Esophageal Contraction Amplitude Research Articles

Hypertensive lower esophageal sphincter (HLES): Prevalence,symptoms genesis and effect of pneumatic balloon dilatation

The Hypertensive lower esophageal sphincter (HLES) is an unusual primary motor disorder of the esophagus. The significance of this motility disorder is still questionable. The objectives were: (a) identification of the prevalence of HLES in these patients, (b) identification of the common presenting symptoms of HLES, (c) study of the correlation of the symptoms with LESP and (d) study of the effectiveness of pneumatic balloon dilation in cases that fail to respond to medical treatment. A retrospective study that includes four thousand one hundred and seventy patients, who were subjected to esophageal manometry in the period from January 1994 to December 2003, among whom sixty-six patients with HLES (LESP> 40 mmHg) were found. In addition to manometry, upper endoscopy was done to forty-nine patients, upper GI barium studies to thirty-eight patients and esophageal pH- metry to sixteen patients. showed that most of our patients were females (45 females and 21 males), with a mean age of 36.6 +/- 14 years. Patients with dysphagia (57.5%) had the highest LESP (52.1 +/- 21, mmHg) while patients with chest pain (47%) had the highest distal esophageal contraction amplitude (153.9 +/- 93.2 mmHg). Endoscopy showed varying degrees of esophagitis in 17 patients (34%). Barium studies showed corkscrew esophagus in seven patients (18.4%) and dilated esophagus in nine patients (23.7%). LESP was highest in patients with dilated esophagus (57.5 +/- 33.4 mmHg). All our patients were subjected to medical treatment, of which twelve patients underwent pneumatic dilation with successfully reduced LESP and symptoms relief in 91% of patients. It was concluded that the prevalence of HLES is around 1.6, in which dysphagia and chest pain are the usual presenting symptom, and that pneumatic balloon dilatation is very effective when properly applied. It will probably occupy the same position it has in achalasia.

To Study the Incidence of Barrettʼs Esophagus in Patients with Liver Cirrhosis

Purpose: GERD is increasing in the general population. In cirrhotic patients, incidence may even be higher because of the use of alcohol, presence of ascites and use of drugs like beta-blockers, which reduce the LES pressure. de la Pena et al showed that the sclerosant used for sclerotherapy provokes GERD. COX-2 gene is overexpressed in patients with cirrhosis and hypothetically may worsen GERD (Grover et al). In patients with esophageal varices, esophageal transit time is delayed and GERD is common in up to 64% of the patients (Fass R et al). Sclerotherapy can decrease the mean amplitude of esophageal contractions and normal peristalsis may be occasionally replaced by non-propagating simultaneous contractions that may cause chest pain and/or dysphagia in the absence of stricture. Cirrhotics have screening EGD's to evaluate for esophageal and gastric varices. The investigators have noted an increased incidence of high-grade dysplasia in cirrhotics. We hypothesize that there may be an increased risk of Barrett's esophagitis in patients with cirrhosis. Methods: Inclusion criteria: All patients with biopsy proven cirrhosis who underwent EGD's at UMass between 1/1/98 to 6/30/03 and control patients who underwent EGD in the month of April 2004 for any other indication. Exclusion criteria: Inability to find the patients in the Meditech system. Also, patients with known Barretts who presented for a surveillance EGD were excluded. Data collection: 249 cirrhotics and 153 controls met the criteria. The control group was divided into two groups, namely subjects with symptoms of GERD (pain, heartburn) and those with all other indications for the EGD. Results: In the cirrhotic group(ages 17 to 82 years, 80 females,168 males), 19/249 had endoscopic appearance of Barretts esophagus, with 14/19 having had a biopsy. 8/14(3.2%) patients had biopsy findings consistent with Barretts esophagus. In the controls with GERD symptoms (ages 29–80 years, 26 females, 10 males), 2/37 had endoscopic Barretts, with 1 with positive biopsy (2.7). In the third group (ages 22–83 years, 51 males and 54 females), 3/105 had endoscopic appearance but only 1/3 (0.95%) had biopsy proven Barretts. Conclusions: This data supports the hypothesis that patients with cirrhosis may be at increased risk of developing Barretts esophagus. A larger, prospective study is needed. If this relationship can be proven, it might become a standard of care to regularly screen cirrhotic patients for Barretts esophagus.

