Impaired Bolus Transit Research Articles

383. LOSS OF PERISTALTIC RESERVE DETERMINED BY MULTIPLE RAPID SWALLOWS CORRELATES WITH DYSPHAGIA AND POOR BOLUS TRANSIT IN INEFFECTIVE ESOPHAGEAL MOTILITY

Abstract Introduction Ineffective esophageal motility (IEM) is a common finding on high resolution esophageal manometry (HRM) and is often of unclear clinical significance as its impact on dysphagia and bolus transit is variable. Multiple rapid swallow (MRS) testing is a provocative maneuver performed during HRM that assesses peristaltic reserve, documented by the presence of contractile augmentation (defined by contractile vigor after MRS greater than that seen with single swallows). Lack of augmentation after MRS is associated with dysphagia after anti-reflux surgery. To date, no studies have evaluated the impact of peristaltic reserve on dysphagia and bolus transit in IEM patients. Methods Retrospective review of 159 patients with Chicago classification 4.0 IEM. 52 patients were excluded due to prior esophageal surgery, technically inadequate MRS, or concomitant esophagogastric junction outflow obstruction. Demographics and brief esophageal dysphagia questionnaire (BEDQ) results were obtained from a prospectively maintained database. MRS and bolus transit data were analyzed using a commercially available software. Impedance analysis documented complete versus incomplete bolus transit. Augmentation was defined as the ratio of post-MRS DCI to mean single swallow DCI > 1. Fisher's exact test for continuous data and linear model ANOVA were used to assess for statistical significance. Results 107 IEM patients were included, 46 of them had loss of peristaltic reserve (no augmentation on MRS). Compared to IEM patients with augmentation, those without augmentation had more severe dysphagia documented by higher mean BEDQ score (6.8 versus 4.8, p= 0.045), and increased rates of impaired bolus transit (73% versus 55%, p-= 0.013). Discussion IEM patients without augmentation on MRS have more severe dysphagia and more frequent incomplete bolus clearance. These findings support adding MRS response to the diagnosis of IEM or using it to describe a subset of patients with more severe disease.

The Utility of Functional Luminal Imaging Probes Measurements to Diagnose Dysmotility and Their Relationship to Impaired Bolus Clearance.

Functional luminal imaging probes (FLIP) have been used by multiple centers to assess esophagogastric junction (EGJ) function in patients at risk for esophageal obstruction but its role in diagnosing peristaltic disorders is less well studied. In particular, there are no studies comparing the sensitivity of FLIP to diagnose motility abnormalities and impaired bolus transit by high-resolution esophageal manometry with impedance. We prospectively recruited 42 patients undergoing high-resolution esophageal manometry with impedance (HRIM) who also underwent FLIP between 2018 and 2020. HRIM parameters were analyzed using Swallow Gateway software to determine peristaltic and lower esophageal sphincter pressure measurements as well as bolus flow parameters. FLIP tracings were analyzed for the presence of repetitive antegrade contractions (RACs), EGJ distensibility, and associated parameters. Forty-two patients were included (11 controls, 7 achalasia, 16 fundoplication, 8 dysmotility). The mean age of patients was 10.1 ± 0.9 years. There were significant differences in bolus flow parameters across diagnosis with longer bolus presence (BPT) in control patients compared with fundoplication and dysmotility patients. There was a significant correlation between EGJ diameter, EGJ distensibility and bolus flow time (BFT) for solid foods (r2 > 0.518, P < 0.02). The presence of RACs and EGJ relaxation during RACs was associated with a greater BFT and BPT across textures (P < 0.05). Forty-two percentage of patients with absent RACs, however, had clear peristalsis by HRIM. The presence of RACs and EGJ relaxation by FLIP correlate with improved bolus flow. Patients with an absence of RACs need HRIM to confirm any diagnoses of dysmotility.

