Reflux oesophagitis and oesophageal transit: evidence for a primary oesophageal motor disorder.

Patients with reflux oesophagitis have a diminished capacity for distal oesophageal clearance. This is considered to be secondary to acid reflux damage to the oesophageal wall. We have postulated that the observed oesophageal dysmotility is a primary phenomenon. Using 24 hour oesophageal pH monitoring and the solid bolus oesophageal egg transit test, we evaluated the oesophageal transit of 55 patients, with symptomatic reflux oesophagitis, and 16 healthy volunteers. The transit for the entire oesophagus was significantly prolonged in the patient group. This delay was evident in all three segments of the oesophagus. Amongst the patients, there was significant correlation between the oesophageal transit time and the number of prolonged reflux events. No correlation was found, however, between symptom score or severity of endoscopic oesophagitis and transit time. These results would indicate that the oesophageal dysmotility is an integral part of gastrooesophageal reflux disease, and is more of a cause than an effect.     

Abnormal oesophageal function in patients with non-toxic goiter or enlarged left atrium, demonstrated by radionuclide transit measurements

In 10 patients with enlarged atrium and in 29 patients with goiters and neck discomfort dynamic oesophageal scintigraphy was performed. The passage of water and capsules, containing 99mTc-pertechnetate, was studied with the patients in the supine and in the sitting positions. As a reference group we examined 35 healthy, age-matched volunteers. Mean transit time (MTT) was calculated, residual activity was expressed as a percentage of maximum activity, and the number of spikes in the curves was defined by visual analysis. Both in patients with enlarged left atrium and in those with large goiters the studies showed significantly prolonged MTT, increased residual activity, and a higher frequency of spikes, compared with healthy volunteers and with patients with small goiters. There was no relationship between symptoms and abnormal scintigraphic results. The passage of capsules was impaired only in cardiac patients. It is concluded that abnormal oesophageal function is often present in patients with enlarged left atrium and in patients with large, but not with small, goiters. Inhibition of oesophageal transit appears to be dependent on mechanical compression, but the nature of oesophageal impairment may vary with the level of compression. The frequent complaints of neck sensations in patients with goiters are probably not of oesophageal origin.     

Postoperative gastrointestinal transit. Results of the measurement of segmental transit times

The postoperative transit times of radioopaque markers through the gastrointestinal tract where measured in 6 patients after gastric surgery, in 13 patients after cholecystectomy, in 10 patients after appendicectomy and in 7 other patients who underwent general anesthesia without laparotomy. After ingestion of 20 markers, overall and segmental transit times were calculated according to their distribution on serial plain films of the abdomen taken 6 and 24 h after the operation, and every 24 h thereafter until complete evacuation of the markers. Overall transit times of the 3 groups of patients with laparotomy (171, 130 and 113 h respectively) were greater than overall transit times of patients without laparotomy (25 h). Overall transit times of patients with gastric operations were greater than overall transit times of patients with cholecystectomy (p less than 0.05) or appendicectomy (p less than 0.01). The increase in overall transit time was mainly due to an increased gastric transit time in patients after gastric surgery and an increased transit time through the right colon in patients who underwent cholecystectomy and appendicectomy. Once markers began to be defecated, their disappearance rate was the same in the 4 groups of patients. These results show that an increased overall transit time may be the consequence either of an increased transit time through the stomach or through the right colon, depending on the type of operation. As well, when digestive propulsive activity returns, it is de novo normal.     

Effect of left atrial size on the oesophageal transit of capsules.

The oesophageal transit time of barium sulphate capsules was measured using X ray fluoroscopy in 20 patients with mitral valve disease and 12 control patients in the erect and supine positions when swallowed with both 15 ml and 60 ml of water. An erect barium swallow was performed, and from a lateral radiograph the area of indentation of the oesophagus caused by the cardiac impression was measured. Left atrial diameter was derived from M mode echocardiography. In 19 patients with mitral valve disease one or more capsules remained in the oesophagus for five minutes and disintegrated there, whereas this occurred in only six control patients. Capsule transit time was significantly slower in the study patients than in the control patients in the supine position with 15 ml water. There was a significant correlation between the area of indentation and mean capsule transit time and supine 15 ml transit time. The area of indentation closely correlated with the left atrial diameter. When capsules were delayed in the oesophagus, this occurred mainly at the level of the left atrial impression in the study patients and at the lower oesophageal sphincter in the control patients. Patients with mitral valve disease are more likely than control patients to have delayed oesophageal transit of capsules because of the anatomical deformity caused by enlargement of the left atrium.     

Impaired oesophageal transit of capsule versus tablet formulations in the elderly.

