Effects of Octreotide on Lower Esophageal Sphincter in Patients with Cirrhosis and Portal Hypertension

We investigated the effects of octreotide infusion on the contractile activity of the esophageal body and lower esophageal sphincter in cirrhotic patients with esophageal varices. Esophageal manometry was performed in 36 alcoholic cirrhotic patients. They were randomly allocated to three groups and received the following treatments blindly for 90 min: an initial 100-g intravenous bolus followed by a continuous 25 g/hr octreotide infusion (group I, N = 13), a continuous 25 g/hr octreotide infusion without an initial bolus (group II, N = 13), and a continuous placebo infusion (group III, N = 10). Before drug infusion, mean lower esophageal sphincter pressure and mean esophageal body contraction pressure and duration were similar in the three groups. Compared to the placebo group, lower esophageal sphincter pressure increased significantly in groups I and II, 30 min (30%, 22%, 3% respectively; P = 0.006), 60 min (44%, 35%, 0.6%; P = 0.0002), and 90 min (67%, 41%, 2.5%; P = 0.0001) after octreotide infusion, as did esophageal body contraction pressure and duration. We conclude that octreotide has a potent effect on LES tone in cirrhotic patients.     

Effect of Gastrin-17 on Lower Esophageal Sphincter Characteristics in Man

We studied the effect of gastrin-17 on loweresophageal sphincter (LES) characteristics in man. Ninehealthy volunteers participated in two experimentsperformed in random order during continuous infusion of saline (control) or gastrin-17 (15pmol/kg/hr). LES pressure (LESP) and transient loweresophageal sphincter relaxations (TLESR), as most theimportant reflux mechanism, were measured withintraesophageal sleeve manometry combined with pH metry.Infusion of gastrin-17 resulted in plasma gastrin levelscomparable to those reached after a mixed meal. Duringcontinuous gastrin infusion, LESP decreasedsignificantly (P 0.05) compared to control. The rate andduration of TLESR was not influenced by gastrin-17.Gastroesophageal reflux and the number of TLESRassociated with reflux were significantly (P 0.05)increased during gastrin infusion. These results suggestthat in humans gastrin at physiological postprandialplasma concentrations decreases LESP, does not influenceTLESR, but increases the percentage of TLESR associated with reflux.     

Four-Channel Sleeve Catheter for Prolonged Measurement of Lower Esophageal Sphincter Pressure

A sleeve catheter capable of monitoring thelower esophageal sphincter (LES) pressure in fourquadrants at right angels has been developed. Thepresent study used this four-quadrant sleeve catheter toassess radial asymmetry in LES in the supine, prone,and upright positions. The results in 37 normal subjectswere compared with those of a conventional side-holecatheter and a Dent sleeve catheter. In vitro studies showed that the response rate of eachradially oriented sleeve is comparable to the Dentsleeve. Mean pressures were not significantly differentbetween the three different types of catheter. The four-quadrant sleeve catheter consistentlydetected a higher LES pressure in the left posteriorposition, regardless of body position. The four quadrantsleeve catheter can be used to record LES pressure from four different quadrants of the LES forprolonged periods.     

Effect of Amino Acids on Lower Esophageal Sphincter Characteristics and Gastroesophageal Reflux in Humans

The effect of a commercially available mixedamino acids solution, when given either intravenously orintragastrically, on lower esophageal sphincter (LES)pressure, frequency of transient LES relaxations (TLESRs) and gastroesophageal reflux (GER) wasinvestigated in six healthy volunteers. LES pressure andesophageal pH were simultaneously recorded on threeseparate occasions 1 hr before (basal) and 3 hr during intravenous or intragastric infusion ofamino acids (250 mg protein/kg/hr) or saline (control).No significant changes in LES pressure were seen in thecontrol experiment. Intravenous amino acids caused a rapid and sustained (P < 0.01)decrease in LES pressure whereas intragastric aminoacids decreased LES pressure only gradually andtemporarily (P < 0.01). In the three experiments nosignificant differences were observed in TLESR frequency,the number of GER episodes, the mechanism of reflux, orduration of acid exposure. In healthy subjects bothintragastric and, especially, intravenous infusion of amino acids significantly decrease LESpressure but do not affect the frequency of TLESRs orGER episodes during a continuous liquid gastricload.     

