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Biomedical subjects

J E Richter

Publications and source records attributed to J E Richter.

At least 19 recordsLinked to original sources
PubMed1992

The contribution of gastroesophageal reflux to chest pain in patients with coronary artery disease.

OBJECTIVE: To describe the effectiveness of investigating and treating the cause of refractory chest pain in patients with coronary artery disease who are receiving optimal antianginal therapy. DESIGN: Cohort study. SETTING: Tertiary referral center. PATIENTS: Between January 1988 and December 1989, 34 patients were identified as having angiographically proven coronary artery disease and atypical chest pain symptoms despite their having received aggressive medical or surgical antianginal therapy, or both. INTERVENTION: Patients with confirmed acid-related symptoms were treated with high-dose histamine-2 (H2) blockers or omeprazole for 8 weeks in an open-label study. MEASUREMENTS: Esophageal manometry and simultaneous 24-hour pH and Holter studies; global improvement in or disappearance of chest pain. RESULTS: Of the 34 patients, 30 (88%) experienced their identical chest pain symptoms during the study. A total of 164 pain episodes was recorded: 38 (23.2%) correlated with acid reflux; 6 (3.7%) were related to cardiac ischemia; and the remaining 120 (73.2%) had no identifiable cause. Of these 30 patients, 20 (67%) had some of their episodes of chest pain (range, 14% to 100%) secondary to acid reflux. After 8 weeks of vigorous acid suppression, 13 of these 20 patients had marked improvement or resolution of chest pain. Four other patients had ischemia-related episodes of chest pain that responded to more aggressive antianginal therapy. No episodes of acid reflux were clearly followed by ischemic chest pain. One patient had both acid- and ischemic-related episodes of chest pain that were indistinguishable. Overall, 24 of 34 (71%) patients had a definite cause of chest pain identified by combined pH and Holter monitoring. CONCLUSIONS: Gastroesophageal reflux disease is a common, treatable cause of chest pain in patients with coronary artery disease who have atypical symptoms and remain symptomatic despite aggressive antianginal therapy. Combined Holter and 24-hour esophageal pH studies are complementary investigations for elucidating the cause of chest pain in these patients.

Adult↗
PubMed1992

Overview of diagnostic testing for chest pain of unknown origin.

Identifying the cause of recurrent chest pain may be difficult. Significant coronary artery disease must be excluded before patients can be assured that their symptoms are truly "noncardiac." A normal coronary angiogram is the most definitive test but this may not preclude the presence of a new "fly in the ointment," i.e., microvascular angina. Musculoskeletal pain syndromes, psychological problems, and esophageal disorders, including both esophageal motility disorders and gastroesophageal reflux disease, are the most common causes of noncardiac chest pain. Nearly 30% of these patients will have an esophageal motility disorder, although its clinical relevance in the asymptomatic patient is controversial. Simple, inexpensive, provocation tests (most commonly edrophonium, bethanechol, and/or balloon distention) have been developed to recreate motility-related chest pain in the laboratory. These tests can identify the esophagus as the source of pain, but in most cases they do not direct therapy. Other disadvantages of provocation tests include the lack of a gold standard reference point, side effects, and the need for placebo because of a subjective end point. Recently, ambulatory esophageal pH and pressure monitoring have been used to define precisely the cause of esophageal chest pain. These systems can record multiple episodes of pain for up to 24 hours in an outpatient setting and have shown that gastroesophageal reflux (rather than motility disorders) is the most common esophageal cause of pain. However, these studies also suggest that many episodes of chest pain do not have an identifiable esophageal cause. Furthermore, this equipment is expensive, uncomfortable, may alter normal activity, and is not useful in patients having infrequent pain episodes. Psychological disturbances should be carefully sought in any patient with noncardiac chest pain: Many patients have anxiety, depression, or panic attacks that may complicate or contribute to their reported symptoms. It is questionable if these patients need additional testing. Rather, the challenge of the future is to prove that the multitude of tests aid in the overall treatment and outcome of patients with noncardiac chest pain.

Angina Pectoris↗
PubMed1992

Psychosocial and psychophysical assessments of patients with unexplained chest pain.