Drug induced oesophageal injury is an important and preventable cause of iatrogenic injury. In most cases the injury is considered to be due to mucosal contact from formulations lodged in the oesophagus. A scintigraphic study was performed comparing the oesophageal transit of enteric coated tablets with similar sized and shaped gelatin capsules, using a population of elderly healthy volunteers similar in age (50-79 years) to the population most likely to be receiving regular treatment. Twenty three volunteers injected the radiolabelled tablet or capsule with 50 ml of water while sitting on two separate occasions according to a randomisation schedule. Oesophageal transit was assessed by gamma scintigraphy. Gastric residence was also assessed in 11 of 23 subjects. While the tablet was readily cleared from the oesophagus, mean transit time 4.3 seconds (range 1.0-14.0), the capsule often showed a comparatively prolonged holdup, mean transit time 20.9 seconds (range 1.5-174.5). Ten of 11 tablets emptied from the stomach intact, while all 11 capsules broke up in the stomach. Gelatin capsules showed a clear tendency to remain within the oesophagus of healthy elderly volunteers, while similar sized enteric coated tablets did not. These studies show the importance of assessing oesophageal transit when designing the formulation of drugs with a potential for oesophageal injury.     

Dynamic radionuclide imaging with 99mTc-sucralfate in the detection of oesophageal ulceration.

Standard oesophageal scintigraphic techniques using 99mTc-colloids rarely identify oesophageal mucosal damage. Sucralfate can be labelled with 99mTc for the detection of oesophageal mucosal ulceration. This method uses two separate supine swallows of 10 MBq 99mTc-colloid in 10 ml, followed by a single supine swallow of 30 MBq 99mTc-sucralfate. The data are processed to give time-activity curves, mean transit times and condensed dynamic images. When oesophageal ulceration is detected, the time-activity curves using sucralfate show residual activity in the oesophagus after the transit time indicated by the colloid swallow. The condensed dynamic image shows a persistence of activity at the level of the ulceration. Erect sucralfate images taken immediately after the dynamic sequence show no oesophageal localisation. The results from a study of 62 patients have shown excellent correlation between the dynamic 99mTc-sucralfate images and endoscopy findings. Sequential sucralfate studies for healing also correlate well. The use of labelled sucralfate to detect oesophageal ulceration could modify the indications for endoscopy in gastrooesophageal reflux disease.     

Solid-phase radionuclide esophageal transit in progressive systemic sclerosis

BACKGROUND/AIMS: In most patients with progressive systemic sclerosis the esophagus is affected. Reflux symptoms are most frequent whilst dysphagia also occurs. The radionuclide esophageal transit study is a sensitive screening test for esophageal dysfunction. In this study, we evaluated the esophageal motility of patients with progressive systemic sclerosis using a solid-phase radionuclide esophageal study. METHODOLOGY: Thirty-two patients with progressive systemic sclerosis and 30 normal volunteers were studied with solid-phase radionuclide esophageal study. Each subject was placed in a supine position above a gamma camera linked to a computer and was given a 4-mL bolus of solid gelatin containing 1 mCi of Tc-99m phytate. Data were acquired in the list mode. RESULTS: Twenty-nine of the 32 patients (91%) had abnormal findings from the study. CONCLUSIONS: The radionuclide esophageal transit study can be regarded as a useful tool for evaluating the esophageal function in patients with progressive systemic sclerosis and in the follow-up of treatment.     

Radionuclide transit studies in the detection of oesophageal dysmotility

A scintigraphic method is described to measure the transit of a fluid bolus through the oesophagus. Transit times in 16 normal subjects ranged from five to 15 seconds and were highly reproducible. Prolonged transit times were observed in 16 of 19 patients with known oesophageal motility disorders, and in these patients inspection of the time activity curves frequently permitted an adynamic oesophagus to be distinguished from one showing excessive incoordinate contractions. The technique was then applied prospectively to 50 patients referred for oesophageal motility studies and a comparison made between the oesophageal transit measurements and the findings on conventional oesophageal manometry. There was agreement between these tests in 42 (84%) of the 50 patients. The measurement of oesophageal transit may be made quickly and safely, without causing discomfort to the patient, and it appears to be at least as sensitive as manometry in the detection of oesophageal motility disorders.     

