Motility Disorders In Patients Research Articles

Comparison of esophageal motility between gastroesophageal reflux disease and functional esophageal disorders based on Lyon consensus

Objective To analyze the differences in esophageal motility between patients with gastroesophageal reflux disease (GERD) and functional esophageal disorders by comparing the esophagogastric junction (EGJ) barrier function, esophageal body motor function and results of provocative test. Methods From December 2016 to December 2018, the 100 patients with typical symptoms of GERD, who visited The First Aftiliated Hospifal of Zhejiang Chinese Medical Universtiy wese selected. According to the Rome Ⅳ standand and the Lyon consensus, and the results of endoscopic examination, 24 h multichannel intratuminal impedante pH (MII-pH) monitoring and esophageal high resolution manometry (HRM), the patients were divided into GERD group (n=32), hypersensitivity(RH) group (n=33) and functional heartburn(FH) group (n=35). According to the results of esophageal HRM, the differences in esophageal dynamics among the groups were analyzed. T test, variance analysis and Chi square test were performed for statistical analysis. Results The lower esophageal sphincter (LES) resting pressure of GERD group was lower than that of FH group ((19.37±7.92) mmHg vs. (25.35±12.38) mmHg (1 mmHg=0.133 kPa)); the EGJ-contractile integral of GERD group and RH group was lower than that of FH group ((20.84±21.52) mmHg·cm and (20.72±19.35) mmHg·cm vs. (35.93±36.82) mmHg·cm), and the level of distal contractile integral of GERD group was lower than that of FH group and RH group ((802.35±496.86) mmHg·s·cm vs. (1 316.84±853.92) mmHg·s·cm and (1 141.65±607.93) mmHg·s·cm), and the differences were statistically significant (t=-2.377, -2.069, -2.149, -3.045 and -2.467, all P<0.05). There were no major motility disorders in patients of the three groups. The incidence of ineffective oesophageal motility of GERD group was higher than that of RH group and FH group (62.5%(20/32) vs. 39.4%(13/33) and 25.7%(9/35)), and the differences were statistically significant (χ2=4.440 and 9.214, both P<0.05). Conclusions GERD patients have abnormal esophageal motility, which is mainly manifested by reduced LES resting pressure, decreased EGJ barrier function, and abnormal peristalsis of the esophagus. Patients with RH also have decreased EGJ barrier function. Key words: Gastroesophageal reflux; Functional heartburn; Reflux hypersensitivity; High resolution manometry; Lyon consensus

1763 Chronic Opioid Use and EGJ Outflow Obstruction: An Important Culprit to Address Before Expensive Management

INTRODUCTION: With the opioid epidemic on the rise, a more thorough understanding of opioid’s side effects on esophageal motility is necessary. Esophageal motility disorders are an unrecognized association with opioid use. CASE DESCRIPTION/METHODS: Case 1: 58-year old female was referred to our clinic for second opinion. She presented with has intermittent solid and fluid dysphagia with sensations of food stuck in her esophagus and subsequent development of severe chest pain. She has a history of a cervical fracture and has been on oxycodone 15 mg TID. Extensive workup was performed, including endoscopy, EUS, CAT scan, cardiac stress test, all of which were negative. HRM showed EGJ outflow obstruction and features of jackhammer esophagus. Her esophagram showed delayed emptying of LES. Case 2: 65-year old female with history of skull fracture and was on hydromorphone 4 mg every 4 hours. She presents with weight loss, esophageal dysphagia, recurrent aspiration pneumonia, and refractory reflux. Upper endoscopy showed hypertonic LES with resistance passing the scope. Barium study showed delayed passage of tablet at the EGJ. HRM showed EGJ outflow obstruction. Symptoms improved with reduction of opioid dose. DISCUSSION: While opiates are known to cause gastrointestinal distress, their effect on esophageal motility is recently being investigated. As the opioid epidemic continues to grow and spread both in the US and abroad, it is vital for health care providers to recognize underreported symptoms caused by opioids. One of the symptoms recently identified in association with opioid use is dysphagia. It has been shown that the lower esophageal sphincter contains opioid receptors which when activated, elicit pathologic deglutition. EGJ outflow obstruction can be caused by chronic opioid use. Achalasia, jackhammer, and esophageal spasm have also been reported with opioid use, although this is less established. When encountering esophageal motility disorder in patients with chronic opioid use, providers should first attempt to reduce opioid dose, instead of using more invasive techniques such as myotomy and dilation. Babaei A, et al. Chronic daily opioid exposure is associated with dysphagia, esophageal outflow obstruction, and disordered peristalsis. Neurogastroenterol Motil. 2019 Ravi, K et al. Achalasia and chronic opiate use: innocent bystanders or associated conditions? Dis Esophagus. 2016;29:15‐21.

