Lower Esophageal Sphincter Residual Pressure Research Articles

Residual lower esophageal sphincter pressure as a prognostic factor in the pneumatic balloon treatment of achalasia.

Pneumatic balloon dilatation (PD) is a mainstay in achalasia treatment. The aim of this study was to identify predictive factors for successful treatment. We retrospectively reviewed 76 patients with a diagnosis of achalasia who underwent PD from June 2010 to May 2013. Clinical symptoms were assessed using Eckardt score and manometry data were analyzed using resting and relaxation pressure (4sIRP) of lower esophageal sphincter (LES) and the distal contractile integral (DCI), which was calculated for 10 s from the start of deglutition between the upper margin of the LES and lower margin of upper esophageal contraction. Patients with achalasia were classified into three groups based on the Chicago classification. Among 76 patients, 52 patients received PD, and the treatment was unsuccessful in 9 patients (6 in class I and 3 in class III). When comparing prognostic factors between successful and unsuccessful treatment groups, the mean value for 4sIRP in the unsuccessful treatment group was significantly lower than that in the successful treatment group (P < 0.05). However, no difference was noticed in resting LES pressure, DCI, age, and sex. Furthermore, a lower mean value of 4sIRP was significantly related to unsuccessful treatment of achalasia (odds ratio, 1.092; 95% confidence interval, 1.001-1.191) even after adjustment for a series of confounding factors. Lower 4sIRP may be a prognostic indicator for poor treatment outcome after PD.

Effects of acupuncture on esophageal motility of patients with refractory gastroesophageal reflux disease

Objective To investigate the effects of acupuncture on the improvement of esophageal motility disorder in patients with refractory gastroesophageal reflux disease （GERD）.Methods From September 2012 to March 2014,40 patients with refractory GERD were enrolled and evenly divided into the treatment group and the control group. High resolution esophageal impedance manometry was conducted in patients.After the first examination,patients of the control group lay down for 30 minutes, and patients of the treatment group received acupuncture treatment at Neiguan,Gongsun and Zusanli points for 30 minutes.Then all the patients underwent high resolution esophageal impedance manometry again.ManoView ESO 3.0 software was used for analysis.The parameters included swallowing peristalsis defect,lower esophageal sphincter （LES）pressure,LES residual pressure,LES length,upper esophageal sphincter （UES）pressure,distal wave amplitude,peristalsis duration time,starting speed of peristalsis wave,speed of edge contraction and integration of the peristaltic waves.Chi-square test or t test was performed for data analysis.Results The percentage of normal swallows of the treatment group before and after treatment was 56.0% （112/200）and 74.0% （148/200）,the percentage of delayed esophageal emptying was 31 .5 % （63/200 ）and 11 .5 % （23/200 ）,and the differences were statistically significant （χ2 =14.242 and 23.700,both P 〈0.01 ）.However there was no significant difference in those of the control group （both P 〉 0.05 ）.The LES resting pressure of the treatment group before and after treatment was （20.2 ±18.8）mmHg （1 mmHg=0.133 kPa）and （26.3±10.1）mmHg,the length of LES was （2.2 ±0.6 ）cm and （3.3 ±0.8）cm,the distal esophageal peristaltic amplitude was （60.2 ± 21 .9）mmHg and （41 .1 ± 16.8 ）mmHg,and the differences were statistically significant （t = 5 .519, 6.580 and 6.881 ,all P 〈0.01 ）.There was no significant difference in LES residual pressure before and after treatment （P 〉0.05 ）.There as no significant difference in LES resting pressure and LES residual pressure of the control group before and after lying down （both P 〉0.05 ）.However,before and after lying down,there were significant differences in the length of LES （（2.3 ±0.6）cm vs （2.5 ±0.6）cm） and UES resting pressure （（67.4 ±21 .2 ）mmHg vs （53.5 ±18.1 ）mmHg）in the control group （t =2.530 and 6.652,both P 〈0.05 ）.The distal wave amplitude of the treatment group before and after treatment was （73.7 ±28.3）mmHg and （88.5 ±29.1 ）mmHg,the duration of peristalsis was （2.9 ± 0.4）s and （3.2 ± 0.4 ）s,the distal contraction integral was （977.7 ± 733.2 ）mmHg · cm · s and （1 225 .9±945 .1）mmHg·cm·s.All the differences were statistically significant （t=7.907,3.404 and 3.325 ,all P 〈0.01）.There were no statistically significant difference in the beginning speed of peristaltic wave and the contractile front velocity （CFV）（all P 〉0.05）.Before and after lying down,there was no significant difference in distal wave amplitude,duration of peristalsis,the beginning speed of the peristaltic wave and CFV of the control group （all P 〉0.05 ）.Conclusion Acupuncture can help increase the LES resting pressure,extend the length of LES,improve the overall peristaltic pressure and completeness of esophageal somatic part,meanwhile,it increases the percentage of normal swallows of patients with refractory GERD. Key words: Acupuncture; High resolution esophageal manometry; Refractory gastroesophageal reflux disease

