Upper Esophageal Sphincter Pressure Research Articles

Esophageal motor dysfunction plays a key role in GERD with globus sensation – Analysis of factors promoting resistance to PPI therapy

Objective. Patients with gastroesophageal reflux disease (GERD) also have various extra-esophageal symptoms. Laryngopharyngeal reflux disease (LPRD) is a subtype of GERD associated with globus sensation, but proton pump inhibitor (PPI) therapy achieves disappointing results. This study investigated esophageal motility in GERD patients with globus sensation who were resistant to PPI therapy. Design.The subjects were 350 patients with globus sensation. All patients underwent both laryngoscopy and upper gastrointestinal endoscopy to exclude organic disease. After 4 weeks of treatment with rabeprazole sodium (20 mg daily), the patients were divided into PPI-responsive and PPI-resistant groups. Then we investigated esophageal motility in the PPI-resistant group by a multichannel intraluminal impedance and manometry study. Results. A total of 119 patients (55.6%) were resistant to PPI therapy, among whom 57 patients (47.9%) had abnormal esophageal motility. They included 36 patients (66.4%) with ineffective esophageal motility, 9 patients (14.4%) with achalasia, 6 patients (9.6%) with diffuse esophageal spasm, 5 patients (8%) with nutcracker esophagus, and 1 patient (1.6%) with hypertensive lower esophageal sphincter. There were significant differences of upper esophageal sphincter pressure and esophageal body peristalsis between the patients with PPI-resistant LPRD and healthy controls matched for age and sex. Conclusion.Among patients with PPI-resistant LPRD, 47.9% had abnormal esophageal motility.

Effects of Submental Neuromuscular Electrical Stimulation on Pharyngeal Pressure Generation

Heck FM, Doeltgen SH, Huckabee M-L. Effects of submental neuromuscular electrical stimulation on pharyngeal pressure generation. ObjectiveTo investigate the immediate and late effects of submental event-related neuromuscular electrical stimulation (NMES) on pharyngeal pressure generation during noneffortful and effortful saliva swallows. DesignBefore-after trial. SettingSwallowing rehabilitation research laboratory. ParticipantsSex-matched (N=20) healthy research volunteers. InterventionsParticipants received 80Hz NMES of 4-second duration to floor of mouth muscles that was time-locked to 60 volitional saliva swallows. Main Outcome MeasuresManometry measures of peak pressures and duration of pressure events in the oropharynx, hypopharynx, and the upper esophageal sphincter (UES) were derived during execution of noneffortful and effortful saliva swallows. Measures were taken at baseline, during stimulation, and at 5-, 30-, and 60-minutes poststimulation. ResultsBaseline pharyngeal and UES pressures did not differ between stimulated and nonstimulated swallows. At 5- and 30-minutes poststimulation, peak pressure decreased at the hypopharyngeal and at the UES sensor during noneffortful swallows. The effect lasted up to an hour only in the hypopharynx. No changes in duration of pressure events were observed. ConclusionsUsing this treatment paradigm, decreased peak amplitude in the hypopharynx up to an hour after treatment indicates a potential risk of decreased bolus flow associated with NMES. On the other hand, decreased UES relaxation pressure may facilitate bolus transit into the esophagus.

Normative values of the esophageal manometry and its influential factors in the healthy subjects: a multiple center study in China

Objective To establish normative values of esophageal manometry in different age groups and standard test method.Methods The values of esophageal manometry were tested in healthy subjects of 3 different age groups (Group Ⅰ: 18-39 years,Group Ⅱ: 40-59 years,Group Ⅲ:≥60 years) with pneumohydraulic capillary perfusion system.The repeatability and stability of this method in lower esophageal sphincter (LES) testing were observed. Results There were no significant differences of LES length (LESL),LES pressure (LESP) at the end of expiration,average LESP,residual pressure of LES and LES relaxation rate (LESRR) in three groups (P＞0.05).The LESP at the end of inspiration in Group Ⅰ (28.98± 1.11 ) mm Hg was significantly lower than that of Group Ⅲ (34.35±1.96) mm Hg (P＜0.05).Trandiaphragmatic pressure (Pdi) in Group Ⅰ (9.55±0.62) mm Hg was significantly lower than that of Group Ⅱ (13.05±0.76) mm Hg (P＜0.05).There were no significant differences in contraction amplitude and duration of proximal and distant esophagus in 3 groups (P＞0.05).UES pressure (UESP) of Group Ⅲ was significantly lower than that of Group Ⅰ and Ⅱ (P＜0.05).As for repeatability,the second recording of LESP in Group Ⅰ and Ⅱ were significantly higher than first recording (P＜0.05).Amplitude of distant esophageal peristaltic contraction (DEPC) of female was significantly higher than of male (P＜0.05).However,there was no significant difference in amplitude of proximal esophageal peristaltic contraction (PEPC)between femal and male (P＞0.05).Conclusions The normative values of esophageal manometry in different age groups have been obtained.The dynamic parameters of LES do not change with age.Between age 40 to 59 years old,the contraction of esophageal body is strongest.UESP decreases significantly in old people.If the subjects have enough time to adapt before test,it will help to get accurate and reliable dynamic parameters of LES. Key words: Esophageal sphincter, lower; Age factors; Esophageogastric junction; manometry; Peristalsis

