Nonspecific Motility Disorder Research Articles

Association between eosinophilic esophagitis and esophageal dysmotility: A systematic review and meta-analysis.

There is conflicting evidence about the association between eosinophilic esophagitis (EoE) and esophageal motility disorders. The aim of this study was to evaluate esophageal manometry findings in EoE. We conducted a systematic review using PubMed, EMBASE, and Web of Science. All articles from 1990 to 2021 with EoE patients who underwent esophageal manometry were eligible. We also included pertinent abstracts from national conferences from 2015 to 2020. The primary outcomes were the prevalence of specific Chicago 3 Classification (CCv3) diagnoses in EoE, as well as broader categories of non-relaxing lower esophageal sphincter, and major and minor peristaltic disorders. When multiple studies reported a specific outcome, we performed random effects meta-analysis to obtain pooled prevalence of each outcome. To reduce heterogeneity, we restricted meta-analysis to high-resolution manometry (HRM) studies only. Of 763 publications identified, 27 original studies met criteria for inclusion, encompassing 706 EoE patients; 14 studies (425 patients) had HRM and underwent meta-analysis. The pooled prevalence of any motility abnormality was 53% (95% CI: 43%-63%), largely comprised of minor motility disorders such as ineffective esophageal motility and fragmented peristalsis. Major motility disorders, classified by CCv3, were less common in EoE, with pooled prevalence of 2% (0%-7%), 10% (5%-16%), and 1% (0%-3%), for achalasia, esophagogastric-junction outflow obstruction, and hypercontractile disorders, respectively. Non-specific motility disorders were common in patients with EoE, but major motility disorders were rare. Further studies are needed to determine the relationship between eosinophilic infiltration and the clinical relevance of abnormal esophageal motility findings in this population.

Parkinsonova choroba a postihnutie GITu

Involvement of the upper part of the gastrointestinal tract in patients with Parkinson disease is reported less frequently than the involvement of the lower part. Its clinical impact is, however, substantial because dysphagic symptoms considerably decrease the quality of life and may lead to life threatening complications. Even though the clinical symptoms related to esophageal motility disorders as a result of Parkinson disease are more common in the advanced stages of the disease, these could be dia­gnosed much earlier using high resolution manometry. The authors describe the basic principles of dia­gnostic management of dysphagia in patients with Parkinson disease and in the clinical part they present an analysis of their patient cohort. They found out that nonspecific and diverse motility disorders are present in most patients, even without dysphagic symptoms. In the experimental part, we outlined new possibilities for dia­gnostic procedures using the most up-to-date methods for the detection of pathological forms of alpha-synuclein and advanced microscopic methods. Key words: esophageal motility disorders – manometry – Parkinson disease – alpha-synuclein – FLIM analysis – immunohistochemistry

3111 Achalasia in a Patient Newly Diagnosed With HIV

INTRODUCTION: Esophageal disease is common during HIV/AIDS infection and varies from esophagitis due to opportunistic infections as candida, cytomegalovirus and herpes simplex, to idiopathic ulcerations and non-specific motility disorders, but it has been suggested also that HIV infection itself can be the culprit of esophageal symptoms. We are presenting a case report of likely achalasia that was discovered in a patient newly diagnosed with HIV-1. CASE DESCRIPTION/METHODS: A 46-years-old male with no significant past medical history presented with 1 month history of recurrent attacks of nausea and non-bilious, non-projectile vomiting, 30-60 minutes following meals associated with anorexia, dysphagia and non-intentional weight loss of 10 lb. He did not have any fever, abdominal pain, diarrhea, constipation, hematemesis or melena. He was in a heterosexual relationship with no known contact to HIV infected patients. Examination was not evident of abdominal tenderness or any body swellings. Labs showed normocytic anemia with hemoglobin of 11.8 g/dl in addition to positive HIV-1 serology with viral load of 151,000 and CD4 count of 153. CT Chest was done showing sub-stantial dilation of the lower cervical, mid and distal esophagus with solid and gaseous contents. After 24 hours of “Nothing by mouth,” upper endoscopy was performed showing markedly dilated esophagus with esophageal mucosa covered with adherent food and secretions in addition to LA grade C esophagitis in the distal esophagus. Esophageal biopsy showed candida esophagitis with negative immunostains for CMV and HSV. He was started on HAART therapy and is awaiting manometry for confirmation of Achalasia diagnosis. DISCUSSION: It is accepted that HIV is aneuropathic virus and it has been related to loss of autonomic nerves in different parts of the body. Motor abnormalities have been identified in the esophagus, stomach and small intestine. The case report highlight that HIV maybe considered as possible infectious cause of achalasia.

