Most recent studies using high-resolution manometry were based on supine liquid swallows. This study was to evaluate the differences in esophageal motility for liquid and solid swallows in the upright and supine positions, and to determine the percentages of motility abnormalities in different states.
Twenty-four asymptomatic volunteers and 26 patients with gastroesophageal reflux disease underwent high-resolution manometry using a 36-channel manometry catheter. The peristalses of 10 water and 10 steamed bread swallows were recorded in both supine and upright positions. Integrated relaxation pressure, contractile front velocity, distal latency (DL) and the distal contractile integral (DCI) were investigated and comparisons between postures and boluses were analyzed. Abnormal peristalsis of patients was assessed applying the corresponding normative values.
In total, 829 swallows from healthy volunteers and 959 swallows from patients were included. (1) The upright position provided lower integrated relaxation pressure, shorter DL and weaker DCI than the supine position. (2) In the comparison of liquid swallows, the mean for contractile front velocity was obviously reduced while DL and DCI were increased in solid swallows. (3) The supine position detected more hypotensive peristalsis than the upright position. The upright position provided more rapid and premature contraction than the supine position but there was no statistically significant difference.
Supine solid swallows occur with more hypotensive peristalsis. Analysis should be based on normative values from the corresponding posture and bolus.
Esophageal motility disorders; High-resolution manometry; Posture
Esophageal manometry is considered the gold standard for assessing esophageal motor function. Although conventional manometry has been widely used to evaluate esophageal motor function, this is not fully satisfactory for explaining esophageal symptoms. High-resolution manometry (HRM) is designed to overcome the limitations of conventional manometric systems with advanced technologies. A solid-state HRM assembly with 36 solid-state sensors spaced at 1 cm intervals (Sierra Scientific Instruments Inc., Los Angeles, CA, USA) has been widely used around the world. Calibration and post-study thermal correction should be performed at each test. The HRM assembly was passed transnasally and positioned to record from the hypopharynx to the stomach. After a 5 minutes resting period to assess basal sphincter pressure, 5 mL water swallows are obtained in a supine posture. The interpretation of HRM data is still being refined. Recently, the HRM Classification Working Group revised the Chicago classification based on a systematic analysis of motility patterns in 75 control subjects and 400 consecutive patients. The below will show you a summary of the new Chicago classification of distal esophageal motility disorders to provide a practical way of interpreting HRM.
Esophageal manometry; High-resolution manometry; Esophagogastric junction; Contractile front velocity; Distal contractile integral
High-resolution manometry (HRM) of the esophagus is a new technique that provides a more precise assessment of esophageal motility than conventional techniques. Because HRM measures pressure events along the entire length of the esophagus simultaneously, clinical procedure time should be shorter because less catheter manipulation is required. According to manufacturer advertising, the new HRM system is more accurate and up to 50% faster than conventional methods.
To test the hypothesis that clinical testing with HRM requires less procedural time than a standard water perfusion (WP) method.
Forty-one consecutive patients were studied (20 underwent WP and 21 underwent HRM). Using time-motion analysis, the start and end times for each task associated with performing the study were recorded. Patient discomfort and study quality were also assessed by using five- and four-point qualitative scales, respectively.
Total procedure time was reduced on average by 25.6% in the HRM group (from 41.8 minutes with WP to 30.7 minutes with HRM, P<0.05). There was no significant difference in the discomfort scores reported by the study subjects and no difference in study quality.
HRM requires less time to complete than conventional manometry and should therefore shorten the wait-times of patients scheduled for esophageal manometry and have a significant impact on the cost of performing this commonly used clinical investigation.
Esophageal manometry; Time-motion analysis
Lower esophageal sphincter (LES) lift seen on high resolution manometry (HRM) is a possible surrogate marker of the longitudinal muscle contraction of the esophagus. Recent studies suggest that longitudinal muscle contraction of the esophagus induces LES relaxation.
Our goal was to determine, 1) the feasibility of prolonged ambulatory HRM and 2) to detect LES lift with LES relaxation using ambulatory HRM color isobaric contour plots.
In vitro validation studies were performed to determine the accuracy of HRM technique in detecting axial movement of the LES. Eight healthy normal volunteers were studied using a custom designed HRM catheter and a 16 channel data recorder, in the ambulatory setting of subject’s home environment. Color HRM plots were analyzed to determine the LES lift during swallow-induced LES relaxation as well as during complete and incomplete transient LES relaxations.
Satisfactory recordings were obtained for 16 hours in all subjects. LES lift was small (2 mm) in association with swallow-induced LES relaxation. LES lift could not be measured during complete transient LES relaxations (TLESR) because the LES is not identified on the HRM color isobaric contour plot once it is fully relaxed. On the other hand, LES lift, mean 7.6 ± 1.4 mm, range 6–12 mm was seen with incomplete TLESRs (n = 80).