It is imperative to assess the psychosocial factors that may influence the subjective experiences and pain behavior of persons with chronic unexplained chest pain. Both psychologists and physicians tend to rely on self-report measures of psychological distress, which provide little unique information about patients with chronic chest pain to differentiate them from patients with other painful disorders such as irritable bowel syndrome, gastroesophageal reflux disease, or coronary artery disease. However, assessment of pain-coping strategies, spouse responses to the patient's pain behaviors, and pain thresholds for esophageal balloon distention do differentiate patients with chronic chest pain from healthy controls and patients with various other chronic pain disorders. Specifically, chronic chest pain patients tend to use relatively passive pain-coping strategies such as praying and hoping, and to report relatively high levels of spouse reinforcement of pain behaviors. Finally, in response to esophageal balloon distention, chronic chest pain patients display low pain thresholds that do not generalize to stimulation by mechanical finger pressure. Preliminary evidence suggests these low thresholds are due primarily to a tendency to set low standards for making pain judgments regarding esophageal stimuli of moderate-to-high intensity levels.

Adaptation, Psychological↗
PubMed1992

Gastroesophageal reflux: diagnosis and management.

The pathologic potential of chronic esophagitis cannot be overemphasized. Persistent reflux causing cycles of mucosal damage followed by healing may eventually lead to end-stage disease, with development of peptic stricture. The most effective drugs available are those that inhibit acid production. Drugs that will enhance lower esophageal function are still in the future.

Alginates↗
PubMed1992

A comparative cytopathologic and histologic study of atypia, dysplasia, and adenocarcinoma in Barrett's esophagus.

As a potentially premalignant condition, Barrett's esophagus has stimulated controversy over the need for surveillance of glandular dysplasia and early carcinoma. This prompted the authors to review their experience with endoscopic cytologic brushings and biopsies from patients with Barrett's esophagus. The authors reviewed 65 consecutive specimens from 42 patients with Barrett's esophagus in which both the concurrently obtained esophageal cytologic brushings and companion biopsy specimens were available. In addition, esophagogastrectomy specimens from 9 nine these patients were reviewed. Cytologic and histologic specimens were assigned to one of four diagnostic categories, based on specifically defined criteria: simple Barrett's esophagus with or without inflammatory atypia; dysplasia; adenocarcinoma; or suspicious for dysplasia or carcinoma. Simple Barrett's esophagus was diagnosed in 38 cytologic brushings and 44 biopsy specimens, dysplasia in 4 brushings and 7 biopsy specimens, and carcinoma in 14 brushings and 10 biopsy specimens. Nine brushings and three biopsy specimens were suspicious. In 13 cases, brushings revealed a higher grade lesion than did histology; in 5 cases, biopsy specimens showed a higher grade lesion. Agreement between the two occurred in 72% (47/65) of all specimens. Accuracy was confirmed in the histologic examinations of the resection specimens. The authors conclude that specific criteria, when consistently applied, allow accurate cytologic diagnoses of epithelial changes in Barrett's esophagus. The use of esophageal brush cytology and biopsy specimens provides two complementary techniques, which detect a greater number of serious lesions than either technique alone.

Adenocarcinoma↗
PubMed1992

Effects of a pH electrode across the lower esophageal sphincter.

Recent studies have suggested that combined monitoring of the esophagus and stomach for prolonged periods may be the best method for investigating patients with upper gastrointestinal complaints. However, the effects of an electrode across the LES on esophageal reflux parameters have not been extensively studied. We studied 10 healthy volunteers and 10 patients with GERD twice with 24-hr pH monitoring. In phase 1, two glass electrodes were placed 1 cm below the UES and 5 cm above the LES. One week later in phase 2, patients were restudied with one electrode 5 cm above and one 5 cm below the LES. Although total acid exposure remained the same in healthy volunteers, three volunteers who spontaneously refluxed at night had abnormal prolongation of their supine acid exposure during phase 2 of the study. In patients with GERD, the electrode across the LES resulted in significant (P = 0.01) increase in supine acid exposure and showed a strong tendency for the number of reflux episodes greater than 5 min supine (P = 0.02) and longest reflux episode supine (P = 0.06) to increase without a change in the number of reflux episodes. In conclusion, a small glass electrode across the LES results in prolongation of supine acid exposure in both healthy volunteers spontaneously refluxing at night and the majority of patients with GERD. This results from the electrode interfering with clearance of refluxed acid in the supine position. Thus, combined esophageal and gastric pH monitoring may have important limitations in investigating gastroesophageal symptoms.

