Inferior Esophageal Sphincter Research Articles

Investigation of the Effect of Radiotherapy Dose on Chewing and Swallowing Structures in Head and Neck Cancer Patients Treated with Concomitant Chemoradiotherapy.

Intensity-modulated radiotherapy (IMRT) is a treatment method that is used in the treatment of head and neck cancers. Impairment of chewing and swallowing functions in the early and late periods of radiotherapy is frequent. Therefore, revealing the dose-effect relationship is important. The main purpose of this study is to investigate the dose-effect relationship between chewing and swallowing structures objectively via a standardized videofluoroscopy protocol. The study included 35 participants treated with chemo-IMRT. A videofluoroscopic swallowing study (VFSS) was performed before IMRT, and 3 and 6months after IMRT. VFSS results were scored according to the Modified Barium Swallow Impairment Profile (MBSImP) and the Penetration-Aspiration Scale (PAS). Maximum interincisor mouth opening, body mass index (BMI), and Functional Oral Intake Scale levels were determined in these cases. The quality of life of participants was evaluated. There was a significant increase in PAS and MBSImP scores and a significant decrease in BMI scores of the patients after treatment. Xerotomy and sticky saliva complaints increased after treatment. The dose to the mastication muscles (> 40Gy) and the temporomandibular joint (> 46Gy) were found to be associated with a decrease in BMI; the dose to the superior pharyngeal constructor muscle (> 58Gy) was found to be associated with pharyngeal stripping wave. The presence of aspiration was associated with the inferior pharyngeal constructor muscle, glottic larynx, supraglottic larynx, and upper esophageal sphincter. Important findings to emerge from this study include detected toxic dose limits. These findings may guide physicians to minimize the side effects of IMRT.

Treatment of Achalasia in the Evidence-Based Medicine Era - A Quest in Search for a Proper Attitude by Reviewing the Present Guidelines

The best way to start a paper like this is with a citation from W. Edwards Deming: Without data, you're just another person with an opinion. In the era of Evidence-Based Medicine (EBM) every surgical procedure has to be backed up by solid statistical data to offer our patients the best treatment. But is EBM always the path to truth? We decided to analyze the literature for achalasia and see if the guidelines and the data are reliable enough to justify a certain attitude. Practically, we engaged in this endeavor not because we do not trust the statements of the guidelines, but to see if a surgeon can find by themselves the proper attitude in this disease. Achalasia is a motility disorder of the esophagus characterized by deficient relaxation of the inferior esophageal sphincter that results in dysphagia. There are several methods of treatment, with various statements in the guidelines. Currently, every treatment should be sustained by data and statistics, evidence-based medicine being mandatory when a method is preferred over another. This article reviews several studies and also the available guidelines in search for an answer to the question which procedure is the best.

Why Would a Patient Complain of Dysphagia and Heartburn After Multiple Bariatric Surgeries?