Myotomy-First Approach to Epiphrenic Esophageal Diverticula.

Introduction: Epiphrenic esophageal diverticula are typically treated with concurrent cardiomyotomy and diverticulectomy. However, resection of these diverticula can be technically difficult and associated with significant morbidity with a staple line leak rate ranging up to 27%. For this reason, and because the diverticulum is secondary to a primary esophageal motility disorder such as achalasia, we decided to adopt a laparoscopic myotomy-first strategy, reserving the diverticulectomy for patients with persistent or recurrent symptoms. Methods: From 2004 to 2018, 22 patients with epiphrenic diverticula were treated by laparoscopic Heller myotomy and partial fundoplication alone, with the plan to add the diverticulectomy as a second stage if needed. There were 13 women and 9 women, with a mean age of 68 years. Results: Patients had been symptomatic for an average of 36 months. The most common presenting symptom was dysphagia (91%), followed by regurgitation (77%). More than half of the diverticula were solitary and on the right side. Esogphagoscopy ruled out cancer. Esophageal manometry (18 patients) showed achalasia in 14 patients, nutcracker esophagus in 3 patients, and nonspecific motility disorder in 1 patient. There were no perioperative complications, and average length of stay was 2.5 days. At a mean follow-up of 68 months, dysphagia resolved in 77% and regurgitation in 86% of patients. Three patients had persistent symptoms: 2 patients underwent a transthoracic diverticulectomy (1 patient with resolution of symptoms and 1 patient with no improvement). Another patient had per oral endoscopic myotomy, but his dysphagia persisted. Conclusions: The laparoscopic myotomy-first approach reduces risk and unnecessary surgery. A laparoscopic Heller myotomy and partial fundoplication provide excellent resolution of symptoms for most, whereasonly a few will need a staged resection of the diverticulum.

Clinical Utility of Esophageal Manometry in the Patients with Dysphagia : Experience from Sudan

The aim of this study was to assess the clinical utility of esophageal manometry among Sudanese patients presenting to the National Centre for Gastrointestinal and Liver Diseases, Ibn Sina Hospital, Khartoum, Sudan. Consecutive patients referred for esophageal manometry at the aforementioned center from July 2008 through January 2011 were included in the study. Manometric studies were done after stopping medicines with a known effect on esophageal motility and an overnight fast. Immediately before the manometric study, the patients' history and clinical examination were recorded using a structured questionnaire. The major referral reason was the investigation of dysphagia in 78 patients (60.5%), followed by the evaluation of Gastroesophageal reflux disease (GERD) in 39 patients (30%), while 11 patients (9%) were referred because of non-cardiac chest pain. The manometric diagnosis in the 78 patients with dysphagia, where 51(65.4%) had achalasia, 13(16.7%) had nonspecific motility disorder, the remaining percentage was formed by GERD diffuse esophageal spasm, connective tissue disease, Nutcracker esophagus, hypertensive lower esophageal sphincter, patient manometry suggestive of myasthenia gravis, and normal manometry. GERD and Achalasia were the commonest conditions among the study group. Patients presenting with achalasia manifest the same clinical symptoms as published in the literature. The leading abnormality predisposing to GERD was hypotensive lower esophageal sphincter and weak esophageal clearance function. GERD was main cause of non-cardiac chest pain in the study population. However, it is difficult to generalize the findings of this study for the whole country since it was a single center study.

