Role of intragastric and intraoesophageal alkalinisation in the genesis of complications in Barrett's columnar lined lower oesophagus.

Patients with Barrett's columnar lined lower oesophagus have severe acid gastrooesophageal reflux and may develop complications, including ulceration, stricture, and carcinoma. The aim of this study was to establish if a relationship exists between the pH profile in the oesophagus and stomach and the development of complications in patients with Barrett's columnar lined lower oesophagus. Twenty four hour ambulatory oesophageal pH monitoring was performed in 26 patients with Barrett's columnar lined lower oesophagus and combined with 24 hour ambulatory gastric pH monitoring in 16. Ten of the 26 with Barrett's columnar lined lower oesophagus had complications including stricture (eight), deep ulceration (one), and carcinoma (one). Oesophageal acid exposure (% time < pH 4) was similar in patients with or without complications (19.2% v 19.3% p > 0.05). Oesophageal alkaline exposure (% time > pH 7) was greater in patients with complications (24.2% v 8.4% p > 0.05). Of the 16 patients who underwent gastric pH monitoring there was a clear relationship between gastric and oesophageal alkalinisation in 13. These results support the hypothesis that complications in Barrett's columnar lined lower oesophagus develop in association with increased exposure of the oesophagus to an alkaline environment which appears to be secondary to duodenogastric reflux. The routine use of 24 hour ambulatory gastric pH monitoring in conjunction with oesophageal pH monitoring can help identify those patients at risk.