Tertiary Contractions Research Articles

Tu1989 Impact of Spatial Resolution on Results of Esophageal High-Resolution Manometry

Introduction: According to the Chicago classification of esophageal motility disorders, distal esophageal spasm (DES) is defined as a normal mean integral relaxation pressure (IRP) in combination with premature esophageal contractions (distal (DL) 9.0 cm/s) but with a normal DL. In the Chicago classification this poorly characterized abnormality is labelled rapid contractions with normal latency (RCNL). Aim: To investigate the differences between patients with DES and patients with RCNL. Methods: We retrospectively evaluated the clinical characteristics and high-resolution manometric recordings of patients with a normal IRP and simultaneous esophageal contractions with and without a short DL. The results of the barium esophagogram were also taken into account (absence or presence of tertiary contractions). Results: Since February 2012, 19 patients were identified. Of these, 8 fulfilled the Chicago criteria for DES (DES), including a short DL. The remaining 11 patients showed simultaneous contractions in the distal esophagus but with DL >4.5 s (RCNL). DES patients were younger than RCNL patients (59 ± 4 versus 72 ± 3 years, P <0.05). There was no difference in gender distribution between DES and RCNL. Symptoms of dysphagia and retrosternal pain occurred similarly in both groups. Weight loss and tertiary contractions on barium esophagogram tended to be more frequent in DES patients, although this was not statistically significant. There was no difference between the groups in the distal contractile integral (DCI, 2006 ± 466 mmHg.cm.s in RCNL versus 2549 ± 955 mmHg.cm.s in DES), nor in the CFV (15.6 ± 3.5 cm/s in RCNL versus 18.5 ± 3.7 cm/s in DES) . Lower esophageal sphincter resting pressure was not different in DES versus RCNL. However, the IRP was significantly higher in DES compared to RCNL (11.7 ± 0.7 mmHg vs 7.6 ± 1.2 mmHg, P <0.05), albeit still within the normal range. Conclusion: Patients with DES (short DL) and patients with RCNL (normal DL) have similar symptom profiles. DES patients are older and tend to show weight loss and an abnormal barium esophagogram more often than RCNL patients. These data suggest that RCNL represents a subgroup of patients within the spastic contraction spectrum, with less severe manifestations in an earlier phase of the disease process compared to DES with premature contractions.

Tu1988 Distal Esophageal Spasm According to the Chicago Classification: Is Timing Everything?

Introduction: According to the Chicago classification of esophageal motility disorders, distal esophageal spasm (DES) is defined as a normal mean integral relaxation pressure (IRP) in combination with premature esophageal contractions (distal (DL) 9.0 cm/s) but with a normal DL. In the Chicago classification this poorly characterized abnormality is labelled rapid contractions with normal latency (RCNL). Aim: To investigate the differences between patients with DES and patients with RCNL. Methods: We retrospectively evaluated the clinical characteristics and high-resolution manometric recordings of patients with a normal IRP and simultaneous esophageal contractions with and without a short DL. The results of the barium esophagogram were also taken into account (absence or presence of tertiary contractions). Results: Since February 2012, 19 patients were identified. Of these, 8 fulfilled the Chicago criteria for DES (DES), including a short DL. The remaining 11 patients showed simultaneous contractions in the distal esophagus but with DL >4.5 s (RCNL). DES patients were younger than RCNL patients (59 ± 4 versus 72 ± 3 years, P <0.05). There was no difference in gender distribution between DES and RCNL. Symptoms of dysphagia and retrosternal pain occurred similarly in both groups. Weight loss and tertiary contractions on barium esophagogram tended to be more frequent in DES patients, although this was not statistically significant. There was no difference between the groups in the distal contractile integral (DCI, 2006 ± 466 mmHg.cm.s in RCNL versus 2549 ± 955 mmHg.cm.s in DES), nor in the CFV (15.6 ± 3.5 cm/s in RCNL versus 18.5 ± 3.7 cm/s in DES) . Lower esophageal sphincter resting pressure was not different in DES versus RCNL. However, the IRP was significantly higher in DES compared to RCNL (11.7 ± 0.7 mmHg vs 7.6 ± 1.2 mmHg, P <0.05), albeit still within the normal range. Conclusion: Patients with DES (short DL) and patients with RCNL (normal DL) have similar symptom profiles. DES patients are older and tend to show weight loss and an abnormal barium esophagogram more often than RCNL patients. These data suggest that RCNL represents a subgroup of patients within the spastic contraction spectrum, with less severe manifestations in an earlier phase of the disease process compared to DES with premature contractions.