Association between visceral fat and inflammatory cytokines in reflux esophagitis.

The results of several previous studies have suggested that abdominal obesity is an important risk factor for reflux esophagitis.1,2 Among factors related to obesity, visceral fat is more associated with erosive esophagitis than body mass index (BMI).3 Physiologic abnormalities related to prolonged esophageal acid exposure have been found to occur more frequently in obese individuals than in those with normal weight. Obese subjects revealed abnormal esophageal manometric findings such as nonspecific motility disorder, nutcracker esophagus, and hypotensive lower esophageal sphincter as the most common manometric results.4 Transient relaxations of the lower esophageal sphincter (TRLES) is also reported to be more common in patients with obesity. The main stimulus for TRLES is gastric distension especially in the gastric fundus.5 Pandofino et al6 reported esophageal manometric findings suggesting that the pressure morphology within and across the esophagogastric junction were altered in obesity, which could augment the flow of gastric juices into the esophageal lumen. This anatomical disruption of the esophagogastric junction results in further hiatal hernia formation. Esophageal mucosal injury is associated with increased exposure to gastric acid. However, maintenance of chronic esophageal mucosal inflammation and esophageal metaplasia such as Barrett’s esophagus (BE) or esophageal carcinoma in obese subjects have been proposed to increase inflammatory cytokines from visceral adipose tissue.7 The relationship between obesity and esophageal neoplasia may be due to alterations in the secretion of adipokines such as adiponection and leptin. Adiponection has an anti-inflammatory effect and stimulates apoptosis, which shows inverse relationship between obesity and adiponection.8 Leptin, a satiety hormone, is secreted by adipocytes and gastric chief cells. Esophageal epithelial cells express leptin receptors. In an esophageal adenocarcinoma cell line, leptin has been shown to stimulate cell proliferation and inhibit apoptosis via cyclooxygenase-2 activation of the epidermal growth factor receptor.9 Several studies have suggested a positive association between plasma leptin and BE.10,11 Kendall et al12 reported that a high serum leptin level is associated with an increased risk of BE among men, but not women. No previous reports have documented the relationship between circulating cytokines and reflux esophagitis (RE). Recently, Nam13 conducted an interesting case-control study that suggested circulating cytokines were correlated with the risk of erosive esophagitis. They used abdominal visceral fat instead of BMI and plasma leptin level had a positive correlation with RE. The visceral fat/total fat ratio was used as an obesity index because there is no standard cut off value for defining obesity. The results indicated that both visceral fat and the visceral fat/total fat ratio were positively correlated with IL-6, IL-8, and IL-1β, but were negatively associated with adiponectin. Leptin showed no association with visceral fat, but had a strong association with the visceral fat/total fat ratio. Only visceral fat/100 and leptin were positively correlated with RE after adjusted analysis for both inflammatory cytokines and obesity indexes. Despite the positive correlation of visceral fat and leptin with risk of RE, they did not classified reflux symptom strength or severity of esophagitis. Moreover, cytokine has its effect through ligand mediate reaction. Elevated plasma levels of cytokines do not always reflect cytokine bioactivity in inflamed regions. Checking the receptor expression and cytokine levels in target tissue provides more information about cytokine-ligand mediated responses.14,15 In conclusion, obesity is an important risk factor for developing gastroesophageal reflux disease. Abdominal visceral fat is a more useful obesity index for RE than BMI. To clarify the role of circulating cytokines in obese subjects with RE, further studies with large populations are needed, which will also help elucidate the pathophysiology between obesity and RE.

A functional study of the esophagus in patients with non-cardiac chest pain and dysphagia.

