Intrabolus Pressures Research Articles

Esophageal Bolus Domain Pressure and Peristalsis Associated With Experimental Induction of Esophagogastric Junction Outflow Obstruction.

Background/AimsIntrabolus pressures are important for esophageal bolus transport and may detect obstructed bolus flow. This study measured the effect esophageal outflow obstruction experimentally induce by a leg-lift protocol.MethodsTwenty-five gastroesophageal reflux disease patients referred for esophageal manometry and a normal motility diagnosis were included. Supine liquid swallows were tested. Leg-lift protocol generated esophageal outflow obstruction by increasing abdominal pressure. Esophageal pressure topography and intrabolus pressure metrics were calculated. These included, (1) mid-domain bolus distension pressure during esophageal emptying (DPE, mmHg) and (2) ramp pressure (mmHg/sec), generated by compression of the bolus between the peristaltic contraction and esophagogastric junction (EGJ).ResultsEGJ relaxation pressure was increased by leg-lift from 13 (11-17) to 19 (14-30) mmHg (P < 0.005) and distal contractile integral also increased from 1077 (883-1349) to 1620 (1268-2072) mmHg∙cm∙sec (P < 0.001) as a physiological response to obstruction. All bolus pressures were increased by leg lift; DPE increased from 17 (15-20) to 27 (19-32) mmHg (P < 0.001), and ramp pressure increased from 3 (1-4) to 5 (2-9) mmHg/sec (P < 0.05).ConclusionMeasuring pressures within the intrabolus domain can quantify changes related to obstruction to outflow and may serve as adjunct measures for confirming a diagnosis EGJ outflow obstruction.

High-Resolution Pharyngeal Manometry and Impedance: Protocols and Metrics-Recommendations of a High-Resolution Pharyngeal Manometry International Working Group.

High-resolution manometry has traditionally been utilized in gastroenterology diagnostic clinical and research applications. Recently, it is also finding new and important applications in speech pathology and laryngology practices. A High-Resolution Pharyngeal Manometry International Working Group was formed as a grass roots effort to establish a consensus on methodology, protocol, and outcome metrics for high-resolution pharyngeal manometry (HRPM) with consideration of impedance as an adjunct modality. The Working Group undertook three tasks (1) survey what experts were currently doing in their clinical and/or research practice; (2) perform a review of the literature underpinning the value of particular HRPM metrics for understanding swallowing physiology and pathophysiology; and (3) establish a core outcomes set of HRPM metrics via a Delphi consensus process. Expert survey results were used to create a recommended HRPM protocol addressing system configuration, catheter insertion, and bolus administration. Ninety two articles were included in the final literature review resulting in categorization of 22 HRPM-impedance metrics into three classes: pharyngeal lumen occlusive pressures, hypopharyngeal intrabolus pressures, and upper esophageal sphincter (UES) function. A stable Delphi consensus was achieved for 8 HRPM-Impedance metrics: pharyngeal contractile integral (CI), velopharyngeal CI, hypopharyngeal CI, hypopharyngeal pressure at nadir impedance, UES integrated relaxation pressure, relaxation time, and maximum admittance. While some important unanswered questions remain, our work represents the first step in standardization of high-resolution pharyngeal manometry acquisition, measurement, and reporting. This could potentially inform future proposals for an HRPM-based classification system specifically for pharyngeal swallowing disorders.

Systematic Review of Pharyngeal and Esophageal Manometry in Healthy or Dysphagic Older Persons (>60 years).

We undertook a systematic review of swallowing biomechanics, as assessed using pharyngeal and esophageal manometry in healthy or dysphagic older individuals aged over 60 years of age, comparing findings to studies of younger participants. PRISMA-P methodology was used to identify, select, and evaluate eligible studies. Across studies, older participants had lower upper esophageal sphincter (UES) resting pressures and evidence of decreased UES relaxation when compared to younger groups. Intrabolus pressures (IBP) above the UES were increased, demonstrating flow resistance at the UES. Pharyngeal contractility was increased and prolonged in some studies, which may be considered as an attempt to compensate for UES flow resistance. Esophageal studies show evidence of reduced contractile amplitudes in the distal esophagus, and an increased frequency of failed peristaltic events, in concert with reduced lower esophageal sphincter relaxation, in the oldest subjects. Major motility disorders occurred in similar proportions in older and young patients in most clinical studies, but some studies show increases in achalasia or spastic motility in older dysphagia and noncardiac chest pain patients. Overall, study qualities were moderate with a low likelihood of bias. There were few clinical studies specifically focused on swallowing outcomes in older patient groups and more such studies are needed.