Our study demonstrates the feasibility of prolonged ambulatory HRM recordings. Similar to a complete TLESR, longitudinal muscle contraction of the distal esophagus occurs during incomplete TLESRs, which can be detected by the HRM. Using prolonged ambulatory HRM, future studies may investigate the temporal correlation between abnormal longitudinal muscle contraction and esophageal symptoms.
Longitudinal Muscle Contraction; Mechanosensitive Motor Neurons
Background and objectives
Abnormal swallowing (dysphagia) among neonates is commonly evaluated using the videofluoroscopic swallow study (VSS). Radiological findings considered high risk for administration of oral feeding include nasopharyngeal reflux, laryngeal penetration, aspiration, or pooling. Our aims were to determine pharyngoesophageal motility correlates in neonates with dysphagia and the impact of multidisciplinary feeding strategy.
Twenty dysphagic neonates (mean gestation ± standard deviation [SD] = 30.9 ± 4.9 weeks; median 31.1 weeks; range = 23.7–38.6 weeks) with abnormal VSS results were evaluated at 49.9 ± 16.5 weeks (median 41.36 weeks) postmenstrual age. The subjects underwent a swallow-integrated pharyngoesophageal motility assessment of basal and adaptive swallowing reflexes using a micromanometry catheter and pneumohydraulic water perfusion system. Based on observations during the motility study, multidisciplinary feeding strategies were applied and included postural adaptation, sensory modification, hunger manipulation, and operant conditioning methods. To discriminate pharyngoesophageal manometry correlates between oral feeders and tube feeders, data were stratified based on the primary feeding method at discharge, oral feeding versus tube feeding.
At discharge, 15 of 20 dysphagic neonates achieved oral feeding success, and the rest required chronic tube feeding. Pharyngoesophageal manometry correlates were significantly different (P <0.05) between the primary oral feeders versus the chronic tube feeders for swallow frequency, swallow propagation, presence of adaptive peristaltic reflexes, oral feeding challenge test results, and upper esophageal sphincter tone. VSS results or disease characteristics had little effect on the feeding outcomes (P = NS).
Swallow-integrated esophageal motility studies permit prolonged evaluation of swallowing reflexes and responses to stimuli under controlled conditions at cribside. The dysfunctional neuromotor mechanisms may be responsible for neonatal dysphagia or its consequences. Manometry may be a better predictor than VSS in identifying patients who are likely to succeed in vigorous intervention programs.
Dysphagia; Motility; Neonates; Videofluoroscopic swallow study
This study used high-resolution impedance manometry (HRIM) to determine pressure topography thresholds of peristaltic integrity predictive of incomplete esophageal bolus clearance.
A total of 16 normal controls and 8 patients with dysphagia were studied using a solid-state HRIM assembly incorporating 36 manometric sensors and 12 impedance segments. Each of the 10 saline swallows in each study was dichotomously scored as either complete or incomplete bolus clearance by impedance criteria, and peristaltic integrity was evaluated using pressure topography isobaric contours ranging from 10 to 30 mm Hg in 5-mm Hg increments. Each isobaric contour plot was characterized by the location and length of breaks in the isobaric contour.
All subjects had normal esophagogastric junction (EGJ) relaxation and none met the pressure topography criteria of hiatus hernia. In all, 70 (29%) of the 240 individual swallows had incomplete bolus clearance. In every case, an intact ≥20 mm Hg isobaric contour was associated with complete bolus clearance. The largest defect in the 20 and 30 mm Hg isobaric contours associated with complete bolus clearance measured 1.7 and 3.0 cm, respectively, in length, whereas the smallest defect predictive of incomplete bolus clearance measured 2.1 and 3.2 cm, respectively.
In individuals with normal EGJ relaxation and morphology, peristaltic contractions with breaks <2 cm in the 20 mm Hg isobaric contour or <3 cm in the 30 mm Hg isobaric contour are associated with complete bolus clearance, and longer breaks predict incomplete bolus clearance.
Esophageal disorders are common in the general population and can be associated with significant morbidity. Several new diagnostic techniques for esophageal disorders have become available in recent years. These include capsule pH-metry, high-resolution manometry, impedance combined with either pH-metry or manometry, and high-frequency ultrasound. Capsule pH-metry is useful in children and in patients who cannot tolerate the conventional pH-metry catheter. It has the advantage of not interfering with a patient’s usual meals and activities during the 24 h study. High-resolution manometery is easier to perform and interpret than conventional manometry. This has led to improved diagnosis of various esophageal motility disorders. Impedance measures the movement of liquid and gas in the esophagus. When combined with pH-metry, impedance can confirm that retrograde bolus movement (ie, reflux) is occurring while simultaneously measuring changes in pH levels. It has also highlighted the importance of weakly acidic reflux in patients who do not respond to proton pump inhibitors. Weakly acidic reflux cannot be diagnosed with pH-metry alone. Impedance combined with manometry can determine whether a manometric abnormality leads to abnormal bolus clearance. In the past, this was performed with fluoroscopy, yet impedance is equally effective and does not carry the risk of increased radiation exposure. High-frequency ultrasound is currently a research tool to image the esophageal wall, particulary the two muscle layers, in real time during swallows and at rest. It has broadened our understanding of the pathophysiology of esophageal motility disorders.