A517 Achalasia after Banded Roux-en-Y Gastric Bypass

Achalasia is an esophageal motility disorder characterized by esophageal aperistalsis and inadequate relaxation of the lower esophageal sphincter to food or liquid. It is a rare condition, but may be more prevalent in patients with a previous bariatric operation1,2. Gastric bands are known to cause pseudo-achalasia, in which a tight band mimics the failure of lower esophageal sphincter relaxation characteristic of true achalasia. While pseudo-achalasia typically resolves with band deflation or removal, Heller myotomy is the operation of choice for achalasia in patients with previous gastric bypass3. The prevalence of motility disorders in patients with gastric bands is well-established4,5, but there are no reported cases of achalasia presenting in a patient with both bypass anatomy and a gastric band. The following describes the case of a 28-year-old female who presented to our clinic with dysphagia to solids and liquids, regurgitation, and recurrent aspiration pneumonia 11 years after laparoscopic Roux-en-y gastric bypass with silastic band placement in Brazil. This was a unique diagnostic problem, as our differential diagnoses included both true achalasia and pseudo-achalasia. Evaluation included the standard workup for achalasia—an upper-GI study and esophageal manometry—but also required an enteroscopy and an abdominal CT scan to rule out pseudo-achalasia. Once the final diagnosis of true achalasia was confirmed, the patient underwent a Heller myotomy with complete resolution of symptoms. We hope to emphasize that care should be taken to rule out achalasia in the evaluation of patients with dysphagia after bariatric surgery, even when pseudo-achalasia is suspected.

The Predictive Factors of Abnormal Esophageal Motility in Systemic Sclerosis Patients by High Resolution Manometry

AbstractBackground: Esophageal motility changes occur in about 80% of systemic sclerosis (SSc) patients with decreasing the motility of the lower two-thirds of the esophagus and lower esophageal sphincter (LES) pressure.Aim of Study: Using high resolution manometry (HRM) to study the esophageal motility disorder in patients with systemic sclerosis to evaluate the predictive factors associated with esophageal affection.Patients and Methods: A prospective study was done on twenty female patients with SSc. Demographic data and esophageal symptoms including Gastroesophageal Reflux disease (GERD) and dysphagia were evaluated. All patients underwent HRM and High Resolution Computed Tomography (HRCT), Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Hemoglobin level (Hgb), Forced Vital Capacity (FVC).Results: High resolution manometry showed normal upper esophageal contraction in 100% of patients. Middle and lower esophageal contraction were normal in 30%, hypoperestalsis in 5%, and aperestalsis in 65% of patients. Regarding the lower esophageal sphincter pressure, it showed normal pressure in 30%, hypotensive in 65% and hypertensive in 5% of patients. The esophageal involvement was GERD in 70% and dysphagia in 45% of patients. The pulmonary involvement was dyspnea in 70% and cough in 40% of patients. All patients had skin involvement. Abnormal motility was present in 14 out of 20 patients (70%) which was significantly related to Interstitial Lung Disease (SSc-ILD) (p= 0.001), SSc subtypes (p=0.03), dyspnea (p=0.01) and FVC (p=0.046). A significant relation between GERD and ILD (p<0.05) was found.Conclusion: This study confirmed an increased prevalence of esophageal motility disorders in SSc patients with and without esophageal symptoms.

Gender, medication use and other factors associated with esophageal motility disorders in non-obstructive dysphagia