Effects of Oxygen Radicals and Radical Scavenging on Opossum Lower Esophageal Sphincter

Nitric oxide mediates esophageal peristalsis andlower esophageal sphincter (LES) relaxation. Superoxideproduced with inflammation inactivates nitric oxide.Superoxide is cleared in biological systems by superoxide dismutase. We tested thehypothesis that superoxide and the superoxide scavengingsystem modulate LES function. Transverse strips ofmuscle from the opossum LES relaxed when stimulated by an electrical field. Diethyldithiocarbamite wasused to inhibit copper/zinc superoxide dismutase.Xanthine and xanthine oxidase were used to generatesuperoxide. Xanthine with xanthine oxidase ordiethyldithiocarbamite alone had no effect on the LES. However,xanthine/xanthine oxidase and diethyldithiocarbamitereduced LES relaxation 34.1% and increased its restingtone 71.2%. Superoxide dismutase did not affect LESfunction, but protected the tissue from the effects ofdiethyldithiocarbamite and xanthine/xanthine oxidase.These studies are consistent with the hypothesis thatsuperoxide acts by inactivating nitric oxide and suggest that these antioxidant enzyme systemsmay play a role in the maintenance of LESfunction.     

Gastroesophageal Reflux After Combined Lower Esophageal Sphincter and Diaphragmatic Crural Sling Inactivation in the Rat

This study tests the hypothesis that eitherselective or combined destruction of the loweresophageal sphincter and the diaphragmatic crural slingshould induce reflux in the rat. Pull-through perfusion manometry was performed before and after loweresophageal myectomy, crural myotomy, or both. pHmonitoring was used to detect reflux. Unmanipulated ratsserved as controls. Paired t tests were used for comparison of pre- and postoperative pressurevalues and contingency tables with Fisher's tests forexamining the association between the interventions andthe appearance of reflux. Esophageal myectomy decreased only sphincteric pressure from 25.9± 15.5 to 9 ± 6 mm Hg (P < 0.01),whereas crural myotomy decreased only sling pressurefrom 26.2 ± 13.3 to 7.3 ± 3.9 mm Hg (P< 0.01). Simultaneous performance of both procedures decreasedsphincteric and crural pressures from 20.4 ± 7.5to 7.6 ± 4.3 mm Hg (P < 0.01) and from 45.9± 20.6 to 18.2 ± 7.4 mm Hg (P < 0.01),respectively. None of the control, myectomy, or myotomy animalsshowed reflux upon pH-metry but 5/8 rats in which bothprocedures were performed had prolonged acid exposure.No esophagitis was seen. In conclusion, normal rats do not have reflux. Selective destructionof either the sphincter or the crural sling does notinduce reflux, despite causing flattening of theirrespective manometric profiles. Conversely, combined inactivation of both components issignificantly associated with reflux.     

Manometric Study of Hiatal Hernia and Its Correlation with Esophageal Peristalsis

The pathogenesis of gastroesophageal refluxdisease (GERD) is considered multifactorial, butalterations of the esophagogastric junction (EGJ) andhiatal hernia play a prominent role. The correlationsbetween hiatal hernia and the other pathogeneticfactors are as yet unclear, and they need to beinvestigated by a methodological approach based on newanatomic and functional criteria. Our aim was to study,by stationary manometry, the relationships betweensmall reducible hiatal hernia, identified by endoscopy,and esophageal peristalsis, in patients with and withoutGERD. According to the absence or presence of esophagitis (E), and the absence or presenceof hiatal hernia (H), 58 subjects were divided into fourgroups: controls 10; H 14; E 10; and HE 24. Stationarymanometry was performed by the rapid pull-through (RPT) technique, with catheter water perfused,to study the lower esophageal high pressure zone [loweresophageal sphincter (LES) and diaphragmatic crura] andthe parameters of esophageal peristalsis. In patients with hiatal hernia, the variouscombinations of peak and/or deflection of manometricline pressure identified five EGJ profiles, only one ofwhich reveals (by one-peak profile due to superimposed LES and diaphragmatic crura) the reducibilityof the hernia. The frequency of the five profiles wascalculated in the HE and H groups: a two-peak profilewas significantly more prevalent in these patients, although less so in the group with esophagitis.In E patients the distal amplitude and the distalpropagation of esophageal waves were significantly lowerthan in the other three groups (P < 0.05 vs controls and group HE; P < 0.01 vs group H).Furthermore, the distal amplitude was significantlyhigher in the group H than in the HE (P < 0.01). Ourresults show a better definition of hiatal hernia morphology, via the RPT technique, disclosingfive pressure profiles. In addition, a significant linkwas found between small reducible hiatal hernia withoutGERD and wave amplitude of the distal esophagus. The amplification of peristaltic clearing maybe considered the initial protective process againstacid reflux; the breakdown of this mechanism may triggerthe pathological sequence of GERD.     