Detection of GERD With Esophageal Manometry With Impedance

Introduction: To investigate the value, if any, of reflux patterns seen on esophageal manometry with impedance. Methods: Studies using esophageal manometry with impedance (Given, Inc.) from Temple University Hospital Digestive Disease Center were examined from 2010-2012. Patients with reflux pattern on impedance were identified. The reflux pattern most often seen is a bolus clearance and a V-shaped bolus reflux pattern from the stomach back up into the esophagus. Control data was taken from normal patients without any upper GI symptoms undergoing esophageal manometry with impedance, along with patients without a reflux pattern on impedance. This group was further subdivided into those with a positive pH study for reflux and those with a negative study. Resting lower esophageal sphincter (LES) pressure, residual LES, presence and size of hiatal hernia, number of reflux episodes on impedance, and mean refluxate height were recorded and analyzed with independent samples T-test using SPSS 22. Results: Seventeen patients had esophageal reflux on impedance. Average reflux height was 11 cm with σ± 3.46, average number of reflux episodes was 9 σ± 3.3. Six of these 17 patients also had a positive pH study while 11 did not (Table 1). Twenty-eight patients did not have an esophageal reflux pattern on impedance; 19 had a positive ambulatory pH study and 9 had a negative pH study. The presence and size of hiatus hernia were larger in the reflux group. There were trends for the refluxate group to have lower LES pressures compared to non-refluxate (Table 2).Table 1: Comparison Between +/− pH study with Refluxate on ImpedanceTable 2: Comparison Between Refluxate on Impedance and Without RefluxateConclusion: Reflux can be detected on the esophageal manometry impedance studies. Patients with reflux pattern on esophageal manometry with impedance have lower resting LES pressures and residual LES pressures but this is not statistically significant, this may be due to the small sample size. Hiatal hernia sizes are larger in those with reflux patterns on impedance. This study suggests that reflux pattern on impedance manometry may define a population of GERD patients with different physiologic parameters than those GERD patients without a reflux pattern.

Evaluation of the Frequency of Nutcracker and Jackhammer Esophagus as the Extreme Phenotypes of Esophageal Hypercontractility: A Single-Center Experience

Introduction: Hypertensive esophageal peristaltic contractions are usually reported as Nutcracker Esophagus in manometry. Recently, extreme high amplitude peristalsis is defined as Jackhammer Esophagus with multipeaked contractions. We conducted a retrospective study to identify the frequency of esophageal hypercontractility in patients referred for manometry and their clinical characteristics. Methods: Charts review was conducted for patients referred for manometry at a tertiary care motility center in USA from January 2012 to April 2014. The threshold for hypercontractility was defined as a wet swallow with distal contractile integral (DCI, mmHg-s-cm)>5000, while the occurrence of at least a single contraction with DCI>8000 met the criteria for Jackhammer. The diagnosis of Nutcracker or Jackhammer Esophagus was also made based on the conclusion reached by RMC who read all studies. Concomitant clinical variables were explored. Results: A total of 179 (113 F/65 M, mean age=57 y/o) patients were referred for esophageal manometry. A total of 22 patients were identified with Nutcracker or Jackhammer Esophagus. All of them had contractile propagation and distal contractile latency within normal limit range and achalasia and distal esophageal spasm were excluded. The diagnosis of Nutcracker was made in 17 patients with an average DCI of 3419 and median maximal DCI of 5668, while the diagnosis of Jackhammer was made in 5 patients with an average DCI of 10161 and median maximal DCI of 16642. The greatest DCI value observed in any swallow was 24208. The average lower esophageal sphincter basal mean pressure was 27.8 mmHg in the Nutcracker group while 56.6 mmHg in the Jackhammer group. The mean lower esophageal sphincter residual pressure was 11.7 mmHg in the Nutcracker group and 29.9 mmHg in the Jackhammer group indicated incomplete relaxation. Hypercontractility was associated with multipeaked contractions in every Jackhammer patient. Dysphagia (17/22) was the dominant indication for the manometric study in patients with both Nutcracker and Jackhammer Esophagus including food impaction. Subsets patients had hypercontractility in the setting of reflux disease (13/22), Hiatal hernia (4/22), Chest pain (3/22). Conclusion: Jackhammer Esophagus, an extreme phenotype of hypercontractility characterized manometrically by at least a single contraction with DCI >8,000, and multipeaked contractions in 2.8% of patients referred to a tertiary center, compared to 9.5% with Nutcracker Esophagus, which has a lower DCI. The patients with these extreme phenotypes of esophageal hypercontractility present mainly with dysphagia, partly explained by incomplete relaxation of the lower esophageal sphincter, which offers one avenue for a therapeutic approach in this subset.