BackgroundHigh-resolution esophageal manometry (HREM) is the diagnostic test of choice for evaluation of non-obstructive dysphagia. Studies regarding the predictors of esophageal dysmotility are limited. Therefore, our aim was to study the prevalence of and factors associated with esophageal motility disorders in patients with non-obstructive dysphagia.MethodsWe performed a retrospective review of all patients with non-obstructive dysphagia who underwent HREM in a tertiary center between 1 January 2014 and 31 December 2015. After obtaining IRB approval (16–051), clinical records were scrutinized for demographic data, symptoms, medication use, upper endoscopic findings and esophageal pH findings. HREM plots were classified per Chicago Classification version 3.0. Primary outcome was prevalence of esophageal motility disorders; secondary outcomes assessed predictive factors.ResultsIn total, 155 patients with non-obstructive dysphagia (55 ± 16 years old, 72% female) were identified. HREM diagnosis was normal in 49% followed by ineffective esophageal motility in 20%, absent contractility in 7.1%, achalasia type II in 5.8%, outflow obstruction in 5.2%, jackhammer esophagus in 4.5%, distal esophageal spasm in 3.9%, fragment peristalsis in 1.9%, achalasia type I in 1.9%, and achalasia type III in 0.6%. Men were five times more likely to have achalasia than women [odds ratio (OR) 5.3, 95% confidence interval (CI): 2.0–14.2; P = 0.001]. Patients with erosive esophagitis (OR 2.9, 95% CI: 1.1–7.7; P = 0.027) or using calcium channel blockers (OR 3.0, 95% CI: 1.2–7.4; P = 0.015) were three times more likely to have hypomotility disorders.ConclusionFrom this study, we concluded that HREM diagnosis per Chicago Classification version 3.0 was normal in 49% of patients with non-obstructive dysphagia. Male gender, erosive esophagitis and use of calcium channel blockers were predictive of esophageal motility disorders.

Factors predictive of gastroesophageal reflux disease and esophageal motility disorders in patients with non-cardiac chest pain

Background: Patients with non-cardiac chest pain (NCCP) are referred for esophageal motility testing and pH monitoring since gastroesophageal reflux disease (GERD) and esophageal motility disorders are frequently encountered in these patients. Our aim was to determine the prevalence and distribution of these disorders and to identify predictors of abnormal esophageal function testing.Methods: We performed a retrospective study of NCCP patients who presented after a negative cardiac evaluation and underwent esophageal manometry, esophageal pH monitoring and upper endoscopy from January 2010 to January 2017.Key results: In a total of 177 patients, esophageal motility disorders were diagnosed in 31% and GERD in 35% of the patients. The most common diagnoses were ineffective esophageal motility (IEM) in 14.1%, jackhammer esophagus in 6.8%, diffuse esophageal spasm in 5.1% and achalasia in 2.3% patients. Older age [for every 5-year increment, odds ratio (OR) 1.2 (95% confidence intervals (CI) 1.00–1.3) p = .047] and dysphagia [OR 3.8 (95% CI, 1.9–7.5) p < .001] were predictors of esophageal motility disorders. Older age [for every 5-year increment, OR 1.2 (95% CI, 1.01–1.3) p = .032] was predictive of GERD. Abnormal esophageal testing was associated with male gender [OR 2.2 (95% CI, 1.04–4.6) p = .039], older age [for every 5-year increment, OR 1.2 (95% CI, 1.03–1.3) p = .016] and Caucasian race [OR 3.1 (95% CI, 1.1–8.7) p < .029].Conclusions: Approximately two thirds of patients presenting with NCCP have GERD or esophageal motility disorders. Esophageal function testing in NCCP should be considered in older patients, men, Caucasians and those presenting with dysphagia.

Effects of different food bolus on esophageal motility in patients with non-obstructive esophageal dysphagia