A Case of Acute Pancreatitis Following Botulinum Toxin Injection of Lower Esophageal Sphincter

Purpose: We present a 77-year-old female with chronic back pain who was referred with complaints of daily nausea, acid reflux, weight loss, and solid and liquid dysphagia. A thorough evaluation was undertaken including gastric emptying study, abdominal CT, and impedance pH study, which were unremarkable apart from a mild delay in gastric emptying. We performed esophageal manometry which revealed a hypertensive and poorly relaxing LES which was treated with endoscopic Botox injection, leading to improvement in dysphagia. She returned to our clinic 4 years after her initial evaluation complaining of worsening nausea and dysphagia. CT enterography was unremarkable. Esophageal manometry was repeated and again pointed toward a hypertensive motor disorder. Esophageal body pressures were 357 mmHg at 3 cm above LES and 372 mmHg at 8 cm above LES (normal 35-180 mmHg at both locations). Barium swallow revealed esophageal dysmotility with decreased primary stripping wave and tertiary contractions. During the subsequent several months, she was tried on domperidone to improve gastric emptying but proved ineffective. Sublingual nitroglycerin was prescribed which improved her dysphagia but was discontinued due to hypotension. An upper endoscopy with Botox injection of the LES was repeated given her good initial response. The morning after the Botox injection she developed acute onset of severe abdominal pain. At her local hospital she received an abdominal CT revealing inflammatory changes adjacent to the tail of the pancreas and proximal portion of the stomach. Laboratories revealed a lipase of 9,243 as well as a normal bilirubin, alkaline phosphatase, and calcium. There was a mild elevation in AST and ALT of 189 and 72, respectively. Triglycerides were mildly elevated. She received an abdominal ultrasound which was unremarkable as well as an MRCP which showed no evidence of biliary stones or strictures. A month later we proceeded with an endoscopic ultrasound which showed a normal pancreas and common bile duct. To our knowledge, this is the first described case of presumed acute pancreatitis following Botox injection of the lower esophageal sphincter. Two weeks prior to the injection, the patient had a normal lipase of 49 and had never before suffered an episode of acute pancreatitis. She fully recovered and has not had a recurrence in the subsequent 10 months. Administration of botulinum toxin is generally felt to have a low rate of adverse reactions and complications which makes this case unexpected and clinically relevant given its frequent use to treat spastic gastrointestinal disorders such as achalasia.

An Interesting Case of Oropharyngeal Dysphagia after a Botox injection for Sialorrhea

