Pratt et al (1976) describes a group of 99 patients with globus with normal direct laryngoscopy and normal barium studies who therefore had psychological assessment with the Minne s o t a multi-phasic inventory. The group consisted of 23 men and 76 women, 70% of each group were aged 20 to 50
years. The questionnaires were all analysed by computer. On the questionnaire result, 30% of both men and w o m e n were considered to need psychiatric evaluation. The g r oup as a whole had elevated scores in the depre s s i o n and hypochondriacal parts of the test. This finding was greater in the m a l e s .
1.3.11: CONCLUSION
Several studies have shown that medical treatment of gastro- oesophageal reflux with antacids and e l evation of the head of the bed has abolished or improved the globus symptom (Hallewell 1970, Hunt 1970). Surgical c o r rection of gastro-oesophageal reflux is also effective in relieving pharyngo-oesophageal dysphagia in most patients (Henderson et al 1976). The evidence so far available suggests that globus and gastro-oesophageal reflux may be related and that the diagnosis of "globus hystericus" should be made reluctantly and infrequently. Any patient with the globus sensation should therefore have at least a full ear nose and throat examination followed by a careful b a rium swallow and endoscopy, paying particular attention to the p resence of an hiatus hernia and gastro-oesophageal reflux. Twen t y four hour pH monitoring and manometry of the upper oesophageal sphincter should be reserved for those patients with negative findings. Treatment should be aimed at correction of any reflux present.
Discussion on the globus symptom is confusing w ith the use of different equipment and different groups of patients. The use of intraoesophageal microtransducers should enable
accurate recordings of the rapidly changing upper oesophageal sphincter to be made without the problems associated with perfused catheters such as increased swallowing and the need to stop perfusion in the pharynx to avoid coughing.
Some questions still remain to be answered. Is it possible to show crico-pharyngeal inco-ordination in patients with globus? What is the relationship between primary oesophageal motor disorders and globus? Is globus a symptom of gastro- oesophageal reflux? Twentyfour hour ambulatory pH monitoring is the most accurate way of assessing reflux but globus patients have not been studied. Is it a m a n i f e s t a t i o n of a p sychological disturbance? The following studies aim to answer some of these questions.
CHAPTER 2
AIMS
AIMS
The use of provocative agents in patients with noncardiac chest pain has improved the diagnostic ability of Castell's unit from 25% to 35% (Richter et al 1985c).
Deficiencies of the work so far have posed the following questions :-
1 . What is the clinical significance of a positive edrophonium test?
2. What is the effect of edrophonium on the upper, middle and lower oesophagus?
3. What is the relationship between e d r o p h o n i u m and Bernstein tests?
4. Is edrophonium a nonspecific oesophageal provocative agent?
My aims are :-
1. To determine the usefulness of edrophonium in clinical practice in the diagnosis of diffuse oesophageal spasm with regard to predicting long term success of treatment.
2. To determine the effect of edrophonium on the whole oesophagus and to assess its reproducibility.
3. To compare the effectiveness of Bernstein testing with edrophonium in this group of patients.
There is little evidence of the natural history of motility disorders and virtually no information about the place of b alloon dilatation in the management of diffuse oesophageal spasm with reference to-: a. symptom relief; b. long term effects on motility; c. effects on lower oesophageal
sphincter and thus d. effects on gastro-oesophageal reflux. My aims are:-
1. To assess the effect of a standard pneumatic dilatation in patients with diffuse oesophageal spasm, dilat i n g the area of spasm and preserving the lower oesophageal sphincter f u n c t i o n .
2. To measure gastro-oesophageal reflux pre- and p o s t di l atation in order to determine lower oesophageal sphincter f u n c t i o n .
3. To identify those patients who respond to pneumatic d i l atation of the body of the oesophagus.
4. To investigate the relationship of g a s t ro-oesophageal reflux to the effect of dilatation on diffuse oesophageal spasm.
The evidence so far available suggests that globus and gastro-oesophageal reflux may be related. A b n o r m alities of both the upper oesophageal sphincter and oesophageal body have been reported in globus patients.
My aims are:-
1. To assess the relationship between oesophageal motility of the upper oesophageal sphincter, oesophageal body and lower oesophageal sphincter and globus.
2. To explore the association of globus with gastro- oesophageal reflux using ambulatory pH monit o r i n g and to investigate the effects of acid perfusion on the upper oesophageal sphincter complex.
3. To consider the possibility of globus as a manif e s t a t i o n of a psychological disturbance.
C HAPTER 3