Single Swallows Research Articles

Evaluation of oesophageal transit velocity using the improved Demons technique.

This paper presents a novel method to compute oesophageal transit velocity in a direct and automatized manner by the registration of scintigraphy images. A total of 36 images from nine healthy volunteers were processed. Four dynamic image series per volunteer were acquired after a minimum 8 h fast. Each acquisition was made following the ingestion of 5 ml saline labelled with about 26 MBq (700 µCi) technetium-99m phytate in a single swallow. Between the acquisitions, another two swallows of 5 ml saline were performed to clear the oesophagus. The composite acquired files were made of 240 frames of anterior and posterior views. Each frame is the accumulate count for 250 ms.At the end of acquisitions, the images were corrected for radioactive decay, the geometric mean was computed between the anterior and posterior views and the registration of a set of subsequent images was performed. Utilizing the improved Demons technique, we obtained from the deformation field the regional resultant velocity, which is directly related to the oesophagus transit velocity. The mean regional resulting velocities decreases progressively from the proximal to the distal oesophageal portions and, at the proximal portion, is virtually identical to the primary peristaltic pump typical velocity. Comparison between this parameter and 'time-activity' curves reveals consistency in velocities obtained using both methods, for the proximal portion. Application of the improved Demons technique, as an easy and automated method to evaluate velocities of oesophageal bolus transit, is feasible and seems to yield consistent data, particularly for the proximal oesophagus.

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

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

Esophageal motility after peroral endoscopic myotomy for achalasia.

Peroral endoscopic myotomy (POEM) has been introduced as a novel endoscopic treatment for achalasia. The aim of this work is to assess the changes in esophageal motility caused by POEM in patients with achalasia. Forty-one patients with achalasia underwent POEM from September 2012 to November 2014. Esophageal motility of all patients was evaluated preoperatively and 1 month after POEM utilizing high-resolution manometry, which was performed with ten water swallows, ten steamed bread swallows, and multiple rapid swallows (MRS). In single swallows, including liquid swallows and bread swallows, all the parameters of lower esophagus sphincter resting pressure (LESP), 4-s integrated relaxation pressure (4sIRP), and intra-bolus pressure (IBP) were decreased between pre- and post-POEM patients (all p < 0.05). Postoperatively, the trend of distal contractile integral (DCI) and distal esophageal peristaltic amplitude declined in subtype II and subtype III (subtype II: p < 0.05; subtype III: p > 0.05), but increased in subtype I (subtype I: p > 0.05). In liquid swallows, the Eckardt score of subtype II patients decreased with DCI, and distal esophageal peristaltic amplitude after POEM was significantly lower compared with those showing increased values of those two parameters (p < 0.05). In MRS, the rate of LES relaxation increased from 66.67 to 95.24%, but without normal response in all achalasia patients. POEM reduces LES pressure in achalasia, and partly restores esophageal motility. POEM displayed varying effect on esophageal motility in patients with different patterns of swallowing. In addition, the changes in parameters associated with esophageal peristalsis correlated with decreases in Eckardt score.

A Continent-Wide Migratory Divide in North American Breeding Barn Swallows (Hirundo rustica)

Populations of most North American aerial insectivores have undergone steep population declines over the past 40 years but the relative importance of factors operating on breeding, wintering, or stopover sites remains unknown. We used archival light-level geolocators to track the phenology, movements and winter locations of barn swallows (Hirdundo rustica; n = 27) from populations across North America to determine their migratory connectivity. We identified an east-west continental migratory divide for barn swallows with birds from western regions (Washington State, USA (n = 8) and Saskatchewan, Canada (n = 5)) traveling shorter distances to wintering areas ranging from Oregon to northern Colombia than eastern populations (Ontario (n = 3) and New Brunswick (n = 10), Canada) which wintered in South America south of the Amazon basin. A single swallow from a stable population in Alabama shared a similar migration route to eastern barn swallows but wintered farther north in northeast Brazil indicating a potential leap frog pattern migratory among eastern birds. Six of 9 (67%) birds from the two eastern populations and Alabama underwent a loop migration west of fall migration routes including around the Gulf of Mexico travelling a mean of 2,224 km and 722 km longer on spring migration, respectively. Longer migration distances, including the requirement to cross the Caribbean Sea and Gulf of Mexico and subsequent shorter sedentary wintering periods, may exacerbate declines for populations breeding in northeastern North America.