Purpose: Sialorrhea is caused by excessive salivation that is commonly seen in patients with neurodegenerative diseases. Botox injection to the parotid gland and submandibular gland offer an effective and localized method to decreased saliva secretion. Although botox injection is relatively safe and effective, serious complication such as hypoglossal nerve paralysis, diffuse oropharyngeal muscle paralysis, or death can occur. We present an interesting case of oropharyngeal dysphagia from diffuse muscular paralysis of oropharyngeal muscles and hypoglossal nerve paralysis after a Botox injection for idiopathic sialorrhea. This patient had hypersalivation for over 1 year and was seen by ENT for Botox injections. She received her first Botox injection (25 units of Botox to each parotid gland) 2 months prior with symptomatic improvement. Shortly after the first botox injection, her hypersalivation returned back to baseline. She was seen by a neurologist for evaluation. Patient had a normal EMG and MRI brain. She then returned to ENT for her second botox injection (total of 70 units of botox was injected to bilateral parotid glands and left submandibular gland). Two days after her second Botox injection, the patient developed dysarthria and dysphagia to both solid and liquids. Due to severe dehydration, patient was admitted for intravenous hydration. ENT evaluation showed symmetric and mobile vocal cords with good abduction and closure, intact gag reflex, and laryngeal sensation. CT neck and chest showed a collapsed esophagus. Esophagram was limited with tertiary contractions seen throughout the esophagus. Upper endoscopy was unremarkable and did not reveal any mass or stricture. Video fluoroscopy swallow showed a significant reduced lingual anterior to posterior propulsion, and poor pharyngeal transit resulting in moderate pharyngeal retention. Given the clinical presentation and repeat EMG study, neurology concluded that it is unlikely ALS or myasthenia gravis. In exclusion, patient was thought to have lingular dyscoordination and dysarthria consistent with bilateral cranial nerve XII palsy or diffuse muscular paralysis of oropharyngeal muscles. Due to severe dehydration, patient had a PEG tube placement for nutrition until her symptoms improved. Patient continued to require PEG tube for nutrition 1 year after the initial event because of persistent oropharyngeal dysphagia. An ultrasound-guided Botox injection will offer a safer approach by delivering Botox to the proper location and minimizing complications. Also, decreasing the dose or frequency of botox injections should be considered to avoid serious complications.

Functional mobility, falls risk, level of physical activity and health perception of community dwelling with 65 years or more

department of the university hospital for complaints of upper gastrointestinal systemwere included in the study, and all radiographs were evaluated retrospectively. One thousand and one hundred and twenty-six patients over the age of 50 in total of 2,130 patients (699 patients between the ages of 50–65, 366 cases between 65–80years and 61 cases over 80) were included in the study. These cases were classified according to the common pathological conditions. Statistical data were given as the percentage of data. Results.–Hiatus herniawas detected in 76 cases (6.74%). Hiatus hernia incidence in the 50–65 age rangewas 4.72%, 8.70% between the ages of 65–80, 18.3% over 80years. Gastroesophageal reflux was found in110 cases (9.77%). Tertiary contractionwasdetected in 104 cases (9.24%). The other conditions were found in 98 cases (8.70%). Key conclusions.– According to our results, over the age of 65 ‘hiatal hernia’ incidence increases. In our study, over 50years of age, the most common pathological conditions were found to be gastroesophageal reflux, tertiary contractions and hiatus hernia in our region; respectively.

An Uncommon Cause of Food Impaction

Purpose: Esophageal food impaction is usually secondary to structural abnormalities of the esophagus such as Schatzki's ring, eosinophilic esophagitis or strictures. Nutcracker esophagus (NE) is an esophageal motility disorder characterized by the presence of hypertensive but peristaltic contraction waves, making food impactions rare. We describe a patient with meat impaction associated with NE. A 66-year-old male presented with chest pain and dysphagia 3 hours after ingesting a large meal. His pain was located in the mid chest associated with difficulty swallowing his own saliva. He denied any history of dysphagia, chest pain or heartburn. Physical exam revealed an alert man in mild distress with pooling of saliva in his mouth. Cardiac, pulmonary and abdominal exams were unremarkable. An EKG and three sets of cardiac enzymes ruled out cardiac causes of chest pain. All the initial laboratory results were normal except for a WBC 11,950; with a normal eosinophil count. A CT of the chest revealed foreign material in the esophagus, consistent with undigested food. Prior to endoscopic evaluation, the patient's symptoms spontaneously subsided. Endoscopy revealed mildly hemorrhagic mucosa in the mid esophagus with no strictures, concentric rings or esophageal furrows. Biopsies of the esophagus were normal, with no evidence of eosinophilic esophagitis. A single contrast esophagram revealed tertiary contractions of the esophagus. High resolution manometry (HRM) (Figure 1) revealed normal peristaltic wet swallows with normal contraction amplitudes at 7 and 11 cm above the LES. At 3 cm above the LES, however, the amplitudes ranged from 196-386 mmHg, consistent with NE. The patient was discharged the day after the procedure and returded 1 month later for follow-up. He remained asymptomatic and no treatment was required. Nutcracker esophagus can be diffuse or segmental. The manometry findings in our patient were consistent with a segmental nutcracker esophagus. Only 4 cases have reported of nutcracker esophagus and food impaction, but ours is the first one diagnosed with high resolution manometry. Although rare, nutcracker esophagus can cause esophageal food impaction and HRM is of paramount importance in diagnosing this entity in minimally symptomatic patients.Figure: [573] High resolution manometry showing hypertensive peristaltic waves in the distal esophagus.