Development of pharyngo‐esophageal physiology during swallowing in the preterm infant

Poor feeding is a common cause of prolonged hospitalization of preterm infants. Pharyngeal and upper esophageal sphincter (UES) function of preterm infants has been technically difficult to assess and is therefore poorly characterized. The aim of this study was to assess the development of pharyngeal motility, UES function, and their coordination during nutritive swallowing in preterm infants. Development of swallowing was assessed in 18 preterm infants. High resolution manometry was performed at first oral feeding attempt (31-32 week) and then weekly for 4 weeks. Pharyngeal and UES pressure changes were characterized in 980 swallows. During swallowing, we observed an age-related increase in peak pharyngeal pressure at the laryngeal inlet (1 cm above UES) but an age-related decrease in the time required for the UES to fully relax to nadir. Analysis of the timing of proximal pharyngeal contractile peak and UES nadir showed that the UES was not fully relaxed when bolus propulsive forces were at their peak in the youngest infants. Results show developmental changes in infant swallow physiology that can be clearly linked to the effectiveness of nutritive swallowing. Most preterm infants demonstrated poor pharyngeal pressures at the laryngeal inlet coupled with poor coordination of pharyngeal propulsion with UES relaxation. These pressure patterns were less efficient than those demonstrated by older infants who were more adept at feeding. These observations may explain why infants under 34 weeks are physiologically unable to feed effectively and experience frequent choking and fatigue during feeding.

Hypotonic Upper Esophageal Sphincter With Functional Esophagogastric Junction Obstruction in a Patient With Oropharyngeal and Esophageal Dysphagia

A 71-year-old female visited to the department of gastroenterology for the evaluation of dysphagia for both liquid and solid foods for 1 month. She had several episodes of nasal regurgitation of water 10 to 20 seconds after swallowing. And, also she complained of mild dysphagia when eating solid foods. A high-resolution manometry (HRM, version 2.1, Manoscan, Sierra Scientific Instruments Inc, Los Angeles, CA, USA) was performed. The peak pharyngeal pressure 2.0 cm above mid upper esophageal sphincter (UES) was 65.1 mmHg. The mean basal pressure and residual pressure of UES was 1.4 and 0.8 mmHg. The mean integrated relaxation pressure of esophagogastric junction was 28.0 mmHg and the mean intrabolus pressure was 18.7 mmHg in 10 swallows of 5 mL. According to the classification of individual swallows based on pressure topography criteria, 7 swallows were categorized into elevated intrabolus pressure (Figure), 2 swallows into spasm and the rest one swallow into hypotensive peristalsis. What is your interpretation by the HRM findings? Figure High-resolution manometry findings. It shows 1.4 mmHg of the mean basal pressure of upper esophageal sphincter, normal contractile front velocity, 26.1 mmHg of integrated relaxation pressure and 19.8 mmHg of intrabolus pressure with a swallow compartmentalized ... The HRM of 10 swallows is classified into functional esophagogastric junction obstruction based on the Chicago classification of distal esophageal motility disorders.1 In addition, she had very low resting pressure of UES with preserved coordination of pharygoesophageal junction. Esophagoscopy and esophagogram showed no abnormal findings. Hypotonic UES with preserved coordination between pharynx and UES may be associated intermittent episodes of nasal regurgitation,2,3 and functional esophagogastric junction obstruction may cause mild dysphagia in this patient. However, it is still unclear hypotonic UES cause nasal regurgitation. Video fluoroscopic swallow study can be performed to show how nasal regurgitation occurs in this patient. Further studies are needed to clarify possible causes of abnormal findings of high-resolution esophageal manometry.

