Clinical and Manometric Findings in Benign Peptic Strictures of the Esophagus G E O R G E A H T A R I D I S , MD, W I L L I A M J. S N A P E , JR., MD, and S I D N E Y C O H E N , MD
To determine the possible factors that may contribute to the development of peptic stricture of the esophagus, clinical and manometric features were compared in patients with symptomatic gastroesophageal reflux and those with peptic strictures of the esophagus. Patients with stricture were older and had a longer duration of heartburn than patients without a stricture. Most importantly, patients with stricture had a more marked decrease in lower esophageal sphincter (LES) pressure, 4.9 +- 0.5 mm Hg, than patients without a stricture, 7.5 +- 0.6 mm Hg, P < 0.01. The LES pressure in all patients with stricture was below 8 mm Hg, and did not overlap with normal values. Patients with stricture had either a nonspeeific motor abnormality or aperistalsis (64%), compared to patients with symptomatic reflux (32%), P < 0.05. Thus, peptic stricture of the esophagus is commonly associated with a long duration of reflux symptoms in patients with a very low LES pressure and esophageal motor disorder.
Stricture of the esophagus is one of the major complications of s y m p t o m a t i c gastroesophageal reflux. The clinical factors related to stricture formation are poorly understood. It is unclear why only certain patients with gastroesophageal reflux develop this complication while other s y m p t o m a t i c patients do not. To a n s w e r this question, clinical and m a n o metric features were c o m p a r e d in a group o f patients with d o c u m e n t e d stricture of the esophagus and a group o f patients with p r o m i n e n t s y m p t o m s o f g a s t r o e s o p h a g e a l reflux. The results o f these studies indicate that patients with stricture h a v e a longer history o f reflux s y m p t o m s and also h a v e the combination o f a m a r k e d r e d u c t i o n in l o w e r e s o p h a g e a l s p h i n c t e r ( L E S ) pressure and abnormalities in esophageal peristaltic activity. Manuscript received April 30, 1979; revised manuscript received July 13, 1979; accepted July 16, 1979. From the Gastrointestinal Section of the Department of Medicine, University of Pennsylvania at the Hospital of the University of Pennsylvania and Graduate Hospital, Philadelphia, Pennsylvania. Address for reprint requests: Dr. Sidney Cohen, Gastrointestinal Section, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104.
858
M A T E R I A L S AND M E T H O D S Three groups of subjects and patients were studied: First, 25 normal subjects without esophageal symptoms or known esophageal disease; second, 25 consecutive patients with prominent symptoms of heartburn as their predominant complaint, a positive Bernstein test but no evidence of esophageal stricture on x-ray or endoscopy; third, 25 consecutive patients with benign peptic stricture of the esophagus, as shown on x-ray and endoscopy. All patients were seen at the Hospital of the University of Pennsylvania from January 1975 to the present time. All patients underwent esophageal manometry, barium swallow, and fiberoptic endoscopy. A stricture of the esophagus is defined as a concentric narrowing of the esophageal lumen as diagnosed by a radiologist during barium swallow. Patients with esophageal malignancy or caustic injury are excluded. Manometric studies were performed with the patients resting quietly in the supine position after an 8-hr fasting period. Belt pneumographs around the chest and over the larynx were used to monitor respiration and swallowing, respectively. Water-filled polyvinyl catheters, 1.4 mm internal diameter, were used to transmit intraluminal pressures to external transducer (Statham p23 series). The output from each transducer was recorded on a Beckman rectilinear ink-writing recorder. Three recording catheters were arranged to form a single assembly with three side orifices, 1.2-mm diameter, at 5.0-cm intervals. The Digestive Diseases and Sciences, Vol. 24, No. 1l (November 1979)
0163-2116/79/1100-0858503.00/1 9 1979DigestiveDiseaseSystems,Inc.
