Severe Esophageal Dysmotility Research Articles

PS01.011: PATHOPHYSIOLOGY OF LARYNGOPHARYNGEAL REFLUX DISEASE: ASSOCIATION WITH PULMONARY ASPIRATION ON SCINTIGRAPHY AND INEFFECTIVE OESOPHAGEAL MOTILITY

Abstract Background Gastro-oesophageal reflux disease (GORD) can present with typical symptoms or atypical or laryngopharyngeal reflux (LPR) symptoms. The role of impaired oesophageal motility in these two clinically distinct groups has not been previously examined. Methods This study is a retrospective analysis of 361 consecutive patient records that was extracted from a prospectively populated research database. Patients were categorised by symptom profile as predominantly LPR or GORD (98 GOR and 263 LPR). Presenting symptom profile, pH studies, oesophageal manometry and scintigraphy and the relationship between the above were analysed. Results Severe oesophageal dysmotility was more prevalent in LPR group (P = 0.037). Severe oesophageal dysmotility was strongly associated with isotope aspiration in both groups (P = 0.001). 24 per cent of patients showed evidence of pulmonary aspiration on scintigraphy. Significant correlation was established between total proximal acid on 24-hour pH monitoring and isotope aspiration in both groups (P = 0.00). Rising pharyngeal curves on scintigraphy were the strongest predictors of isotope aspiration (P = 0.00). Conclusion Early research on oesophageal dysmotility has suggested reduced oesophageal clearance in individuals with IOM. This selected group of patients showed a high degree of impaired oesophageal motility, which was associated with rising time-activity curves in both the upper oesophagus and pharynx. The presence of refluxate in the upper oesophagus can stimulate cough via ‘reflex’ afferent pathways and the presence of gastric contents in the pharynx can cause direct irritation to upper airways, both resulting in cough. Reduced pressures in the lower oesophageal sphincter were equally prevalent in LPR and GORD groups and therefore were not discriminatory between the clinical groups. The impairment of oesophageal clearance secondary to diminished oesophageal motility, may offer a plausible explanation for the development of symptoms via combined ‘reflux’ and ‘reflex’ pathways, allowing continued oesophageal exposure or proximal exposure to refluxate. The ROC and cluster analysis demonstrated strong predictive values and linkages between ineffective oesophageal motility and rising pharyngeal time-activity curves for the prediction of lung aspiration. This may form the basis of a new approach to the definitive diagnosis of LPR and lung aspiration. Oesophageal dysmotility is a key factor in pathophysiology of LPR. Severe impaired oesophageal motility is strongly associated with pulmonary aspiration in both LPR and GORD. Disclosure All authors have declared no conflicts of interest.

Gastro-Oesophageal Reflux and Aspiration: Does Laparoscopic Fundoplication Significantly Decrease Pulmonary Aspiration?

Pulmonary aspiration of gastric refluxate is one of the indications for anti-reflux surgery. Effectiveness of surgery in preventing pulmonary aspiration post-operatively has not been previously tested. The aim of this project is to assess effectiveness of anti-reflux surgery on preventing pulmonary aspiration of gastric refluxate. Retrospective analysis of prospectively populated database of patients with confirmed aspiration of gastric refluxate on scintigraphy. Patients that have undergone anti-reflux surgery between 01/01/2014 and 31/12/2015 and had scintigraphy post-operatively were included. Objective data such as resolution of aspiration, degree of proximal aero-digestive contamination, surgical complications and oesophageal dysmotility as well as patient quality of life data were analysed. Inclusion criteria were satisfied by 39 patients (11 male and 28 female). Pulmonary aspiration was prevented in 24 out of 39 patients (61.5%) post-operatively. Significant reduction of isotope contamination of upper oesophagus supine and upright (p = 0.002) and pharynx supine and upright (p = 0.027) was confirmed on scintigraphy post-operatively. Severe oesophageal dysmotility was strongly associated with continued aspiration post-operatively OR 15.3 (95% CI 2.459-95.194; p = 0.02). Majority (24/31, 77%) of patients were satisfied or very satisfied with surgery, whilst 7/31 (23%) were dissatisfied. Pre-operative GIQLI scores were low (mean 89.77, SD 20.5), modest improvements at 6 months (mean 98.4, SD 21.97) and deterioration at 12 months (mean 88.41, SD 28.07) were not significant (p = 0.07). Surgery is partially effective in reversing pulmonary aspiration of gastric refluxate on short-term follow-up. Severe oesophageal dysmotility is a predictor of inferior control of aspiration with surgery.

