HYPERTENSIVE LOWER ESOPHAGEAL SPHINCTER PRESSURES AND GASTROESOPHAGEAL REFLUX - AN APPARENT PARADOX THAT IS NOT UNUSUAL

The association of a hypertensive lower esophageal sphincter pressure (LESP) with significant gastroesophageal reflux (GER) has always seemed paradoxical because of the original association of a hypotensive sphincter with reflux. Objectives and Methods: In this study, the manometric and ambulatory pH studies of a group of consecutive patients evaluated over a 3-yr period were reviewed to identify and characterize patients with a hypertensive LESP and abnormal GER as defined by increased acid exposure in the distal esophagus as measured on ambulatory pH monitoring. Results: Eighteen such patients were identified, which represented 5.2% of all patients with abnormal GER and 23.4% of all patients with a hypertensive LESP. Heartburn (nine patients) and chest pain (nine patients) represented the dominant symptoms. LESP ranged from 47 to 73 mm Hg. Incomplete LES relaxation in response to swallow was found in nine out of 18 patients. Intact peristalsis was found in all patients, and seven patients had a nutcracker esophagus. Patients showed a wide range of abnormal distal esophageal acid exposure times with only slightly abnormal recumbent or upright reflux times to greater than 25% pH less than 4 total (although most patients had mild reflux with 17 out of 18 patients having total distal esophageal acid exposure less than 10%). There was no correlation between LESP and total % pH less than 4 (r = 0.11). Of 16 patients, 12 responded to antireflux treatment, including the three patients who required fundoplication. The four patients who did not respond to treatment had poor correlation of reflux episodes to symptoms on pH monitoring, had markedly elevated LESPs, and did not present with heartburn. Conclusions: The association of a hypertensive LESP and abnormal GER is not uncommon. When abnormal GER does occur in these patients, it tends to be mild but can be clinically important and respond to antireflux treatments. We recommend that patients with a hypertensive LESP and/or nutcracker esophagus who present with heartburn or chest pain should undergo ambulatory pH monitoring to evaluate the possibility of GER disease.