Effect of peristaltic dysfunction on esophageal volume clearance

Prolonged esophageal acid clearance, found in some patients with esophagitis, can be attributed in part to the peristaltic dysfunction observed in this population. In this study, we undertook to define the effect of commonly observed peristaltic dysfunction on volume clearance by obtaining concurrent videofluoroscopic and manometric recordings in patients with nonobstructive dysphagia or heartburn. Excellent correlation existed between the findings from the two studies. A single normal peristaltic wave resulted in 100% clearance of a barium bolus from the esophagus. At each recording site, luminal closure, as demonstrated by videofluoroscopy, coincided with the upstroke of the peristaltic pressure complex. Absent or incomplete peristaltic contractions invariably resulted in little or no volume clearance from the involved segment. Regional hypotensive peristalsis was associated with incomplete volume clearance by the mechanism of retrograde escape of barium through the region of hypotensive contraction. The regional peristaltic amplitude required to prevent retrograde escape of barium was greater in the distal compared with the proximal esophagus. The mean peristaltic amplitude associated with instances of retrograde escape was 25 mmHg in the distal esophagus compared with 12 mmHg in the proximal esophageal segments. Thus, the peristaltic dysfunction commonly seen in patients with esophagitis (failed and hypotensive peristalsis) likely leads to impaired volume clearance.     

轻度反流性食管炎与非糜烂性反流病远端食管酸暴露和食管动力学变化

目的:探讨轻度反流性食管炎(RE)与非糜烂性反流病(NERD)食管远端酸暴露及食管动力变化特点.方法:符合洛杉矶诊断标准的RE30例(LA-A16例,LA-B14例),NERD16例,健康对照组10例被纳入本研究,所有患者及对照组均接受24h食管pH监测及压力测定,比较食管pH监测及测压结果.结果:LA-A组、LA-B组、NERD组DeMeester评分明显高于对照组,差异显著(P<0.05).LA-A组与NERD组比较DeMeester评分无明显差异,但NERD组的立位反流时间百分比与长反流周期数多于LA-A组,差异显著;LA-B组DeMeester评分比LA-A组和NERD组明显增高,LA-B组与LA-A组比较食管pH监测各项指标均存在明显差异.LA-A组、NERD组及对照组比较下食管括约肌静息压(LESP)、食管体部蠕动波幅度(PA)无显著差异,LA-A组和NERD组食管下段PA有增高趋势;LA-B组与LA-A组、NERD组及对照组比较LESP明显降低(P<0.05),LA-B组食管下段PA明显低于LA-A组(P<0.05).RE组无效食管运动(IEM)明显高于对照组,差异显著.结论:轻度RE(LA-B)与NERD远端食管酸暴露存在差异.DeMeester评分、LES功能不全及食管蠕动功能障碍与RE的严重程度呈正相关.LES功能不全及食管蠕动功能障碍可能不是轻度RE(LA-A)及NERD的主要致病因素.IEM与RE关系密切,且与RE有关的食管动力异常主要为IEM.     

Reflux esophagitis patients in Singapore have motor and acid exposure abnormalities similar to patients in the Western hemisphere

OBJECTIVE: Endoscopic esophagitis is less common in the East than in the West. The reason for this is unknown. This study examines prospectively the relationship between endoscopic esophagitis and lower esophageal sphincter pressure, distal esophageal contractility, esophageal peristaltic performance, esophageal acid exposure, gastric acid output, and Helicobacter pylori (H. pylori) status in a consecutive series of Asian patients. METHODS: Esophageal manometry and ambulatory pH monitoring were carried out in 48 patients with endoscopic esophagitis and 208 patients with symptoms suspicious of gastroesophageal reflux disease but without esophagitis. Gastric acid output and H. pylori serology were determined in 22 of the esophagitis group and 36 of the nonesophagitis group. RESULTS: Compared to the nonesophagitis patients, esophagitis patients had a higher prevalence of hypotensive lower esophageal sphincter (49% vs 24%, p < 0.001), impaired esophageal contractility (45% vs 22%, p < 0.005), poor peristaltic performance (23% vs 12%, p < 0.05), and pathological acid reflux (48% vs 27%, p < 0.005). However, there was no difference in the two groups with respect to gastric acid output and H. pylori positivity. CONCLUSIONS: Lower esophageal sphincter competence, esophageal peristaltic contractility, and esophageal acid exposure were important factors in the pathogenesis of reflux esophagitis--results identical to Western studies. Gastric acid output per se and H. pylori infection might not be responsible for susceptibility to esophagitis.     