Diagnostic techniques; Esophageal motility disorders; GERD
Esophago-pharyngeal regurgitation is implicated in various otolaryngologic and respiratory disorders. The pathophysiological mechanisms causing regurgitation are still largely unknown.
To determine the principal mechanisms behind esophago-pharyngeal regurgitation.
We studied 11 patients with extra-esophageal GORD symptoms in whom esophago-pharyngeal acid regurgitation had previously been demonstrated using ambulatory, dual (pharyngo-esophageal) pH metry (>2 episodes/day using previously validated pH-metric criteria). Patients underwent continuous, 24 hr, stationary monitoring of pharyngo-esophageal manometry and dual (pharyngeal and esophageal) pH recordings. They were intubated with a 14-channel manometric assembly incorporating 2 sleeve sensors monitoring the upper and lower esophageal sphincters simultaneously. A dual pH catheter recorded pH signals 2 cm above the UES midpoint and 7 cm above the LES midpoint.
A total of 32 episodes of spontaneous esophago-pharyngeal acid regurgitation were recorded. All episodes occurred in the upright posture and 91% occurred within 3 hrs post-prandium. All regurgitation events were associated with a relaxation of the UES, which were classified as transient non-swallow related relaxations in 29 (91%) and swallow-related in the remaining 3 (9%). Straining was an additional associated factor in 41% of regurgitation events, but strain alone was not sufficient to cause esophago-pharyngeal regurgitation.
Some form of active UES relaxation is necessary for regurgitation to occur. The dominant mechanism underlying esophago-pharyngeal acid regurgitation is the non-swallow related, transient UES relaxation.
Level of Evidence
Achalasia patients would feel exacerbated dysphagia, chest pain and regurgitation when they drink cold beverages or eat cold food. But these symptoms would relieve when they drink hot water. Reasons are unknown.
Twelve achalasia patients (mean age, 34 ± 10 years; F:M, 3:9) who never had any invasive therapies were chosen from Peking Union Medical College Hospital. They were asked to fill in the questionnaire on eating habits including food temperature and related symptoms and to receive high-resolution manometry examination. The exam was done in 2 separated days, at swallowing room temperature (25℃) then hot (50℃) water, and at room temperature (25℃) then cold (2℃) water, respectively. Parameters associated with esophageal motility were analyzed.
Most patients (9/12) reported discomfort when they ate cold food. All patients reported no additional discomfort when they ate hot food. Drinking hot water was effective in 5/8 patients who ever tried to relieve chest pain attacks. On manometry, cold water increased lower esophageal sphincter (LES) resting pressure (P = 0.003), and prolonged the duration of esophageal body contraction (P = 0.002). Hot water decreased LES resting pressure and residue pressure during swallow (P = 0.008 and P = 0.002), increased LES relaxation rate (P = 0.029) and shortened the duration of esophageal body contraction (P = 0.003).
Cold water could increase LES resting pressure, prolong the contraction duration of esophageal body, and exacerbate achalasia symptoms. Hot water could reduce LES resting pressure, assist LES relaxation, shorten the contraction duration of esophageal body and relieve symptoms. Thus achalasia patients are recommended to eat hot and warm food and avoid cold food.
Esophageal achalasia; Esophageal motility disorders; Food; Temperature
Manometry of the pharynx and the upper esophageal sphincter (UES) provides important information on the swallowing mechanism, especially about details on the pharyngeal contraction and relaxation of the UES. However, UES manometry is challenging because of the radial asymmetry of the sphincter, and upward movement of the UES during swallowing. In addition, the rapidity of contraction of the pharyngoesophageal segment requires high frequency recording for capturing these changes in pressure; this is best done with the use of solid state transducers and high-resolution manometry. UES manometry is not required for routine patient care, when esophageal manometry is being performed. The major usefulness of UES manometry in clinical practice is in the evaluation of patients with oropharyngeal dysphagia.
Achalasia, cricopharyngeal; Dysphagia, oropharyngeal; Esophageal sphincter, upper; Manometry
To date, high-resolution manometry has been used mainly in the study of esophageal motility disorders and has been shown to provide more physiological information than conventional manometry, and is easier to interpret. This study aimed to evaluate the usefulness of high-resolution anorectal manometry (HRARM) compared to water-perfused anorectal manometry.
