Lower Esophageal Sphincter Relaxation Research Articles

IDIOPATHIC ACHALASIA PRIMARILY DIAGNOSED AS BULIMIA NERVOSA: THE IMPORTANCE OF THE NUTROLOGYST

Idiopathic achalasia is a primary esophageal motor disorder characterized byesophageal aperistalsis and abnormal lower esophageal sphincter relaxation in responseto deglutition. Bulimia nervosa is an eating disorder, which amongst other symptomspresents with self-induced vomiting after repetitive episodes of binge eating in order toprevent weight gain. The present study reports the case of a female patient initiallydiagnosed with bulimia nervosa, after ruling out an etiology of organic cause throughlab tests and endoscopy. The patient was referred to a nutrologyst for treating the eatingdisorder, and after nutritional evaluation, she received nutritional supplementation dueto severe dysphagia, regurgitation and weight loss. As diagnostic criteria of bulimianervosa were not met, a further investigation was conducted, which eventuallyconfirmed idiopathic achalasia through two specific tests: digitalesophagogastroduodenal seriography, and esophageal manometry. Chagas disease, themajor cause of idiopathic achalasia in Brazil, was ruled out by specific lab test. In viewof the severity of the disease, the patient underwent urgent cardiomyotomy andfundoplication. Later, balloon dilators were also used in two occasions. After sixteenmonths of medical and nutrology follow-up, the patient now is in good nutritional statusand was able to go back to her daily activities and healthy lifestyle.

Upper Esophageal Sphincter Motility and Thoracic Pressure are Determinants of Pressurized Waves in Achalasia Subtypes According to the Chicago Classification.

Phenotypes of achalasia are based on esophageal body pressurization during swallow. The reasons that lead to pressurized waves are still unclear. This study aims to evaluate manometric parameters that may determine pressurized waves in patients with achalasia. A total of 100 achalasia high-resolution manometry tests were reviewed. We measured before each swallow: upper esophageal sphincter (UES) basal pressure, esophageal length, lower esophageal sphincter (LES) basal pressure, LES length, gastric and thoracic pressure, transdiaphragmatic pressure gradient and the LES retention pressure (LES basal pressure-TPG); during swallow: UES pressure, UES residual pressure, UES recovery time, LES relaxation pressure, gastric and thoracic pressure, transdiaphragmatic pressure gradient and after swallow: esophageal length, LES length, wave pressure, gastric and thoracic pressure and transdiaphragmatic gradient pressure. Univariate analysis showed in pressurized waves before swallow: higher thoracic, UES and LES basal pressure, longer LES length and decrease in LES retention pressure; during swallow: higher thoracic, gastric and UES pressure, higher UES and LES relaxation pressure and after swallow: higher thoracic and gastric pressure. Multivariate analysis in pressurized waves showed as significant before swallow: thoracic and UES basal pressure; during swallow: thoracic, gastric and UES pressure, UES residual pressure and UES recovery time and after swallow: thoracic pressure. Basal esophageal pressurization and the UES are independent variables that may be associated with pressurized waves.

Morphology of the Esophageal Hiatus: Is It Different in 3 Types of Hiatus Hernias?

Background/AimsThe esophageal hiatus is formed by the right crus of the diaphragm in the majority of subjects. Contraction of the hiatus exerts a sphincter-like action on the lower esophageal sphincter (LES). The aim is to study the hiatal anatomy (using CT scan imaging) and function (using high-resolution manometry [HRM]), and esophageal motor function in patients with sliding and paraesophageal hiatal hernia.MethodsWe assessed normal subjects (n = 20), patients with sliding type 1 hernia (n = 18), paraesophageal type 2 hernia (n = 19), and mixed type 3 hernia (n = 19). Hernia diagnosis was confirmed on the upper gastrointestinal series. The hiatal morphology was constructed from the CT scan images. The LES pressure and relaxation, percent peristalsis, bolus pressure, and hiatal squeeze pressure were assessed by HRM.ResultsThe CT images revealed that the esophageal hiatus is formed by the right crus of the diaphragm in all normal subjects and 86% of hernia patients. The hiatus is elliptical in shape with a surface area of 1037 mm2 in normal subjects. The hiatal dimensions were larger in patients compared to normal subjects. The HRM revealed impaired LES relaxation and higher bolus pressure in patients with paraesophageal compared to the sliding hernia. The hiatal pinch on HRM was recognized in significantly higher number of patients with sliding as compared to paraesophageal hernia.ConclusionsUsing a novel approach, we provide details of the esophageal hiatus in patients with various kinds of hiatal hernia. Impaired LES relaxation in paraesophageal hernia may play a role in its pathophysiology and genesis of symptoms.

