Occult (silent) gastroesophageal reflux disease (GER, GERD) is believed to be an important etiologic factor in the development of many inflammatory and neoplastic disorders of the upper aerodigestive tract. In order ot test this hypothesis, a human study and an animal study were performed. The human study consisted primarily of applying a new diagnostic technique (double-probe pH monitoring) to a population of otolaryngology patients with GERD to determine the incidence of overt and occult GERD. The animal study consisted of experiments to evaluate the potential damaging effects of intermittent GER on the larynx. Two hundred twenty-five consecutive patients with otolaryngologic disorders having suspected GERD evaluated from 1985 through 1988 are reported. Ambulatory 24-hour intraesophageal pH monitoring was performed in 197; of those, 81% underwent double-probe pH monitoring, with the second pH probe being placed in the hypopharynx at the laryngeal inlet. Seventy percent of the patients also underwent barium esophagography with videofluoroscopy. The patient population was divided into seven diagnostic subgroups: carcinoma of the larynx (n = 31), laryngeal and tracheal stenosis (n = 33), reflux laryngitis (n = 61), globus pharyngeus (n = 27), dysphagia (n = 25), chronic cough (n = 30), and a group with miscellaneous disorders (n = 18). The most common symptoms were hoarseness (71%), cough (51%), globus (47%), and throat clearing (42%). Only 43% of the patients had gastrointestinal symptoms (heartburn or acid regurgitation). Thus, by traditional symptomatology, GER was occult or silent in the majority of the study population. Twenty-eight patients (12%) refused or could not tolerate pH monitoring. Of the patients undergoing diagnostic pH monitoring, 62% had abnormal esophageal pH studies, and 30% demonstrated reflux into the pharynx. The results of diagnostic pH monitoring for each of the subgroups were as follows (percentage with abnormal studies): carcinoma (71%), stenosis (78%), reflux laryngitis (60%), globus (58%), dysphagia (45%), chronic cough (52%), and miscellaneous (13%). The highest yield of abnormal pharyngeal reflux was in the carcinoma group and the stenosis group (58% and 56%, respectively). By comparison, the diagnostic barium esophagogram with videofluoroscopy was frequently negative. The results were as follows: esophagitis (18%), reflux (9%), esophageal dysmotility (12%), and stricture (3%). All of the study patients were treated with antireflux therapy. Follow-up was available on 68% of the patients and the mean follow-up period was 11.6 +/- 12.7 months.(ABSTRACT TRUNCATED AT 400 WORDS)

The Otolaryngologic Manifestations of Gastroesophageal Reflux Disease (GERD): A Clinical Investigation of 225 Patients Using Ambulatory 24‐Hour pH Monitoring and an Experimental Investigation of the Role of Acid and Pepsin in the Development of Laryngeal Injury

Neurogastroenterology is defined as neurology of the gastrointestinal tract, liver, gallbladder and pancreas and encompasses control of digestion through the enteric nervous system (ENS), the central nervous system (CNS) and integrative centers in sympathetic ganglia. This Review provides a broad overview of the field of neurogastroenterology, with a focus on the roles of the ENS in the control of the musculature of the gastrointestinal tract and transmucosal fluid movement. Digestion is controlled through the integration of multiple signals from the ENS and CNS; neural signals also pass between distinct gut regions to coordinate digestive activity. Moreover, neural and endocrine control of digestion is closely coordinated. Interestingly, the extent to which the ENS or CNS controls digestion differs considerably along the digestive tract. The importance of the ENS is emphasized by the life-threatening effects of certain ENS neuropathies, including Hirschsprung disease and Chagas disease. Other ENS disorders, such as esophageal achalasia and gastroparesis, cause varying degrees of dysfunction. The neurons in enteric reflex pathways use a wide range of chemical messengers that signal through an even wider range of receptors. These receptors provide many actual and potential targets for modifying digestive function.