UES Pressure During Phonation Using High-resolution Manometry and 24-h Dual-probe pH-metry in Patients with Muscle Tension Dysphonia

Muscle tension dysphonia (MTD) is the pathological condition in which excessive tension of the (para)laryngeal musculature leads to a disturbed voice. This study was developed to investigate if differences in pressure in the upper esophageal sphincter (UES) were present in patients with MTD in comparison with normal speakers. Concurrently, all patients were screened for gastroesophageal reflux disease (GERD) as an associated cause or aggravating factor in MTD. The study's design was a prospective case-control study. Fourteen patients with MTD (mean age=40.2years, range=22-62years) and 14 adult controls (mean age=33.9years, range=23-58years) were studied. A water-perfusion assembly with 22 sensors was positioned to record pressures during phonation. The mean values of the phonation pressures at the UES were measured. All patients underwent a dual-probe 24-h ambulatory pH impedance in order to measure the pH and the height of the refluxes from the lower esophageal sphincter to the hypopharynx. There were no significant differences in the UES pressures of patients with MTD compared to those of normal speakers during phonation tasks and reading. Two patients were identified with GERD. In these patients the refluxate reached the UES but this did not influence the UES pressures. We conclude that this study was not able to detect differences in phonation-induced UES pressures between patients with MTD and normal speakers using a standard water-perfusion high-resolution manometry assembly. Future investigation should be focused on developing probes with closely spaced sensors in the hypopharynx and the esophagus in order to investigate if differences in UES pressures in these study populations are present.

IL-25-Induced Immunotherapy Against Obesity and the Associated Metabolic Syndrome

Background/Aim: UES contractile reflex was described in 1957 by Creamer and Schlegel. The physiological role of this reflex in preventing pharyngeal reflux of gastric content and protecting the airway has been studied extensively. However, to date the defect of this reflex has not been described. Our aim was to characterize the UES pressure response to a variety of esophageal distensions in a group of patients with complaints of regurgitation and refluxattributed supraesophageal complications. Methods: We studied 8 patients (51 ± 20 yrs., 2F) with complaints of regurgitation and supraesophageal symptoms as well as 12 healthy asymptomatic controls (25 ± 5 yrs., 6F) in the supine position. Of the 8 patients, 6 had an intact esophagus, 1 had colonic interposition, and 1 had a partial esophagectomy and gastric pull-up. We tested the UES response to esophageal distension; simulating GE reflux by rapid and slow infusion of normal saline (10, 20, 30, and 60 mL) and air (10, 20, 30, 50 mL) and each injection was repeated 3 times. UES and esophageal pressures were monitored by high resolution intraluminal manometry. Pharyngeal reflux/regurgitation was monitored by high resolution esophagopharyngeal impedance recording. Patients were instructed to signal if pharyngeal reflux was perceived. Results: There were significant differences in the UES response to rapid and slow fluid injections between patients and controls (Chi-square< 0.0001) (Table). All patients but none of the controls reported pharyngeal reflux during slow and rapid esophageal fluid infusion. UES contraction(C) was absent during slow infusion only in patient group. Pharyngeal reflux was documented by impedance in six of eight patients with intact esophagus. All rapid fluid infusions produced UES contraction in the control group, while only 70-75% of rapid fluid infusions produced a UES contraction in patients. UES response to air distension, however, was relaxation(R) in both groups. Conclusions: UES contractile response to slow esophageal fluid distention is defective in patients with complaints of regurgitation and supraesophageal complications, allowing escape of refluxate into the pharynx. UES response to esophageal slow fluid infusion can serve as a test for recognizing this defect.