Effects of remifentanil on esophageal and esophagogastric junction (EGJ) bolus transit in healthy volunteers using novel pressure-flow analysis.

Remifentanil is associated with subjective dysphagia and an objective increase in aspiration risk. Studies of opioid effects have shown decreased lower esophageal sphincter relaxation. We assessed bolus transit through the esophagus and esophagogastric junction (EGJ) during remifentanil administration using objective pressure-flow analysis. Data from 11 healthy young participants (23±3years, 7M) were assessed for bolus flow through the esophagus and EGJ using high-resolution impedance manometry (Manoscan™, Sierra Scientific Instruments, Inc., LES Angeles, CA, USA) with 36 pressure and 18 impedance segments. Data were analyzed for esophageal pressure topography and pressure-flow analysis using custom Matlab analyses (Mathworks, Natick, USA). Paired t tests were performed with a P-value of <.05 regarded as significant. Duration of bolus flow through (remifentanil/R 3.0±0.3 vs baseline/B 5.0±0.4seconds; P<.001) and presence at the EGJ (R 5.1±0.5 vs B 7.1±0.5seconds; P=.001) both decreased during remifentanil administration. Distal latency (R 5.2±0.4 vs B 7.5±0.2seconds; P<.001) and distal esophageal distension-contraction latency (R 3.5±0.1 vs B 4.7±0.2seconds; P<.001) were both reduced. Intrabolus pressures were increased in both the proximal (R 5.3±0.9 vs B 2.6±1.3mmHg; P=.01) and distal esophagus (R 8.6±1.7 vs B 3.1±0.8mmHg; P=.001). There was no evidence of increased esophageal bolus residue. Remifentanil-induced effects were different for proximal and distal esophagus, with a reduced time for trans-sphincteric bolus flow at the EGJ, suggestive of central and peripheral μ-opioid agonism. There were no functional consequences in healthy subjects.

Modulation of Upper Esophageal Sphincter (UES) Relaxation and Opening During Volume Swallowing.

UES opening occurs following cricopharyngeus deactivation and submental muscle contraction causing hyolaryngeal elevation and UES distraction. During impedance manometry, the inverse of impedance (admittance) can be used to measure bolus presence and infer UES opening. We hypothesized that the temporal relationship between UES relaxation, opening and hyolaryngeal elevation would change with increasing bolus volume. Simultaneous intramuscular cricopharyngeal (CP) electromyography (EMG), surface submental EMG (SM-EMG), and high-resolution impedance manometry were recorded in eight (aged 27±7years, 5M) healthy volunteers, while swallowing 0.9% saline boluses of 2, 5, 10, and 20ml. Data were exported and analyzed via Matlab. Statistical analysis comprised repeated measures one-way ANOVA and Pearson correlation. A P value of <0.05 was considered significant. Duration of CP deactivation increased at 20ml volume (P<0.001). UES relaxation and opening increased with increasing bolus volume (P<0.001); however, overall duration of SM activation did not change. As UES opening occurs progressively earlier with increasing volumes, peak SM-EMG activity occurs relatively later (P<0.001) and shifts from occurring before to following peak UES distention. During healthy swallowing, there is sensory modulation of cricopharyngeal and submental muscle activity. Intrabolus pressures, transmitted from the tongue base and pharynx, play a progressively more important role in sphincter opening with increasing volume. The findings may explain why some healthy elderly and patients with oropharyngeal dysphagia have difficulty swallowing larger while tolerating smaller bolus volumes.

