Lower esophageal sphincter pressure in Chagas' disease

It is known that lower esophageal sphincter (LES) pressure in patients with idiopathic achalasia is higher than in normal subjects, but in patients with Chagas' disease, who have esophageal disease with similar clinical, manometric, and radiologic results, studies of LES pressure show contradictory findings. We measured the LES pressure in 118 patients with chronic Chagas' disease, 14 patients with idiopathic achalasia, and 50 control subjects using a perfused catheter and the stationary pull-through (SPT) technique. The patients with Chagas' disease had normal esophageal radiologic examination (group A, N=50), delay in esophageal clearance without dilatation (group B, N=41), or delay in esophageal clearance with dilatation (group C, N=27). The LES pressure of Chagas' disease patients of group A (18.6 ±9.1 mm Hg, mean ±SD), group B (17.8 ±9.7mm Hg), and group C (21.6 ±10.1 mm Hg) was lower (P<0.001) than the LES pressure of the controls (24.9 ±10.2 mm Hg). In patients with idiopathic achalasia, the LES pressure (40.7 ±17.8 mm Hg) was higher than in control subjects (P<0.01) and Chagas' disease patients (P<0.001). We conclude that the LES pressure of patients with Chagas' disease tended to be lower than that of control subjects and achalasia patients.Presented in part at the 8th World Congress of Gastroenterology, September 1986, São Paulo, Brazil, and published in abstract form inDig Dis Sci 31:273, 1986.     

Lower esophageal sphincter pressure as an index of gastroesophageal acid reflux

The purpose of this study was to determine the relationship of lower esophageal sphincter (LES) pressure and the volume of acid placed into the stomach required to induce gastroesophageal reflux in man. LES pressure was recorded continuously and by station pull-through by three radially oriented catheters in both symptomatic and asymptomatic subjects during the graded infusions of 0.1 N HCl acid into the stomach. Sumptomatic subjects had a mean LES pressure of 7.5±0.7 mm Hg and refluxed at a volume of 140.0±21.0 ml. Fifty-five percent of asymptomatic subjects refluxed at a mean volume of 380.0±24.7 ml, and had a mean LES pressure of 13.8±0.4 mm Hg. Asymptomatic nonrefluxers at a volume of 500 ml of 0.1 HCL acid had a mean LES pressure of 18.9±1.1 mm Hg. The mean LES pressure and acid volumes showed statistical significance between the three groups (P<0.01). There was an excellent overall correlation between LES pressure and acid volume required to produce reflux in all subjects (r=0.91,P<0.001). Following reflux, asymptomatic but not symptomatic subjects showed a significant increase in LES pressure. These studies suggest that: (1) LES pressure does provide an accurate index of the gastroesophageal antireflux mechanism, provided that acid volume is considered; and (2) asymptomatic subjects showing acid reflux have higher LES pressures, reflux at higher volumes, and develop an LES contractile response after the reflux episode.This work was supported by a grant from the Smith Kline & French Laboratories, Philadelphia, Pennsylvania.     

Effect of an oral beta2-adrenergic agonist on lower esophageal sphincter pressure in normals and in patients with achalasia

The effect of the beta₂-adrenergic agonist, carbuterol, was studied on the lower esophageal sphincter (LES) pressure in normals and in patients with achalasia. In normals, the mean LES pressure decreased from 23.1±6.2 mm Hg (mean±sem) to 16.0±5.0 mm Hg at a 4.0-mg dose of carbuterol (P<0.05). In patients with achalasia, the mean LES pressure decreased from 50.1±5.1 mm Hg to 22.7±2.4 mm Hg after a 4.0-mg dose of carbuterol (P<0.01). The duration of action following oral administration exceeded 90 min. These studies indicate that the LES in man has beta₂-adrenergic receptors that mediate a reduction in pressure. The magnitude of LES pressure reduction in patients with achalasia suggests that this drug may be of therapeutic benefit.     

