Solid Swallows Research Articles

Inter-observer agreement of water and solid swallows in high resolution manometry

IntroductionHigh Resolution Manometry (HRM) with presentation of pressure data as spatiotemporal plots highlights oesophageal landmarks and contractions that facilitates data analysis and interpretation. Normal values have been published for water...

Inclusion of solid swallows and a test meal increase the diagnostic yield of high resolution manometry (HRM) in patients with reflux symptoms

IntroductionManometry is applied in patients with suspected gastro-oesophageal reflux disease (GORD) to exclude motility disorders as a cause of symptoms. Routine studies use a small number of small volume water...

High resolution manometry during a standardised test meal and free drinking

IntroductionPublished reference values for oesophageal High Resolution Manometry (HRM) are available only for 5 ml water swallows in the supine position; however this is not representative of normal behaviour and...

The cause of dysphagia in eosinophilic oesophagitis: obstruction to bolus passage not oesophageal dysmotility

IntroductionEosinophilic Oesophagitis (EO) presents with dysphagia and chest pain; however the cause of symptoms remains uncertain. Endoscopy reveals fibrotic and inflammatory mucosal disease but rarely tight stenosis. Conventional manometry with...

Taxonomical study of species Zygophyllum fabago L. in Iraq.

The present study dealt with taxonomic characters of species Zygophyllum fabago L. in Iraq . this study included the exo-morphological characters which indicated that the species was sub-shrub with solid stem and swallow nodes ,with compound bifoliate and stipulate leaves, the flower is complete and perfect with clawed petals . stamen colored with scaly appendage , fruit capsule with ribs . Anatomical study of vegetative parts indicate that the sclerenchymal tissue was very diffuse in stem such as fibers and sclerides ( stone cells ) , the leaves were bifacial . The geographical distiribution of the species plants was studied . The results supported with photographs

Taxonomical study of species Zygophyllum fabago L. in Iraq.

The present study dealt with taxonomic characters of species Zygophyllum fabago L. in Iraq . this study included the exo-morphological characters which indicated that the species was sub-shrub with solid stem and swallow nodes ,with compound bifoliate and stipulate leaves, the flower is complete and perfect with clawed petals . stamen colored with scaly appendage , fruit capsule with ribs . Anatomical study of vegetative parts indicate that the sclerenchymal tissue was very diffuse in stem such as fibers and sclerides ( stone cells ) , the leaves were bifacial . The geographical distiribution of the species plants was studied . The results supported with photographs

Inclusion of solid swallows and a test meal increase the diagnostic yield of high resolution manometry (HRM) in patients with dysphagia

Inclusion of solid swallows and a test meal increase the diagnostic yield of high resolution manometry (HRM) in patients with dysphagia

Normative values and inter-observer agreement for liquid and solid bolus swallows in upright and supine positions as assessed by esophageal high-resolution manometry

High-resolution manometry (HRM) with spatiotemporal representation of pressure data is a recent advance in esophageal measurement. At present, normal values are available for 5mL water swallows in the supine position. This study provides reference values for liquid and solid bolus swallows in the upright seated and supine positions. A total of 23 asymptomatic volunteers (11M:12F, age 20-56) underwent HRM (Manoscan 360; Sierra Scientific Instruments) with 5mL water and 1cm3 bread swallows in the upright and supine positions. Normal values for primary parameters associated with effective bolus transport [proximal transition zone length (PTZ, assesses peristaltic coordination], contraction front velocity (CFV), distal contractile index (DCI) and integrated relaxation pressure (IRP)] are presented. For each parameter, median values along with the 5-95th percentile range are reported. Inter-observer agreement between independent observers is reported using the intra-class correlation coefficient. A higher proportion of swallows were peristaltic for liquids than solids in both the upright and supine positions (both P<0.05). As workload increases with solid bolus and on moving from the upright to the supine position the esophageal contractile response resulted in a shorter PTZ, a slower CFV, and a more vigorous DCI. Also IRP increased during solid bolus transit (all P<0.01). There was significant agreement between independent observers for HRM parameters. Normative values for esophageal function for solids as well as liquids and in the 'physiologic', upright position will optimize the utility of HRM studies. The high level of inter-observer agreement indicates that these can be applied as reference values in clinical practice.