Pressure-Flow Analysis for the Assessment of Pediatric Oropharyngeal Dysphagia

To determine which objective pressure-impedance measures of pharyngeal swallowing function correlated with clinically assessed severity of oropharyngeal dysphagia (OPD) symptoms. Forty-five children with OPD and 34 control children without OPD were recruited and up to 5 liquid bolus swallows were recorded with a solid-state high-resolution manometry with impedance catheter. Individual measures of pharyngeal and upper esophageal sphincter (UES) function and a swallow risk index composite score were derived for each swallow, and averaged data for patients with OPD were compared with those of control children without OPD. Clinical severity of OPD symptoms and oral feeding competency was based on the validated Dysphagia Disorders Survey and Functional Oral Intake Scale. Those objective measures that were markers of UES relaxation, UES opening, and pharyngeal flow resistance differentiated patients with and without OPD symptoms. Patients demonstrating abnormally high pharyngeal intrabolus pressures and high UES resistance, markers of outflow obstruction, were most likely to have signs and symptoms of overt Dysphagia Disorders Survey (OR 9.24, P = .05, and 9.7, P = .016, respectively). Pharyngeal motor patterns can be recorded in children by the use of HRIM and pharyngeal function can be defined objectively with the use of pressure-impedance measures. Objective measurements suggest that pharyngeal dysfunction is common in children with clinical signs of OPD. A key finding of this study was evidence of markers of restricted UES opening.

Pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography-a normative study of younger and older adults.

We aimed to define normative values for novel pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography. The effects of age, gender, and bolus properties were examined. Concurrent high-resolution manometry (HRM) and videofluoroscopy data were collected from 22 younger (aged 21-40) and 22 older (aged 60-80) healthy subjects. Pressure topography was analyzed by correlating pressure domains with videofluoroscopic events. Nine pressure topography metrics of the pharyngeal and proximal esophageal swallow were extracted; four of these were also compared with previously obtained esophageal HRM studies to assess the effects of catheter diameter. Older individuals exhibited more vigorous contractility in the pharynx than did younger subjects with all bolus types, but the greatest values for both groups were with effortful swallow and on that measure the age groups were similar. Upper esophageal sphincter (UES) intrabolus pressure during sphincter opening was also greater in the older subjects. Some gender differences were observed, particularly related to proximal esophageal contractile vigor. Bolus consistency had no consistent effect. Studies using the larger catheter diameter resulted in significantly greater contractile vigor in the UES and proximal esophagus. Older adults exhibited more vigorous pharyngeal contractions than young adults, albeit within a similar range of capacity, perhaps reflecting a compensatory response to other age-related physiological changes. Greater UES intrabolus pressures observed during bolus transit in the older group likely reflect reduced UES compliance with age. Normative data on novel HRM metrics collected in this study can serve as a reference for future clinical studies.

Functional and Anatomic Esophagogastic Junction Outflow Obstruction: Manometry, Timed Barium Esophagram Findings, and Treatment Outcomes.

Little is known about the clinical features, radiology and manometry findings, and treatment outcomes of patients with functional and mechanical esophagogastic junction outflow obstruction (EGJOO). Between November 2011 and February 2015, a total of 1443 high-resolution manometries were reviewed and 49 patients (3.4%) met the manometric criteria for EGJOO. Then, we performed a retrospective chart review, collecting data from manometric studies, timed barium esophagram findings (TBEs), endoscopic reports, and clinical records. Twenty-seven patients had functional EGJOO and 22 patients had an anatomic esophageal obstruction. Common causes of anatomic EGJOO included strictures (36% of patients) and hiatal hernias (31% of patients). There were no differences between groups in manometric or radiographic metrics. Each group had increased basal lower esophageal sphincter and intrabolus pressures, compared with individuals without EGJOO, and most patients had abnormal findings on TBE analysis. Two patients with functional EGJOO progressed to type 3 achalasia. We conclude that patients diagnosed with EGJOO based on manometry findings can have anatomic obstruction or functional EGJOO; high-resolution manometry and TBE do not distinguish between disease causes.

Tu1454 Inter-Rater Agreement for Analysis of Pharyngeal High Resolution Manometry Parameters