Tu1983 Correlation of Esophageal Diameter With Manometric Parameters in Subtypes of Achalasia Patients

Background: It was commonly thought that significantly dilated esophagus in Achalasia is associated with prolonged disease process. Comparing to type II Achalasia, type I diagnosed by manometry is thought to be a later stage achalasia which is less responsive to the treatment. Objective: To compare the esophageal diameter in different subtypes of achalasia based on High Resolution Impedance Manometry (HRIM) and therefore to further determine the clinical significance of this radiographic parameter. Method: Data of HRIM findings and esophagram of 71 Achalasia patients were retrospectively analyzed. Following parameters were obtained: height of the bolus column based on impedance recordings, lower esophageal sphincter residual pressure i.e. integrated relaxation pressure (IRP), and pan-esophageal pressure in supine and upright positions. The largest esophageal diameter was measured above esophagogastric (EG) junction on anteroposterior (AP) view of esophogram images. The patients were separated into 3 groups based on diameter of the esophagus as 8cm. The above manometric findings were compared with esophageal diameter. Esophageal diameter was also compared in different subtypes of Achalasia. Results: Thirty three out of 71 Achalasia patients with available esophogram were studied (M:F 15:18, age range 20-88 years; mean 58.6). Of these 33 patients, 6 patients were type I, 20 were type II, and 5 were type III Achalasia based on Chicago classification. Two patients were labeled as unclassified Achalasia due to presence of segmental peristalsis. Unexpectedly, Achalasia patients with wider esophageal diameter were more commonly seen in type II Achalasia rather than type I Achalasia as shown in table 1. 16 out of 20 type II Achalasia patients (80%) had dilated esophagus ≥ 5cm; comparing to 3 out of 6 type I patients (50%), and 1 out of 5 type III patients (20%) who had dilated esophagus of ≥ 5cm. There was no statistically significant correlation between esophageal diameter and LES residual pressure and pan esophageal pressures in both supine and upright swallows. However, the bolus height as determined by HRIM in upright position was associated with wider esophageal diameter on barium esophagram with correlation factor of 0.387 (P=0.07). Conclusion: In this study, we showed that wider esophageal diameter was associated with greater height of the bolus column in the upright position. Type II Achalasia patients are more commonly seen with larger esophageal diameter than other types. Since type II Achalasia responds to treatment better than other types, the degree of esophageal dilatation may not be a reliable prognosis predictor for Achalasia patients. Table 1. Correlation of esophageal diameter with subtypes of Achalasia

Bolus retention in hiatal hernia identified by high-resolution esophageal manometry with impedance

Esophageal acid retention in a hiatal hernia (HH) may play a role in gastro-esophageal reflux. The aims of this study were to determine the prevalence of bolus retention (BR) in HH and to compare pressure profiles in patients with HH with BR in the hernia to those with bolus clearance (BC) through the hernia using high-resolution esophageal manometry with impedance (HREMI). Clinical HREMI studies with HH ≥1.5cm were analyzed for lower esophageal sphincter (LES) and crural diaphragm (CD) pressures and pressure profiles during 12 saline swallows. Impedance was analyzed for swallow retention in the HH. Bolus retention in a HH was present in 35 of 53 (66%) patients with a HH. Patients with BR had overall lower pressure profiles including a lower basal LES pressure (14.8±10.6 vs 28.9±16.8mmHg; p=0.0001), LES-CD gradient (6.8±17.9 vs 20.6±12.2mmHg; p=0.002), residual LES pressure (2.5±4.6 vs 6.1±12.2mmHg; p=0.017), amplitude of distal esophageal contractions (83.2±38.8 vs 111.2±42.8mmHg; p=0.020), and distal contractile integral (1487±1016 vs 2608±1221mmHg-cm-sec; p=0.001) compared to the BC group. Patients with BR were more likely to have a larger sized HH compared to the BC group (3.1±1.6 vs 2.1±0.6cm; p=0.016); similar pressure changes were found when the groups were divided up by HH sizes. Bolus retention was seen in 66% of patients with HH. Bolus retention in the HH was associated with larger HH size, lower LES pressure, and lower esophageal contractile pressures compared to those with BC.

Opioid-Induced Esophageal Dysfunction (OIED) in Chronic Opioid Users: Presidential Poster

