Increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention in reflux patients with hiatal hernia  Peter J. Kahrilas*, Guoxiang Shi*, Michael Manka*, Raymond J. Joehl‡  Gastroenterology  Volume 118, Issue 4, Pages 688-695 (April 2000) DOI: 10.1016/S0016-5085(00)70138-7 Copyright © 2000 American Gastroenterological Association Terms and Conditions

Fig. 1 The number of acid reflux events related to different mechanisms during baseline recording and during a period with intragastric air infusion among subject groups. Air infusion resulted in a significant increase in reflux events only by the tLESR mechanism. *P < 0.05, baseline vs. air infusion. Gastroenterology 2000 118, 688-695DOI: (10.1016/S0016-5085(00)70138-7) Copyright © 2000 American Gastroenterological Association Terms and Conditions

Fig. 2 Esophageal acid exposure time associated with different mechanisms of reflux during baseline recording and during a period of intragastric air infusion among subject groups. Note the diminished significance of swallow-induced reflux in the hernia patients compared with Figure 1. Analogous to the data in Figure 1, air infusion significantly increased acid exposure time attributable to the tLESR mechanism. *P < 0.05, baseline vs. air infusion. Gastroenterology 2000 118, 688-695DOI: (10.1016/S0016-5085(00)70138-7) Copyright © 2000 American Gastroenterological Association Terms and Conditions

Fig. 3 Individual data on the frequency of tLESRs in normal controls, nonhernia patients, and hernia patients during baseline recording and during a period with intragastric air infusion. Air infusion increased tLESR frequency in all subject groups (P < 0.05). However, the median increase was 9.5/h among the hernia patients compared with only 4.5/h among nonhernia patients and 4.0/h among normal controls. Thus, both patient groups had a significantly higher tLESR frequency than the control group during air infusion (P < 0.05), and the hernia patients had a significantly higher frequency than nonhernia patients (P < 0.01). Gastroenterology 2000 118, 688-695DOI: (10.1016/S0016-5085(00)70138-7) Copyright © 2000 American Gastroenterological Association Terms and Conditions

Fig. 4 Correlation of the distance between SCJ and hiatal center and the number of tLESRs per hour during a period with intragastric air infusion for individual subjects. Gastroenterology 2000 118, 688-695DOI: (10.1016/S0016-5085(00)70138-7) Copyright © 2000 American Gastroenterological Association Terms and Conditions

Fig. 5 EGJ length during recordings averaged over 30-minute periods. Data are shown as mean ± SEM. *P < 0.05 vs. normal; †P < 0.05 vs. nonhernia patients; ‡P < 0.05 vs. baseline. Gastroenterology 2000 118, 688-695DOI: (10.1016/S0016-5085(00)70138-7) Copyright © 2000 American Gastroenterological Association Terms and Conditions

Fig. 6 Example of a tLESR with a reflux event recorded during baseline (left) and air infusion (right) in normal control subjects. The side-hole recording sites are at 1-cm intervals straddling the EGJ high-pressure zone. Note that the distal part of the high-pressure zone relaxes before the proximal part as evidenced by an attenuation of the inspiratory pressure increases, as well as a reduction in basal pressure. During the baseline tLESR (left), the subject swallows, as evidenced by the EMG recording, but this event is clearly after the onset of LES relaxation and reflux. Gastroenterology 2000 118, 688-695DOI: (10.1016/S0016-5085(00)70138-7) Copyright © 2000 American Gastroenterological Association Terms and Conditions