Failure to respond to physiologic challenge characterizes esophageal motility in erosive gastro-esophageal reflux disease

Non-specific esophageal dysmotility with impaired clearance is often present in patients with gastro-esophageal reflux disease (GERD), especially those with erosive disease; however the physio-mechanic basis of esophageal dysfunction is not well defined. Retrospective assessment of patients with erosive reflux disease (ERD; n=20) and endoscopy negative reflux disease (ENRD; n=20) with pathologic acid exposure on pH studies (>4.2% time/24 h) and also healthy controls (n=20) studied by high resolution manometry. Esophageal motility in response to liquid and solid bolus swallows and multiple water swallows (MWS) was analyzed. Peristaltic dysfunction was defined as failed peristalsis, spasm, weak or poorly coordinated esophageal contraction (>3cm break in 30 mmHg isocontour). Peristaltic dysfunction was present in 33% of water swallows in controls, 56% ENRD and 76% ERD respectively (P<0.023 vs controls, P=0.185 vs ENRD). The proportion of effective peristaltic contractions improved with solid compared to liquid bolus in controls (18%vs 33%, P=0.082) and ENRD (22%vs 54%, P=0.046) but not ERD (62%vs 76%, P=0.438). Similarly, MWS was followed by effective peristalsis in 83% of controls and 70% ENRD but only 30% ERD patients (P<0.017 vs controls and P<0.031 vs ENRD). The association between acid exposure and dysmotility was closer for solid than liquid swallows (r=0.52 vs 0.27). Peristaltic dysfunction is common in GERD. ERD patients are characterized by a failure to respond to the physiologic challenge of solid bolus and MWS that is likely also to impair clearance following reflux events and increase exposure to gastric refluxate.

T1889 Inclusion of Solid Swallows and a Test Meal Increase the Clinical Utility of High Resolution Manometry in Patients With Dysphagia

T1889 Inclusion of Solid Swallows and a Test Meal Increase the Clinical Utility of High Resolution Manometry in Patients With Dysphagia

T1891 Solid Swallows and a Test Meal Increase the Clinical Utility of High Resolution Manometry in Patients Presenting With Reflux Symptoms

T1891 Solid Swallows and a Test Meal Increase the Clinical Utility of High Resolution Manometry in Patients Presenting With Reflux Symptoms

CC-010 Laying on of the healing hands

Introduction Rumination Syndrome is common yet under-diagnosed and is becoming increasingly recognised in healthy individuals. The primary feature is regurgitation occurring 5–10 min after initiating a meal. It is often confused with disorders such as gastro-oesophageal reflux disease, and patients may be subject to extensive yet unnecessary investigations. Treatment effectiveness with acid reducing medications and prokinetics is limited. The most favourable outcome is achieved with Diaphragmatic Breathing exercises. This case presentation describes the journey of a patient who was found to have rumination syndrome following high-resolution manometry (HRM) and was treated successfully with Diaphragmatic Breathing. Methods HRM (Manoscan 360°, SSI) with 10×5 ml water and 5×1 cm3 solid (bread) swallows and a 250 ml milkshake was performed in the in the upright seated position. This was followed by dual channel 24-h catheter-based pH monitoring. Treatment encompassed two sessions of diaphragmatic therapy. Results HRM: During the bread swallows and after drinking the milkshake, typical symptoms of regurgitation were reproduced. These were associated with short, sharp increases in the intragastric pressure sensors typical of Rumination Syndrome. 24-h Ambulatory reflux study: This exhibited a normal measurement for frequency of reflux events and a positive Symptom Index (87.1%; positive greater than or equal to 50%) for regurgitation. Conclusion Although in this example it was discovered with the use of HRM in a tertiary centre, Rumination Syndrome should be easily diagnosed based only on clinical history. This condition is usually treated with diaphragmatic breathing techniques, however patient commitment to therapy and perseverance is paramount. Diaphragmatic breathing is thought to overwhelm the subconscious yet voluntary abdominal wall muscle contractions which lead to regurgitation, and was successful in this case.

Pediatric Esophageal High-Resolution Manometry: Utility of a Standardized Protocol and Size-Adjusted Pressure Topography Parameters