Esophageal Swallowing Phase Assessed by Audiosignal Recording (Relationship with Manometry in Gastroesophageal Reflux Disease Patients)

The acoustic technique has been used forpharyngeal exploration but to date no such technique hasbeen devised to assess esophageal motility. The aim ofthis study was to demonstrate that displacement through the esophagus can be quantified using thismethod in healthy subjects and in patients withgastroesophageal reflux. Concurrent manometric andacoustic recordings were also performed in the patients.Fifteen controls (38.5 ± 13 years old) and 10patients (34.9 ± 6 years old) were included. Allwere recorded during wet and dry swallow sequences withmicrophones placed below the cricoid cartilage and onthe xiphoid appendix. Standard manometry wasperformed for lower esophageal sphincter (LES)exploration. For the acoustic technique, the frequencyof xiphoid signals (FX), esophageal transit time (ETT),duration of xiphoid sound (SD), and for the manometricstudy, the duration of LES relaxation (RD) were recordedand mean values were calculated (FXm), (ETTm), (SDm),(RDm). FXm for wet (94 vs 81.6%) and dry swallows (86 vs 66.6%) decreased in patients. ETTm wassignificantly higher (P < 0.01) for wet than for dryswallows (5.6 ± 0.9 vs 5.2 ± 1.2 sec) forcontrols but not for patients. ETTm was significantly higher for patients for wet (7.2 ± 2.1sec) and for dry swallows (6.5 ± 2.3 sec) thanfor controls and SDm was lower. Xiphoid sound appearedin the second half of LES relaxation. Our noninvasiveacoustic technique is simple and reproducible. It iswell correlated with manometry, and it allowscharacterization of the displacement of the bolusthrough the esophagus and the LES. The technique couldbe used alone to determine appropriate pharmacologicaland surgical treatments for esophageal motilitydisorders.     

Extraesophageal Autonomic Dysfunction in Patients with Achalasia

A disagreement exists as to whetherextraintestinal parasympathetic autonomic function isaltered in patients with esophageal achalasia.Therefore, we assessed autonomic dysfunction inesophageal achalasia and considered the most relevant parameters ofparasympathetic autonomic function in these patients. Ina prospective study, heart rate variation and pupillaryfunction were investigated in 15 patients with achalasia of the esophagus and in 15controls by application of a battery of standardizedautonomic function tests. Significant differencesbetween patients and controls were detected for variousparameters of heart rate variation and pupillometry. Whencompared to values obtained from large groups of healthysubjects, none of the controls but 11 patients had atleast one abnormal parameter of parasympathetic autonomic function. It is suggested that inesophageal achalasia parasympathetic dysfunction thatextends beyond the gastrointestinal tract can befrequently detected. This finding supports the view of a generalized alteration of the autonomicnervous system in achalasia.     

Globus Sensation Is Associated with Hypertensive Upper Esophageal Sphincter but Not with Gastroesophageal Reflux