545 - Surgical Management of Gastroesophageal Reflux Disease in Patients with Severe Esophageal Dysmotility: A Prospectively Collected Clinical Data Base Review

545 - Surgical Management of Gastroesophageal Reflux Disease in Patients with Severe Esophageal Dysmotility: A Prospectively Collected Clinical Data Base Review

P098 <break /> Esophageal diameter is associated with systemic sclerosis-associated interstitial lung disease severity and progression

Rationale: Up to 90% of patients with systemic sclerosis (SSc) have gastrointestinal tract involvement, often including severe esophageal dysmotility. Repeated episodes of gastroesophageal reflux may be related to the initiation and progression of interstitial lung disease (ILD). We studied a cohort of systemic sclerosis-associated interstitial lung disease (SSc-ILD) patients to determine if …

Esophageal Motor Abnormalities in Patients With Scleroderma:Heterogeneity, Risk Factors, and Effects on Qualityof Life.

Systemic scleroderma (SSc) is associated with esophageal aperistalsis and hypotensive esophagogastric junction pressure, although there could be a gradation in esophageal motor dysfunction. We characterized esophageal motor function by high-resolution esophageal manometry (HRM) and assessed associations between SSc severity, health-related quality of life (HRQOL), and HRM findings in patients. We performed a prospective study of 200 patients with SSc and 102 patients without SSc (controls) who underwent HRM at Mayo Clinic Arizona from May 2006 through January 2015. We used data on integrated relaxation pressure, distal contractile integral, and distal latency to classify esophageal motility disorders according to the Chicago Classification v 3.0. A subset of subjects (n= 122) completed SSc-specific gastrointestinal symptom and HRQOL questionnaires. HRM findings, symptoms, and HRQOL data were compared among diffuse SSc, limited SSc, and control subjects. Categorical variables were compared by using the χ2 or Fisher exact test; continuous variables were compared by using Mann-Whitney or Kruskal-Wallis test. Multivariable logistic regression was used to assess the association between severity of esophageal dysmotility and baseline clinical factors. Among patients with SSc, 83 had diffuse SSc (42%), and 117 had limited SSc (58%). Absent contractility was more frequent in patients with SSc than in controls (56% vs 13%; P < .001). HRM findings varied among the patients; absent contractility (56%) was the most frequent diagnosis, followed by normal motility (26%) and ineffective esophageal motility (10%). Classic scleroderma esophagus (esophagogastric junction pressure with absent contractility) was only observed in 33% of patients (34% with diffuse SSc vs 32% limited SSc) (P= .880). Severe esophageal dysmotility was associated with disease duration, interstitial lung disease, and higher gastrointestinal symptom scores (P < .001). HRQOL was decreased in patients with SSc and severe esophageal dysmotility. Although severe dysmotility is more common in patients with SSc than in controls, we observed the so-called scleroderma esophagus in only one-third of patients with SSc. Esophageal motor function appears to be heterogeneous in SSc. Esophageal dysmotility reduces HRQOL in patients with SSc.

A Case Study of Severe Esophageal Dysmotility following Laparoscopic Sleeve Gastrectomy.

