A 33-year-old man visited the gastrointestinal department of the Gil Medical Center with throat discomfort for the previous month. He denied symptoms of dysphagia, but suffered from occasional hoarseness, coughing and heartburn. There was no known history of excessive alcohol intake and smoking. His past medical history and family history were unremarkable. Physical examination revealed that the vital signs were stable and the patient's pharynx and abdomen appeared unremarkable.
On gastroesophageal endoscopic findings, there was no definite abnormal findings on the lower esophagus and stomach. Upon withdrawal of the endoscope, a patch of salmon colored epithelium was clearly demarcated from the surrounding normal mucosa in the upper esophagus (Figure 1A). Its diameter was between one-quarter and one-half fully expanded, and it was located just below the upper esophageal sphincter. Endoscopic biopsy finding from the patches revealed gastric-type columnar epithelium with parietal cells and Helicobacter pylori was not found on the Giemsa stain (Figure 1B).
A 24-hour ambulatory pH monitoring was performed to demonstrate acid secretion from this patch. Esophageal manometry was performed to confirm the level of the lower and upper esophageal sphincters. The level of the lower esophageal sphincter was 39 to 42 cm and that of the upper sphincter was about 19 cm from the incisor.
A dual-probe antimony pH catheter with a diameter of 2.1 mm (Synectics Medical Inc., Irving, Tx.) was placed transnasally after an overnight fast. The distal probe was placed at 5 cm above the manometrically defined lower esophageal sphincter. The proximal electrode was placed at 19 cm from the incisor, which corresponded approximately with the endoscopic findings of the heterotopic gastric mucosa. The pH values from both intraesophageal electrodes were recorded continuously on an ambulatory Mark III Digitrapper (Synectics Medical Inc.), and the data were downloaded to an IBM-compatible computer for calculation and analysis by Gastrosoft (Synecitics Medical Inc.).
A 24-hour ambulatory pH monitoring showed that the pH in the proximal esophagus less than 4 (including supine and upright positions) were 3.8% of the time in total (normal value < 1), 3.3% (normal value < 1.3) in the upright position, and in 4.6% (normal value is 0) in the supine position, respectively. The pH less than 4 in distal esophagus was 9.2% (normal value < 4.5) of the time in total (including supine and upright positions), 13.1% (normal value < 6.3%) in the upright position and in 3.5% (normal value < 1.2) in the supine position, respectively. Despite the increased acid exposure in the proximal pH probe, there was no acid reflux in supine position from 15:45 to 16:10 (Figure 2). The patient was treated with 40 mg of omeprazole, once daily, which resulted in improvement of the throat discomfort, hoarseness and cough.