Nutcracker esophagus and non-specific motility disorders are the main causes of non-cardiac chest pain (NCCP), with gastroesophageal reflux in 60% of cases. Achalasia and diffuse esophageal spasm are the most frequent anomalies described in patients with dysphagia. The goal of this study was to evaluate the occurrence of esophageal body and lower esophageal sphincter motor abnormalities in patients with dysphagia, NCCP, or both. This study is a retrospective analysis of 716 patients with NCCP and/or dysphagia tested between January 1994 and December 2010. 1023 functional studies were performed, 707 of which were esophageal manometries, 225 esophageal pH-meters, and 44 bilimetries. We divided the patients into three groups: group 1 was composed of patients affected with dysphagia, group 2 with NCCP and group 3 with NCCP and dysphagia. Manometric anomalies were detected in 84.4% of cases (p<0.001). The most frequent esophageal motility alteration was achalasia (36%). The lower esophageal sphincter was normal in 45.9% of patients (p<0.001). In all 3 groups, 80.9%, 98.8%, and 93.8, respectively, of patients showed normal upper esophageal sphincter (p=0.005). Our data differs from those of other studies because they were collected from and analyzed by a single tertiary level referral center by a single examiner. This could have eliminated the variability found in different hands and different experiences. The high percentage of symptomatic patients with non-pathologic esophageal motility pattern suggests an unclear origin of the disease, with possible neuromuscular involvement. As a result, these patients may need more-detailed diagnostic studies.

Greatly increased prevalence of esophageal dysmotility observed in persons with spinal cord injury.

The effects of spinal cord injury (SCI) on esophageal motility are largely unknown. Furthermore, due to the complete or partial loss of sensory innervation to the upper gastrointestinal tract, a symptom-based diagnosis of esophageal dysmotility is problematic in the SCI population. To determine the prevalence and characterize the type of motility disorders observed in persons with chronic SCI compared with that of able-bodied (AB) controls based on esophageal pressure topography isometrics acquired by high-resolution manometry and categorized by application of the Chicago Classification. High-resolution manometry of the esophagus was performed in 39 individuals: 14 AB, 12 with paraplegia (level of injury between T4-T12) and 13 with tetraplegia (level of injury between C5-C7). A catheter containing multiple pressure sensors arranged at 360° was introduced into the esophagi of subjects at a distance that allowed visualization of both the upper esophageal sphincters (UES) and lower esophageal sphincters (LES). After a period to acquire pressures at baseline, subjects were asked to perform 10 wet swallows with 5-mL boluses of isotonic saline while esophageal pressure and impedance were being recorded. No significant differences were noted for gender, age, or body mass index between AB and SCI groups. Twenty-one of 25 (84%) subjects with SCI had at least one motility abnormality: 12% with Type II achalasia, 4% with Type III achalasia, 20% with esophagogastric junction outflow obstruction, 4% with the hypercontractile esophagus, and 48% with peristaltic abnormalities (weak peristalsis with small or large defects or frequent failed peristalsis). In contrast, only 7% (1 out of 14) of the AB subjects had any type of esophageal motility disorder. Despite the lack of subjective complaints and clinical awareness, esophageal dysmotility appears to be a highly prevalent condition in persons with SCI. The use of new and improved techniques, as well as a more stringent classification system, permitted the identification of the presence of nonspecific motility disorders in almost all SCI subjects, including four individuals who were previously undiagnosed with achalasia. Future work in persons with SCI is required to clarify the clinical impact of this observation and to study potential associations between esophageal dysmotility, gastroesophageal reflux disease, and pulmonary function. An increased awareness of esophageal dysfunction in the SCI population may lead to the development of new clinical guidelines for the diagnosis, prevention, and treatment of these largely unrecognized disorders.