Objective To analyze the effects of different food bolus on esophageal motility in patients with non-obstructive esophageal dyshagia by high-resolution esophageal manometry. Methods From March 2014 to June 2015, 48 patients with non-obstructive esophageal dysphagia and 12 healthy volunteers (healthy control group) were enrolled. High-resolution manometry was tested when swallowing liquid food, semisolid food and solid food. The lower esophageal sphincter pressure (LESP), 4 second integrated relaxation pressure (4 s IRP), distal contractile integral (DCI), distal latency (DL), and breaks were analyzed. T test was performed for statistical analysis. Results According to the 2014 Chicago classification standard, among 48 patients with dysphagia, esophageal dysmotility was diagnosed in 35 patients (72.9%), while 13 patients (27.1%) had normal esophageal motility, and the most common type of esophageal motility disorder was ineffective esophageal motility (31.2%, 15/48). The LESP of the healthy control group was (10.85±3.75) mmHg (1 mmHg=0.133 kPa) and 4 s IRP was (1.90±0.84) mmHg. The LESP of dysphagia group was (12.20±8.93) mmHg and 4 s IRP was (3.25±1.02) mmHg. There was no significant difference in LESP and 4 s IRP between two groups (both P>0.05). The DCIs of liquid swallows, semisolid swallows and solid swallows of healthy control group were (589.00±292.90), (690.17±52.41) and (808.00±448.53) mmHg·s·cm, respectively, which were significantly lower than those of complete normal group in Chicago classification ((1 346.62±244.83), (1 542.46±231.19) and (1 890.31±363.26) mmHg·s·cm; t=4.76, 4.68 and 3.79; all P=0.001). The DL of solid swallows of healthy control group was (7.72±1.15) s, which was significantly lower than that of complete normal group in Chicago classification ((9.00±1.23) s; t=2.61, P=0.021). The breaks of liquid swallows, semisolid swallows and solid swallows of healthy control group were (2.33±1.74), (2.37±1.72) and (1.53±1.22) cm, respectively, which were higher than those of complete normal group in Chicago classification ((0.58±0.48), (0.52±0.47) and (0.85±0.53) cm), and the differences were statistically significant (t=3.02, 3.68 and 2.54, all P<0.05). Conclusions The most common type of esophageal motility disorder in patients with non-obstructive esophageal dysphagia is ineffective esophageal molitity. When swallowing food, the patients with dysphagia but normal results of esophageal manometry according to Chicago classification require more strength of the esophagus, more complete contraction and longer peristaltic time to swallow food bolus. Key words: High-resolution esophageal manometry; Non-obstructive esophageal dysphagia; Different food bolus swallow

Prevalence of Gastric Motility Disorders in Patients with Functional Dyspepsia.

Background/AimsGastric motility abnormalities have been considered to be pathophysiological features of functional dyspepsia (FD) that are closely related to dyspepsia symptoms, especially postprandial distress syndrome (PDS). The aims of this study are to (1) investigate the prevalence of gastric motility disorders and (2) evaluate the association between gastric motility abnormalities and dyspeptic symptoms using gastric scintigraphy in the PDS type of FD.MethodsForty healthy subjects and 94 PDS type FD patients were enrolled in the study. The volunteers and patients ingested a radiolabeled (technetium-99m) solid test meal, and scintigraphic images were recorded. Gastric accommodation and emptying were assessed by scintigraphic imaging. The patients’ dyspeptic symptoms were also explored using self-completed symptom questionnaires with 10 variables (4 scales, 0–3 points) at the same time.ResultsIn 94 Japanese FD patients, the prevalence of impaired gastric accommodation and delayed emptying were 14.9% (14/94) and 10.6% (10/94), respectively. Gastric motility abnormalities were seen in 25.5% (24/94) of FD patients. There was no association between gastric motility abnormalities and dyspeptic symptoms.ConclusionsGastric motility abnormalities were seen in 25.5% of Japanese PDS type FD patients. However, there was no association between gastric motility abnormalities and dyspeptic symptoms on gastric scintigraphy.

Tu1678 - Prevalence of Gastric Motility Disorders in Patients with Functional Dyspepsia

Tu1678 - Prevalence of Gastric Motility Disorders in Patients with Functional Dyspepsia

Microstructural changes of the whole brain in patients with comitant strabismus: evidence from a diffusion tensor imaging study.

ObjectiveThe aim of this study was to investigate the fractional anisotropy (FA) and mean diffusivity (MD) using a diffusion tensor imaging technique and whole-brain voxel-based analysis in patients with comitant strabismus.Patients and methodsA total of 19 (nine males and ten females) patients with comitant strabismus and 19 age-, sex-, and education-matched healthy controls (HCs) underwent magnetic resonance imaging examination. Imaging data were analyzed using two-sample t-tests to identify group differences in FA and MD values. Patients with comitant strabismus were distinguishable from HCs by receiver operating characteristic curves.ResultsCompared with HCs, patients with comitant strabismus exhibited significantly decreased FA values in the brain regions of the left superior temporal gyrus and increased values in the bilateral medial frontal gyrus, right globus pallidus/brainstem, and bilateral precuneus. Meanwhile, MD value was significantly reduced in the brain regions of the bilateral cerebellum posterior lobe and left middle frontal gyrus but increased in the brain regions of the right middle frontal gyrus and left anterior cingulate.ConclusionThese results suggest significant brain abnormalities in comitant strabismus, which may underlie the pathologic mechanisms of fusion defects and ocular motility disorders in patients with comitant strabismus.

Esophageal Impedance Monitoring: Clinical Pearls and Pitfalls.