Proximal Esophageal Contractions in Laryngectomized Patients

After laryngectomy for treatment of laryngeal cancer, the distal esophageal contractions have low amplitude. Our hypothesis is that proximal esophageal contractions are also impaired. We studied the proximal esophageal contractions in 20 laryngectomized patients (16 men) with a mean age of 44.2 years, 12 rehabilitated patients with esophageal speech, and 12 controls (7 men, mean age of 46.5 years). We used the manometric method with continuous perfusion. All subjects were studied in the sitting position and performed five swallows of a 5-ml bolus of water alternated with five dry swallows. The contractions were measured 2 cm below the high-pressure zone of the pharyngoesophageal transition. The results showed that the amplitude and duration of contractions were different in laryngectomized patients compared with controls. The amplitude of contractions of patients (wet swallows: 37.3+/-20.7 mmHg, mean+/-SD) was lower than that of controls (81.1+/-31.7 mmHg). The duration of contractions was also lower in laryngectomized patients (2.2+/-0.7 s) than in controls (2.6+/-0.6 s). We conclude that the proximal esophageal contraction amplitude and duration of laryngectomized patients are lower than controls, a fact suggesting that laryngectomy may affect the proximal esophageal contractions.

Typical GERD Symptoms and Esophageal pH Monitoring Are Not Enough to Diagnose Pharyngeal Reflux

Abnormal pharyngeal reflux of acid (PR) (as measured by pH monitoring) is associated with microaspiration, and is a good predictor of airway symptom response to medical and surgical anti-reflux therapy. However, in clinical practice the link between airway disease and Gastroesophageal reflux disease (GERD) is still based on the presence of typical symptoms (e.g., heartburn) and/or standard esophageal function testing (manometry and 24-pH monitoring). PR is rarely measured directly. We undertook this study to determine if typical symptoms and standard testing could reliably predict the presence of PR. The study group consisted of 518 patients with suspected reflux induced airway disease evaluated from December 1998 through January 2002. Each patient completed a standardized symptom questionnaire, underwent esophageal manometry, and 24-h esophageal and pharyngeal pH monitoring. Patients were classified having abnormal pharyngeal reflux (PR+) if they had >1 episode of PR detected during pH monitoring. One hundred eighty-one patients were PR+ and 337 were PR-. The most common symptoms, namely cough (PR +73%, PR- 68%), hoarseness (PR +64%, PR- 66%), and dyspnea (PR +59%, PR- 59%) were present with similar incidence in PR+ and PR- patients. The incidence of heartburn was 54% in the PR+ and 52% in the PR- patients. Logistic regression analysis revealed that abnormal esophageal acid exposure was a predictor of PR+ (P < 0.001). Neither the presence of heartburn or specific respiratory symptoms, the pressure of the lower esophageal sphincter (LES) or upper esophageal sphincter (UES), or amplitude of esophageal contractions predicted PR+. There was substantial variability in esophageal length (UES to LES), thus the placement of the distal pH probe from the LES varied considerably (median = 13 cm, 2-20 cm). Using established normal values of acid exposure at multiple levels of the esophagus, 24% of PR+ patients had normal amounts of esophageal acid exposure. Typical GERD symptoms, such as heartburn, and typical symptoms of aspiration such as hoarseness, cough, or dyspnea are not enough to positively identify PR. While patients with abnormal esophageal acid exposure are three times more likely than those with normal values to have PR, abnormal esophageal acid exposure alone does not identify all patients with PR. Therefore, relying on symptoms and standard diagnostic testing may fail to identify patients with extraesophageal reflux. Pharyngeal pH monitoring should be considered for patients with suspected reflux-induced airway disease.