High resolution esophageal manometry—The switch from “intuitive” visual interpretation to Chicago classification

High resolution esophageal manometry (HREM) has been interpreted all along by visual interpretation of color plots until the recent introduction of Chicago classification which categorises HREM using objective measurements. It compares HREM diagnosis of esophageal motor disorders by visual interpretation and Chicago classification. Using software Trace 1.2v, 77 consecutive tracings diagnosed by visual interpretation were re-analyzed by Chicago classification and findings compared for concordance between the two systems of interpretation. Kappa agreement rate between the two observations was determined. There were 57 males (74 %) and cohort median age was 41 years (range: 14-83 years). Majority of the referrals were for gastroesophageal reflux disease, dysphagia and achalasia. By "intuitive" visual interpretation, the tracing were reported as normal in 45 (58.4 %), achalasia 14 (18.2 %), ineffective esophageal motility 3 (3.9 %), nutcracker esophagus 11 (14.3 %) and nonspecific motility changes 4 (5.2 %). By Chicago classification, there was 100 % agreement (Kappa 1) for achalasia (type 1: 9; type 2: 5) and ineffective esophageal motility ("failed peristalsis" on visual interpretation). Normal esophageal motility, nutcracker esophagus and nonspecific motility disorder on visual interpretation were reclassified as rapid contraction and esophagogastric junction (EGJ) outflow obstruction by Chicago classification. Chicago classification identified distinct clinical phenotypes including EGJ outflow obstruction not identified by visual interpretation. A significant number of unclassified HREM by visual interpretation were also classified by it.

Nonspecific motility disorders, irritable esophagus, and chest pain

This paper presents commentaries on whether Starling's law applies to the esophagus; whether erythromycin affects esophageal motility; the relationship between hypertensive lower esophageal sphincter and vigorous achalasia; whether ethnic- and gender-based norms affect diagnosis and treatment of esophageal motor disorders; health care and epidemiology of chest pain; whether normal pH excludes esophageal pain; the role of high-resolution manometry in noncardiac chest pain; whether pH-impedance should be included in the evaluation of noncardiac chest pain; whether there are there alternative therapeutic options to PPI for treating noncardiac chest pain; and the usefulness of psychological treatment and alternative medicine in noncardiac chest pain.

Upper gastrointestinal investigations before gastric banding

Long-term complications after laparoscopic gastric banding (LAGB) are frequent, leading to reoperations for a substantial number of patients. It is not known whether esophageal motility or the lower esophageal sphincter (LES) play a role in the development of complications. The results of preoperative upper gastrointestinal (GI) testing were compared with outcome after LAGB. Before LAGB, 68 bariatric patients had esophageal manometry, endoscopy, and pH monitoring. For 61 of these patients (90% follow-up rate), the differences in weight loss, complications, and reoperation rate were retrospectively compared. Of these patients, 8.2% had a nonspecific motility disorder of the esophagus, 44.3% had an incompetent sphincter shown by manometry, and 17.5% had acid reflux shown by pH monitoring. Endoscopic evaluation showed esophagitis in 10.3% and hiatal hernia in 33.8% of the patients. Abnormal pH monitoring and endoscopic findings were not predictive for the long-term outcome or complications. The presence of an incompetent LES led to reoperation for a greater number of patients (44.4 vs. 14.7%; p = 0.01), especially if the band was placed using the pars flaccida technique. Endoscopy and pH monitoring do not predict outcome for gastric banding and therefore have no relevance in the selection of patients for gastric banding. Patients with an incompetent LES shown by manometry had a higher reoperation rate. If this finding can be confirmed, patients with LES incompetence may need another intervention.