Clinical and manometric findings on elderly patients with achalasia

Introduction: Data regarding the age impact on the clinical presentation and esophageal motility in adults with idiopathic achalasia are scarce. Objective: To asses the clinical and manometric features of elderly patients with idiopathic achalasia. Methods: The medical charts of 159 patients diagnosed with achalasia were divided into two groups according to the patients' age: ?60 years (n = 123) and >60 years (n = 36). Clinical and manometric findings [esophageal body aperistalsis, basal lower esophageal sphincter (LES) pressure and abnormal LES relaxation] of both groups were compared upon diagnosis. Patients with previous esophageal interventions were excluded. Results: Only chest pain was more common in the ?60 year-old group (51.2% vs. 22.2%, p <0.003). This difference remained when comparing the group of men ?60 years. Other presenting features (including sex, weight loss, and presence of dysphagia, regurgitation and heartburn) did not differ between the groups. The LES relaxation was incomplete in 70.4% of the cases. No differences on the basal LES pressure, residual LES pressure or the amplitude of the esophageal body contractions between both groups were found. Considering only the classic achalasia cases, symptomatic time before diagnosis was greater in ?60 years compared with older patients: 24 vs. 12 months (p <0.05), respectively. Conclusions: These results suggest that chest pain is more common in younger male achalasia patients and residual LES pressure decreases with age.     

Reevaluation of manometric criteria for vigorous achalasia

Clinical and manometric data from 97 consecutive patients with idiopathic achalasia were analyzed to see if a distinct subset with vigorous achalasia could be identified. Statistical analyses failed to detect a unique group of subjects based on the distribution of contraction wave amplitudes alone. Because of this, patients falling above the 95th percentile (N=4, mean wave amplitude>100 mm Hg for each) were compared with those having mean amplitudes above the conventional threshold for the diagnosis of vigorous achalasia (mean amplitude 60–100 mm Hg,N=4), and with the remainder (N=89, mean amplitude <60 mm Hg). Subjects with mean amplitudes <60 mm Hg and with mean amplitudes 60–100 mm Hg closely resembled each other in all measured clinical features, whereas subjects with mean amplitudes >100 mm Hg were all male, were older (67±4 years vs 47±2 years; P<0.01), and appeared to have somewhat longer duration of symptoms when compared with the remainder (82±41 vs 44±10 months;P=0.4). Chest pain and other esophageal symptoms, basal and residual lower sphincter pressures, and response to first treatment did not differ among the three groups. These data indicate that high-fidelity manometry techniques identify a rare subset of achalasia patients with mean contraction amplitudes exceeding 100 mm Hg that, although older and possibly with greater duration of symptoms, presents similarly to others with idiopathic achalasia. Outcome from conventional treatment is also similar for the vigorous and nonvigorous patients, making the distinction of questionable value.Supported in part by a grant (AM07130) from the United States Public Health Service. Dr. Todorczuk is supported by a grant from Smith Kline and French.     

Chest pain and dysphagia in patients with prolonged peristaltic contractile duration of the esophagus

Dysphagia and chest pain are well-described symptoms in subjects with achalasia, diffuse esophageal spasm (DES), and high-amplitude peristaltic contractions, a subset of nonspecific motor disorders (NEMD). We observed a high incidence of chest pain and dysphagia in a different NEMD subgroup characterized by prolonged peristaltic contractile duration (PPCD) and normal contractile amplitude. We compared the manometric characteristics of patients with PPCD to healthy controls and compared the clinical profile of PPCD patients to that of patients with achalasia, DES, and high-amplitude peristalsis. In 2o patients with PPCD, mean contractile duration was 7.4±0.3 sec, significantly greater than healthy controls (3.7±0.1 sec) (P<0.001). PPCD was associated with an 85% incidence of chest pain and 65% incidence of dysphagia. These symptoms were similar to those observed in patients with achalasia, DES, and highamplitude peristalsis. In PPCD patients, chest pain was more frequently of long duration in comparison to achalasia and DES. PPCD was encountered more frequently than either achalasia or DES in patients referred to our laboratory. This study suggests that in symptomatic NEMD patients, abnormal duration of peristaltic contractions, rather than abnormal amplitude, may be a distinguishing manometric feature.This study was presented in part at the annual meeting of the American Gastroenterological Association, 1981, and published as an abstract inGastroenterology 80:1173, 1981.This study was supported solely by a grant from the Alton Ochsner Medical Foundation.     