Globus sensation (globus) is best described asa constant feeling of a lump or fullness in the throat.Although the etiology of globus remains unclear, it hasbeen attributed to a hypertensive upper esophageal sphincter (UES) resting pressure and togastroesophageal reflux (GER). The aim of this studywas, therefore, to determine if significant associationsexisted among globus, UES resting pressure, and GER. We reviewed the records of all patients who hadstationary esophageal manometry over a 21 -year intervalwith specific attention to symptoms of globus, UESpressures, and ambulatory pH studies. Patients with hypotensive UES (<30 mm Hg) wereexcluded. Chi square (²) test was usedto determine significant associations. Six hundred fiftypatients had normal UES resting pressures and 101patients had hypertensive UES (>118 mm Hg). Seventeen ofthe 650 (3%) (16 women/1 man; mean age: 48, range 32-81years) with normal UES described globus. Conversely, 28of the 101 (28%) (15 women/13 men; mean age: 43, range 23- 61 years) patients withhypertensive UES described globus. There was asignificant association between hypertonicity of the UESand globus (² = 93.42, P < 0.0001).In patients with normal UES, globus occurred predominantly infemales (² = 6.33, P < 0.01).Twenty-three (16 women/7 men; mean age: 43, range 23-60years) of the 45 patients with globus had priorambulatory pH studies. Six of 23 (26%) had GER. Compared to an age-,sex-, and UES-pressure-matched group of 23 patients (16women/7 men; mean age: 44, range 22-75 years) withoutglobus, nine (39%) had GER, thus showing no significant association of globus with GER (P = 0.35).There also was no significant association of GER withnormal UES or with hypertensive UES in these patients.In conclusion, there is a significant association between hypertensive UES and globus. The datasuggest two possible etiologies: female patients withnormal UES pressure potentially having increasedafferent sensation and a group with equal sexdistribution but abnormally elevated UES resting pressure.This study does not support GER as an etiology ofglobus.     

Intersubject and Interswallow Variability in Topography of Esophageal Motility

Topographic plots linking averaged manometricdata in time and space suggest that sequentialcontraction segments form esophageal peristalsis. Asystem capable of plotting individual swallows wasdeveloped to verify this observation and to determineintersubject and interswallow variability in theirtopographic appearance. Fourteen volunteers were studiedwith a novel computerized assimilation method capable of generating topographic contour plots as wellas conventional wave forms for analysis. Contractionsegments in the proximal body and lower sphincter wereidentified in all subjects as being separate from the remainder of the esophagus with littleinterswallow variation. The appearance of peristalsisthrough the distal body was more variable because of itsintermittent separation into two dominant contraction segments (59.8% of swallows) that had poorlycorrelated contraction strength (median r = 0.15).Intersubject variability exceeded interswallowvariability in topographic landmarks, resulting indistinctive topographic fingerprints ofperistalsis for each subject. We conclude thattopographic plotting of single swallows is feasible andconfirms the presence of sequential contraction segmentsin the esophagus. Interswallow variability helps demonstrate twosegments within the smooth-muscle body, an anatomicalregion of seeming homogeneity, that have sufficientcontraction independence to indicate separateneuromuscular units responding to different contractileinfluences.     

Efficacy and Safety of Cardiomyotomy in Patients with Achalasia After Failure of Pneumatic Dilatation

In patients with achalasia, it has beensuggested that pneumatic dilatation could makecardiomyotomy more difficult to perform, diminishing itsefficacy and safety. Our aim was to evaluate theefficacy and safety of elective cardiomyotomy afterfailure of pneumatic dilatation in achalasia. During 14years, 32 of 276 consecutive patients with achalasiahave been operated on because of failure of dilatation therapy. Twenty patients have been followed-upfor at least one year after surgery. After failure ofdilatation, Heller's cardiomyotomy and 180 anteriorfundoplication were performed. Clinical status was evaluated before and after surgery. Loweresophageal sphincter pressure and esophageal body basalpressure were measured by manometry, esophageal diameterby barium meal, and gastroesophageal reflux by endoscopy and 24-hr esophageal pH monitoring.No technical difficulties were found during operation.Postoperative morbidity was infrequent and mortality wasabsent. Cardiomyotomy improved clinical status in 19 of 20 patients. The results of surgerywere considered excellent or good in 16 patients (80%;CI: 56-94%). The pressure of the lower esophagealsphincter was significantly reduced, falling in most patients to under 10 mm Hg. Gastroesophagealreflux appeared after surgery in eight patients, four ofthem with endoscopic esophagitis, but it was controlledin all patients with medical therapy. In conclusion, cardiomyotomy is a safe and effective therapyin achalasia after failed pneumaticdilatation.     