PEPTIC STRICTURES OF THE ESOPHAGUS TABLE 1. COMPARISON OF PATIENT AGE AND DURATION OF HEARTBURN IN THE TWO GROUPS
Age* (yr) Symptomatic gastroesophageal reflux Peptic stricture
-rE
Duration o f heartburn* (yr)
35 30
#_25 48.6 • 3.7 56.4 • 2.1
2.9 • 0.6 6.7 • 1.5
o~o
_~ ZO
tC3. O3
*Mean • SEM.
-
15
g ~o
oo~o
o
pressure recording tubes were infused with distilled water by a syringe pump at a constant rate of 1.2 ml/min. All pressures were expressed using gastric pressure as a zero reference. The recording assembly was positioned with all orifices in the stomach. After a rest period, the assembly was moved at 1-cm intervals through the full length of the esophagus. Pressures were expressed as the mean value of the recording from each of the three catheters as obtained from the zone of maximal lower esophageal sphincter pressure. The recording system gave a greater than 250 mm Hg rise in LES pressure upon occlusion of the recording orifice. Esophageal manometric records were tabulated for the mean LES pressure in each subject and patient. Esophageal peristalsis to dry and wet swallows were evaluated for propagation over the three recording orifices. The percentages of total esophageal responses that were simultaneous (nonpropulsive) or repetitive were tabulated for each individual. A wave was considered abnormal if two consecutive recording sites showed either a nonpropulsive or repetitive contraction. Records were interpreted in a blinded fashion by two investigators. Statistical analysis was performed using the Student's t test.
RESULTS In Table 1 is shown a comparison of age and duration of symptoms in all patients. Patients with reflux symptoms and a positive Bernstein test (11 males, 14 females) were significantly younger than the patients with stricture (13 males, 12 females) (P > 0.05). The duration of heartburn at time of presentation was greater in the stricture group (P < 0.05). All patients with stricture had dysphagia, with a mean duration of 5.2 -- 1.2 years. Dysphagia was not present in any patient with reflux symptoms, alone. In Figure 1 is shown the L E S pressures as obtained in all subjects and patients. The mean L E S pressure in patients with reflux was 7.5 - 0.6 mm Hg as c o m p a r e d to 19.2 - 1.3 mm Hg in normal subjects (P < 0.01). Patients with stricture had mean L E S pressure of 4.9 - 0.5 mm Hg, a level significantly less than recorded in either the normal Digestive Diseases and Sciences, Vol. 24, No. 1l (November 1979)
O00
hi
o~oo
31
0 ..1
o~
0
, OO00 ~ oooo
i
Normal
Reflux
Stricture
Fig 1. Lower esophageal sphincter pressures in normal subjects, in patients with symptomatic gastroesophageal reflux with a positive Bernstein test, and in patients with a peptic stricture of the esophagus. The mean • SEM is shown for each group.
or reflux groups (P < 0.01). H o w e v e r , it is important to note that while symptomatic reflux patients showed an overlap with the normals, the stricture group showed no such overlap in individual L E S pressures. All patients with peptic stricture had an L E S pressure below 8.0 mm Hg, while 24% of reflux patients had an L E S pressure above 10 mm Hg. In Figure 2 the changes in esophageal peristalsis are shown. Esophageal motor function is classified as normal, nonspecific motor abnormality, and aperistalsis. Normal is defined as having over 85% progressive peristaltic waves (1). Nonspecific motor abnormality is defined as having 15% or greater simultaneous or repetitive contractions. Aperistalsis is defined as having absent or very low amplitude (less than 5 mm Hg) peristaltic waves in the distal two thirds of the esophagus. Patients with reflux had normal peristalsis in 68% of patients, while 32% showed a nonspecific motor abnormality. In patients with stricture, normal peristalsis was infrequent with most patients having nonspecific motor abnormalities or aperistalsis. The total percent of patients with stricture having motor dysfunction (64%) was significantly greater than the total number of patients with reflux having motor abnormalities (32%), (P < 0.05). Associated diseases were also evaluated in all patients. In the stricture group, three patients were found to have scleroderma, and three had idiopathic Raynaud's disease without other evidence of rheu-
859
AHTARIDIS ET AL
~_
9
D S,rictore
# 0 9 Normal
Non-Specific Motor Disorder
Distal Aperistalsis
Fig 2. Percent of patients with symptomatic gastroesophageal reflux and patients with peptic stricture of the esophagus who have normal peristalsis, a nonspecific motor abnormality or aperistalsis.