Patients who complained of chronic constipation with/without fecal incontinence underwent both water-perfused anorectal manometry and HRARM in a random order on the same day. Resting and squeezing pressures of the anal sphincter, attempted defecation, rectoanal inhibitory reflex, rectoanal contractile reflex, Rao’s type of dyssynergia during attempted defecation, anal canal length, defecation dynamic parameters and measurement times for each method were analyzed.
Of 14 patients, 7 were female, and the median age was 59 years (range 35–77). Indications for manometry were constipation (n = 8) and constipation with fecal incontinence (n = 6). Resting and squeezing pressures showed that the 2 methods were strongly correlated (resting pressure: r = 0.746, P = 0.002; squeezing pressure: r = 0.921, P < 0.001). In attempted defection, one equivocal case with water-perfused anorectal manometry was diagnosed type I pelvic floor dyssynergia with HRARM providing detailed pressure changes in internal and external anal spincters, and puborectalis muscle which improved assessment of anorectal disorders. The measurement time for HRARM was significantly shorter than that for water-perfused anorectal manometry (11.3 vs 23.0 minutes, P < 0.001).
Both water-perfused anorectal manometry and HRARM are well tolerated and reliable methods of evaluating defecation disorders of pelvic floor dysfunction. HRARM is likely to provide better physiological information and to require a shorter measurement time compared to water-perfused anorectal manometry.
Constipation; Defecation; Fecal incontinence; Manometry; High-resolution manometry
Background and aims
Although, the current protocol for high resolution manometry (HRM) using the Chicago Classification is based on the supine posture, some practitioners prefer a sitting posture. Our aims were to establish normative esophageal pressure topography (EPT) data for the sitting position and to determine the effect of applying those norms to Chicago Classification diagnoses.
EPT studies including test swallows in both a supine and sitting position of 75 healthy volunteers and 120 patients were reviewed. Integrated relaxation pressure (IRP), distal contractile integral (DCI), contractile front velocity (CFV) and distal latency (DL) were measured and compared between postures. Normative ranges were established from the healthy volunteers and the effect of applying sitting normative values to the patients was analyzed.
Normative values of IRP, DCI and CFV all decreased significantly in the sitting posture. Applying normative sitting metrics to patient studies (27% reduction in IRP (15 to 11 mmHg), 69% reduction in DCI (8,000 to 2500 mmHg-s-cm)) reclassified 13/120 (11%) patients as having abnormal EGJ relaxation and 26/120 (22%) as hypercontractile. Three patients with an abnormal supine IRP normalized when sitting with elimination of a vascular artifact.
Clinical HRM studies should include both a supine and sitting position to minimize misdiagnoses attributable to anatomical factors. However, until outcome studies demonstrating the significance of isolated abnormalities of IRP or DCI in the sitting position are available, the Chicago Classification of esophageal motility disorders should continue to be based on supine swallows using normative data from the supine posture.
High resolution manometry; position; Chicago classification
Esophageal manometry utilizes water swallows to evaluate esophageal motor abnormalities in patients with dysphagia, chest pain, or reflux symptoms. Although manometry is the gold standard for evaluation of these symptoms, patients with dysphagia often have normal results in manometry studies.
The objective of this work was to test the hypothesis that challenging the esophagus with viscous apple sauce boluses uncovers motor abnormalities in patients with dysphagia not seen when using water swallows.
High-resolution esophageal manometry was performed using ten water swallows followed by ten apple sauce swallows in consecutive subjects presenting with dysphagia. Subjects with grossly abnormal water swallow evaluations were excluded. Each swallow was categorized as normal, hypotensive (distal isobaric contour plots of <30 mmHg over >5 cm), or simultaneous (distal esophageal velocity ≥8.0 cm/s). Ineffective esophageal motility (IEM) was defined as ≥30% hypotensive swallows, and pressurization was defined as ≥20% simultaneous pressure waves.
Data from 41 subjects was evaluated. Overall, 96.3% of water swallows were normal, 2.9% hypotensive, and 0.7% simultaneous. Only 70.3% of viscous swallows were normal; 16.7% were hypotensive and 13.0% were simultaneous (P < 0.001 all groups). Seven (17.1%) met criteria for IEM, and pressurization with viscous swallows was observed for nine (22.0%). Fourteen subjects (34.1%) had abnormal results from viscous studies. The presence of any abnormal water swallows was predictive of abnormal viscous swallows (OR = 9.00, CI = 2.15–80.0), although the presence of hypotensive or simultaneous water swallows was not associated with IEM (OR = 0.63, CI = 0.16–2.17) or pressurization (OR = 7.00, CI = 0.90–315.4) with viscous apple sauce.
Apple sauce challenge increased identification of classifiable motor disorders in patients with dysphagia and may be preferred to alternative bolus materials.