Glial Cell Line Derived Neurotrophic Factor Prevents High Fat Diet Induced Obesity

Background/Aim: UES contractile reflex was described in 1957 by Creamer and Schlegel. The physiological role of this reflex in preventing pharyngeal reflux of gastric content and protecting the airway has been studied extensively. However, to date the defect of this reflex has not been described. Our aim was to characterize the UES pressure response to a variety of esophageal distensions in a group of patients with complaints of regurgitation and refluxattributed supraesophageal complications. Methods: We studied 8 patients (51 ± 20 yrs., 2F) with complaints of regurgitation and supraesophageal symptoms as well as 12 healthy asymptomatic controls (25 ± 5 yrs., 6F) in the supine position. Of the 8 patients, 6 had an intact esophagus, 1 had colonic interposition, and 1 had a partial esophagectomy and gastric pull-up. We tested the UES response to esophageal distension; simulating GE reflux by rapid and slow infusion of normal saline (10, 20, 30, and 60 mL) and air (10, 20, 30, 50 mL) and each injection was repeated 3 times. UES and esophageal pressures were monitored by high resolution intraluminal manometry. Pharyngeal reflux/regurgitation was monitored by high resolution esophagopharyngeal impedance recording. Patients were instructed to signal if pharyngeal reflux was perceived. Results: There were significant differences in the UES response to rapid and slow fluid injections between patients and controls (Chi-square< 0.0001) (Table). All patients but none of the controls reported pharyngeal reflux during slow and rapid esophageal fluid infusion. UES contraction(C) was absent during slow infusion only in patient group. Pharyngeal reflux was documented by impedance in six of eight patients with intact esophagus. All rapid fluid infusions produced UES contraction in the control group, while only 70-75% of rapid fluid infusions produced a UES contraction in patients. UES response to air distension, however, was relaxation(R) in both groups. Conclusions: UES contractile response to slow esophageal fluid distention is defective in patients with complaints of regurgitation and supraesophageal complications, allowing escape of refluxate into the pharynx. UES response to esophageal slow fluid infusion can serve as a test for recognizing this defect.

Pharyngeal and Oesophageal Dysmotility and Dysfunction in Patients With Chronic Cough: Assessment by High-Resolution Manometry

Introduction Laryngopharyngeal reflux (LPR) of gastric contents is a cause of chronic cough; however the pathophysiology of this disease remains unclear. Conventional manometry has insufficient spatial resolution for the functional assessment of the pharynx, upper oesophageal sphincter (UOS) and coordination between the proximal and distal oesophageal contractions that clear refluxate from the laryngopharynx and proximal oesophagus. This study applied high resolution manometry (HRM) in patients with chronic cough with and without association to reflux events. Methods Consecutive patients referred for investigation of chronic cough in 2009 were reviewed. Patients with hiatus hernia, severe co-morbidity and previous oeosphageal surgery were excluded. Of 66 patients referred, 34 (52%) (21 F:13 M) were eligible. HRM (ManoScan 360, Sierra) with detailed analysis (ManoView 2.0, Sierra) of 10 water swallows was performed followed by 24-h ambulatory pH-monitoring. Of this group 21 patients had negative reflux-cough symptom association probability (SAP; group A) and 13 had positive SAP (group B). Results from 23 healthy controls were available for comparison. A secondary analysis to assess the association of gastro-oeosphageal reflux (GOR) disease and motility was performed. Results Mean patient age was 55±15 (19–77). Mean acid exposure time was similar in group A and B (4.9±6.5 vs 3.7±4.0; p=0.34) and a similar proportion had pathologic reflux >4.2% acid exposure/24 h (7/21, 4/13; p=0.198). Moreover there was no significant interaction between the presence of GOR on pH-monitoring and any measurement of pharyngeal or oesophageal motility in this population. There was no significant differences for baseline UOS pressure; however residual UOS intrabolus pressure on 5 ml water swallows was higher in group A and B than controls (−0.34±0.69 and 1.09±0.64 mm Hg vs −4.4±5.8 mm Hg; p The percentage of primary peristaltic contractions was lower in group B with reflux associated cough than groups A and C (56% vs 79% and 87%; p=0.03 and p Conclusion Detailed analysis of swallowing and oesophageal motility by HRM revealed changes to UOS and oesophageal function that impair clearance from the pharynx and oesophagus in patients with cough compared to healthy controls. These changes were most marked in patients in whom cough was associated to reflux events. These findings suggest that not only GOR but also impaired clearance of luminal contents from the pharynx and proximal oesophagus contribute to chronic cough.