Introduction: Pharyngeal manometry using high resolution technology is a developing field that is being advocated for evaluation of dysphagic symptoms that are not explained by a conclusive or objective finding on routine evaluation such as radiography. Fundamental to the success of this approach, automated analysis techniques not withstanding, is the reliability and reproducibility of the measurements performed by the clinicians. Our aim was to determine the inter-rater reliability for measurements of deglutitive pharyngeal peristaltic pressure wave characteristics such as peak peristaltic amplitude, pharyngeal contractile integral (PCI), nadir upper esophageal sphincter (UES) deglutitive pressure and intrabolus pressure (IBP). Methods: We studied 11 healthy individuals (age 56±25 years, 6F) by high resolution manometry using a catheter with 36 recording sites spaced at 1 cm intervals that recorded from the entire pharyngeal contractile zone, UES and proximal esophagus. Each volunteer swallowed 0.5 ml of room temperature water 40 times with 20 seconds intervals between swallows. Three raters (one seasoned, two with recent training) each independently analyzed a total of 3080 pressure signatures, 440 pharyngeal contractile integrals and 440 intra-bolus pressures. Measured parameters included peak peristaltic wave pressures at specific manometric locations 2, 3, 4, 5, 6, 7, and 8 cm above the upper margin of the UES high pressure zone, as well as PCI, nadir UES deglutitive pressure and IBP. Inter-rater agreement was evaluated using Bland-Altman intra-class correlation coefficient (ICC) analysis. Results: As seen in the table, agreement among the three raters all for all manometric locations was highly significant (p<0.001) with sites p2 and p3 (2 and 3cm above the upper margin of the UES) having the lowest levels of agreement. Furthermore, metrics with a single value for each swallow like PCI and UES nadir pressure also showed highly significant agreement whereas IBP measurements did not. A graphical depiction of intra-rater agreement is shown in the figure for PCI as a representative parameter. Conclusion: Analysis of pharyngeal pressure parameters by individuals with proper training is reproducible as evidenced by high level of agreement between the results obtained independently by three different raters. Supported in part by EOPH grant and PPG. Supported in part by R01DK025731 and P01DK068051

Oesophageal function assessed by high-resolution manometry in patients with diabetes and inadequate glycaemic control.

To describe oesophageal function in people with diabetes and poor glycaemic control using oesophageal high-resolution manometry and to compare the result between control subjects and patients with gastro-oesophageal reflux disease. The results of oesophageal high-resolution manometry and a gastric emptying test were reviewed in 20 patients with diabetes. The high-resolution manometry protocol consisted of 5-ml swallows of water and multiple swallows of water. Oesophageal motility disorders were classified according to the Chicago classification system. The occurence of multiphasic contractions and intragastric and intrabolus pressures were measured. High-resolution manometry results were compared between 10 control subjects and 20 patients with gastro-oesophageal reflux disease. Data were expressed as medians and compared using Mann-Whitney and chi-squared tests. Oesophageal motility disorders were similarly distributed between the groups. Multiphasic contractions occurred more frequently in patients with diabetes than in those with gastro-oesophageal reflux disease (60 vs 20% per patient; P<0.01) and were not observed in control subjects. Gastric emptying was delayed in six patients with diabetes and did not correlate with symptoms or oesophageal motility disorders. Intrabolus pressure was higher in patients with diabetes and gastroparesis than in those without (17 vs 10 mmHg; P=0.02) and correlated with intragastric pressure (r=0.46, P<0.01). During multiple swallows of water, oesophageal contractile activity was incompletely inhibited in 83% of patients with diabetes and gastroparesis vs 9% without (P<0.01). Oesophageal function and gastric emptying were not influenced by fasting glycaemia. Patients with gastroparesis might present with impaired inhibition of contractile activity during multiple swallows of water. Increased intrabolus pressure is suggestive of delayed oesophageal clearance as a consequence of gastroparesis.

339 Nadir UES Relaxation and Hypopharyngeal Intra Bolus Pressures Are More Sensitive to Consistency and Viscosity Challenge Than Pharyngeal Peristalsis Parameters Measured by High Resolution Manometry

339 Nadir UES Relaxation and Hypopharyngeal Intra Bolus Pressures Are More Sensitive to Consistency and Viscosity Challenge Than Pharyngeal Peristalsis Parameters Measured by High Resolution Manometry

Mo1719 The Clinical Spectrum of Esophagogastric Junction Outflow Obstruction Identified via High Resolution Manometry