matic disease. All six patients had distal aperistalsis. Other associated diseases were not noted in the reflux patients or other patients with stricture, except one patient with stricture had several episodes of pneumonia.
DISCUSSION Peptic stricture of the esophagus is a recognized major complication of gastroesophageal reflux occurring in about 11% of patients with reflux disease (2). The specific etiology of peptic stricture is unclear. The purpose of the present study is to evaluate the clinical and manometric features in patients with peptic stricture, and to compare these findings to those in a similar group of patients with symptomatic gastroesophageal reflux but no stricture formation. These studies demonstrate several important findings. First, patients with stricture formation are older and generally have a longer duration of reflux symptoms. Second, all patients with stricture have an LES pressure below 8 mm Hg. Third, many patients with stricture have an underlying motor abnormality of the esophagus that may be nonspecific in character, or related to scleroderma or Raynaud's disease. In the present study, consecutive patients with stricture formation as diagnosed by radiographic examination were compared to a parallel, consecutive group of patients with prominent gastroesophageal reflux disease. The latter group was diagnosed on the basis of their typical symptoms of heartburn and a positive Bernstein test. Heartburn, the classical symptom of reflux, was present in all patients. The duration of symptoms in the stricture group was significantly longer, suggesting chronicity of reflux as being related to stricture formation.
860
However, considerable overlap in duration of symptoms in individuals in each group was noted. Patients with strictures were also older, consistent with this longer duration of symptoms. Surprisingly, the duration of dysphagia in the stricture group was longer than expected, indicating a chronic, slow-developing process prior to presentation or referral to a specialist. Patients with reflux alone had no dysphagia. All patients with stricture had a markedly incompetent LES, with no value being above 8.0 mm Hg. There was no overlap in LES pressures in this group with our normals. There was marked overlap in LES pressure with the reflux patients. However, the reflux patients without stricture did have a slightly higher mean LES value and did overlap with normals. This observation may be of importance. Several previous reports have demonstrated that patients with reflux have a mean LES pressure below the normal level, but individual values may overlap with the normal range as confirmed in this Present study (3-5). This observation has led to the suggestion by some investigators that the LES pressure may be helpful, but overall it is not of great value in diagnosing reflux disease (6, 7). The present study suggests that finding a very low LES pressure may be of value in distinguishing patients at risk for developing a stricture or other complications of reflux disease. Lower esophageal sphincter pressures have been reported only in several studies where the scope of the investigation was confined to peptic stricture (8). In reports confined to patients with strictures, a mean LES pressure of 4.5 -+ 0.5 mm Hg was found (8, 9). However, there was minimal overlap of LES pressure with normals. Pressures of 10 mm Hg were measured in two patients, and 12 mm Hg in one patient. The LES pressures in the presently reported patients and the patients in the two published reports would indicate that the overlap with normal values as seen in reflux disease is less common in patients with stricture. Further support for this finding is found in studies showing that surgical restoration of LES competence without stricture dilation resulted in spontaneous regression of the stricture (10, 11). Abnormalities in esophageal peristalsis were observed in patients with stricture and those with reflux only. The frequency of these abnormalities was higher in the stricture group, but this difference was due mainly to the patients with distal aperistalsis in the stricture population. Nonspecific motor abnorDigestive Diseases and Sciences, Vol. 24, No. 11 (November 1979)
