Improvement In Esophageal Motility Research Articles

Iatrogenic esophageal dysmotility as a barrier to transplantation in pulmonary arterial hypertension

Esophageal dysmotility is identified as a contraindication to lung transplantation at some centers due to increased risks of acute rejection, pulmonary infection, and chronic lung allograft dysfunction. Phosphodiesterase-type 5 inhibitors (PDE5i) are a cornerstone pharmacotherapy for pulmonary arterial hypertension (PAH) and are known to exert off-target effects that may impact lung transplant candidacy, including impaired esophageal contractility and decreased lower esophageal sphincter tone. We report two patients with PAH who were initially declined listing for lung transplantation due to iatrogenic esophageal dysmotility induced by PDE5is. Upon discontinuation of PDE5i therapy, these patients experienced significant improvement in esophageal motility within 14 days and met criteria for transplant listing at their centers. Recognizing and mitigating the off-target effects of PDE5i medications is critical for maximizing access to transplant for patients with PAH.

The impact of lung transplantation on esophageal motility and inter-relationships with reflux and lung mechanics in patients with restrictive and obstructive respiratory disease.

For many patients with lung disease the only proven intervention to improve survival and quality of life is lung transplantation (LTx). Esophageal dysmotility and gastroesophageal reflux (GER) are common in patients with respiratory disease, and often associate with worse prognosis following LTx. Which, if any patients, should be excluded from LTx based on esophageal concerns remains unclear. Our aim was to understand the effect of LTx on esophageal motility diagnosis and examine how this and the other physiological and mechanical factors relate to GER and clearance of boluses swallowed. We prospectively recruited 62 patients with restrictive (RLD) and obstructive (OLD) lung disease (aged 33-75 years; 42 men) who underwent high resolution impedance manometry and 24-h pH-impedance before and after LTx. RLD patients with normal motility were more likely to remain normal (p = 0.02), or if having abnormal motility to change to normal (p = 0.07) post-LTx than OLD patients. Esophageal length (EL) was greater in OLD than RLD patients' pre-LTx (p < 0.001), reducing only in OLD patients' post-LTx (p = 0.02). Reduced EL post-LTx associated with greater contractile reserve (r = 0.735; p = 0.01) and increased likelihood of motility normalization (p = 0.10). Clearance of reflux improved (p = 0.01) and associated with increased mean nocturnal baseline impedance (p < 0.001) in RLD but not OLD. Peristaltic breaks and thoraco-abdominal pressure gradient impact both esophageal clearance of reflux and boluses swallowed (p < 0.05). RLD patients are more likely to show improvement in esophageal motility than OLD patients post-LTx. However, the effect on GER is more difficult to predict and requires other GI, anatomical and pulmonary factors to be taken into consideration.

Clinical efficacy and mechanism of transcutaneous neuromodulation on ineffective esophageal motility in patients with gastroesophageal reflux disease.

Esophageal motility disorder is one of the pathogenesis of gastroesophageal reflux disease (GERD). The clinical and functional relationship between the ineffective esophageal motility (IEM) and GERD have been found. PPI is a widely used drug of this diaease, but some patients have poor efficacy. The purpose of this study was to investigate the efficacy and possible mechanism of Transcutaneous Neuromodulation in these patients. Fifty-six patients with GERD with IEM were enrolled and randomly divided into two groups, one group was TN ST-36 group, the other group was sham TN group. The GERD questionnaire (GerdQ), quality of life score, MOS item short from health survey (SF-36), Hospital Anxiety and Depression Scale (HADS) were used to assess the severity of symptoms. High-resolution esophageal manometry (HRM) test was performed to assess low esophageal sphincter (LES) pressure and distal contractile integral (DCI). The heart rate variability (HRV) test was performed to assess autonomic nervous function. Compared with sham TN, chronic TN treatment decreased the GERD-Q score (p< 0.001). The anxiety score (p= 0.058) and depression score (p= 0.156) were decreased, but there were no statistical differences. Chronic TN treatment also significantly improved the quality of life of patients, mainly in physical function, physical pain, overall health, vitality, social function, emotional function, and mental health. Acute TN treatment increased the DCI (p< 0.001) and LES pressure (p< 0.001) significantly and decreased the combined percentage of failed and weak peristalsis (p< 0.001). Concurrently, acute TN enhanced vagal activity (p< 0.001). IEM is an important link in the pathogenesis of GERD. Chronic TN treatment can significantly improve the clinical symptoms of patients. Acute TN treatment can significantly increase LES pressure and DCI and reduce the frequency of esophageal lost peristalsis and weak peristalsis. The improvement of esophageal motility in GERD patients with IEM by TN treatment may be related to the regulation of autonomic nervous function.