The development of intraluminal esophageal impedance monitoring has improved our ability to detect and measure gastroesophageal reflux without dependence on acid content. This ability to detect previously unrecognized weak or nonacid reflux episodes has had important clinical implications in the diagnosis and management of gastroesophageal reflux disease (GERD). In addition, with the ability to assess bolus transit within the esophageal lumen, impedance monitoring has enhanced the recognition and characterization of esophageal motility disorders in patients with nonobstructive dysphagia. The assessment of the intraluminal movement of gas and liquid has also been proven to be of diagnostic value in conditions such as rumination syndrome and excessive belching. Further, alternative applications of impedance monitoring, such as the measurement of mucosal impedance, have provided novel insights into assessing esophageal mucosal integrity changes as a consequence of inflammatory change. Future applications for esophageal impedance monitoring also hold promise in esophageal conditions other than GERD. However, despite all of the clinical benefits afforded by esophageal impedance monitoring, important clinical and technical shortcomings limit its diagnostic value and must be considered when interpreting study results. Overinterpretation of studies or application of impedance monitoring in patients can have deleterious clinical implications. This review will highlight the clinical benefits and limitations of esophageal impedance monitoring and provide clinical pearls and pitfalls associated with this technology.

High-Resolution Manometry Improves the Diagnosis of Esophageal Motility Disorders in Patients With Dysphagia: A Randomized Multicenter Study.

High-resolution manometry (HRM) might be superior to conventional manometry (CM) to diagnose esophageal motility disorders. We aimed to compare the diagnosis performed with HRM and CM and confirmed at 6 months in a multicenter randomized trial. Patients with unexplained dysphagia were randomized to undergo either CM or HRM. Motility disorders were diagnosed using the Castell and Spechler classification for CM and the Chicago classification for HRM. Diagnosis confirmation was based on clinical outcome and response to treatment after 6-month follow-up. The initial diagnosis and percentage of confirmed diagnoses were compared between the two arms (CM and HRM). In total, 247 patients were randomized and 245 analyzed: 122 in the CM arm and 123 in the HRM arm. A manometric diagnosis was more frequently initially achieved with HRM than with CM (97% vs. 84%; P<0.01). Achalasia was more frequent in the HRM arm (26% vs. 12% in the CM arm; P<0.01) while normal examinations were more frequent in the CM arm (52% vs. 28% in the HRM arm; P<0.05). After follow-up, the initial diagnosis was confirmed in 89% of patients in the HRM arm vs. 81% in the CM arm (P=0.07). Finally, overall procedure tolerance was better with CM than with HRM (P<0.01). This randomized trial demonstrated an improved diagnostic yield for achalasia with HRM compared with CM. Diagnoses tended to be more frequently confirmed in patients who underwent HRM, suggesting that esophageal motility disorders could be identified earlier with HRM than with CM (ClinicalTrial.gov, NCT01284894).

Patterns of esophageal pressure responses to a rapid drink challenge test in patients with esophageal motility disorders.

Multiple rapid swallow has been proposed as a challenge test that can help diagnosis and management of patients with esophageal motility disorders. Our aim was to characterize specific pressure patterns in response to a rapid drink challenge test in patients with esophageal motility disorders, and to determine the potential of these patterns in the diagnosis of patients with esophageal symptoms but normal single swallow manometry. Pressure responses to a rapid drink challenge test (rapid swallow of 200 mL water) were prospectively analyzed in 30 healthy controls and 285 patients with esophageal symptoms: 33 achalasia, 68 hypocontractile motility, 27 hypercontractile motility and 160 patients with normal manometry. Three different patterns of responses were characterized: (i) hypopressive or normal pattern that was shared by healthy subjects and patients with hypocontractile peristalsis, and discriminated patients with non-obstructive hypercontractile motility or achalasia (p < 0.001; sensitivity 80% and specificity 93%), (ii) brief hyperpressive pattern observed in patients with non-obstructive hypercontractile disorders (distal spasm and hypercontractile esophagus), and (iii) prolonged hyperpressive pattern, that discriminated achalasia from patients with non-obstructive hypercontractile disorders (p < 0.001; sensitivity 70% and specificity 85%). Seventeen percent of patients with esophageal symptoms but normal single swallow manometry had abnormal responses to the drink challenge test: 14% a brief hyperpressive pattern, and 3% a prolonged hyperpressive pattern. Specific patterns of responses to a rapid drink challenge test could help identification of motility disorders in patients with esophageal symptoms but unclear or normal esophageal manometry.