A Migrant Heart by Denis Sampson (review)

Reviewed by: A Migrant Heart by Denis Sampson Chris Arthur A Migrant Heart, by Denis Sampson, pp. 238. Montreal: Linda Leith Publishing, 2014. $16.95 (paper). At the end of the 1980s, when Denis Sampson was teaching at the Université de Caen, he and his family were living in a centuries-old farmhouse in Normandy. Sampson describes himself sitting in the cobblestone yard in a beach chair, reading The Engima of Arrival. As he is drawn into this compelling “novel in five parts”—though Sampson wisely questions whether V.S. Naipaul’s thinly disguised autobiographical reflection is really fiction—he finds that, for a time, it becomes “a kind of prayer book.” Throughout A Migrant Heart, memoir is interlaced with such literary electrocardiographs. Their lines show the extent to which literature has been a formative influence on the author’s life, often to the extent that it seems to serve an almost religious function. It is not just Nai-paul who provides him with his sacred texts. Irish writers have a special place in the reader’s heart that Sampson explores with such disarming openness—John McGahern and Brian Moore, for example, figure prominently—but it is clear he has engaged with literature far beyond any merely national boundaries. Quite apart from the light it sheds on how leaving Ireland and returning to it can incise powerful feelings of attachment and betrayal on the psyches of its migrant natives, there is much to recommend in Denis Sampson’s book, simply in terms of the insights it offers into the impact of reading on a life. At one point he says, “The most intense reading, as the most intense writing, comes out of our hidden life, and so it is that writing about reading is a form of memoir.” Without any of the distracting flourishes of an approach that over-dramatizes self realization—a temptation some, indeed many, memoirists give in to—A Migrant Heart modestly, but lucidly, explores the hidden life, reflecting on the intensities of reading and writing that have done so much to mold its author’s identity. The cover of A Migrant Heart features a stunning photograph of a single swallow caught on the wing. The picture is apt both for the way in which swallows symbolize migration, and because of how swallows glimpsed in Normandy remind Sampson of seeing the birds at the farm in Ireland where he grew up. He describes the French birds as “my madeleine,” taking him back to his childhood world beside the Shannon. The cover illustration also brings to mind Horatio Clare’s A Single Swallow (2009), a mix of nature writing, travelogue, and memoir that tells the story of following—by train, motorbike, canoe, ship, and on foot—the migratory route of the birds from Africa to Europe. It would be interesting to know how many human Irish “swallows” there are—people who, for a whole variety of reasons, live most of their lives away from the country but make regular returns, often over considerable distances. Denis Sampson is one of them. Not only does he chart the geography of his move from Ireland to Canada, his many returns to his birthplace, and occasional diversions to other countries, he [End Page 146] also explores the inner dynamics of this migratory life. He takes readers on a journey less obviously arduous than the one undertaken by Horatio Clare, but no less epochal. This is a memoir of moving honesty and depth. It carries the glint of wisdom in the cadences of its recollections and reflections. Much of the charm of the book comes from the acuity with which Sampson recalls his Irish childhood, and the intelligence he brings to bear in understanding how it has influenced the person he has become. Considering his family’s farm, he suggests, The long isolation of that house in its own world by the lakeside, in its many layers of withdrawal and inwardness, gave me a sense of something beautiful and a training in contemplation. It also gave me something else; a detachment, a turning away towards reading, and the contemplation of natural beauty, and also a suspicion of people’s motivations and the forces...