Stress induces alteration of esophageal pressures in healthy volunteers and non-cardiac chest pain patients

The present study was designed to explore the relationship between psychological stress and esophageal motility disorders. Nineteen non-cardiac chest pain patients (10 with the nutcracker esophagus and nine with normal baseline manometry) and 20 healthy control subjects were administered two acute stressors: intermittent bursts of white noise and difficult cognitive problems. The results indicated that the esophageal contraction amplitudes and levels of anxiety-related behaviors of non-cardiac chest pain patients and control subjects were significantly greater during the stressors than during baseline periods. All patients demonstrated significantly greater (P<0.01) increases in contraction amplitude and anxiety-related behavior during cognitive problems than during the noise stressor. The nutcracker esophagus patients showed a greater increase in contraction amplitude during the problems (23.50±9.42 mm Hg, ¯X ±SE) than control subjects (P<0.01), while the amplitude changes of chest pain patients with normal baseline manometry were not significantly greater than that of control subjects (9.00±1.91 mm Hg). The present results identified an increase in contraction amplitude as the primary esophageal response to stress. The possible interaction of esophageal contraction abnormalities, psychological stress, and the perception of chest pain is discussed.This work was supported by Public Health Services grant AM 34200-01AI from NIADDK.     

Dysphagia and Advancing Age: Are Manometric Abnormalities More Common in Older Patients?

The universal process of aging may result in physiologic deterioration. Dysphagia may be more common in older patients. The effect of aging on esophageal manometry is not well established. The aim of this study was to determine if esophageal motility studies and associated symptoms in older patients with dysphagia differ significantly from younger patients. Patients who were 65 years of age or older (N = 53) were compared with patients who were 18–45 years of age (N = 53). Presenting symptoms, manometric findings, and diagnoses were compared between the two groups. In the older group, there were 29 women (55%), in the younger group there were 35 women (66%). The mean age of the older group was 75 ± 7 years, the mean age in the younger group was 34 ± 7 years. All patients reported dysphagia to solids. No significant differences were found in the reporting of associated symptoms. There were no significant differences in average lower esophageal sphincter (LES) resting pressure, residual LES pressure, LES relaxation, or peristalsis between groups. Older patients were as likely to have a normal study as younger patients (18% vs 23%, P = NS) and were also as likely to have the diagnosis of achalasia (32% vs 34%, P = NS). In conclusion, older and younger patients referred for manometric study of dysphagia have similar manometric findings. Esophageal manometry can be helpful in determining abnormalities in motility in both older and younger patients.     

The hypertensive lower esophageal sphincter

Controversy exists as to whether the hypertensive lower esophageal sphincter (HLES) represents a clinical motility disorder of the esophagus or is merely the right-sided expression of a normal distribution curve. In the present study we describe 16 patients with HLES, defined as a lower esophageal sphincter (LES) pressure of 40 mm Hg (mean +3sd of controls) with normal peristalsis. All of the patients suffered from chest pain and nine from dysphagia. Delayed bolus transit at the gastroesophageal junction was demonstrated in four patients by radiography. Manometric studies showed that during swallowing the LES residual pressures were significantly greater (9.2±5.0 mm Hg) than observed in normal controls (1.8±2.2 mmHg) (mean±1sd). However, the percent LES relaxation in patients did not differ significantly from controls. Clinical improvement was associated with pharmacological or mechanical reduction of resting LES pressure with an accompanying fall in the nadir pressure. These observations suggest that HLES may have clinical and pathophysiological significance and that evidence for the entity should be sought during manometric studies in the clinical laboratory.     