Proximal and distal esophageal contractions in patients with vigorous or classic esophageal Chagas' disease

Some patients with achalasia have distal esophageal contraction amplitude in the normal range, a condition called vigorous achalasia, and others have low contraction amplitude, a condition named classic achalasia. The difference in distal contraction amplitude may also be associated with a difference in proximal contraction amplitude. To study the proximal and distal esophageal contractions in patients with Chagas' disease. We studied 28 patients with Chagas' disease, all with dysphagia and an esophageal radiologic examination with retention without dilation, and 18 controls. The patients with Chagas' disease had vigorous achalasia (distal amplitude over 34 mm Hg, n = 13) or classic achalasia (distal amplitude below 34 mm Hg, n = 15). We measured the contractions by the manometric method with continuous perfusion at 2, 7, 12 and 17 cm below the upper esophageal sphincter after five swallows of a 5 mL bolus of water. There was no difference in proximal amplitude of contractions between classic or vigorous achalasia, and controls. In the proximal esophagus there was also no difference in duration or area under curve of contractions. In the distal esophagus, duration and area under curve were lower in classic than vigorous disease. Failed and simultaneous contractions were more frequent in patients than controls. Simultaneous contractions were seen more frequently in classic disease, and peristaltic contractions were seen more frequently in vigorous disease. We did not find differences in proximal esophageal contractions of patients with classical or vigorous esophageal Chagas' disease, except for the higher number of simultaneous contractions seen in classic disease.

Manometric evaluation of achalasia in the elderly

The effect of ageing on oesophageal motility in patients with achalasia is not well described. Oesophageal contraction amplitude is decreased in otherwise healthy elderly subjects. To evaluate whether ageing influences the motor function of the oesophagus in achalasia. Initial manometry studies of patients with achalasia were reviewed and findings (lower oesophageal sphincter basal and residual pressures and oesophageal body contraction amplitudes) were compared between two groups of patients, those 65 years of age or older (49 patients) and those younger than 65 years (68 patients). The older group was further divided into those > or =70 years and those <70 years. Patients 65 years and older had significantly higher lower oesophageal sphincter basal pressures compared with younger patients (65.6 +/- 4.9 vs. 52.3 +/- 2.7, P = 0.02). At an age cut-off of 70 years, older patients had significantly higher basal (70.7 +/- 1.6 vs. 53.0 +/- 2.4, P = 0.02) and residual (19.7 +/- 1.6 vs. 15.9 +/- 0.7, P = 0.03) lower oesophageal sphincter pressures compared with younger patients. Amplitude of oesophageal contractions was not different between the groups. Across all age groups, there was no linear correlation between age and basal or residual lower oesophageal sphincter pressures (r = 0.28 and 0.12, respectively). Older patients with achalasia have higher lower oesophageal sphincter pressures, however there is no linear correlation between age and lower oesophageal sphincter pressures. Unlike healthy subjects, advanced age is not associated with a decrease in oesophageal contraction amplitude in patients with achalasia.

Comparison of Air-Coupled Balloon Esophageal and Anorectal Manometry Catheters with Solid-State Esophageal Manometry and Water-Perfused Anorectal Manometry Catheters

Clinical gastrointestinal manometry studies are currently performed with multilumen water-perfused polyvinyl or strain gauge sensor solid-state catheters. A disposable catheter incorporating air-filled balloons has been developed with performance characteristics suitable for esophageal and anorectal manometry studies. Our aim was to compare esophageal and anorectal pressure measurements using this newly developed catheter with measurements obtained using standard solid-state or water-perfused catheters. Measurements of resting LES pressure, esophageal contraction amplitudes, and anorectal rest and squeeze pressures were obtained in 10 healthy volunteers using a solid-state esophageal catheter, a water-perfused anorectal catheter, and air-filled balloon esophageal and anorectal catheters. Correlation coefficient analysis demonstrated that LES pressures, esophageal contraction amplitudes, and anorectal resting and squeeze pressures were not significantly among between the different catheters. We conclude that recently developed air-filled balloon esophageal and anorectal manometry catheters provide very similar measurements of LES, esophageal body, and anorectal sphincter pressures compared to presently used manometry catheters.

