Lower esophageal sphincter relaxation characteristics using a sleeve sensor in clinical manometry

Objective: We undertook this study to determine the characteristics of swallow-induced lower esophageal sphincter (LES) relaxation in the setting of clinical manometry using a standardized methodology.
Methods: We reviewed 170 manometric recordings performed using a perfused manometric assembly with a sleeve sensor and a computer polygraph. Patients were categorized as patient controls, gastroesophageal reflux disease (GERD), diffuse esophageal spasm (DES), or achalasia. Tracing were semiautomatically analyzed for basal LES pressure, LES pressure during deglutitive relaxation (relaxation LES pressure), duration of LES relaxation, timing of LES relaxation, and the success rate of primary peristalsis.
Results: Forty-six patient controls, 93 with GERD, five with DES, and 26 with achalasia were identified. GERD and achalasia patients had lower or higher basal LES pressures than patient controls, respectively. Compared with patient controls, achalasia patients had higher relaxation LES pressures, lower percent LES relaxation, and shorter durations of LES relaxation. The best single measure for distinguishing achalasia was the relaxation LES pressure; using the 95th percentile value of patient controls (12 mm Hg) as the upper limit of normal, its sensitivity and positive predictive value for the diagnosis of achalasia were 92% and 88%, respectively. Coupled with the finding of aperistalsis, a relaxation LES pressure ≥10 mm Hg achieved 100% sensitivity and positive predictive value among these patients.
Conclusion: Sleeve sensor recording is a practical method for clinical manometry that reliably records LES relaxation characteristics and is amenable to both a standardized manometry protocol and a semiautomated analysis routine. Relaxation LES pressure has a high diagnostic value for achalasia.     

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.     

Esophageal pneumatic dilation for postfundoplication dysphagia: safety,efficacy, and predictors of outcome

OBJECTIVE: Persistent dysphagia occurs in 5-10% of patients after fundoplication. The cause is obscure in most cases, and the management has not been well established. The aim of this study is to evaluate the clinical outcomes and the predictors of success for esophageal pneumatic dilations in patients with dysphagia after fundoplication. METHODS: We retrospectively reviewed 14 patients who underwent pneumatic dilation for persistent postfundoplication dysphagia. All patients had esophageal manometry before dilations. RESULTS: There were nine responders to pneumatic dilations (30-40-mm balloons). The nadir lower esophageal sphincter (LES) relaxation pressure was the only significant predictor for successful dilation and was higher among the responders than nonresponders (median 10 mm Hg vs 5 mm Hg). All six of 14 patients with nadir LES pressure > or = 10 mm Hg had a good response. There was no significant difference in the LES basal pressure between the responders and nonresponders (median 20 mm Hg vs 12 mm Hg). The median distal peristaltic amplitude (74 mm Hg vs 69 mm Hg), percent of failed peristalsis (8% vs 45%), and ramp pressure (19 mm Hg vs 17 mm Hg) did not differ significantly between the responders and nonresponders. No perforations occurred. CONCLUSIONS: Pneumatic dilation is a reasonably safe and effective treatment for patients with postfundoplication dysphagia. Raised nadir LES relaxation pressure seems to be a useful predictor of successful outcome.     

Is aperistalsis with complete lower esophageal sphincter relaxation an early stage of classic achalasia?

BACKGROUND: Aperistalsis with complete lower esophageal sphincter (LES) relaxation, characterized by the complete relaxation of the LES and aperistalsis of the esophageal body on manometry, has been considered by some authors to be an early manifestation of classic achalasia, which is defined as incomplete relaxation of the LES and aperistalsis of the esophageal body. The aim of the present study was to compare the clinical features of patients with aperistalsis with complete LES relaxation, with those of patients with classic achalasia. METHODS: Eighteen patients with aperistalsis with complete LES relaxation and 53 patients with classic achalasia were analyzed with regard to clinical history, the maximal diameter of the esophageal body on barium esophagogram, LES resting pressure and the duration of LES relaxation on manometric recordings, and the selected treatment and its efficacy. RESULTS: The aperistalsis with complete LES relaxation group had distinctly different features compared to those of the classic achalasia group including older age, more frequent association with non-cardiac chest pain, less frequent association with dysphagia and weight loss, lower LES resting pressures, and longer duration of LES relaxation. However, the two groups were similar in terms of maximal diameter of the esophageal body, and efficacy associated with pneumatic dilation. CONCLUSIONS: Aperistalsis with complete LES relaxation on manometry is not necessarily an early manifestation of classic achalasia. However, this condition does not preclude a diagnosis of achalasia or a good response to achalasia therapy.     