The Effects of Aspiration Status, Liquid Type, and Bolus Volume on Pharyngeal Peak Pressure in Healthy Older Adults

The reasons for aspiration in healthy adults remain unknown. Given that the pharyngeal phase of swallowing is a key component of the safe swallow, it was hypothesized that healthy older adults who aspirate are likely to generate less pharyngeal peak pressures when swallowing. Accordingly, pharyngeal and upper esophageal sphincter pressures were examined as a function of aspiration status (i.e., nonaspirator vs. aspirator), sensor location (upper vs. lower pharynx), liquid type (i.e., water vs. milk), and volume (i.e., 5 vs. 10ml) in healthy older adults. Manometric measurements were acquired with a 2.1-mm catheter during flexible endoscopic evaluation. Participants (N=19, mean age=79.2years) contributed 28 swallows; during 8 swallows, simultaneous manometric measurements of upper and lower pharyngeal and upper esophageal pressures were obtained. Pharyngeal manometric peak pressure was significantly less for aspirators (mean=82, SD=31mmHg) than for nonaspirators (mean=112, SD=20mmHg), and upper pharyngeal pressures (mean = 85, SD = 32mmHg) generated less pressure than lower pharyngeal pressures (mean=116, SD=38mmHg). Manometric measurements vary with respect to aspiration status and sensor location. Lower pharyngeal pressures in healthy older adults may predispose them to aspiration.

Body positions and esophageal sphincter pressures in obese patients during anesthesia

The lower esophageal sphincter (LES) and the upper esophageal sphincter (UES) play a central role in preventing regurgitation and aspiration. The aim of the present study was to evaluate the UES, LES and barrier pressures (BP) in obese patients before and during anesthesia in different body positions. Using high-resolution solid-state manometry, we studied 17 patients (27-63 years) with a BMI>or=35 kg/m(2) who were undergoing a laparoscopic bariatric surgery before and after anesthesia induction. Before anesthesia, the subjects were placed in the supine position, in the reverse Trendelenburg position (+20 degrees) and in the Trendelenburg position (-20 degrees). Thereafter, anesthesia was induced with remifentanil and propofol and maintained with remifentanil and sevoflurane, and the recordings in the different positions were repeated. Before anesthesia, there were no differences in UES pressure in the different positions but compared with the other positions, it increased during the reverse Trendelenburg during anesthesia. LES pressure decreased in all body positions during anesthesia. The LES pressure increased during the Trendelenburg position before but not during anesthesia. The BP remained positive in all body positions both before and during anesthesia. LES pressure increased during the Trendelenburg position before anesthesia. This effect was abolished during anesthesia. LES and BPs decreased during anesthesia but remained positive in all patients regardless of the body position.

SP130 – Evaluation of head rotation on UES pressure

SP130 – Evaluation of head rotation on UES pressure

W1827 Globus Sensation Is Caused By a Vagal Reflex Due to Gastroesophageal Reflux with UES Pressure Elevation

W1827 Globus Sensation Is Caused By a Vagal Reflex Due to Gastroesophageal Reflux with UES Pressure Elevation

Hyperdynamic Upper Esophageal Sphincter Pressure: A Manometric Observation in Patients Reporting Globus Sensation

Although globus sensation is a common symptom, its pathogenesis is poorly defined. The aim of this study was to quantify the timing and magnitude of respiratory variation in upper esophageal sphincter (UES) pressure with high-resolution manometry (HRM) in patients with globus sensation, normal controls, and gastroesophageal reflux disease (GERD) patients without globus sensation. HRM recordings spanning from the hypopharynx to the stomach were analyzed in 131 consecutive globus patients with normal (64) and abnormal (67) distal esophageal motility. Resting UES pressure was analyzed up to 5 min before 10 5-ml water swallows. Change in UES pressure, its average magnitude between inspiration and expiration, and nadir UES relaxation pressure in globus patients were compared with those in 68 controls and 46 GERD patients without globus. UES pressure typically increased during inspiration in both controls and patients. Respiration-related change in resting UES pressure was significantly amplified in globus patients (37.3 mm Hg) compared with controls (10.6 mm Hg) and GERD patients (13.0 mm Hg) (P<0.0001). A respiratory change in UES pressure>27 mm Hg was found in >60% of globus patients and <15% of controls and GERD patients without globus. This hyperdynamic UES was not associated with other abnormalities of esophageal motor function. Hyperdynamic respiratory UES pressure changes were prevalent in patients reporting globus sensation irrespective of their deglutitive UES and distal esophageal motility. Although the etiology of this hyperdynamic UES is unclear, it does appear to be a frequent manometric observation in this patient group and may provide a new focus for further studies into pathogenesis and therapy.

