by Harwood Academic Publishers GmbH Printed in Singapore Endoscopic Appearance of the Gastroesophageal Valve and Competence of the Cardia

The endoscopic appearance of the gastroesophageal valve, viewed by the retroflexed gastroscope, has been studied in 51 patients with and without reflux esophagitis. Esophagitis was graded according to its severity, and the yield pressure (YP) was measured in all patients to assess the competence of the cardia. There was a close relationship between the YP and the grades of the gastroesophageal valve. YP was significantly lower in patients with endoscopic oesophagitis than in patients with no evidence of reflux esophagitis (p <0.0001). An increased abnormality of the gastroesophageal valve was associated with all grades of esophagitis and with a low YP. The valve mechanism at the cardia has an important role in determining its competence. YP is possibly a measure of the flap valve component of the gastroesophageal junction.


et al., the l
wer esophageal sphincter (LOS) pressure has been used to assess the com- petence of the antireflux mechanism.This has persisted despite a poor correlation between LOS pressure and gas- troesophageal reflux (GOR). 2 It seems unlikely that such an important physiological function would be vested solely in such a weak sphincter, and other mechanisms might be expected to contribute to the competence ofthe cardia.The acute angle between the esophagus and the stomach was described by His) and he suggested that it increased with gastric distention.Marchand 4 confirmed this finding and concluded that the altered angle is a factor of paramount importance in the genesis ofGOR.Some investigators have failed to demonstrate a flap valve at the cardia. 5,6Others stressed the importance of gastric sling fibers in maintain- ing the gastroesophageal angle and preventing GOR. 7,8ntraluminal esophageal pressure is lower than abdom- inal pressure and, at rest, closure of the abdominal seg-Address forcorrespondence: J. Bancewicz, University ofManchester, Department of Surgery, Hope Hospital, Salford M6 8HD, United Kingdom.147 ment is maintained by external compression.The esophagus is compressed from the front against the spine.Computed tomographic examination of the intra-abdom- inal esophagus appears to confirm this flattened cross-sec- tion rather than the circular section, which would be expected of sphincter contraction. 9It has been suggested recently that the gastroesophageal valve is a flat musculomucosal structure created by the angle of His.The intact valve in the living human is a complex structure that allows free flow of food and fluid into the stomach but presents a highly effective barrier against retrograde flow.Hill et al. have suggested that the valve and the sphincter can be seen working together-the valve does the heavy work, withstanding the large pres- sures exerted against the gastroesophageal Junction.The sphincter does the discriminatory work, iscriminating between gas, fluid, and solids.

This study was designed to assess the endoscopic ap- pearances of the gastroesophageal valve and to examine the relationship between these appearances and the com- petence of the cardia.We used yield pressure (YP) mea- surement as a method for assessment of the competence of the cardia as our previous studies have shown an in- verse linear relationship between esophage

acid expo- sure and
ield pressure of the cardia. 1


PATIENTS AND METHODS

The study included 51 patients (27 men and 24 women).The median age was 48 years (range 23 to 78 years).Patients were studied during routine endoscopy examina- tions.Those with esophageal cancer, gastric cancer, or achalasia were excluded.Those with benign strictures were included if the gastroscope could pass through the stricture and the stricture was above the cardia (e.g., Barrett's esophagus).The YP was measured in all patients.Esophagitis was graded according the AFP classification suggested by Bancewicz et al. and modified by the International Society for Diseases of the Esophagus. 3P denotes pathology and was graded according to severity as follows: P0, no macroscopic mucosal abnormality; P1, isolated or nonconfluent erosive lesions of the mucosa; P2, circumferential or confluent erosive lesions in the mu- cosa; P3, chronic lesions involving the wall, e.g., stricture, short esqphagus, and penetrating ulcer.

The valvular appearance of the cardia visualized from below by the retroflexed gastroscope was described using a new grading system, V grades (Fig. 1).This classifica- tion is based on the actual valve appearance of the cardia closing around the gastroscope and the presence or ab- sence of hiatus hernia as follows: V0, no hiatus hernia and normal valve appearance; V1, small hiatus her- nia, the cardia closed around the gastroscope; V2, open vo v1 V2 Figure 1 Artist's impression of the grades of the gastroesophageal valve (V grades) viewed through the retroflexed gastroscope.cardia with minimum distention an no hiatus hernia; V3, open cardia and hiatus hernia.

A Fujinon UG1 F4 gastroscope with external diameter of 11 mm was used, and one surgeon performed all endo- scopic examinations in the study.A Lignocaine throat spray was used, and the patient was sedated with diazepam (10 to 20 mg.i.v.) until drowsy.Hyoscine hydrobromide (Buscopan), 10 mg i.v., was also given.

The endoscope was passed into the stomach under di- rect vision, insufflating as little air as possible.A polyvinyl catheter 230 cm long, 2 mm external diameter, and 1 mm internal diameter, was passed down the biopsy channel, so that approximately 1 cm protruded beyound the distal end of the gastroscope.It was connected to a pressure trans- ducer (Gould P23 ID, California) and was continuously perfused with water at a rate of 0.6 ml/min using a low compliance pneumohydraulic capillary infusion system (Arndorfer Medical Specialities, Wisconsin).The tip of the endoscope was then retroverted and the instrument withdrawn so that the cardia could be visualised from below.The valve appearance was graded by the endo- scopist according to the classification mentioned above.The resting gastric pressure (RGP) was recorded using a Polygraph 7E eight channel recorder (Grass Instruments, Quincy, MA).Air was insufflated until rising intragastric pressure forced the cardia open.The opening pressure (OP) at this point was recorded.The YP of the cardia cal- culated as YP OP-RGP.All pressure measurements were made independently by another ob

rver who
was not aware of the endoscopic findings.


RESULTS

Relationship Between the Gastroesophageal Valve and YP In 22 patients with a normal looking valve, the median YP was 15 mm Hg.YP was progressively reduced with in- creasing valve abnormality (Fig. 2).In 13 patients with V grade the median YP was 8 mm Hg (p < 0.0004).In the group with V2 grade the median YP was 4.5 mm Hg, whereas in 10 patients with grossly abnorm l valves of V3 grade, the median YP was 0.5 mm Hg.


Relationship Between Grades of Esophagitis and YP

There was a significant difference in YP between patients with grade esophagitis and those with no evidence of macroscopic esophagitis, (p < 0.0001).In five patients with grade 2 and 3 esophagitis, the median YP was simi- larto the group with grade esophagitis although the num-

rs are too small for st
tistical comparison (Fig. 3).The majority of patients with a normal valve had no esophagitis.The different grades of abnormal valves we

associated
with all grades ofesophagitis.Few patients with abnormal valves had no esophagitis and some of these pa-


ENDOSCOPIC APPEARANCE OF GASTROESOPHAGEAL VALVE


Grades of oesophagitis

Relationship between grades of esophagitis and grades of tients were receiving omeprazole treatment at the time of endoscopy (Fig. 4).


DISCUSSION

In this study we have described a new classification for the appearance of the gastroesophageal valve.We have shown for the first time a significant relationship between the dif- ferent grades of valve abnormality and the YP measure- ment.To our knowledge this is the first demonstration of a correlation between the valve mechanism at the gastroesophageal junction and a specific pressure measurement.

Hill and his colleagues n0 have stressed the importance of the gastroesophageal valve and described a different grading system for its appearance; however, these grad- ings were not correlated with any particular measurement of gastroesophageal competence.This study supports the concept of the flap valve at the gastroesophageal junction as an important factor af ecting its competence.We have previously shown that YP is a useful measurement for as- sessment of the compet