A Novel Treatment for Pseudoachalasia Secondary to Malignant Mesothelioma Using Botulinum Toxin

Purpose: Background: Secondary achalasia due to mesothelioma is a rare event that carries a poor prognosis. Most patients with mesothelioma will not respond to its primary treatment and may require palliative therapy. We present the first case, to our knowledge, of a patient with secondary achalasia due to mesothelioma treated successfully with botulinum toxin injections into the lower esophageal sphincter (LES). Case Description: A 66 year-old male recently diagnosed with malignant mesothelioma and being treated with chemotherapy, presented with progressive dysphagia to solids and liquids. His past history was remarkable for gastroesophageal reflux being treated with omeprazole twice daily. The patient had previously worked as a plumber. The physical exam was normal except for decreased breath sounds in the left lung. A CT scan of the chest revealed extensive soft tissue prominence from the level of the thoracic inlet with involvement of the mediastium, but sparing the distal esophagus. A double contrast esophagram showed a smoothly tapering stricture of the distal esophagus without associated mucosal abnormality. There were diffuse esophageal tertiary contractions, and decreased esophageal peristalsis. The patient refused esophageal manometry. Esophagogastroduodenoscopy (EGD) was performed, revealing a mildly dilated esophagus with uncoordinated contractions, no appreciable esophageal peristalsis, and a hypertonic LES, which was easily traversed with the endoscope. The mucosa was normal and the rest of the EGD was unremarkable. Botulinum toxin was injected directly into the four quadrants of the LES using 20 units of toxin per injection. The patient's dysphagia improved following this treatment and maintained symptomatic response during a 3-month follow-up. Discussion: Dysphagia is a rare preterminal event associated with mesothelioma. Postmortem examinations in cases of mesothelioma have shown the esophagus to be involved rarely or not at all. There have been several cases describing pseudoachalasia secondary to mesothelioma. The prognosis is poor, and the goal with these patients is to improve their quality of life. In previous cases that have addressed dysphagia secondary to mesothelioma, treatments included tumor resection, local myotomy, or pallative stents. To our knowledge this is the first reported case of a patient with pseudoachalasia secondary to mesothelioma treated successfully with botulinum toxin injections. In conclusion, just as in primary achalasia where botulinum toxin is an option primarily used for high-risk surgical candidates; we see that its use can be extended to include patients with pseudoachalasia secondary to mesothelioma.

Epiphrenic diverticulum and associated hypokalemia

Fig. 1. Barium swallow depicting an epiphrenic diverticulum. Preoperative manometry revealed significant tertiary contractions with intact primary peristalsis. The lower esophageal sphincter relaxed normally which excluded the diagnosis of achalasia. Fig. 2. Resected diverticular sac demonstrating retained potassium supplementation pills. The patient had undergone a successful diverticulectomy, distal esophageal myotomy, and Belsey partial fundoplication through a left thoracotomy. There was minimal mucosal damage or peridiverticular inflammation as these were enteric coated pills. Following surgery, the patient’s hypokalemia resolved.