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.     

Apparent complete lower esophageal sphincter relaxation in achalasia

Seven of 23 patients (30%) seen in 2 yr with clinical and radiologic manifestations of achalasia underwent esophageal manometry demonstrating aperistalsis but apparent complete lower esophageal sphincter (LES) relaxation. Detailed clinical and laboratory evaluation suggests these patients may represent an early stage of achalasia. Duration of dysphagia and weight loss were significantly less (p less than 0.05), whereas LES pressure was similar in the 7 patients compared with the 16 more traditional achalasia patients. Isotope retention during radionuclide esophageal solid-emptying studies showed intermediate delay in emptying between normal subjects and achalasia patients. The duration of LES relaxation in this group was significantly shorter (p less than 0.01) than in normal subjects. Although complete, sphincter relaxation in these patients is functionally inadequate and may be the result of this shortened duration. The small size of standard manometry catheters may also contribute to this confusing finding. Apparent complete LES relaxation may be seen during manometry in achalasia and should not exclude its diagnosis.     

贲门失驰缓症及滑动型食管裂孔疝患者食管多通道阻抗-压力测定分析

目的应用食管联合多通道阻抗-压力测定(MII-EM)技术研究贲门失驰缓症及滑动型食管裂孔疝患者的食管动力异常特点。 方法连续选取2013年4月至2014年6月到首都医科大学附属北京同仁医院就诊,入组内镜或食管造影诊断的贲门失驰缓症患者6名、滑动型食管裂孔疝患者10名以及健康志愿者10名行MII-EM检查,分析比较二个患病组与对照组间各检测指标差异。 结果与对照组相比,二个患病组的食团传送率均显著降低。贲门失驰缓症患者LES残余压显著升高,同步收缩及逆行收缩率明显增加,LES松弛率显著降低,食管中上段收缩压力也减低(P<0.05),但未发现其在LES静息压、LES长度、及UES各功能指标上的差异。滑动型食管裂孔疝患者LES静息压较对照组显著降低,UES舒张时间延长,食管近端收缩压力减低(P<0.05),但未发现食管中、下段收缩功能的异常。 结论MII-EM技术能够评估贲门失驰缓症及滑动型食管裂孔疝的食管功能障碍,具有一定的辅助诊断价值。     

Incomplete Upper Esophageal Sphincter Relaxation: Association with Achalasia but Not Other Esophageal Motility Disorders

Incomplete upper esophageal sphincter (UES) relaxation is not well understood. We compared clinical and manometric characteristics of patients with normal and abnormal UES relaxation. Consecutive patients (n = 208) underwent manometric evaluation of the lower esophageal sphincter (LES), esophageal body, and UES/pharynx. The patients were divided into those with abnormal UES relaxation (residual pressure >6.7 mmHg) (n = 21) and normal relaxation (n = 187). Clinical and manometric profiles were compared. Sex, age, and presenting complaint did not correlate with UES relaxation. Normal esophageal peristaltic sequences were more frequently present in the normal UES group (73.6%) compared with the abnormal (55.8%) (p < 0.01). The UES relaxation was shorter in the group with abnormal relaxation (410.0 ms vs. 510.2 ms, p < 0.001). All other manometric parameters were not different between the two groups. When individual manometric diagnoses were analyzed, only achalasia was noted to be more common in the abnormal UES group (23.8% vs. 9.1%, p < 0.05), and a trend was noted toward diffuse esophageal spasm being more common (14.3% vs. 9.6%, not significant). We conclude that incomplete UES relaxation is a rare manometric finding, associated with achalasia and not specifically associated with any other motility disturbance. This finding may represent a secondary response to the poor esophageal emptying seen in achalasia.     

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.     