Symptom hypersensitivity to acid infusion is associated with hypersensitivity of esophageal contractility.

Several investigators have observed that repeated acid infusions induce stronger symptoms (symptom hypersensitivity). The goal of our study was to determine whether symptom hypersensitivity is associated with esophageal contractile hypersensitivity. Subjects with chronic heartburn symptoms underwent simultaneous pressure and ultrasound imaging of esophagus. Normal saline and 0.1 N HCl were sequentially infused into the esophagus, and subjects scored heartburn symptoms on a 1-10 scale. Saline and HCl infusions were repeated in 10 subjects with a positive Bernstein test. Esophageal contraction amplitude and duration and muscularis propria thickness were measured using a computerized method during recording. Acid infusion induced heartburn. Esophageal contractions had higher amplitudes (pressure 114.2 +/- 7.0%) and longer duration (116.8 +/- 4.4%) during acid infusion compared with saline infusion. Average muscle thickness was greater during acid infusion than saline infusion (107.0 +/- 2.0%). Sustained esophageal contractions (SECs) were identified during acid infusion. A second acid infusion (acid-2) induced heartburn with shorter latency (93.0 +/- 15.0 vs. 317.0 +/- 43.0 s) and stronger severity (8.5 +/- 0.5 vs. 5.3 +/- 0.8) than the first acid infusion (acid-1). Contraction amplitudes (140.2 +/- 13.0%), average muscle thickness (118.0 +/- 3.3%), and contraction duration (148.5 +/- 5.6 vs. 116.8 +/- 4.4%) were higher during acid-2 than acid-1. Also, numbers of SECs were greater during acid-2 than acid-1 (31 in 8 subjects vs. 11 in 6 subjects). Our data show that acid infusion into esophagus induces esophageal hypersensitivity and that a close temporal correlation exists between symptom hypersensitivity and contractility hypersensitivity.

Manometric analysis of patients with gastrointestinal manifestations of scleroderma

Purpose: The aim of this study was to analyze esophageal, anorectal and small bowel manometry studies in patients with scleroderma to determine whether GI symptoms correlate with manometric findings, and to determine if the findings of one GI manometric study predict the findings of another. Methods: Esophageal, duodenal and anorectal manometry studies from 32 scleroderma patients with GI symptoms were evaluated. Symptoms were recorded at the time of initial evaluation. Esophageal manometry (EMS) parameters included: LES pressure, percent LES relaxation, and amplitude of esophageal body contractions. Anorectal manometry (ARM) parameters analyzed included: Anal canal pressures, presence of rectoanal inhibitory reflex, external anal sphincter tone, and rectosigmoid compliance. Antroduodenal manometry was reviewed to assess neuromuscular function of the stomach and small intestine in response to drug challenges. Upper endoscopy and gastric emptying scans were reviewed, if available. Results: Mean age was 52.8 years (range 30 –77 years) with 27F:3M. Symptoms included: GERD in 31/32, dysphagia in 25/32, severe nausea/vomiting in 25/32, abdominal pain in 29/32 patients, abdominal bloating and distention in 25/32 patients, constipation in 16/32, and fecal incontinence in 14/32 patients. Mean LES pressure was 14.7 mm Hg; LES relaxation with water was complete in 10 patients and incomplete in 10. At 5 cm above LES, mean amplitude of contraction was 24.9 mm Hg. Anorectal manometry in 12 patients showed mean anal canal pressure of 31.4 mm Hg, relative EAS squeeze pressure of 40.4 mm Hg, average compliance of 3.62 ml/mm Hg and RAIR present in 6/12 patients. Small bowel motility in 5 patients demonstrated a reduced amplitude of contraction in the small intestine in 3 patients (normal in 2 patients). In 10 patients who underwent both EMS and ARM, low esophageal body contractile amplitudes were associated with low anal canal pressures. Conclusions: Symptoms of dysphagia and GERD were associated with low amplitude of contractions in the esophageal body, and fecal incontinence was associated with low anal canal pressures. Patients who had reduced esophageal body amplitudes were also likely to have reduced anal canal pressures. EMS findings did not correlate with small bowel manometric findings. Thus in scleroderma patients with complaints of both dysphagia and incontinence, the finding of low smooth muscle tone in the esophagus is likely to predict low anal canal pressures.