The level of impaired esophageal bolus transit measured by multichannel intraluminal impedance: Cross-sectional study

BackgroundEsophageal motility disorders (EMDs) are often diagnosed manometrically, yet the underlying pathology is not always clear. Esophageal function testing (EFT), which incorporates manometry and multichannel intraluminal impedance (MII), is considered a useful tool in the assessment of EMDs. ObjectiveThis study aims to assess the most likely level of impaired bolus transit within the esophagus which may help further localize and characterize EMDs. MethodsIn a retrospective study design, we reviewed consecutive EFTs over a period of 12 months. Data included diagnosis, presenting symptoms, and EFT results of liquid and viscous swallows. Each patient underwent 10 liquid and 10 viscous swallows, and bolus transit is measured at 5, 10, 15 and 20 cm above the gastroesophageal junction (GEJ). We recorded the initial level of impaired bolus transit for each swallow. ResultsA total of 2358 swallows in 118 patients was included for analysis. Of these, 837 swallows (35.5%) were incompletely transmitted. The proportions of impaired bolus transit were 39%, 41%, 15.6%, 4.4% at 20 cm, 15 cm, 10 cm, and 5 cm above the GEJ, respectively. The common symptoms at presentation were dysphagia (47%), heartburn (44%), chest pain (24.6%) and regurgitation (18%). The mean lower esophageal sphincter (LES) pressure was 24 ± 13.9 mmHg whereas the mean contraction amplitude was 84 ± 46.6 mmHg. ConclusionIn patients with abnormal esophageal clearance, the most likely levels of impaired bolus transit are 15 and 20 cm above the GEJ. These levels of the esophagus should be a focus of attention in future studies evaluating the pathophysiology of esophageal dysmotility.

Multiple Rapid Swallow Maneuver Enhances the Clinical Utility of High-Resolution Manometry in Patients Showing Ineffective Esophageal Motility.

The clinical significance of ineffective esophageal motility (IEM) together with multiple rapid swallow (MRS) has not been yet evaluated in the Chicago Classification v3.0. This study evaluated the adjunctive role of MRS in IEM and determined the criteria of abnormal MRS to maximize the utility of IEM. We analyzed 186 patients showing IEM or normal esophageal motility (NEM), who underwent esophageal high-resolution impedance–manometry for esophageal symptoms. Two different criteria for abnormal MRS were applied to IEM subjects, resulting in 2 corresponding subgroups: IEM-A when distal contractile integral (DCI) ratio between an average wet swallows and MRS contraction was <1 and IEM-B when MRS contraction DCI was <450 mm Hg-s-cm. One IEM subject inadequately performed MRS. Among the remaining 52 IEM subjects, 18 (34.6%) were classified into IEM-A and 23 (44.2%) into IEM-B. IEM subjects showed less complete bolus transit (median 0.0%, interquartile range 0.0–20.0% vs 60.0%, 30.0–80.0; P < 0.001) resulting in higher impaired bolus transit than NEM subjects (98.1% vs 66.9%, P = 0.001). IEM-B subjects showed additionally higher pathologic bolus exposure than NEM subjects (55.6% vs 29.3%, P = 0.001), whereas IEM-A subjects could not. Although IEM-B subjects had the highest prevalence of gastroesophageal reflux disease among the subjects groups, it did not reach statistical significance. In conclusion, IEM patients with abnormal MRS contraction have an increased risk of prolonged bolus clearance, poor bolus transit, and pathologic bolus exposure. IEM patients need to be assessed concerning whether MRS contraction DCI is <450 mm Hg-s-cm to segregate clinically relevant patients.

The Chicago Classification of esophageal motility disorders, v3.0.

The Chicago Classification (CC) of esophageal motility disorders, utilizing an algorithmic scheme to analyze clinical high-resolution manometry (HRM) studies, has gained acceptance worldwide. This 2014 update, CC v3.0, developed by the International HRM Working Group, incorporated the extensive clinical experience and interval publications since the prior (2011) version. Chicago Classification v3.0 utilizes a hierarchical approach, sequentially prioritizing: (i) disorders of esophagogastric junction (EGJ) outflow (achalasia subtypes I-III and EGJ outflow obstruction), (ii) major disorders of peristalsis (absent contractility, distal esophageal spasm, hypercontractile esophagus), and (iii) minor disorders of peristalsis characterized by impaired bolus transit. EGJ morphology, characterized by the degree of overlap between the lower esophageal sphincter and the crural diaphragm and baseline EGJ contractility are also part of CC v3.0. Compared to the previous CC version, the key metrics of interpretation, the integrated relaxation pressure (IRP), the distal contractile integral (DCI), and the distal latency (DL) remain unchanged, albeit with much more emphasis on DCI for defining both hypo- and hypercontractility. New in CC v3.0 are: (i) the evaluation of the EGJ at rest defined in terms of morphology and contractility, (ii) 'fragmented' contractions (large breaks in the 20-mmHg isobaric contour), (iii) ineffective esophageal motility (IEM), and (iv) several minor adjustments in nomenclature and defining criteria. Absent in CC v3.0 are contractile front velocity and small breaks in the 20-mmHg isobaric contour as defining characteristics. Chicago Classification v3.0 is an updated analysis scheme for clinical esophageal HRM recordings developed by the International HRM Working Group.