Radiographic and manometric correlation in achalasia with apparent relaxation of the lower esophageal sphincter

We compared the clinical, radiographic, and manometric findings in 10 patients with atypical achalasia showing complete lower esophageal sphincter (LES) relaxation to 39 patients with classic achalasia (i.e., incomplete LES relaxation). Those with atypical achalasia were younger (46.1 vs 60.6 years), had dysphagia of shorter duration (18.7 vs 45.7 mos), had lost less weight (8.2 vs 21.5 lbs), and had less esophageal dilatation (2.8 vs 3.9 cm). However, the mean LES pressures (34.5 vs 37.7 mmHg) and the esophagogastric junction calibers (4.5 vs 4.8 mm) were similar. Radionuclide esophageal emptying studies were done in 15 patients (6 with atypical achalasia; 9 with classic achalasia) and were abnormal in all. Most patients in both groups (90 and 92%) responded well to pneumatic dilatation. We conclude that achalasia with apparent LES relaxation may represent an early form of this motor disorder and that the radiographic findings remain characteristic except for less dilatation of the esophagus.     

Esophageal manometry

Pressure transients in the pharyngoesophagus vary widely, from about 2500 mm Hg/sec in the pharynx to 150 mm Hg/sec in the lower esophageal sphincter (LES). Perfused side-hole and Dent-sleeve manometry have limitations with respect to their inability to record pharyngeal pressure transients and their relative inability to record abrupt pressure increases in the upper esophageal sphincter (UES), although falling pressure changes, ie, relaxations, of more than 1000 mm Hg/sec can be detected easily by the Dent sleeve. Hence, accurate pharyngeal and UES recordings require pressure sensors that are able to record pressure transients faster than 2500 mm Hg/sec. Microtransducers meet this requirement. Except for their relatively high costs of acquisition, microtransducers have a lot of advantages in comparison with the perfused side-hole methods: the small outer diameter and flexibility enable easy intubation; baseline pressures are not affected by subject position; and plumbing necessary for infusion is eliminated. After presoaking in water, calibration is stable and the baseline drift is acceptable. They have an excellent linearity and a negligible hysteresis. Their durability is satisfactory. The microtransducer assemblies can be designed in almost any configuration and even circumferentially sensitive microtransducers for acute sphincter measurements have been developed. For long-interval recordings of the UES and the LES, however, microtransducers are not suitable: for these the Dent sleeve is required. Recently, microtransducers have been used more frequently because they are indispensable in the 24-hr ambulatory esophageal manometry technology.     

Long-term outcome of esophageal myotomy for achalasia

AIM:Modified Heller‘s myotomy is still the first choice for achalasia and the assessment of surgical outcomes is usually made based on the subjective sensation of patients.This study was to objectively assess the long-term outcomes of esophageal myotomy for achalasia using esophageal manometry, 24-hour pH monitoring,esophageal scintigraphy and fiberoptic esophagoscopy.METHODS:From February 1979 to October 2000, 176 patients with achalasia underwent modified Heller‘s myotomy, including esophageal myotomy alone in 146 patients, myotomy in combination with Gallone or Dor antirefiux procedure in 22 and 8 patients, respectively. Clinical score,pressure of the lower esophageal sphincter (LES),esophageal clearance rate and gastroesophageal reflux were determined before and i to 22 years after surgery.RESULTS: After a median follow-up of 14 years, 84.5% of patients had a good or excellent relief of symptoms,and clinical scores as well as resting pressures of the esophageal body and LES were reduced compared with preoperative values (P&lt;0.001).However,there was no significant difference in DeMeester score between pre-and postoperative patients(P=0.51).Esophageal transit was improved in postoperative patients, but still slower than that in normal controls. The incidence of gastroesophageal reflux in patients who underwent esophageal myotomy alone was 63.6% compared to 27.3% in those who underwent myotomy and antirefiux procedure (P=-0.087). Three (1.7%) patients were complicated with esophageal cancer after surgery.CONCLUSION: Esophageal myotomy for achalasia can reduce the resting pressures of the esophageal body and LES and improve esophageal transit and dysphagia. Myotomy in combination with antireflux procedure can prevent gastroesophageal reflux to a certain extent,but further randomized studies should be carried out to demonstrate its efficacy.     