Esophageal function in esophageal atresia

In order to determine the spectrum of esophageal dysfunction in repaired esophageal atresia, 14 patients were evaluated with esophageal manometry, intraluminal pH recording, and radiology. Nine patients had no difficulty in swallowing but six had symptoms suggestive of gastroesophageal (GE) reflux. On pH recording, six had evidence of GE reflux. Basal sphincter pressure was 22 mm Hg in both reflux and nonreflux patients. No patient had manometric evidence of peristalsis in the proximal esophagus, but six had peristalsis in the distal esophagus. On radiology all had a normal peristaltic stripping wave in the cervical esophagus, and peristalsis was absent in the proximal thoracic esophagus in all patients but present in the distal esophagus in five of the 10 patients studied. Esophageal dysfunction is present in all patients with repaired esophageal atresia even when symptoms are absent.Supported by grant AM 25731 from the National Institutes of Health.     

Aging and esophageal motility in patients with gastroesophageal reflux disease

BACKGROUND: Alterations of esophageal contractions may worsen the esophageal lesions caused by gastroesophageal reflux. The impairment of the contractions may be localized only in the distal esophagus or in the entire esophageal body, and may be worse with the aging process. AIMS: To evaluate the proximal and distal esophageal contractions in patients with gastroesophageal reflux symptoms with or without esophagitis. PATIENTS AND METHODS: We studied esophageal motility in 104 patients with gastroesophageal reflux symptoms, 42 with normal esophageal endoscopic examination, 47 with mild esophagitis and 15 with severe esophagitis. The esophageal contractions were measured by the manometric method at 2, 7, 12 and 17 cm from the upper esophageal sphincter, after five swallows of a 5 mL bolus of water. RESULTS: The amplitude and area under the curve of contractions were lower in patients with severe esophagitis than in patients without esophagitis or with mild esophagitis in the distal part of the esophageal body (17 cm from the upper esophageal sphincter). In the proximal esophageal body there was no difference in amplitude or area under the curve. In the entire esophageal body there was no difference between the three groups of patients in duration, velocity of peristaltic contractions, or proportion of failed, simultaneous, non-propagated or peristaltic contractions. There was no difference between the patients with less than 50 years or with more than 50 years of age. CONCLUSIONS: Patients with severe esophagitis had lower distal esophageal contraction amplitude than patients without esophagitis or with moderate esophagitis. There was no effect of aging on esophageal contractions.     

Improvement in Esophageal Motor Dysfunction with Treatment of Reflux Esophagitis: A Report of Two Cases

We report two patients with reflux esophagitis who had decreased lower esophageal sphincter pressures and marked decreased frequency of peristaltic response to swallowing and peristaltic amplitude on pretreatment esophageal motility tracings. Both patients responded to medical therapy of reflux esophagitis with symptomatic clinical improvement, increased lower esophageal sphincter pressures, and increased frequency of peristaltic propagation and amplitude of peristalsis. Measures to treat reflux esophagitis may he effective in some cases, in part, because they permit healing of esophageal inflammation to improve esophageal motor activity, the latter which results in improvement of esophageal acid clearing.     

Esophageal motility and gastric acid secretion in patients with Barrett's esophagus

Patients with Barrett's esophagus (BE) usually have low resting lower esophageal sphincter (LES) pressure, and also have impaired esophageal body motility, with low amplitude and failed peristaltic contractions on swallowing being common. These motor abnormalities contribute to excessive esophageal acid exposure in patients with BE. However, gastric acid secretion is not different between patients with BE and reflux esophagitis.     

Dysphagia and esophageal motor dysfunction in gastroesophageal reflux are corrected by fundoplication

Abnormalities in esophageal peristaltic function and acid clearance appear to be responsible for prolonged esophageal acid exposure, a major determinant of the reflux esophagitis and esophageal stricture. We evaluated esophageal motility by manometry in 50 healthy controls and in 35 symptomatic reflux patients before, within 6 months, and 1 year after Nissen fundoplication. Preoperative motility was analyzed in relation to the presence or absence of both nonobstructive dysphagia and erosive esophagitis. We found that (a) preoperative dysphagia was related more to peristaltic dysfunction than to esophagitis; (b) peristaltic wave amplitude and duration were significantly lower than control values in patients with reflux, without correlation to degree of esophagitis or lower esophageal sphincter hypotension; (c) dysphagia ceased in most patients after antireflux surgery at the same time that normal motility was restored independently of lower esophageal sphincter pressure increments. These results suggest that motility disturbances are an important cause of dysphagia in reflux disease, and that reflux is the cause of, rather than the consequence of, peristaltic dysfunction.     