Purpose: Bowel dysfunction characterized by reduced motility has been recognized as a predominant side effect of opioid use. Even though, the effects of opioids on stomach and intestines have been well studied, there are limited data on opioid induced esophageal dysfunction. Aim: To compare esophageal pressure topography (EPT) of patients taking opioids at the time of the EPT (≤ 24 hours) with chronic opioid users that were studied off opioid medications for at least 24 hours using the Chicago classification. Methods: A retrospective review of the motility database identified 123 chronic opioid users that completed high-resolution EPT between March 2010 and August 2012. Manometry was performed using Manoscan (Given Imaging, USA), and was analyzed using Manoview Analysis version 3.0 software. The Chicago classification system was used to characterize esophageal dysmotility. Demographic and manometric data were compared between the two groups using General Linear Models or chi-square (SPSS v 20.0, Chicago, IL). Results: Current opioid use was reported in 67 patients [76% female; mean (SD) age 57 (16) years], and 56 reported no opioid use in the past 24 hours [68% female; mean (SD) age 53 (17) years]. The last opioid dose was taken within 4h of manometry in 31 (46%) of those studied on opioids. The last dose in patients studied off opioids ranged from 2 days to 186 days (median 7 days). Outflow obstruction was more prevalent in patients using opioids within 24h compared to those that did not (22.4% vs. 7.1%; P=0.02). Resting lower esophageal sphincter (LES) pressures tended be higher on opioids (21.25 vs. 15.45 mmHg; P=0.07), but the mean LES residual pressure was significantly higher in patients studied on opioids (10.54 vs. 6.70 mmHg, P=0.034). Distal esophageal spasm also tended to be more frequent in patients studied on opioids (13.4% vs. 3.6%; P=0.056). The distal contractile interval (DCI) also tended be higher on opioids (3273 vs. 2310 mmHg; P=0.08). Achalasia Subtype III criteria were met more frequently in patients studied on opioids (10.4% vs. 0.0%; P=0.016). Achalasia Subtype I (3.0% v 0.0%, P=0.500) and II (7.5% vs. 1.8%; P=0.219) were numerically higher in patients on vs. off opioids, but not statistically significant. The prevalence of other Chicago classifications was similar between the groups. Conclusion: Opioid induced esophageal dysfunction was found in both chronic and current opioid users. Patients taking opioids within 24h of manometry exhibited more frequent outflow obstruction and spastic esophageal dysmotility patterns compared with opioid users that stopped opioid for at least 24h prior to the study. Further studies are needed to better ascertain this relationship.

AAA Syndrome: Successful Management of a Rare Cause of Dysphagia

Introduction: AAA syndrome (also known as Allgrove syndrome or triple A syndrome) is a rare autosomal recessive disorder characterized by the triad of ACTH-resistant adrenal insufficiency, achalasia, and alacrima. This case highlights the gastroenterological presentation of this multisystem disorder and successful management. Case presentation: A 35-year-old Indian woman presented to the outpatient office with recurrent episodes of dysphagia to solids and liquids since childhood. Over the years, she modified her diet by avoiding meats and eating soft foods but reported an inability to gain weight. At age 17 years, she was reported to have a distal esophageal stricture at an outside facility. Four empiric endoscopic esophageal dilations were performed over a 10-year period with minor symptom improvement. In her 20s, she was diagnosed with primary adrenal insufficiency of an idiopathic nature (Addison's disease), and has been continuously treated with oral hydrocortisone. She also reported chronic dry eyes. On examination, she was 4'10”, 75 lbs with a BMI of 15.6. She had a nasal tone of voice and pigmentation of her lips and tongue. Other than a slender build, the remainder of the physical examination was unremarkable. High-resolution manometry was performed, which showed elevated lower esophageal sphincter (LES) pressures (27.2 mmHg) with abnormal LES relaxation (LES residual pressure of 34.4 mmHg), and absent esophageal body peristalsis with panesophageal compartmentalization of intrabolus pressure. These findings were consistent with achalasia, categorized as type II by the Chicago classification scheme. Upper endoscopy (EGD) revealed a mildly dilated esophageal body with a puckered and hypertonic LES. The findings on manometry and EGD confirmed the diagnosis of achalasia. The additional diagnoses of Addison's disease and longstanding alacrima were consistent with the AAA syndrome. The patient was referred for laparoscopic Heller myotomy to treat the achalasia and has remained asymptomatic 18 months after surgery. Discussion: AAA syndrome is rare, with fewer than 200 cases reported since it was initially described in 1978 by Allgrove. It usually manifests in childhood although neurological symptoms and autonomic instability may manifest later. The gene has been mapped to chromosome 12 and the protein it encodes is involved in the normal development of the nervous system. Achalasia in young patients is best treated surgically with laparoscopic myotomy and provides significant long-term relief of symptoms. AAA syndrome is uncommon, but a high index of suspicion in patients with any of the classic findings can result in early recognition and successful management.

An Evidence of Esophageal Decompensation in Patients With Achalasia in the View of Its Subtype: A Retrospective Study

Background/AimsAchalasia is a primary motility disorder of esophagus. Many parameters represent esophageal function and morphologic changes, but their interrelationship is not yet established. We hypothesized that esophageal body would need to generate unusual pressure to empty the food bolus through the non-relaxing lower esophageal sphincter in patients with achalasia; therefore, higher is the residual lower esophageal sphincter pressure, greater would be the contraction pressure in the esophageal body in these patients. To verify the hypothesis, correlations among parameters from esophageal manometry, esophagography and esophageal transit study had been investigated.MethodsA retrospective review of 34 patients was conducted. Resting lower esophageal sphincter pressure and contraction pressure of esophageal body were obtained from conventional esophageal manometry. Diameter of esophageal body was measured from barium column under esophagography. Radionuclide imaging was performed to assess the esophageal transit, designated as R30, which was the residual radioactivity at 30 seconds after ingesting radioactive isotope.ResultsIn vigorous achalasia group, contraction pressure of esophageal body was negatively correlated to dilated diameter of esophageal body (P = 0.025, correlation coefficient = -0.596). Esophageal transit was more delayed as dimensions of esophageal body increased in classic achalasia group (P = 0.039, correlation coefficient = 0.627).ConclusionsDiameter of esophageal body in classic achalasia was relatively wider than that of vigorous achalasia group and the degree of delayed esophageal transit was proportionate to the luminal widening. Patients with vigorous achalasia had narrower esophageal lumen and relatively shorter transit time than that of classic achalasia group. Proper peristalsis is not present in achalasia patients but remaining neuromuscular activity in vigorous achalasia patients might have caused the luminal narrowing and shorter transit time.

