Bread Swallows Research Articles

The yield of solid swallows in high resolution esophageal manometry among patients with dysphagia and gastro-esophageal reflux symptoms.

Swallowing disorders are frequently reported esophageal symptoms and represent a common cause for referrals to gastroenterology consultations. Esophageal high-resolution manometry (HRM) is considered the gold standard modality for the evaluation of esophageal peristalsis and esophageal sphincter. The standard protocol of HRM includes water swallows only, that may not assess appropriately esophageal function and symptoms. Hence, we investigated the diagnostic yield of combining solid food swallows (SFS) to standard HRM. We conducted a retrospective study at the Unit of Gastroenterology of EMMS Nazareth Hospital, Israel. Patients who underwent manometry mainly due to dysphagia or reflux symptoms between November 2019 and November 2020 were enrolled. All patients underwent routine HRM and completed ten 5 mL water swallows and 5 bread swallows. Analysis and reports were done by an expert gastroenterologist, based on the Chicago Classification version 3. Overall, 99 patients (45.5% men, mean age 52.1±16 years) who underwent HRM were included. The addition of solid swallows to the test changed manometry results in 43 patients (43.4%) (P<0.005). Furthermore, SFS improved the contractility in 26/42 cases of ineffective and/or absent motility (61%) (P<0.005). Finally, SFS aggravated symptoms in 44 patients (44.6% more aggravation than in liquid only) (P<0.005). Combining SFS to HRM can improve the diagnostic yield of the study. Adding solid swallows is of special value in cases of ineffective esophageal motility but induces a high rate of symptoms aggravation.

Effect of Topical Nasal Anesthetic on Comfort and Swallowing in High-Resolution Impedance Manometry.

Use of topical nasal anesthetic (TNA) is common in high-resolution impedance manometry (HRIM). This study investigated the effect of TNA on swallowing and procedure tolerability during HRIM with a 4.2-mm catheter, a more commonly used catheter size with impedance capabilities. Randomised experimental study with blinding of participants. Twenty healthy participants (mean age=33 years, 16 female) were randomized to undergo HRIM using the ManoScan™ ESO Z 4.2-mm catheter twice, 1 week apart, under two conditions: with TNA (viscous lidocaine) and with placebo. Analyses included esophageal data of three saliva, three saline (5mL), and three bread swallows (2cm × 2cm) performed while reclined 45°, and pharyngeal data under the same conditions while seated upright. Pharyngeal and upper esophageal sphincter (UES) HRIM parameters were analyzed using the Swallow Gateway analysis platform. Visual analogue scale (VAS) scores rating procedural comfort were analyzed. There were no significant physiological differences in pharyngeal and UES parameters between conditions. There were also no significant differences in VAS scores under placebo (mean=54.8, standard deviation (SD)=19.3) and TNA (mean=60.0, SD=21.9) (t[19] = -0.9, P= .4) conditions; however, there was a significant difference in the first versus second session (t[19])=5.1, P< .05). TNA did not improve comfort, but it also did not significantly affect swallowing behavior. There was, however, a practice effect regardless of TNA use with improved tolerance of the 4.2-mm catheter and likely more natural swallowing behavior during the second session of HRIM. 3 Laryngoscope, 132:2124-2131, 2022.

The differences in the esophageal motility between liquid and solid bolus swallows: A multicenter high-resolution manometry study in Chinese asymptomatic volunteers.

The results of the esophageal body motility differences between liquid and solid swallows from high-resolution manometry (HRM) studies are not consistent. The information of the frequency of ineffective liquid and solid bolus swallows in healthy individuals during HRM procedure is limited. The normative values of the HRM parameters of both liquid and solid swallows for Chinese population are lacking. The esophageal HRM data of 101 healthy volunteers from multicenters in China were analyzed. The values of the HRM parameters were summarized and compared between liquid and solid swallows. The frequencies of ineffective liquid and solid swallows were summarized. Esophagus contracted stronger and slower in solid bolus swallows than water swallows with HREM. Ineffective water swallow (DCI<450mmHg.s.cm) and ineffective bread swallow (DCI<800mmHg.s.cm) were frequently seen in asymptomatic individuals. The adding of bread swallows to the HREM procedure might cause diagnostic change in about 15.8% (16/101) of the asymptomatic individuals. The vigor and velocity of the esophageal peristalsis between liquid and solid bolus swallows are different. Ineffective water and solid bolus swallows are not rare. Adding solid bolus swallows brings diagnostic change, and it may be needed routinely for the HRM procedure.