Insights Gained From the Symptomatic Evaluation of Classification of Esophageal Motility Disorders: A Review of 4215 Patients

Purpose: Achalasia (Ach), diffuse esophageal spasm (DES), nutcracker esophagus (NC), and non specific motility disorder (NSMD), are described primary esophageal body motility disorders. The relationship between manometric diagnosis and clinical symptoms is poorly understood. The aim of this study is to examine the correlation between patient's presenting symptoms and manometric findings. Methods: Manometric findings and reported symptoms of all patients undergoing esophageal manometry and pH studies at the Creighton University Medical Center were prospectively entered in a database. Twenty-four year data was accessed and analyzed to understand symptom correlation. Results: Of the 4215 patients, 130(3.1%) had Ach, 192 (4.6%) had DES, 290 (6.9%) had NC, 508 (12.1%) had NSMD and 3095 (73.4%) had normal esophageal body motility. There is significant symptom overlap between the groups. The pattern of symptom distribution is similar in patients with Ach and DES with dysphagia correlating with increasing simultaneous waves. Patients with NC, normal body motility and NSMD predominantly presented with reflux symptoms. Twenty-four hour pH score and reflux associated symptoms are inversely related to the LES competence. Conclusion: Symptoms and manometric diagnosis do not correlate well on an individual basis. Achalasia- DES seem to be part of the same clinical spectrum. Lower esophageal sphincter competence plays an important role in preventing gastro-esophageal reflux. Treatment of GERD and its related esophageal body motility disturbances should be directed at restoring LES competence.

Diagnosis and treatment of megaesophagus after adjustable gastric banding for morbid obesity

Background Laparoscopic adjustable gastric banding (LAGB) can impair esophageal peristalsis and can also cause a lack of relaxation of the lower esophageal sphincter, possibly leading to esophageal dilation. The aim of the present study was to determine the incidence of megaesophagus, the role of preoperative manometry in predicting its occurrence, and the management of megaesophagus after gastric banding in the setting of a research clinic. Methods We performed a retrospective review of a prospectively collected database. A total of 257 patients underwent LAGB from January 2002 to December 2006. The incidence of megaesophagus, its relationship to the preoperative esophageal manometry and upper gastrointestinal series findings, and the treatment of patients with this complication were analyzed. Results Of the 257 patients, 5 (1.9%) presented with megaesophagus after gastric banding. The mean interval to development was 32 months (range 24–36). The diagnosis was made using the symptoms, signs, and upper gastrointestinal series findings. The preoperative esophageal manometry findings were normal in 4 (80%) of these 5 patients, and 1 patient (20%) had a nonspecific motility disorder. The mean age was 54.5 years (range 30–76). The mean preoperative weight was 127.1 kg (range 112.7–145.9), and the body mass index was 43.2 kg/m 2 (range 41–49). In all cases, the management of megaesophagus was gastric band removal. All the patients improved partially after band deflation but required band removal because of continued symptoms. Conclusion Megaesophagus is a possible late complication after LAGB. The preoperative manometry results cannot predict for its occurrence. The management of megaesophagus caused by LAGB requires, in most cases, band removal.

USE OF SAEED BANDING DEVICE FOR REMOVAL OF IMPACTED FOOD IN CHILDREN WITH EOSINOPHILIC ESOPHAGITIS

Introduction: Esophageal food impaction in children is rare and can result from an anatomical narrowing, non-specific motility disorder or eosinophilic esophagitis. Patients with retrosternal pain and difficulty swallowing due to the impaction require endoscopic retrieval. Snares and nets have been used, but the impacted food is usually fragile and multiple attempts are generally necessary. We report four patients with esophageal food impaction that was safely removed using the Saeed banding device. Methods and Results: Four patients, median age 12 years, all male, presented with retrosternal pain and drooling after a meal. Three patients had eosinophilic esophagitis (EE) and one had no specific abnormality. Upper endoscopy under anesthesia confirmed the site of food impaction in the mid and lower esophagus in all four, and distance to the impaction was measured from the lips. The endoscope was removed and a housing cylinder from a Saeed bander without the bands (device used for esophageal variceal ligation), was snuggly fixed to the tip of the endoscope (Pentax EG-2730). The endoscope, with the housing cylinder in place, was then reintroduced into the esophagus, the plastic cylinder was placed on the food and suction applied. After the food was drawn into the cylinder, the scope was removed slowly, with continued suction until the endoscope was out of the mouth. In all four patients, the impacted food (a piece of chicken in two, and a piece of hot dog in two) was removed in a single attempt. Conclusions: Food impaction is being increasingly recognized in children with EE, and this technique offers an easy and safe method to remove impacted food from the esophagus.

