A missing sphincteric component of the gastro-oesophageal junction in patients with GORD.

It was recently shown that the tonic pressure contribution to the high-pressure zone of the oesophago-gastric segment (OGS) contains the contributions from three distinct components, two of which are smooth muscle intrinsic sphincter components, a proximal and a distal component [J Physiol 2007; 580.3: 961]. The aim of this study was to compare the pressure contributions from the three sphincteric components in normal subjects with those in gastro-oesophageal reflux disease (GORD) patients. A simultaneous endoluminal ultrasound and manometry catheter was pulled through the OGS in 15 healthy volunteers and seven patients with symptomatic GORD, before and after administration of atropine. Pre-atropine (complete muscle tone), postatropine (non-muscarinic muscle tone plus residual muscarinic tone) and subtracted (pure muscarinic muscle tone) pressure contributions to the sphincter were averaged after referencing spatially to the right crural diaphragm and the pull-through start position. In the normal group, the atropine-resistant and atropine-attenuated pressures identified the crural and two smooth muscle sphincteric components respectively. The subtraction pressure curve contained proximal and distal peaks. The proximal component moved with the crural sling between full inspiration and full expiration and the distal component coincided with the gastric sling-clasp fibre muscle complex. The subtraction curve in the GORD patients contained only a single pressure peak that moved with the crural sphincter, while the distal pressure peak of the intrinsic muscle component, which was previously recognized in the normal subjects, was absent. We hypothesize that the distal muscarinic smooth muscle pressure component (gastric sling/clasp muscle fibre component) is defective in GORD patients.