Healing of severe reflux esophagitis with PPI does not improve esophageal dysmotility

Esophageal dysmotility is frequently associated with gastroesophageal reflux disease (GERD). The aim of this study was to investigate the relationship between the severity of reflux esophagitis and esophageal dysmotility and evaluate the effect of prolonged treatment with proton pump inhibitor (lansoprazole 30 mg/day) on esophageal motility in patients with severe reflux esophagitis associated with esophageal motility disorder. Twelve healthy subjects (HS) and 100 patients with reflux disease were involved in the study consisting of two parts: (i) comparison of esophageal motility in HS and patients with non-eroseive reflux disease (NERD), mild esophagitis and severe esophagitis; (ii) effect of 3-6 months lansoprazole therapy on esophageal motility in 23 patients with severe esophagitis, pathologic acid reflux and esophageal peristaltic dysfunction. Results included the following. (i) Esophageal dysmotility was noted in both patients with NERD and erosive GERD. (ii) Severe esophagitis was associated with severe esophageal dysmotility. (iii) Healing of severe esophagitis did not improve esophageal dysmotility. The resting lower esophageal sphincter pressure was 3.9 mmHg (range 1.7-20) before treatment and 4.8 mmHg (range 1.2-18.3) after esophagitis healing (P = 0.23, vs. before treatment), the amplitude of distal esophageal contraction was 28.8 mmHg (range 10.9-80.6) before treatment and 33.3 mmHg (range 10.0-72.5) after esophagitis healing (P = 0.59, vs. before treatment) and the frequency of failed peristalsis was 70% (range 0-100%) before treatment and 70% (range 0-100%) after esophagitis healing (P = 0.78, vs. before treatment). Both esophageal motility disorders and acid reflux play important roles in the mechanism of GERD, especially in severe esophagitis. Esophageal dysmotility is not secondary to acid reflux and esophagitis; it should be a primary motility disorder.     

Lower esophageal sphincter pressure, esophageal body motor functioning, and esophageal acid sensitivity

Esophageal acid sensitivity is believed to develop as a result of esophageal acid exposure, contributing factors being gastroesophageal reflux and delayed esophageal acid clearance. The relationship among lower esophageal sphincter pressure, motor functioning of the body of the esophagus, and esophageal acid sensitivity was examined by comparing the results from 912 patients and normal subjects studied with both esophageal manometric and Bernstein acid infusion tests. Positive acid infusions were statistically more closely associated with hypotensive lower esophageal sphincter pressures than with any motor abnormality in the body of the esophagus. Of the several esophageal body motor abnormalities considered, only feeble peristalsis had significantly more positive Bernstein tests than did normal esophageal body motor functioning. The findings from this study demonstrate that hypotensive lower esophageal sphincter pressure is more closely associated with an acid-sensitive esophagus than is impaired esophageal body motor functioning.     

Esophageal motility and gastric emptying in PSS patients, correlation with symptoms

Progressive systemic sclerosis (PSS) commonly involves the esophagus. Dysphagia and heartburn are the most common esophageal symptoms. In this study we evaluated the relationship between esophageal symptoms and esophago-gastric motility. On esophageal manometry, loss of peristalsis, peristaltic contraction amplitude of distal esophagus less than 30 mmHg and decreased LES pressure were critical for esophageal symptoms. The degree of symptoms correlated to esophageal dysmotility. The gastric emptying in PSS patients was delayed, but there was no significant difference in gastric emptying between the patients with and without reflux esophagitis. Esophageal dysmotility is considered to be much responsible for the reflux esophagitis in PSS patients than gastric emptying.     

Peristaltic dysfunction associated with nonobstructive dysphagia in reflux disease

An evaluation was done of 325 consecutive patients who underwent esophageal manometry to investigate the relationship between solid food dysphagia and peristaltic dysfunction in gastroesophageal reflux disease. All patients with dysphagia were endoscoped to evaluate for mechanical obstruction. Manometry was done focusing on the incidence of peristaltic dysfunction (failed peristaltic sequences or sequences characterized by foci of hypotensive peristalsis). The major finding was that the severity of manometrically demonstrated peristaltic dysfunction in reflux patients correlated with the prevalence of dysphagia. After excluding patients with esophageal rings or strictures from the analysis, the overall prevalence of dysphagia was 39% among the 157 reflux patients. Within this group, 29% of patients with minimal peristaltic dysfunction experienced dysphagia compared to 78% of patients with severe peristaltic dysfunction. We conclude that peristaltic dysfunction should be considered along with mechanical obstruction as a potential cause of dysphagia in patients with gastroesophageal reflux disease.     