Comparison of idiopathic achalasia and Chagas' disease esophagopathy at the light of high-resolution manometry

The comparison between idiopathic achalasia (IA) and Chagas' disease esophagopathy (CDE) may evaluate if treatment options and their outcomes can be accepted universally. This study aims to compare IA and CDE at the light of high-resolution manometry. We studied 86 patients with achalasia: 45 patients with CDE (54% females, mean age 55 years) and 41 patients with IA (58% females, mean age 49 years). All patients underwent high-resolution manometry. Upper esophageal sphincter parameters were similar (basal pressure CDE = 72 ± 45 mmHg, IA = 82 ± 57 mmHg; residual pressure CDE = 9.9 ± 9.9 mmHg, IA = 9.8 ± 7.5 mmHg). In the body of the esophagus, the amplitude was higher in the IA group than the CDE group at 3 cm (CDE = 15 ± 14 mm Hg, IA = 42 ± 52 mmHg, P = 0.003) and 7 cm (CDE = 16 ± 15 mmHg, IA = 36 ± 57 mmHg, P = 0.04) above the lower esophageal sphincter (LES). The LES basal pressure (CDE = 17 ± 16 mmHg, IA = 40 ± 22 mmHg, P < 0.001) and residual pressure (CDE = 12 ± 11 mmHg, IA = 27 ± 13 mmHg, P < 0.001) were also higher in the IA group. Our results show that: (i) there is no difference in regards to the upper esophageal sphincter; (ii) higher pressures of the esophageal body are noticed in patients with IA; and (iii) basal and residual pressures of the LES are lower in patients with CDE. Our results did not show expressive manometric differences between IA and CDE. Some differences may be attributed to a more pronounced esophageal dilatation in patients with CDE.

Where Is the Acid Coming from? Esophago-Gastric Fistula Following Laparoscopic Nissen Fundoplication

A 61-year-old Caucasian female presented for evaluation of worsening retrosternal chest pain, heartburn, acid regurgitation, and dysphagia. She described a sensation of a bubble getting stuck in the bottom of her throat and chest after swallowing liquids. She also noted early satiety, belching, and nausea aggravated by greasy meals, weight loss, and frequent episodes of diarrhea. Three years prior, she had undergone a combined laparoscopic Nissen fundoplication, hiatal hernia repair, and cholecystectomy. Immediately after the operation, she experienced persistent nausea and vomiting, followed by recurrent reflux symptoms. Since a computed tomography scan obtained on the second post-operative day was unremarkable, she was reassured. She consulted a gastroenterologist due to progressive symptoms worsening over the ensuing 6 months. After a reportedly normal endoscopy, antisecretory drug therapy was started but failed to alleviate her symptoms. Over the next 30 months, her symptoms continued to worsen until she was evaluated in our unit. Her past medical and surgical histories were significant for overactive bladder, oral herpes, hypertension, hysterectomy, tubal ligation with subsequent reversal, carpal tunnel repair, and tendon repairs of both her hands. Having no known allergies, she was taking oxybutynin, acyclovir, lisinopril, and hydrochlorothiazide. Retired and living with her husband and daughter, she enjoyed gardening. She reported a 30-pack-year smoking history and denied alcohol and recreational drug use. Her family history was remarkable for Parkinson’s disease, breast cancer, and cholelithiasis. Further review of systems was unremarkable. Her physical exam was significant for a blood pressure 190/93 but was otherwise normal. Upper endoscopy revealed a fistula connecting her distal esophagus to her gastric cardia and a non-displaced but erythematous and tight fundoplication (Fig. 1a, b). The fistula was noted just proximal to the wrap, with an exit point at the level of the cardia, which was confirmed by a barium swallow that showed a 17-mm connection between the distal esophagus and the gastric fundus bypassing the lateral aspect of the wrap, consistent with an esophagogastric fistula (Fig. 1c). Esophageal manometry revealed a lower esophageal sphincter (LES) pressure of 23.3 mmHg (normal 10–30 mmHg) with a residual LES pressure of 17 mmHg and 40 % relaxation (normal [70 %) with swallowing, likely secondary to her prior fundoplication and consistent with an effective anti-reflux procedure. Nevertheless, an ambulatory pH study off anti-secretory medications revealed severe, mostly upright, pathologic acid reflux with a DeMeester score of 113.4 and a percentage fraction of time with a pH of \4.0 in the distal esophagus of 31.9 %. There was an excellent correlation between symptoms and acid events; the intra-gastric pH was normal when the patient was off protein-pump inhibitor therapy. C. L. Chun (&) Department of Internal Medicine, Oregon Health and Science University, Portland, OR, USA e-mail: chun@ohsu.edu