Functional swallowing outcomes in nasopharyngeal cancer treated with IMRT at 6 to 42 months post-radiotherapy.

We sought to evaluate the swallowing function of 18 patients surviving nasopharyngeal cancer, who had been treated using an intensity-modulated radiotherapy (IMRT) protocol designed to minimise functional impairment. We compared the outcomes of a patient-reported oral function score with fiberoptic endoscopic examination of swallow (FEES), Australian Therapy Outcome Measures (AusTOMs) and a measure of trismus. While all patients returned to a fully oral diet, there was ongoing swallow dysfunction characterised by bolus residue and delay, but no aspiration. Dysphagia was of mild or moderate severity on all measures, generally because of the need for texture modification, impaired bolus transit or dysgeusia. There was xerostomia on self-reported measurement combined with reports of behaviours adaptive to xerostomia on AusTOMs; however, salivary functioning was less impaired on FEES. There was no trismus in this cohort. Our cohort lacked the morbidity experienced by cohorts reported in earlier studies, potentially due to the use of IMRT.

Tu1976 The 4 Phases of Swallowing: a Functional Model Based on Esophageal Pressure Topography Landmarks

OBJECTIVES: Noncardiac chest pain (NCCP) is defined as recurrent chest pain which does not originate from cardiac cause. Gastroesophageal reflux disease (GERD) is themost common cause of NCCP. However, there are patients presenting NCCP whose symptom is not related with GERD. This study aims to evaluate novel mechanism of non-GERD-related NCCP using high-resolution impedance manometry (HRIM) and 24-hour multichannel intraluminal impedance-pH (MII-pH) testing. PATIENTS AND METHODS: This retrospective study was conducted at Samsung Medical Center between June 2011 and December 2012. A total of 77 NCCP patients and 14 healthy volunteers (control group) were included. The subjects underwent upper endoscopy, esophageal HRIM and 24-hr MII-pH testing. According to the presence of erosive esophagitis and/or pathologic acid exposure, patients were divided into GERD-related group and non-GERD-related group. We measured mean esophageal baseline intraluminal impedances and investigated esophageal motility disorders and/or peristaltic abnormalities. The mean baseline intraluminal impedance was measured at distal and proximal esophagus, 3 cm and 17 cm above the lower esophageal sphincter. The esophageal motility disorders and peristaltic abnormalities were determined by Chicago classification. RESULTS: Among 77 NCCP patients, 16 (11.7%) were included in GERD-related group and 61 (88.3%) were included in non-GERD-related group. The distal mean baseline intraluminal impedance did not differ between NCCP patients and control group. However, the proximal mean baseline intraluminal impedance was lower in NCCP patients than in control group (2463±631 vs. 3739±486 V, P<0.001). In subgroup analysis, the distal mean baseline intraluminal impedance was lower only in GERD-related group than in non-GERD-related NCCP group (1924±802 vs. 2666±804 V, P<0.001) and control group (1924±802 vs. 3739±486 V, P=0.02). There was no difference in distal mean baseline intraluminal impedance between non-GERD-related group and control group. On the contrary, the proximal mean baseline intraluminal impedance was lower both in GERD-related (2391±711 vs. 3739±486V, P<0.001) and non-GERD-related group (2482±614 vs. 3739±486V, P<0.001) than in control group. The proximal mean baseline intraluminal impedance did not differ between GERD-related and non-GERD-related group. There was no difference in esophageal motility disorders, peristaltic abnormalities or impaired bolus transit among these groups. CONCLUSIONS: The proximal esophageal mucosal integrity impairment may play a causative role in patients with non-GERD-related NCCP. The proximal mucosal integrity seems to be impaired by another mechanism rather than esophageal hypomotility and impaired bolus transit.