PEPTIC STRICTURES OF THE ESOPHAGUS malities consisting of simultaneous or repetitive contractions have been noted frequently in patients with esophagitis or stricture. In one report, all patients with stricture had this type of motor abnormality (8). It has been shown that the highest incidence and more severe grades of esophagitis were found in patients with excessive acid exposure in the supine position as a result of delayed esophageal acid clearing (12, 13). Impaired peristaltic function may therefore contribute to esophagitis or stricture formation (14). The patients with distal aperistalsis, with either scleroderma or Raynaud's phenomenon, presented with esophageal disease as their major symptom. In three patients, classic skin changes of scleroderma were observed, and the patients met the critiera for the diagnosis of this disease (15). It is important to emphasize that the scleroderma and its associated n o n e s o p h a g e a l manifestations were minimal in these patients and previously not recognized. Raynaud's disease without scleroderma has been associated with distal aperistalsis and L E S incompetence (15). It is unclear whether these patients will e v e n t u a l l y d e v e l o p scleroderma, or whether the manometric changes are a false-positive manifestation of scleroderma. In either case, the finding of LES incompetence, peptic stricture, and distal aperistalsis may be the presenting manifestation in either scleroderma or Raynaud's disease. The present study fails to define unequivocal criteria that would distinguish those patients with gastroesophageal reflux who will eventually develop a peptic stricture of the esophagus. However, certain clinical and manometric findings should alert the clinician to potential high-risk patients. Such findings are a long duration of reflux symptoms and the manometric findings of a markedly incompetent LES associated with an abnormality in esophageal peristaltic function.
Digestive Diseases and Sciences, Vol. 24, No. 11 (November 1979)
REFERENCES 1. Creamer B, Donoghue E, Code CF: Pattern of esophageal motility in diffuse spasm. Gastroenterology 34:782-796, 1958 2. Palmer ED: Subacute erosive ("peptic") esophagitis: Clinical study of one hundred cases. Arch Intern Med 94:364374, 1954 3. Cohen S, Harris LD: Does hiatus hernia affect competence of the gastroesophageal sphincter? N Engl J Med 284:10531056, 1971 4. Haddad J: Relation of gastroesophageal reflux to yield sphincter pressures. Gastroenterology 58:175-184, 1970 5. Cohen S, Harris LD: Lower esophageal sphincter pressure as an index of lower esophageal spincter strength. Gastroenterology 58:157-162, 1970 6. Pope CE, II: Is LES enough? Gastroenterology 71:328-329, 1976 7. Fisher RS, Malmud LS, Roberts GS, Lobis IF: The lower esophageal sphincter as a barrier to gastroesophageal reflux. Gastroenterology 72:19-22, 1977 8. Heitman P, Csendes A, Strauszer T: Esophageal strictures and lower esophagus lined with columnar epithelium. Functional and morphologic studies. Am J Dig Dis 16:307-319, 1971 9. Larrain A, Csendes A, Uribe P, Ayala M: Manometric evaluation after posterior gastropexy for treatment of strictures of the esophagus secondary to reflux. Surg Gynecol Obstet 136:564-566, 1973 10. Larrain A, Csendes A, Pope CE, II: Surgical correction of reflux. An effective therapy for esophageal strictures. Gastroenterology 69:578-583, 1975 11. Naef AP, Savary M: Conservative operations for peptic esophagitis with stenosis in columnar-lined lower esophagus. Ann Thorac Surg 13:543- 551, 1972 12. Stanciu C, Bennett JR: Oesophageal acid clearing: One factor in the production of reflux esophagitis. Gut 15:852- 857, 1974 13. DeMeester TR, Johnson LF, Guy JJ, Toscano MS, Hall AW, Skinner DB: Patterns of gastroesophageal reflux in health and disease. Ann Surg 184:459-470, 1976 14. Johnson LF, DeMeester TR, Haggitt RC: Esophageal epithelial response to gastroesophageal reflux. A quantitative study. Am J Dig Dis 23:498-509, 1978 15. Cohen S, Fisher RS, Lipshutz WH, Turner R, Myers A, Schumacher R: The pathogenesis of esophageal dysfunction in scleroderma and Raynaud's disease. J Clin Invest 51:2663- 2668, 1972
861
To determine the possible factors that may contribute to the development of peptic stricture of the esophagus, clinical and manometric features were compared in patients with symptomatic gastroesophageal reflux and those with peptic strictures of the esophagus. Patients with stricture were older and had a longer duration of heartburn than patients without a stricture. Most importantly, patients with stricture had a more marked decrease in lower esophageal sphincter (LES) pressure, 4.9 +- 0.5 mm Hg, than patients without a stricture, 7.5 +- 0.6 mm Hg, P < 0.01. The LES pressure in all patients with stricture was below 8 mm Hg, and did not overlap with normal values. Patients with stricture had either a nonspeeific motor abnormality or aperistalsis (64%), compared to patients with symptomatic reflux (32%), P < 0.05. Thus, peptic stricture of the esophagus is commonly associated with a long duration of reflux symptoms in patients with a very low LES pressure and esophageal motor disorder.
