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
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
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
Both high-resolution manometry (HRM) and impedance-pH/manometry monitoring have established themselves as research tools and both are now emerging in the clinical arena. Solid-state HRM capable of simultaneously monitoring the entire pressure profile from the pharynx to the stomach along with pressure topography plotting represents an evolution in esophageal manometry. Two strengths of HRM with pressure topography plots compared with conventional manometric recordings are (1) accurately delineating and tracking the movement of functionally defined contractile elements of the esophagus and its sphincters, and (2) easily distinguishing between luminal pressurization attributable to spastic contractions and that resultant from a trapped bolus in a dysfunctional esophagus. Making these distinctions objectifies the identification of achalasia, distal esophageal spasm, functional obstruction, and subtypes thereof. Ambulatory intraluminal impedance pH monitoring has opened our eyes to the trafficking of much more than acid reflux through the esophageal lumen. It is clear that acid reflux as identified by a conventional pH electrode represents only a subset of reflux events with many more reflux episodes being composed of less acidic and gaseous mixtures. This has prompted many investigations into the genesis of refractory reflux symptoms. However, with both technologies, the challenge has been to make sense of the vastly expanded datasets. At the very least, HRM is a major technological tweak on conventional manometry, and impedance pH monitoring yields information above and beyond that gained from conventional pH monitoring studies. Ultimately, however, both technologies will be strengthened as outcome studies evaluating their utilization become available.
AIM: To compare the demographic and clinical features of different manometric subsets of ineffective oesophageal motility (IOM; defined as ≥ 30% wet swallows with distal contractile amplitude < 30 mmHg), and to determine whether the prevalence of gastro-oesophageal reflux differs between IOM subsets.
METHODS: Clinical characteristics of manometric subsets were determined in 100 IOM patients (73 female, median age 58 years) and compared to those of 100 age-and gender-matched patient controls with oesophageal symptoms, but normal manometry. Supine oesophageal manometry was performed with an eight-channel DentSleeve water-perfused catheter, and an ambulatory pH study assessed gastro-oesophageal reflux.
RESULTS: Patients in the IOM subset featuring a majority of low-amplitude simultaneous contractions (LASC) experienced less heartburn (prevalence 26%), but more dysphagia (57%) than those in the IOM subset featuring low-amplitude propagated contractions (LAP; heartburn 70%, dysphagia 24%; both P ≤ 0.01). LASC patients also experienced less heartburn and more dysphagia than patient controls (heartburn 68%, dysphagia 11%; both P < 0.001). The prevalence of heartburn and dysphagia in IOM patients featuring a majority of non-transmitted sequences (NT) was 54% (P = 0.04 vs LASC) and 36% (P < 0.01 vs controls), respectively. No differences in age and gender distribution, chest pain prevalence, acid exposure time (AET) and symptom/reflux association existed between IOM subsets, or between subsets and controls.
CONCLUSION: IOM patients with LASC exhibit a different symptom profile to those with LAP, but do not differ in gastro-oesophageal reflux prevalence. These findings raise the possibility of different pathophysiological mechanisms in IOM subsets, which warrants further investigation.
Age; Dysphagia; Heartburn; Ineffective oesophageal motility; Oesophageal manometry; Simultaneous contractions
To quantify the effect of swallowing maneuvers on pharyngeal pressure events using high resolution manometry (HRM).
Seven subjects swallowed multiple, five ml water boluses in three different postural conditions: neutral, head turn, and chin tuck. Pressure and timing events were recorded with a 36-sensor HRM catheter. We analyzed the regions of the velopharynx and base of tongue for maximal pressure, rate of pressure increase, pressure gradient, and duration of pressure above baseline. In the region of the upper esophageal sphincter (UES), we analyzed duration of pressure declination, minimum pressure during opening, and maximum pressures before and after UES opening.
Maneuvers did not have a significant effect on maximum pressure, rate of pressure increase, or pressure gradients in the velopharyngeal or tongue base regions. Duration of pressure above baseline was significantly longer in the velopharynx for head turn. Pre-swallow maximum UES pressure was significantly greater for neutral swallows compared to head turn and post-swallow maximum pressure was significantly lower for chin tuck. Both maneuvers appeared to prolong UES pressure declination duration, but neither reached significance.
HRM allows for optimal spatial and temporal resolution during recording of pressure events along the length of the pharynx and revealed previously undetected task-dependent pressure and timing differences during chin tuck and head turn in healthy adults. These maneuvers appear to influence the UES to a greater degree than the velopharynx and tongue base. Further studies designed to quantify the effect of other maneuvers and bolus consistencies on the generation of pharyngeal pressure events in both normal and disordered subjects may lead to hypothesis-driven, optimal, individualized, swallowing therapies.