The study of tongue pressure during swallowing liquid in healthy adults

To investigate the tongue pressure (TP) produced by tongue-hard palate contact in the process of normally swallowing liquid in healthy adults. Thirteen adult male subjects were recruited to perform a single swallow of 5 ml water when sitting with upright position. The tongue pressure sensor sheet was used to monitor TP as a result of tongue-hard palate approximatation in the anteriomedian, midmedian, posteriomedian and circumferential parts, and the swallowing sound was recorded by microphone. The temporal sequence of TP at each measured part was obtained after setting the swallowing sound as the reference time. Also, the total duration, pre-peak duration, post-peak duration, maximum magnitude and integrated value of TP were recorded and compared among the measured parts. TP was produced from anterior to posterior along the midline of hard palate during normal swallowing of water [Ch1: (-0.40 ± 0.22) s, Ch2: (-0.36 ± 0.21) s, Ch3: (-0.24 ± 0.18) s], with the circumferential TP [Ch4: (-0.38 ± 0.23) s, Ch5: (-0.40 ± 0.23) s] occurring nearly to the anteriomedian one (P > 0.05). Before the swallowing sound (P < 0.05), TP at each part reached a peak synchronously [Ch1: (-0.12 ± 0.24) s, Ch2: (-0.16 ± 0.22) s, Ch3: (-0.13 ± 0.21) s, Ch4: (-0.16 ± 0.23) s, Ch5: (-0.17 ± 0.23) s] in a rapid manner (P > 0.05), then decreased gradually until disappeared simultaneously [Ch1: (0.32 ± 0.23) s, Ch2: (0.27 ± 0.21) s, Ch3: (0.23 ± 0.16) s, Ch4: (0.33 ± 0.31) s, Ch5: (0.33 ± 0.29) s] (P > 0.05) after the swallowing sound (P < 0.05). The TP related parameters (the total duration of TP:Ch1: (0.72 ± 0.20) s, Ch2: (0.63 ± 0.16) s, Ch3: (0.47 ± 0.17) s, Ch4: (0.70 ± 0.35) s, Ch5: (0.73 ± 0.29) s; the pre-peak duration of TP: Ch1: (0.28 ± 0.21) s, Ch2: (0.20 ± 0.16) s, Ch3: (0.12 ± 0.10) s, Ch4: (0.21 ± 0.22) s, Ch5: (0.23 ± 0.21) s; the post-peak duration of TP: Ch1: (0.44 ± 0.23) s, Ch2: (0.43 ± 0.18) s, Ch3: (0.36 ± 0.18) s, Ch4: (0.49 ± 0.25) s, Ch5: (0.50 ± 0.23) s; the maximum magnitude of TP: Ch1: (13.80 ± 7.73) kPa, Ch2: (12.40 ± 6.51) kPa, Ch3: (10.26 ± 7.15) kPa, Ch4: (12.16 ± 5.38) kPa, Ch5: (13.08 ± 5.05) kPa; the integrated value of TP: Ch1: (4.99 ± 3.69) kPa×s, Ch2: (4.25 ± 2.13) kPa×s, Ch3: (2.88 ± 1.87) kPa×s, Ch4: (4.32 ± 3.47) kPa×s, Ch5: (4.63 ± 2.49) kPa×s were significantly smaller in the posteriomedian part among all the five parts measured. No laterality was found in TP produced at the circumferential parts of the hard palate (P > 0.05). The TP at each part coordinates precisely during swallowing. The effective measurement of TP by tongue pressure sensor sheet will facilitate the evaluation of oral swallowing and the diagnosis of dysphagia simply and non-invasively.

Usefulness of low- and high-volume multiple rapid swallowing during high-resolution manometry

BackgroundIt has been suggested that multiple rapid swallowing should be added to oesophageal manometry. AimTo prospectively evaluate whether 10 and 200mL multiple rapid swallowing provide different information concerning motor function. Methods30 consecutive patients with oesophageal symptoms, 13 achalasia patients after successful pneumatic dilation and 19 healthy subjects performed eight 5mL single swallows, two 10mL and one 200mL multiple rapid swallowing. ResultsAlmost all of the healthy subjects and two-thirds of the patients with oesophageal symptoms showed motor inhibition during both 10 and 200mL multiple rapid swallowing. The oesophago-gastric pressure gradient was significantly higher during 200mL multiple rapid swallowing within each group (p<0.01), and significantly higher in the achalasia patients than in the other two groups (p<0.0001). Presence of a contraction and increased contraction strength in comparison with single swallows were both more frequent after 10mL than after 200mL multiple rapid swallowing in the healthy subjects and the patients (p<0.05). ConclusionMotor inhibition could be similarly evaluated by means of 10 and 200mL multiple rapid swallowing; 10mL evaluated the after-contraction, whereas 200mL multiple rapid swallowing was more valuable in identifying increased resistance to outflow.