Question: A 43-year-old woman presented for management of a complication of her bariatric surgery. The history goes back to September 2000 when the patient presented with a body mass index (BMI) of 45 (120 kg to 1.63 m). An adjustable gastric band was placed. One year postoperatively, the band migrated, which resulted in removal of the band. In 2003, the patient regained weight and reached a BMI of 47 kg/m2. She underwent a Roux-en-Y gastric bypass. The Roux-en-Y gastric bypass failed in the long term; the patient regained weight and reached a BMI of 45. A supportive band was also placed on the gastric pouch and failed to result in significant weight loss, which necessitated its removal. Currently, the patient has a BMI of 55 and she complains of heartburn accompanied by intermittent abdominal epigastric pain and dysphagia for solid food for the last few months. A 3-dimensional thoracoabdominal computed tomography (CT) scan was done (Figure A–C). What is the diagnosis and how it should be managed? Look on page 654 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. A 3-dimensional thoracoabdominal CT scan was done that showed herniation of the gastric pouch, the gastrojejunal anastomosis, the alimentary limb, and the residual excluded stomach into the thoracic cavity through the hiatal orifice (Figure A–C). The patient underwent laparoscopic reduction of the intrathoracic contents into the abdominal cavity and repair of the hiatal orifice. Mesh repair of the hiatal defect was preferred. The postoperative course was uneventful. She was doing well at follow-up 6 months after surgery. Bariatric surgery is booming in all countries.1Debs T. Petrucciani N. Kassir R. et al.Trends of bariatric surgery in France during the last 10 years: analysis of 267,466 procedures from 2005–2014.Surg Obes Relat Dis. 2016; 12: 1602-1609Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar However, hiatal hernia is an uncommon pathology after bariatric surgery. The patient underwent multiple bariatric surgeries, with repeated dissection of the angle of His and the diaphragmatic crura, which might have increased the risk of herniation, owing to enlargement of natural orifices such as the hiatal orifice. The reduced formation of adhesions owing to the laparoscopic approach could also play a role. Morbid obesity itself is an independent risk factor for development of hiatal hernia. The intra-abdominal and visceral fat in obese patient leads to a higher intragastric pressure. In addition, obesity reduces the inferior esophageal sphincter pressure and causes esophageal motility problems. Abnormal changes in the collagen and reduced elastin in the diaphragmatic crura after bariatric surgery predispose these patients to hiatal hernias.2Pandolfino J.E. El-Serag H.B. Zhang Q. et al.Obesity: a challenge to esophagogastric junction integrity.Gastroenterology. 2006; 30: 639-649Abstract Full Text Full Text PDF Scopus (395) Google Scholar, 3Curci J.A. Melman L.M. Thompson R.W. et al.Elastic fiber depletion in the supporting ligaments of the gastroesophageal junction: a structural basis for the development of hiatal hernia.J Am Coll Surg. 2008; 207: 191-196Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Management of hiatal hernia after bariatric surgery consists of reduction of the contents into the abdominal cavity, closure of the hiatal orifice and mesh repair.

Dysphagia and Eosinophilic Infiltration of the Esophageal Muscular Layer: A Case Report

Eosinophilic gastrointestinal diseases are a group of pathological entities characterized by an eosinophilic infiltration of the gastrointestinal tract without known cause. Eosinophilic esophagitis (EE) is one of these conditions, which has three diagnostic criteria: symptoms of esophageal dysfunction, mucosal infiltration of 15 eosinophils per high-power field (HPF) microscope and no response to high-dose proton pump inhibitors (PPIs). A 51-year-old patient attended to the emergency department claiming to suffer from heartburn, dysphagia, regurgitation and chest pain. He was treated with high doses of PPIs without success and the condition progressed to food impaction. An esophagogram, which showed esophageal motor dysfunction in the middle and lower part of the esophagus, was performed, and pathologic examination of an esophageal biopsy taken by endoscopy revealed histopathological changes suggestive of gastroesophageal reflux disease. An esophageal manometry was carried out and it reported diffuse esophageal spasms and a hypertensive inferior esophageal sphincter with incomplete relaxation. A Heller cardiomyotomy was performed and the biopsy specimen revealed fibrosis and eosinophilic infiltration of the muscular layer. Symptoms ceased for 6 months after which symptoms reappeared. The patient was diagnosed with EE and treated with budesonide orally 12 mg/day with complete remission of all symptoms. In this peculiar case, the eosinophilic infiltration was in the muscular layer of the esophagus, not in the mucosa; therefore, it did not meet the diagnostic criteria of EE nor its differential diagnoses. Nevertheless, treatment with oral steroids was in fact effective. J Med Cases. 2014;5(12):621-626 doi: http://dx.doi.org/10.14740/jmc1942w