Esophageal Dysmotility in Patients Who Have Eosinophilic Esophagitis

The understanding of esophageal motility alterations in patients who have eosinophilic esophagitis (EE) is in its infancy despite the common presenting complaint of dysphagia. A diversity of motility disorders has been reported in patients who have EE including achalasia, diffuse esophageal spasm, nutcracker esophagus, and nonspecific motility alterations including high-amplitude esophageal body contractions, tertiary contractions, abnormalities in lower esophageal sphincter pressure, and other peristaltic problems. Some evidence suggests that treatment of EE will improve motility. Technological advances such as high-resolution manometry and combined manometry with impedance may provide new insight into more subtle motility abnormalities.

SEVERE GASTROINTESTINAL DYSMOTILITY SECONDARY TO PARANEOPLASTIC ANTIBODIES IN A PATIENT WITH A REMOTE HISTORY OF MALIGNANT THYMOMA

CASE: 65-year-old male with history of successfully treated malignant thymoma 8 years ago, presented with increasing dysphagia, vomiting, constipation and a 40 lb weight loss over a 3 year period. Other symptoms included disabling dysarthria, facial weakness, orthostatic dizziness, dry mouth, anhydrosis and erectile dysfunction. EGD showed retained solid food in the stomach. Esophagogram showed abnormal motility in the distal esophagus with absent primary peristaltic wave and tertiary contractions. Manometry showed abnormal esophageal body peristalsis. These findings were consistent with achalasia. Radionuclide study showed delayed gastric emptying and small bowel transit, with only 5% of the activity having left the small bowel at 6 hours. The patient had an impacted colon with no evidence of obstruction. EMG was consistent with bulbar myasthenia gravis. Paraneoplastic studies were positive for muscle Ach R binding, blocking, and modulating antibodies and high titers of striated muscle antibodies. CRMP-5 was also detected by western blot. We did not detect ganglionic Ach R antibodies or calcium channel antibodies. The panel was highly suggestive of recurrent thymoma, however, despite thorough investigation, a neoplasia was not identified. The patient was treated with pyridostigmine, IVIG And plasmapheresis with significant improvement of his symptoms. DISCUSSION: Gastrointestinal dysmotility is a manifestation of paraneoplastic dysautonomia. Various neoplasms have been implicated including thymoma and small cell lung carcinoma, and in fact this remains the main differential diagnosis. The association of myasthenia gravis and dysautonomia has been suggested previously in the literature. In a published case series of 7 patients with both these disorders 4/7 patients had thymoma. This case is of particular interest because a thymoma has not yet been identified despite the high likelihood of its presence due to the previous history. This could suggest that gastrointestinal dysautonomia could potentially be a very early presentation of thymoma. The extensive involvement of the esophagus with the presentation of severe dysphagia and achalasia is another unusual manifestation. As previously reported, paraneoplastic dysautonomia with GI dysmotility has been successfully managed with steroids, plasmapheresis and IVIG.

Vigorous achalasia with high-amplitude esophageal body contractions: a case report

A 25-year-old woman presented with dysphagia and chest pain in November 1999. Esophagography revealed esophageal stasis with spindle-shaped tapering at the cardia without dilatation of the lower esophagus. Manometry showed a hypertonic sphincter with incomplete relaxation on swallowing. Esophageal body contractions were simultaneous with an amplitude in excess of 200 mm Hg with tertiary contractions. These findings were not compatible with “classic” achalasia, but with vigorous achalasia. The patient underwent pneumatic dilatation with immediate relief of her symptoms. However, improvement in dysphagia and chest pain was temporary, necessitating four sessions of dilatation over three and a half years. The literature on this rare esophageal motility disorder is reviewed.

