The supersensitive hypertensive lower esophageal sphincter. Precipitation of pain by small doses of intravenous pentagastrin.

The clinical and investigative features of eight patients with attacks of epigastric pain believed due to a hypertensive lower esophageal sphincter (LES) are described. Radionuclide esophageal transit studies were normal in all but one patient. Two patients had positive acid perfusion studies. Only three had an abnormal baseline esophageal manometry, but after small intravenous doses of pentagastrin all subjects experienced their presenting pain coincident with increases in LES pressure ranging from 75 to 140 mmHg. Five patients eventually required surgical myotomy of the LES, but pain relief which was immediate and complete in all proved permanent in only one. Two of the operated patients continued to experience severe attacks of pain refractory to medical therapy. The diagnosis of a hypertensive LES is best made by pentagastrin stimulation of the sphincter, but cutting the sphincter may not cure the patient.