Achalasia in the elderly

Clinical and manometric data from 13 elderly subjects with idiopathic achalasia (mean age 79±2 years) were compared with findings from younger subjects with the same disease (n=79) to see if aging altered the presentation and outcome of this motor disorder. Fewer elderly subjects complained of chest pain (27% vs 53%), and the pain was significantly less severe (P<0.01). Other presenting features (including sex, duration of symptoms, and presence and severity of dysphagia) did not differ between the groups. Across all patients, age weakly and inversely correlated with residual postdeglutitive lower esophageal sphincter (LES) pressure (R=–0.34), and residual pressure was significantly lower in the older subjects (8.0±1.3 mm Hg vs 11.9±0.8 mm Hg;P=0.02). No differences in basal LES pressure or esophageal-body contraction amplitudes were present between the groups. Initial success with pneumatic dilation was similar in the two subject groups, but the number of older subjects available for analysis was too small to draw strong conclusions. These results indicate that aging decreases the elevation of LES residual pressure that occurs with achalasia. As elderly achalasia patients also present with less chest pain, the findings may be interrelated.Supported in part by grant AMO7130 from the United States Public Health Service. Dr. Todorczuk is supported by an educational grant from Smith, Kline, and French.     

Esophageal Impairment in Adult Celiac Disease With Steatorrhea

Objective: A high prevalence of reflux esophagitis in celiac children and gut motor disorders in adult patients have been described. The aim of this study is to investigate the prevalence of esophageal symptoms and the esophageal motility pattern in adult celiac patients before and after gluten-free diet.
Methods: In 22 consecutive adult celiac patients, before and after gluten-free diet, and in controls we calculated an esophageal symptom score regarding heartburn, regurgitation, dysphagia, and chest pain, and performed esophageal manometry using a constantly perfused multilumen catheter.
Results: Patients were divided into two groups: with and without steatorrhea. Before gluten-free diet, the prevalence of esophageal symptoms was 45.5% in all patients, but was significantly higher in patients with steatorrhea than in those without and in 44 control subjects (80% vs 16.7% and 27%,   p < 0.05  ). Lower esophageal sphincter pressure was 17.5 ± 5.3 in all patients, but was significantly lower in patients with steatorrhea than in patients without steatorrhea and 11 controls subjects (13.1 ± 4.1 vs 21.0 ± 2.9 and 20.7 ± 3.7 mm Hg (mean ± SD,   p < 0.05  ). After the diet, the prevalence of esophageal symptoms diminished in all patients (9% vs 45.4%,   p < 0.05  ) and lower esophageal sphincter pressure, measured in 13 patients, increased (19.0 ± 3.7 vs 15.7 ± 5.3 mm Hg,   p < 0.05  ).
Conclusion: Adult celiac patients with steatorrhea present a higher prevalence of esophageal symptoms and a lowered lower esophageal sphincter pressure compared with celiac patients without steatorrhea and control subjects, but these phenomena can be reverted to control levels by gluten-free diet.     

High resolution manometric findings in patients with Chagas' disease esophagopathy

ObjectiveTo describe high resolution manometry features of a population of symptomatic patients with Chagas' disease esophagopathy (CDE).MethodsSixteen symptomatic dysphagic patients with CDE [mean age (54.81±13.43) years, 10 women] were included in this study. All patients underwent a high resolution manometry.ResultsMean lower esophageal sphincter (LES) extension was (3.02±1.17) cm with a mean basal pressure of (15.25±7.00) mmHg. Residual pressure was (14.31±9.19) mmHg. Aperistalsis was found in all 16 patients. Achalasia with minimal esophageal pressurization (type 1) was present in 25% of patients and achalasia with esophageal compression (type 2) in 75%, according to the Chicago Classification. Upper esophageal sphincter (UES) mean basal pressure was (97.96±54.22) mmHg with a residual pressure of (12.95±6.42) mmHg.ConclusionsOur results show that LES was hypotensive or normotensive in the majority of the patients. Impaired relaxation was found in a minority of our patients. Aperistalsis was seen in 100% of patients. UES had impaired relaxation in a significant number of patients. Further clinical study is needed to investigate whether manometric features can predict outcomes following the studies of idiopathic achalasia.     