Tu1975 The Impairment of Proximal Esophageal Mucosal Integrity May Play a Causative Role in Patients With Noncardiac Chest Pain

OBJECTIVES: Noncardiac chest pain (NCCP) is defined as recurrent chest pain which does not originate from cardiac cause. Gastroesophageal reflux disease (GERD) is themost common cause of NCCP. However, there are patients presenting NCCP whose symptom is not related with GERD. This study aims to evaluate novel mechanism of non-GERD-related NCCP using high-resolution impedance manometry (HRIM) and 24-hour multichannel intraluminal impedance-pH (MII-pH) testing. PATIENTS AND METHODS: This retrospective study was conducted at Samsung Medical Center between June 2011 and December 2012. A total of 77 NCCP patients and 14 healthy volunteers (control group) were included. The subjects underwent upper endoscopy, esophageal HRIM and 24-hr MII-pH testing. According to the presence of erosive esophagitis and/or pathologic acid exposure, patients were divided into GERD-related group and non-GERD-related group. We measured mean esophageal baseline intraluminal impedances and investigated esophageal motility disorders and/or peristaltic abnormalities. The mean baseline intraluminal impedance was measured at distal and proximal esophagus, 3 cm and 17 cm above the lower esophageal sphincter. The esophageal motility disorders and peristaltic abnormalities were determined by Chicago classification. RESULTS: Among 77 NCCP patients, 16 (11.7%) were included in GERD-related group and 61 (88.3%) were included in non-GERD-related group. The distal mean baseline intraluminal impedance did not differ between NCCP patients and control group. However, the proximal mean baseline intraluminal impedance was lower in NCCP patients than in control group (2463±631 vs. 3739±486 V, P<0.001). In subgroup analysis, the distal mean baseline intraluminal impedance was lower only in GERD-related group than in non-GERD-related NCCP group (1924±802 vs. 2666±804 V, P<0.001) and control group (1924±802 vs. 3739±486 V, P=0.02). There was no difference in distal mean baseline intraluminal impedance between non-GERD-related group and control group. On the contrary, the proximal mean baseline intraluminal impedance was lower both in GERD-related (2391±711 vs. 3739±486V, P<0.001) and non-GERD-related group (2482±614 vs. 3739±486V, P<0.001) than in control group. The proximal mean baseline intraluminal impedance did not differ between GERD-related and non-GERD-related group. There was no difference in esophageal motility disorders, peristaltic abnormalities or impaired bolus transit among these groups. CONCLUSIONS: The proximal esophageal mucosal integrity impairment may play a causative role in patients with non-GERD-related NCCP. The proximal mucosal integrity seems to be impaired by another mechanism rather than esophageal hypomotility and impaired bolus transit.

Delayed Dysphagia After Removal of Foreign Bodies Near Upper Esophageal Sphincter

A 70-year-old male presented to the emergency department with sudden onset of dysphagia. He had medical history of hypertension for 10 years and cerebral infarction in the territory of the middle cerebral artery 7 year ago. Lateral neck radiography revealed foreign bodies in the upper esophagus (Fig. 1A) and an upper endoscopy was performed. Two seashells with sharp edge were impacted near the upper esophageal sphincter and they were removed using hard straight cap and grasping forceps (Fig. 1B). Figure 1 Radiograph of a 70-year-old man who presented with dysphagia. Foreign bodies were lodged in the upper esophagus (blue arrow) (A) and 2 seashells were removed with endoscopic grasping forceps (B). Although white blood cell was elevated and small laceration with periesophageal inflammation was suspected at CT scan, his condition improved with non-operative management including broad spectrum antibiotics. However, dysphagia continued for 10 days after removal of foreign bodies. Modified barium swallowing showed large volume of valecular residue with tracheal aspiration despite improvement of inflammation on follow-up CT scan. High-resolution impedance manometry (HRIM) was performed to rule out esophageal motility disorder. HRIM revealed a failure of upper esophageal sphincter relaxation with impaired bolus transit (Fig. 2). Two days later, he refused to receive further treatment and was discharged.When he visited outpatient clinic 4 days after discharge, dysphagia was improved and he could take soft diet. Figure 2 High-resolution impedance manometry (HRIM) findings with 30 mmHg isobaric contour. HRIM presents a failure of upper esophageal sphincter relaxation (red arrow) with impaired bolus transit and intrapharyngeal saline pooling (yellow arrow). Recently, HRIM system was used to develop the clinical parameters of deglutitive upper esophageal sphincter relaxation and normal range values were acquired from healthy volunteers.1 In the near future, more accurate diagnosis of dysphagia might be possible based on the objective manometric findings in swallowing difficulty.