Esophageal high-resolution manometry (EHRM) has evolved rapidly from a research tool to a routine investigation in adult clinical practice. This study proposes and evaluates a standardized EHRM protocol for use in pediatric clinical practice. Thirty pediatric patients underwent unsedated EHRM. Indications for EHRM were dysphagia, feeding difficulty, or pre-fundoplication assessment. Two 20-channel customized water-perfused silicone catheters, with an outside diameter of 3.8 mm (MuiScientific, Ontario, CA), were used. The catheters had one distal gastric channel, five channels 0.5 cm apart for the e-sleeve, and 14 proximal channels either 1 cm (for children <5 years) or 2 cm apart (for children >5 years). Single wet swallows, multiple rapid swallows (MRS), and solid swallows were systematically studied. The median age was 10 years (range 6 months-15 years). The esophageal motor findings were normal peristalsis (n=15), peristaltic dysfunction (n=12), achalasia (n=3), and spasm on consumption of solid food (n=2). The distal contractile integral adjusted for esophageal length (DCIa) of patients with peristaltic dysfunction was significantly lower than that of patients without peristaltic dysfunction (P<0.001). On MRS, aperistalsis with lack of esophagogastric junction (EGJ) relaxation was observed in patients with achalasia, and aperistalsis with complete EGJ relaxation was observed in patients with severe peristaltic dysfunction. On consumption of solid food, esophageal spasm associated with bolus impaction was observed in two patients. This study provides objective information with regard to topography pressure parameters in esophageal motility disorders of childhood while using a standardized EHRM protocol. The new DCIa variable may be useful for the assessment of patients with peristaltic dysfunction.

The effect of eating on lower esophageal sphincter electrical activity

Electrical activity of the lower esophageal sphincter (LES) has been recorded mainly in vitro and in anesthetized animals. Swallowing produces relaxation of the LES, followed by its contraction. These changes should be associated with changes in LES electrical activity. To determine whether changes in LES electrical activity can be used to recognize the beginning of a meal, four dogs were implanted with two electrodes in the longitudinal axis of the LES. The electrodes were connected to an implantable device for recording of electrical activity. After recovery, dogs underwent two experiments: 1) combined recordings of LES electrical activity and esophageal manometry to test the effect of dry swallows, water, and solid food swallows on LES electrical activity and 2) telemetric recording of LES electrical activity during a standard meal. All amplitudes were in mV, means+/-SD, ANOVA, P<0.05. In experiment 1, an increase in the amplitude of LES electrical activity was associated with the substance being swallowed, i.e., at rest: 0.31+/-0.06; dry swallows: 0.6+/-.0.1; water: 0.67+/-0.12; solid food: 1.06+/-0.17, P<0.001. In experiment 2, there was a pronounced and characteristic increase in amplitude of LES electrical activity during feeding, 0.26+/-0.1; during fasting, 0.99+/-0.23; while eating, 0.31+/-0.1 postprandial, P<0.001. In conclusion, the beginning and duration of a meal are identified by distinct, easily recognizable changes in the amplitude of LES electrical activity. These changes depend on the type of the substance being swallowed and are most prominent with solid food. Changes in LES electrical activity can potentially be used for automatic eating detection.

Oesophageal bolus transit and clearance by secondary peristalsis in normal individuals

Secondary peristalsis is important for the clearance of retained refluxate or material from the oesophagus. Combined impedance and manometry can directly detect both oesophageal contraction and bolus transit. To apply combined impedance and manometry to characterize oesophageal bolus transit and clearance by secondary peristalsis in healthy individuals. Eleven healthy volunteers underwent combined impedance and manometry with a catheter containing seven impedance-measuring segments and eight water-perfusion pressure transducers. Saline and solid agar boluses of 5 ml were applied for primary peristalsis and secondary peristalsis was stimulated by rapid mid-oesophageal injections of saline. The rate for complete bolus clearance of secondary peristalsis with saline injections was less than that of primary peristalsis with saline swallows (69 vs. 95%, P=0.02). No statistical difference in bolus propagation time between primary and secondary peristalsis was observed (P=0.45). Bolus presence time of secondary peristalsis was significantly longer than that of primary peristalsis for all impedance-measuring segments (all P<0.05). Solid swallows differed from saline swallows with lower rate of complete bolus transit and longer bolus transit time. Our data show that the impedance technique can successfully characterize oesophageal bolus transit and clearance by secondary peristalsis. These findings suggest that secondary peristalsis may be less effective than primary peristalsis regarding oesophageal transit and clearance of a liquid bolus.

Proximal versus distal oesophageal motility as assessed by combined impedance and manometry

Regional differences in oesophageal motility have been shown in primary peristalsis, but it is unclear whether such differences occur in secondary peristalsis. We investigated whether oesophageal motor function differs between the proximal and distal oesophagus. Eleven healthy subjects were studied with combined impedance and manometry. Saline and solid agar boluses of 5 ml were applied for primary peristalsis, and secondary peristalsis was stimulated by rapid mid-oesophageal injections of saline. Impedance tracings were analysed and compared for bolus presence time, bolus transit time in the proximal and distal oesophagus. Most of the manometric parameters were not significantly different between the proximal and distal oesophagus. Bolus presence time was longer in the distal oesophagus for both primary peristalsis and secondary peristalsis (p<0.001). The proximal bolus transit time was shorter than the distal bolus transit time during saline and solid swallows (p<0.001). Bolus transit time and bolus presence time were shorter for primary peristalsis than secondary peristalsis induced by saline injection. Our data demonstrated that the impedance technique can successfully detect functional differences between the proximal and distal oesophagus, and such differences were still noticeable when the oesophagus was directly stimulated by saline injection.