Predictive Factors Associated with the Success of Pneumatic Dilatation in Japanese Patients with Primary Achalasia: A Study Using High-Resolution Manometry

Background/Aims: A new classification of achalasia using high-resolution manometry (HRM) has recently been suggested. Pneumatic dilatation (PD) is a common treatment for primary achalasia. The usefulness of the new classification and HRM for the treatment and follow-up of patients after PD is unknown. The aim of this study was to evaluate the PD effectiveness and the predictive factors of success in Japanese patients with achalasia using HRM and the new classification of achalasia. Methods: Twenty-five patients were diagnosed with primary achalasia using HRM and treated by PD in our hospital. We evaluated symptom scores and esophageal manometry 6 and 12 months after the first PD. Results: After the first PD treatment, remission occurred in 24 out of 25 (96.0%) patients at 6 months and in 19 out of 25 (76.0%) patients at 12 months. With the new classification of achalasia, the success rates were 83.3, 80.0 and 50% for types I, II and III, respectively, 12 months after PD. The median age of the successful group was significantly greater than that of the failure group (47.1 vs. 37.0 years, p <0.05). The median residual lower esophageal sphincter (LES) pressure 6 months after PD in the successful group was significantly lower than that of the failure group (9.0 vs. 15.5 mm Hg, p <0.05). Conclusion: Good predictors of PD success were old age (>40 years) and residual LES pressures less than 15 mm Hg 6 months after PD.

Correlation between obstructive sleep apnea hypopnea syndrome and gastroesophageal reflux disease

To discuss the occurrence correlation between obstructive sleep apnea hypopnea syndrome (OSAHS) and gastroesophageal reflux disease (GERD). Forty-three patients suspected of laryngopharyngeal reflux disease underwent combined multichannel intraluminal impedance and esophageal manometry (MII-EM), twenty-four-hour esophageal and pharyngeal pH and impedance monitoring and PSG. Subjects were grouped according to the detections. The difference of the measurement between groups were Compared. The possible relationship between the two diseases was analyzed. Fourteen of all the subjects can be diagnosed to have GERD (32.6%). Twenty-six can be diagnosed to have OSAHS (60.5%). There were 10 patients had OSAHS and GERD simultaneously, which took over 38.5% of the OSAHS group, and 71.4% of the GERD group. BMI (P = 0.000) and lower esophageal sphincter (LES) residual pressure (P = 0.021) were significantly different among the four groups OSAHS, GERD, OSAHS and GERD, and control (non-OSAHS and non-GERD), but no linear relationship between LES residual pressure and prevalence or severity of the two diseases was found. In OSAHS group, AHI were positively correlated with the following indictors: the DeMeester score (r = 0.45), acid exposure of the distal esophagus (r = 0.491). There seems to be no Linear correlation among reflux indicators, sleep indicators, and esophageal functional indicators in GERD group. Linear correlation was not found among reflux indicators, sleep indicators, and esophageal functional indicators in OSAHS and GERD group (P > 0.05). The incidence and the severity of GERD and OSAHS were related to each other. Reflux events may aggravate OSAHS. The two diseases may have some relationship on the esophageal function, especially on the regulation of the LES pressure.

Examination of the Effects of Vardenafil on Esophageal Function Using Multichannel Intraluminal Impedance and Manometry

Background/AimsTo evaluate the effects of the phosphodiesterase type 5 (PDE5) inhibitor vardenafil on esophageal function, including bolus transit, using multichannel intraluminal impedance and esophageal manometry (MII-EM).MethodsSixteen healthy volunteers (15 men) underwent an MII-EM study including 10 liquid swallows and 10 viscous swallows in a seated position after fasting. Then, each subject was asked to ingest 50 mL distilled water or 10 mg vardenafil dissolved in 50 mL water, in a double-blind manner. After 25 minutes, the MII-EM study was repeated.ResultsEight men received vardenafil and eight subjects received water. Resting and residual lower esophageal sphincter pressures differed significantly only in the vardenafil group (from 18 ± 6.7 to 6.6 ± 5.3 mmHg, P < 0.001 and from 4.9 ± 2.6 to 2.1 ± 3.6 mmHg, P = 0.006, respectively). Mean distal esophageal amplitude decreased significantly only in the vardenafil group (from 86.7 ± 41.6 to 34.0 ± 38.0 mmHg, P < 0.05). Complete bolus transits of liquid and viscous meals decreased significantly only after vardenafil ingestion (from 80.2% ± 13.8% to 49.4% ± 27.9%, P < 0.05 and from 72.8% ± 33.6% to 21.5% ± 29.0%, P = 0.01, respectively).ConclusionsVardenafil decreased esophageal bolus transit in the seated position, despite decreased lower esophageal sphincter pressure.