The enteric nervous system and neurogastroenterology

PREVIOUS STUDIES on the motor activity of the human (6) and canine (4, 5, 7, 8, l0) small intestine have demonstrated the occurrence of migrating motor complexes. The observations, however, were confined to short segments of the bowel, and the electric events responsible for the motor complex were not studied. The purpose of this report is to describe a migrating electric complex that occurs in fasting dogs. The complex is composed of a consecutive series of slow waves, on each of which is superimposed a burst of Iargeamplitude action potentials that distinguish it from other electric activity in the small bowel of fasting dogs. The complex develops in the upper small bowel and then migrates caudad to the ileum; as it terminates there, another starts in the duodenum or upper jejunum, and the recycling continues. A correlation is made between these findings and those relating to migrating motor complexes observed by others. The term electric complex will be used when referring to the migrating bursts of action potentials. It is not meant to signify an electric event that is different from the action potential and slow wave. Rather, it is used to indicate a pattern of electric activity in which action potentials occur

A migrating electric complex of canine small intestine

Intraluminal pressures were measured in the gastric antrum and at different levels of the upper small intestine in 18 normal subjects to investigate whether or not the interdigestive motor complex, identified in several animal species, occurs in man and, if so, to determine its characteristics. In all normal subjects, the activity front of the interdigestive motor complex was readily identified as an uninterrupted burst of rhythmic contraction waves that progressed down the intestine and that was followed by a period of quiescence. Quantitative analysis of various parameters of the complex and simultaneous radiological and manometrical observations revealed that it resembled closely the canine interdigestive motor complex. To test the hypothesis that disorders of this motor complex may lead to bacterial overgrowth in the small intestine, similar studies were performed in 18 patients with a positive 14CO2 bile acid breath test and in an additional control group of 9 patients with a normal 14CO2 breath test. All but five patients had normal interdigestive motor complexes. The five patients in whom the motor complex was absent or greatly disordered had bacterial overgrowth as evidenced by 14CO2 bile acid breath tests before and after antibiotics. These studies establish the presence and define the characteristics of the normal interdigestive motor complex in man. They also suggest that bacterial overgrowth may be due to a specific motility disorder i.e., complete or almost complete absence of the interdigestive motor complex.

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The Interdigestive Motor Complex of Normal Subjects and Patients with Bacterial Overgrowth of the Small Intestine

A sphincter treatment apparatus includes an energy delivery device introduction member including a proximal end with a first radius of curvature and a distal end with a second radius of curvature. The introduction member is configured to be introduced into the sphincter in a non-deployed state and to be expanded to a deployed state to at least partially expand the sphincter or an adjoining structure. An energy delivery device is coupled to the introduction member. A retainer member is coupled to the energy delivery device introduction member and configured to controllably position the introduction member in an orifice of the sphincter.

Sphincter treatment apparatus

The gastroesophageal sphincter in healthy human beings.

Functional significance of gastric mucosal barrier to sodium.

KELLY, KEITH A., CHARLES F. CODE, AND LILA R. ELVEBACK. Patterns uf canine gastric electrical activity. Am. J. Physiol. 2 17C2) : 46 l-470. 1969.~Eight electrodes were implanted serially from the fundus to the pylorus on the gastric wall of 12 dogs. After recovery, electrical activity was recorded during fasting and after gastric-balloon distention and gastric instillation of water and cottonseed oil, and correlated with intraluminal pressure and cinefluoroscopic observations. In fasting animals a regular, triphasic fluctuation in electrical potential, the pacesetter potential (PP), was detected by an orad corporal electrode and by all others caudad to it. Its amplitude was greater in the antrum than in the corpus, but its frequency (5.3 cycles/min) was the same in the two sites. Its velocity increased with caudad propagation. Action potentials (AP), indicating contractions, were superimposed on 26% of the fasting antral cycles. Balloon distention decreased PP frequency, slowed the velocity of corporal and enhanced the velocity of antral propagation, and increased the incidence of antral AP. Water instillation decreased PP frequency, slowed the velocity of corporal propagation, slowed or enhanced the velocity of antral propagation, and increased the incidence of antral AP. Oil instillation caused wide variations in PP frequency, slowed the velocity of corporal and antral propagation, and decreased the incidence of antral AP,

Charles F. Code

Papers

The gastroesophageal sphincter in healthy human beings.

Functional significance of gastric mucosal barrier to sodium.

Patterns of canine gastric electrical activity.

Control of the interdigestive myoelectric activity in dogs by the vagus nerves and pentagastrin.

Histamine and gastric secretion.