Radially asymmetric gastroesophageal acid reflux in the distal esophagus: examinations with novel pH sensor catheter equipped with 8 pH sensors

Background

Esophageal mucosal breaks in patients with Los Angeles (LA) grade A or B esophagitis are mainly found in the right anterior wall of the distal esophagus. The aim of this study was to reveal radial acid exposure in the distal esophagus and determine whether radial asymmetry of acid exposure is a possible cause of radially asymmetric distribution of the lesions.

Methods

We developed a novel pH sensor catheter using a polyvinyl chloride catheter equipped with 8 antimony pH sensors radially arrayed at the same level. Four healthy volunteers, 5 patients with non-erosive reflux disease (NERD), and 10 with LA grade A or B esophagitis were enrolled. The sensors were set 2?cm above the upper limit of the lower esophageal sphincter, and post-prandial gastroesophageal acid reflux was monitored for 3?h with the subjects in a sitting position.

Results

We successfully examined radial acid exposure in the distal esophagus in all subjects using our novel pH sensor catheter. Radial variations of acid exposure in the distal esophagus were not observed in the healthy subjects. In contrast, the patients with NERD and those with reflux esophagitis had radial asymmetric acid exposure that was predominant on the right wall of the distal esophagus. In the majority of patients with reflux esophagitis, the directions of longer acid exposure coincided with the locations of mucosal breaks.

Conclusions

Radial acid exposure could be examined using our novel 8-channel pH sensor catheter. We found that the directions of longer acid exposure were associated with the locations of mucosal breaks.     

Dysplastic Barrett''s Esophagus in Scleroderma

A review of 107 patients with Barrett's esophagus revealed three patients who concomitantly had scleroderma. Two of the three patients had pathological evidence of high-grade dysplasia of the columnar-lined epithelium, and the third patient had nondysplastic columnar-lined epithelium in the distal esophagus. Patients with scleroderma often have an incompetent lower esophageal sphincter, poor or absent distal esophageal peristalsis, and reflux esophagitis, all of which are believed to predispose to Barrett's esophagus. The importance of Barrett's esophagus is its potential for malignant transformation. Identification of such patients permits aggressive medical treatment and endoscopic and pathological surveillance.     

Effect of rioprostil, an oral prostaglandin E1 (PGE1) analogue, on lower esophageal sphincter pressure and on the motility of the distal esophagus in healthy volunteers

The influence of rioprostil on the resting pressure of the lower esophageal sphincter (LESP) and on the bolus-stimulated contraction wave amplitude of primary peristalsis was investigated in 9 healthy male volunteers receiving placebo or 300 and 600 micrograms of rioprostil orally in a randomised, double-blind, threefold cross over study. Manometry was performed using the low-compliance pneumohydraulic infusion system. Rioprostil in a dose of 600 micrograms slightly increased LESP and contraction wave amplitudes measured 5 cm and 10 cm above LES. The duration of the peristaltic contractions was not altered. We conclude that rioprostil in doses which inhibit effectively gastric acid and pepsin secretion and heal peptic ulcers has no inhibitory effects on esophageal motility. Thus rioprostil may be a candidate to treat reflux esophagitis and studies are warranted to establish its efficacy.     

Simultaneous two-level esophageal 24-hour pH monitoring in patients with mild and severe esophagitis

Simultaneous ambulatory esophageal pH monitoring was performed in 10 patients (group 1) with normal distal acid exposure and in 40 patients (group 2) with pathological distal reflux. The probes were placed 5 and 10 cm above the lower esophageal sphincter to quantify variations of pH values that can be due to a displacement of pH sensor. In group 1 the median percent time with pH<4 for total and upright monitoring periods and composite score were significantly lower at the proximal than the distal level. In group 2 all pH data were significantly lower at the proximal than the distal level. The patients with pathological reflux were subdivided into two subgroups based on endoscopic findings (mild and severe esophagitis). The patients with severe esophagitis showed a proximal acid reduction higher than in patients with mild esophagitis. Nine patients with mild esophagitis showed normal values at 10 cm, but all patients with severe esophagitis had abnormal proximal acid exposure.     

胆碱能神经对反流性食管炎食管动力的影响

目的研究内源性胆碱能神经在反流性食管炎食管动力机制异常中的作用.方法经下食管括约肌切开制备反流性食管炎的猫模型,用连续水灌注测压系统检测正常猫及反流性食管炎的猫食管体部动力;用分光光度法分别测定正常猫及反流性食管炎的猫食管中段、远段肌组织中的乙酰胆碱转移酶和乙酰胆碱酯酶活力.结果反流性食管炎组食管远段平均收缩波幅度明显低于正常对照组(P＜0.0001),食管远段传导速度低于正常对照组(P＜0.05);反流性食管炎时食管中段及远段肌组织中乙酰胆碱转移酶活力均低于正常对照组的中段及远段(P＜0.05及P＜0.0001),以远段更明显(P＜0.0001).反流性食管炎组食管中段及远段肌组织中的乙酰胆碱酯酶活力与对照组比较差异均无显著性(P＞0.05).结论反流性食管炎可导致食管远段动力低下,内源性胆碱能神经功能异常是其重要机制之一.     