OC-071 Dysphagia Patients with Normal Oesophageal High Resolution Manometry: Assessing The Diagnostic Value of Bread Swallows

Introduction High resolution manometry (HRM) is currently the gold standard technique to investigate oesophageal motility in patients with dysphagia. However, with routine HRM procedure and use of Chicago classification, a group of patients with dysphagia are considered as being normal and dysphagia remains unexplained. The aim of this study is to assess the diagnostic value of solid bolus swallows in patients with dysphagia and normal HRM. Methods Patients having dysphagia and normal HRM studies during January-October 2015 were selected. Solid bolus swallows of bread (1cm 3 single bread swallows and/or a sandwich meal) followed the routine water swallows on HRM. Patients with a double high pressure zone, oesophageal diverticulum or history of antireflux surgery were excluded. The patients were categorised to symptomatic and asymptomatic groups based on having dysphagia reproduced on bread swallows. Hospital odynophagia and dysphagia questionnaire (HODQ) score, integrated relaxation pressure (IRP), distal contractile integration (DCI), distal latency (DL) and peristaltic abnormality during water swallows were investigated and compared between groups. ROC curve was used to identify the optimum level of sensitivity and specificity of the significant parameters in identifying patients who have a meaningful abnormality on bread swallows. Student t-test is used to compare significance of differences. P value Results 72 patients referred with dysphagia and diagnosed with normal HRM were selected. In the asymptomatic group, 7/22 patients showed abnormality on bread swallows and in the symptomatic group, 45/50 showed abnormal motility (P = 0.0001). ROC analysis showed that having >33.3% abnormal bread swallows has sensitivity of 72%, specificity of 90.91% and likelihood ratio of 7.9 to detect patients who may have abnormal motility and dysphagia on bread swallows. Analysis of water swallow parameters comparing the asymptomatic group against the symptomatic group with abnormal motility on bread swallows did not reveal any significant difference in HODQ score (P = 0.2), IRP (P = 0.17), DL (P = 0.3) and peristaltic abnormalities (P = 0.4). Conclusion Performing solid swallows on HRM can explain dysphagia in a considerable number of patients with dysphagia and normal routine HRM. This complementary test is readily available, and avoids the need for Barium swallowing and radiation exposure. Disclosure of Interest None Declared

Esophageal motility after peroral endoscopic myotomy for achalasia.

Peroral endoscopic myotomy (POEM) has been introduced as a novel endoscopic treatment for achalasia. The aim of this work is to assess the changes in esophageal motility caused by POEM in patients with achalasia. Forty-one patients with achalasia underwent POEM from September 2012 to November 2014. Esophageal motility of all patients was evaluated preoperatively and 1 month after POEM utilizing high-resolution manometry, which was performed with ten water swallows, ten steamed bread swallows, and multiple rapid swallows (MRS). In single swallows, including liquid swallows and bread swallows, all the parameters of lower esophagus sphincter resting pressure (LESP), 4-s integrated relaxation pressure (4sIRP), and intra-bolus pressure (IBP) were decreased between pre- and post-POEM patients (all p < 0.05). Postoperatively, the trend of distal contractile integral (DCI) and distal esophageal peristaltic amplitude declined in subtype II and subtype III (subtype II: p < 0.05; subtype III: p > 0.05), but increased in subtype I (subtype I: p > 0.05). In liquid swallows, the Eckardt score of subtype II patients decreased with DCI, and distal esophageal peristaltic amplitude after POEM was significantly lower compared with those showing increased values of those two parameters (p < 0.05). In MRS, the rate of LES relaxation increased from 66.67 to 95.24%, but without normal response in all achalasia patients. POEM reduces LES pressure in achalasia, and partly restores esophageal motility. POEM displayed varying effect on esophageal motility in patients with different patterns of swallowing. In addition, the changes in parameters associated with esophageal peristalsis correlated with decreases in Eckardt score.