A Peculiar Initial Presentation of Achalasia

Introduction: A 56-year-old man with history of Roux-en-y gastric bypass presented with a 2 year history of progressively worsening hiccups. They occurred every few seconds and greatly impacted his quality of life. Eating or drinking exacerbated the symptom, while self-induced vomiting led to a 15-30 minute symptom free period. Several months after the start of the hiccups, he began experiencing symptoms of dysphagia to solids and liquids as well as regurgitation. He was evaluated on multiple occasions by a variety of specialists without reaching a diagnosis. He was given thorazine which helped him greatly but was unable to tolerate side effects. Baclofen was then tried but with only mild improvement. His outside evaluation included several imaging studies of the brain, abdomen and chest as well as upper endoscopy. Apart from LA Grade B esophagitis, gastritis, and evidence of a prior gastric bypass, no etiology was found. At presentation, his blood pressure was 140/90 mmHg, with a heart rate of 88 beats/min. He had hiccups every 2-3 seconds, which hampered his speech. Abdominal examination and laboratory testing were normal. A barium esophagram showed a narrowed inferior esophageal sphincter with intermittent relaxation. A repeat upper endoscopy showed a nodular mid esophageal segment, but was otherwise normal. Computed tomography (CT) showed a thickened wall in the lower third of the esophagus as well as residual contrast within the esophagus, suggestive of a narrowing of the distal esophagus. Finally, he received esophageal manometry testing which was consistent with Type II Achalasia which was supported by EUS showing diffuse wall thickening in the lower esophagus without signs of malignancy. Subsequently, botulin toxin was injected which led to complete resolution of symptoms, including the hiccups. In light of his gastric bypass, we opted for surgical myotomy as opposed to pneumatic dilation for more definitive therapy. Though still present, the frequency and intensity of the hiccups are significantly less. Overall, his quality of life has improved dramatically and he has successfully returned to work. Achalasia is a disease characterized by failure of lower esophageal sphincter relaxation and loss of esophageal peristalsis which leads to the classic symptoms of dysphagia to solids and liquids, regurgitation, chest pain and weight loss. In a minority of patients, hiccups can develop and are felt to be a result of distal esophageal obstruction leading to stimulation of esophageal afferent vagal fibers. To our knowledge, this is the first case where hiccups preceded the development of the more typical symptoms of achalasia.

Dysphagia and Eosinophilic Infiltration of the Esophageal Muscular Layer: A Case Report

Eosinophilic gastrointestinal diseases are a group of pathological entities characterized by an eosinophilic infiltration of the gastrointestinal tract without known cause. Eosinophilic esophagitis (EE) is one of these conditions, which has three diagnostic criteria: symptoms of esophageal dysfunction, mucosal infiltration of 15 eosinophils per high-power field (HPF) microscope and no response to high-dose proton pump inhibitors (PPIs). A 51-year-old patient attended to the emergency department claiming to suffer from heartburn, dysphagia, regurgitation and chest pain. He was treated with high doses of PPIs without success and the condition progressed to food impaction. An esophagogram, which showed esophageal motor dysfunction in the middle and lower part of the esophagus, was performed, and pathologic examination of an esophageal biopsy taken by endoscopy revealed histopathological changes suggestive of gastroesophageal reflux disease. An esophageal manometry was carried out and it reported diffuse esophageal spasms and a hypertensive inferior esophageal sphincter with incomplete relaxation. A Heller cardiomyotomy was performed and the biopsy specimen revealed fibrosis and eosinophilic infiltration of the muscular layer. Symptoms ceased for 6 months after which symptoms reappeared. The patient was diagnosed with EE and treated with budesonide orally 12 mg/day with complete remission of all symptoms. In this peculiar case, the eosinophilic infiltration was in the muscular layer of the esophagus, not in the mucosa; therefore, it did not meet the diagnostic criteria of EE nor its differential diagnoses. Nevertheless, treatment with oral steroids was in fact effective. J Med Cases. 2014;5(12):621-626 doi: http://dx.doi.org/10.14740/jmc1942w

