intragastric and intraesophageal pH in patients with symptomatic erosiveGERD.Methods: Thirteen subjects (12 male) with EGD-documented erosiveGERD were dosed (double-blind) with placebo run-in followed by eitherpantoprazole 40 mg PO or omeprazole 20 mg PO (cross-over design, 2week washout). Five 24-hour pH-monitoring studies were performed dur-ing baseline (placebo) and on Day 1 and Day 5 of each PPI treatment.Subjects received 3 standard meals at 2, 6 and 10 hours after dosing at 0700hours. Statistical analysis was performed independent of PPI therapy, asstudy results remain blinded.Results: After placebo, the 24-hour percent time esophageal pH � 4.0 was17.5 � 0.3% (range � 5.7–29.5%). PPI therapy significantly reduced the% time pH � 4.0 on Day 1 and Day 5 to 7.3 � 0.2 and 6.1 � 0.2%,respectively (P � 0.01). The number of heartburn symptoms quantitatedover7 days declined significantly from 6.5 � 0.3 episodes/day on placeboto 1.8 � 0.2 episodes/day on PPI (P � 0.01). The % time gastric pH � 4.0was 7.4 � 0.3% with placebo and on Day 5 after PPI therapy was 37.3 �0.3% (P � 0.0001). After placebo, mean 24-hour intragastric pH was 1.5 �0.1 and intraesophageal pH was 5.3 � 0.1. With PPI therapy, Day 1 andDay 5 24-hour mean intragastric pH increased significantly to 2.1 � 0.1and 3.0 � 0.1, respectively, whereas mean intraesophageal pH was 5.3 �0.1 and 5.2 � 0.1, respectively. No significant correlation between meangastric and esophageal pH was observed.Conclusions: In subjects with symptomatic erosive GERD, PPI therapyreduced gastroesophageal reflux, incidence of symptoms and increasedmean 24-hour gastric pH to 3. Improvement in esophageal acid exposure(pH � 4) on PPI does not depend on prolonged duration of gastric pH �4 or raising the mean gastric pH to �4.

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Unusual case of esophageal perforationAffan Quadri, Geetha Ganesan and Thomas Puetz*. 1Gastroenterology,University of WI Milwaukee Campus SSMC, Milwaukee, WI, UnitedStates.

Purpose: More than 50 percent of cases of esophageal perforations are dueto iatrogenic causes. We are reporting a very unusual case of hematemesisafter esophageal perforation, which resulted after an attempt to place anAutomatic implantable cardioverter defibrillator (AICD).Case Report: Our Patient is a 66 y/o female who was admitted to thehospital for CAD and Unstable angina. She underwent myocardial revas-cularization and in the postoperative period developed two episodes ofventricular tachycardia (VT). To prevent Sudden Cardiac Death it wasdecided to place an AICD. An attempt was made through the right sub-clavian vein. After making a small incision in the skin a guide wire waspassed into the right subclavian vein, then an introducer sheath was passedover the wire. Difficulty was noted in the passage of the sheath. A suddenand unexpected bout of hematemesis rapidly ensued. An urgent Gastroen-terology consult was called and an upper endoscopy was performed in theoperating room. Examination of the esophagus showed the bleeding site at20–22 CMS. from incisors with a blood clot and a mucosal flap identified.CT scan of the chest and abdomen showed bilateral pleural effusions andthere was no evidence of hematoma or free air in the mediastinum.Esophagogram did not reveal any leakage from the perforation site. Shewas started on IV antibiotics and remained well except for occasional mildchest discomfort. Oral feeding was started after 3 days and no difficulty wasencountered. She was discharged 9 days later in a stable condition.Conclusions: A thorough review of the literature does not reveal anesophageal perforation arising as a result of AICD or pacemaker placement.In this unusual case placement of the catheter may have been renderedmore difficult by the fact that the previously placed porta-cath may havecaused weakening of the vascular wall resulting in penetration of the vesseland posterior advancement of the guide wire with introducer sheath into theesophagus. Esophageal perforation in general can be managed conserva-

tively if certain criteria are met. Our patient fulfilled these criteria and wasmanaged appropriately with rapid recovery and no complications.