Clinical correlation of esophageal and gastric pathologic changes in achalasia

PURPOSE: 1) Characterize pathological changes in esophageal and gastric muscle biopsies of patients with achalasia. 2) Correlate these pathological changes with prospectively collected clinical and manometric parameters. METHODS: Full thickness biopsies taken from both esophageal (ESO) and gastric (GAS) aspects of myotomy during laparoscopic surgery from 47 patients with achalasia were studied via light microscopy with H&E staining. The pathologic features examined included: 1 ) number of ganglion cells 2) presence of ganglionitis 3) degree of myentenc inflammation. After excluding biopsies not containing adequate tissue, 47 ESO specimens and 34 GAS specimens were analyzed. Marm-Whimey test was used to correlate pathological findings with clinical and manometric parameters. Clinical parameters assessed a prospective, preoperative symptom questionnaire included age, disease duration, and symptom scores for dysphagia, chest pain, and regurgitation. Manometric parameters analyzed were basal lower esophageal sphincter (LES) pressure, relaxation LES pressure, esophageal body contraction amplitude and esophageal-gastric pressure gradient. RESULTS: Acha[asia patients with intact ganglion cells in ESO specimens had significantly higher esophageal body contractile amplitude and lower esophageal-gastric pressure gradient compared to those without ganglion cells (Table). Ganglion cell integrity was not associated with age, seventy of dysphagia or disease duration. The frequency of finding intact ganglion cells was significantly higher in gastric compared to esophageal specimens (47% vs 18%). No significant correlation was found between severity of inflammation or integrity of ganglion cells in GAS specimens and cfiincal/manometric parameters. CONCLUSIONS: (1) Achalasia patients with myenteric ganglion cells had greater esophageal function compared to those with agangfionosis. (2) Ganglion cell loss was significantly greater in the esophagus than in the proximal stomach consistent with relative site-specificity of the disease process.

Acid reflux and asthma.

The association between asthma and gastroesophageal reflux (GER) has been further delineated with recent clinical investigations. The prevalence of GER development in asthmatics is higher than in control populations. Furthermore, asthmatics with GER have a higher risk of asthma hospitalization. Asthma medications may be one of the promoting factors for GER development in asthmatics. Inhaled albuterol decreases lower esophageal sphincter (LES) pressure and esophageal contraction amplitude. Furthermore, oral prednisone results in increased esophageal acid contact times. Respiratory symptoms also correlate with esophageal acid events. The role of neurogenic inflammation in asthma-induced bronchoconstriction is also being further developed. Therapy of GER may improve asthma outcomes in selected asthmatics. Currently, there are no double-blind, placebo-controlled, multicenter trials reporting asthma outcomes with antireflux therapy.

Relationship between esophageal muscle thickness and intraluminal pressure in patients with esophageal spasm.