Esophageal manometry: a comparison of findings in younger and older patients

Objective: We sought to determine the utility of esophageal manometry in an older patient population.
Methods: Consecutively performed manometry studies (470) were reviewed and two groups were chosen for the study, those ≥ 75 yr of age (66 patients) and those ≤ 50 years (122 patients). Symptoms, manometric findings (lower esophageal sphincter [LES], esophageal body, upper esophageal sphincter [UES]) and diagnoses were compared between the groups.
Results: Dysphagia was more common (60.6% vs 25.4%), and chest pain was less common (17.9 vs 26.2%) in older patients. In the entire group, there were no differences in LES parameters. Older patients with achalasia had lower LES residual pressures after deglutition (2.7 vs 12.0 mm Hg), but had similar resting pressures (31.4 vs 35.2 mm Hg) compared with younger achalasia patients. Duration and amplitude of peristalsis were similar in both groups, whereas peristaltic sequences were more likely to be simultaneous in the older group (15% vs 4%). The UES had a lower resting pressure in the older patients (49.6 vs 77.6 mm Hg) and a higher residual pressure (2.0 vs −2.7 mm Hg). The older patients were less likely to have normal motility (30.3% vs 44.3%) and were more likely to have achalasia (15.2% vs 4.1%) or diffuse esophageal spasm (16.6% vs 5.0%). When only patients with dysphagia were analyzed, achalasia was still more likely in the older group (20.0% vs 12.9%).
Conclusions: When older patients present with dysphagia, esophageal manometry frequently yields a diagnosis to help explain their symptoms.     

Basal and residual lower esophageal pressures increase in old age in classic achalasia,but not vigorous achalasia

Background and Aim: The relationship between age and esophageal motility parameters (i.e. basal and residual pressure of the lower esophageal sphincter [LES]) remains to be established in achalasia patients, possibly because most previous studies did not distinguish between classic and vigorous achalasia patients. We investigated the relationship between age and esophageal motility parameters in both classic and vigorous achalasia patients. Methods: A retrospective review of esophageal manometry data in a single center was undertaken. Basal and residual pressure for LES was analyzed. A total of 103 achalasia patients were enrolled, comprising 84 classic and 19 vigorous types. They were subdivided into three different age groups as follows: 21–40 years old (group A), 41–60 years old (group B), and over 60 years old (group C). Results: In classic achalasia patients (M : F = 27:57, mean age = 44 ± 15 years old) the older age group showed a significantly higher basal LES pressure (49.62 ± 19.63 mmHg) than the younger age group (P < 0.0001). Moreover, the older age group also showed significantly high residual LES pressure (20.46 ± 8.61 mmHg) than the younger age group (P = 0.0006). In contrast, in vigorous achalasia patients (M : F = 12:7, mean age: 47 ± 15 years old) there were no difference between age and motility indices (all P > 0.05). Conclusion: In classic achalasia patients there appears to be a correlation between age and esophageal motility indices, especially basal and residual LES pressure. Such correlations do not appear to exist for vigorous achalasia patients.     

Lower esophageal sphincter function in cirrhosis

Lower esophageal sphincter (LES) function in cirrhosis was evaluated using an infused manometric system. LES pressure (LESP) in 10 subjects with cirrhosis (22+1 mm Hg) (mean±se) was not significantly (P>0.05) different from that of 10 control subjects (21±1 mm Hg) but was significantly (P<0.01) greater than the LESP recorded in 5 subjects with cirrhosis and ascites (16±2 mm Hg). There was no significant difference in LES response to intravenous pentagastrin, intravenous edrophonium, or straight-leg raising in the three groups. After loss of ascitic fluid, LESP significantly (P<0.01) increased (P9±3 mm Hg) and gastric pressure (GP) significantly (P<0.01) decreased (P8±2 mm Hg). The changes in LESP and GP revealed a significant (R=0.83,P<0.001) linear correlation. These data indicate (1) cirrhosis is associated with normal LES function, and (2) the mechanism of lowered LESP with ascites may be the inability of the LES to maintain a sustained response to chronic increases in GP.Supported by Bureau of Medicine and Surgery Clinical Invesgation Program Project No. 4-16-259.The opinions or assertions expressed herein are those of the author and are not to be construed as official or as reflecting the views of the Navy Department or the naval service at large.     