Stricture of the esophagus is one of the major complications of s y m p t o m a t i c gastroesophageal reflux. The clinical factors related to stricture formation are poorly understood. It is unclear why only certain patients with gastroesophageal reflux develop this complication while other s y m p t o m a t i c patients do not. To a n s w e r this question, clinical and m a n o metric features were c o m p a r e d in a group o f patients with d o c u m e n t e d stricture of the esophagus and a group o f patients with p r o m i n e n t s y m p t o m s o f g a s t r o e s o p h a g e a l reflux. The results o f these studies indicate that patients with stricture h a v e a longer history o f reflux s y m p t o m s and also h a v e the combination o f a m a r k e d r e d u c t i o n in l o w e r e s o p h a g e a l s p h i n c t e r ( L E S ) pressure and abnormalities in esophageal peristaltic activity. Manuscript received April 30, 1979; revised manuscript received July 13, 1979; accepted July 16, 1979. From the Gastrointestinal Section of the Department of Medicine, University of Pennsylvania at the Hospital of the University of Pennsylvania and Graduate Hospital, Philadelphia, Pennsylvania. Address for reprint requests: Dr. Sidney Cohen, Gastrointestinal Section, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104.
858
M A T E R I A L S AND M E T H O D S Three groups of subjects and patients were studied: First, 25 normal subjects without esophageal symptoms or known esophageal disease; second, 25 consecutive patients with prominent symptoms of heartburn as their predominant complaint, a positive Bernstein test but no evidence of esophageal stricture on x-ray or endoscopy; third, 25 consecutive patients with benign peptic stricture of the esophagus, as shown on x-ray and endoscopy. All patients were seen at the Hospital of the University of Pennsylvania from January 1975 to the present time. All patients underwent esophageal manometry, barium swallow, and fiberoptic endoscopy. A stricture of the esophagus is defined as a concentric narrowing of the esophageal lumen as diagnosed by a radiologist during barium swallow. Patients with esophageal malignancy or caustic injury are excluded. Manometric studies were performed with the patients resting quietly in the supine position after an 8-hr fasting period. Belt pneumographs around the chest and over the larynx were used to monitor respiration and swallowing, respectively. Water-filled polyvinyl catheters, 1.4 mm internal diameter, were used to transmit intraluminal pressures to external transducer (Statham p23 series). The output from each transducer was recorded on a Beckman rectilinear ink-writing recorder. Three recording catheters were arranged to form a single assembly with three side orifices, 1.2-mm diameter, at 5.0-cm intervals. The Digestive Diseases and Sciences, Vol. 24, No. 1l (November 1979)
0163-2116/79/1100-0858503.00/1 9 1979DigestiveDiseaseSystems,Inc.