Esophageal acid exposure and altered neurocardiac function in GERD patients with idiopathic arrhytmias

under i7 years (mean age i2 yxs) and 352 adults (i78 men, mean age 53 yrs). The children presented a mean of 2.4 years (range 0-11) after symptom onset, while adults did so after 62 years (range 0,5-40; p = 0.01 t-test). Presenting symptoms in children and adults respecnvely were dysphagia (100/99%, n.s.), regurgitation (73/70%, n.s.), retrostemal pain (42140%, n.s), pyrosis (4/24%, p=0.01), cough (31/18%, n.s.) and weight loss (27/47% >5 kg, n.s.). Esophageal manometry showed no difference between both groups. Barium swallow showed dilation in 65% and 81%(n.s.); all patients in both groups had a typical bird beak with stasis of contrast. Endoscopy showed dilation in 58% and 76% (p =0,05), tertiary contractions in 11% and 21% (n.s) and food retention in 77% and 74%(n.s.). In 16 children pneumo-dilation failed after a mean 32 months, compared with 86 failures after a mean 38 months in adults (p = 0.00 ] ). Statistical analysis of presenting symptoms, diagnostic delay, patient characteristics and clinical features in relation to treatment success revealed only age as a predictor of outcome; in comparing the two groups as well as within the adult group younger age adversely effects success of pneumo-dilation. CONCLUSION Children generally present with similar clinical symptoms as adults, with exception of pyrosis. Diagnosuc eva[nation shows more frequent esophageal dilation in adults at barium swallow and endoscopy and the delay until diagnosis is shorter in children than in adults. Young age adversely affects outcome of pneumo-dilation (p = 0.003), all other parameters am no predictors of balloon dilation outcome

Vigorous achalasia: original description requires minor change.

Vigorous achalasia was described in 1957 as a subset of achalasia with a higher contraction amplitude (>37 mm Hg), minimal esophageal dilatation, prominent tertiary contractions, and higher incidence of chest pain. Ascertain the existence of a distinct achalasia group based on manometric, radiographic, and clinical grounds. The records of 209 idiopathic achalasia patients seen over a 9-year interval were reviewed for duration and frequency of dysphagia, chest pain, heartburn, weight loss, and nocturnal symptoms, as well as for treatment outcome. Manometric tracings were reanalyzed for lower esophageal sphincter pressure (LESP), LES residual pressure, distal esophageal contraction amplitude, and presence of repetitive waves. Patients were subsequently divided into classic (amplitude < or =37 mm Hg) and vigorous (amplitude >37 mm Hg) achalasia groups. Esophagrams were reassessed blindly for esophageal diameter both in the upright and recumbent positions and presence of lumen-occlusive tertiary contractions. One hundred forty-four classic and 65 vigorous achalasia patients were identified. These groups were similar in age and gender, as well as duration of symptoms. Chest pain was equally prevalent in both groups. Lower esophageal sphincter pressure was higher ( p < 0.01) and repetitive waves more common ( p < 0.0001) in the vigorous achalasia group. Upright esophageal diameter was smaller ( p = 0.0003) and tertiary contractions more frequent ( p = 0.0004) in this group. The original manometric and radiographic description of vigorous achalasia is accurate. The incidence of chest pain is similar to that of patients with classic achalasia.

A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition. Indications for pediatric esophageal manometry.

A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition. Indications for pediatric esophageal manometry.

Pharyngo-esophageal dysphagia in Parkinson's disease.

The radiologic characteristics of pharyngoesophageal (PE) dysfunction in Parkinson's disease (PD) are not well established, partly because most previous studies have examined only small numbers of patients. We administered a dynamic videofluoroscopic swallowing function study to 71 patients with idiopathic PD. Using the Hoehn and Yahr disease severity scale, patients were subdivided into those with mild/moderate disease, subgroup I (n = 38), and advanced PD disease, subgroup II (n = 33). From pharyngeal ingestion to gastric emptying, bolus transport was normal in only 2 patients. The most common abnormalities occurring during pharyngeal ingestion included impaired motility, vallecular and pyriform sinus stasis, supraglottic and glottic aspiration, and deficient epiglottic positioning and range of motion. Esophageal abnormalities were multiple but most commonly included delayed transport, stasis, bolus redirection, and tertiary contractions. Typical aberrations of lower esophageal sphincter (LES) function included an open or delayed opening of the LES and gastro-esophageal reflux. A pathogenesis linking PE with the pathology of PD is proposed.