Circadian Rhythm↗
PubMed1992

Gastroesophageal pH step-up inaccurately locates proximal border of lower esophageal sphincter.

Limiting the widespread use of 24-hr pH monitoring is the necessity of manometrically placing the pH probe 5 cm above the proximal lower esophageal sphincter (LES) border. Therefore, we prospectively compared LES localization by gastroesophageal pH step-up with manometry in 71 patients and 14 asymptomatic volunteers. The gastroesophageal pH step-up significantly correlated with the proximal LES border in patients (r = 0.53, P less than 0.0001) and volunteers (r = 0.91, P less than 0.0001). Based on previously published criteria, the pH step-up value was considered acceptably accurate if it was within +/- 3 cm (6 cm total span) of the manometrically determined proximal LES border. In 58% of patients and 29% of volunteers the pH step-up occurred outside this accuracy range. Esophagitis (P = 0.015) and abnormal reflux parameters (P = 0.002) were variables contributing to this error. Subsequent analysis found that the pH step-up overestimated the proximal LES border and occurred at the midportion of the sphincter. The pH step-up still inaccurately located the mid LES in 34% of patients. Therefore, manometry should remain the standard for accurate LES localization prior to placing the pH probe.

Adolescent↗
PubMed1992

Normal 24-hr ambulatory esophageal pH values. Influence of study center, pH electrode, age, and gender.

Although the most sensitive and specific test for diagnosing gastroesophageal reflux disease, normal standards for prolonged esophageal pH monitoring are based on small sample sizes with questions raised about the effects of pH electrode, older age, gender, and methods of data analysis on pH variables. Recently three groups have established normal data bases using similar methodology. Multiple regression and nonparametric analyses showed that the values for the six traditional pH parameters were comparable across study centers. Therefore, the groups were combined for a total study population of 110 healthy subjects (47 men, 63 women, mean age 38 years with a range of 20-84 years). Further nonparametric analyses revealed the following: (1) type of pH electrode (antimony vs glass) is not significantly related to parameters of physiologic acid reflux; (2) age is not independently related to pH parameters; (3) men tend to have more physiologic reflux than women; and (4) older men tend to experience longer episodes of reflux than younger men and women. There was a significant effect of gender and a significant interaction between age and gender on the number of episodes greater than 5 min (P = 0.008). Nearly significant differences were found for percentage of total acid exposure time (P = 0.03), total reflux episodes (P = 0.02), and the longest reflux episode (P = 0.02). We believe these normal esophageal pH values can be used confidently as standards in any laboratory, and consideration should be given to developing separate standards for men and women.

Adult↗
PubMed1992

Two doses of omeprazole versus placebo in symptomatic erosive esophagitis: the U.S. Multicenter Study.

Two hundred thirty patients with reflux symptoms and endoscopically proven erosive esophagitis were enrolled from 15 U.S. centers into a randomized, double-blind, dose-ranging study comparing placebo with omeprazole, 20 or 40 mg given once daily in the morning. Esophagitis grade 2 was present in 44% of patients, grade 3 in 37% of patients, and grade 4 in 19% of patients. Endpoints, defined as complete relief of heartburn and complete esophageal mucosal healing, were assessed after 4 and 8 weeks of treatment. Both omeprazole doses were significantly superior to placebo in complete endoscopic healing. After 8 weeks of treatment, 73.5% of patients in the 20-mg omeprazole group and 74.7% in the 40-mg omeprazole group, compared with 14.0% in the placebo group, had complete healing of the esophageal mucosa. At the end of the study, complete relief of daytime heartburn was obtained in 79.5% of patients in the 20-mg omeprazole group, 81.6% in the 40-mg omeprazole group, and 37.2% in the placebo group (P less than or equal to 0.05). Complete relief of nighttime heartburn was noted by 79.5% of patients in the 20-mg omeprazole group, 85.1% in the 40-mg omeprazole group, and 34.9% in the placebo group (P less than or equal to 0.05). The median time to complete relief of daytime and nighttime heartburn occurred earlier in the 40-mg group than in the 20-mg group (9 vs. 17 days and 9 vs. 20 days, respectively); however, these differences were not statistically significant. Relief of acid regurgitation and dysphagia also occurred earlier in the 40-mg group. Omeprazole was well tolerated in this group of patients. No unexpected adverse experiences occurred. The results of this study confirm those of six multicenter, international trials in which omeprazole in doses of 20-60 mg provided a degree of esophageal mucosal healing and complete relief of reflux symptoms superior to any other medical treatment.