PEPTIC STRICTURES OF THE ESOPHAGUS TABLE 1. COMPARISON OF PATIENT AGE AND DURATION OF HEARTBURN IN THE TWO GROUPS
Age* (yr) Symptomatic gastroesophageal reflux Peptic stricture
-rE
Duration o f heartburn* (yr)
35 30
#_25 48.6 • 3.7 56.4 • 2.1
2.9 • 0.6 6.7 • 1.5
o~o
_~ ZO
tC3. O3
*Mean • SEM.
-
15
g ~o
oo~o
o
pressure recording tubes were infused with distilled water by a syringe pump at a constant rate of 1.2 ml/min. All pressures were expressed using gastric pressure as a zero reference. The recording assembly was positioned with all orifices in the stomach. After a rest period, the assembly was moved at 1-cm intervals through the full length of the esophagus. Pressures were expressed as the mean value of the recording from each of the three catheters as obtained from the zone of maximal lower esophageal sphincter pressure. The recording system gave a greater than 250 mm Hg rise in LES pressure upon occlusion of the recording orifice. Esophageal manometric records were tabulated for the mean LES pressure in each subject and patient. Esophageal peristalsis to dry and wet swallows were evaluated for propagation over the three recording orifices. The percentages of total esophageal responses that were simultaneous (nonpropulsive) or repetitive were tabulated for each individual. A wave was considered abnormal if two consecutive recording sites showed either a nonpropulsive or repetitive contraction. Records were interpreted in a blinded fashion by two investigators. Statistical analysis was performed using the Student's t test.
RESULTS In Table 1 is shown a comparison of age and duration of symptoms in all patients. Patients with reflux symptoms and a positive Bernstein test (11 males, 14 females) were significantly younger than the patients with stricture (13 males, 12 females) (P > 0.05). The duration of heartburn at time of presentation was greater in the stricture group (P < 0.05). All patients with stricture had dysphagia, with a mean duration of 5.2 -- 1.2 years. Dysphagia was not present in any patient with reflux symptoms, alone. In Figure 1 is shown the L E S pressures as obtained in all subjects and patients. The mean L E S pressure in patients with reflux was 7.5 - 0.6 mm Hg as c o m p a r e d to 19.2 - 1.3 mm Hg in normal subjects (P < 0.01). Patients with stricture had mean L E S pressure of 4.9 - 0.5 mm Hg, a level significantly less than recorded in either the normal Digestive Diseases and Sciences, Vol. 24, No. 1l (November 1979)
O00
hi
o~oo
31
0 ..1
o~
0
, OO00 ~ oooo
i
Normal
Reflux
Stricture
Fig 1. Lower esophageal sphincter pressures in normal subjects, in patients with symptomatic gastroesophageal reflux with a positive Bernstein test, and in patients with a peptic stricture of the esophagus. The mean • SEM is shown for each group.
or reflux groups (P < 0.01). H o w e v e r , it is important to note that while symptomatic reflux patients showed an overlap with the normals, the stricture group showed no such overlap in individual L E S pressures. All patients with peptic stricture had an L E S pressure below 8.0 mm Hg, while 24% of reflux patients had an L E S pressure above 10 mm Hg. In Figure 2 the changes in esophageal peristalsis are shown. Esophageal motor function is classified as normal, nonspecific motor abnormality, and aperistalsis. Normal is defined as having over 85% progressive peristaltic waves (1). Nonspecific motor abnormality is defined as having 15% or greater simultaneous or repetitive contractions. Aperistalsis is defined as having absent or very low amplitude (less than 5 mm Hg) peristaltic waves in the distal two thirds of the esophagus. Patients with reflux had normal peristalsis in 68% of patients, while 32% showed a nonspecific motor abnormality. In patients with stricture, normal peristalsis was infrequent with most patients having nonspecific motor abnormalities or aperistalsis. The total percent of patients with stricture having motor dysfunction (64%) was significantly greater than the total number of patients with reflux having motor abnormalities (32%), (P < 0.05). Associated diseases were also evaluated in all patients. In the stricture group, three patients were found to have scleroderma, and three had idiopathic Raynaud's disease without other evidence of rheu-
859
AHTARIDIS ET AL
~_
9
D S,rictore
# 0 9 Normal
Non-Specific Motor Disorder
Distal Aperistalsis
Fig 2. Percent of patients with symptomatic gastroesophageal reflux and patients with peptic stricture of the esophagus who have normal peristalsis, a nonspecific motor abnormality or aperistalsis.
matic disease. All six patients had distal aperistalsis. Other associated diseases were not noted in the reflux patients or other patients with stricture, except one patient with stricture had several episodes of pneumonia.