588 THE INFLUENCE OF CHANGE OF DIET COMPOSITION ON ESOPHAGEAL MOTILITY PATTERNS IN PATIENTS WITH NON-EROSIVE GERD

Abstract The aim of the study was to evaluate the influence of change in diet composition on high-resolution esophageal manometry (HRM) patterns. Methods The data of 43 NERD patients with low (&amp;lt;20 g/day) dietary fibre intake served as a source data. These patients were examined with the use of standard food frequency questionnaire and HRM. Thirty of them received psyllium 5.0 G TID 10 days additionally to their usual diet (NCT01882088). Control group was formed by the database search for patients who had repeated HRM examinations and dietary assessments at the same time point and if no significant change in diet composition was revealed. HRM assessment was in accordance to Chicago-3.0. Non-parametric statistics were used to assess the change in HRM metrics. Results Minimal LES resting pressure at rest and after 10 water swallows increased in study group: 5.41 ± 10.1 vs 11.3 ± 9.4 mmHg, P = 0.023 and 14.1 ± 8.0 vs 14.9 ± 6.4 mmHg, P = 0.008. No difference was found in those whose diet composition was stable. Ineffective esophageal motility initially was found in 46.7% patients of the study group and 53.8% in the control group (P = 0.7). IEM resolved in 71.4% of the study group, and in 14.3% of controls (P = 0.0135). IEM not changed in 28.6% of the study group and in 85.7% of controls, P = 0.014. New IEM revealed in 12.5% of the study group and 16.7% among the controls (P = 0.13). Conclusion Change of diet composition by additional quantity of dietary fibre (psyllium) to the standard rations may result in the improvement of esophageal motility.

The Effect of Diet Composition Change on High-Resolution Oesophageal Manometry Metrics in Non-Erosive Gastroesophageal Reflux Disease Patients

Abstract Objectives To evaluate the influence of change of diet composition on esophageal manometry metrics. Methods The data of 43 NERD patients with low (&amp;lt;20 g/day) baseline dietary fiber intake served as a source data. These patients were examined with the use of standard food frequency questionnaire and high-resolution esophageal manometry. Thirty of them received psyllium 5.0 g TID 10 days in addition of their usual diet within registered clinical trial (NCT01882088). The other 13 were found in the database by diagnosis; their data were eligible in case of the presence of repeated high-resolution esophageal manometry examination and dietary assessments at the same time point and if no significant change in diet composition was revealed. The changes were assessed in accordance to Chicago classification 3.0. Non-parametric statistics (Wilcoxon matched pairs test, Mann-Whitney U-test) were used to assess the change in HRM metrics in these groups. Results In those who received psyllium, significant increase of minimal lower esophageal resting pressure at rest and after 10 water swallows was registered: 5.41 ± 10.1 vs 11.3 ± 9.4 mm Hg, P = 0.023 and 14.1 ± 8.0 vs 14.9 ± 6.4 mm Hg, P = 0.008, accordingly. No significant difference was found in the group with no change of diet composition by these parameters. At baseline, ineffective esophageal motility was found in 46.7% patients of the study group and 53.8% in the control group (P = 0.7). Esophageal motility became normal in 71.4% of those who had IEM initially in the study group after 10 days of treatment, and in 14.3% among the controls (P = 0.0135). This type of peristaltic abnormality was found not changed in 28.6% of the study group and in 85.7% among the control group, P = 0.014. New cases of ineffective esophageal motility revealed in 12.5% of the study group and 16.7% among the controls (P = 0.8) Conclusions Change of diet composition by additional quantity of psyllium may result in the improvement of esophageal motility. Funding Sources Federal Research Center of Nutrition and Biotechnology.