Detection of esophageal motor disorders by radionuclide transit studies

Radionuclide measurement of esophageal transit has been proposed as a screening test for esophageal motor dysfunction. In this study we evaluated the radionuclide esophageal transit test in 49 consecutive patients undergoing esophageal manometry for esophageal motor disorders. Esophageal transit was assessed using a 10-ml water bolus labeled with 250 Ci technetium-99m sulfur colloid. In preliminary studies in 14 healthy controls, mean transit time was 9.6±2.1 (SD) sec. Prolonged transit (>15 sec) was observed in two of 28 swallow sequences in the control subjects. Transit times were prolonged in all patients with achalasia or diffuse esophageal spasm, and in five of seven patients with nonspecific abnormalities of peristaltic progression. The test was abnormal in only three of seven patients with high-amplitude peristalsis (nutcracker esophagus) and in none of three patients with hypertensive lower esophageal sphincter. Additionally, prolonged transit was seen in two of 18 patients with normal manometry. We conclude that the radionuclide transit test using a liquid bolus successfully identifies motor disorders characterized by defective peristaltic progression but not disorders in which peristalsis is intact. A major limiting factor appears to be the small number of swallow sequences tested. The test may not, therefore, be accurate enough to consider adopting as a sensitive and noninvasive screening test in the evaluation of patients with suspected esophageal motor disorders.     

Esophageal dysfunction and radionuclide transit in progressive systemic sclerosis

Sixty patients with progressive systemic sclerosis (PSS) were studied by radionuclide esophageal transit (RT) and esophageal cineradiography. Fifty-two patients (87%) had abnormal RT with prolonged transit time and 28 (47%) had stagnation of radionuclide. RT was positively correlated to duration of disease (p less than 0.01). A positive correlation between transit time and the presence of dysphagia was observed. Reduced esophageal motility evaluated by cineradiography was observed in 44 patients (73%). In patients with moderate-severe esophageal dysfunction there was a positive association between prolonged RT and hypomotility at the radiological examination (p = 0.001). RT is a safe and non-invasive method which is more sensitive than cineradiography and might be used as a screening test to evaluate esophageal involvement in patients with PSS.     

Quality of life measurement in patients with oesophageal cancer.

Quality of life (QOL) measurement may aid decision making in the treatment of patients with oesophageal cancer but must be clinically valid to be useful. This study considered if the European Organisation for Research and Treatment of Cancer QOL questionnaire, the QLQ-C30, showed differing results in two clinically distinct groups of patients with oesophageal cancer and also investigated the correlation between dysphagia grade and various scales of QOL. Patients treated by oesophagectomy reported significantly better physical, emotional, cognitive, and global health scores than those in the palliative treatment group. Patients who received palliative treatment had significantly worse pain, fatigue, appetite loss, constipation, and dysphagia. The correlations between dysphagia grade and each of the QOL scales and items in both groups of patients were poor. This questionnaire differentiates clearly between the two clinically distinct groups of patients, but to be an entirely appropriate indicator of QOL in patients with oesophageal cancer, an additional specific oesophageal module including a dysphagia scale is required.     

Scintigraphic evaluation of oesophageal transit during radiotherapy to the mediastinum

Background  

To quantitatively evaluate radiation-induced impaired oesophageal transit with oesophageal transit scintigraphy and to assess the relationships between acute oesophagitis symptoms and dysmotility.     

Prognostic value of radionuclide angiography in cerebral vascular disease.

To ascertain the prognostic value of the radionuclide angiogram in ischemic cerebral vascular disease, we reviewed the results of this study in 2200 patients who underwent this procedure. The arterial phase showed decreased activity in 175 patients studied in detail during the acute phase of their neurologic illnesses. In the 120 patients who proved to have ischemic disease and persisting neurologic signs, two basic patterns appeared during the venous phase: (1) no increased (diminished or equal) perfusion, or (2) increased perfusion. Following the initial incident, the clinical course varied from no change to marked clinical improvement. In the first group with either diminished or equal venous perfusion, the chances against improvement are greater than 6:1. In the latter group the chances for improvement or deterioration are equal.     

Predictive value of radionuclide joint scintigrams

Twenty-two patients with normal or “noninflammatory” ^99mtechnetium-labeled polyphosphate (TPP) peripheral joint scintigrams taken between 1974 and 1976 were reevaluated clinically. Retrospective chart review revealed that all initially had persistent polyarthralgia of more than 3 months duration. At followup, a mean of 3.6 years later, none had evidence of inflammatory joint disease, although 1 patient had systemic lupus erythematosus and 2 had polymyalgia rheumatica. A noninflammatory joint scintigram as part of a thorough rheumatologic evaluation may be a useful procedure in excluding inflammatory joint disease in selected patients with chronic persistent polyarthralgia.     