Introduction: The identification of esophagogastric junction (EGJ) outflow obstruction via high resolution manometry (HRM) is increasingly common and of unclear clinical significance. The objective of this study was to review the HRM characteristics of EGJ outflow obstruction and to assess how this diagnosis translates into clinical practice. Methods: A retrospective review was conducted of 1105 symptomatic patients who underwent HRM between 9/09 and 8/12. EGJ outflow obstruction was defined as an elevated 4 second lower esophageal sphincter integrated relaxation pressure (IRP). Patients with elevated IRP were divided into 3 groups: achalasia, mechanical obstruction (large hiatal hernia, postoperative and neoplasia) and functional obstruction (no obvious underlying cause). Clinical and demographic data, presenting symptoms, upper endoscopic findings, treatment and posttreatment outcomes were compared among the groups. Results: Of the 1105 patients studied, 237 (21%) had an elevated IRP. Sixty four percent were female with a mean age of 56.8±15.4 years. Mechanical causes of obstruction were most common (100/237, 42%) including postoperative in 50, large hiatal hernia in 48 and esophageal cancer in 2. Achalasia was present in 75 patients (32%). The remaining 62 (26%) had an elevated IRP without evidence of mechanical obstruction. Dysphagia was the primary presenting symptom in 85% of patients in the achalasia group, 31% of the mechanical group and 13% of the functional group (p,0.009). Interestingly, upper respiratory symptoms were significantly more common in patients with functional outflow obstruction (26% vs. 1% achalasia and 4% mechanical, p,0.001). The mean IRP also varied amongst the clinical groups, highest in achalasia 31.0±11.7mmHg, intermediate in mechanical obstruction (23.5 ±8.6 mmHg) and lowest in the functional group (18.7±3.8 mmHg) p,0.001. A similar pattern was seen in the mean intra-bolus pressures 28.6±15.0 mmHg, 20.1±7.4 mmHg and 14.9±4.0 mmHg, respectively. Nearly 40% (22/57) of the patents with functional outflow obstruction parameters were pH positive suggesting GE barrier failure despite the manometric findings. Fundoplication was performed in 9 of these 22 patients (41%) with good response. Five of the remaining functional patients underwent treatment; myotomy in one and Botox in 4. Conclusions: The predominant etiologies of EGJ outflow obstruction are mechanical obstruction and achalasia. Mechanical causes should be excluded before functional outflow obstruction is diagnosed and treated. HRM parameters of functional outflow obstruction may be present in a subset of patients with pH positive GERD. The ideal management of patients with symptomatic functional obstruction remains unclear.

Impact of a Laryngectomy and Surgical Closure Technique on Swallow Biomechanics and Dysphagia Severity

The incidence of self-reported dysphagia following a laryngectomy is high (72%). The impact, if any, of a surgical closure technique on swallowing biomechanics and dysphagia severity is not known. To date, there is no recommended standard procedure for pharyngeal reconstruction during laryngectomy surgery. The aim of this study was to determine how laryngectomy surgery alters swallowing biomechanics, pharyngeal peak deglutitive pressure, and hypopharyngeal intrabolus pressures and whether these changes in pressure correlate with specific surgical closure after total laryngectomy or with dysphagia severity. Combined videoradiography and manometry was used to measure peak mid-pharyngeal, tongue, and intrabolus pressures; anatomical derangements; postswallow residue; and pharyngeal dimensions. Radiology Department, St George Hospital, Sydney, Australia. Twenty-four patients following total laryngectomy surgery and age-matched control data. When compared to controls, peak mid-pharyngeal pressures were significantly reduced in laryngectomy patients (P < .001). Hypopharyngeal intrabolus pressures were significantly higher in patients when compared to controls (P < .001). Patients who had undergone mucosa-and-muscle pharyngeal reconstruction had higher peak mid-pharyngeal pressures compared to those who had mucosa-alone closure (P ≤ .04). Combined mucosa-and-muscle closure was also associated with reduced postswallow residue, indicative of a more efficient swallow. Following laryngectomy surgery, pharyngeal pro-pulsive contractile forces are impaired, and there is increased resistance to bolus flow across the pharyngoesophageal segment. These adverse biomechanical effects can be influenced by surgical techniques, providing surgeons with evidence for optimum pharyngeal closure following a laryngectomy to improve swallowing outcomes.