The adverse effect of chocolate on lower esophageal sphincter pressure

Decreased lower esophageal sphincter (LES) pressure after ingestion of chocolate has been previously noted. We have further evaluated the effect of chocolate on the known ability of gastric alkalinization or bethanechol to increase LES tone. 9 normal subjects were studied using an infused open-tip recording system. Pressure was monitored for a 15-min basal period, and for 60 min after ingestion of 120 ml of chocolate syrup either alone or with the concurrent administration of commercial antacid, oral bethanechol, or subcutaneous bethanechol. After chocolate ingestion, mean basal LES pressure of 14.6±1.1 (±SEM) mm Hg decreased significantly (P<0.01) to 7.9±1.3 mm Hg. An identical LES response occurred when antacid was given with the chocolate dose. Oral bethanechol (25 mg) and chocolate together resulted in lesser decreases in LES pressure. Subcutaneous bethanechol (5 mg) and chocolate produced significant increases (P<0.05) in sphincter pressure, although of lesser magnitude than reported with bethanechol alone. These results indicate that the adverse effect of chocolate on the LES is not reversed by gastric alkalinization and suggest that bethanechol in sufficient dose may overcome chocolate-induced decreases in LES pressure.This work was supported by the Department of the Navy Clinical Investigation Program Grant #5-05-530R.     

Manometry and impedance characteristics of achalasia. Facts and myths

BACKGROUND: Achalasia is defined manometrically by an aperistaltic esophagus. Variations in the manometric findings occur in achalasia suggesting that all manometric features should not be required to diagnose achalasia. Combined multichannel intraluminal impedance and esophageal manometry (MII-EM) allows both a functional and a manometric evaluation of esophageal motility and identifies chronic fluid retention. AIM: To compare manometric and MII characteristics in patients with achalasia. METHODS: Retrospective review of 73 MII-EM tracings from patients with achalasia done in our laboratory between October 2001 and December 2004 (38 females; mean age=53.5 y). Patients with previous esophageal interventions were excluded. Manometric and MII characteristics were identified and compared during 10 liquid and 10 viscous swallows. Patients were also divided into 2 groups: vigorous achalasia (VA) and achalasia. RESULTS: Twenty-two of the seventy-one (31%) achalasia patients had a hypertensive lower esophageal sphincter (LES). The mean lower esophageal sphincter pressure (LESP) for the 71 patients with achalasia was 37.9+/-21.2 mm Hg compared with 27.3+/-9.3 mm Hg (P<0.05) in the 73 patients with normal motility. The mean LESP in patients with achalasia was 36+/-20.3 mm Hg compared with 47+/-23.2 mm Hg (P<0.05) in patients with VA. Elevated intraesophageal pressure (IEP) was noted in 45/73 (61.6%). The mean LESP in this group was 41.1+/-22.9 mm Hg compared with 32.5+/-17 mm Hg (P<0.05) with normal IEP. The mean baseline impedance for achalasia was 801+/-732 compared with 1265.2+/-829.5 Omega (P<0.05) for the VA patients. CONCLUSIONS: Most patients with achalasia have elevated IEP, elevated LES residual pressure, normal LES pressure, and low baseline impedance. All manometric features should not be required to diagnose achalasia. Patients with an elevated IEP are likely to have an elevated LES pressure and LES residual pressure. Low MII values identify chronic fluid retention and helps confirm the diagnosis.     