High-resolution manometry in the diagnosis of diffuse esophageal spasm: A rare motility disorder

Background: Diffuse esophageal spasm (DOS) is a rare motility disorder. High-resolution manometry (HRM) is used for the diagnosis of DOS in patients confirmed with non-cardiac chest pain and/or dysphagia. The body of the esophagus and the lower esophageal sphincter (LOS) exhibit various motility characteristics that are typical to DOS. The study was conducted to study the HRM patterns in DOS using a 16-channel water perfusion high-resolution esophageal manometer. Aims and Objectives: The objective of the study was to analyze the various motility patterns in DOS with the help of HRM and also to look for those patients who, at the time of the HRM recording, did not reveal overt patterns of motility that is typical to DOS. Materials and Methods: HRM was performed in 13 adult patients (mean age = 61 years) referred as cases of DOS, out of which three had HRM features of DOS. All patients were subjected to HRM following which the results were analyzed. Results: Ten cases had essentially normal HRM findings. The other three patients had a high basal LOS pressure (BLOSP) and elevated distal wave amplitudes. However, all three cases had a normal LOS relaxation pattern. Manometric features of DOS may not be obvious in all referred cases of DOS, and hence, false-negative results are likely. DOS often has high BLOSP along with very high distal wave amplitudes. However, the LOS relaxation during swallows does not get affected. Although the mean age for DOS is 71 years, yet it can also occur in younger adults. Conclusion: Most of the DOS patients may not manifest manometrically at the time when they are actually undergoing the recording, which leaves a number of cases with a normal HRM finding. Thus, it would not be reasonable to rule out DOS in the absence of HRM confirmation.

Pseudocyst presenting as pseudoachalasia

Achalasia cardia is a primary motility disorder of esophagus which is due to loss of ganglion cells in myentric plexus, etiology of which is unknown. The condition causes dysphagia due to failure of relaxation of lower esophageal sphincter. Pseudoachalasia is a similar disorder which occurs usually due to adenocarcinoma of the cardia and also due benign tumors at this level. We present a rare case of pseudocyst of pancreas extending into mediastinum which mimics as pseudoachalasia.

1803 Pseudoachalasia Following Nissen Fundoplication: A Progression Documented With High Resolution Manometry

INTRODUCTION: Pseudoachalasia, indistinct from achalasia in symptoms and high-resolution manometry (HRM) findings, varies by a secondary etiology. Over half of the occurrences arise from malignancy and seldom following surgeries involving the esophagus. This case presents a rare development of pseudoachalasia following Nissen fundoplication, further unique by documenting complete progression on HRM. CASE DESCRIPTION/METHODS: A 68-year-old male with continued dysphagia and gastroesophageal reflux disease underwent repeat EGD showing progression to LA grade B (from grade A) esophagitis and a 5cm (from 3cm) hiatal hernia. Initial HRM had normal findings (Figure 1A). Laparoscopic Nissen fundoplication was performed. Recurrence of symptoms led to two stricture dilations in one year. Repeat HRM showed intact peristalsis and normal LES relaxation, but six of ten swallows had decreased distal latency < 4.5 seconds consistent with esophageal spasm (Figure 1B). He was referred to an esophageal disease clinic and reported dysphagia, poor pill swallow and 15lb unintentional weight loss. Timed barium esophagram revealed a high-grade obstruction in the distal esophagus (Figure 2). EGD had significant resistance to gastric intubation of the scope concerning for an extrinsic compression or achalasia. A CT chest, abdomen and pelvis showed no extrinsic masses or alternative malignancy. HRM had 100% incomplete liquid bolus transit, elevated LES basal (56.7mmHg) and median integrated relaxation (22.4 mmHg) pressures with complete aperistalsis validating Type I Achalasia by Chicago Classifications (Figure 1C). Diagnosis was mechanical esophagogastric junction outflow obstruction with pseudoachalasia secondary to a tight Nissen fundoplication. After Nissen fundoplication takedown, dysphagia resolved and results were maintained at follow up. DISCUSSION: The etiology of pseudoachalasia in this case was theorized as myenteric plexus injury during wrap construction or degeneration from sustained distal obstruction. Intermediary esophageal spasms on HRM may forewarn of developing pseudoachalasia. One should understand the risk, albeit rare, of post-Nissen fundoplication dysmotility. Being cognizant of a possible HRM progression, as identified in this patient, may spur earlier clinical follow up, repeat testing or intervention. Finally, those with rapid onset of achalasia symptoms over age 50 should raise concern and be evaluated with barium esophagram, EGD with biopsies, CT scan and HRM to decipher a secondary etiology.