Chest Pain in an Aspirin-Sensitive Asthmatic Patient: Eosinophilic Esophagitis Causing Esophageal Dysmotility

We describe a case of eosinophilic esophagitis in a 38-year-old man with aspirin-sensitivity asthma which presented as noncardiac chest pain. Manometric measurements demonstrated tertiary contractions. Biopsies showed a dense eosinophilic infiltrate in the mucosa. There was no response to therapy for reflux. Symptoms quickly resolved with corticosteroid therapy. Subsequent manometric values recorded after corticosteroid therapy showed resolution of the dysmotility. Biopsies showed normal mucosa. Adult asthmatic subjects with noncardiac chest pain should receive further investigation if reflux therapy fails to resolve the symptoms.

Functional abnormalities of the esophagus: a prospective analysis of radiographic findings relative to age and symptoms.

The prevalence and severity of functional abnormalities of the esophagus seen on fluoroscopic examination were compared with the age and symptoms of the patients. The esophagus was examined radiographically in 139 consecutive outpatients 19-84 years old. All patients completed a data sheet about their symptoms, and medical records were reviewed to determine the main indication for the examination. Videofluoroscopy was used to evaluate primary peristalsis, proximal escape, and tertiary activity in the esophagus. The severity of proximal escape and activity was classified. Patients were categorized into three age groups: 39 years old or younger (n = 33); from 40 to 60 years old (n = 55); and 61 years old or older (n = 51). Abnormal esophageal motility, defined as disruption of peristalsis on two or more of five swallows, was found in 24% of patients 39 years old or younger, 36% of patients from 40 to 60 years old, and in 49% of patients 61 years old or older (p > .05). However, evaluation of the number of disrupted peristaltic swallows by age revealed 18% abnormal swallows in patients 39 years old or older, 27% in patients from 40 to 60 years old, and 37% in patients 61 years old or older (p < .01). Proximal escape and tertiary contractions increased significantly with the age of the patient. Regardless of age, proximal escape was seen in 79% of swallows and tertiary contractions were seen in 48% of swallows with disrupted peristalsis. The prevalence and severity of proximal escape and tertiary contractions increased in the older patients. Symptoms had no correlation with status of esophageal motility (p > .05). In 22 patients with secondary diseases, including rheumatoid arthritis and diabetes mellitus, those diseases showed no correlation with the status of esophageal motility. The prevalence of functional abnormalities of the esophagus increased with age. Most patients with abnormal swallows showed proximal escape with or without tertiary activity. Patients' symptoms and other diseases did not correlate with the status of their esophageal motility.

Unexplained Chest Pain: The Hypersensitive, Hyperreactive, and Poorly Compliant Esophagus

To determine whether neuromuscular dysfunction of the esophagus causes chest pain in patients in whom no disease is found on cardiac work-up, upper gastrointestinal endoscopy, esophageal manometry, and 24-hour pH studies. Prospective study. Tertiary referral center. 24 consecutive patients and 12 healthy controls. A new technique, impedance planimetry, was used to measure the sensory, motor, and biomechanical properties of the human esophagus. The impendance planimeter, which consists of a probe with four ring electrodes, three pressure sensors, and a balloon, simultaneously measures intraluminal pressure and cross-sectional areas. This allows calculation of the biomechanical variables of the esophageal wall. Stepwise balloon distentions from 5 to 50 cm H2O induced a first sensation at a mean pressure (+/- SD) of 15 +/- 9 cm H2O in patients and 30 +/- 11 cm H2O in controls (P < 0.001). Moderate discomfort and pain were reported by 20 of 24 patients (83%) at 26 +/- 9 cm H2O and at 36 +/- 9 cm H2O, respectively, but by none of the controls (P < 0.001). Typical chest pain was reproduced in 20 of 24 patients (83%). In patients, the reactivity of the esophagus to balloon distention was greater (P = 0.01), the pressure elastic modulus was higher (P = 0.02), and the tension-strain association showed that the esophageal wall was less distensible (P = 0.02). Distention excited tertiary contractions and secondary peristalsis at a lower threshold of pressure (P = 0.05) and with a higher motility index in patients than in controls (P = 0.04). In patients with chest pain and normal cardiac and esophageal evaluations, impedance planimetry of the esophagus reproduces pain and is associated with a 50% lower sensory threshold for pain, a 50% lower threshold for reactive contractions, and reduced esophageal compliance.