Esophageal Motility in the Supine and Upright Positions for Liquid and Solid Swallows Through High-resolution Manometry

Background/AimsMost 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.MethodsTwenty-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.ResultsIn 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.ConclusionsSupine solid swallows occur with more hypotensive peristalsis. Analysis should be based on normative values from the corresponding posture and bolus.

Influence of the catheter diameter on the investigation of the esophageal motility through solid-state high-resolution manometry

Past studies have shown that catheter diameter is one of the device-dependent problems which influence the manometric results in the conventional water perfusion esophageal manometry. High-resolution solid-state manometry which abandons water perfusion is thought as an improved manometry method benefited from more pressure sensors, and it is gradually widely used in many present esophageal motility studies. There was no research to evaluate the influence of catheter diameter on the solid-state high-resolution manometry results. The aim of this study was to investigate whether solid-state high-resolution catheters of different diameter provide different data and results. Nine asymptomatic volunteers and 18 gastroesophageal reflux disease patients accepted high-resolution manometry examinations with two solid-state catheters of different outer diameter (4.2 mm and 2.7 mm). Every examination contained 5 minutes resting pressure, 10 water swallows and 10 bread swallows. Some important parameters of the esophageal sphincters and esophageal body peristalsis were analyzed. They included the locations and resting pressure of sphincters, the distal contractile integral, the 4-second integrated relaxation pressure etc. Then, these parameters and the diagnosis of each swallow based on them provided by the two different diameter catheters were compared. (i) The 4.2 mm thick catheter provided higher upper esophageal sphincter resting pressure than the 2.7 mm thick catheter (59.4 ± 21.1 mmHg vs. 49.7 ± 21.4 mmHg); (ii) the 2.7 mm thick catheter provided higher 4-second integrated relaxation pressure than the 4.2 mm thick catheter (10.9 ± 4.5 mmHg vs. 8.5 ± 3.8 mmHg) in water swallows; (iii) the mean distal contractile integral of the water and bread swallows in the large diameter catheter were higher than in the small diameter catheter (989.2 ± 650.0 mmHg/cm/s vs. 806.3 ± 563.7 mmHg/cm/s in water swallows, 1762.5 ± 1440.6 mmHg/cm/s vs. 1275.7 ± 982.0 mmHg/cm/s in bread swallows); (iv) on the lower esophageal sphincter resting pressure, most parameters in bread swallows provided by the two catheters were of no statistical significance; (v) the 2.7 mm thick catheter detected more hypotensive peristalsis swallows than the other catheter in water swallows; and (vi) the final diagnosis of about half of the subjects provided by the two catheters were different. The 2.7 mm thick solid-state high-resolution manometry catheter provides somewhat different data from the usually used 4.2 mm thick catheter. It is needed to set up different and independent series of normative value for the solid-state high-resolution manometry catheters of different outer diameter. The normative value and diagnostic criterion got from one catheter is not universal and acceptable for researches with catheter of different diameter.

Inclusion of Solid Swallows and a Test Meal Increase the Diagnostic Yield of High Resolution Manometry (HRM) in Patients With Reflux Symptoms