Tu1191 Impaired Bolus Transit of Esophageal Swallows May Play an Important Role in Eliciting Globus: A Study Using High-Resolution Impedance Manometry

Background/Aims: Although gastroesophageal reflux disease (GERD) has been suggested to be a major etiology of globus, there is still considerable debate about the causative role of GERD in globus patients. We aimed to investigate the new etiology of globus and its mechanism using high-resolution impedance manometry (HRIM). Methods: A total of 57 consecutive patients with globus sensation, who underwent HRIM, impedance-pH monitoring, and upper endoscopy at Samsung Medical Center, Seoul, Korea, between June 2011 and August 2012, were identified. In addition, 9 normal subjects were recruited and included into analysis. The patients were divided according to the presence of GERD and impaired bolus transit (IBT) for analysis. Using HRIM, esophageal peristalsis parameters, esophageal hypomotility markers including intersegmental trough (IST), extended IST, proximal latency (PL), prolonged PL and fragmented or failed sequence, and bolus transit pattern were evaluated. Esophageal motility abnormality was determined according to the Chicago classification. Results: Of the 57 globus patients, 28 (49.1%) were male and the mean age was 52.3 ± 13.0 (SD) years. Thirteen globus patients (22.8%) were diagnosed with GERD and 42 (73.7%) showed IBT. In comparison between globus patients and normal controls, globus patients were older and more likely to have IBT and had higher integrated relaxation pressure and longer peristaltic break and IST than normal controls (P,0.05). However, there were no significant differences between the two groups with regard to sex, body mass index, reflux esophagitis, other peristalsis parameters, motility abnormality, and other hypomotility markers. In comparison between GERD-related and non GERD-related globus groups, no significant differences were identified with regard to age, sex, body mass index, underlying disease, concomitant symptom, peristalsis parameters, motility abnormality, hypomotility markers, and IBT. Regardless of GERD, the majority of globus patients showed IBT: 9 (69.2%) in GERD-related globus group and 33 (75.0%) in non GERD-related globus group (P=0.73). In comparison between IBT and normal bolus transit globus groups, IBT globus group had higher distal contractile integral and contractile front velocity and longer peristaltic break, IST, and PL and was more likely to have motility abnormality and fragmented or failed sequence than normal bolus transit globus group (P,0.05). Although the majority of globus patients (20/21, 95.2%) with motility abnormality showed IBT, a significant portion of globus patients (22/42, 52.4%) with IBT did not have motility abnormality. Conclusion: IBT may be a major etiologic factor in globus patients. Esophageal motility abnormality alone does not explain the IBT enough, suggesting that other mechanisms are involved in determining IBT in globus patients.

Tu1193 Impaired Bolus Transit of Esophageal Swallows May Play an Important Role in Eliciting Non-Cardiac Chest Pain: A Study Using High-Resolution Impedance Manometry