Visceral perception in health and functional dyspepsia

The symptoms of functional dyspepsia are still unexplained. To evaluate the possible role of abnormal visceral perception, we studied the symptomatic responses and the pressure variations during progressive gastric distension in 10 female healthy control subjects (mean age 33.6 years) and in 10 female patients with functional dyspepsia (mean age 35.2 years). A rubber balloon was positioned 4 cm below the lower esophageal sphincter (LES) and inflated with progressively larger volumes of air by steps of 50 ml; pressures at the gastric fundus and at the LES were continuously recorded by perfused manometric catheters. Each subject was studied on two separate occasions after randomized double-blind administration of either placebo or 20 mg of domperidone. Symptomatic responses and the manometric data were analyzed at the time of the initial recognition of distension (bloating step) and at the time of reporting pain or up to a maximum of 700 ml of balloon inflation (pain or 700-ml step). On placebo, the volumes of gastric distension were more than two times lower in patients than in control subjects at the bloating step (185±32 ml vs 470±40 ml,P=0.001) and at the pain or 700-ml step (265±54 ml vs 600±34 ml,P<0.005), while the pressure gradients (pressure at inflation steps minus baseline pressure before beginning inflation) were not statistically different between the two groups. On domperidone, the volumes at each of the two steps did not change in comparison to results on placebo except in healthy controls at the bloating step (470±40 ml on placebo vs 355±35 ml on domperidone,P<0.001); however, there was a trend for pressure gradients to increase on domperidone in comparison to results on placebo. We conclude that patients with functional dyspepsia have a lower threshold both to the initial symptomatic recognition and to perception of pain during gastric distension and that domperidone might have an effect on the threshold of these conscious visceral sensations. This increased visceral perception may alone or with other abnormalities of the gastroduodenal tract explain the symptoms of functional dyspepsia.This study was supported in part by a grant from Janssen Pharmaceutica Inc., Canada.     

Mean pressure obtained by modified rapid pull-through technique used to assess lower esophageal sphincter function

Lower esophageal sphincter pressure, length of sphincter, and contraction of the crural diaphragm are determinants of esophageal function. Mean pressure manometrics in modified rapid pull-through reflects these three factors. Reproducibility and interobserver variability were studied to assess this method's efficacy and were compared with the maximum expiratory pressure in station pull-through in 44 individuals divided into three groups: achalasia, gastroesophageal reflux, and healthy volunteers. Mean pressure in rapid pull-through showed high reproducibility, no significant differences (14.4 ± 8.4 vs 12.6 ± 8.2 mm Hg) between two measurements, and a high correlation coefficient (r = 0.9). Interobserver variability was lower than that seen for maximum expiratory pressure (P < 0.001). Mean pressure was lower than maximum expiratory pressure in patients with achalasia (21.1 ± 7 vs 30.7 ± 8.6 mm Hg). Both methods showed identical sensitivity to establish a hypotensive sphincter in patients with reflux (73%). We think that mean pressure obtained by rapid pull-through is a good methodology to assess lower esophageal sphincter competence. It is rapid, simple, shows good reproducibility and low interobserver variability, and is clinically valid.     

Clinical remission following endoscopic placement of retrievable,fully covered metal stents in patients with esophageal achalasia

Metal stents may represent an alternative therapy in the treatment of achalasia. We therefore evaluated the effectiveness of retrievable, fully covered metal stents in patients with achalasia. Fifty‐nine patients with achalasia were treated with retrievable, fully covered metal stents. Symptoms using a global symptom score (0–10), lower esophageal sphincter (LES) resting pressure, LES relaxation, and simultaneous contraction of the esophagus were analyzed before and 1 week and 1 month after intervention. Complications and treatment outcomes were followed up at 6, 12, 18, and 24 months postoperatively. Stent placement was successful, and clinical symptoms resolved (P < 0.01) in all patients. Regurgitation, dysphagia and chest pain improved significantly (all P < 0.01). Therapy improved LES resting pressure (51.4 ± 9.7 mmHg pretherapy vs. 20.9 ± 8.1 mmHg post‐therapy), LES relaxation (58.1 ± 17.1% pretherapy vs. 84.5 ± 18.9% post‐therapy), and simultaneous contraction of the esophagus (36.1 ± 8.6% pretherapy vs. 69.4 ± 23.1% post‐therapy) 1 month after stent placement (all P < 0.01). The cumulative clinical remission rates 6, 12, 18, 24, 30, and 36 months after stent removal were 90.9%, 81.8%, 76.4%, 69.1%, 65.5%, and 49.1%, respectively. All patients tolerated stent placement. Twelve patients (25.5%) complained of substernal pain and five (10.6%) had substernal burning. Stents migrated in four patients (8.5%). Insertion of retrievable, fully covered metal stents is an effective and safe treatment in patients with achalasia.     