Systemic and metabolic effects of PDE5-inhibitor drugs

Phosphodiesterase type-5 inhibitor (PDE5-i) drugs were first marketed in 1998 (sildenafil) for 'ondemand' treatment of male erectile dysfunction (ED) of any origin. They selectively inhibit intrapenile PDE5 isoenzyme which in turn increases intracellular cyclic guanosine monophosphate levels, thus resulting in prolonged relaxation of cavernosum smooth muscle cells and facilitating the erectile process. Since 2003, two new molecules (tadalafil and vardenafil) have been introduced, resulting in greater interest in these compounds and leading patients to ask for more prescriptions from their doctors. The vast use of PDE5-i in diabetic and cardiovascular ED patients led researchers to investigate their possible extra sexual effects. Several studies investigating their effects on endothelium, coronary and pulmonary circulation, inferior oesophageal sphincter and kidney functions have appeared and, finally, sildenafil was approved for the treatment of pulmonary arterial hypertension. Recent animal studies highlighted a possible interaction between chronic PDE5 inhibition and glucose homeostasis which occurs through a marked improvement of high fat diet induced insulin resistance. If this data is extended to humans, a new scenario will be opened for the chronic use of PDE5-i for sexual rehabilitation along with cardiovascular and metabolic benefits.

Esophageal manometry in 28 systemic sclerosis Brazilian patients: findings and correlations

Systemic sclerosis (SSc) is a multisystem disease of unknown etiology. Esophageal involvement affects 50-90% of patients and is characterized by abnormal motility and hypotonic lower esophageal sphincter. Data on the association of esophageal abnormalities and age, gender, SSc subset or duration, autoantibody profile, esophageal symptoms, and medication are lacking or conflicting. The aim of this study was the evaluation of these associations in Brazilian sclerodermic patients from the Rheumatology Division, Clinics Hospital, Federal University, Minas Gerais. They underwent medical records review, clinical interview, and esophageal manometry. The normal cutoff level for lower esophageal sphincter pressure was 14 mmHg. Abnormal peristalsis occurred when less than 80% of peristaltic waves were propagated. P-values less than 0.05 were considered significant. Twenty-eight patients were included: 71% were women. The population presented medium age and disease duration of 46 years and 12 years, respectively. Cutaneous diffuse SSc occurred in 39% and its limited form in 61%. Dysphagia, pyrosis, and regurgitation occurred, respectively, in 71%, 43%, and 61% of patients. Lower esophageal sphincter pressure and number of peristaltic waves-propagated medias were, respectively, 17.2 mmHg and 2.3. SSc-related manometric abnormalities were present in 86% of patients. Manometry revealed distal esophageal body hypomotility, hypotonic lower esophageal sphincter, or both, respectively, in 82%, 39%, and 36% of patients. One patient presented the manometric pattern of esophageal achalasia. Male patients more frequently presented hypotonic inferior esophageal sphincter. Manometric findings have had no relationship with the other variables. Nifedipine use did not influence manometric findings.

Achalasie oder Pseudoachalasie? Fallstricke der Diagnostik und Therapieentscheidung

Patient 1 (female, aged 55 years) had for some time complained of morning nausea. She reported symptoms of reflux with regurgitation of food for two-and-a-half years and also dysphagia with retrosternal bolus obstruction for the last eighteen months. Patient 2 (male, aged 84 years) complained of restrosternal dysphagia with each intake of food for one year, weight loss of 12 kg and occasional regurgitation of food. The general condition of patient 1 was only slightly impaired but that of patient 2 markedly reduced. Routine laboratory tests were unremarkable in both. Barium meal in patient 1 revealed fixed narrowing in the region of the esophageal hiatus. The inferior esophageal sphincter was closed but opened under pressure during esophagogastroscopy. At computed tomography (CT) of the thorax and abdomen an esophageal fistula was detected and bronchoscopy confirmed its opening into the esophagus. Barium meal in patient 2 (done at another hospital) demonstrated a spastic esophagus. Manometry of the esophagus revealed at rest an abnormal increase in the inferior esophageal sphincter without relaxation. Patient 1 had an achalasia and an esophagogastric fistula with recurrent aspiration pneumonia, bronchial carcinoma being excluded. The fistula was closed by suture, followed by cardiomyotomy and anterior partial gastric fundectomy. In patient 2 an isolated achalasia had at first been suspected and botulinum toxin injected into the inferior esophageal sphincter. This caused a progressively worse dysphagia. CT of the thorax and abdomen established the diagnosis of a pseudoachalasia due to an adenoma of the cardia, proven by biopsy at an exploratory laparotomy. A stent was implanted in the esophagus: the postoperative course was without complication. Patient 2 with the pseudoachalasia had a relatively short history of dysphagia, marked weight loss and was elderly. This compares with the history in patient 1: shorter period of dysphagia, no weight loss and a younger age. The differential diagnosis between the two conditions may be difficult with routine methods and other imaging modalities: exploratory surgery may be necessary for a definitive diagnosis.