Introduction Manometry is applied in patients with suspected gastro-oesophageal reflux disease (GORD) to exclude motility disorders as a cause of symptoms. Routine studies use a small number of small volume water swallows, however dysmotility and symptoms are more likely to occur with normal eating behaviour. This approach has not entered clinical practice because of difficulty interpreting complex pressure events during ingestion of solids and a standardised meal as well as a lack of control values. This study aimed to assess the prevalence of symptomatic oesophageal dysfunction following individual liquid and solid bolus swallows and a standardised meal in patients with reflux symptoms and asymptomatic volunteers. Methods 45 consecutive patients with predominant reflux symptoms and 23 healthy volunteers underwent HRM (Manoscan 360°, SSI) with 10×5 ml water and 5×1 cc bread swallows in the upright seated position. A test meal (cheese and onion pie; 500 kcal, 34 g fat) was provided if patients consented. Ambulatory reflux studies were performed in patients. Results Water and bread swallows were completed in 44/45 patients (16 M:28 F, age 32–76) and all healthy volunteers (11 M:12 F, age 20–56). 18 patients and 10 volunteers completed the test meal. No healthy subject had clinically significant dysmotility or symptoms during the study. There were no symptoms with water swallows. 14/44 (32%) complained of symptoms with bread (p =0.0013), 7/18 during the meal and 16/44 (36%) when results of bread and meal were combined (p=0.0006). Bread swallows and a test meal resulted in a change of manometry diagnosis in 18/44 (41%) patients. In 13 patients dysmotility was present with solid but not water swallows: hypertensive contractility (3), oesophageal spasm (4), resistance at the gastro-oesophageal junction (4), variant achalasia (1) and severe peristaltic dysfunction (1). Conversely, normal peristalsis was seen in 5 asymptomatic patients with hypotensive motility on water swallows. Symptoms were associated with oesophageal dysfunction during the test meal in 7/16 (44%) patients: hypertensive contractility (1), oesophageal spasm (3), and resistance at the gastro-oesophageal junction (3). Ambulatory reflux studies were completed in 40/45 patients and 18/40 (45%) patients had an objective diagnosis of GORD. A new diagnoses based on symptomatic dysmotility was present in 1/18 (6%) patients with GORD, and 6/22 (27%) patients without GORD (p=0.016). Conclusion The inclusion of solid swallows and a test meal increased the diagnostic yield of HRM in patients referred for investigation of reflux symptoms compared to standard water swallows, in particular, in the patient group without GORD on reflux studies.

Inclusion of Solid Swallows and a Test Meal Increase the Diagnostic Yield of High Resolution Manometry (HRM) in Patients With Dysphagia

Introduction Standard manometry studies diagnose oesophageal dysmotility in patients presenting with dysphagia on the basis of a small number of small volume water swallows. The association of symptoms with abnormal pressure events strongly support the clinical relevance of manometry findings; however, patients report symptoms infrequently with 5–10 ml water swallows. Solid swallows and normal eating behaviour have not entered clinical practice because of the difficulty interpreting the complex pressure events and a lack of control values. The aim of this study was to assess the prevalence of symptomatic oesophageal dysfunction following individual liquid and solid bolus swallows and a standardised test meal in patients presenting with dysphagia and asymptomatic volunteers Methods 30 consecutive patients referred for investigation of endoscopy negative dysphagia and 23 healthy volunteers underwent HRM (Manoscan 360°, SSI) with 10 × 5 ml water and 5 × 1 cc bread swallows in the upright seated position. A test meal (cheese and onion pie: 500 Kcal, 34 g fat) was provided if patients consented and for 10 healthy volunteers Results Water and bread swallows were successful in 29/30 patients (12 M:18 F, age 16–86) and all healthy volunteers (11 M:12 F, age 20–56). 10 patients and 10 volunteers completed the test meal. No healthy subject had clinically significant dysmotility or complained of symptoms. 2/29 (7%) patients experienced their typical symptoms with water, 13/29 (45%) with bread (p = 0.023), 8/10 (80%) with the meal and 16/29 (55%) when results of bread and meal were combined (p = 0.008 compared to water swallows). A change in HRM diagnosis was made in 8/29 (28%) patients on the basis of solid compared to water swallows, of whom 5 (17%) complained of typical symptoms. When a meal was provided, there was a change in HRM findings in 7/10 patients compared to 5 ml water, of whom 4 complained of typical symptoms. When results were combined 10/29 (35%) showed a change in diagnosis and 5 had typical symptoms. Pathology that would have been missed with water swallows alone included: hypertensive contractility (2), spasm (2), variant achalasia (1) and increased resistance to flow at the gastro-oesophageal junction (3). The clinical relevance of 5/8 (62.5%) of these was confirmed with typical symptoms coincident with abnormal pressure events. Two patients with asymptomatic hypotensive dysmotility with water showed normalisation with solid swallows Conclusion The diagnostic yield and ability to associate symptoms with oesophageal dysfunction is increased with inclusion of solid swallows and a test meal compared to water swallows alone in patients with endoscopy-negative dysphagia