Characteristics of achalasia subtypes in untreated Chinese patients: A high‐resolution manometry study

To evaluate and compare the clinical characteristics, manometric results and treatment outcomes of different subtypes of achalasia in untreated Chinese patients using high-resolution esophageal manometry. A total of 75 achalasia patients and 34 healthy controls were enrolled in the study, and three achalasia subtypes were determined based on the Chicago classification. Clinical characteristics, manometric and treatment outcomes were compared. In all, 25 patients were classified as type I, 46 as type II and 4 as type III. The mean overall length of lower esophageal sphincter (LES) in type III was significantly longer than those in the controls and type I patients (P < 0.05), and abdominal LES length was significantly longer in type III than those in controls, type I and type II patients. All subtypes of achalasia had higher resting and residual LES pressures than those found in healthy controls (P < 0.05). Resting upper esophageal sphincter (UES) pressure in type III patients was significantly lower than those in healthy controls and type I patients, whereas types I and II patients had higher residual UES pressures compared with healthy controls (P < 0.05). Type II patients had a better response to the treatment than type I and III patients. Type II is more common in untreated Chinese achalasia patients, and type II patients had better treatment outcomes than other types of patients. Large-sample multicenter trials are necessary in the future.

Multiple rapid swallow responses segregate achalasia subtypes on high-resolution manometry.

Multiple rapid swallows (MRS) inhibit esophageal peristalsis and lower esophageal sphincter (LES) tone; a rebound excitatory response then results in an exaggerated peristaltic sequence. Multiple rapid swallows responses are dependent on intact inhibitory and excitatory neural function and could vary by subtype in achalasia spectrum disorders. Consecutive subjects with incomplete LES relaxation on high-resolution manometry (HRM) (Sierra Scientific, Los Angeles, CA, USA) in the absence of mechanical obstruction were prospectively identified. Achalasia spectrum disorders were classified and HRM plots reviewed according to Chicago criteria. Esophageal peristaltic performance and LES function were assessed after 10 wet swallows and MRS (five 2 mL water swallows 2-3 s apart). Findings were compared with 18 healthy controls (28.5 ± 0.6 years, 44% women). A total of 46 subjects (57.1 ± 2.1 years, 52.2% women) met inclusion criteria. There was complete failure of peristalsis with MRS in all subjects with achalasia subtypes 1 and 2. In contrast, 80% of achalasia subtype 3 and incomplete LES relaxation (EGJ outflow obstruction) with preserved esophageal body peristalsis had a contractile response to MRS (P < 0.001 compared with subtypes 1 and 2); controls demonstrated 94.4% peristalsis. Percent decrease in LES residual pressure during MRS (compared to wet swallows) segregated achalasia subtypes; those with aperistalsis (subtypes 1 and 2) had a lesser decline (22.6%) compared to those with retained esophageal body peristalsis (40.5%) and controls (51.3%, P < 0.001 across groups). Multiple rapid swallow responses segregate achalasia spectrum disorders into two patterns differentiated by presence or absence of esophageal body contraction response to wet swallows. These findings support subtyping of achalasia, with pathophysiologic implications.

Short‐term electrical stimulation of the lower esophageal sphincter increases sphincter pressure in patients with gastroesophageal reflux disease

Electrical stimulation (ES) of the lower esophageal sphincter (LES) increases resting LES pressure (LESP) in animal models. Our aims were to evaluate the safety of such stimulation in humans, and test the hypothesis that ES increases resting LESP in patients with gastroesophageal reflux disease (GERD). A total of 10 subjects (nine female patients, mean age 52.6 years), with symptoms of GERD responsive to PPIs, low resting LES pressure, and abnormal 24-h intraesophageal pH test were enrolled. Those with hiatal hernia >2 cm and/or esophagitis >Los Angeles Grade B were excluded. Bipolar stitch electrodes were placed longitudinally in the LES during an elective laparoscopic cholecystectomy, secured by a clip and exteriorized through the abdominal wall. Following recovery, an external pulse generator delivered two types of stimulation for periods of 30 min: (i) low energy stimulation; pulse width of 200 μs, frequency of 20 Hz and current of 5-15 mA (current was increased up to 15 mA if LESP was less than 15 mmHg), and (ii) high energy stimulation; pulse width of 375 ms, frequency of 6 cpm, and current 5 mA. Resting LESP, amplitude of esophageal contractions and residual LESP in response to swallows were assessed before and after stimulation. Symptoms of chest pain, abdominal pain, and dysphagia were recorded before, during, and after stimulation and 7-days after stimulation. Continuous cardiac monitoring was performed during and after stimulation. All patients were successfully implanted nine subjects received high frequency, low energy, and four subjects received low frequency, high energy stimulation. Both types of stimulation significantly increased resting LESP: from 8.6 mmHg (95% CI 4.1-13.1) to 16.6 mmHg (95% CI 10.8-19.2), P < 0.001 with low energy stimulation and from 9.2 mmHg (95% CI 2.0-16.3) to 16.5 mmHg (95% CI 2.7-30.1), P = 0.03 with high energy stimulation. Neither type of stimulation affected the amplitude of esophageal peristalsis or residual LESP. No subject complained of dysphagia. One subject had retrosternal discomfort with stimulation at 15 mA that was not experienced with stimulation at 13 mA. There were no adverse events or any cardiac rhythm abnormalities with either type of stimulation. Short-term stimulation of the LES in patients with GERD significantly increases resting LESP without affecting esophageal peristalsis or LES relaxation. Electrical stimulation of the LES may offer a novel therapy for patients with GERD.