Rectal distention increases the frequency and duration of transient lower esophageal sphincter relaxations in anesthetized dogs– a putative rectoesophageal reflex

Introduction: The esophagus is subject to frequent reflux of gastric contents as a normal phenomenon during episodes of transient lower esophageal sphincter relaxation (tLESR), responsible too, for pathologic reflux. However, pathologic reflux is mostly associated with reflux of acid contents. Distending the stomach provokes an increase in frequency of tLESR. Objective: To investigate the effect of distending the rectum on the tLESR and possible involved pathways. Methods: Forty four (Protocol: 096/07) street dogs were selected and divided into respective protocols: Rectal distention (RD), Gastric distention (GD), RD+GD, Atropine+RD, Hexamethonium+RD, Baclofen+RD, Bilateral Pudendal nerve section+RD and Spinal cord transection+RD. We determined and compared the tLESR of each group and subjected data to statistical analysis. Values of p<0.05 were regarded as statistically significant. Results: RD provoked a significant increase in the tLESR just as GD, with RD+GD provoking the highest value of tLESR. This increase in tLESR due to RD was prevented in A+RD, B+RD, Bilateral Pudendal nerve section+RD and Spinal cord transection+RD but not Hexamethonium+RD protocols. Conclusion: RD is a significant inducer of an increase in tLESR with participation of muscharinic and GABAβ, sensitive and spinal cord neurons, but not nicotinic receptors.

Do Prolonged Nasogastric Tube Feedings Reduce Gastroesophageal Reflux in Infants

Background: Gastroesophageal reflux (GER) is common in the neonatal population. While generally benign in infancy, it may lead to adverse respiratory and nutritional outcomes and lengthen hospital stay. Prolonged nasogastric (NG) feeding is frequently used to reduce GER. However, prolonging NG feeds may delay gastric emptying or increase transient lower esophageal sphincter relaxation. Multi-channel intraluminal impedance with pH probe (MII-pH) is considered the gold standard for evaluation of GER. To our …

A rare ca(u)se of dysphagia

Achalasia is a rare lower esophageal motility disorder, in which there is destruction of myenteric plexi leading to the loss of esophageal peristalsis and inadequate relaxation of the lower esophageal sphincter in response to swallowing. Although the etiology of achalasia cardia is unclear, it is likely to be caused by autoimmune etiology. It is characterized by dysphagia of solids and liquids, regurgitation, weight loss, chest pain, heartburn, and nocturnal cough. Achalasia can be diagnosed on the clinical history and confirmed by barium swallow, and esophageal manometry which is the gold standard technique for diagnosis. Even though achalasia cannot be cured permanently, pneumatic balloon dilatation and myotomy remain the definitive treatment of choice in spite of availabilities of pharmacological therapies. We report a case of 25-year-old male admitted with chronic dysphagia and weight loss, diagnosed to be having achalasia cardia and treated accordingly.

Cannabis Use in Patients Presenting to a Gastroenterology Clinic: Associations with Symptoms, Endoscopy Findings, and Esophageal Manometry

Recreational cannabis use is increasing with its legalization in many states. Animal studies suggest cannabis can reduce transient lower esophageal sphincter relaxations (TLESRS), reflux and vomiting, while human studies report conflicting findings. There are currently no large studies investigating gastrointestinal symptoms in patients with chronic cannabis use. This was a retrospective case-control study including patients who presented to an outpatient Gastroenterology office, with documented cannabis use. Their main presenting complaint, demographics, frequency and duration of cannabis use, endoscopic and high-resolution esophageal manometry (HREM) with impedance findings were recorded. Cannabis users were more likely to complain of abdominal pain (25% vs. 8%, p < 0.0001), heartburn (15% vs. 9%, p < 0.0001), and nausea & vomiting (7% vs. 1%, p < 0.0001). They were also more likely to have findings of esophagitis (8% vs. 3%, p = 0.0002), non-erosive gastritis (30% vs. 15%, p = 0.0001) and erosive gastritis (14% vs. 3%, p < 0.0001) on upper endoscopy. Cannabis users were more likely to have impaired esophageal bolus clearance (43% vs. 17%, p = 0.04) and a hypertensive lower esophageal sphincter (LES) (29% vs. 7%, p = 0.04). This study is the largest to date evaluating GI complaints of patients with chronic recreational cannabis use. Our results suggest that cannabis use may potentiate or fail to alleviate a variety of GI symptoms which goes against current knowledge.