Editorial: Globus: Are We Any Nearer to Understanding It?

Globus is a common functional symptom without a clearly accepted etiology. Upper esophageal sphincter (UES) hypertension and gastroesophageal reflux have been proposed but not confirmed. Kwiatek et al. report a detailed study in globus patients using high-resolution manometry (HRM). The study showed greater respiratory augmentation of UES pressure compared with control groups among two-thirds of globus patients. Further prospective studies are needed to confirm these findings and to establish whether they are of etiologic significance.

Effects of Age, Gender, Bolus Condition, Viscosity, and Volume on Pharyngeal and Upper Esophageal Sphincter Pressure and Temporal Measurements During Swallowing

The purpose of this study was to determine the effects of trial (i.e., Trial 1 vs. Trial 2); viscosity (i.e., saliva, thin, nectar-thick, honey-thick, and pudding-thick water); volume (i.e., 5 mL vs. 10 mL); age (i.e., young vs. older adults); and gender on pharyngeal (i.e., upper and lower) and upper esophageal sphincter (UES) pressures, durations, and onsets (i.e., onset of upper pharyngeal pressures relative to onsets of UES relaxations and onset of lower relative to upper pharyngeal pressures). Twenty-three young adults (M=30 years) and 21 older healthy adults (M=75 years) participated. Measurements were acquired with a 2.1-mm catheter during simultaneous manometric and endoscopic swallowing assessment. Participants contributed 18 swallows, affording a study total of 792 swallows for analyses. There was no significant effect of trial on any measurement of pressure, duration, and onset (ps=.63, .39, and .71, respectively). It was found that viscosity, volume, age, and gender affected pressure, duration, and onset measurements (e.g., onset of upper pharyngeal pressures relative to onsets of UES relaxations) but in varying degrees relative to the location in the pharynx or UES and the type of measurement (e.g., pressure, onset). Manometric measurements vary with respect to age, gender, and bolus variables and interactions of each. Consideration of these variables is paramount in understanding normal and pathological swallowing if manometry is to develop as a quantitative adjunct to videofluoroscopic and endoscopic swallowing tools.

Zenker’s Diverticula: Feasibility of a Tailored Approach Based on Diverticulum Size

BackgroundZenker’s diverticula (ZD) can be treated by transoral diverticulostomy or open surgery (upper esophageal sphincter myotomy and diverticulectomy or diverticulopexy). The aim of this study was to compare the effectiveness of a minimally invasive (group A) versus a traditional open surgical approach (group B) in the treatment of ZD. Material and MethodsBetween 1993 and September 2007, 128 ZD patients underwent transoral diverticulostomy (n = 51) or cricopharyngeal myotomy and diverticulectomy or diverticulopexy (n = 77). All patients were evaluated for symptoms using a detailed questionnaire. Manometry recorded upper esophageal sphincter (UES) pressure, relaxations, and intrabolus pharyngeal pressure. The size of the pouch was measured on the barium swallow. The choice of treatment was based on the size of the diverticulum and the patients’ preference. Long-term follow-up data were available for 121/128 (94.5%) patients with a median follow-up of 40 months (interquartile range, 17–83). ResultsMortality was nil. Three patients in group A (5.8%) and ten in group B (13%) had postoperative complications (p = n.s.). Hospital stays were markedly shorter for patients after diverticulostomy (p < 0.01). Postoperative manometry showed a reduction in UES pressure, improved UES relaxation, and lower intrabolus pressure in both groups (p < 0.05). Four patients in the open surgery group (5.2%) complained of severe dysphagia after surgery (three of them required endoscopic dilations). In the transoral diverticulostomy group, 11 patients (21.5%) required additional septal reduction (n = 8) or a surgical myotomy (n = 3) for persistent symptoms (p < 0.01); nine of these 11 patients had a ZD ≤ 3 cm in size. After primary and complementary treatments, symptoms disappeared or improved significantly at long-term follow-up in 93.5% of patients in group A and 96% of those in group B. ConclusionDiverticulostomy is safe, quick, and effective for most patients with medium-sized ZD, but open surgery offers better long-term results as a primary treatment and should be recommended for younger, healthy patients, especially those with small diverticula. Small ZD may represent a formal contraindication to the transoral approach because an excessively short septum prevents a complete division of the sphincter fibers.