DISCUSSION Peptic stricture of the esophagus is a recognized major complication of gastroesophageal reflux occurring in about 11% of patients with reflux disease (2). The specific etiology of peptic stricture is unclear. The purpose of the present study is to evaluate the clinical and manometric features in patients with peptic stricture, and to compare these findings to those in a similar group of patients with symptomatic gastroesophageal reflux but no stricture formation. These studies demonstrate several important findings. First, patients with stricture formation are older and generally have a longer duration of reflux symptoms. Second, all patients with stricture have an LES pressure below 8 mm Hg. Third, many patients with stricture have an underlying motor abnormality of the esophagus that may be nonspecific in character, or related to scleroderma or Raynaud's disease. In the present study, consecutive patients with stricture formation as diagnosed by radiographic examination were compared to a parallel, consecutive group of patients with prominent gastroesophageal reflux disease. The latter group was diagnosed on the basis of their typical symptoms of heartburn and a positive Bernstein test. Heartburn, the classical symptom of reflux, was present in all patients. The duration of symptoms in the stricture group was significantly longer, suggesting chronicity of reflux as being related to stricture formation.
860
However, considerable overlap in duration of symptoms in individuals in each group was noted. Patients with strictures were also older, consistent with this longer duration of symptoms. Surprisingly, the duration of dysphagia in the stricture group was longer than expected, indicating a chronic, slow-developing process prior to presentation or referral to a specialist. Patients with reflux alone had no dysphagia. All patients with stricture had a markedly incompetent LES, with no value being above 8.0 mm Hg. There was no overlap in LES pressures in this group with our normals. There was marked overlap in LES pressure with the reflux patients. However, the reflux patients without stricture did have a slightly higher mean LES value and did overlap with normals. This observation may be of importance. Several previous reports have demonstrated that patients with reflux have a mean LES pressure below the normal level, but individual values may overlap with the normal range as confirmed in this Present study (3-5). This observation has led to the suggestion by some investigators that the LES pressure may be helpful, but overall it is not of great value in diagnosing reflux disease (6, 7). The present study suggests that finding a very low LES pressure may be of value in distinguishing patients at risk for developing a stricture or other complications of reflux disease. Lower esophageal sphincter pressures have been reported only in several studies where the scope of the investigation was confined to peptic stricture (8). In reports confined to patients with strictures, a mean LES pressure of 4.5 -+ 0.5 mm Hg was found (8, 9). However, there was minimal overlap of LES pressure with normals. Pressures of 10 mm Hg were measured in two patients, and 12 mm Hg in one patient. The LES pressures in the presently reported patients and the patients in the two published reports would indicate that the overlap with normal values as seen in reflux disease is less common in patients with stricture. Further support for this finding is found in studies showing that surgical restoration of LES competence without stricture dilation resulted in spontaneous regression of the stricture (10, 11). Abnormalities in esophageal peristalsis were observed in patients with stricture and those with reflux only. The frequency of these abnormalities was higher in the stricture group, but this difference was due mainly to the patients with distal aperistalsis in the stricture population. Nonspecific motor abnorDigestive Diseases and Sciences, Vol. 24, No. 11 (November 1979)
