Mechanisms of gastroesophageal reflux in ambulant healthy human subjects

doi:10.1016/0016-5085(95)90011-X

Gastroenterology

Volume 108, Issue 1, January 1995, Pages 83-91

https://doi.org/10.1016/0016-5085(95)90011-X Get rights and content

Abstract

$Background/Aims$ : Investigation of the motor events underlying gastroesophageal reflux has largely been confined to resting, recumbent subjects. The motor events associated with reflux during physical activity remain unknown. The aim of this study was to investigate the patterns of lower esophageal sphincter (LES) function underlying reflux in healthy subjects and the effect of exercise and physical activity on reflux mechanisms. $Methods$ : LES pressure was recorded with a perfused sleeve sensor in 10 healthy subjects; intraluminal transducers recorded pressure in the stomach, esophagus, and pharynx, and pH was recorded 5 cm above the LES. Signals were stored in a portable datalogger. Recordings were made for 24 hours, including moderate physical activity, periods of rest and sleep, standardized meals, and standardized exercise. $Results$ : Most reflux episodes (81 of 123; 66%) occurred in the 3 hours after food intake: only 2 episodes occurred during exercise. LES pressure was ≤3 cm H₂O in 79% of reflux episodes. Transient LES relaxation was the mechanism of reflux in 82% of episodes, irrespective of activity or body position, whereas swallow-related LES relaxations accounted for 13% and persistently absent LES pressure accounted for 1%. Straining occurred in only 20% of episodes. $Conclusions$ : In ambulant healthy subjects, accurate continuous recording of LES function is possible, reflux usually occurs during transient LES relaxations, and straining is not a major factor in the induction of reflux.