The Effect of Bolus Consistency and Position Change on the Coordination of Peristaltic Contractions in Healthy Volunteers

Introduction Previous studies have shown that oesophageal contractility increases with workload (eg, swallowing solids); however mechanistic studies suggest that effective oesophageal clearance depends more on effective coordination between the proximal and distal peristaltic contractions at the proximal transition zone (PTZ) than contractile pressure per se. This study assessed the effects of bolus consistency and position change on coordination of oesophageal contractions as assessed by the PTZ physiology in healthy, asymptomatic volunteers using high resolution manometry (HRM). Methods 23 healthy volunteers (11M:12F, age 20–56) underwent HRM (Manoscan 360°, SSI) with 10×5 ml water and 21 with 5×1 cc bread swallows in the upright seated and supine positions. Measurements of the PTZ mean pressure and break in peristalsis length defined by 30 mm Hg isocontour were recorded. In addition, the length of the proximal contraction (upper oesophageal sphincter to start of PTZ) and distal contraction (end of PTZ to lower oesophageal sphincter) defined by 30 mm Hg isocontour and normalised to oesophageal length (%) were calculated. Results PTZ mean pressure increased from liquid to solid in the upright (12.3 (8.3–17.8) vs 20.3 (12.9–29.5) mm Hg; p Conclusion Increased bolus consistency and position change from upright to supine position both increase the coordination of peristaltic contraction in healthy subjects. This effect is achieved by promoting contractility in the distal segment. This response to ‘physiologic challenge’ may increase specificity of manometric studies and provide a useful test of the oesophagus9 ability to adapt to increased workload (eg, after fundoplication).

The Cause of Dysphagia in Eosinophilic Esophagitis: Obstruction to Bolus Passage Not Oesophageal Dysmotility

Introduction Eosinophilic Oesophagitis (EO) presents with dysphagia and chest pain; however the cause of symptoms remains uncertain. Endoscopy reveals fibrotic and inflammatory mucosal disease but rarely tight stenosis. Conventional manometry with water swallows is usually normal; however this may not be clinically relevant as most patients report dysphagia on eating bread and meat but not on drinking liquids. This study applied HRM with water and solid bolus swallows to identify abnormal oesophageal function in EO patients and to associate abnormal pressure events with symptoms. Methods Retrospective case review of 14 consecutive patients (10 male; age 36 (26–65)) on two sites referred for HRM with EO on biopsy of proximal and distal oesophagus. HRM studies in the seated position included 10×5 ml water swallows and 5–10 solid (bread) swallows. 23 healthy volunteers (11 M:12 F, age 20–56) served as control. Association between abnormal pressure events and symptoms was assessed on a per patient and per swallow basis. Results HRM identified oesophageal dysfunction in 3/14 (21%) patients with water swallows and 11/14 (79%) patients with solids (p Per patient: Typical symptoms were reported with IBPG >30 mm Hg by 1 (7%) patient with water and 7 (50%) patients with solids (p=0.039). Conversely, 7/11 (64%) patients with IBPG >30 mm Hg had symptoms (7/7 patients with IBPG >50 mm Hg). Per swallow: There was temporal association between raised IBPG and patient reports of symptoms (p 30 mm Hg triggered dysphagia; compartmentalised IBP >50 mm Hg between peristalsis and LOS triggered either dysphagia or chest pain. No association was present for any other pressure event. Patients that had received steroids and/or dilation (n=7) had lower IBPG and reported less symptoms than untreated patients (n=7) (both p One healthy subject had increased frequency of low-amplitude oesophageal spasm; however none had raised OGPG >30 mm Hg with solids and none reported symptoms. Conclusion Patients with EO have normal motility but evidence of structural obstruction to solid bolus passage (usually across the LOS), presumably due to oesophageal stenosis or reduced LOS compliance due to fibrosis and inflammation. In all but one case this was evident only with solid bolus. Raised IBPG was closely associated with patient reports of symptoms and both improved on treatment.