Surgical experience in treatment of achalasia cardia with minimal invasive surgery

Background: achalasia cardia is a motor disorder that result from absence of esophageal peristalsis combined with loss of relaxation of lower esophageal sphincter. Aims: To analyze the safety of laparoscopic Heller's myotomy with particular regard to the technical difficulties encountered, complications, the learning curve and outcome.Patients and methods: This study was done at Al - Sader Teaching Hospital, Basrah - Iraq in the period from February 2013 to June 2016. Thirty-two patients were included in the study of both gender and of different ages who were subjected to laparoscopic Heller's myotomy for achlasia cardia. They were observed regarding the development of operative and early post-operative complications, improvement of their symptoms, development of late post-operative complications and recurrence rate. Results: All patients underwent laparoscopic Heller's myotomy with Dor fundoplication except one patient had Toupet fundoplication. The mean operative time was 87 minutes and the median hospital stay was four days. Intra- operative complications include mucosal perforation in 3 patients, vagus nerve injury in 3 patients, and pleural perforation in 2 patients. Post-operative complications include atelectasis in 3 patients, pneumonia in 1 patient, GERD in 1 patient, post-operative leak in one patient and mortality in one patient. All patients improved regarding dysphagia (100%) and weight gain achieved in (91.3%), chest pain improved in (59%) and regurgitation improved in (84.6%) of the patients.Conclusion: Laparoscopic Heller's myotomy is safe and effective method for treatment of achalasia cardia.

Pharmacologic interrogation of patients with esophagogastric junction outflow obstruction using amyl nitrite.

The Chicago Classification of esophageal motility includes a group of patients who show evidence of esophagogastric junction outflow obstruction (EGJOO) as demonstrated by elevated integrated relaxation pressure (IRP) and preserved peristalsis. Our aim is to classify EGJOO patients based on response to amyl nitrite (AN) during high-resolution manometry. Patients were considered to have true EGJOO if elevated IRP during supine swallow persisted in the upright position and was associated with high intrabolus pressure. The EGJ response to AN was compared between patients with achalasia type 2 (A2) and normal esophageal motility. Based on the relaxation gain (deglutitive IRP-AN IRP) value that best discriminated these two groups (10mmHg), patients with true EGJOO were categorized as being in either the AN-responsive (AN-R) or AN-unresponsive (AN-U) subgroups. In the group of 49 patients with true EGJOO, the AN response classified 27 patients (IRP=25±10mmHg) with AN-R and 22 patients (IRP=20±5mmHg) with AN-U (P=0.2). In AN-R, AN produced a relaxation gain and rebound after-contraction response at the EGJ comparable to A2 patients. AN-U patients had an elevated IRP after AN and a relaxation gain similar to normal esophageal motility patients. AN-U patients were obese and had higher prevalence of sleep apnea (P<0.05). Among patients with true EGJOO, only half have pharmacologic evidence of impaired LES relaxation. Pharmacologic interrogation of the EGJ is thus necessary to identify the subgroup of EGJOO patients who could be expected to benefit from LES ablative therapies.

Long-Chain Fatty Acid Receptors Mediate Relaxation of the Porcine Lower Esophageal Sphincter.

Long-chain fatty acids activate the free fatty acid receptor 1 (FFA1) and FFA4. In the gastrointestinal system, FFA1 and FFA4 have been found in the pancreas and intestine. Fatty food and decreased lower esophageal sphincter (LES) motility are associated with gastroesophageal reflux disease. The effect of long-chain fatty acids on the esophageal motility is unknown. The purpose of this study is to investigate the effects of long-chain fatty acids on the porcine LES motility ex vivo using isometric transducers. In endothelin 1-precontracted porcine LES strips, the FFA1 selective agonists, fasiglifam, TUG424, and GW9508, caused marked relaxations in a concentration-dependent manner. The relative efficacies to elicit relaxation were GW9508 > TUG424 > fasiglifam in both clasp and sling strips. In contrast, the FFA4 specific agonists, TUG891 and GSK137647, produced mild relaxations. In addition, the endogenous FFA1 agonist DHA caused a mild relaxation whereas GW1100, an FFA1 antagonist, inhibited GW9508 induced relaxation of the porcine LES clasp and sling muscle. Both real-time PCR and immunohistochemistry revealed that FFA1 and FFA4 were expressed in the porcine LES. Real-time PCR analysis showed that the FFA4 expression was much lower than FFA1. Taken together, long-chain fatty acid receptor agonists elicit relaxation of the porcine LES. FFA1 might influence LES motility.