Apple sauce; Dysphagia; Esophagus; High-resolution manometry; Motility
Nephrotic syndrome is associated with altered renal handling of water and sodium and changes in the levels of aquaporins (AQPs) and epithelial Na channels (ENaCs). The dried sclerotia of Poria cocos Wolf (WPC) have been used for treating chronic edema and nephrosis. We evaluated the effects of WPC on puromycin aminonucleoside- (PAN-) induced renal functional derangement and altered renal AQP2 and ENaC expression. In the nephrotic syndrome rat model, animals were injected with 75 mg/kg PAN and then treated with Losartan (30 mg·kg−1·day−1) or WPC (200 mg·kg−1·day−1) for 7 days. In the WPC group, proteinuria and ascites improved significantly. Plasma levels of triglyceride, total cholesterol, and low-density lipoprotein- (LDL-) cholesterol reduced significantly in the WPC group. In addition, the WPC group exhibited attenuation of the PAN-induced increase in AQP2 and ENaC α/β subunit protein and mRNA levels. WPC suppressed significantly PAN-induced organic osmolyte regulators, reducing serum- and glucocorticoid-inducible protein kinase (Sgk1) and sodium-myo-inositol cotransporter (SMIT) mRNA expression. Our results show that WPC improves nephrotic syndrome, including proteinuria and ascites, through inhibition of AQP2 and ENaC expression. Therefore, WPC influences body-fluid regulation via inhibition of water and sodium channels, thereby, improving renal disorders such as edema or nephrosis.
The purpose of this study was to determine important manometric metrics for the analysis of pharyngeal and upper esophageal sphincter (UES) function and to investigate the effect of viscosity and other confounding factors on manometric results.
Manometric studies were performed on 26 asymptomatic volunteers (12 men and 14 women; age, 19–81 years). The manometric protocol included 5 water swallows (5 mL), 5 barium swallows (5 mL) and 5 yogurt swallows (5 mL). Evaluation of high-resolution manometry parameters including basal pressure of the UES, mesopharyngeal contractile integral (mesopharyngeal CI, mmHg · cm · sec), CI of the hypopharynx and UES (hypopharyngeal CI), relaxation interval of UES, median intrabolus pressure and nadir pressure at UES was performed using MATLAB.
Mesopharyngeal CIs for barium and yogurt swallows were significantly lower than those for water swallows (both P < 0.05). Hypopharyngeal CIs for water swallows were significantly lower than those for barium swallows (P = 0.004), and median bolus pressure at UES for barium swallows was significantly higher than that for water and yogurt swallows (both P < 0.05). Furthermore, hypopharyngeal CI and median intrabolus pressure at UES were significantly related to age for 3 swallows (all P < 0.01 and P < 0.05, respectively). A significant negative correlation was also noted between nadir pressure at UES and age for water and yogurt swallows (all P < 0.05).
Manometric measurement of the pharynx and UES varies with respect to viscosity. Moreover, age could be a confounding variable in the interpretation of pharyngeal manometry.
Manometry; Deglutition; Esophageal sphincter, upper; Fluoroscopy; Pharynx
AIM: To investigate the agreement between esophageal manometry and pH step-up method in two different patient positions.
METHODS: Eighteen subjects were included in the study. First, the distance from the nose to the proximal border of the lower esophageal sphincter (LES) was measured manometrically. Then a different investigator, who was blinded to the results of the first study, measured the same distance using the pH step-up method, with the patient in both upright and supine positions. An assessment of agreement between the two techniques was performed.
RESULTS: In the supine position, the measurement of only one subject was outside the range accepted for correct positioning (≤ 3 cm distal or proximal to the LES). In the upright position, errors in measurement were recognized in five subjects. Bland-Altman plots revealed good agreement between measurements obtained manometrically and by the pH-step up method with the patient in the supine position.
CONCLUSION: In the case of nonavailability of manometric detection device, the pH step-up method can facilitate the positioning of the 24 h pH monitoring catheter with the patient in the supine position. This should increase the use of pH-metry in clinical practice for subjects with suspected gastroesophageal reflux disease if our results are supported by further studies.
pH monitoring; Esophageal manometry; pH step-up method; Gastroesophageal reflux
BACKGROUND AND AIMS—It has been shown that gastro-oesophageal reflux plays a role in the pathogenesis of intestinal metaplasia (IM) limited to the oesophagogastric junction (OGJ), similar to the pathogenesis of IM in long segments of columnar lined oesophagus. The aim of this study was to examine lower oesophageal sphincter (LOS) function by means of prolonged recording in patients with IM limited to a normal appearing OGJ.
