Clinical and Manometric Investigations of the Lower Esophageal Sphincter and its Reactivity to Pentagastrin in Patients with Hiatus Hernia

Abstract

After a careful clinical investigation (anamnesis, analysis of stomach secretion, X-ray tests, esophagoscopy with biopsies) of 45 patients with axial hiatus hernia and 20 healthy volunteers with no radiological signs of reflux, manometric analysis of the lower esophageal sphincter (LES) was performed. The manometric tests applied were: (1) 3-point manometry for measuring the reflexive pressure increase in the LES after abdominal compression and (2) the continuous withdrawal method before and after intravenous injection of 0.6 µg/kg pentagastrin (LES pentagastrin test). According to the results obtained by all methods applied, the patients with hiatus hernia could be divided into two groups. Group I consists of 12 patients with moderate clinical symptoms and essentially normal pressures and reactions of the LES. Group II comprises 33 patients with more severe symptomatology such as X-ray evidence of reflux (33), stenosis (3) or esophagitis of the lower esophagus (17), hyperacidity of the stomach (5), insufficient reaction of the LES to abdominal compression (29), reduced maximum pressure in the LES and an abnormally low response of the LES to intravenous pentagastrin (19). Essentially by means of the results of the LES pentagastrin test, group II could by subdivided into group IIA, with a normal, and group IIB with significantly reduced pentagastrin response. There was a good correlation between the reduced pentagastrin response and the exhibition of more severe symptoms of the other parameters tested. Thus, it could be shown that the LES-pentagastrin test could contribute to a further differentiation, which is important in respect to the therapeutic consequences and assist in a better understanding of the pathophysiological basis of the disease.

The Relationship between Serum IRG Levels and LES Pressure under Various Conditions

“…On the other hand, if the lack of gastrin is responsible alone for the disturbance of the LES function a substitution of gastrin ought to improve the sphincter function. We must agree with Farrell et al (9) that the insufficient sphincter in patients with reflux esophagitis even shows a diminished reaction to exogenous injection of penta gastrin (25). In our opinion these findings cannot be taken as proof of the importance of gastrin for sphincter function in reflux disease.…”

“…From the experiments with exogenous injection of pentagastrin and gastrin we know that the LES reacts directly upon a changing in serum gastrin levels (5,25,32). Therefore, the delayed reaction of the LES in the investiga tions of Farrell et al (9) is difficult to explain.…”

Responses of the competent and incompetent lower oesophageal sphincter to pentagastrin and abdominal compression.

“…The demonstrations that human LOS pressure could be modified by gastric infusions of acid and alkali (Castell and Harris, 1970;Beiles et al, 1972;Castell and Levine, 1972;Higgs et al, 1974); that LOS pressure could be consistently increased by gastrin and pentagastrin (Giles et al, 1969;Castell and Harris, 1970;Cohen and Lipshutz, 1971;Lipshutz et al, 1973;Siewert et al, 1974;Trindade et al, 1975); and that LOS pressure in the opossum could be drastically diminished by the use of gastrin antiserum (Lipshutz, et al, 1972) led to the proposal that gastrin was of primary importance in the regulation of LOS pressure. Recent studies, however, have cast considerable doubt upon the physiological relevance of gastrin in this context (Grossman, 1973;Sturdevant and Kun, 1973;Farrell et al, 1974;Goyal and McGuigan, 1975;Walker et al, 1975).…”

Klinische Ergebnisse der Fundoplicatio

“…Voraussetzung ffir eine erfolgreiche Fundoplicatio ist daher ein erniedrigter Druck im unteren Oesophagussphincter. Wie unsere Untersuchungen an Refluxpatienten zeigen, geht durchaus nicht jeder gastrooesophageale Reflux mit einer deutlichen Sphincterhypotonie einher [22]. Erst beim Vorliegen einer Oesophagitis ist mit einer eindeutigen Sphincterhypotonie zu rechnen.…”