Esophageal Dysmotility in Young Dogs

Background:Abnormal esophageal motility can exist without megaesophagus, although its prevalence in dogs is unknown and its cause has not been elucidated.Hypothesis:Esophageal dysmotility without overt megaesophagus exists in both symptomatic and asymptomatic young dogs, and motility can improve with age.Animals:Dogs examined at the Department of Veterinary Medicine, University of Cambridge for regurgitation, but without evidence of megaesophagus on radiographs, and a further group of asymptomatic dogs.Methods:Dogs underwent an initial and a repeat videofluoroscopic swallowing study. Images were reviewed and 5 criteria of esophageal motility evaluated.Results:Eight affected dogs were identified (median age 9 months), and terrier dogs predominated (6 terriers of 3 breeds). Esophageal motility was reduced either globally (n = 3) or segmentally (n = 5). Repeat examination at a median of 3 months revealed that regurgitation had reduced or resolved in the majority of terrier dogs, and 4 of 6 cases demonstrated an improvement in esophageal motility. Videofluoroscopic evaluation of young (median age 11 months) asymptomatic dogs of various breeds (n = 22) revealed evidence of esophageal dysmotility in 4 of 5 control terrier dogs. Repeat evaluation demonstrated an improvement in esophageal motility in 3 dogs.Conclusion and Clinical Importance: Esophageal dysmotility without overt megaesophagus occurs in young terrier dogs, and affected animals can be symptomatic or asymptomatic. Further, an improvement in esophageal motility occurs with time in some dogs, and might represent a syndrome of delayed esophageal maturation.

Esophageal Dysmotility in Young Dogs

Abnormal esophageal motility can exist without megaesophagus, although its prevalence in dogs is unknown and its cause has not been elucidated. Esophageal dysmotility without overt megaesophagus exists in both symptomatic and asymptomatic young dogs, and motility can improve with age. Dogs examined at the Department of Veterinary Medicine, University of Cambridge for regurgitation, but without evidence of megaesophagus on radiographs, and a further group of asymptomatic dogs. Dogs underwent an initial and a repeat videofluoroscopic swallowing study. Images were reviewed and 5 criteria of esophageal motility evaluated. Eight affected dogs were identified (median age 9 months), and terrier dogs predominated (6 terriers of 3 breeds). Esophageal motility was reduced either globally (n = 3) or segmentally (n = 5). Repeat examination at a median of 3 months revealed that regurgitation had reduced or resolved in the majority of terrier dogs, and 4 of 6 cases demonstrated an improvement in esophageal motility. Videofluoroscopic evaluation of young (median age 11 months) asymptomatic dogs of various breeds (n = 22) revealed evidence of esophageal dysmotility in 4 of 5 control terrier dogs. Repeat evaluation demonstrated an improvement in esophageal motility in 3 dogs. Esophageal dysmotility without overt megaesophagus occurs in young terrier dogs, and affected animals can be symptomatic or asymptomatic. Further, an improvement in esophageal motility occurs with time in some dogs, and might represent a syndrome of delayed esophageal maturation.

Timing of surgical intervention does not influence return of esophageal peristalsis or outcome for patients with achalasia

It has been suggested that abnormal function of the lower esophageal sphincter is the primary abnormality in esophageal achalasia, and that the absence of esophageal peristalsis is secondary to the outflow obstruction caused by the lower esophageal sphincter. Furthermore, it has been proposed that early elimination of the resistance at the level of the gastroesophageal junction by surgical intervention could result in return of esophageal peristalsis. This study aimed to assess whether the timing of surgical intervention affects the return of esophageal peristalsis and the clinical outcome for patients with achalasia. Between January 1991 and May 2003, 173 patients underwent a Heller myotomy by minimally invasive surgery for treatment of esophageal achalasia. Of these patients, 41 (24%) had pre- and postoperative esophageal manometry. These patients were divided into three groups based on the duration of symptoms: group A (10 patients; duration of symptoms 12 months group B (19 patients, duration of symptoms 12 to 60 months), and group C (12 patients; duration of symptoms longer than 60 months). The average duration of symptoms (dysphagia was present in all patients) was as follows: group A (8 +/- 4 months), group B, (35 +/- 16 months), and group C, (157 +/- 94 months). Vigorous achalasia was present in 40%, 21%, and 17% of the groups respectively. The differences between the groups were not significant. Postoperatively, improvement in esophageal motility was seen in no patient in group A, 1 patient (5%) in group B, and 1 patient (8%) in group C. Excellent or good results were obtained for 90% of the group A patients, 95% of group B patients, and 92% of the group C patients. Again, the differences were not significant. The results show that: a) the presence of vigorous achalasia is independent of symptoms duration; b) the timing of surgical intervention does not influence the return of peristalsis; and c) the results of a Heller myotomy are independent of symptoms duration.