PATIENTS AND METHODS—Eighteen patients with IM at the OGJ (five females, 13 males; mean age 55.4 years) and 22 patients without IM (nine females, 13 males; mean age 53.9 years) underwent conventional stationary oesophageal manometry. Thereafter, seven hour water perfused manometry with simultaneous pH measurement (probe 5 cm proximal to the LOS) was performed. Swallowing was monitored with a pharyngeal sidehole and LOS pressure was recorded with a Dent sleeve. Patients were studied in the fasted state (three hours) and after a standardised meal (four hours). LOS pressure was analysed using customised software, and the incidence of reflux episodes (pH <4 for at least five seconds) and transient LOS relaxations (TLOSRs) were examined. TLOSRs were judged to be accompanied by reflux if a decrease of 1 pH unit occurred during relaxation.
RESULTS—Patients with IM at the OGJ had a higher prevalence of postprandial acid reflux compared with patients without IM. No differences were observed in LOS pressure (pre- and postprandially) or in the prevalence of TLOSRs. However, in the postprandial phase, the rate of TLOSRs accompanied by acid reflux was increased in patients with IM.
CONCLUSION—Patients with IM at the OGJ have a higher prevalence of postprandial acid reflux. This is not associated with a higher prevalence of TLOSRs or a decreased LOS pressure but with a higher rate of TLOSRs accompanied by reflux.
Keywords: intestinal metaplasia; gastro-oesophageal reflux; transient lower oesophageal sphincter relaxations; oesophagogastric junction
Achalasia is an esophageal motility disorder of unknown cause, characterized by aperistalsis of the esophageal body and impaired lower esophageal sphincter relaxation. Patients present at all ages, primarily with dysphagia for solids/liquids and bland regurgitation. The diagnosis is suggested by barium esophagram and confirmed by esophageal manometry. Achalasia cannot be cured. Instead, our goal is to relieve symptoms, improve esophageal emptying and prevent the development of megaesophagus. The most successful therapies are pneumatic dilation and surgical myotomy. The overall success rate of graded pneumatic dilation is 78%, with women and older patients responding best. Laparoscopic myotomy, usually combined with a partial fundoplication, has an overall success rate of 87%. Young patients, especially men, are the best candidates for surgical myotomy. Botulinum toxin injection into the lower esophageal sphincter and smooth muscle relaxants are usually reserved for older patients or those with co-morbid illness. The prognosis for achalasia patients to return to near normal swallowing is good, but the disease is rarely "cured" with a single procedure and intermittent touch-up procedures may be required.
Achalasia; Balloon dilation; Esophageal sphincter lower; Muscle, smooth; Botulinum toxin
OBJECTIVE: To investigate anorectal function in women patients with systemic sclerosis (SSc), with and without lower gastrointestinal symptoms. METHODS: Anorectal manometry was performed in 16 patients with SSc: six with no or minimal bowel symptoms, seven with constipation, and three with diarrhoea and faecal incontinence. Eleven healthy women acted as control subjects. Pressure data were recorded via an eight lumen polyvinylchloride water perfused catheter. Station and rapid pull through techniques were used. RESULTS: In the patients with SSc, mean resting pressure, maximal voluntary squeeze effort, and squeeze vector volume were lower, and squeeze asymmetry was greater, compared with the healthy controls. Differences were significant in the subgroup with constipation. CONCLUSION: Radial asymmetry and vector volume parameters provide detailed analysis of segmental anal canal function. Our findings suggest significant segmental deficits in those patients with SSc who have lower gastrointestinal symptoms. The trend towards smaller pressures and squeeze vector volumes in the asymptomatic SSc group suggests subclinical dysfunction in these patients.
Obesity has emerged as a major health problem in the developed world and has been found to be associated with several respiratory, cardiovascular, neurological and digestive diseases. Few studies have investigated esophageal dysmotility in obese populations; however, they have reported conflicting results, primarily due to varying measures and classification systems. This prospective study aimed to determine the prevalence of esophageal motor disorders in a group of obese patients in Montreal, Quebec.
Obesity is an important health problem affecting >500 million people worldwide. Esophageal dysmotility is a gastrointestinal pathology associated with obesity; however, its prevalence and characteristics remain unclear. Esophageal dysmotilities have a high prevalence among obese patients regardless of gastrointestinal symptoms.
To identify the prevalence of esophageal dysmotility among obese patients. The secondary goals were to characterize these pathologies in obese patients and identify risk factors.
A prospective study from January 2009 to March 2010 at the University of Montreal Hospital Centre (Montreal, Quebec) was performed. Every patient scheduled for bariatric surgery underwent preoperatory esophageal manometry and was included in the study. Manometry was performed according to a standardized protocol with the following measures: superior esophageal sphincter – coordination and release during deglutition; esophageal body – presence, propagation, length, amplitude and type of esophageal waves of contraction; lower esophageal sphincter – localization, tone, release, intragastic pressure and intraesophageal pressure. All reference values were those used in the digestive motility laboratory. A gastrointestinal symptoms questionnaire was completed on the day manometry was performed. Chart reviews were performed to identify comorbidities and treatments that could influence the results.