Colonic transit scintigraphy. A physiologic approach to the quantitative measurement of colonic transit in humans

Colonic transit scintigraphy was developed to quantitatively evaluate colonic transit. Using this technique the progression of a radiolabeled marker from cecal instillation to defecation was studied in 7 normal male volunteers. An 8-ml bolus containing 50 mu Ci of indium 111-diethylene triamine pentaacetic acid was instilled into the cecum via a 2-mm tube, which was passed orally, and serial scintigrams were obtained over 48 h. By 48 h, 70.7% +/- 9.1% (mean +/- SEM) of the instilled activity had been defecated. The cecum and ascending colon emptied rapidly, with a half-emptying time of 87.6 +/- 27.0 min. Geometric center analysis showed an initial logarithmic progression of activity in the proximal colon and a linear progression distally. This study suggests that the transverse colon, not the cecum and ascending colon, may be the primary site for fecal storage. Colonic transit scintigraphy is a safe, physiologic, and quantitative method for evaluating the colonic transit of fecal material and may provide a useful tool for evaluating normal and abnormal large intestinal physiology.     

Effect of left atrial size on the oesophageal transit of capsules

The oesophageal transit time of barium sulphate capsules was measured using X ray fluoroscopy in 20 patients with mitral valve disease and 12 control patients in the erect and supine positions when swallowed with both 15 ml and 60 ml of water. An erect barium swallow was performed, and from a lateral radiograph the area of indentation of the oesophagus caused by the cardiac impression was measured. Left atrial diameter was derived from M mode echocardiography. In 19 patients with mitral valve disease one or more capsules remained in the oesophagus for five minutes and disintegrated there, whereas this occurred in only six control patients. Capsule transit time was significantly slower in the study patients than in the control patients in the supine position with 15 ml water. There was a significant correlation between the area of indentation and mean capsule transit time and supine 15 ml transit time. The area of indentation closely correlated with the left atrial diameter. When capsules were delayed in the oesophagus, this occurred mainly at the level of the left atrial impression in the study patients and at the lower oesophageal sphincter in the control patients. Patients with mitral valve disease are more likely than control patients to have delayed oesophageal transit of capsules because of the anatomical deformity caused by enlargement of the left atrium.     

术中即时桥血管流量测定在不停跳冠状动脉旁路移植术中的应用研究

目的:探讨术中即时血流测定(transit time flow measurement,TTFM)在不停跳冠状动脉旁路移植术中的应用价值。方法:2009年12月至2010年12月,对在北京安贞医院心外科行不停跳冠状动脉旁路移植术的427例患者,共计1 123支桥血管行术中即时血流测定,根据测定结果,定义满足以下3点标准中的2点者为桥血管失功能:1.搏动指数(PI)>5,2.左侧冠状动脉平均流量(mean graft flow,MGF)<10mL/min,右侧冠状动脉桥血管MGF<15mL/min,3.舒张期血流比例(diastolic flow,DF):左侧冠状动脉桥血管<50%,右侧冠状动脉桥血管<40%。对失功能的桥血管进行修正后再次测定血流量。结果:41例患者(41/427,9.6%)的47支桥血管(47/1 123,4.2%)诊断为失功能桥血管,修正的桥血管中13支为前降支桥血管,7支为对角支桥血管,15支为回旋支桥血管,11支为右侧冠状动脉桥血管。45支桥血管修正后流量满意,成功率为95.7%;2支桥血管修正后无明显改善。但术后6个月冠状动脉CTA检查示桥血管均通畅。结论:术中TTFM能便捷、有效地检测出由于吻合口狭窄导致的桥血管失功能,提高手术疗效,减少围术期不良心脏事件发生率。但对于冠状动脉远端血管床阻力较高的患者,其应用价值有待进一步观察。     

Radionuclide oesophageal transit scintigraphy – a useful method for verification of oesophageal dysmotility by cervical vertebropathy

We followed up a group of 43 patients suffering from cervical vertebropathy. Dynamic scintigraphy revealed a significant prolongation of oesophageal transit time of 10 ml of labelled liquid (mean transit time, MTT) in comparison with a control group. Patients treated with acupuncture showed a significant reduction in MTT in comparison with patients receiving a placebo needle application. The group of patients treated with manipulative techniques showed in addition to symptom alleviation a significant reduction in MTT. Dynamic scintigraphy facilitates verification of oesophageal dysmotility in patients suffering from vertebropathy and enables the success of therapy to be readily monitored.     

Assessment of esophageal abnormalities in progressive systemic sclerosis using radionuclide transit

Radionuclide transit (RT) is a noninvasive test of esophageal function with a sensitivity equivalent to manometry. Using RT, 34 patients with progressive systemic sclerosis (PSS), 15 with diffuse scleroderma and 18 with the CRST variant, were studied and compared to 22 patients with other connective tissue diseases and 20 normal volunteers. Abnormalities were present in 87% of patients with diffuse scleroderma, 72% with CRST, 38% with other connective tissue diseases and in none of the controls. The most frequent abnormality in PSS was that of adynamic transit. Abnormalities correlated with disease duration in the diffuse scleroderma group but not the CRST group. There was a positive association between abnormal RT and the presence of esophagitis in the PSS patients (p = 0.003).