Background/Aims: Although gastroesophageal reflux disease (GERD) has been suggested to be a major etiology of globus, there is still considerable debate about the causative role of GERD in globus patients. We aimed to investigate the new etiology of globus and its mechanism using high-resolution impedance manometry (HRIM). Methods: A total of 57 consecutive patients with globus sensation, who underwent HRIM, impedance-pH monitoring, and upper endoscopy at Samsung Medical Center, Seoul, Korea, between June 2011 and August 2012, were identified. In addition, 9 normal subjects were recruited and included into analysis. The patients were divided according to the presence of GERD and impaired bolus transit (IBT) for analysis. Using HRIM, esophageal peristalsis parameters, esophageal hypomotility markers including intersegmental trough (IST), extended IST, proximal latency (PL), prolonged PL and fragmented or failed sequence, and bolus transit pattern were evaluated. Esophageal motility abnormality was determined according to the Chicago classification. Results: Of the 57 globus patients, 28 (49.1%) were male and the mean age was 52.3 ± 13.0 (SD) years. Thirteen globus patients (22.8%) were diagnosed with GERD and 42 (73.7%) showed IBT. In comparison between globus patients and normal controls, globus patients were older and more likely to have IBT and had higher integrated relaxation pressure and longer peristaltic break and IST than normal controls (P,0.05). However, there were no significant differences between the two groups with regard to sex, body mass index, reflux esophagitis, other peristalsis parameters, motility abnormality, and other hypomotility markers. In comparison between GERD-related and non GERD-related globus groups, no significant differences were identified with regard to age, sex, body mass index, underlying disease, concomitant symptom, peristalsis parameters, motility abnormality, hypomotility markers, and IBT. Regardless of GERD, the majority of globus patients showed IBT: 9 (69.2%) in GERD-related globus group and 33 (75.0%) in non GERD-related globus group (P=0.73). In comparison between IBT and normal bolus transit globus groups, IBT globus group had higher distal contractile integral and contractile front velocity and longer peristaltic break, IST, and PL and was more likely to have motility abnormality and fragmented or failed sequence than normal bolus transit globus group (P,0.05). Although the majority of globus patients (20/21, 95.2%) with motility abnormality showed IBT, a significant portion of globus patients (22/42, 52.4%) with IBT did not have motility abnormality. Conclusion: IBT may be a major etiologic factor in globus patients. Esophageal motility abnormality alone does not explain the IBT enough, suggesting that other mechanisms are involved in determining IBT in globus patients.

M1152 Integrity of Esophageal Emptying in Spasm Patients: A High-Resolution Impedance Manometry Study

Chest pain and dysphagia are the most common symptoms reported by patients diagnosed with esophageal spasm. The role of esophageal emptying in the etiology of symptoms in these patients is unclear. Our AIM was to determine the integrity of esophageal emptying in patients with manometrically defined esophageal spasm using high-resolution impedance manometry (HRIM). METHODS: Esophageal HRIM data were retrospectively reviewed from 12 patients (7 male) classified as esophageal spasm (Pandolfino et al, AJG, 2008). Data were collected using a solid state HRIM system with 36 manometry and 8 impedance sensors (MMS Inc, Dover, NH). All patients underwent 10 5-ml water swallows and 10 5-ml viscous swallows. Patients were classified based on symptoms as either chest pain dominant (n=5) or dysphagia dominant (n=7). Esophageal motility and lower sphincter relaxation were quantified using the distal contractile integral (DCI), propagation front velocity (PFV) and the 4-second integrated relaxation pressure (IRP). Manometric parameters reflecting bolus transit, i.e. flow permissive time (FPT) and bolus domain pressure (BDP) were quantified using MATLAB programs (The Mathworks Inc, Natick, MA). Complete esophageal emptying was defined as a recovery back to 50% of baseline impedance on all intraesophageal sensors. All results are average ± std dev. RESULTS: Two manometric patterns were noted in spasm patients, (i) spastic contractions with DCI >5000 mmHg.cm.s and contractions restricted to the mid-esophagus (Type I), and (ii) spastic contractions with DCI > 7000 mmHg.cm.s and contractions spanning the mid and distal esophagus (Type II). 1/5 chest pain dominant patients was classified in type I and the remaining 4 chest pain patients were classified in Type II. Of the 7 dysphagia dominant patients, 3 were type I and 4 type II. Type I patients had complete bolus transit in all 4 patients, while 5 of the 8 type II patients had incomplete bolus emptying on at least two consecutive impedance sensors. FPT was longer in type I vs type II patients (3.2 ± 2.7 s vs. 1.9 ± 1.0 s; p 0.05). All patients had complete LES relaxation, 4-s IRP = 12.8±4.1 mmHg). Viscous swallows showed higher frequency of bolus retention compared to water swallows. CONCLUSIONS: Two manometric variations are seen in spasm patients. Type II patients have a stronger association with incomplete bolus transit and are more likely to have symptoms of dysphagia than chest pain. This suggests that impaired bolus transit is likely an important factor in the etiology of dysphagia but not of chest pain in the symptomatology of spasm patients.