Impedance planimetry: an integrated approach for assessing sensory, active, and passive biomechanical properties of the human esophagus.

Our objective was to study the biomechanical properties and their relationships to the sensory and motor function of the esophagus, which has seldom been examined in humans. We used impedance planimetry, to study these properties. This system measures cross-sectional area (CSA) and intraluminal pressure simultaneously and facilitates calculation of some of the biomechanical properties of the esophageal wall. We performed 15 studies in 12 healthy volunteers. In three subjects, the studies were repeated to test reproducibility. Stepwise increments in balloon pressure from 5 to 40 cm H2O induced an increase in CSA (mean +/- SD), 91 +/- 27 to 469 +/- 63 mm2, the wall tension 27 +/- 4 to 484 +/- 32 mm x cm H2O, and the strain 0.2 +/- 0.1 to 1.3 +/- 0.3. The tension/strain relationship increased exponentially. The compliance did not change. The threshold for first sensation was 30 +/- 11 cm H2O (mean +/- SD). In three subjects, when the balloon was distended > 40 cm H2O, chest pain was induced at a threshold of 62 +/- 3 cm H2O, and the compliance decreased. Balloon distension induced tertiary contractions and secondary peristalsis at thresholds of 15 +/- 4 cm H2O, and 19 +/- 5 cm H2O. Repeat studies showed good correlation (r = 0.9). Graded balloon distension increases esophageal CSA, wall tension, and strain. When a threshold is reached, tertiary contractions and secondary peristalsis develop at pressures less than 50% of sensory threshold. At higher pressures, chest pain is induced. Impedance planimetry promises to be a simple, objective, reproducible, and comprehensive technique for evaluating the sensory, motor, and viscoelastic properties of the esophagus.

Long-term effect of total fundoplication on the myotomized esophagus

From 1978 to 1983, 17 patients had an esophagocardiomyotomy with an added short total fundoplication as an antireflux procedure. Thirteen had achalasia and 4, diffuse esophageal spasm. All patients initially had the usual symptoms of these motor disorders. Early after the operation all became asymptomatic, but over the years of follow-up, symptoms reappeared in 14 of 17 patients, and 5 required reoperation. The distal esophageal transverse diameter showed progressive dilatation from 3.9 cm preoperatively to more than 6 cm after 10 years of evolution. Over the same period, deterioration in the esophageal emptying capacity caused esophageal stasis to increase from 32% to 75%. Manometric changes were significant after the operation: resting pressures in the esophageal body decreased from 10.5 to 4.4 mm Hg ( p < 0.001) proximally and from 12.2 to 4.6 mm Hg distally ( p < 0.001). Peak contraction pressures became significantly weaker: 38 to 30 mm Hg in the proximal esophagus ( p < 0.001) and from 49.2 to 28.1 in the distal esophagus ( p < 0.001). Tertiary contractions were unchanged distally, but peristalsis reappeared in more than 30% of all swallows in the proximal half of the esophageal body. The resting pressure gradient in the lower esophageal sphincter area was reduced from 25.5 to 7.4 mm Hg by the operation. This gradient remained stable over 10 years of follow-up. No significant acid exposure was documented in 8 patients undergoing 24-hour pH recordings after their operation. Endoscopy revealed dilatation and retention without evidence of reflux esophagitis damage. Total fundoplication when associated with esophageal myotomy results in improved symptoms in the early postoperative phase. Aperistalsis remains unchanged, and the lower esophageal sphincter gradient remains low. Over time a progressive increase in esophageal retention occurs with poor emptying and recurrence of symptoms. Despite good reflux control, total fundoplication is not appropriate to the myotomized esophagus over time.