON LAPAROSCOPIC ANTI–REFLUX SURGERY James Smith, M.D.* and Bret Garretson, M.D. Gastroenterology, Ochsner Clinic Foundation, New Orleans, LA. Purpose: To evaluate how often pre– operative motility alters the surgical fundoplication procedure and does this affect post– operative persistent dysphagia rates. Methods: A retrospective study of the laparoscopic anti–reflux surgeries done at Ochsner Clinic Foundation between 1997–1999. Data was col- lected on various pre– operative symptoms and endoscopic findings as well as pre– operative motility results, type of surgery, and post– operative outcomes. Results: 126 anti–reflux surgeries for GERD were reviewed. Five were excluded (4 without pre– op motility results and 1 was not laparoscopic). Post– op follow up averaged 6 –12 months. Of the 121 cases in the final data analysis, 97 had pre– op effective esophageal motility and 24 had ineffec- tive motility (defined as 30% dropped swallows or dropped swallows S15 AJG – September, Suppl., 2002 Abstracts
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Transcript of Most GERD symptoms are not due to acid reflux in patients with very low 24–hour acid contact times
Purpose: A 29–year–old female was admitted to the hospital for emergentevaluation of hematemesis.
She was in her usual state of good health until three weeks prior to thisadmission when she developed fluid filled lesions on her neck and arms. Adermatologic evaluation that included a skin biopsy at another hospital wasconsistent with Bullous Pemphigoid. One week prior to her admission shedetected a bullous lesion on the left buccal mucosa and began to experiencemild dysphagia to solids. She reported no corrosive ingestions, was on nomedications, and did not have a history of reflux. On admission she had ahematocrit of 27.6% and an activated partial thromboplastin time (aPTT) of75 seconds (normal range 30.3–43.5). After fluid resuscitation, an emer-gent esophagastroduodenoscopy revealed fresh heme oozing in a denudedesophageal mucosa with bullous lesions, and multiple casts of varyinglengths throughout the esophagus (fig. 1). The elevated aPTT persisteddespite fresh frozen plasma administration and the hematocrit dropped to20.1%. Coagulation studies revealed a Factor VIII level of �1% (normal65–150). A time–dependent inhibitor was demonstrated by activated par-tial thromboplastin time mixing studies.
The patient was treated with activated factor VIII, aminocaproic acid,prednisone, and cyclophosphamide with resultant stabilization of the he-matocrit.
Esophagitis Dessicans Superficialis (EDS) refers to the sloughing of theesophageal mucosa with the production of casts. It has been described inindividuals with Pemphigus Vulgaris, as well as Bullous Pemphigoid. Thedevelopment of a factor VIII inhibitor (acquired hemophilia A) has beenreported in individuals with the previously mentioned skin conditions, butnever in conjunction with EDS.
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MOST GERD SYMPTOMS ARE NOT DUE TO ACID REFLUXIN PATIENTS WITH VERY LOW 24–HOUR ACID CONTACTTIMESBryan Green, M.D., Judy Smith, R.N. and J. Barry OConnor, M.D.*.Department of Medicine, GI Division, Duke University Medical Center,Durham, NC.
Purpose: Not all symptoms potentially attributable to GERD are due toacid reflux. Ambulatory esophageal 24–hour pH testing provides informa-tion on total acid contact time and symptom index (SI; % of symptomsassociated with concomitant reflux). The aim of this study was to comparethe relationship between total acid contact time and the SI in two groups:patients with very low vs. very high total acid contact times.Methods: We retrospectively reviewed 973 consecutive 24–hour pH stud-ies performed at a U.S. tertiary referral center from 1997 to 2001. Exclu-sions: taking PPIs, had antireflux surgery or lung transplantation. The 49patients with the lowest and the 49 patients with the highest total acidcontact times were compared. SI was determined in each group for heart-burn, regurgitation, cough, chest pain, nausea and for all these symptomscombined. Scores on the hospital anxiety and depression screening ques-tionnaire (HAD) were recorded in a subset.Results: The low reflux group was significantly younger (median 50 vs 54yrs, p�0.026) and more predominantly female (78% vs 47%, p�0.002)than the high reflux group. Low refluxers were 73% white, 14% black, notsignificantly different from the high refluxers. The median SI was signif-icantly lower in the low reflux group versus the high reflux group for allsymptoms (Table). Median HAD scores were similar in both groups (anx-iety subscale 4.9 vs 5; p�0.961 and depression subscale 2 vs 3; p�0.239).
Comparison of Low and High reflux groups
Totalacid
contacttime%
Heart-burn
SI
Regurgi-tation
SICough
SI
ChestpainSI
NauseaSI
SI for allsymptomscombined
Low reflux group 0.6% 0 0.2 0 0 0 0.12High reflux group 26.4% 1 1 0.55 0.75 1 0.86
All values expresssed as median, p � 0.05 for all comparisons, SI � symptom index.
Conclusions: In patients with very low acid contact times, only 12% ofsymptoms are associated with acid reflux, compared with 86% in patientswith very high acid contact times. These differences apply to both typicaland atypical reflux symptoms. Younger females are over–represented in thein the very low reflux, low SI group. Neither anxiety nor depression areassociated with the observed differences in SI.
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THE IMPACT OF PRE–OPERATIVE EVALUATION ONLAPAROSCOPIC ANTI–REFLUX SURGERYJames Smith, M.D.* and Bret Garretson, M.D. Gastroenterology,Ochsner Clinic Foundation, New Orleans, LA.
Purpose: To evaluate how often pre–operative motility alters the surgicalfundoplication procedure and does this affect post–operative persistentdysphagia rates.Methods: A retrospective study of the laparoscopic anti–reflux surgeriesdone at Ochsner Clinic Foundation between 1997–1999. Data was col-lected on various pre–operative symptoms and endoscopic findings as wellas pre–operative motility results, type of surgery, and post–operativeoutcomes.Results: 126 anti–reflux surgeries for GERD were reviewed. Five wereexcluded (4 without pre–op motility results and 1 was not laparoscopic).Post–op follow up averaged 6–12 months. Of the 121 cases in the final dataanalysis, 97 had pre–op effective esophageal motility and 24 had ineffec-tive motility (defined as �� 30% dropped swallows or dropped swallows
S15AJG – September, Suppl., 2002 Abstracts