Utility and Standards in Esophageal Manometry

Esophageal manometry is a specialized procedure used to evaluate lower and upper esophageal sphincter pressure, esophageal body contraction amplitude, and peristaltic sequence. The procedure is clinically useful in evaluation of a patient with nonstructural dysphagia, unexplained or noncardiac chest pain, a compendium of symptoms suggested because of gastroesophageal reflux disease, and in the preoperative evaluation for antireflux surgery. Manometric findings in 95 normal subjects evenly distributed across age groups were reported in 1987, and are the values still used in our and most laboratories today. The subsequent review will offer our "view" on the clinical utility of esophageal manometry, on the basis of years of experience and performance techniques that have remained constant over decades.

T1964 Dilation of Intercellular Spaces in Esophageal Epithelium in Non-Erosive and Erosive Reflux Disease Patients and Appropriate Controls

and pH recordings. c) sleep stages using standardized EEG, EOG and EMG recording. Results: A total of 96 EPR were recorded only three of which occurred during sleep, therefore, data regarding the remaining 93 episodes were pooled. Of these refluxates, 10 were fluid, 78 were gas and 5 were mixed. UES and esophageal pressure behavior for refluxates of different physical properties were similar and this data was pooled. Two types of UES pressures were identified during pharyngeal reflux. The UES nadir pressure for complete UES relaxation (cUES-R) averaged -2.1±3.0 mmHg. UES nadir pressure for partial relaxation (pUES-R) averaged 9.4±4.0 mmHg. Complete relaxation occurred in 26/93 (28%) of EPR while incomplete relaxation occurred in 67/93(72%). Pharyngeal reflux events occurred within 1-2 seconds of or as late as 10s after GE reflux (GER) (table). Reflux-induced CC pressure was either equal to or significantly greater than UES residual pressure (p<0.01, table). This was also true for the three pharyngeal reflux events during sleep. GER events not associated with EPR had an average CC pressure of 7.5±3.7 mmHg and a UES pressure of 54±27 mmHg. Conclusions: 1) EPR during sleep is rare. 2) EPR is accompanied by either complete or partial relaxation of UES. 3) Reflux-induced CC pressure equals or exceeds UES nadir pressure.

80 Upper Esophageal Sphincter and Gastroesophageal Junction Pressure Changes Act to Prevent Reflux During Obstructive Sleep Apnea in GERD Patients

Introduction: Gastroesophageal reflux (GER) is thought to be induced by deceasing intraesophageal pressure during obstructive sleep apnea (OSA). However, pressure changes in the upper esophageal sphincter (UES) and gastroesophageal junction (GEJ) pressure during OSA events have not been measured. Aims: Determine UES and GEJ pressure change during OSA and characterize the GER and esophago-pharyngeal reflux (EPR) events during sleep. Methods: We studied 12 controls, 5 GERD without OSA and 6 GERD with OSA patients for 6-hours post-prandially during sleep. We concurrently recorded: a) UES, GEJ and esophageal body (ESO) pressures with a high-resolution manometric system. b) pharyngeal and esophageal reflux events by impedance and pH recordings. c) sleep stages and respiratory events using polysomnogram. End inspiration UES, GEJ and ESO pressures over intervals of OSA were averaged in GERD/OSA patients and compared to average values for randomly selected ten-second intervals during sleep in controls and GERD patients. Results: Total sleep time was 309±46, 317±39 and 306±58 minutes in controls, GERD and OSA patients, respectively. Our findings confirm previous reports of decreasing ESO pressures during OSA events, however, end-inspiratory UES and GEJ pressures at the end of OSA events were significantly higher than those at the beginning of OSA (p<0.01, Table 1). End-expiratory pressure in UES, GEJ and ESO at the beginning of OSA was not changed during OSA. Only two GER events during OSA were recorded in OSA patients. The incidence of GER and EPR events during sleep in GERD/OSA patients did not differ from those in controls and GERD patients (Table 2). Conclusion: Despite a decrease in ESO pressure during OSA events, compensatory changes in UES and GEJ pressures prevent GERD patients with OSA from having an increase in reflux events.