Intraesophageal Balloon Distension Test in Chagas' Disease Patients with Noncardiac Chest Pain

Patients with Chagas' disease often have chestpain as a prominent symptom. The objective of this studywas to compare the results of intraesophageal balloondistension in chagasic and nonchagasic patients with chest pain not caused by coronaryobstruction. We studied 40 patients with chest pain andangiographically normal coronary arteries, 25 with apositive serologic test for Chagas' disease (Chagasgroup, 16 women, mean age 53 ± 10 years), and15 with a negative serologic test (control group, 11women, mean age 46 ± 10 years). All patients hadradiologic and endoscopic examinations of esophagus,stomach, and duodenum, esophageal manometry with theacid infusion test in the distal esophagus, andintraesophageal balloon distension. None of them hadesophageal dilation or any signs of cardiovasculardisease. A 25-mm-long latex balloon located 10 cm abovethe lower esophageal sphincter was inflated and deflatedover a period of 10 sec at 1-ml increments of air untilthe subjects reported chest pain or to a maximum volume of 20 ml. The test caused chest pain in14 subjects in the control group (93%) and in 12 in theChagas' disease group (48% , P < 0.05). The meanvolume of air that caused chest pain was 10 ± 3ml in the control group and 15 ± 4 ml in theChagas' disease group (mean ± SD, P < 0.05).The maximum intraesophageal pressure during theexamination was higher in Chagas' disease patients withchest pain during balloon distension (60 ± 21mm Hg) than in patients who did not have chest pain (37± 18 mm Hg, P < 0.05) and did not differ fromthe control group (48 ± 16 mm Hg, P > 0.05).With the other examinations there was no differencebetween groups or between patients with or without chestpain during the balloon distension test. Althoughesophagitis was observed in 47% of patients in the control group and in 40% of the Chagas' diseasegroup, the acid infusion test was positive in 27% ofpatients in the control group and in 4% of patients inthe Chagas' disease group. We conclude that, as compared to a group of patients with similarchest pain, chagasic patients are less sensitive toesophageal distension. Thus, it is unlikely that theirchest pain is related to esophagealmechanisms.     

Comparison of idiopathic achalasia and Chagas' disease esophagopathy at the light of high‐resolution manometry

The comparison between idiopathic achalasia (IA) and Chagas' disease esophagopathy (CDE) may evaluate if treatment options and their outcomes can be accepted universally. This study aims to compare IA and CDE at the light of high‐resolution manometry. We studied 86 patients with achalasia: 45 patients with CDE (54% females, mean age 55 years) and 41 patients with IA (58% females, mean age 49 years). All patients underwent high‐resolution manometry. Upper esophageal sphincter parameters were similar (basal pressure CDE = 72 ± 45 mmHg, IA = 82 ± 57 mmHg; residual pressure CDE = 9.9 ± 9.9 mmHg, IA = 9.8 ± 7.5 mmHg). In the body of the esophagus, the amplitude was higher in the IA group than the CDE group at 3 cm (CDE = 15 ± 14 mm Hg, IA = 42 ± 52 mmHg, P = 0.003) and 7 cm (CDE = 16 ± 15 mmHg, IA = 36 ± 57 mmHg, P = 0.04) above the lower esophageal sphincter (LES). The LES basal pressure (CDE = 17 ± 16 mmHg, IA = 40 ± 22 mmHg, P < 0.001) and residual pressure (CDE = 12 ± 11 mmHg, IA = 27 ± 13 mmHg, P < 0.001) were also higher in the IA group. Our results show that: (i) there is no difference in regards to the upper esophageal sphincter; (ii) higher pressures of the esophageal body are noticed in patients with IA; and (iii) basal and residual pressures of the LES are lower in patients with CDE. Our results did not show expressive manometric differences between IA and CDE. Some differences may be attributed to a more pronounced esophageal dilatation in patients with CDE.