Concurrent Fluoroscopy and Manometry Reveal Differences in Laparoscopic Nissen and Anterior Fundoplication

A prospective double-blind randomized trial wasinitiated to examine two types of laparoscopicfundoplication (Nissen and anterior). Thirty-twopatients with proven gastroesophageal reflux diseasepresenting for primary laparoscopic antireflux surgerywere randomized to undergo either Nissen fundoplication(N = 13) or anterior hemifundoplication (N = 19).Postoperative fluoroscopic and manometric examinationwas carried out concomitantly. Nissenfundoplication resulted in significantly greaterelevation of resting (33.5 vs 23 mm Hg) and residuallower esophageal sphincter pressures (17 vs 6.5 mm Hg)and lower esophageal ramp pressure (26 vs 20.5 mm Hg) than theanterior partial fundoplication. A smallerradiologically measured sphincter opening diameter wasseen following Nissen fundoplication (9 mm) comparedwith anterior fundoplication (12 mm). Lower esophageal ramppressure correlated weakly (r = 0.37, P = 0.04) withpostoperative dysphagia. It is concluded that the typeof fundoplication performed significantly influences postoperative manometric and video bariumradiology outcomes. The clinical relevance of thisrequires further investigation.     

A New Method for the Detection of Incomplete Lower Esophageal Sphincter Relaxation in Patients with Achalasia

Background: In patients with early stages of achalasia manometry is of significant diagnostic value. Technically, however, measurement of lower esophageal sphincter (LES) relaxation is not always easy. Accordingly, we looked for a simpler way of measuring incomplete LES relaxation. Methods: In 186 consecutive patients referred to esophageal motility testing the esophageal body base-line pressure was measured during continuous swilling of 180 ml fluid within 20 sec. Results: Seventeen of the 186 patients had achalasia. Fourteen of these patients were compliant for the swill test, and all had a positive test, characterized by a steady increase in base-line pressure with negative deflections on deglutition. All non-achalasia patients could complete the test, which was negative in all except one patient, who had a severe peptic stricture. Conclusions: The swill test is diagnostic for incomplete lower esophageal relaxation in achalasia in compliant patients without organic stenosis.     

Prospective Randomized Comparison of Pneumatic Dilatation Technique in Patients with Idiopathic Achalasia

We performed a randomized prospective study ofpneumatic dilatation comparing a 30-mm and 35-mmMicrovasive balloon dilator inflated for either 15 or 60sec in patients diagnosed with idiopathic achalasia who were previously untreated. Twenty-fourpatients, 11 men, 13 women, mean age 45, range 18-81years), were prospectively randomized for dilatation.History and physical examination, esophageal manometry, and barium swallow were performed beforedilatation. Symptom self scores were assessed beforedilatation, and one month and six months afterdilatation. Pneumatic dilatation was successfullycompleted in all 24 patients, with one patient experiencinga confined perforation. Conservative treatment wasemployed, and the patient recovered fully. Two patientsexperienced a recurrence of symptoms and required a second dilatation. Evaluation ofposttreatment symptom self scores indicates nodifference between the 30-mm and 35-mm Microvasiveballoon or inflation durations of either 15 or 60 sec.These data indicate that the more conservative 30-mm dilatorinflated for just 15 sec delivers a symptom responseequal to a more aggressive approach with the largerdilator inflated over longer duration.     

Endoscopic Ultrasonography of the Lower Esophageal Sphincter in Reflux Esophagitis and Achalasia

Abstract: The endoscopic ultrasonography findings at the lower esophageal sphincter (LES) were compared in patients with reflux esophagitis and esophageal achalasia to clarify the differences in wall structure between these diseases. In reflux esophagitis, the esophageal wall was hypertrophied at the LES and featured both irregularity and interruption of the submucosa, muscularis propria, and adventitia. In achalasia, there was generalized hypertrophy of the esophageal wall at the LES including the mucosa, submucosa, muscularis propria and adventitia but for each layer the normal 5-layer structure was visualized well. Thus achalasia and reflux esophagitis both featured hypertrophy at the LES, but the detailed findings were quite different. This difference was thought to arise from the presence of inflammation in reflux esophagitis and no inflammation in achalasia.     

Anti-Myenteric Neuronal Antibodies in Patients with Achalasia (A Prospective Study)

Achalasia is a motility disorder of theesophagus characterized by the loss of inhibitoryneurons in the distal esophagus. Although idiopathic innature, autoimmune mechanisms have been proposed, and we set out to determine the presence of myentericneuronal antibodies. We prospectively studied 18patients with well-characterized achalasia (by clinical,x-ray, and manometric evidence), nine withgastroesophageal reflux disease, and analyzed the sera from 22disease-free controls. Using double-label, indirectimmunofluorescence techniques, rat esophageal andintestinal sections were double-labeled with sera(dilutions of 1:50 to 1:400) from the three groups andwith neurofilament antibody to localize neurons. Sevenof 18 achalasia patients had sera that stained themajority of neurons within plexi in the esophageal and intestinal sections, including both NADPHdiaphorase (nitric oxide synthase) -positiveand-negative neurons. None of the gastroesophagealreflux patients or the controls showed staining.Neuronal antibodies in achalasia provide an attractive hypothesisto explain this diffuse, possibly immune-based disorder.     