Mechanisms of Excessive Esophageal Acid Exposure in Patients with Reflux Esophagitis

The pathophysiology of excessive esophageal acid exposure, including the way refluxed acid extends towards the proximal esophagus, in patients with reflux esophagitis (RE), is not yet clear. For 3 h after a meal, concurrent esophageal manometry and pH monitoring was carried out on 14 patients with severe RE, 15 patients with mild RE, and 15 healthy subjects. At 2 cm above the proximal margin of the lower esophageal sphincter (LES) there was no difference between the three groups in the total number of acid-reflux episodes, the rate of transient LES relaxations (TLESRs), or the rate of acid reflux during TLESRs. The rate of acid reflux at 7 cm above the proximal margin of the LES, during TLESRs, in patients with severe RE (50.9%, median) was, however, significantly higher than in patients with mild RE (35.7%) and healthy subjects (15.4%). In addition, the rate of acid reflux during TLESRs in patients with mild RE was significantly higher than in healthy subjects. Both the amplitude and the success rate of primary peristalsis in patients with severe RE were significantly lower than those of healthy subjects and patients with mild RE but there was no difference between healthy subjects and patients with mild RE. The cause of excessive acid exposure in patients with RE is the difference in the way refluxed acid extends towards the proximal esophagus and acid bolus clearance, not the number of acid-reflux episodes.     

Comparison of esophageal acid exposure distribution along the esophagus among the different gastroesophageal reflux disease (GERD) groups

BACKGROUND: Patients with nonerosive reflux disease (NERD) have the lowest esophageal acid exposure profile compared with the other gastroesophageal reflux disease (GERD) groups. AIM: To compare lower esophageal acid exposure recordings 1 cm above the lower esophageal sphincter (LES) with those 6 cm above the LES as well as to determine the characteristics of esophageal acid exposure along the esophagus among the different GERD groups. METHODS: Patients with classic heartburn symptoms were enrolled into the study. Patients were evaluated by a demographics questionnaire and the validated GERD Symptom Checklist. Upper endoscopy was performed to evaluate the presence of esophageal erosions and Barrett's esophagus (BE). Ambulatory pH testing was performed using a commercially available 4-sensor pH probe with sensors located 5 cm apart. The distal sensor was placed 1 cm above the LES. RESULTS: Sixty-four patients completed the study. Of those, 21 patients had NERD, 20 had erosive esophagitis (EE), and 23 had BE. All patient groups demonstrated greater esophageal acid exposure 1 cm above the LES than 6 cm above the LES. In NERD and EE, this phenomenon was primarily a result of a higher mean percentage of upright time with pH <4. Unlike patients with EE and BE, those with NERD had very little variation in esophageal acid exposure throughout the esophagus (total and supine). CONCLUSIONS: ALL GERD groups demonstrated significant greater esophageal acid exposure at the very distal portion of the esophagus, primarily as a result of short upright reflux events. Unlike erosive esophagitis and BE, NERD patients demonstrate a more homogenous acid distribution along the esophagus.     

Normal and Abnormal Proximal Esophageal Acid Exposure: Results of Ambulatory Dual-Probe pH Monitoring

Ambulatory esophageal pH monitoring was performed in 26 normal volunteers, 20 patients with normal distal acid exposure, and 23 patients with abnormal distal acid exposure in an attempt to define normal values for proximal esophageal acid exposure using a standardized technique. We used a dual pH sensor with antimony electrodes spaced at 15 cm. The distal electrod was placed manometrically at 5 cm above the lower esophageal sphincter. Proximal electrode thus was located below the upper esophageal sphincter in the esophageal inlet. the patients underwent 24-h ambulatory pH monitoring and were told to pursue normal daily activities. The percentage of acid exposure time and number of episodes per 24 h at both pH <4.0 and 5.0 were measured for the total, upright, and supine periods. Since the pH values were not normally distributed, the medians and 95th percentiles were used to define normal values. Minimal acid exposure occurred in the proximal esophagus (<1% total; 0% supine) in volunteers and patients with normal distal reflux. Patients with abnormal distal acid exposure had significantly greater proximal reflux.