Inclusion of solid swallows and a test meal increase the diagnostic yield of high resolution manometry (HRM) in patients with reflux symptoms

IntroductionManometry is applied in patients with suspected gastro-oesophageal reflux disease (GORD) to exclude motility disorders as a cause of symptoms. Routine studies use a small number of small volume water...

Inter-observer agreement of water and solid swallows in high resolution manometry

IntroductionHigh Resolution Manometry (HRM) with presentation of pressure data as spatiotemporal plots highlights oesophageal landmarks and contractions that facilitates data analysis and interpretation. Normal values have been published for water...

Normative values and inter-observer agreement for liquid and solid bolus swallows in upright and supine positions as assessed by esophageal high-resolution manometry

High-resolution manometry (HRM) with spatiotemporal representation of pressure data is a recent advance in esophageal measurement. At present, normal values are available for 5mL water swallows in the supine position. This study provides reference values for liquid and solid bolus swallows in the upright seated and supine positions. A total of 23 asymptomatic volunteers (11M:12F, age 20-56) underwent HRM (Manoscan 360; Sierra Scientific Instruments) with 5mL water and 1cm3 bread swallows in the upright and supine positions. Normal values for primary parameters associated with effective bolus transport [proximal transition zone length (PTZ, assesses peristaltic coordination], contraction front velocity (CFV), distal contractile index (DCI) and integrated relaxation pressure (IRP)] are presented. For each parameter, median values along with the 5-95th percentile range are reported. Inter-observer agreement between independent observers is reported using the intra-class correlation coefficient. A higher proportion of swallows were peristaltic for liquids than solids in both the upright and supine positions (both P<0.05). As workload increases with solid bolus and on moving from the upright to the supine position the esophageal contractile response resulted in a shorter PTZ, a slower CFV, and a more vigorous DCI. Also IRP increased during solid bolus transit (all P<0.01). There was significant agreement between independent observers for HRM parameters. Normative values for esophageal function for solids as well as liquids and in the 'physiologic', upright position will optimize the utility of HRM studies. The high level of inter-observer agreement indicates that these can be applied as reference values in clinical practice.

CC-010 Laying on of the healing hands

Introduction Rumination Syndrome is common yet under-diagnosed and is becoming increasingly recognised in healthy individuals. The primary feature is regurgitation occurring 5–10 min after initiating a meal. It is often confused with disorders such as gastro-oesophageal reflux disease, and patients may be subject to extensive yet unnecessary investigations. Treatment effectiveness with acid reducing medications and prokinetics is limited. The most favourable outcome is achieved with Diaphragmatic Breathing exercises. This case presentation describes the journey of a patient who was found to have rumination syndrome following high-resolution manometry (HRM) and was treated successfully with Diaphragmatic Breathing. Methods HRM (Manoscan 360°, SSI) with 10×5 ml water and 5×1 cm3 solid (bread) swallows and a 250 ml milkshake was performed in the in the upright seated position. This was followed by dual channel 24-h catheter-based pH monitoring. Treatment encompassed two sessions of diaphragmatic therapy. Results HRM: During the bread swallows and after drinking the milkshake, typical symptoms of regurgitation were reproduced. These were associated with short, sharp increases in the intragastric pressure sensors typical of Rumination Syndrome. 24-h Ambulatory reflux study: This exhibited a normal measurement for frequency of reflux events and a positive Symptom Index (87.1%; positive greater than or equal to 50%) for regurgitation. Conclusion Although in this example it was discovered with the use of HRM in a tertiary centre, Rumination Syndrome should be easily diagnosed based only on clinical history. This condition is usually treated with diaphragmatic breathing techniques, however patient commitment to therapy and perseverance is paramount. Diaphragmatic breathing is thought to overwhelm the subconscious yet voluntary abdominal wall muscle contractions which lead to regurgitation, and was successful in this case.