Esophageal hypertensive peristaltic disorders

Esophageal motility abnormalities include a series of manometric findings that differ to a significant degree from findings in normal, asymptomatic volunteers. Current review summarizes conventional and high-resolution esophageal manometry criteria used to define and characterize esophageal hypertensive motility abnormalities. In the conventional esophageal manometry classification scheme hypertensive esophageal motility abnormalities include nutcracker esophagus (average distal contraction amplitude >180 mmHg), hypertensive lower esophageal sphincter (average resting LES pressure >45 mmHg) and poorly relaxing lower esophageal sphincter (average LES residual pressure >8 mmHg). The new, high resolution esophageal manometry scheme includes in the group of hypertensive peristaltic disorders hypertensive peristalsis ("nutcracker esophagus": mean DCI >5000 mmHg*sec*cm) and hypercontractile esophagus ("jackhammer esophagus": at least one contraction with DCI > 8,000 mmHg*sec*cm) and defines a separate group for disorders with impaired esophageal-gastric junction relaxation (mean integrated residual (LES) pressure >15 mmHg). Hypertensive motility disorders represent a heterogeneous condition subdivided into hypercontractile esophagus and hypertensive peristalsis. Further studies are required to determine the clinical relevance of this new classification.

Effect of peroral endoscopic myotomy on esophageal manometry in patients with achalasia

Objective To determine the effect of peroral endoscopic myotomy （POEM） on esophageal manometry in patients with aehalasia. Methods Esophageal manometric data of 3 patients with aehala- sia before and after POEM was retrospectively analyzed. Results The post-POEM lower esophageal sphincter pressure （LESP） and upper esophageal sphincter residual pressure （UESRP） were significantly lower than those of before （ P 〈 0. 05 ）. The average post-POEM lower esophageal sphincter residual pressure （LESRP） decreased （P 〉 0. 05 ）, with significant decrease to normal level in 2 patients and almost unchanged （above normal） in the other. The esophageal aperistalsis remained after POEM in all 3 patients. The lower esophageal sphincter relaxing rate （LESRR） remained lower than normal after POEM as before. The average upper esophgeal sphincter pressure （UESP） decreased after POEM without statistical significance. Conclusion POEM can improve the outcomes of esophageal manometry in patients with aehalasia in the short term. Key words: Esophageal aehalasia; Esophageal manometery; Peroral endoscopic myotomy

Effect of buspirone, a 5-HT1A receptor agonist, on esophageal motility in healthy volunteers

There are limited data concerning the effects of 5-HT(1A) receptor activation on esophageal motility. Sumatriptan, a 5-HT(1A) receptor agonist, was recently reported to enhance esophageal peristalsis after intravenous administration. Buspirone, an orally available 5-HT(1A) receptor agonist, was shown to modulate gastroduodenal motor function. Our aim was to evaluate the effect of buspirone on esophageal motility of healthy volunteers. On two separate visits, 20 healthy volunteers aged 21-29 years (nine women) underwent esophageal manometry before and 10, 30, and 60 minutes after the administration of buspirone 20-mg or placebo capsule, according to a double-blind crossover design. At each time point, we compared buspirone and placebo effects on: resting pressure of the lower esophageal sphincter (LES); residual pressure and duration of LES relaxation; amplitude, duration, and onset velocity of esophageal body contractions, during 10 swallows of 5 mL of water. Significant analysis of variance differences (P < 0.05) are presented as mean ± standard deviation. Buspirone significantly increased mean distal esophageal wave amplitude (151 vs. 87 mmHg, P < 0.05) and duration (6.1 vs. 4.2 seconds, P < 0.05). Similarly, buspirone significantly increased mean LES resting pressure (26 vs. 21 mmHg, P < 0.05) and mean residual LES pressure (7.9 vs. 2 mmHg, P < 0.05), whereas reduced mean LES relaxation duration (7.2 vs. 8.0 seconds, P < 0.05) and mean distal onset velocity (7.6 vs. 14.7 cm/second, P < 0.05). Buspirone enhances esophageal peristalsis and LES function in healthy volunteers. Further study is warranted on the effects of buspirone on esophageal function and symptoms in patients with ineffective esophageal motility.