Severe dysphagia after laparoscopic fundoplication: Usefulness of barium meal examination to identify causes other than tight fundoplication—a prospective study

Background. The aim of this study was to determine the results of a barium meal examination after laparoscopic wrap in symptomatic patients (SPs) with no upper endoscopic anomalies and no increase in inferior esophageal sphincter pressure (SPs). Radiologic results were compared with results from patients with no symptoms (ASPs) and were compared with the surgical findings in patients who underwent reoperation. Methods. Twenty SPs were included 27 ± 6 months after a total wrap (n = 13 Nissen procedures) or a posterior wrap (n = 7 Toupet procedures) performed in several hospitals in Haute Normandie. All patients had severe symptomatic dysphagia with epigastric pain (n = 18 patients) and/or marked weight loss (n = 16 patients). Control subjects were 31 consecutive ASPs within our center who were prospectively included 4 ± 1 months after a Nissen (n = 6 patients) or a Toupet (n = 25 patients) procedure. A barium meal examination was performed in all patients and interpreted by 3 independent observers who knew that the patients had undergone a wrap but who did not know whether the patients had symptoms.Fifteen of the 20 SPs underwent a second operation. Results. Barium meal examination was more often abnormal in SPs than in ASPs (17/20 vs 4/31 patients; P <.001), whichever the type of wrap. Two abnormal radiologic results were observed in both groups: an esophageal barium level and an esogastric plication. Only a high barium level in the esophagus was more frequently observed in SPs than in ASPs (P <.05). Three radiologic results were specifically observed in SPs: a long cardial narrowing beginning above the wrap, a mediogastric plication, and a gastric volvulus. A comparison of radiologic anomalies and surgical findings showed that (1) a radiologic long cardial narrowing was explained by fibrotic stenosis of the muscular esophageal hiatus (n = 6 patients), (2) a mediogastric plication (n = 4 patients) was due to gastric volvulus (n = 3 patient) or to gastric wrap (n = 1 patient), and (3) results of volvulus (n = 5 patients) indicated a gastric volvulus. Additional surgical procedures resulted in the disappearance of symptoms in 13 of 15 patients. Conclusions. After laparoscopic fundoplication when upper endoscopy and esophageal manometry are normal, results of a barium meal examination can explain the cause of dysphagia in almost all patients. Three radiologic results were specific for SPs and indicated major morphologic disturbances that could not be treated by endoscopic dilation but that could be treated by additional surgical procedures. (Surgery 2000;128:392–8.)

Digital Radiography in the Evaluation of Oesophageal Motility Disorders

AIMS: To develop a simple technique for examination of the oesophagus by digital radiography and to assess its role in the evaluation of motility disorders of the oesophagus.MATERIALS AND METHODS: Forty-nine patients and 44 control subjects underwent manometry and digital examination of the oesophagus. The digital study consisted of two parts: firstly examination of the pharynx and cervical oesophagus using 15ml of fluid barium in anterio-posterior (AP) and lateral views, with image acquisition of four frames/s for 2s. Secondly, examination of the thoracic oesophagus and oesophagogastric junction using 25ml of barium in two prone oblique and one supine AP series, with image acquisition of one frame/s for 20s. Oesophageal transit time (OTT) was measured in each case. Abnormal or non-peristaltic contractions were described regarding their morphology, time of visualization and length. The presence or absence of hiatal hernia, reflux or any associated organic lesions was noted.RESULTS: Digital radiography diagnosed 14 cases of achalasia and 28 cases of non-specific oesophageal motility disorder (NOMD). Normal OTT was 11.95±1.304s. The OTT was prolonged (16s or more) in all patients except five; four of these were cases of NOMD. Abnormal contractions were classified into circular and longitudinal types. The circular non-obliterating type was commoner. Achalasia was diagnosed in all cases, as failure of relaxation of the inferior oesophageal sphincter was always present and easily depicted by digital radiography. Abnormal contractions in the body of the oesophagus were elicited in 57% of cases of achalasia. The sensitivity of digital radiography in detecting oesophageal motility disorders was 85.7% based on the presence of abnormal contractions and 91.6% by eliciting a prolonged OTT.CONCLUSIONS: Examination of the oesophagus by digital radiography is simple, non-invasive, reproducible, rapid and without discomfort to patients. It allows the diagnosis of motility disorders of the oesophagus by detecting abnormal contractions and/or prolonged OTT and showed any associated organic lesions.Aly, Y. A. (2000). Clinical Radiology55, 561–568.