Zaburzenia motoryki przewodu pokarmowego u chorych na jadłowstręt psychiczny – przegląd piśmiennictwa

Anorexia nervosa is a disease carrying havoc on many levels of the body functioning. The presence of numerous somatic complications as a consequence of starvation is an important part of the clinical picture of this disease. Symptoms of the gastrointestinal tract are one of the most common complaints reported by patients, especially in the initial period of realimentation. Most common symptoms are associated with gastrointestinal motility disorders. The available data show that as many as half of patients suffering from anorexia nervosa manifest significant gastrointestinal motility disorders (incomplete relaxation of the upper and lower oesophageal sphincter, impaired compliance of the stomach, delayed gastric emptying, intestinal transit extension, decreased motility of the rectum and anus). These disorders along with gastrointestinal tract ailments may impede the restoration of proper diet, if not detected early and treated. There are relatively few studies on gastrointestinal motility disorders in patients suffering from anorexia nervosa, which do not clearly answer the question whether these disorders are genetic, or result from cachexia and whether they disappear along with the restoration of the normal body weight. No reference of research results to the clinical practice, and the lack of standard procedures for diagnosis and treatment of gastrointestinal disorders in patients with anorexia nervosa are significant problems for specialists in the field of psychiatry and gastroenterology.

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

Tu1967 High Resolution Manometry Improves the Diagnosis of Esophageal Motility Disorders in Patients With Dysphagia: Preliminary Results of a Randomized Multicenter Trial

Tu1967 High Resolution Manometry Improves the Diagnosis of Esophageal Motility Disorders in Patients With Dysphagia: Preliminary Results of a Randomized Multicenter Trial

Spastic Achalasia and Detrusor Spasm: Combined Visceral Neuromuscular Disorders in a Patient with Williamʼs Syndrome

Introduction: William's syndrome is a rare congenital disorder caused by deletions at chromosomal band 7q11.23. The condition is characterized by distinctive facies, gregarious personality, developmental delay and supravalvular aortic stenosis. Spastic motility disorders and diverticulosis of the bladder are often seen. Abdominal pain, constipation, gastroesophageal reflux and colonic diverticulosis are gastrointestinal manifestations of William's Syndrome. However, spastic motility disorders of the esophagus have not previously been described. Case Description: The patient is a 37-year-old male with William's syndrome. He exhibited neonatal failure to thrive, without the typical swallowing difficulties expected in infants with William's syndrome. Bedwetting was reported until the age of four years old and was corrected by training with an enuresis alarm. At age 25, the patient developed a poor urinary stream, straining, and incomplete bladder evacuation. A urodynamic study showed detrusor spasm. A suprapubic catheter was placed at age 27. When the patient was 33 years old, he was evaluated for severe abdominal pain and mild dysphagia. Abdominal examination was unremarkable. A computed tomography (CT) scan of the abdomen revealed dilation of the esophagus above the esophageal hiatus. An upper endoscopy showed esophageal diverticula. This was confirmed by an esophagram displaying a large epiphrenic esophageal diverticulum (4-5 cm in diameter) and a second more proximal diverticulum (2-3 cm in diameter). The patient began to experience worsening dysphagia and weight loss (from 120 pounds to 100 pounds), and vomiting after eating. An esophageal manometry performed at a tertiary care center showed a large transition zone defect in the mid-esophagus and very rapidly conducted distal contractions. Retrograde escape occurred with about 50% of the esophageal contractions. These findings are consistent with the manometric diagnosis of spastic achalasia. Botulinum toxin A (Botox) injection or esophageal myomectomy were recommended but declined by the patient and his family. A pureed diet was initiated with subsequent weight gain and marked improvement of dysphagia. Discussion: Detrusor spasm and diverticulosis of the bladder are frequently described in patients with William's syndrome. To our knowledge, spastic achalasia (a very rare esophageal motility disorder) and esophageal diverticula are new findings in this condition. We propose that esophageal and bladder motility disorders are part of an overall visceral neuromuscular defect related to the pathophysiology of William's syndrome. Physicians should recognize the potential for esophageal motility disorders in patients with William's syndrome.