Ultrasound Pulsed Wave Doppler Imaging of the Esophagus Illustrates the Effects of Water Volume on Bolus Kinematics

AbstractThis study aimed to elucidate the effects of water volume on flow properties of bolus (passage time and velocities) at the esophagus orifice using ultrasonic pulsed wave Doppler method. Five healthy males and five females were asked to consume 3, 6, 9 and 12 mL water in a single swallow. An ultrasound probe was placed against each subject's neck to observe the flow properties of bolus. The velocity spectra of the bolus at the esophagus orifice were analyzed. Our results revealed that velocity of bolus was easily affected by volume of water, and the passage time and velocities increased as the increase in volume.Practical ApplicationsUltrasonography, using a medical ultrasound instrument, is an effective method for observing bolus kinematics during swallowing. The velocity spectra of bolus can be visualized for different volume of water using the pulsed wave Doppler method. When a bolus of food is swallowed, aspiration that the bolus partly enters the trachea instead of the esophagus may occur. Water is known to show a high possibility of aspiration. This study revealed that reducing volume of water decreases the passage time and velocities of bolus at the esophageal entrance. Therefore, this technique can be used for designing the texture of food materials for people who experience aspiration or suffocation by food.

A hypothetical, aetiological relationship between the horse's bit, nasopharyngeal asphyxia and negative pressure pulmonary oedema

SummaryTentative explanations for the aetiology of soft palate instability and dorsal displacement at exercise are based on the proposition that it is caused by one or more, as yet unidentified, neuromuscular or inflammatory diseases. As judged by reviews, none of the treatments based on these assumptions are entirely satisfactory. Most researchers agree that their cause is unknown. In 1999, Cook proposed that they were caused by the bit breaking what should be an airtight lip seal. The present article describes a development of this hypothesis – loss of oral compartment subatmospheric pressure. The feral horse is an obligate nose‐breather and runs with a closed mouth and no air in the oral cavity and oropharynx. Evacuation of air from these compartments is proposed as the primary mechanism, strengthened by the cohesive force of surface tension, whereby the soft palate resists the elevating force of negative pressure on inspiration. It is suggested that subatmospheric pressure in the oral compartment is generated by a single swallow before running. Poll extension supplements the rigidity of the nasopharyngeal tube and reinforces the ostium intrapharyngium seal. In the domesticated horse, the lip seal is broken by a bit and bit‐induced poll flexion, jaw and tongue movement often breaks the ostium seal. Oral atmospheric pressure is proposed as the mechanism for nasopharyngeal asphyxia. It is considered that negative pressure pulmonary oedema – currently known as exercise‐induced pulmonary haemorrhage and conventionally thought to be a separate problem – is one of its clinical signs. It is suggested that the bit is the most common cause of nasopharyngeal asphyxia and that this, in turn, results in a cascade of dynamic obstructions in the larynx and cervical trachea, leading ultimately to pulmonary oedema and ‘bleeding.’ It is concluded that these are sequelae to rules in many disciplines that mandate bit usage.

Effects of tongue pressure sensor sheet on the signal waveform of laryngeal movement produced by bend sensor during deglutition

To evaluate the effects of the application of tongue pressure sensor sheet on the signal waveform of laryngeal movement produced by the bend sensor during deglutition. Twelve adult male subjects were recruited to perform a single swallow of 5 ml water when sitting on the dental chair with upright position. The data recorded by bend sensor was obtained with attaching tongue pressure sensor sheet simultaneously or not. Then the measured parameters by bend sensor with or without concurrent application of tongue pressure sensor sheet were compared. There were no significant differences between the same time point on the signal waveform produced by bend sensor whether concurrently attaching tongue pressure sensor sheet or not (P > 0.05). Additionally, we found no statistical significances between matched phases on the signal waveform recorded by bend sensor with or without application of tongue pressure sensor sheet (P > 0.05). The findings in this study suggest us that the usage of tongue pressure sensor sheet exerted no influences on the waveform of the laryngeal movement produced by bend sensor during deglutition, facilitating us to further apply tongue pressure sensor sheet and bend sensor simultaneously to record tongue pressure production and hyoid activity during deglutition.

