Upper intestinal endoscopy.
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OBJECTIVE: Several recent reports suggest there may be a relationship between chronic rhinitis and extraesophageal manifestations of gastroesophageal reflux (EER). It is hypothesized that this relationship is a result of autonomic nervous system (ANS) dysfunction. STUDY DESIGN: Patients with isolated vasomotor rhinitis (VR), both VR and EER, and a control group were studied by a battery of tests designed to objectively evaluate ANS function. In addition all 3 groups underwent barium esophagogram and 4-site (proximal pharynx, distal pharynx, proximal esophagus, and distal esophagus) ambulatory pH monitoring. Adult patients fulfilling diagnostic criteria for VR, and with both VR and EER underwent objective ANS testing in a recently developed ANS testing laboratory. The control group consisted of age- and sex-matched adults without diagnostic criteria for VR or EER. RESULTS: In patients with VR only (n = 9), 2 patients had a positive esophagogram, whereas a positive pharyngeal reflux probe was found in 1 and an abnormal composite autonomic scoring scale (CASS) was found in 8 (mean VR CASS = 1.750 vs control CASS 0.556, P =.02). The group with VR and EER (n = 12) had a positive esophagogram in 10 patients, positive pharyngeal reflux by probe in 9, and all 12 had an abnormal CASS (mean CASS VR/EER = 2.909 vs CASS control = 0.556, P =.001 and vs VR CASS = 1.750, P =.05). The control patients (n = 9) had normal transesophageal gastroduodenoscopy in 8, 1 had a positive pharyngeal probe study, and all 9 had a normal CASS. In addition ANS testing in patients with diagnostic criteria for both VR/EER revealed statistically significant evidence of an adrenergic deficit as compared with control patients on the basis of mean phase II blood pressure response to Valsalva maneuver (mean phase II VR/EER = -16.730 vs control = -7.780, P =.05). In the VR only group, the phase II blood pressure decrease was greater than in control patients, but did not reach statistical significance (mean phase II VR = -9.370 vs control = -7.780, P = 0.672). CONCLUSION: Patients with VR and VR/EER have objective evidence of ANS dysfunction when compared with a group of age- and sex-matched control patients. Patients with both VR/EER demonstrate a significantly greater degree of ANS dysfunction than patients with isolated VR. The mechanism by which VR and EER interact is not entirely clear, but ANS dysfunction is objectively associated with both disorders. In addition, patients with VR/EER seem to demonstrate hypofunction of the adrenergic component of the ANS, in contrast to the generally held hypothesis that VR results from increased cholinergic activity. Further characterization of the type of ANS abnormality may allow the development of novel pharmacologic therapies for these disorders.
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A critical review of the use of barium examinations of the gastrointestinal tract compared with endoscopy provides evidence of a valid role for barium studies in contemporary radiology. It is concluded that there is no clinical, scientific, or economic justification for the wholesale replacement of barium radiology by endoscopy.
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Four hundred and forty-one consecutive patients referred for endoscopy after a negative double-contrast barium meal were studied to determine the reliability of good quality radiology in excluding significant upper gastrointestinal pathology. Endoscopic abnormalities were detected in 23 patients (5.2%), nine of which were reporting errors. Duodenal ulcer was the commonest lesion missed radiologically, 50% of these patients either having a history of overt upper gastrointestinal bleeding, a family history or impressive symptomatic relief with H2-receptor antagonists. The three patients with radiologically undetected gastric cancer presented with classical symptoms; the radiological demonstration of gastric mucosal atrophy in this clinical context should alert the referring clinician to initiate urgent endoscopy.
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