Peroral Endoscopic Myotomy with the Stag Beetle Knife (SB Knife): Feasibility and Follow-Up.

BackgroundRecently, a stag beetle (SB) knife was introduced to reduce the difficulty of peroral endoscopic myotomy (POEM). The objective of this study was to evaluate the efficacy and safety of the SB knife.Material/MethodsA total of 71 patients undergoing POEM with the SB knife for esophageal achalasia were included. We used esophagography, manometry, esophagogastroduodenoscopy (EGD), and Eckardt score to assess the utility and safety.ResultsAll cases were completed for POEM. The incidence of adverse events during the operation were 2.8%; however, all cases were treated conservatively. There was a vast improvement in clinical symptoms and endoscopic findings. The average Eckardt score was 6.9 before and 0.6 at 1 year after POEM (p<0.05). The average lower esophageal sphincter (LES) pressure before and 6 months after POEM were 44.34±14.83 mmHg and 19.14±6.74 mmHg (p<0.05), respectively. The average LES relaxation pressure before and 6 months after POEM was 12.11±5.02 mmHg and 3.22±2.29 mmHg (p<0.05), respectively.ConclusionsPOEM with the SB Knife is technically efficient and safe in treating achalasia and is associated with favorable short-term outcomes.

Tu1216 – Rapid Sequence Ct Scan Imaging to Visualize Dynamic Motion of the Lower Esophageal Sphincter and Hiatus During Swallow-Induced Les Relaxation

Tu1216 – Rapid Sequence Ct Scan Imaging to Visualize Dynamic Motion of the Lower Esophageal Sphincter and Hiatus During Swallow-Induced Les Relaxation

Chronic daily opioid exposure is associated with dysphagia, esophageal outflow obstruction, and disordered peristalsis.

Opioid receptors are present in the esophagus, and chronic opioid therapy may be associated with esophageal dysfunction. Given the current opioid epidemic in the United States, the potential contribution of opioids to esophageal dysmotility is important from both public health and patient care perspectives.Therefore our aim is toinvestigate the potentialcontribution of opioids to dysphagia and the prevalence of major motor disorders in patients undergoing manometric evaluation. The anonymized electronic medical records of patients linked to their de-identified high-resolution manometry (HRM) studies were reviewed. The patients were grouped based on their opioid exposure history at the time of HRM: opioid-naïve and chronic daily users. The oral morphine milligram equivalent daily dose (MMED) of opioids was computed. KEYRESULTS: 10% of patients referred for esophageal HRM were taking opioid analgesics on a chronic daily basis, and they had a significantly higher prevalence of dysphagia than their opioid-naïve counterparts. The chronic daily opioid users displayed a significantly higher prevalence of achalasia type 3 (ACH3) and esophagogastric junction outflow obstruction (EGJOO) motility phenotypes. The MMED of opioids was a significant predictor of esophageal pressure metrics and motility diagnoses (P<0.0001). Chronic daily opioid intake is associated with impaired deglutitive LES relaxation and disorganized peristaltic sequence. While a minority of patients on chronic daily opioid therapy present with major esophageal motor disorders, they comprise nearly half of ACH3 and a third of EGJOO motility phenotypes.