30 ESOPHAGEAL DYSMOTILITY IN EOSINOPHILIC ESOPHAGITIS: ANALYSIS USING HIGH-RESOLUTION ESOPHAGEAL MANOMETRY.

<h3>Background</h3> Eosinophilic esophagitis (EE) is an increasingly recognized cause of dysphagia and food impaction. In many cases, strictures are not apparent on endoscopy, raising questions as to the mechanism of impaired deglutition. Prior reports have documented eosinophilic infiltration of the muscularis propria and myenteric plexus that could induce esophageal dysmotility. <h3>Aim</h3> Characterize esophageal motor function in EE using high-resolution esophageal manometry (HRM) and newly described manometric parameters. <h3>Methods</h3> Twenty-four patients with EE were studied with a 36-channel solid-state HRM assembly and analyzed using <i>ManoView</i> software (Sierra Scientific). Analysis was based on 10 5 mL water swallows per patient. Esophageal peristalsis was quantified by distal esophageal body peristaltic point velocity and pressurization front velocity (PFV), which was the propagation rate of an intact 30 mm Hg pressure wave. In the absence of a continuous propagation wave, a swallow was classified as a null PFV. A patient was classified as null, normal, or elevated PFV based on the dominant pattern (6) of 10 swallows. Esophagogastric junction (EGJ) relaxation was quantified using the lowest mean residual pressure over a 3-second interval (E-sleeve relaxation) and integrated relaxation resistance (IRR). A higher IRR signifies impaired EGJ relaxation and consequently higher resistance to esophageal emptying. All abnormal HRM values were referenced to the 95% upper limit of normal values derived from 75 controls. <h3>Results</h3> The median patient age was 42 years (range 14-80 years). The most common presenting symptoms were dysphagia (83%) and heartburn (12.5%). Endoscopic findings included rings (50%), furrows (58%), and exudates (33%). On HRM, 14 patients (58%) had increased distal segment contraction velocity (median 8.4 cm/s), whereas 3 patients (12%) had an elevated PFV (median 4.2 cm/s). Two patients had elevated intrabolus pressures as evidenced by an elevated PFV but normally propagated peristaltic contraction. Nine patients were classified as having a null PFV and only one had significantly elevated esophageal contractile pressures (295 mm Hg). Seven patients had an elevated IRR (median 3.3 mm Hg/s), and of this group, 5 patients also had increased E-sleeve relaxation pressures (median 18 mm Hg). <h3>Conclusions</h3> (1) Manometric manifestations of EE are heterogeneous. (2) An elevation in esophageal peristaltic velocity was the most common abnormality. (3) Subsets of EE patients demonstrated failed esophageal peristalsis (null PFV) and impaired EGJ relaxation (elevated IRR). (4) Functional abnormalities on the basis of neuromuscular involvement could contribute to dysphagia in EE.

Development of A MEMS Based Manometric Catheter for Diagnosis of Functional Swallowing Disorders.

Silicon pressure sensors based on micro-electro-mechanical-systems (MEMS) technologies are gaining popularity for applications in bio-medical devices. In this study, a silicon piezo-resistive pressure sensor die is used in a feasibility study of developing a manometric catheter for functional swallowing disorders diagnosis. The function of a manometric catheter is to measure the peak and intrabolus pressures along the esophageal segment during the swallowing action. Previous manometric catheters used the water perfusion technique to measure the pressure changes. This type of catheter is reusable, large in size and the pressure reading is recorded by an external transducer. Current manometric catheters use a solid state pressure sensor on the catheter itself to measure the pressure changes. This type of catheter reduces the discomfort to the patient but it is reusable and is very expensive. We carried out several studies and experiments on the MEMS-based pressure sensor die, and the results show the MEMS-based pressure sensors have a good stability and a good linearity output response, together with the advantage of low excitation biasing voltage and extremely small size. The MEMS-based sensor is the best device to use in the new generation of manometric catheters. The concept of the new MEMS-based manometric catheter consists of a pressure sensing sensor, supporting ring, the catheter tube and a data connector. Laboratory testing shows that the new calibrated catheter is capable of measuring pressure in the range from 0 to 100mmHg and maintaining stable condition on the zero baseline setting when no pressure is applied. In-vivo tests are carried out to compare the new MEMS based catheter with the current version of catheters used in the hospital.

Manometric abnormalities and gastroesophageal reflux disease in the morbidly obese.