Laparoskopische partielle Fundoplicatio nach Toupet als generelle chirurgische Therapieform der gastrooesophagealen Refluxkrankheit 1-Jahresresultate einer auf 5 Jahre ausgelegten prospektiven Langzeitstudie

A variety of laparoscopic antireflux operations exist for patients with gastroesophageal reflux diseases (GERD). Most surgeons operate using the concept of "tailored approach", which depends on esophageal motility. We have abandoned this concept because of the relatively high incidence of wrap-related complications in patients treated with laparoscopic Nissen fundoplication compared with patients treated with partial fundoplication. It is our policy to perform laparoscopic Toupet partial fundoplication in all patients suffering from GERD, independent of their esophageal motility. In a prospective trial we have assessed and evaluated our 1-year results of the first 100 consecutive patients treated with Toupet partial fundoplication. All patients underwent esophagogastroscopy and 24-h pH manometry before operation. One third of patients (n = 34) underwent control manometry 8 weeks postoperatively. The patients were followed up clinically 1, 2, 6 and 12 months postoperatively. In this study group we achieved a healing rate in GERD of 97%. In 3% of patients GERD recurred. The median clinical DeMeester score decreased from 4.27 +/- 1.5 points preoperatively to 0.25 +/- 0.5 points 1 year postoperatively (P < 0.0005). The median fractional time with pH < 4 decreased from 17.8% +/- 12.5% preoperatively to 0.9% +/- 1.2% 8 weeks postoperatively (P < 0.0005). Because of persistent dysphagia 5% of our patients required postoperative dilatation therapy. The rate of reoperation and mortality was 0%. The total morbidity rate was 18%. In 50% of patients with preoperatively recorded esophageal motility disorder, an improvement of esophageal motility was found postoperatively. Our 1-year results encourage us to continue to perform laparoscopic Toupet partial fundoplication as the primary repair in all GERD patients, independent of their esophageal motility. Laparoscopic Toupet partial fundoplication has proven to be a safe and highly successful therapeutic option in these patients.

Esophageal dysmotility in children breast-fed by mothers with silicone breast implants. Long-term follow-up and response to treatment.

Our aims were to determine the long-term clinical and manometric follow-up of 11 children with previously documented esophageal dysmotility, who had been breast-fed by mothers with silicone breast implants, their response to prokinetic agents, and to analyze changes in macrophage activation. Seven of 11 children had subjective clinical improvement. Weight/ height ratios remained the same or improved in 9/11. Biopsies at follow-up endoscopy were either normal or demonstrated mild esophagitis in 8/10. LES and UES pressures and percent propagation were not significantly different at follow-up, while wave amplitude significantly increased. Following intravenous metoclopramide, LES pressure, percent propagation, and wave amplitude significantly increased while UES pressure was unchanged. Urinary neopterin significantly decreased at follow-up, while urinary nitrates were unchanged. Esophageal dysmotility is chronic in this group of children, suggesting persistent autonomic nervous system dysfunction. Prokinetic agents may be useful in long-term management. The decreasing urinary neopterin levels suggest that, ultimately, there may be improvement in esophageal motility.

Antireflux mechanism of Nissen fundoplication. A manometric study.

To analyze the mechanisms by which Nissen fundoplication controls gastroesophageal reflux, the pre- and post-operative manometric findings in 34 patients were compared. The postoperative assessment showed an increase in both the infradiaphragmatic length and basal pressure of the lower esophageal sphincter and a notable improvement in esophageal motility (increase in the amplitude of the waves and decrease in the mean percentage of deglutitions without response and tertiary waves) in those who preoperatively presented with defective esophageal peristalsis.

Treatment of familial dysautonomia with bethanecol (Urecholine)

The effects of Urecholine have been investigated in six children with familial dysautonomia. There was an increase in eye moisture, a reduction in gastric distension and vomiting, improvement in esophageal motility, and better bladder control. Urecholine may prove an effective therapeutic agent for selected patients with familial dysautonomia.

Reserpine in Raynaud's disease and phenomenon. Short-term response to intra-arterial injection.

Nineteen patients had Raynaud's disease or Raynaud's phenomenon. A heat-loss measuring device showed marked differences in superficial digital blood flow between the control patients and the patients both at rest and during exposure to cold. Short-term improvement in superficial blood flow followed intra-arterial reserpine in 7 of the 13 patients treated. Those patients not responding to intra-arterial reserpine probably had such extensive intrinsic or extrinsic obstructive disease that lessening of the autonomic nervous system control was of no appreciable benefit. Esophageal motility was abnormal in several patients, especially upon direct measurement. Abnormal peristalsis was replaced by normal motility after intra-arterial reserpine in two of the five patients studied. Whether the improvement in esophageal motility was spontaneous or was related to the reserpine treatment is not clear. Seven brachial arteriograms were abnormal. Pulmonary hypertension was found in one young girl with systemic lupus erythematosus and Raynaud's phenomenon.