Effect of Cold Water on Esophageal Motility in Patients With Achalasia and Non-obstructive Dysphagia: A High-resolution Manometry Study

Background/AimsSwallowing of cold liquids decreases amplitude and velocity of peristalsis in healthy subjects, using standard manometry. Patients with achalasia and non obstructive dysphagia may have degeneration of sensory neural pathways, affecting motor response to cooling. To elucidate this point, we used high-resolution manometry.MethodsFifteen healthy subjects, 15 non-obstructive dysphagia and 15 achalasia patients, after pneumatic dilation, were studied. The 3 groups underwent eight 5 mL single swallows, two 20 mL multiple rapid swallows and 50 mL intraesophageal water infusion (1 mL/sec), using both water at room temperature and cold water, in a randomized order.ResultsIn healthy subjects, cold water reduced distal contractile integral in comparison with water at room temperature during single swallows, multiple rapid swallows and intraesophageal infusion (ratio cold/room temperature being 0.67 [95% CI, 0.48-0.85], 0.56 [95% CI, 0.19-0.92] and 0.24 [95% CI, 0.12-0.37], respectively). A similar effect was seen in non-obstructive dysphagia patients (0.68 [95% CI, 0.51-0.84], 0.69 [95% CI, 0.40-0.97] and 0.48 [95% CI, 0.20-0.76], respectively), whereas no changes occurred in achalasia patients (1.06 [95% CI, 0.83-1.29], 1.05 [95% CI, 0.77-1.33] and 1.41 [95% CI, 0.84-2.00], respectively).ConclusionsOur data suggest impairment of esophageal reflexes induced by cold water in patients with achalasia, but not in those with non obstructive dysphagia.

How to Perform and Interpret Timed Barium Esophagogram

Timed barium esophagogram (TBE) is a simple and objective method for assessing the esophageal emptying. The technique of TBE is similar to usual barium swallow with some modifications, which include taking multiple sequential films at pre-decided time interval after a single swallow of a fixed volume of a specific density barium solution. While many authors have used height and width of the barium column to assess the esophageal emptying, others have used the area of the barium column. TBE is being used in patients with suspected or confirmed achalasia and to follow-up those who have been treated with pneumatic dilation or myotomy. This review discusses technique of performing TBE, interpretation and its utility in clinical practice.

OC-154 Inter-observer agreement for manometry classification of individual swallows and diagnoses using high-resolution manometry (HRM) with esophageal pressure topography (EPT): results of high participation web-based studies by the HRM working group

IntroductionRecently the HRM Working Group presented a classification system for esophageal motility disorders using HRM/EPT (Pandolfino, NGM 2009). This study reports inter-observer agreement for classification of individual HRM/EPT water swallows...

Lung Volume Measured During Sequential Swallowing in Healthy Young Adults

Outcomes from studying the coordinative relationship between respiratory and swallow subsystems are inconsistent for sequential swallows, and the lung volume at the initiation of sequential swallowing remains undefined. The first goal of this study was to quantify the lung volume at initiation of sequential swallowing ingestion cycles and to identify the respiratory pattern(s) surrounding each sequential swallow ingestion cycle. The second goal was to compare these results with existing data for single swallows. Twenty healthy young adults served as participants, 9 males and 11 females, between 19 and 28 years of age (M = 22 years of age). Participants completed 2 trials each of 100 mL of water self-delivered by cup and by straw. Calibrated respiratory inductance plethysmography, surface electromyography, and a contact throat microphone were used to detect respiratory parameters, identify swallow-related muscle contraction, and identify swallowing sounds, respectively. Significantly higher lung volume initiation for trials delivered by straw and more variable respiratory patterns surrounding cup and straw sequential swallowing ingestion cycles existed compared with single swallows. Results show that as the physiologic demands of swallowing deviate from single, small bolus swallows, the integration of the swallowing and respiratory systems change. This may reflect obligate differences in airway protection strategy and prolonged competition for respiratory resources.

M1168 Gastro-Oesophageal Mechanisms of Recurrent Postprandial Vomiting in Young Patients With Joint Hypermobility Syndrome and Autonomic Dysfunction