Pharyngeal pressure; swallowing maneuver; high resolution manometry; dysphagia
This study was aimed to evaluate the anorectal dysfunction in systemic sclerosis (SSc) and propose the clinical significance of anorectal manometry in patients with SSc. Seven patients with SSc were evaluated with manometry for anorectal function and an additional 11 normal subjects were collected as a control group. The study group underwent esophageal manometry as well and the correlation between the degree of anorectal and esophageal dysfunction was evaluated. Patients showed a lower tolerance for balloon distention of the rectum than controls (minimal sensory volume and urgency volume, P < 0.05). The resting and squeezing pressure of the anal sphincter and the functional length of the anal canal showed no significant difference in these two groups. Rectoanal inhibitory reflex was absent in one (14%) and diminished in two (29%) of seven patients with SSc. SSc patients also showed abnormal esophageal manometry findings, notably decreased LES pressure and body amplitude of distal 2/3 esophagus. The comparison between manometric profiles of anorectum and esophagus showed no significant correlation by statistical analysis. In conclusion, our data could suggest that anorectal function may be impaired in patients with SSc which could reflect the involvement of the anorectum by the disease, and that anorectal manometric studies can be useful to detect such dysfunction in patients with SSc, even before clinical symptoms.
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
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
Conventional manometry presents significant challenges, especially in assessment of pharyngeal swallowing, because of the asymmetry and deglutitive movements of oropharyngeal structures. It only provides information about intraluminal pressure and thus it is difficult to study functional details of esophageal motility disorders. New technology of solid high resolution impedance manometry (HRIM), with 32 pressure sensors and 6 impedance sensors, is likely to provide better assessment of pharyngeal swallowing as well as more information about esophageal motility disorders. However, the clinical usefulness of application of HRIM in patients with oropharyngeal dysphagia or esophageal dysphagia is not known. We experienced a case of Huntington’s disease presenting with both oropharyngeal and esophageal dysphagia, in which HRIM revealed the mechanism of oropharyngeal dysphagia and provided comprehensive information about esophageal dysphagia.
Dysphagia; Esophagus; High resolution impedance manometry; Huntington’s disease; Oropharynx
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
To evaluate the effects of the phosphodiesterase type 5 (PDE5) inhibitor vardenafil on esophageal function, including bolus transit, using multichannel intraluminal impedance and esophageal manometry (MII-EM).
Sixteen healthy volunteers (15 men) underwent an MII-EM study including 10 liquid swallows and 10 viscous swallows in a seated position after fasting. Then, each subject was asked to ingest 50 mL distilled water or 10 mg vardenafil dissolved in 50 mL water, in a double-blind manner. After 25 minutes, the MII-EM study was repeated.
Eight men received vardenafil and eight subjects received water. Resting and residual lower esophageal sphincter pressures differed significantly only in the vardenafil group (from 18 ± 6.7 to 6.6 ± 5.3 mmHg, P < 0.001 and from 4.9 ± 2.6 to 2.1 ± 3.6 mmHg, P = 0.006, respectively). Mean distal esophageal amplitude decreased significantly only in the vardenafil group (from 86.7 ± 41.6 to 34.0 ± 38.0 mmHg, P < 0.05). Complete bolus transits of liquid and viscous meals decreased significantly only after vardenafil ingestion (from 80.2% ± 13.8% to 49.4% ± 27.9%, P < 0.05 and from 72.8% ± 33.6% to 21.5% ± 29.0%, P = 0.01, respectively).
Vardenafil decreased esophageal bolus transit in the seated position, despite decreased lower esophageal sphincter pressure.
Manometry; Phosphodiesterase 5 inhibitor; Vardenafil
To determine the effect of bolus volume on pharyngeal swallowing using high resolution manometry (HRM).
Repeated measures with subjects serving as own controls.
Twelve subjects swallowed four bolus volumes in the neutral head position: saliva; 5 ml water; 10 ml water; and 20 ml water. Pressure measurements were taken along the length of the pharynx using a high resolution manometer, with emphasis placed on the velopharynx, tongue base, and upper esophageal sphincter (UES). Variables were analyzed across bolus volumes using three-way repeated measures analysis of co-variance (ANCOVA) investigating the effect of sex, bolus volume, and pharynx length. Pearson’s product moment tests were performed to evaluate how pharyngeal pressure and timing events changed across bolus volume.
Velopharyngeal duration, maximum tongue base pressure, tongue base pressure rise rate, UES opening duration, and total swallow duration varied significantly across bolus volume. Sex did not have an effect, while pharynx length appeared to affect tongue base pressure duration. Maximum velopharyngeal pressure and minimum UES pressure had a direct relationship with bolus volume, while maximum tongue base pressure had an inverse relationship. Velopharyngeal pressure duration, UES opening duration, and total swallow duration increased as bolus volume increased.