Obesity is an epidemic in the USA. Many disorders are associated with obesity including gastroesophageal reflux disease (GERD). However, the prevalence of GERD and esophageal motility disorders in the morbidly obese population is unclear. During evaluation for bariatric surgery, 61 morbidly obese patients underwent preoperative 24-hr pH and esophageal manometry. A single reviewer evaluated all 24-hr pH and manometric tracings. Johnson-DeMeester score >14.7 was considered diagnostic of GERD. Manometric criteria for motility disorders were from published values. All values are given as mean +/- SD. Mean age was 44.4 + 10.3 years. 55 of the patients (90%) were female. Mean BMI was 50.1 +/- 7.2 kg/m(2). 23 patients (38%) complained of GERD symptoms (reflux and/or heartburn). 1 patient (2%) complained of noncardiac chest pain. Mean Johnson-DeMeester score was 19.6 +/- 17.8. Mean intragastric and intrabolus pressures were both elevated (8.3 +/- 1.6 mmHg and 15 +/- 9 mmHg). 33 patients (54%) had abnormal manometric findings: 10 had a mechanically defective LES, 11 had a hypertensive LES, 2 had diffuse esophageal spasm, 3 had nutcracker esophagus,1 had ineffective esophageal disorder and 14 had nonspecific esophageal motility disorder. Some patients had more than one disorder. 20 patients (33%) had significantly elevated (>180 mmHg) contraction amplitudes at the most distal channel (210.0 +/- 28.7 mmHg). Prevalence of manometric abnormalities in the morbidly obese is high. Presence of a nut cracker-like distal esophagus in the morbidly obese is significant and warrants further evaluation.

The hypertensive lower esophageal sphincter: a motility disorder with manometric features of outflow obstruction.

The aim of this study was to define the clinical presentation, motility characteristics, and prevalence and patterns of gastroesophageal reflux in patients with hypertensive lower esophageal sphincter (HTLES). HTLES was defined by a resting pressure measured at the respiratory inversion point on stationary manometry of greater than 26 mm Hg (ninety-fifth percentile of normal). One hundred consecutive patients (80 women, 20 men; mean age 54.7 years, range 23 to 89 years), diagnosed with HTLES at our institution between September 1996 and October 1999, were studied. Patients with achalasia or other named esophageal motility disorders or history of foregut surgery were excluded, but patients with both HTLES and "nutcracker esophagus" were included. The most common symptoms in patients with HTLES were regurgitation (75%), heartburn (71%), dysphagia (71%), and chest pain (49%). The most common primary presenting symptoms were heartburn and dysphagia. The intrabolus pressure, which is a manometric measure of outflow obstruction, was significantly higher in patients with HTLES compared to normal volunteers. The residual pressure measured during LES relaxation induced by a water swallow was also significantly higher than in normal persons. There were no significant associations between any of the relaxation parameters studied (residual pressure, nadir pressure, duration of relaxation, time to residual pressure) and either the presence or severity of any symptoms or the presence of abnormal esophageal acid exposure. Seventy-three patients underwent 24-hour pH monitoring, and 26% had increased distal esophageal acid exposure. Compared to a cohort of patients with gastroesophageal reflux disease but no HTLES (n=300), the total and supine periods of distal esophageal acid exposure were significantly lower in the patients with HTLES and abnormal acid exposure. Patients with HTLES frequently present with moderately severe dysphagia and typical reflux symptoms. Approximately one quarter of them have abnormal esophageal acid exposure on pH monitoring. Patients with HTLES have significantly elevated intrabolus and residual relaxation pressures on liquid boluses, suggesting that outflow obstruction is present.

Current trends in management of Zenker diverticulum.

Zenker's diverticulum is a relatively common problem encountered by head and neck surgeons. Careful review of the available literature regarding its pathogenesis indicates that Zenker diverticulum likely occurs as a result of increased intrabolus pressures during swallowing secondary to cricopharyngeal spasm. Rational treatment for Zenker diverticulum therefore addresses cricopharyngeal spasm. The traditional approach to diagnosis and management of Zenker diverticulum has been based on standard techniques and principles. For example, diverticulectomy with concurrent cricopharyngeal myotomy is an acceptable form of treatment with a high success rate. However, recent advances in endoscopic stapling and carbon dioxide laser technologies have added new options to the therapeutic armament of the otolaryngologist. For appropriately selected patients, endoscopic staple-assisted diverticulostomy is a minimally invasive, safe, and effective procedure associated with shorter hospital stays, more rapid postoperative recovery, decreased time to resumption of oral intake, and high levels of patient satisfaction.