Constipation Is More Frequent Than Diarrhea in Patients Fed Exclusively by Enteral Nutrition

Digestive complications in enteral nutrition (EN) can negatively affect the nutrition clinical outcome of hospitalized patients. Diarrhea and constipation are intestinal motility disorders associated with pharmacotherapy, hydration, nutrition status, and age. The aim of this study was to analyze the frequency of these intestinal motility disorders in patients receiving EN and assess risk factors associated with diarrhea and constipation in hospitalized patients receiving exclusive EN therapy in a general hospital. The authors performed a sequential and observational study of 110 hospitalized adult patients fed exclusively by EN through a feeding tube. Patients were categorized according to the type of intestinal transit disorder as follows: group D (diarrhea, 3 or more watery evacuations in 24 hours), group C (constipation, less than 1 evacuation during 3 days), and group N (absence of diarrhea or constipation). All prescription drugs were recorded, and patients were analyzed according to the type and amount of medication received. The authors also investigated the presence of fiber in the enteral formula. Patients classified in group C represented 70% of the study population; group D comprised 13%, and group N represented 17%. There was an association between group C and orotracheal intubation as the indication for EN (P < .001). Enteral formula without fiber was associated with constipation (logistic regression analysis: P < .001). Constipation is more frequent than diarrhea in patients fed exclusively by EN. Enteral diet with fiber may protect against medication-associated intestinal motility disorders. The addition of prokinetic drugs seems to be useful in preventing constipation.

Opiate‐induced oesophageal dysmotility

Opiates have well characterized (troublesome) untoward effects on the gastrointestinal tract. Opioid bowel dysfunction has been a subject of research and even drug design, but surprisingly little is known with regard to clinical effects of opiates on the oesophagus. To characterize opiate effects on motor function of the oesophagus in patients presenting with dysphagia. Retrospective review of 15 patients with dysphagia referred for oesophageal manometry while on chronic opiates. Manometry was completed during opiate use and in three cases, after opiates were discontinued. All patients demonstrated motility abnormalities. Incomplete lower oesophageal sphincter (LOS) relaxation (11.5 +/- 1.6 mmHg) was seen in most cases. Ten patients demonstrated nonperistaltic contractions in > or =3 of 10 swallows. Additional abnormalities included high amplitude contractions; triple peaked contractions; and increased velocity. The average resting lower oesophageal sphincter (LOSP) met criteria for hypertensive LOS in three patients. These features were suggestive of spasm or achalasia. Repeat manometry off opiates was performed in three cases. LOS relaxation was noted to be complete upon repeat manometry in these cases. There was also improved peristalsis and normal velocity. A range of manometric abnormalities were seen in patients with dysphagia in the setting of opiate use: impaired LOS relaxation, high amplitude/velocity and simultaneous oesophageal waves. These data suggest that the oesophagus is susceptible to the effects of opiates and care must be taken before ascribing dysphagia to a primary oesophageal motility disorder in patients taking opiates.

Exercise-provoked esophageal motility disorder in patients with recurrent chest pain

To investigate the relationship between exercise-provoked esophageal motility disorders and the prognosis for patients with chest pain. The study involved 63 subjects with recurrent angina-like chest pain non-responsive to empirical therapy with proton pump inhibitor (PPI). In all, a coronary artery angiography, panendoscopy, 24-h esophageal pH-metry and manometry, as well as a treadmill stress test with simultaneous esophageal pH-metry and manometry monitoring, were performed. Thirty-five subjects had no significant coronary artery lesions, and 28 had more than 50% coronary artery narrowing. In patients with hypertensive esophageal motility disorders, a calcium antagonist was recommended. The average follow-up period was 977 ± 249 d. The prevalence of esophageal disorders, such as gastroesophageal reflux or diffuse esophageal spasm, was similar in patients both with and without significant coronary artery narrowing. Exercise prompted esophageal motility disorders, such as a decrease in the percentage of peristaltic and effective contractions and their amplitude, as well as an increase in the percentage of simultaneous and non-effective contractions. In 14 (22%) patients the percentage of simultaneous contractions during the treadmill stress test exceeded the value of 55%. Using Kaplan-Meier analysis and the proportional hazard Cox regression model, it was shown that the administration of a calcium channel antagonist in patients with such an esophageal motility disorder significantly decreased the risk of hospitalization as a result of a suspicion of acute coronary syndrome after the 2.7-year follow-up period. In patients with chest pain non-responsive to PPIs, a diagnosis of exercise-provoked esophageal spasm may have the effect of lowering the risk of the next hospitalization.