Differences in pharyngeal pressures and timing of key pressure events were detected across varying bolus volumes. Knowing the relationships between bolus volume and pharyngeal pressure activity can be valuable when diagnosing and treating dysphagic patients.
Level of evidence
Pharyngeal pressure; bolus volume; high-resolution manometry; swallowing physiology; deglutition
The sensitivity of the upper and lower esophageal mucosa to acid is considered to differ. We investigated the relationship between pH changes in different sites of the esophagus and generation of gastroesophageal reflux symptoms during an acid infusion test.
An acid infusion catheter was placed at 5 or 15 cm above the lower esophageal sphincter (LES) in 18 healthy volunteers, while a 2-channel pH sensor catheter was also placed in each with the sensors set at 5 and 15 cm above the LES. Solutions containing water and hydrochloric acid at different concentrations were infused through the infusion catheter.
Acid infusion in the upper esophagus caused a pH drop in both upper and lower esophageal sites, whereas that in the lower esophagus resulted in a significant pH drop only in the lower without a corresponding pH decline in the upper esophagus. Stronger heartburn, chest pain, and chest oppression symptoms were noted when acid was infused in the upper as compared to the lower esophagus, while increased intra-esophageal acidity strengthened each symptom. Regurgitations caused by upper and lower esophageal acid infusions were similar, and not worsened by a larger drop in intra-esophageal pH. Chest pain was caused only by lowered intra-esophageal pH, while heartburn, chest oppression, and regurgitation were induced by a less acidic solution.
Higher intra-esophageal acidity caused stronger heartburn, chest pain, and chest oppression symptoms. However, regurgitation was not significantly influenced by intra-esophageal acidity. The upper esophagus showed higher acid sensitivity than the lower esophagus.
Heartburn; Esophagus; Gastroesophageal reflux
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
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
Diffuse esophageal spasm (DES) is an uncommon motility disorder of unknown etiology in which the abnormal motility has been offered as a possible cause for the patient's dysphagia or chest pain. Esophageal manometry is the gold standard for the diagnosis of DES and the diagnostic hallmark is identification of simultaneous contractions in at least 20% of wet swallows, alternating with normal peristalsis. Recently, a new diagnostic technique, high-resolution manometry has been reported to improve the accuracy and detail in describing esophageal function. We report a female patient with intermittent dysphagia and chest pain occurring only when swallowing a large amount of water. On HRM, this patient had esophageal spasms, increased pressurization front velocity attributable to rapid contractile wave front, associated with symptoms, which were provoked by a multiple rapid swallowing test, and thereby was diagnosed with DES.
Chest pain; Esophageal spasm, diffuse; Manometry
Although colonic manometry provides useful information regarding colonic physiology, considerable variability has been reported both for regional motility and manometric patterns. Whether colonic manometry is reproducible is not known.
Seven healthy volunteers (m/f= 3/4, mean age = 34 yrs) underwent two studies of 24-hour ambulatory colonic manometry, each two weeks apart. Manometry was performed by placing a 6-sensor solid-state probe, up to the hepatic flexure and anchored to colonic mucosa. Colonic motility was assessed by the number and area-under-curve (AUC) of pressure waves and motility patterns such as high-amplitude propagating contractions (HAPC). Waking and meal-induced gastrocolonic responses were also assessed. Paired t-test was used to examine the reproducibility and intra- and interindividual variability.
The number of pressure waves and propagating pressure waves and HAPC, and AUC were similar between the two studies. Diurnal variation, waking and meal-induced gastrocolonic responses were also reproducible. There was some variability in the incidence of individual colonic motor patterns.
Colonic manometry findings were generally reproducible, particularly for the assessment of key physiologic changes, such as meal-induced gastrocolonic, HAPC and waking responses.
Ambulatory colonic manometry; reproducibility; intraindividual and interindividual variation
Achalasia is an esophageal motility disorder characterized by increased lower esophageal sphincter pressure and absence of peristalsis in the lower esophagus. Patients typically present with complaints of progressive difficulty swallowing over a period of several years. Diagnosis is confirmed by esophageal manometry. Complications of achalasia include esophagitis, aspiration and possibly an increased risk of esophageal carcinoma. Medical treatment options include pneumatic dilatation, esophageal bougienage, nitrates, calcium channel blockers and botulinum toxin injections. The primary method of surgical treatment is the Heller myotomy, in which longitudinal incisions are made in the muscle fibers of the lower esophageal sphincter to reduce sphincter pressure. Frequently, a fundoplication is performed in addition to the myotomy to decrease the likelihood of development of gastroesophageal reflux. In recent years, the Heller myotomy has been performed both thoracoscopically and laparoscopically. An additional development has been the placement of an endoscope in the esophagus to provide transillumination during surgery; intraoperative endoscopy allows improved assessment of the depth of myotomy incisions and reduces the risk of esophageal perforation. The case report below describes a 64-year-old-man with achalasia who presented with persistent dysphagia despite multiple attempts at medical treatment. A laparoscopic Heller myotomy with Toupet fundoplication was performed with subsequent eradication of symptoms. A discussion of the epidemiology, etiology, clinical presentation, diagnosis and treatment of achalasia follows the case report.