W1898 Interobserver Agreement for Impedance Manometry Findings in Patients with Non-Obstructive Dysphagia

Introduction: Impedance manometry (MII-EM) allows a more comprehensive evaluation of esophageal function by concomitantly measuring pressure changes and bolus transit. Still, there is limited information on the reliability and inter-observer agreement on MII-EM findings in patients with non-obstructive dysphagia. Aim: To evaluate the inter-observer agreement for impedance manometry readings in patients with non-obstructive dysphagia during liquid and solid swallows. Methods: Patient referred for evaluation of dysphagia underwent stationary MII-EM using a solid state catheter with 5 pressure channels and 5 impedance segments. Pressure changes were measured in the esophageal body 5, 10, 15 and 20cm above the lower esophageal sphincter (LES) and bolus presence data 2, 5, 10, 15 and 20 cm above the LES. Each subject received 10 saline and 10 yoghurt swallows in recumbent position. Tracings were reviewed independently by 4 investigators. Bolus presence time (BTT), distal esophageal amplitude (DEA) and lower esophageal sphincter residual pressure (LESRP) were quantified. Overall manometric and bolus transit abnormalities were based on previously established criteria (Am J Gastroenterol. 2004;99:1011). Results: From 20 patients (12 f, mean age 50, range 21-69 years) 15 (75%) had normal manometry, 2 IEM, 2 nutcracker esophagus and 1 poorly relaxing LES. 80% of patients had normal bolus transit. We found an excellent correlation between the readings of all 4 raters for DEA (intraclass correlation coefficient (ICC) 0.999), BTT (ICC 0.991) and LESRP (ICC 0.979). There was a very good interobserver agreement for both manometric and impedance findings with kappa values ranging from 0.77 to 0.99 (Table 1) Conclusion: The good inter-observer agreement for bothmanometric and bolus transit findings supports the reliability of combined impedance-manometry in clinical practice. Table 1: Kappa statistics for manometry and impedance findings

W1893 Assessing Dysphagia During Stationary Impedance-Monitoring (MII-EM): How Well Do Liquid and Solid Swallows Reproduce Patients' Symptoms?

W1893 Assessing Dysphagia During Stationary Impedance-Monitoring (MII-EM): How Well Do Liquid and Solid Swallows Reproduce Patients' Symptoms?

910 Assessing Dysphagia During Esophageal Manometry: How Well Do Liquid and Solid Swallows Reproduce Patients' Symptoms?

910 Assessing Dysphagia During Esophageal Manometry: How Well Do Liquid and Solid Swallows Reproduce Patients' Symptoms?

Total Fundoplication Does Not Obstruct the Esophageal Secondary Peristalsis: Investigation with Pre- and Postoperative 24-Hour pH-Multichannel Intraluminal Impedance

Aim: To determine the impact of total fundoplication on the spontaneous esophageal clearance, known as secondary peristalsis. Background: Although there is general agreement that total fundoplication is not an obstacle to bolus swallowing (primary peristalsis), whether it is an obstacle to spontaneous esophageal clearance (secondary peristalsis) is still not clear. Based on 24-hour monitoring, multichannel intraluminal impedance was used to calculate the time of spontaneous bolus clearance (BCT). Methods: Mean BCT was prospectively calculated in 15 consecutive patients before and after total fundoplication. BCT was calculated in seconds including all the gastroesophageal reflux episodes, whereas bolus swallows (solid meals and liquid swallows) were excluded from the analysis. Results: BCT was extrapolated from 1,057 episodes in the 623 h of study. Overall, BCT did not change after surgery (13.6 ± 4 vs. 15.2 ± 10 s; p = nonsignificant) and in the upright (12.2 ± 3 vs. 16.5 ± 7 s; p = nonsignificant) and recumbent position (22.9 ± 9 vs. 23.0 ± 9 s; p = nonsignificant). Conclusions: In this study total fundoplication did not affect the BCT by combined 24-hour ph monitoring and multichannel intraluminal impedance.