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A disappearing esophageal massMohammad Quamruzzaman, Mohsin Khan and Kiran Bhat*.1Medicine, Flushing Hospital Medical Center, Flushing, New York,United States.

Purpose: In recent years the wide spread use of endoscopy, CT Scanningand endoscopic ultrasound has provided a wealth of information aboutesophageal masses. Squamous cell carcinoma, adenocarcinoma, leiomy-oma, leiomyosarcomas are the most common esophageal masses. Althoughhematomas are reported in the literature, there rarely seen with emetogenicinjury and bleeding abnormalities. We present a case of a man with anesophageal mass, diagnosed by EGD after upper GI bleeding with subse-quent spontaneous disappearance.Case: An 81 years old man with history of chronic atrial fibrillation,congestive heart failure, hypertension presented in ER with frank hemate-mesis. He denied fever, weight loss, abdominal pain, as well as dysphagia.Physical examination revealed BP 150/90, pulse 110/min. He was not onanticoagulation therapy. His hemoglobin was 13.1 gm with normal plateletsof 159,000/ml and prothrombin time of 12.9 sec. Patient was intubated toprotect the airway, resuscitated and emergent EGD was performed. But dueto presence of large clots in the esophagus and resistance to passageendoscope the EGD was inconclusive. The following day repeat endoscopyshowed a 10 cm friable mass extending from upper esophageal sphincter tomid-esophagus. Multiple mucosal biopsy of the mass showed abundantfibrinous material admixed with inflammatory cells and bacterial coloniesbut no malignant cells. Snare tissue biopsy was not performed due to riskof bleeding. PEG was placed during a repeat EGD. CT scan of esophagusrevealed abnormal thickening of esophageal wall mostly in the proximalhalf. Broncoscopy did not show any evidence of bronco-esophageal fistula.Patient was extubated three weeks after and discharged with follow up inthe clinic. Two days later he was re-admitted for CHF exacerbation. He wasstabilized and follow up endoscopy showed normal stomach and duodenumwith no mass in the esophagus.Conclusions: Esophageal trauma may occur after vomiting or in conditionswhere intrathoracic pressure is changed as in Boerhaave’s and Mallory-Weiss Syndromes. We propose that our patient developed a spontaneousesophageal hematoma secondary to forceful emesis. Spontaneous intramu-ral esophageal hematoma is a rare entity, but well described with esoph-ageal dilatation, sclerotherapy, foreign body ingestion and medications.Diagnosis and follow up are done with CT scan and endoscopy. Althoughpathogenesis is disputed, the prognosis is favorable. Interesting features ofthis case include appearance of a large esophageal mass without docu-mented trauma, instrumentation, bleeding diasthesis, or medication andsubsequent complete resolution of mass spotaneously in a short period oftime.

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Characterization of manometric changes in dyssynergic defecation(anismus)Satish Rao, MD; FACG, Ranjit Mudipalli MD; Mary Stessman RN;Konrad Schulze, MD; FACG; University of Iowa Hospitals and Clinics,Iowa City, IA.

Background: Inappropriate anal contraction (anismus) during attempteddefecation was first proposed as the key pattern in dyssynergia. Recently,adequate propulsion with inappropriate contraction has been proposed(Rome II).Aim: To examine the manometric patterns and anorectal pressure profilesin patients with constipation and difficult defecation.Methods: 161 consecutive patients (M/F � 28/133) who fulfilled Rome IIcriteria for constipation were examined by anorectal manometry between