Normal oesophageal transit time on digital radiography

OBJECTIVE: To develop a simple radiological technique for measuring normal oesophageal transit time. DESIGN: 72 patients with no oesophageal or gastrointestinal complaints underwent manometry and radiological oesophageal transit time (ROTT). ROTT was perfomed using 2 ml of fluid barium on a digital X-ray machine. Digital image acquisition started with the beginning of swallowing using 1 frame/s for 15 s. These images were printed on a single film. The effect of ageing on ROTT was also assessed. RESULTS: ROTT had a mean value of 10.08 s. ROTT was divided into three segments: proximal-to-left-main-bronchus; retrocardiac; and inferior oesophageal sphincter segments. The mean transit time across these segments was 2.84, 3.07, and 4.15 s, respectively. ROTT in patients over 40 years was longer than in patients under 40 years. CONCLUSION: ROTT is a physiological, rapid, non-invasive, and reproducible technique for measuring the normal oesophageal transsit time, without discomfort to patients.

Radiological and manometrical investigation of the inferior esophageal sphincter. Experimental research: A. Marte, R. Ferrari, V. Steola and G. Amici. Osp Ital Pediatr 15:633, 1980

Radiological and manometrical investigation of the inferior esophageal sphincter. Experimental research: A. Marte, R. Ferrari, V. Steola and G. Amici. Osp Ital Pediatr 15:633, 1980

Gastro-oesophageal reflux, hiatus hernia and the radiologist, with special reference to children

Gastro-oesophageal reflux can lead to peptic oesophagitis and stricture formation. This is particularly true in infants in whom the condition should be suspected if the patient presents with vomiting, anaemia and failure to thrive. The anatomy of the oesophago-gastric junction is described. The inferior oesophageal sphincter is the main barrier to reflux, and marks the functional junction between oesophagus and stomach. It is under nervous and hormonal control. It is weak in the neonate who therefore frequently refluxes. An hiatus hernia can cause problems due to its bulk but the main problem of peptic oesophagitis is due to gastro-oesophageal reflux. The radiological examination should be carried out carefully with the patient swallowing in a prone position. The patient should be put in the Trendenlenberg position and compression applied to the abdomen. Reflux is intermittent and a negative examination should be repeated if the clinical findings suggest a diagnosis of peptic oesophagitis. Associated pyloric stenosis should always be excluded. Radiological examination of the gastro-oesophageal junction remains the quickest, simplest, and most convenient and safe technique as long as its limitations are appreciated.

ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULA

Esophageal atresia should be diagnosed by lack of success in passing a tube from mouth to stomach soon after birth. Chest and abdominal radiographs are necessary to determine the presence of pneumonia, tracheoesophageal fistula, and coexisting anomalies which affect the treatment and prognosis. A review of 228 children with esophageal atresia, or tracheoesophageal fistula, or both seen at The Hospital for Sick Children in a 10 year period showed 83 per cent of them to have atresia with distal fistula, 10 per cent to have atresia without fistula, six per cent to have H fistulas, and less than one per cent to have proximal fistulas. Coexisting anomalies and prematurity were important in determining the prognosis. A remarkable 26 per cent of patients with atresia alone also had Down's syndrome. Patients with repaired esophageal atresia often have a characteristic cough and recurrent respiratory infections. They have a narrow and collapsible trachea which may be lined with squamous epithelium. There is a typical esophageal motility pattern in patients with repaired atresia. Peristalsis starts normally in the proximal esophagus but stops a short distance above the site of anastomosis. Contraction of the distal esophagus may be peristaltic or static and may or may not be accompanied by relaxation of the inferior esophageal sphincter. Intraluminal pressure studies may be helpful in clarifying distorted motility.