A total of 53 patients were included (mean [± SD] age 43±10 years; mean body mass index 46±7 kg/m2; 70% female). Esophageal manometry revealed dysmotility in 51% (n=27) of the patients. This dysmotility involved the esophageal body in 74% (n=20) of the patients and the inferior sphincter in 11% (n=3). Mixed dysmotility (body and inferior sphincter) was found in 15% (n=4) of cases. The esophageal body dysmotilities were hypomotility in 85% (n=23) of the patients, either from insignificant waves (74% [n=20]), nonpropagated waves (11% [n=3]) or low-amplitude waves (33% [n=9]). Gastroesophageal symptoms were found in 66% (n=35) of obese patients, including heartburn (66% [n=23]), regurgitation (26% [n=9]), dysphagia (43% [n=15]), chest pain (6% [n=2]) and dyspepsia (26% [n=9]). Among symptomatic patients, 51% (n=18) had normal manometry and 49% (n=17) had abnormal manometry (statistically nonsignificant). Among asymptomatic patients (n=18), 44% (n=8) had normal manometry and 56% (n=10) had abnormal manometry (statistically nonsignificant). Furthermore, no statistical differences were found between the normal manometry group and the abnormal manometry group with regard to medication intake or comorbidities.
Esophageal dysmotilities had a high prevalence in obese patients. Gastrointestinal symptoms cannot predict the presence of esophageal dysmotility. Hypomotility of the esophageal body is the most common dysmotility, especially from the absence of significant waves.
Bariatric surgery; Esophageal manometry; Obesity
The concept of high-resolution manometry (HRM) is to use sufficient pressure sensors such that intraluminal pressure can be monitored as a continuum along luminal length much as time is viewed as a continuum in conventional manometry. When HRM is coupled with pressure topography plots, pressure amplitude is transformed into spectral colors with isobaric conditions indicated by same-colored regions on the display. Together, these technologies are called high-resolution esophageal pressure topography (HREPT). HREPT has several advantages compared with conventional manometry, the technology that it was designed to replace. (i) The contractility of the entire esophagus can be viewed simultaneously in a uniform format, (ii) standardized objective metrics can be systematically applied for interpretation, and (iii) topographic patterns of contractility are more easily recognized and have greater reproducibility than with conventional manometry. Compared with conventional manometry, HREPT has improved sensitivity for detecting achalasia, largely due to the objectivity and accuracy with which it identifies impaired esophagogastric junction (EGJ) relaxation. In addition, it has led to the subcategorization of achalasia into three clinically relevant subtypes based on the contractile function of the esophageal body: classic achalasia, achalasia with esophageal compression, and spastic achalasia. Headway has also been made in understanding hypercontractile conditions, including diffuse esophageal spasm and a newly described entity, spastic nutcracker. Ultimately, clinical experience will be the judge, but it seems likely that HREPT data, along with its well-defined functional implications, will improve the clinical management of esophageal motility disorders.
BACKGROUND AND AIMS—Conventional short term manometry is a valuable tool in the diagnosis of achalasia but the technique may fail to detect intermittent motor events. The aim of this study was to investigate the pattern of lower oesophageal sphincter (LOS) and oesophageal pressures during prolonged recording in patients with achalasia.
METHODS—Eleven patients with idiopathic achalasia were studied. Prolonged combined oesophageal pH and manometric recordings of the pharynx, LOS, and stomach were performed using a pH glass electrode and a multiple lumen assembly incorporating a Dent sleeve connected to a portable water perfused manometric system.
RESULTS—LOS pressure varied during the day. Postprandial LOS pressures were lower than those recorded preprandially (1.2 v 1.8 kPa; p=0.005) and basal LOS pressures were significantly higher during phase III of the migrating motor complex than during the subsequent phase I (3.3 v 1.8 kPa; p=0.028). Complete LOS relaxations were occasionally observed in seven patients (0.48/h). Complete LOS relaxations were longer in duration than incomplete LOS relaxations (10.8 v 2.8 s; p=0.01) and 57% of complete relaxations fulfilled the criteria of a transient LOS relaxation (TLOSR). Complete LOS relaxations were associated with oesophageal pressure waves with higher amplitudes and longer durations. In addition, a higher proportion of these oesophageal pressure waves were spontaneous (55.6% v 0%; p<0.02) and multipeaked (72.7% v 0%). During prolonged manometry, high amplitude oesophageal pressure waves (>10 kPa) were recorded in six patients and retrograde oesophageal pressure waves in four, phenomena which were not observed during short term manometry.