Results of 24-hour esophageal impedance-pH monitoring in 141 patients with gastroesophageal reflux disease

Objective To analyze the relationship between body type, age, gender, esophageal motility function, lower esophageal sphincter pressure (LESP) and clinical classification and type of reflux contents of patients with gastroesophageal reflux disease (GERD). Methods From September 2015 to July 2016, at Beijing Tongren Hospital of China Capital Medical University, the results of 24-hour esophageal impedance-pH monitoring of 141 patients with GERD were retrospectively analyzed. The differences of reflux contents were compared in patients with GERD among different body type, age, gender, esophageal motility function, LESP and clinical classification. Mann-Whitney test was performed for comparison between groups. Results Acid reflux was more common in obese patients (body mass index more than 23.9 kg/m2) compared with patients with normal body type (body mass index from 18.5 to 23.9 kg/m2) (18.5, 7.0 to 45.3 vs. 10.0, 2.0 to 32.0), and the difference was statistically significant (Z=-2.320, P=0.020). Patients under 65 years old had more numbers of weak acid reflux, non-acid reflux and gas reflux than patients over 65 years old (58.5, 32.8 to 95.0 vs. 40.0, 24.0 to 71.0; 19.5, 6.0 to 47.5 vs. 8.0, 3.0 to 19.0; 46.0, 23.8 to 79.3 vs. 35.0, 11.0 to 56.0), and the differences were statistically significant (Z=-2.690, -3.286 and -2.091, all P 0.05). Patients with reflux esophagitis(RE)and /or Barrett′s esophagus (BE) had more weak acid reflux, non-acid reflux and gas reflux compared with patients with non-erosive reflux disease (NERD) (61.0, 31.3 to 102.5 vs. 44.0, 24.5 to 66.5; 18.0, 8.0 to 36.5 vs. 8.0, 2.0 to 22.0; 49.5, 27.5 to 86.5 vs. 26.0, 11.0 to 47.0), and the differences were statistically significant (Z=-2.585, -2.942 and -3.278, all P<0.05). Patients with lower esophageal sphincter (LES) relaxation were more likely to have weak acid reflux than patients with normal LES function (57.0, 32.3 to 87.0 vs. 40.0, 21.0 to 73.0), the difference was statistically significant (Z=-2.065, P=0.039). Conclusion Body type, age, gender, LESP and clinical classification are related to type of reflux contents in GERD patients, while esophageal peristalsis is irrelevant. Key words: Gastroesophageal reflux; 24-hour esophageal impedance pH monitoring; Patterns of reflux episodes

Achalasia diagnosed despite normal integrated relaxation pressure responds favorably to therapy.

Achalasia diagnosis requires elevated integrated relaxation pressure (IRP; manometric marker of lower esophageal sphincter [LES] relaxation). Yet, some patients exhibit clinical features of achalasia despite normal IRP and have LES dysfunction demonstrable by other means. We hypothesized these patients to exhibit equivalent therapeutic response compared to standard achalasia patients. Symptomatic achalasia-like cases, despite normal IRP, displayed evidence of impaired LES relaxation using rapid drink challenge (RDC), solid swallows during high-resolution manometry, and/or barium esophagogram; were treated with achalasia therapies and compared to standard achalasia patients with raised IRP. Outcomes included equivalence for short- and long-term symptom response and stasis on barium esophagogram. Twenty-nine normal IRP achalasia cases (14 males, median age 50year, median Eckardt 6, barium stasis 12±7cm) and 29 consecutive standard achalasia controls underwent therapy. Among cases, LES dysfunction was most often identified by RDC and/or barium esophagogram. Short-term symptomatic success was equivalent in cases vs controls (90% vs 93%; 95% CI for difference: -19% to 13%). Median short-term (1 vs 1; 95% CI for difference: 0-1) and long-term Eckardt scores (2 vs 1; 95% CI for difference: 0-2) were similar in cases and controls, respectively. Adequate clearance was observed in 67% of cases vs 81% of controls on post-therapy esophagogram. We described a subset of achalasia patients with normal IRP, but impaired LES relaxation identifiable only on additional provocative tests. These patients benefited from treatment, suggesting that such tests should be performed to increase the number of clinically relevant diagnoses.

Multiple Rapid Swallows (MRS) Complements Single-Swallow (SS) Analysis for High-Resolution Esophageal Manometry (HREM)