W1803 High Resolution Manometry with Large Volume Multiple Repeated Swallows AIDS the Detection of Oesophageal Pathology

Conventional manometry does not provide a diagnosis in many patients referred with esophageal symptoms because, in part, it fails to predict effective bolus transport.[1,2] High resolution manometry (HRM) measures contractile activity and the intra-bolus pressure (IBP) gradient that drives fluidmovement.[3] In the pharynx, the position of maximum IBP gradient following 10-20ml swallows identifies pathology causing clinically significant resistance to flow.[4] A similar approach with larger volumes has not been tested in the relatively wide lumen of the esophagus. AIMS & METHODS: To assess whether HRM during multiple repeated swallows of water (MRS) can help identify esophageal pathology and quantify functional and structural resistance to flow in the esophageal body and lower esophageal sphincter (LES). A prospective study of 160 consecutive patients undergoing investigation of esophageal symptoms was performed. HRM for ten water (10ml) and five bread swallows were obtained in the upright position. Peristaltic pressure, baseline and nadir LES pressure, IBP, and IBP gradient were recorded. Patients then drank 200ml water by MRS. Symptom events were recorded. RESULTS: 125 studies provided complete data for analysis (78%). Failed swallows (p 20mmHg (p<0.01 vs. lower values). CONCLUSION: HRM with 200ml MRS is a simple, physiological test that helps to localize and quantify the severity of esophageal pathology by increasing IBP above and IBP gradient across the lesion compared to 10ml water swallows. Functional and structural disease were identified by this technique. In addition, raised IBP during MRS was associated with the occurrance of typical, clinically relevant symptoms. REFERENCE(S): 1.Fox NGM 04, 2.Tutuian AJG 04, 3.Pandolfino AJP 06., 4.Pal AJP 03

Influence of Bolus Consistency and Position on Esophageal High-Resolution Manometry Findings

Conventional esophageal manometry evaluating liquid swallows in the recumbent position measures pressure changes at a limited number of sites and does not assess motility during solid swallows in the physiologic upright position. To evaluate esophageal motility abnormalities during water and bread swallows in the upright and recumbent positions using high-resolution manometry (HRM). Thirty-two-channel HRM testing was performed using water (10 ml each) and bread swallows in the upright and recumbent positions. The swallows were considered normal if the distal peristaltic segment >30 mmHg was >5 cm, ineffective if the 30-mmHg pressure band was <5 cm, and simultaneous if the onset velocity of the 30 mmHg pressure band was >8 cm/s. Abnormal esophageal manometry was defined as the presence of > or =30% ineffective and/or > or =20% simultaneous contractions. The data from 96 patients (48 F; mean age 51 years, range 17-79) evaluated for dysphagia (56%), chest pain (22%), and gastroesophageal reflux disease (GERD) symptoms (22%) were reviewed. During recumbent water swallows, patients with dysphagia, chest pain, and GERD had a similar prevalence of motility abnormalities. During upright bread swallows, motility abnormalities were more frequent (p = 0.01) in patients with chest pain (71%) and GERD (67%) compared to patients with dysphagia (37%). Evaluating bread swallows in the upright position reveals differences in motility abnormalities overlooked by liquid swallows alone.