Adult↗
PubMed1992

Gastroesophageal reflux disease in pregnancy.

Heartburn during pregnancy occurs in approximately two thirds of all pregnancies. The origin is multifactorial, but the predominant factor is a decrease in LES pressure resulting from female sex hormones, especially progesterone. Mechanical factors play a small role. Serious reflux complications during pregnancy are rare outside the obstetric setting. Therapy involves lifestyle modifications and nonsystemic medications as the initial choices. H2 blockers are probably safe in severe and refractory cases.

Anesthesia, Obstetrical↗
PubMed1992

Effect of alprazolam (Xanax) on esophageal motility and acid reflux.

Recent studies suggest that psychotropic drugs may help the symptoms associated with spastic esophageal motor disorders. However, the physiologic effects of central nervous system depression (a side effect of such therapy) on esophageal function is not known. Therefore, we studied the effect of alprazolam (Xanax), a popular new benzodiazepine anxiolytic, in 10 healthy volunteers, using a randomized, placebo-controlled design. Stationary esophageal motility, 24-h pH monitoring, and 24-h ambulatory motility monitoring was done while on placebo or one tablet (0.25 mg) of alprazolam taken three times a day. Alprazolam had no significant effect on lower esophageal sphincter pressure or motility in the esophagus. Upper esophageal sphincter pressure, however, was significantly decreased. What is more important, one-third of the healthy volunteers had abnormal amounts of nocturnal acid reflux during the alprazolam phase of the study. This effect was probably due to alprazolam-induced central nervous system depression interfering with normal nocturnal acid clearance mechanisms triggered by arousal from sleep.

Adult↗
PubMed1992

The LES locator: accurate placement of an electrode for 24-hour pH measurement with a combined solid state pressure transducer.

Twenty-four-hour esophageal pH monitoring is the gold standard for diagnosing gastroesophageal reflux disease. A possible limitation to the widespread use of this test is that manometry is required for accurate placement of the pH electrode 5 cm above the lower esophageal sphincter. We compared the accuracy of a single solid state pressure transducer, combined with a pH electrode, in determining the proximal border of the lower esophageal sphincter (LES) with the values obtained from stationary manometry in 40 patients referred to our laboratory for 24-h pH studies. Not only was there a strong correlation (r = 0.9) between LES values obtained by the two techniques, but none of the values obtained by the single solid state transducer were outside the clinically accepted range of greater than +/- 3 cm. The presence of a hiatal hernia or low sphincter pressure did not affect these measurements. The larger probe was tolerated somewhat less well (p = 0.02) than a standard antimony electrode during the prolonged pH studies. In conclusion, a single solid state pressure transducer on a pH probe with the help of a LES locator accurately identifies the proximal border of the LES. Therefore, stationary esophageal manometry is no longer needed prior to 24-h pH monitoring, potentially making this important clinical tool available to a wider variety of clinicians at all levels of the health care system, in investigating gastroesophageal reflux and its protean clinical presentations.

Adult↗
PubMed1991

Acid perfusion test and 24-hour esophageal pH monitoring with symptom index. Comparison of tests for esophageal acid sensitivity.