Following bariatric surgery, a proportion of patients have been observed to experience reflux, dysphagia, and/or odynophagia. The etiology of this constellation of symptoms has not been systematically studied to date. This case describes a 36-year-old female with severe esophageal dysmotility following LSG. Many treatments had been used over a course of 3 years, and while calcium channel blockers reversed the esophageal dysmotility seen on manometry, significant symptoms of dysphagia persisted. Subsequently, the patient underwent a gastric bypass, which seemed to partially relieve her symptoms. Her dysphagia was no longer considered to be associated with a structural cause but attributed to a “sleeve dysmotility syndrome.” Considering the difficulties with managing sleeve dysmotility syndrome, it is reasonable to consider the need for preoperative testing. The question is whether motility studies should be required for all patients planning to undergo a LSG to rule out preexisting esophageal dysmotility and whether conversion to gastric bypass is the preferred method for managing esophageal dysmotility after LSG.

Lymphocytic Esophagitis Presenting as Severe Dysphagia

Purpose: A 35-year-old African-American male with a history of childhood asthma, eczema, and food, drug and seasonal allergies presented with dysphagia. His symptoms began at age 7 years when he presented with regurgitation and dysphagia. There was no toxic ingestion. He was treated with antacids and H2 blockers. Symptoms were troublesome for years but resolved by age 10 years. He presented again at age 27 years with inability to tolerate solid foods. Upper endoscopy (EGD) at his local hospital was reportedly normal. He underwent manometry and was reportedly diagnosed with achalasia. A surgical myotomy was performed with only minimal improvement in symptoms. The patient presented to our institution with progressive severe solid dysphagia and weight loss. He denied odynophagia, fever, or night sweats. Physical exam: thin male, no oral lesions or lymphadenopathy. Labs: normal hemoglobin, electrolytes, and serum albumin. HIV negative. Barium esophagram: dilated esophagus with severe esophageal dysmotility. Repeat EGD: severely fibrotic and nodular mucosa. Biopsies caused linear tears and bleeding, requiring endoscopic clipping. Pathology showed active esophagitis and an inflammatory infiltrate composed of lymphocytes with admixed neutrophils and eosinophils. Based on the patient's history and pathologic findings, a clinical diagnosis of severe longstanding lymphocytic esophagitis (LE) or eosinophilic esophagitis (EoE) was made. A trial of high-dose PPI and topical budesonide was unsuccessful. Given the severity of the endoscopic findings and lack of response to medical therapy, the patient underwent an esophagectomy. Post-operatively he is able to tolerate a solid diet without recurrent dysphagia. Lymphocytic esophagitis is a poorly-understood entity. The primary symptom is dysphagia, though symptoms can include chest pain, abdominal pain, and heartburn. A wide range of ages at diagnosis has been reported. Patients often have GERD and atopic comorbidities. Endoscopic findings include rings, esophagitis, strictures, furrows, and nodularity. Biopsies are required for diagnosis and show a high number of intraepithelial lymphocytes but no more than rare neutrophils and eosinophils. Appropriate treatment for LE has not yet been defined, though prognosis appears to be good. This patient's pathology does not meet strict histologic criteria for LE. This may reflect a diagnosis of EoE, an overlap syndrome, or LE with post-surgical changes. LE should be considered in the differential diagnosis of dysphagia and more research is needed on the diagnosis, management, and natural history of this disorder.

Pseudoachalasia and Laparoscopic Gastric Banding

Pseudoachalasia and Laparoscopic Gastric Banding

Comparison of Surgical Approaches to Recalcitrant Gastroesophageal Reflux Disease in the Patient with Scleroderma

Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility seen in this disease. We hypothesized that laparoscopic Roux-en-Y gastric bypass (RYGBP) would lead to less dysphagia and better control of GERD symptoms. This report summarizes our initial results of RYGBP compared with other surgical approaches. A retrospective review identified scleroderma patients who underwent surgical management of GERD from 1995 to 2006. Complications and reinterventions were recorded. Symptom control was assessed by validated questionnaires that measured dysphagia (0 to 5; 0 = no dysphagia), GERD-heartburn-related quality of life index (0 to 45; 0 = best, 45 = worst), and overall quality of life with the Medical Outcomes Study 36-Item Short Form Health Survey. Twenty-three scleroderma patients underwent surgical treatment for GERD (fundoplication, n = 10; RYGBP, n = 8; esophagectomy, n = 5). One patient died after esophagectomy and major morbidity occurred in 3 of the remaining 4 patients. No major complications occurred in any patient undergoing either fundoplication or RYGBP. Eighteen patients underwent evaluation by questionnaire at a median of 21 months postoperatively. Decreased dysphagia (0.42 versus 1.86, p = 0.05) and improved control of reflux (GERD-heartburn-related quality of life index score 4 versus 15.6, p = 0.05) were observed in the RYGBP patients compared with those undergoing fundoplication. A high complication rate was seen among patients undergoing esophagectomy. Both reflux control and dysphagia rates were improved in the RYGBP group compared with fundoplication. This finding suggests that RYGBP may be an option for the primary management of scleroderma-associated gastroesophageal reflux.

Healing of severe reflux esophagitis with Ppi does not improve esophageal dysmotility

Esophageal dysmotility is frequently associated with gastroesophageal reflux disease (GERD). The aim of this study was to investigate the relationship between the severity of reflux esophagitis and esophageal dysmotility and evaluate the effect of prolonged treatment with proton pump inhibitor (lansoprazole 30 mg/day) on esophageal motility in patients with severe reflux esophagitis associated with esophageal motility disorder. Twelve healthy subjects (HS) and 100 patients with reflux disease were involved in the study consisting of two parts: (i) comparison of esophageal motility in HS and patients with non-eroseive reflux disease (NERD), mild esophagitis and severe esophagitis; (ii) effect of 3-6 months lansoprazole therapy on esophageal motility in 23 patients with severe esophagitis, pathologic acid reflux and esophageal peristaltic dysfunction. Results included the following. (i) Esophageal dysmotility was noted in both patients with NERD and erosive GERD. (ii) Severe esophagitis was associated with severe esophageal dysmotility. (iii) Healing of severe esophagitis did not improve esophageal dysmotility. The resting lower esophageal sphincter pressure was 3.9 mmHg (range 1.7-20) before treatment and 4.8 mmHg (range 1.2-18.3) after esophagitis healing (P = 0.23, vs. before treatment), the amplitude of distal esophageal contraction was 28.8 mmHg (range 10.9-80.6) before treatment and 33.3 mmHg (range 10.0-72.5) after esophagitis healing (P = 0.59, vs. before treatment) and the frequency of failed peristalsis was 70% (range 0-100%) before treatment and 70% (range 0-100%) after esophagitis healing (P = 0.78, vs. before treatment). Both esophageal motility disorders and acid reflux play important roles in the mechanism of GERD, especially in severe esophagitis. Esophageal dysmotility is not secondary to acid reflux and esophagitis; it should be a primary motility disorder.

Severely disordered esophageal peristalsis is not a contraindication to laparoscopic Nissen fundoplication