Esophageal solid bolus transit: studies using concurrent videofluoroscopy and manometry

OBJECTIVE: Our aim was to assess the efficacy and mechanism of solid bolus transit through the esophagus. METHODS: Eight healthy volunteers were studied with concurrent manometry and videofluoroscopy while swallowing 5 ml liquid barium, a 5–6 mm diameter bread ball, and 4 g chewed bread in both a supine and upright posture. As many as four successive swallows were performed until clearance was achieved. RESULTS: The esophageal clearance of liquid barium was 100% with the first swallow. Clearance of the unchewed bread ball occurred with the first swallow in only 6.7% of trials in the upright posture and 5.9% in the supine posture. After four swallows, clearance was 100% and 52.9% in the upright and supine postures, respectively. Chewed bread was more readily cleared than unchewed bread, with 100% clearance after two swallows in the upright posture and 91% clearance after four swallows in the supine posture. The most common locus of bread stasis was at the aortic arch and carina. The bread boluses were noted to move more effectively when localized in the head as opposed to the tail of the bolus composite. Nonocclusive contractions often occurred at the bolus tail despite the increased peristaltic amplitude seen with the chewed bread. Failed peristalsis, a frequent cause for solid clearance failure, was observed during 30% of all bread swallows. This usually occurred distal to the stopping point of the bolus, suggesting it to be the result rather than the cause of impaired transit. CONCLUSIONS: Although infrequently perceived by these normal subjects and in contradistinction to liquid clearance, bread is rarely cleared from the esophagus with a single swallow. Mastication and an upright posture facilitate the esophageal transport of solids. Bolus composition and impaired bolus transit alter the amplitude and conductance of peristalsis. Manometric data pertaining to liquid clearance through the esophagus do not readily apply to bread.

Esophageal solid bolus transit: studies using concurrent videofluoroscopy and manometry.

Our aim was to assess the efficacy and mechanism of solid bolus transit through the esophagus. Eight healthy volunteers were studied with concurrent manometry and videofluoroscopy while swallowing 5 ml liquid barium, a 5-6 mm diameter bread ball, and 4 g chewed bread in both a supine and upright posture. As many as four successive swallows were performed until clearance was achieved. The esophageal clearance of liquid barium was 100% with the first swallow. Clearance of the unchewed bread ball occurred with the first swallow in only 6.7% of trials in the upright posture and 5.9% in the supine posture. After four swallows, clearance was 100% and 52.9% in the upright and supine postures, respectively. Chewed bread was more readily cleared than unchewed bread, with 100% clearance after two swallows in the upright posture and 91% clearance after four swallows in the supine posture. The most common locus of bread stasis was at the aortic arch and carina. The bread boluses were noted to move more effectively when localized in the head as opposed to the tail of the bolus composite. Nonocclusive contractions often occurred at the bolus tail despite the increased peristaltic amplitude seen with the chewed bread. Failed peristalsis, a frequent cause for solid clearance failure, was observed during 30% of all bread swallows. This usually occurred distal to the stopping point of the bolus, suggesting it to be the result rather than the cause of impaired transit. Although infrequently perceived by these normal subjects and in contradistinction to liquid clearance, bread is rarely cleared from the esophagus with a single swallow. Mastication and an upright posture facilitate the esophageal transport of solids. Bolus composition and impaired bolus transit alter the amplitude and conductance of peristalsis. Manometric data pertaining to liquid clearance through the esophagus do not readily apply to bread.

Analysis of the pharyngoesophageal pressure profile in amyotrophic lateral sclerosis

Treatment of dysphagia resulting from bulbar amyotrophic lateral sclerosis has included cricopharyngeal myotomy for many years but is successful in only a minority of cases. The purpose of this study was to explore the rationale for this procedure with modern manometric techniques. The results of pharyngoesophageal manometry in 13 patients with amyotrophic lateral sclerosis were compared with 13 age- and sex-matched healthy volunteers by Mann-Whitney analysis. There was no significant difference between patients and control subjects in distal esophageal or lower esophageal sphincter motility nor any pressure parameter of pharyngoesophageal motility. Separate analysis of the seven significantly dysphagic subjects showed a significantly reduced upper esophageal sphincter after-contraction amplitude during water and bread swallows in patients than in control subjects. These data suggest that the dysphagia of amyotrophic lateral sclerosis is not due to upper esophageal sphincter spasm and that treatment by cricopharyngeal myotomy may be inappropriate. (OTOLARYNGOL HEAD NECK SURG 1995;112:258-61.)