S32 Abstracts AJG – Vol. 96, No. 9, Suppl., 2001

January 1998 and September 2000. The manometric patterns, the intrarectaland anal residual pressures during straining and their ratio (defecationindex) were assessed. Results: A normal pattern consisting of adequatepropulsive force and adequate relaxation was seen in 65 (40%) patients.Additionally, three types of abnormal patterns were recognized (fig); Type1: Adequate propulsive force with inappropriate anal contraction, n � 30(19%); Type II: Inadequate propulsive force with inappropriate anal con-traction, n � 46 (29%); Type III: Adequate propulsive force with failure torelax, n � 20 (12%). The intrarectal pressure (mmHg, mean � SEM) was:50 � 3 (normal pattern), 55 � 4 (Type I), 21 � 2 (Type II), and 44 � 3(Type III). The anal residual pressure was: 28 � 2 (normal pattern), 79 �5 (Type I), 61 � 6 (Type II), and 44 � 4 (Type III). The defecation indexwas: 3 � 0.6 (normal pattern), 0.7 � 0.005 (Type I), 0.7 � 0.3 (Type II),and 1.2 � 0.1 (Type III). Conclusions: Sixty percent of patients withdifficult defecation exhibited abnormal manometry, all of whom had a low(p � 0.05) defecation index suggestion of rectoanal incoordination ordyssynergia. Inadequate propulsive force (Type II) is a common phenom-enon in patients with difficult defecation. All three patterns should beconsidered as diagnostic of dyssynergia.

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Age, specialty, and practice setting predict GERD prescribing behaviorRandal P. Riesett, M.D.1, Brian E. Lacy, M.D.1* and Amy Mitchell,B.S.1, 1Marvin M. Schuster Motility Center, Johns Hopkins UniversitySchool of Medicine, Baltimore, Maryland, United States.

Purpose: Gastroesophageal reflux disease (GERD) affects 40% of adultAmericans each month. Despite the high prevalence of GERD, and theexpense of diagnosing and treating it, little is known about physicianbehavior in the evaluation and treatment of GERD.Aims: To examine physician patterns of evaluating GERD, and determinethe prescribing behavior of different physicians (FP � family practice;INT � internal medicine; GI � gastroenterology) using 8 case scenarios.Methods: 687 physicians in Maryland were randomly identified frommedical society lists and professional organizations. An identical 2 pagesurvey was sent to each physician. 1 week later, a reminder postcard wassent. If the questionnaire was not returned within 2 weeks, a second,identical questionnaire was mailed, with a reminder postcard 1 week later.The survey contained 7 demographic questions (age, sex, degree, specialty,practice setting, practice location, years in practice); 8 questions whichinvolved daily practice, and knowledge of published GERD guidelines; and8 case scenarios which ranged from mild, intermittent GERD Sx, toconstant Sx, to the presence of warning signs.Results: 214 questionnaires (31.1%) were returned; 36.3% � FP, 29.6% �INT; 29.6% � GI, 4.7% � other. 82% were Male, 18% were Female. Yearsof practice: 60.5% �15 yrs; 17.6% � 11–15 yrs; 15.7% � 5–10 yrs; 6.2%� 1–4 yrs. For uncomplicated reflux disease, 77.8% recommended notesting, while 5.9% requested a barium swallow. 8% of FP requested abarium swallow, compared to 6% INT, and 1.6% GI (p � .02). In a casewith persistent GERD Sx and dysphagia, 52% of FP recommended EGD,as opposed to 69% of INT, and 85% of GI (p � .0002). For chronic GERDSx �5 yrs without warning signs, 82% of GI recommended EGD, whileonly 45% of FP did (p � .0122). The number of years of practice was foundto influence prescribing behavior for mild intermittent GERD Sx (p � .03),and persistent chronic GERD Sx (p � .0017). Physicians �50 yrs of agewere significantly (p � .038) more likely to prescribe PPIs for mild topersistent GERD Sx, as opposed to physicians � age 50. Physicians in anacademic setting were more likely to employ step-down therapy in patientswith well-controlled GERD Sx on a PPI, as opposed to physicians in anHMO setting.