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
The esophagogastric junction (EGJ) is a complex structure that challenges accurate manometric recording. This study aimed to define EGJ pressure morphology relative to the squamocolumnar junction (SCJ) during respiration with 3D high-resolution manometry (3D-HRM).
A 7.5 cm long 3D-HRM array with 96 independent solid-state pressure sensors (axial spacing 0.75 cm, radial spacing 45°) was used to record EGJ pressure in 15 normal subjects. Concurrent videofluoroscopy was used to localize the SCJ marked with an endoclip. Ex-vivo experiments were done on the effect of bending the probe to match that seen fluoroscopically.
3D-HRM EGJ pressure recordings were dominated by an asymmetric pressure peak superimposed on the lower esophageal sphincter (LES) attributable to the crural diaphragm (CD). Median peak CD pressure at expiration and inspiration (51 and 119 mmHg respectively) was much greater in 3D-HRM than evident in HRM with circumferential pressure averaging. EGJ length, defined as the zone of circumferential pressure exceeding that of adjacent esophagus or stomach was also substantially shorter (2.4 cm) than evident in conventional HRM. No consistent circumferential EGJ pressure was evident distal to the SCJ in 3D-HRM recordings and ex-vivo experiments suggested that the intrgastric pressure peak seen contralateral to the CD related to bending the assembly rather than the sphincter per se.
3D-HRM demonstrated a profoundly asymmetric and vigorous CD component to EGJ pressure superimposed on the LES. EGJ length was shorter than evident with conventional HRM and the distal margin of the EGJ sphincteric zone closely correlated with the SCJ.
crural diaphragm; esophagogastric junction; lower esophageal sphincter; esophageal pressure topography; squamocolumnar junction; esophageal manometry
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.
AIM: To study the effect of viscosity on axial force in the esophagus during primary peristalsis using a newly validated impedance-based axial force recording technique.
METHODS: A probe able to simultaneously measure both axial force and manometry was positioned above the lower esophageal sphincter. Potable tap water and three thickened fluids were used to create boluses of different viscosities. Water has a viscosity of 1 mPa·s. The three thickened fluids were made with different concentrations of Clinutren Instant thickener. The viscous fluids were in appearance comparable to pudding (2 kPa·s), yogurt (6 kPa·s) and slush ice (10 kPa·s). Six healthy volunteers swallowed 5 and 10 mL of boluses multiple times.
RESULTS: The pressure amplitude did not increase with the bolus viscosity nor with the bolus volume whereas the axial force increased marginally with bolus volume (0.1 > P > 0.05). Both techniques showed that contraction duration increased with bolus viscosity (P < 0.01). Association was found between axial force and pressure but the association became weaker with increasing viscosity. The pressure amplitude did not increase with the viscosity or bolus volume whereas the axial force increased marginally with the bolus size.
CONCLUSION: This indicates a discrepancy between the physiological functions that can be recorded with axial force measurements and pressure measurements.
Axial force; Manometry; Esophagus; Primary peristalsis; Viscosity
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.
In Japan, it is customary to take a daily bath during which the body is immersed in water to the neck. During full-body immersion, hydrostatic pressure is thought to compress the chest and abdomen, which might influence esophageal motor function and intra-gastric pressure. However, whether water immersion has a significant influence on esophageal motor function or intragastric pressure has not been shown. The aim of this study was to clarify the influence of full-body water immersion on esophageal motor function and intragastric pressure.
Nine healthy male volunteers (mean age 40.1 ± 2.8 years) were enrolled in this study. Esophageal motor function and intragastric pressure were investigated using a high-resolution 36-channel manometry device.
All subjects completed the study protocol. Intragastric pressure increased significantly from 4.2 ± 1.1 to 20.6 ± 1.4 mmHg with full-body water immersion, while the lower esophageal high pressure zone (LEHPZ) value also increased from 20.5 ± 2.2 to 40.4 ± 3.6 mmHg, with the latter being observed regardless of dietary condition. In addition, peak esophageal peristaltic pressure was higher when immersed as compared to standing out of water.
Esophageal motor function and intragastric pressure were altered by full-body water immersion. Furthermore, the pressure gradient between LEHPZ and intragastric pressures was maintained at a high level, and esophageal peristaltic pressure was elevated with immersion.
Esophageal sphincter, lower; Gastroesophageal reflux; Peristalsis