Multiple rapid swallows (MRS) during HREM assess post-deglutitive inhibition, LES relaxation, and subsequent esophageal contraction. (1) To determine the relationship between MRS and single-swallow (SS) responses and (2) to determine if MRS provides information for symptomatic patients. Healthy volunteers (HVs) and patients underwent HREM [30-s landmark, ten 5-mL SS, MRS (5 consecutive 2-mL swallows every 2-3s)] and were analyzed with ManoView software version 3 with CC version 3.0. In 20 HVs, MRS response consisted of: (1) reduction in GEJ pressure; (2) absence of esophageal contractile activity during MRS; and (3) post-MRS peristaltic contraction greater than SS contractions. In 20 HVs and 403 patients, MRS IRP correlated with SS IRP (r = 0.65; p < 0.0001) and post-MRS contraction DCI correlated with SS DCI (r = 0.76; p < 0.0001). Abnormally elevated MRS IRP was seen in 68% type 2 achalasia, 50% type 3 achalasia, 47% EGJOO, and 9% jackhammer. Increased MRS DCI was seen in 53% type 2 achalasia, 92% type 3 achalasia, 10% EGJOO, 22% jackhammer, and 18% DES. Increased DCI post-MRS was seen in 38% patients with jackhammer, 8% type 3 achalasia, 12% EGJOO, and 9% DES. 14 out of 143 (10%) patients with normal or indeterminate results on SS analysis had at least one abnormality on MRS. MRS IRP correlated with SS IRP, and post-MRS DCI correlated with SS DCI. Patients with defined CC disorders have abnormalities on MRS. There were MRS abnormalities in some patients with normal SS studies, most notably suggesting impaired LES relaxation and/or spastic esophageal motility. MRS may complement the baseline SS study analysis.

Clinical features and esophageal motility characteristics of patients with esophagogastric junction outflow obstruction

Objective To analyze the clinical features and esophageal motility characteristics of patients with esophagogastric junction outflow obstruction (EGJOO). Methods From January 2015 to January 2018, at Affiliated Hospital of Zunyi Medical College, the clinical data of 663 outpatients with various gastrointestinal symptoms were collected. Gastroscopy and esophageal high resolution manometry (HRM) were performed to exclude gastrointestinal organic lesions. The 120 patients were divided into EGJOO group (71 cases) and non-EGJOO group (49 cases). Furthermore, according to integrated relaxation pressure (IRP) the 71 EGJOO patients were divided into mild group (41 cases), moderate group (20 cases) and severe group (10 cases). Independent sample t test and one-way analysis of variance were performed for statistical analysis. Results Among 71 EGJOO patients, 43.7% (31/71) showed post sternal heartburn or acid regurgitation, 32.4% (23/71) showed obstruction or dysphagia, 21.1% (15/71) showed chest pain, 21.1% (15/71) showed other atypical symptoms such as hiccups and bloating, and 5.6% (4/71) showed upper abdominal pain. The IRP, lower esophageal sphincter (LES) length, LES resting pressure and intrabolus pressure (IBP) of the EGJOO group were higher than those of the non-EGJOO group ((18.24±3.07) mmHg (1 mmHg=0.133 kPa) vs. (10.92±2.37) mmHg, (3.47±0.85) cm vs. (3.11±0.80) cm, (32.33±9.11) mmHg vs. (21.31±6.55) mmHg, (6.22±3.74) mmHg vs. (4.69±2.68) mmHg), and the differences were statistically significant (t=-13.947, -2.303, -7.706 and -2.626; all P<0.05). The LES relaxation rate and distal contractile integral (DCI) of the EGJOO group were lower than those of the non-EGJOO group ((44.03±9.86)% vs. (53.86±11.33)%, (1 410.13±794.23) mmHg·s·cm vs. (1 741.86±894.16) mmHg·s·cm), and the differences were statistically significant (t=5.046 and 2.136, both P<0.05). The LES resting pressure of the mild group was higher than that of the moderate group ((30.76±9.23) mmHg vs. (29.69±5.87) mmHg); the LES resting pressure of the moderate group was lower than that of the severe group ((29.69±5.87) mmHg vs. (42.02±9.23) mmHg); and the differences were statistically significant (both Tamhane test, P=0.012 and 0.011). The IBP of the mild group was lower than that of the moderate group and the severe group ((5.16±3.41) mmHg vs. (8.02±2.58) mmHg and (7.46±3.48) mmHg), and the differences were statistically significant (both least-significant difference test, both P<0.05). The DCI of the mild group was lower than that of the moderate group ((1 241.41±606.12) mmHg·s·cm vs. (1 438.55±644.74) mmHg·s·cm), and the difference was statistically significant (Tamhane test, P=0.011). Conclusions Heartburn, acid reflux and dysphagia are common clinical symptoms in EGJOO patients. The weaker the peristalsis of the esophageal body of EGJOO patients, the more obvious of dysphagia. Increased IBP is an indirect manifestation of esophagogastric junction relaxation disorder. Key words: Esophagogastric junction outflow obstruction; Esophageal motility; Clinical characteristics; High resolution manometry