Introduction We have recently demonstrated a high prevalence of functional GI disorders in patients with joint hypermobility syndrome.1 These patients frequently have autonomic nerves dysfunction and may present with recurrent vomiting, severe dyspepsia and constipation. We aimed to characterise the OGJ mechanisms underlying recurrent postprandial vomiting in a series of consecutive patients with joint hypermobility syndrome and/or autonomic dysfunction. Methods Twelve patients (mean age=25.5 years, 9 females, 3 males) referred for gastro-oesophageal motility testing due to recurrent postprandial vomiting were studied during fasting and postprandial periods using combined high-resolution manometry-impedance. Eating disorders, neurologic and other organic gastrointestinal disorders were previously excluded. Median duration of postprandial vomiting was 17 months. Using Beighton Hypermobility Score, 7/12 patients were diagnosed with Joint Hypermobility Syndrome (JHS). In five of these patients we found autonomic dysfunction symptoms. Combined stationary HRM-impedance (Sandhill Scientific) was performed in semirecumbent position. The protocol included 10 single wet swallows, 2 multiple rapid swallows sequences, a semisolid standard meal followed by 30 min postprandial monitoring. Chicago Classification 2009 was used to classify oesophageal motility disorders. Results Hiatus hernia was diagnosed in 4/12 patients. Normal oesophageal motility was observed in 6/12 patients and the remaining patients had intermittent hypotensive peristalsis. All patients vomited after the standard meal. Nausea preceding vomiting was present in only 5/12 patients. Aerophagia, objectively detected by impedance, was a major feature, found in 8/12 patients. However, only 4 patients had an impedance pattern of belching-liquid regurgitation. The majority of patients had objective abdominal straining (detected with HRM as abrupt, low amplitude, simultaneous increase in gastro-oesophageal pressure) followed by liquid intra-oesophageal retrograde flow with high proximal extent. Conclusion JHS was present in a significant proportion of these young patients with recurrent postprandial vomiting. Aerophagia was a significant consistent finding in these patients. We hypothesise that patients with JHS and oesophago-gastro-intestinal involvement may perceive early postprandial mild gastric discomfort (probably due to liquid accumulation in the gastric cardiac region) and develop an aerophagic behaviour to alleviate their discomfort by belching. Subsequently, straining to belch is associated with vomiting.

Comparison of Sequential Swallowing in Patients With Acute Stroke and Healthy Adults

Murguia M, Corey DM, Daniels SK. Comparison of sequential swallowing in patients with acute stroke and healthy adults. Objectives To compare hyolaryngeal complex (HLC) movement and leading-edge-of-the-bolus location patterns of sequential swallowing in patients with stroke and healthy adults, and to determine whether these patterns affect swallowing safety. Design Between-groups comparison. Setting Veterans hospital. Participants Consecutively admitted patients with acute unilateral supratentorial stroke (right hemisphere damage, n=13; left hemisphere damage, n=16) and age-matched healthy participants (n=25). Interventions Not applicable. Main Outcome Measures HLC movement pattern, bolus location, Penetration-Aspiration (P-A) Scale score. Results No significant group differences were observed for HLC movement pattern, bolus location, and P-A Scale score. Specific HLC movement patterns and bolus location were not associated with a higher P-A Scale score. A significant correlation between HLC movement pattern and bolus location was observed. Bolus location was typically inferior to the valleculae between swallows when the HLC was partially elevated. Across all groups, P-A Scale scores were significantly higher during sequential swallowing than single swallows. Conclusions HLC movement pattern and bolus location do not appear related to airway invasion, at least in persons without significant dysphagia. Given higher P-A Scale scores during sequential swallowing as compared with single swallows, sequential swallowing should always be evaluated in all patients.

Multiple rapid swallowing: a complementary test during standard oesophageal manometry

Multiple rapid swallowing (MRS) stimulates neural inhibition resulting in abolition of contractions in the oesophageal body (OB) and complete lower oesophageal sphincter (LOS) relaxation which is followed by peristalsis and LOS contraction. The aim of this study was to evaluate the yield of MRS to detect abnormalities in inhibitory or excitatory oesophageal mechanisms in patients with oesophageal symptoms and either normal standard manometry or ineffective oesophageal motility (IOM). MRS (five water swallows, 2 mL, separated by 2-3 s) was evaluated in 23 healthy subjects, 109 symptomatic patients with normal standard sleeve manometry and in 48 patients with IOM. Healthy subjects had complete inhibition of OB motility during MRS and a strong motor response after MRS, i.e. amplitude of OB contractions in the oesophageal body and LOS tone being higher than after single swallows. Almost 70% of patients with oesophageal symptoms and normal manometry had abnormal MRS, mainly consistent on inability to increase amplitude of OB contractions after MRS. Nearly, half of the patients with IOM were able to normalize OB contractions after MRS. MRS is a simple complementary test that can be added to standard oesophageal manometry. Two-thirds of patients with normal manometry show abnormal MRS that could potentially underlie their symptoms. A normal response to MRS in patients with severe IOM might be used to predict response to prokinetic treatment.