Laparoscopic Nissen fundoplication (LNF) is the preferred operation for the control of gastroesophageal reflux disease (GERD). The use of a full fundoplication for patients with esophageal dysmotility is controversial. Although LNF is known to be superior to a partial wrap for patients with weak peristalsis, its efficacy for patients with severe dysmotility is unknown. We hypothesized that LNF is also acceptable for patients with severe esophageal dysmotility. A multicenter retrospective review of consecutive patients with severe esophageal dysmotility who underwent an LNF was performed. Severe dysmotility was defined by manometry showing an esophageal amplitude of 30 mmHg or less and/or 70% or more nonperistaltic esophageal body contractions. In this study, 48 patients with severe esophageal dysmotility underwent LNF. All the patients presented with symptoms of GERD, and 19 (39%) had preoperative dysphagia. A total of 10 patients had impaired esophageal body contractions, whereas 32 patients had an abnormal esophageal amplitude, and 6 patients had both. The average abnormal esophageal amplitude was 24.9 +/- 5.2 mmHg (range, 6.0-30 mmHg). The mean percentage of nonperistaltic esophageal body contractions was 79.4% +/- 8.3% (range, 70-100%). There were no intraoperative complications and no conversions. Postoperatively, early dysphagia occurred in 35 patients (73%). Five patients were treated with esophageal dilation, which was successful in three cases. One patient required a reoperative fundoplication. Overall, persistent dysphagia was found in two patients (4.2%), including one patient with severe preoperative dysphagia, which improved postoperatively. Abnormal peristalsis and/or distal amplitude improved postoperatively in 12 (80%) of retested patients. There were no cases of Barrett's progression to dysplasia or carcinoma. During an average follow-up period of 25.4 months (range, 1-46 months), eight patients (16%) were receiving antireflux medications, with six of these showing normal esophageal pH study results. The LNF procedure provides low rates of reflux recurrence with little long-term postoperative dysphagia experienced by patients with severely disordered esophageal peristalsis. Effective fundoplication improved esophageal motility for most of the patients. A 360 degrees fundoplication should not be contraindicated for patients with severe esophageal dysmotility.

Saliva transport to the distal esophagus

Objective. During esophageal acid clearance, saliva should reach the most distal esophagus. The mechanisms responsible for saliva transport are not completely understood but it is assumed that normal peristalsis plays a significant role. The aim of this study was to assess the role of esophageal peristalsis and gravity in saliva transport to the distal esophagus. Material and methods. Esophageal transit and presence times of a 2-ml bolus of radiolabeled artificial saliva were assessed using concurrent scintigraphy and manometry in 10 healthy volunteers in the upright and supine positions before and after disruption of esophageal motility with sildenafil (50 mg). Results. With normal peristalsis, there was no difference in saliva transit to the distal esophagus between supine and upright positions 3.9 (1.5– > 60.0) versus 3.3 s (1.3–8.3). Low amplitude contractions did not affect saliva transit but the disappearance of contractions after sildenafil was associated with prolonged saliva transit in supine position 7.4 (1.0– > 60.0). Saliva presence time was significantly prolonged in both the upright and supine positions by esophageal dysmotility. Conclusions. Saliva transport to the distal esophagus does not require complete normal peristalsis or gravity and mainly depends on an efficient pharyngeal pump. However, subjects in supine position with severe esophageal dysmotility might have both impaired volume clearance and delayed saliva transport, leading to abnormal acid clearance and esophagitis.

Dysfunction of oesophageal motility in Helicobacter pylori-infected patients with reflux oesophagitis.

Helicobacter pylori infection has been suggested to be protective against gastro-oesophageal reflux disease. However, a significant proportion of patients with gastro-oesophageal reflux disease are infected by H. pylori. To study oesophageal motor function in H. pylori-infected patients with reflux oesophagitis. Patients with erosive reflux oesophagitis were recruited prospectively for stationary oesophageal manometry and 24-h ambulatory oesophageal pH monitoring. H. pylori status was determined by biopsy urease test. Non-reflux volunteers were recruited as controls. Seventy-four patients with erosive oesophagitis (34 H. pylori-positive, 40 H. pylori-negative) and 48 non-reflux patient controls (22 H. pylori-positive, 26 H. pylori-negative) were recruited. There was no difference in severity of oesophagitis (median grade, 1; P=0.53) or oesophageal acid exposure (total percentage time oesophageal pH < 4, 7.6% vs. 6.8%; P=0.57) between H. pylori-positive and H. pylori-negative groups. Compared to H. pylori-negative patients, H. pylori-positive patients had significantly lower basal lower oesophageal sphincter pressure (12.2 mmHg vs. 15.3 mmHg; P=0.03) and amplitude of distal peristalsis (56.9 mmHg vs. 68.4 mmHg; P=0.03). Ineffective oesophageal motility (14% vs. 7%; P=0.02) and failed oesophageal peristalsis were also significantly more prevalent in H. pylori-positive patients. Among patients with a similar degree of reflux oesophagitis, H. pylori-infected patients have more severe oesophageal dysmotility and lower oesophageal sphincter dysfunction. Oesophageal motor dysfunction probably plays a dominant role in the development of gastro-oesophageal reflux disease in patients with H. pylori infection.