Physiology of the oesophageal transition zone in the presence of chronic bolus retention: studies using concurrent high resolution manometry and digital fluoroscopy

Distinct contraction waves (CWs) exist above and below the transition zone (TZ) between the striated and smooth muscle oesophagus. We hypothesize that bolus transport is impaired in patients with abnormal spatio-temporal coordination and/or contractile pressure in the TZ. Concurrent high resolution manometry and digital fluoroscopy were performed in healthy subjects and patients with reflux oesophagitis; a condition associated with ineffective oesophageal contractility and clearance. A detailed analysis of space-time variations in bolus movement, intra-bolus and intra-luminal pressure was performed on 17 normal studies and nine studies in oesophagitis patients with impaired bolus transit using an interactive computer based system. Compared with normal controls, oesophagitis patients had greater spatial separation between the upper and lower CW tails [median 5.2 cm (range 4.4-5.6) vs 3.1 cm (2.2-3.7)], the average relative pressure within the TZ region (TZ strength) was lower [30.8 mmHg (28.3-36.5) vs 45.8 mmHg (36.1-55.7), P < 0.001], and the risk of bolus retention was higher (90%vs 12%; P < 0.01). The presence of bolus retention was associated with a wider spatial separation of the upper and lower CWs (>3 cm, the upper limit of normal; P < 0.002), independent of the presence of oesophagitis. We conclude that bolus retention in the TZ is associated with excessively wide spatial separation between the upper and lower CWs and lower TZ muscle squeeze. These findings provide a physio-mechanical basis for the occurrence of bolus retention at the level of the aortic arch, and may underlie impaired clearance with reflux oesophagitis.

W1793 Identification of Impaired Bolus Transit and Clearance By Secondary Peristalsis in Patients with Non-Obstructive Dysphagia

W1793 Identification of Impaired Bolus Transit and Clearance By Secondary Peristalsis in Patients with Non-Obstructive Dysphagia

Regional Esophageal Dysfunction in Scleroderma and Achalasia using Multichannel Intraluminal Impedance and Manometry

Achalasia and scleroderma are esophageal motility abnormalities characterized by severely impaired bolus transit. Combined multichannel intraluminal impedance and manometry (MII-EM) enables the simultaneous measurement of intraesophageal pressures and bolus transit at various levels within the esophagus. The aim of the study was to evaluate and characterize regional pressure and transit profile differences in scleroderma and achalasia patients. A retrospective analysis was carried out of MII-EM studies of patients with scleroderma (15), achalasia (20), and poorly relaxing lower esophageal sphincter (LES) with normal esophageal body function (20) as a control group. Bolus presence and segmental transit were evaluated by MII. In patients with achalasia, bolus transit was impaired across all four sites compared with scleroderma (P < 0.0125) even though distal esophageal pressures were higher (P < 0.05) in patients with achalasia. Pressures in patients with achalasia were similar across all four sites (ANOVA; saline, P = 0.373; viscous, P = 0.615). Bolus clearance rates and contraction amplitudes in patients with scleroderma decreased from proximal to distal. In the control group, bolus clearance was complete during > or = 83% of all swallows and esophageal pressure amplitudes increased distally. While the overall bolus transit is impaired in both patients with achalasia and scleroderma regional pressure and bolus transit differences exist. Bolus transit abnormalities result from abnormal esophageal body contraction and not abnormal LES relaxation.

えん下障害の外科的治療

Since the digestive tract traverses the respiratory passage at the pharynx level, defects in pharyngeal swallowing are some of the most difficult and distressing disorders to deal with. It is common to see patients with swallowing disorders suffering not only from malnutrition but also from pneumonia due to aspiration. Several surgical procedures have been employed to treat patients with swallowing disorders. These surgical procedures are classified into two groups based upon their main purpose. One group of operations aims to improve the impaired bolus transit, and the other to prevent aspiration. These surgical procedures are reviewed.

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.