Comparison of Methods for Determining Cricopharyngeal Intrabolus Pressure in Normal Patients as Possible Indicator for Cricopharyngeal Myotomy

We sought to compare methods for determining intrabolus cricopharyngeal pressure as a possible indicator for cricopharyngeal myotomy. We determined multiple intrabolus pressures in the cricopharyngeal region of 20 normal volunteers, of whom 12 were 20 to 35 years old and 8 were older than 75 years. Data were collected using a commercially available manofluorography system and a 6-sensor unidirectional solid-state 2- x 4-mm catheter. Each subject underwent 5 5-mL and 5 10-mL liquid barium swallows. Data were analyzed, and young subjects were compared with old subjects. The mean mid-bolus pressures in young subjects were 5.2 +/- 4.9 mm Hg and 7.2 +/- 6.5 mm Hg for the 5-mL and 10-mL swallows, respectively, and in older subjects, 10.8 +/- 8.8 mm Hg and 12.3 +/- 7.4 mm Hg. The mean gradient pressures across the 3-cm cricopharyngeal region in young subjects were 2.02 +/- 5.0 mm Hg, and -0.91 +/- 4.8 mm Hg for the 5-mL and 10-mL swallows, respectively, and for older subjects, 4.38 +/- 3.1 mm Hg and 2.82 +/- 3.4 mm Hg. Cricopharyngeal intrabolus pressures were lower in young than in older subjects. The mid-bolus pressure and the gradient pressure across the cricopharyngeal region appeared to be the most consistent methods for evaluating intrabolus pressures. Intrabolus pressure anomalies in the cricopharyngeal region have been proposed as an indicator for selecting patients who would benefit from cricopharyngeal myotomy. The methods of determining intrabolus pressures vary, with resulting variations in recommendations.

Pharmacological analysis of stimulation action of histamine on gastric secretion

Aim: To define the clinical presentation, motility characteristics, and prevalence and patterns of gastroesophageal reflux in patients with hypertensive lower esophageal sphincter (HTLES). Methods: HTLES was defined by a resting LES pressure measured at the respiratory inversion point on stationary manometry of > 26 mmHg (95'h percentile of normals). 100 consecutive patients (80 F, mean age 54.7 yrs, range 23-89 yrs) with HTLES were investigated at this institution between September 1996 and October 1999. Patients with HTLES represented ~7% of all patients investigated by motility examination during this period. Patients with another esophageal motility disorder or a history of foregut surgery were excluded. Results: The most common symptoms in HTLES patients were regurgitation (75%), heartburn (71%), dysphagia (71%), and chest pain (49%). 73 patients underwent 24 hour pH monitoring, of whom 26% had increased distal esophageal acid exposure. 48% of patients had moderately severe or severe dysphagia. Nutcracker esophagus was present in 23 patients. The intrabolus pressure, measured 5cm above the LES, was significantly higher in patients with HTLES compared to normal volunteers (P<O.OOOI). The residual pressure measured during LES relaxation in response to a 5 mL water swallow was also significantly higher than in normal individuals (P<O.OOOI). There were no significant associations between any of the relaxation parameters studied (residual pressure, nadir pressure, duration of relaxation, time to residual pressure) and either the presence or severity of any symptoms, or the presence of GERD. Comparison of HTLES patients with normal relaxation (n=38) with those with incomplete relaxation (n=62), using the previousl~ determined normal upper limit for the residual relaxation pressure (95' percentile value for normal volunteers; 7.5 mmHg), found no differences between the two groups for any symptoms. Compared to a cohort of patients with GERD but no HTLES (n=300), patients with HTLES and GERO had significantly lower total (P=O.004) and supine (P=0.02) period distal esophageal acid exposure. Conclusions: Patients with HTLES frequently present with typical reflux symptoms and approximately one quarter of them have objective GERD on pH monitoring. Moderately severe or severe dysphagia is common. Patients with HTLES have significantly elevated intrabolus and residual relaxation pressures, but neither these nor any other manometric measurements are significantly associated with the presence of any symptoms or with the diagnosis of GERD.