CONCLUSION—In contrast with short term stationary manometry, prolonged manometry in achalasia patients revealed the occurrence of complete LOS relaxations, TLOSRs, variations in LOS pressure associated with a meal or phase III, and high amplitude and retrograde oesophageal pressure waves.
Keywords: achalasia; lower oesophageal sphincter; manometry; oesophagus
Management of chronic constipation with refractory symptoms can be challenging. Although new drugs and behavioral treatments have improved outcome, when they fail, there is little guidance on what to do next. At this juncture, typically most doctors may refer for surgical intervention although total colectomy is associated with morbidity including complications such as recurrent bacterial overgrowth. Recently, colonic manometry with sensory/tone/compliance assessment with a barostat study has been shown to be useful. Technical challenges aside, adequate preparation, and appropriate equipment and knowledge of colonic physiology are keys for a successful procedure. The test itself appears to be safe with little complications. Currently, colonic manometry is usually performed with a 6–8 solid state or water-perfused sensor probe, although high-resolution fiber-optic colonic manometry with better spatiotemporal resolutions may become available in the near future. For a test that has evolved over 3 decades, normal physiology and abnormal findings for common phenotypes of chronic constipation, especially slow transit constipation, have been well characterized only recently largely through the advent of prolonged 24-hour ambulatory colonic manometry studies. Even though the test has been largely restricted to specialized laboratories at the moment, emerging new technologies and indications may facilitate its wider use in the near future.
Barostat; Colon; Constipation; Manometry
We investigated early systemic sclerosis (SSc) (that is, Raynaud's phenomenon with SSc marker autoantibodies and/or typical capillaroscopic findings and no manifestations other than puffy fingers or arthritis) versus undifferentiated connective tissue disease (UCTD) to identify predictors of short-term disease evolution.
Thirty-nine early SSc and 37 UCTD patients were investigated. At baseline, all patients underwent clinical evaluation, B-mode echocardiography, lung function tests and esophageal manometry to detect preclinical alterations of internal organs, and were re-assessed every year. Twenty-one early SSc and 24 UCTD patients, and 25 controls were also investigated for serum endothelial, T-cell and fibroblast activation markers.
At baseline, 48.7% of early SSc and 37.8% of UCTD patients had at least one preclinical functional alteration (P > 0.05). Ninety-two percent of early SSc patients developed manifestations consistent with definite SSc (that is, skin sclerosis, digital ulcers/scars, two or more teleangectasias, clinically visible nailfold capillaries, cutaneous calcinosis, X-ray bibasilar lung fibrosis, X-ray esophageal dysmotility, ECG signs of myocardial fibrosis and laboratory signs of renal crisis) within five years versus 17.1% of UCTD patients (X2 = 12.26; P = 0.0005). Avascular areas (HR = 4.39 95% CI 1.18 to 16.3; P = 0.02), increased levels of soluble IL-2 receptor alpha (HR = 4.39; 95% CI 1.03 to 18.6; P = 0.03), and of procollagen III aminopropeptide predicted disease evolution (HR = 4.55; 95% CI 1.18 to 17; P = 0.04).
Most early SSc but only a few UCTD patients progress to definite SSc within a short-term follow-up. Measurement of circulating markers of T-cell and fibroblast activation might serve to identify early SSc patients who are more likely to develop features of definite SSc.
Although globus sensation is a common symptom, its pathogenesis is poorly defined. The aim of this study was to quantify the timing and magnitude of respiratory variation in upper esophageal sphincter (UES) pressure with high-resolution manometry (HRM) in patients with globus sensation, normal controls, and gastroesophageal reflux disease (GERD) patients without globus sensation.
HRM recordings spanning from the hypopharynx to the stomach were analyzed in 131 consecutive globus patients with normal (64) and abnormal (67) distal esophageal motility. Resting UES pressure was analyzed up to 5 min before 10 5-ml water swallows. Change in UES pressure, its average magnitude between inspiration and expiration, and nadir UES relaxation pressure in globus patients were compared with those in 68 controls and 46 GERD patients without globus.
UES pressure typically increased during inspiration in both controls and patients. Respiration-related change in resting UES pressure was significantly amplified in globus patients (37.3 mm Hg) compared with controls (10.6 mm Hg) and GERD patients (13.0 mm Hg) (P < 0.0001). A respiratory change in UES pressure >27 mm Hg was found in > 60% of globus patients and <15% of controls and GERD patients without globus. This hyperdynamic UES was not associated with other abnormalities of esophageal motor function.
Hyperdynamic respiratory UES pressure changes were prevalent in patients reporting globus sensation irrespective of their deglutitive UES and distal esophageal motility. Although the etiology of this hyperdynamic UES is unclear, it does appear to be a frequent manometric observation in this patient group and may provide a new focus for further studies into pathogenesis and therapy.