Small Bowel Dysmotility in Patients with Postcholecystectomy Sphincter of Oddi Dysfunction

Postcholecystectomy patients (N = 27) withsevere recurrent biliary-like pain who had no evidenceof organic disease were subdivided into those with andthose without objective evidence of sphincter of Oddi dysfunction (SOD) based on two separatecriteria: (1) clinical criteria — elevated liverfunction tests and/or amylase with pain, and/or adilated bile duct, and/or delayed drainage at ERCP (N =14, SOD classes I and II); and (2) abnormal biliary manometry(N = 19). Prolonged (24–48 hr) ambulant recordingof duodenojejunal motor activity was performed in allpatients and interdigestive small bowel motor activity compared between patient subgroups and ahealthy control group. Phase II motor abnormality wasmore frequent in patients with, compared to thosewithout, objective clinical criteria of SOD (7/14 vs0/13, P = 0.003). Phase III abnormality also tendedto be more frequent in these patients (7/14 vs 2/13, P= 0.06). In addition, both phase III (P = 0.03) andphase II (P = 0.03) motility index (MI) was higher inpatients with sphincter dyskinesia compared to controls;phase II MI was also higher in patients with sphincterstenosis (P = 0.005). Disturbances of small bowelinterdigestive motor activity are more prevalent in postcholecystectomy patients with, compared tothose without, objective evidence of SOD, and especiallyin patients with SO dyskinesia. Postcholecystectomy SODin some patients may thus represent a component of a more generalized intestinal motordisorder.     

Transient Lower Esophageal Sphincter Relaxations and Esophageal Body Muscular Contractile Response in Reflux Esophagitis

In patients with gastroesophageal reflux disease (GERD), transient lower esophageal sphincter relaxations (TLESRs) are more frequently accompanied by acid reflux than in normals. The role of esophageal tone during gastroesophageal reflux events is unknown. We studied the tonic motor activity in the body of the esophagus during TLESRs with and without acid reflux in 11 patients with erosive esophagitis and compared the results with those previously obtained in healthy subjects. Esophageal peristaltic contractions were recorded 13, 8, and 3 cm above a sleeve that measured LES pressure. An intraluminal balloon was inflated 8 cm above the sleeve to induce an esophageal tonic contraction [artificial high pressure zone (HPZ)]. The percentage of TLESRs with acid reflux was significantly higher in patients with esophagitis than in healthy controls (58.3% vs 37.3%, P < 0.05). TLESRs per se were not associated with an inhibition or increase in esophageal body contractility, which, however, changed substantially immediately after reflux. In patients with esophagitis the esophageal body tonic contractility was inhibited in 59.5% of TLESRs vs 36% in controls (P < 0.05). Esophageal contractions during TLESRs traveled down the esophagus in 77% of the instances in patients vs 96.5% in controls (P < 0.05). In conclusion, gastroesophageal reflux during TLESRs was more frequently associated with inhibition of esophageal body tonic contractility in patients with esophagitis than in normals. The different response of the esophageal body to reflux observed in GERD patients may partially contribute to the higher prevalence of reflux during TLESRs in these patients.     

The Effect of Verapamil on the Lower Esophageal Sphincter Pressure in Normal Subjects and in Achalasia

Verapamil hydrochloride is an organic calcium antagonist that is known to decrease the contraction of smooth muscle. The purpose of our study was to determine if verapamil has a similar effect on the resting lower esophageal sphincter pressure in normal subjects and in patients with achalasia. Esophageal manometry was performed using a continuously perfused catheter assembly. Infusion of verapamil (0.15 mg/kg) over a 2-min period resulted in a statistically significant decrease in resting lower esophageal sphincter pressure in both normal subjects (n = 8) and patients with achalasia (n = 7) within 10 min postinfusion. This study suggests that verapamil may have potential as a drug therapy in treating the clinical symptoms of achalasia and diffuse esophageal spasm.