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A majority of patients with gastroesophageal reflux disease (GERD) have normal endoscopy. We aimed to investigate whether esophageal primary and secondary peristalsis influence esophageal reflux parameters in patients with normal endoscopy.
We enrolled consecutive patients with typical reflux symptoms and normal endoscopy. All patients underwent High resolution manometry (HRM) and 24-h impedance-pH studies off therapy. During HRM, secondary peristalsis was evaluated using ten 20-mL rapid air infusions into the esophagus, while primary peristalsis was evaluated using ten 5-mL water swallows.
A total of 43 patients completed the study; 13 patients had normal motility, 20 had ineffective esophageal motility (IEM), and 10 had absent contractility. Acid exposure time (AET) (total, supine, and upright) was significantly higher in those with absent primary peristalsis (absent contractility) compared to normal motility (P = 0.001; 0.01; 0.007) and IEM (P = 0.002; 0.02; 0.03). Supine AET was significantly higher in patients without secondary peristalsis compared to those with secondary peristalsis (P = 0.04).
In the setting of normal endoscopy, acid reflux burden is more profound in patients with absent primary peristalsis, as well as in patients lacking a secondary peristaltic response to esophageal air distension.
Clinical impact of gastroesophageal reflux disease in patients with subacute/chronic cough
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While gastroesophageal reflux disease (GERD) is one of the commonest causes of subacute/chronic cough along with cough-variant asthma (CVA) and rhinosinusitis, its clinical impact remains unknown. Therefore, we sought to investigate the impact of GERD in patients with subacute/chronic cough.
Between April 2012 and March 2018, a total of 312 patients presenting subacute or chronic cough lasting for ≥3 weeks [median cough duration, 4.9 (0.7–434) months] underwent diagnostic tests. GERD symptoms and cough-specific QoL were evaluated through the Frequency Scale for Symptoms of Gastroesophageal reflux (FSSG) and the Japanese version of the Leicester Cough Questionnaire (J-LCQ). According to the FSSG domains, patients with GERD were arbitrarily categorized into 3 groups; acid-reflux predominant, dysmotility predominant, and pauci-symptoms groups, respectively.
The average scores of J-LCQ was 12.5 (SD3.7). One hundred-forty three were diagnosed as having GERD-related cough based on classical reflux symptoms including heartburn and characteristic triggers of cough such as phonation, rinsing, lying, and eating. Most of them (89.8%) had other causative diseases including CVA. Cough lasted longer (p = 0.019) and required a longer time until alleviation (p = 0.003) in patients with GERD than in those without GERD. They also scored lower J-LCQ than counterpart group (p < 0.0001). In terms of symptom stratification, dysmotility predominant group showed significant more response to specific GERD treatments than the remnants (p = 0.002).
These results indicate that GERD is associated with the aggravation of other causes including CVA. Particularly, dysmotility symptoms may be potential therapeutic target for GERD-related cough.
The consumption of snacks and soft drinks between meals may contribute to the development and to persistence of gastro-esophageal reflux disease
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The habit of snacking and drinking soft beverages between breakfast, lunch and dinner, which is very widespread in the western world, could be a primum movens, thereby contributing to the development and subsequent persistence of gastroesophageal reflux disease (GERD).
The high prevalence of GERD suggests that it is very probably caused by factors, which are intrinsic and widespread in a western lifestyle. Ingesting snacks or imbibing soft drinks between breakfast, lunch and dinner causes additional gastric acid secretion, acid pocket formation, and additional transient lower esophageal sphincter relaxations (TLESRs) with acid reflux; the latter are proportional to the number of ingestions. Moreover, there is increased esophageal acid exposure, which can last up to several hours in a 24-h period. The majority of patients with GERD do not have a hiatal hernia, and TLESRs are the main pathophysiological factor, resulting in an increase in esophageal acid exposure and, therefore, symptoms and the disease. Overweight/obese people very frequently consume snacks and imbibe soft drinks between breakfast, lunch and dinner and they would, therefore, share according to the hypothesis of the authors of this paper. That is, the same eating habit can cause the two conditions obesity and GERD.
Every time a snack is ingested or a soft drink imbibed between the three daily meals, gastric acid is re-secreted, the acid pocket reforms, the TLESRs are triggered again and acid reflux events recur. The greater the number of snacks and/or soft drinks consumed, the greater the esophageal engagement of the cleaning system with, over time, increasing impairment. This mechanism may account for disease onset. According to the hypothesis outlined in this paper, GERD patients should consume moderate portions constituting three meals a day, thereby limiting the quantity of acid reflux from TLESRs.
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Citation Excerpt :
After a reflux episode, swallow-induced or primary peristalsis effects volume clearance and helps swallowed saliva reach the distal esophagus to neutralize acid.27 Because sleeping inhibits swallowing, secondary or distention-induced peristalsis may be more important during night time as a protective mechanism from refluxate.20,28 Schoeman and Holloway29 showed that the rate of triggering secondary peristalsis in response to esophageal distention was significantly lower in patients with GERD compared to healthy subjects.
This relationship between gastroesophageal reflux and airway disorders is complex, possibly bidirectional, and not clearly defined. The tools used to investigate gastroesophageal reflux are mostly informative about involvement of gastroesophageal reflux within the gastrointestinal tract, although they are often utilized to study the relationship between gastroesophageal reflux and airway issues with are suspected to occur in relation to reflux. These modalities often lack specificity for reflux-related airway disorders. Co-incidence of gastroesophageal reflux and airway disorders does not necessarily infer causality. While much of our focus has been on managing acidity, controlling refluxate is an area that has not been traditionally aggressively pursued. Our management approach is based on some of the evidence presented, but also often from a lack of adequate study to provide further guidance.
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^☆: Supported by a project grant from the National Health and Medical Research Council. Dr. Schoeman is supported by a National Health and Medical Research Council Postgraduate Scholarship and a Royal Adelaide Hospital Dawes Scholarship.

^☆☆: Presented at the annual meeting of the American Gastroenterological Association in San Francisco in May 1992 and published in abstract form (Gastroenterology 1992;102:A162).

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Mechanisms of gastroesophageal reflux in ambulant healthy human subjects☆,☆☆

Abstract

Gastroenterology

Gastroenterology

Gastroenterology

Gastroenterology

Gastroenterology

Gastroenterology

Mechanism of gastroesophageal reflux in recumbent asymptomatic human subjects

J Clin Invest

Mechanisms of lower oesophageal sphincter incompetence in patients with symptomatic gastro-oesophageal reflux

Gut

Mechanisms of gastroesophageal reflux in patients with reflux esophagitis

N Engl J Med

Does body posture affect the incidence and mechanism of gastro-oesophageal reflux?

Gut

Esophageal function in patients with angina-like chest pain and normal coronary angiograms

Ann Surg

Exertional gastro-oesophageal reflux: a mechanism for symptoms in patients with angina pectoris and normal coronary angiograms

Br Med J

The effect of different types of exercise on gastro-oesophageal reflux

Gut

Gastroesophageal reflux in runners

Ann Intern Med

Gastroesophageal reflux induced by exercise in healthy volunteers

J Am Med Assoc

Pressure events surrounding oesophageal acid reflux episodes and acid clearance in ambulant healthy volunteers

Gut