Upper gastrointestinal disease in rheumatoid arthritis.

Upper gastrointestinal series were done in 140 consecutive patients with rheumatoid arthritis, irrespective of the presence or absence of symptoms suggesting upper gastrointestinal disease. In addition, intraluminal pH and manometric studies of the esophagus and esophagoscopy were done in 66 of these 140 patients. Gastric ulcers were found in 12 patients, and duodenal ulcers in 27, an incidence of peptic ulcer disease of 27.8%. The higher incidence of ulcer disease was found in patients on corticoid and in combination with indomethacin or phenylbutazone. No ulcer occurred in patients receiving gold therapy. Of the 66 patients who had esophageal motility study, a significantly lower mean amplitude of peristaltic contractions was noted in the lower two-thirds of the esophagus. The resting pressure in the inferior esophageal sphincter was also significantly lower than in the control group. However, no correlation was found between these two parameters and the duration or ARA stages of rheumatoid arthritis. It is impossible to determine whether the upper gastrointestinal dysfunction observed in these patients is another systemic manifestation of the rheumatoid disease or due to drugs.

Correlation of manometric and endoscopic data from the esophagogastric area

In 9 patients the inferior esophageal sphincter was identified manometrically and simultaneously by direct vision at endoscopy. It was related to the squamocolumnar junction which was identified visually. The average length of the sphincter was 1.6cm and it was proximal to the hiatus and squamocolumnar junction in all but 1 of the patients. The method described makes it possible to study the closing mechanism of the distal esophagus in vivo.

Fundoplication for gastroesophageal reflux. Indications, surgical technique, and manometric results.

Fundoplication (Nissen operation) was employed in 27 patients with hypotension of the inferior esophageal sphincter. In 17 there was an esophageal hiatal hernia; in six patients gastroesophageal reflux followed operative or manipulative procedures on the esophagogastric junction. No anatomic abnormality was detected in three patients, and in one the sphincter had been rendered nonfunctional by slceroderma. Eighty-nine percent of the patients were improved by operation, the results being better in those without shortening of the esophagus or stricture formation or both. Only one patient complained of the gas bloat syndrome. Preoperative and postoperative esophageal manometry revealed statistically significant ( P

Intraluminal pressure, transmucosal potential difference, and pH studies in the oesophagus of patients before and after Collis repair of a hiatal hernia.

Intraluminal pressure, transmucosal potential difference, and endo-oesophageal pH measurements were studied in patients with hiatal hernia—before and after a hiatal repair. The operation employed is the Collis (1968) repair for uncomplicated hiatal hernia and does not refer to gastroplasty as recommended for peptic stricture (Collis, 1961). Postoperative studies show that the repair approximates the inferior oesophageal sphincter to the hiatus with the production of a single band of raised pressure at the lower end of the oesophagus. This band is similar to that seen in normal subjects and its appearance was associated with cure of the symptoms, abolition of the gastro-oesophageal reflux, and improvement in the function of the inferior oesophageal sphincter and the musculature of the body of the oesophagus. Certain physiological implications of this study are discussed.

The diaphragm as an anti-reflux barrier. A monometric, oesophagoscopic, and transmucosal potential study.

An infusion technique was used to measure pressures at the lower end of the oesophagus in normal patients and in those with hiatus hernia. These studies show a band of raised pressure at the lower end of the oesophagus in normal patients. This band was abnormally long in the majority of patients with hiatus hernia, but in others it resolved into two bands, particularly in patients with hiatus hernia and a short oesophagus. When the distance between these two bands was compared with the length of the oesophagogastric junction above the hiatus radiologically and at oesophagoscopy, a significant correlation was found. It, therefore, is postulated that one of these bands is produced by the inferior oesophageal sphincter and the other by the diaphragm, and thus it is demonstrated that the diaphragm must be included among the factors controlling reflux.