We previously showed, in normal subjects, a positive correlation between the esophageal contraction amplitude and peak muscle thickness. The goal of this study was to determine the relationship between esophageal muscle thickness and contraction amplitude in patients with high-amplitude peristaltic and simultaneous contractions. Eleven patients with high-amplitude peristaltic contractions, 8 with diffuse esophageal spasm (DES), 7 with nonspecific (NS) motor disorder of the esophagus, and 10 normal subjects were studied using simultaneous pressure and ultrasound imaging. Pressure was recorded by manometry and ultrasound imaging with a high-frequency ultrasound probe catheter. Recordings were performed in the lower esophageal sphincter (LES) and at 2, 4, 6, 8, and 10 cm above the LES during resting state and swallow-induced contractions. Baseline esophageal muscle was thicker in the distal, compared with the proximal esophagus both in normal subjects and patient groups. Patients with DES and nutcracker esophagus (NC) have a higher baseline muscle thickness compared with normal and NS patients. Correlation between the peak pressure and the peak muscle thickness was weaker in patients with NC and DES compared with normal subjects and patients with NS. Whereas normal subjects have good correlation between delta (difference between peak and baseline) muscle thickness and peak pressures, this relationship was absent in patients with NC and DES. Increase in contraction amplitude in patients with NC and DES was associated with an increase in baseline thickness of esophageal muscularis propria. Increase in baseline thickness was specific to patients with spastic motor disorders and was not seen in patients with NS.

Influence of esophageal motility on esophageal speech of laryngectomized patients.

After laryngectomy for treatment of cancer of the larynx, the patient may have vocal rehabilitation by esophageal speech. Some patients fail to achieve the esophageal speech due to reasons involving surgery, radiotherapy, and psychological alterations. Our hypothesis is that the esophageal motility alterations consequent to laryngectomy may be involved in the failure to achieve esophageal speech. Using manometry with continuous perfusion, we studied the esophageal motility of 25 laryngectomized patients, 10 of them able to produce esophageal speech and 15 unable to produce esophageal speech, and 40 asymptomatic normal volunteers. The lower esophageal sphincter (LES) pressure was measured by the rapid pull-through method and the upper esophageal sphincter (UES) pressure by the station pull-through method. The contractions were measured at 5, 10, and 15 cm above the LES after the subjects performed 10 swallows with a 5-mL bolus of water. By comparing volunteers and laryngectomized patients, we found a lower UES pressure, lower amplitude of contractions, and increased percentage of simultaneous contractions in laryngectomized patients (p < 0.05). There was no difference between patients able and unable to produce esophageal speech in LES and UES pressure, esophageal contraction duration and velocity, or in the percentage of failed and simultaneous contractions. The esophageal contraction amplitude was lower in patients who acquired esophageal speech than in patients who did not (p < 0.05 at 10 cm from LES). We conclude that there are esophageal motility alterations in laryngectomized patients but only the decrease of esophageal contraction amplitude seems to be associated with the acquisition of esophageal speech.

Twenty-Four-Hour Ambulatory versus Stationary Esophageal Manometry in the Evaluation of Esophageal Motility in Patients with Gastroesophageal Reflux Disease

Background: Although stationary manometry commonly reveals esophageal body motility disorders in patients with gastroesophageal reflux disease (GERD), esophageal function cannot be fully and precisely assessed during normal daily activities by this investigatory modality. Aim: To compare the results of 24-hour ambulatory manometry with those of stationary manometry and to determine the specificity and accuracy of the former to detect motility disorders in patients with GERD. Patients and Methods: 15 patients with documented GERD were included in the study. Clinical assessment, upper alimentary endoscopy and stationary manometry as well as 24-hour ambulatory manometry with concomitant 24-hour monitoring of the esophageal pH were performed in each patient. Results: 24-hour ambulatory manometry revealed a significant number of dropped or interrupted esophageal contractions in patients who were found to have only complete peristalsis on stationary manometry. Furthermore, in certain patients, ambulatory manometry detected an increased incidence of dropped or interrupted contractions as compared to those recorded during stationary manometry. Ineffective contractions, suggestive of poor esophageal motility, although absent on stationary manometry, were detected in a large number of patients during a 24-hour period of recording. Also, the amplitude of esophageal contractions was clearly overestimated when evaluated by stationary manometry. Conclusions: 24-hour ambulatory esophageal manometry reveals esophageal motor abnormalities to a greater extent than those demonstrated at stationary manometry, in patients with GERD. This might be of significance in designing the treatment and predicting possible outcome.