The acid perfusion (Bernstein) test and esophageal pH monitoring are the two most popular tests for identifying esophageal acid sensitivity in difficult cases of reflux disease. Therefore, we prospectively compared these test results in 75 consecutive noncardiac chest pain patients who had both an acid perfusion test and chest pain during 24-hr pH testing. A positive acid perfusion test was defined by the replication of the patient's typical chest pain twice by the acid infusion. Esophageal pH testing identified abnormal amounts of acid reflux and correlated symptoms with acid reflux--the "symptom index." Fifteen patients (20%) had a positive acid perfusion test while 45 patients (59%) had a positive symptom index (range 6-100%). Only 9/34 (26%) patients with abnormal reflux had a positive acid perfusion test. Although it had excellent specificity (83-94%), the acid perfusion test had poor sensitivity (32-46%) when compared to the symptom index regardless of the percent positive cutoff level. The best positive predictive value for the acid perfusion test was 87%, but this occurred when the test sensitivity was 32%. Modifying the end point of a positive acid perfusion test to include heartburn improves the sensitivity (52-67%) while markedly compromising specificity and positive predictive value. Thus, esophageal pH monitoring correlating symptoms with acid reflux is superior to the acid perfusion test for identifying an acid sensitive esophagus in patients with noncardiac chest pain.

Chest Pain↗
PubMed1991

Diffuse esophageal spasm. A rare motility disorder not characterized by high-amplitude contractions.

Diffuse esophageal spasm (DES) has frequently been described as a motility disorder characterized by simultaneous, high-amplitude contractions. We reviewed the results of esophageal manometry testing on a total of 1480 patients referred to our lab over 36 months. Lower esophageal sphincter (LES) pressure was determined by a mean of four station pull-through. Esophageal body motility was assessed following 10 wet swallows. In our lab a diagnosis of DES is made when greater than 10% but less than 100% of contractions are simultaneous. Manometric findings of DES were rare, with an overall prevalence of 4% (56/1480). Of the 56 patients with a manometric diagnosis of DES, high-amplitude (mean greater than or equal to 180 mm Hg) peristaltic contractions were found in only two (4%). No simultaneous contractions with amplitude greater than or equal to 180 mm Hg were seen. Pressures of simultaneous contractions were consistently lower than peristaltic contractions. A hypertensive LES pressure (greater than or equal to 45 mm Hg) was present in 5/56 DES patients (9%). Poor LES relaxation was found in 7/56 DES patients (13%). We conclude that DES is a rare manometric finding, regardless of the reason for referral, and that the occurrence of high-amplitude contractions in DES is equally rare.

Esophageal Spasm, Diffuse↗
PubMed1991

Investigation and management of non-cardiac chest pain.

Recurring substernal chest pain is an important clinical problem, causing anxiety for patients and their physicians because of the fear of possible cardiac disease. The differential diagnosis includes coronary artery disease, oesophageal disorders such as acid reflux disease and motility disturbances, musculoskeletal problems, psychological disorders including panic attacks, and a new 'fly in the ointment'--microvascular angina. History alone usually cannot distinguish cardiac from non-cardiac chest pain. After exclusion of significant coronary artery disease, attention must be turned to oesophageal disorders, which may be seen in as many as 50% of these patients. Oesophageal motility disorders, particularly the nutcracker oesophagus, are common, but the relationship between pain and abnormal contraction pressures is not well established. Provocative tests such as edrophonium (Tensilon) and balloon distension help to identify the oesophagus as the source of chest pain but do not direct therapy. Recent studies with ambulatory oesophageal monitoring suggest that gastro-oesophageal reflux may be a more common cause of chest pain than motility disorders. This is an important finding as acid reflux is a treatable problem, while therapies for motility disorders may only worsen reflux disease. The recent observation that oesophageal disorders are frequently associated and interact with psychological disorders such as anxiety, depression, somatization and panic attacks complicates the evaluation and understanding of chest pain. How these various abnormalities may be linked is an unresolved issue. Increased central nervous system stimulation and altered visceral and/or central pain sensitivity could be the common factors. It is hoped that further research into these areas will lead to new understandings of and possible solutions to the complex problem of non-cardiac chest pain.

Angina Pectoris↗