Factors influencing lower esophageal sphincter relaxation after deglutition

AIM:To study the relationship between upper esophageal sphincter (UES) relaxation,peristaltic pressure and lower esophageal sphincter (LES) relaxation following deglutition in non-dysphagic subjects.METHODS:Ten non-dysphagic adult subjects had a high-resolution manometry probe passed transnasally and positioned to cover the UES,the esophageal body and the LES.Ten water swallows in each subject were analyzed for time lag between UES relaxation and LES relaxation,LES pressure at time of UES relaxation,duratio...     

Pharyngeal and upper esophageal sphincter manometry in the evaluation of dysphagia

The use of esophageal manometry seems to be increasing, but the utility of pharyngeal and upper esophageal sphincter (UES) manometry is not widely recognized. This article is intended to clarify this subject. Initially, we review the anatomy and physiology of this area. Most studies indicate that the manometry of the UES and pharynx provides useful information primarily in patients that have symptoms of oropharyngeal dysfunction. Oropharyngeal dysphagia has high morbidity, mortality, and cost. It occurs in one third of all stroke patients and is common in the chronic care setting; up to 60% of nursing home occupants have feeding difficulties, of whom a substantial portion have dysphagia. For patients with oropharyngeal dysphagia, as for those with esophageal dysphagia, barium swallow study and manometry are complimentary. Their combined use permits us to enhance the understanding of the pathophysiologic process that causes the patient's symptoms. Abnormalities have been noted in a variety of diseases, such as Parkinson's disease, oculopharyngeal muscular dystrophy, achalasia, and scleroderma. Thus, it is possible to determine the primary pathology that is causing the patient's dysphagia by analyzing the manometry results. Pharyngeal and UES manometry also has a value in evaluating patients who are candidates for myotomy or dilatation, as it can help identify patients with a prospective good outcome.     

Achalasia (The Usefulness of Manometry for Evaluation of Treatment)

Although manometry is used with increasingfrequency to evaluate the effectiveness of differenttreatments for achalasia, the criteria for a successfulmanometric response have not been well defined.Manometric responses were collected before and after 43treatments in 35 patients with achalasia in order todetermine manometric changes after different clinicaloutcomes: 15 unsuccessful outcomes and 28 successful outcomes were reported. In the latter, restingpressure of the lower esophageal sphincter decreased to12.8 mm Hg, whereas in unsuccessful outcomes this wassignificantly higher (28.2 mm Hg). A decrease of lower esophageal sphincter pressure below 17mm Hg or more than 40% of the pretreatment level wasassociated with successful outcomes. Our data suggestthat manometry is a good indicator of therapeutic effectiveness and we propose that it be usedsystematically for objective evaluation of achalasiatreatment.     

Intrasphincteric botulinum toxin injection in the treatment of chagasic achalasia.

According to the WHO, 16-18 million people in Central and South America are infected by Trypanosoma cruzi. Chagasic achalasia affects between 7.1% and 10.6% of the population. The aim of this study was to evaluate the effects of Botox injections in the clinical response and esophageal function of patients with dysphagia due to chagasic achalasia. In total, 24 symptomatic patients with chagasic achalasia were randomly chosen to receive Botulinum Toxin (BT) or saline injected by endoscopy in the lower esophageal sphincter (LES). Patients were monitored with a clinical score of dysphagia and an objective assessment (esophagograms, scintillography, manometry, and nutritional assessment) for a period of 6 months. Clinical improvement of dysphagia was statistically significant (P < 0.001) in patients receiving BT when compared with the placebo. There was no significant difference in the placebo group regarding clinical score, LES basal pressure and esophageal emptying time. Esophageal emptying time in the toxin group was significantly lower than in the placebo (P=0.04) after 90 days. There were non-significant increases in esophageal emptying of 25.36% and 17.39%, respectively, at 90 and 180 days, in the BT group (P=0.266). Gender, age, and baseline LES pressure did not influence the response to BT. Our data strongly suggests that intrasphincteric injection of BT in LES is clinically effective in the treatment of chagasic achalasia.