Does Dysphagia Indicate Recurrence of Benign Esophageal Strictures?

Esophageal dilatation in dysphagic patients with benign strictures is usually considered successful if the patients' dysphagia is alleviated. However, the relation between dysphagia and the diameter of a stricture is not well understood. Moreover, the dysphagia may also be caused by an underlying esophageal motor disorder. In order to compare symptoms and objective measurements of esophageal stricture, 28 patients were studied with interview and a radiologic esophagram. The latter included swallowing of a solid bolus. All patients underwent successful balloon dilatation at least one month prior to this study. Recurrence of a stricture with a diameter of less than 13 mm was diagnosed by the barium swallow in 21 patients. Recurrence of dysphagia was seen in 15 patients. Thirteen patients denied any swallowing symptoms. Chest pain was present in 9 patients. Of 15 patients with dysphagia 2 (13%) had no narrowing but severe esophageal dysmotility. Of 13 patients without dysphagia 9 (69%) had a stricture with a diameter of 13 mm or less. Of 21 patients with a stricture of 13 mm or less 14 (67%) were symptomatic while 7 (33%) were asymptomatic. Four of 11 patients with retrosternal pain had a stricture of less than 10 mm. Three patients with retrosternal pain and obstruction had severe esophageal dysmotility. Whether or not the patients have dysphagia may be more related to diet and eating habits than to the true diameter of their esophageal narrowing. We conclude that the clinical history is non-reliable for evaluating the results of esophageal stricture dilatation. In order to get an objective measurement of therapeutic outcome, barium swallow including a solid bolus is recommended.

Oesophageal dysfunction in familial amyloidosis with polyneuropathy.

Sixteen patients with familial amyloidosis and polyneuropathy (FAP) and 14 health subjects underwent oesophageal manometry. Six of the patients had a severe oesophageal dysmotility with almost completely abolished propulsive pressure waves on swallowing in the lower 2/3 of the oesophagus. Ten patients had moderate dysfunction with reduced propulsive pressure wave amplitudes. Neostigmine increased the pressure wave amplitudes in healthy subjects but less so in the FAP patients. Scopolamine (Scopyl)-terbutaline (Bricanyl) almost abolished the propulsive pressure waves in healthy subjects and all patients in the lower 2/3 of the esophagus. Oesophageal distensibility, tested by inflating a rubber balloon in the oesophagus, was similar in FAP patients and healthy subjects. Thus, it is unlikely that amyloid deposits in the mucosal wall increased the oesophageal stiffness. An autonomic, predominantly vagal, denervation probably explains the disturbed function.

Operative treatment for the gastroesophageal reflux syndrome in children

Surgical treatment for symptomatic gastroesophageal reflux (GER) was performed on 420 infants and children over a 19-year period. Esophageal motility disorders were present in more than 35% of patients and delayed gastric emptying (DGE) was present in approximately 50% of patients studied. Gastroesophageal fundoplication (GEF) alone was performed for 357 patients, whereas 51 patients underwent GEF and pyloroplasty; 12 patients underwent pyloroplasty alone. When there is more than 60% gastric retention of technetium-99m sulphur colloid in semisolid feedings at 90 minutes, pyloroplasty appears to be useful. Twenty-two percent of the last 275 refluxing children underwent pyloroplasty combined with GEF. Most infants and young children undergoing evaluation for severe GER, particularly those with neurologic disorders, may benefit from having a gastric emptying study. Children with severe reflux and esophageal dysmotility should have a loose GEF performed. The absence of persistent dumping, and the very low incidence of complications suggests that pyloroplasty should be used more frequently when significant DGE is present.