Vigorous achalasia: original description requires minor change.

Vigorous achalasia was described in 1957 as a subset of achalasia with a higher contraction amplitude (>37 mm Hg), minimal esophageal dilatation, prominent tertiary contractions, and higher incidence of chest pain. Ascertain the existence of a distinct achalasia group based on manometric, radiographic, and clinical grounds. The records of 209 idiopathic achalasia patients seen over a 9-year interval were reviewed for duration and frequency of dysphagia, chest pain, heartburn, weight loss, and nocturnal symptoms, as well as for treatment outcome. Manometric tracings were reanalyzed for lower esophageal sphincter pressure (LESP), LES residual pressure, distal esophageal contraction amplitude, and presence of repetitive waves. Patients were subsequently divided into classic (amplitude < or =37 mm Hg) and vigorous (amplitude >37 mm Hg) achalasia groups. Esophagrams were reassessed blindly for esophageal diameter both in the upright and recumbent positions and presence of lumen-occlusive tertiary contractions. One hundred forty-four classic and 65 vigorous achalasia patients were identified. These groups were similar in age and gender, as well as duration of symptoms. Chest pain was equally prevalent in both groups. Lower esophageal sphincter pressure was higher ( p < 0.01) and repetitive waves more common ( p < 0.0001) in the vigorous achalasia group. Upright esophageal diameter was smaller ( p = 0.0003) and tertiary contractions more frequent ( p = 0.0004) in this group. The original manometric and radiographic description of vigorous achalasia is accurate. The incidence of chest pain is similar to that of patients with classic achalasia.

The Effects of an Inhaled β2-Adrenergic Agonist on Lower Esophageal Function: A Dose-Response Study

Albuterol, a beta(2)-adrenergic agonist that is commonly used to treat asthma, reduces bronchial smooth muscle tone. The pharmacodynamics of inhaled albuterol on esophageal function were studied in healthy volunteers. A prospective, randomized, placebo-controlled, double-blind crossover design. An academic medical center. Nine healthy volunteers (five men, four women; age, 22 to 30 years). Albuterol (2.5 to 10 mg) or placebo was given via nebulizer. Volunteers were studied at two sessions, 1 week apart, using a 6-cm manometry assembly and a low-compliance pneumohydraulic pump. The percentage of lower esophageal sphincter (LES) relaxation, the frequency of transient LES relaxations (TLESRs), and the amplitude, duration, and propagation velocity of esophageal contractions were measured at 5 and 10 cm above the LES. Dependent measures were evaluated using two-way, repeated-measures analysis of variance. Albuterol therapy reduced LES basal tone in a dose-dependent manner (baseline, 17.0 +/- 2.6 mm Hg; at 10 mg, 8.9 +/- 2.1 mm Hg; p = 0.01). The frequency of TLESRs was not different from placebo (not significant). Albuterol reduced the amplitude of esophageal contractions at 5 cm above the LES (baseline, 72.5 +/- 18.6 mm Hg; at 10 mg, 48.8 +/- 10.0 mm Hg; p<0.05). A significant reduction in esophageal body contractile amplitudes was noted at 10 cm (F[1,6] = 7.05; p<0.05). Inhaled albuterol reduced LES basal tone and contractile amplitudes in the smooth muscle esophageal body in a dose-dependent manner. Inhaled beta(2)-agonists may increase the likelihood of acid reflux in a subset of patients who receive cumulative dosing.

Effect of sildenafil, a phosphodiesterase-5 inhibitor, on oesophageal peristalsis and lower oesophageal sphincter function in cats.