Oral vs. pharyngeal dysphagia: surface electromyography randomized study

BackgroundA clear differential diagnosis between oral and pharyngeal dysphagia remains an unsolved problem. Disorders of the oral cavity are frequently overlooked when dysphagia/odybophagia complaints are assessed. Surface electromyographic (sEMG) studies were performed on randomly assigned patients with oral and pharyngeal pathology to evaluate their dysphagia complaints for the sake of differential diagnosis.MethodsParameters evaluated during swallowing for patients after dental surgery (1: n = 62), oral infections (2: n = 49), acute tonsillitis (3: n = 66) and healthy controls (4: n = 50) included timing and amplitude of sEMG activity of masseter, infrahyoid and submental muscles.ResultsThe duration of swallows and drinking periods was significantly increased in dental patients and was normal in patients with tonsillitis. The electric activity of masseter was significantly lower in Groups 1 and 2 in comparison with the patients with tonsillitis and controls. The submental and infrahyoid activity was normal in dental patients but infrahyoid activity in patients with tonsillitis was high.ConclusionDysphagia following dental surgery or oral infections does not affect pharynx and submental muscles and has clear sEMG signs: increased duration of a single swallow, longer drinking time, low activity of the masseter, and normal range of submental activity. Patients with tonsillitis present hyperactivity of infrahyoid muscles. These data could be used for evaluation of symptoms when differential dental/ENT diagnosis is needed.

583 The Role of Adenosine in Esophageal Nociception in Patients with Functional Chest Pain

esophageal motility (IEM), 9 with nutcracker esophagus (NE) and 1 with diffuse esophageal spasm (DES). Abnormal manometry in VS was demonstrated in 31 patients (67.4%, 21 IEM, 9 NE, 1 DES). Abnormal transit in LS and VS was demonstrated in 14 (25.9 %) and 18 (33.3%), respectively. The manometric and transit abnormalities were more common in patients with dysphagia (78.5% vs. 21.4%, p=0.04) and in patients with posture instability gait disturbance assessed by UPDRS (p=0.02). Abnormal esophageal function was not correlated to age or Hoehn & Yahr stage. Repetitive deglutition during single swallow was observed in 143 of 540 (26.5%) swallows (mean 1.4±0.4/LS, 1.4±0.5/VS). Repetitive deglutition was significantly correlated with failed peristalsis and incomplete bolus transit (p<0.0001). Abnormal inhibition of motor activity in the oesophageal body during MRS was observed in 30 out of 49 (61.2%) patients; 26 with incomplete inhibition (repetitive contraction), and 4 with failed peristalsis. Abnormal MRS response correlated with abnormal manometry (p=0.043). Conclusion: Repetitive deglutition with abnormal inhibition of motor activity in the oesophageal body is frequently observed in patients with early PD. MRS provides further evidence of selective involvement of either the brain stem or the esophageal myenteric plexus in the early PD.

584 An Optimal Dysphagia-Sensitive Algorithm for Assessing Deglutitive Intrabolus Pressure Using Esophageal High-Resolution Manometry

esophageal motility (IEM), 9 with nutcracker esophagus (NE) and 1 with diffuse esophageal spasm (DES). Abnormal manometry in VS was demonstrated in 31 patients (67.4%, 21 IEM, 9 NE, 1 DES). Abnormal transit in LS and VS was demonstrated in 14 (25.9 %) and 18 (33.3%), respectively. The manometric and transit abnormalities were more common in patients with dysphagia (78.5% vs. 21.4%, p=0.04) and in patients with posture instability gait disturbance assessed by UPDRS (p=0.02). Abnormal esophageal function was not correlated to age or Hoehn & Yahr stage. Repetitive deglutition during single swallow was observed in 143 of 540 (26.5%) swallows (mean 1.4±0.4/LS, 1.4±0.5/VS). Repetitive deglutition was significantly correlated with failed peristalsis and incomplete bolus transit (p<0.0001). Abnormal inhibition of motor activity in the oesophageal body during MRS was observed in 30 out of 49 (61.2%) patients; 26 with incomplete inhibition (repetitive contraction), and 4 with failed peristalsis. Abnormal MRS response correlated with abnormal manometry (p=0.043). Conclusion: Repetitive deglutition with abnormal inhibition of motor activity in the oesophageal body is frequently observed in patients with early PD. MRS provides further evidence of selective involvement of either the brain stem or the esophageal myenteric plexus in the early PD.