Eosinophilic Esophagitis in Adults: What is the Clinical Significance?

Eosinophilic esophagitis is a condition that is being increasingly recognized in adults. The main presenting symptoms are dysphagia (93 %), food impaction (62 %), and heartburn (24 %). A history of allergy is obtained in 52 % of patients and peripheral eosinophilia is found in 31 % of patients with this condition. Esophageal manometric studies have provided evidence of a nonspecific motility disorder in 40 % of patients. Endoscopic findings include mucosal fragility or edema (59 %), solitary or multiple concentric rings (49 %), strictures (40 %), whitish pinpoint exudates or papules (16 %), and a small-caliber esophagus (5 %); 9 % of patients present with a normal endoscopy. Esophageal dilation in adults with eosinophilic esophagitis has limited efficacy and is associated with an increased complication rate compared with dilation in patients with benign strictures. The administration of inhaled or systemic corticosteroids results in symptomatic improvement in nearly 95 % of patients. A trial with corticosteroids before bougienage may reduce active inflammation and therefore the complication rate of the procedure.

Clinical implications of abnormal oesophageal motility.

The usefulness of oesophageal manometry as a clinical tool has been assessed in 202 patients requiring detailed investigation for troublesome oesophageal symptoms, who first presented between June 1979 and May 1982. Only 12 were found to have specific motility disorders such as achalasia and scleroderma. A total of 147 had a variety of non-specific motility disorders and, of these, 112 (76.2 per cent) had coexistent gastro-oesophageal reflux. There was a significant association between the symptoms of dysphagia and the occurrence of predominantly non-propagated motor activity in the oesophagus. A similarly significant relationship existed between crushing chest pain and oesophageal spasm. Despite this statistical association, detection and treatment of gastro-oesophageal reflux was found to be the most useful part of clinical management. Symptoms of associated motility disorders resolved in more than 90 per cent of patients treated by Nissen fundoplication. Preoperative assessment of motility was of no value in detecting those who might develop postoperative dysphagia. Oesophageal manometry is useful for the assessment of a small proportion of patients with oesophageal symptoms in whom gastro-oesophageal reflux has been excluded by vigorous investigation, including 24 h pH recording.

Gastric Banding Interferes With Esophageal Motility and Gastroesophageal Reflux

Gastroesophageal reflux and progressive esophageal dilatation can develop after gastric banding (GB). Gastric banding may interfere with esophageal motility, enhance reflux, or promote esophageal dilatation. Before-after trial in patients undergoing GB. University teaching hospital. Between January 1999 and August 2002, 43 patients undergoing laparoscopic GB for morbid obesity underwent upper gastrointestinal endoscopy, 24-hour pH monitoring, and stationary esophageal manometry before GB and between 6 and 18 months postoperatively. Reflux symptoms, endoscopic esophagitis, pressures measured at manometry, esophageal acid exposure. There was no difference in the prevalence of reflux symptoms or esophagitis before and after GB. The lower esophageal sphincter was unaffected by surgery, but contractions in the lower esophagus weakened after GB, in correlation with preoperative values. There was a trend toward more postoperative nonspecific motility disorders. Esophageal acid exposure tended to decrease after GB, with fewer reflux episodes. A few patients developed massive postoperative reflux. There was no clear correlation between preoperative testing and postoperative esophageal acid exposure, although patients with abnormal preoperative acid exposure tended to maintain high values after GB. Postoperative esophageal dysmotility and gastroesophageal reflux are not uncommon after GB. Preoperative testing should be done routinely. Low amplitude of contraction in the lower esophagus and increased esophageal acid exposure should be regarded as contraindications to GB. Patients with such findings should be offered an alternative procedure, such as Roux-en-Y gastric bypass.