Conclusions: The age, scope of practice (specialty type), number of yearsin practice, and practice setting were found to significantly affect howpatients with GERD were evaluated and treated, using a case scenarioquestionnaire. Note: This study was funded by the Marvin M. SchusterMotility Center and an unrestricted educational grant from Wyeth-Ayerst.

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Outcomes of laparoscopic Nissen fundoplications at The WesternPennsylvania HospitalGilbertas Rimkus, M.D.1, Devora E Hathaway, BSN1, Daniel J Gagne,M.D.1 and Philip F Caushaj, M.D., FACG1*. 1Department of Surgery,Temple University School of Medicine Clinical Campus, The WesternPennsylvania Hospital, Pittsburgh, Pennsylvania, United States.

Purpose: In the U.S., more than 10% of adults have symptoms of gastro-esophageal reflux disease (GERD). Most patients can be effectively treatedwith traditional medical management utilizing dietary modification, weightloss, raising the head of the bed, antacids, H2 blockers and proton pumpinhibitors (PPI). Although there is minimal literature data comparing PPIand surgical treatment, it seems that long-term relief of GERD may beachieved more efficiently with antireflux surgery or Laparoscopic Nissenfundoplication.Methods: Using retrospective chart review we evaluated outcomes of 29laparoscopic Nissen fundoplications done at The Western PennsylvaniaHospital between April, 1996 and March, 2001. Outcome evaluation in-cluded reflux symptoms, preoperative and postoperative studies, compli-cations of surgery and need for medical antireflux therapy postoperatively.Results: All patients were diagnosed with GERD preoperatively, 11 pa-tients had hiatel and 4 had paraesophageal hernias. Eighty-four percent ofpatients were treated with PPI preoperatively. Duration of treatment variedbetween 1 month and 3 years. No deaths, esophageal injuries, or splenicinjuries occured. Average hospital stay was 3 days. Eighty-six percent ofpatients were symptomatically improved after the surgery. Thirty-fourpercent of patients had transient postoperative dysphagia. Preoperativesymptoms did not correlate with postoperative dysphagia; also there was nocorrelation between additional procedures preformed with laparoscopicNissen fundoplication and postoperative symptoms (P � 0.05). Threepatients had recurrent heartburn postoperatively and required medications,two of them were found to have failed fundoplication and underwernt re-dosurgery.Conclusions: Current trends indicate that laparoscopic fundoplication isbeing used increasingly as an alternative to long-term medical therapy ofGERD. Relief of typical reflux symptoms can be anticipated in over 90%of patients undergoing Nissen fundoplication, although mild dysphagiaoccurs after the procedure, this is transient in most patients. LaparoscopicNissen fundoplication can be performed safely and effectively in thecommunity hospital setting with all of the advantages of a minimallyinvasive approach. This can be achieved with a hospital stay of 48 hoursand a low incidence of postsurgical complications.

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Rabeprazole efficacy in erosive GERD: subgroup analyses from thefuture of acid suppression therapy (F.A.S.T.) trialMalcolm Robinson, MD; Eddie Cheung, MD; Anita Murthy, PharmD;Leonard Jokubaitis, MD Oklahoma Foundation for Digestive Research,University of Oklahoma Health Sciences Center, Oklahoma City, OK.

Purpose: To evaluate symptom relief with rabeprazole (RAB) 20 mg inpatients with endoscopically diagnosed erosive gastroesophageal refluxdisease (GERD). Efficacy was analyzed according to age, gender, esoph-agitis severity, and presence of Barrett’s esophagus (BE).Methods: Open-label RAB 20 mg once daily was given, and patients ratedsymptom severity at baseline, Days 1 through 7, and Week 4, using a4-point scale (0 � none to 3 � severe). Results: From Day 1 through Day7, all subgroups achieved significant relief of daytime or nighttime heart-

S33AJG – September, Suppl., 2001 Abstracts