The propagation of oesophageal peristaltic contractions and lower oesophageal sphincter (LOS) relaxation depends on neural release of nitric oxide (NO) which acts to increase intracellular cGMP. Sildenafil, a phosphodiesterase-5 inhibitor that increases cGMP, reduces basal LOS pressure in patients with achalasia. We investigated the effect of sildenafil on the propagation of oesophageal contractions and LOS relaxation in the cat. Oesophageal manometry was performed in five cats under light sedation. Peristaltic contractions were monitored at 1, 2, 3, 4 and 8 cm proximal to the LOS, at the LOS using a Dent sleeve, and at 3 cm distal to the upper oesophageal sphincter. Swallow-induced oesophageal contractions and LOS relaxation were recorded during 30 min before and 30 min after intravenous administration of sildenafil. Sildenafil reduced the amplitude of oesophageal contractions only in the smooth muscle oesophagus. The latency from swallow to distal oesophageal contractions was significantly delayed. LOS pressure was significantly reduced but the relaxation nadir was not modified by sildenafil. Sildenafil has profound effects on oesophageal motility: it modifies propagation and amplitude of oesophageal contractions and reduces LOS pressure. Slowing down the propagation of contractions in the transitional zone between the striated and smooth muscle can be a useful tool in patients with segmental aperistalsis or intermittent simultaneous contractions, while the effect on the LOS can benefit patients with achalasia.

Relationship between esophageal muscle thickness and intraluminal pressure: an ultrasonographic study.

A number of studies show a close temporal relationship between the rate of change in muscle thickness as detected by high-frequency intraluminal ultrasonography (HFIUS) and intraluminal pressure measured by manometry. There is a marked variability in esophageal contraction amplitude from one swallow to another at a given level in the esophagus and along the length of the esophagus. Furthermore, peristaltic pressures are higher in the distal compared with the proximal esophagus. The goal of this study was to evaluate the relationship between the baseline and peak muscle thickness and the contraction amplitude during swallow-induced contractions along the length of the esophagus. Fifteen normal subjects were studied using simultaneous esophageal pressures and HFIUS or HFIUS alone. Recordings were made during baseline and standardized swallows in the lower esophageal sphincter (LES) and at 2, 4, 6, 8, and 10 cm above the LES. HFIUS images were digitized, and esophageal muscle thickness and peak contraction amplitudes were measured. In the resting state, muscle thickness is higher in the LES compared with the rest of the esophagus. Baseline muscle thickness is also significantly higher at 2 cm vs. 10 cm above the LES. In a given subject and among different subjects, there is a good relationship between peak muscle thickness and peak peristaltic pressures (r = 0.55) at all sites along the length of the esophagus. The positive correlation between pressure and muscle thickness implies that the mean circumferential wall stress is fairly uniform from one swallow to another, irrespective of the contraction amplitude.

Relationship between severity of reflux esophagitis according to the Los Angeles classification and esophageal motility.

We investigated the relationship between the severity of reflux esophagitis (RE) according to the Los Angeles (LA) classification and esophageal motility. We examined 28 healthy subjects (HS) and 48 RE patients (grade A of the LA classification, 16 patients; grade B, 16 patients; grade C or D, 16 patients). Esophageal manometry was performed by the intraluminal microtransducer method. Resting lower esophageal sphincter (LES) pressure was assessed by the rapid pull-through method. Esophageal contraction after ten repeated 5-ml water swallowings separated by 30-s intervals was measured at 3, 8, 13, and 18 cm above the LES. The resting LES pressure and the amplitude of esophageal contraction 3 cm above the LES in the grades C + D group were significantly lower than those in the HS group. The amplitude of esophageal contraction 3 cm above the LES in the grade B group was significantly lower than those in the grade A group and the HS group. The frequency of failed peristalsis in the grades C + D group was significantly higher than that in the HS group and the grade A and grade B groups. The present findings suggested that the severity of RE according to the LA classification would be likely to mainly reflect esophageal volume clearance.

Gastric emptying: a contributory factor in gastro-oesophageal reflux activity?

AIMSTo evaluate the impact of total and proximal stomach emptying on 24 hour and postprandial reflux as well as the number of reflux episodes per hour in relation to the...