Effects of manometrically discovered nonspecific motility disorders of the esophagus on the outcomes of antireflux surgery.

Nonspecific motility disorders (NMDs) of the esophagus are common manometric findings in patients evaluated for gastroesophageal reflux disease (GERD). However, it is unclear how these disorders affect the outcomes of antireflux surgery. The purpose of this study was to assess symptomatic outcomes of patients with and without NMDs undergoing surgical treatment for GERD. A prospectively gathered database of all patients undergoing antireflux surgery was retrospectively reviewed for preoperative symptoms, symptom severity using the GERD-HRQL (best score 0, worst score 50), esophageal manometry measurements, presence of NMD, type of operation, any transient or permanent postoperative dysphagia, severity of postoperative dysphagia (best score 0, worst score 5), and postoperative symptom severity. A total of 239 patients were studied; 24% had a NMD identified by preoperative esophageal manometry, and 17% of this +NMD group had preoperative dysphagia or atypical chest/epigastric pain compared to 28% of those without a NMD (-NMD group) (P=NS). Preoperative symptom scores were +NMD 33 vs. -NMD 27 (P=0.01). Postoperative symptom scores were +NMD 5 vs. -NMD 3 (P=NS). There were no differences in preoperative or postoperative dysphagia scores. Transient postoperative dysphagia was 15.8% in the +NMD group vs. 16.4% in the -NMD group (P=NS). Postoperative dilation was 0% in the +NMD group vs. 2% in the -NMD group (P=NS). Manometrically discovered NMDs do not appear to affect preoperative symptoms or symptomatic outcomes of patients surgically treated for GERD. These findings my reflect the severity of GERD and may improve with antireflux surgery.

A review of oesophageal manometry testing in a district general hospital

Although several modalities are available to investigate oesophageal motility disorders, manometry is the gold standard. The procedure is increasingly available in district general hospitals but the clinical utility of this...

The short- and long-term efficacy of empirical esophageal dilation in patients with nonobstructive dysphagia: a prospective, randomized study

OBJECTIVE: The efficacy of empirical esophageal dilation for nonobstructive dysphagia (NOD) is unknown. Our aim was to assess the efficacy and safety of empirical dilation with a large bougie in patients with NOD. METHODS: Patients with NOD (normal barium swallow, free passage of a 13-mm barium pill, and normal esophagogastroduodenoscopy) were randomized to dilation with either a 50-Fr (Group A) or 26-Fr (Group B) Maloney dilator. Before dilation, the dysphagia (DyspSC) and diet (DietSc) scores were recorded and an esophageal manometry performed. Both scores were reassessed at 1, 3, 7, and 14 days after dilation. Success was defined at day 14 as an improvement in the DietSc of at least 25% from baseline, or a DyspSc of ≤3. Nonresponders were crossed-over to the alternate dilator and restudied. RESULTS: Twenty-three patients (58.7 ± 1.9 yr) were enrolled: 13 in Group A and 10 in Group B. Both groups were matched for age, baseline DyspSc (4.2 ± 0.6 vs 3.8 ± 0.5), baseline DietSc (13.3 ± 1.7 vs 12.0 ± 1.9), and manometric findings. A nonspecific motility disorder was seen in 43.4% patients. Group A had an initial response rate significantly greater (84.6%) than Group B (40%) ( p = 0.03; odds ratio [OR] = 8.25). The DyspSc and DietSc were better than baseline with both dilators, but only the DietSc improved significantly in patients dilated with the 50-Fr dilator (5.3 ± 1.9 vs 12.3 ± 1.4; p = 0.004). At 2 yr, 80% of the patients responding to the 50-Fr Maloney had a sustained response. CONCLUSION: Empirical dilation with a large (50-Fr) bougie is safe, effective, and long-lasting in improving nonobstructive dysphagia.