PEPTIC STRICTURES OF THE ESOPHAGUS malities consisting of simultaneous or repetitive contractions have been noted frequently in patients with esophagitis or stricture. In one report, all patients with stricture had this type of motor abnormality (8). It has been shown that the highest incidence and more severe grades of esophagitis were found in patients with excessive acid exposure in the supine position as a result of delayed esophageal acid clearing (12, 13). Impaired peristaltic function may therefore contribute to esophagitis or stricture formation (14). The patients with distal aperistalsis, with either scleroderma or Raynaud's phenomenon, presented with esophageal disease as their major symptom. In three patients, classic skin changes of scleroderma were observed, and the patients met the critiera for the diagnosis of this disease (15). It is important to emphasize that the scleroderma and its associated n o n e s o p h a g e a l manifestations were minimal in these patients and previously not recognized. Raynaud's disease without scleroderma has been associated with distal aperistalsis and L E S incompetence (15). It is unclear whether these patients will e v e n t u a l l y d e v e l o p scleroderma, or whether the manometric changes are a false-positive manifestation of scleroderma. In either case, the finding of LES incompetence, peptic stricture, and distal aperistalsis may be the presenting manifestation in either scleroderma or Raynaud's disease. The present study fails to define unequivocal criteria that would distinguish those patients with gastroesophageal reflux who will eventually develop a peptic stricture of the esophagus. However, certain clinical and manometric findings should alert the clinician to potential high-risk patients. Such findings are a long duration of reflux symptoms and the manometric findings of a markedly incompetent LES associated with an abnormality in esophageal peristaltic function.
Digestive Diseases and Sciences, Vol. 24, No. 11 (November 1979)
REFERENCES 1. Creamer B, Donoghue E, Code CF: Pattern of esophageal motility in diffuse spasm. Gastroenterology 34:782-796, 1958 2. Palmer ED: Subacute erosive ("peptic") esophagitis: Clinical study of one hundred cases. Arch Intern Med 94:364374, 1954 3. Cohen S, Harris LD: Does hiatus hernia affect competence of the gastroesophageal sphincter? N Engl J Med 284:10531056, 1971 4. Haddad J: Relation of gastroesophageal reflux to yield sphincter pressures. Gastroenterology 58:175-184, 1970 5. Cohen S, Harris LD: Lower esophageal sphincter pressure as an index of lower esophageal spincter strength. Gastroenterology 58:157-162, 1970 6. Pope CE, II: Is LES enough? Gastroenterology 71:328-329, 1976 7. Fisher RS, Malmud LS, Roberts GS, Lobis IF: The lower esophageal sphincter as a barrier to gastroesophageal reflux. Gastroenterology 72:19-22, 1977 8. Heitman P, Csendes A, Strauszer T: Esophageal strictures and lower esophagus lined with columnar epithelium. Functional and morphologic studies. Am J Dig Dis 16:307-319, 1971 9. Larrain A, Csendes A, Uribe P, Ayala M: Manometric evaluation after posterior gastropexy for treatment of strictures of the esophagus secondary to reflux. Surg Gynecol Obstet 136:564-566, 1973 10. Larrain A, Csendes A, Pope CE, II: Surgical correction of reflux. An effective therapy for esophageal strictures. Gastroenterology 69:578-583, 1975 11. Naef AP, Savary M: Conservative operations for peptic esophagitis with stenosis in columnar-lined lower esophagus. Ann Thorac Surg 13:543- 551, 1972 12. Stanciu C, Bennett JR: Oesophageal acid clearing: One factor in the production of reflux esophagitis. Gut 15:852- 857, 1974 13. DeMeester TR, Johnson LF, Guy JJ, Toscano MS, Hall AW, Skinner DB: Patterns of gastroesophageal reflux in health and disease. Ann Surg 184:459-470, 1976 14. Johnson LF, DeMeester TR, Haggitt RC: Esophageal epithelial response to gastroesophageal reflux. A quantitative study. Am J Dig Dis 23:498-509, 1978 15. Cohen S, Fisher RS, Lipshutz WH, Turner R, Myers A, Schumacher R: The pathogenesis of esophageal dysfunction in scleroderma and Raynaud's disease. J Clin Invest 51:2663- 2668, 1972
861
