无效食管动力对伴呼吸道症状胃食管反流病发病机制及临床意义的研究

目的 观察伴有呼吸道症状的胃食管反流病(GERD)患者食管动力异常的类型及发生率,探讨无效食管动力(IEM)在其发病机制中的作用及临床意义.方法 应用多功能胃肠动力仪对首都医科大学附属北京朝阳医院2005年1月至2007年1月收治的34例伴有哮喘、慢性咳嗽和咽喉部不适等呼吸道症状的GERD患者进行食管压力测定及24h食管动态pH监测,测定下食管括约肌(LES)压力、食管体部蠕动波幅、蠕动时限及蠕动速度,计算pH＜4的时间百分比,卧位及立位pH＜4的时间百分比,平均食管酸清除时间(pH＜4的时间/酸反流次数),算出DeMeester评分.结果 伴有呼吸道症状GERD组LES压力及食管近端、远端蠕动波幅与典型反流症状GERD组及正常对照组比差异无统计学意义;伴有呼吸道症状CERD组的食管动力异常类型主要表现为IEM,IEM发生率为41.2%,明显高于典型反流症状GERD组(18.5%)及正常对照组(0);在伴有呼吸道症状GERD患者中,存在IEM组患者食管pH＜4的总时间百分比及立、卧位食管pH＜4的时间百分比均明显高于食管动力正常组;IEM组患者卧位食管酸清除时间(pH＜4的时间/酸反流次数)较食管动力正常组明显延长.结论 在伴有呼吸道症状GERD患者中,IEM是其最常见的动力异常类型;IEM与食管内酸暴露总时间及立、卧位时间,卧位食管酸清除时间均密切相关,因此,IEM在伴有呼吸道症状GERD患者的发病机制中起重要作用.     

Esophageal resection for non-specific esophageal motility disorder

A 47-year-old patient presented with a history of dysphagia for solid food for almost 10 years and weight loss of more than 50 kg. Non-resecting surgical as well as endoscopic procedures (laparoscopic cardiomyotomy with secondary antireflux operations, balloon dilation, Botulinum-toxin injection) were without success. A barium esophagogram showed a confinement of the distal esophagus with a filiform passage of the contrast medium and undigested food in the prestenotic dilated esophageal corpus. Manometry displayed a hypertensive lower esophageal sphincter with a resting pressure of 43.8 mmHg - although completely relaxing. The tubular esophagus was aperistaltic with 100 % simultaneous and repetitive contractions. As all attempts of previous therapy had failed, a transhiatal esophagectomy with gastric pull-up and cervical esophagogastrostomy ensued. Neuropathological examination of the esophagus showed that degeneration of the myenteric plexus was not severely involved, whereas inflammatory and fibrotic changes were obvious. Esophageal resection provided the only chance of a long-term benefit for our patient with relief of dysphagia.     

Subtotal esophageal resection in motility disorders of the esophagus

BACKGROUND: Esophagectomy for motility disorders is performed infrequently. It is indicated after failed medical therapy, pneumatic dilation, non-resecting surgical and redo procedures. Patient selection in this group is challenging and the operative risk has to be weighted carefully against the poor quality of life with persistent or recurrent dysphagia. PATIENTS AND METHODS: Between September 1985 and April 2004, subtotal esophageal resections for advanced esophageal motility disorders of the esophagus not responding to previous therapy were carried out in 8 patients (6 females, 2 males). The median age of these patients was 59.5 (43-78) years. Six patients had a megaesophagus secondary to achalasia; 1 patient had a non-specific esophageal motility disorder with a stenosis of the distal esophagus, and a further patient displayed a recurrent huge epiphrenic diverticulum, which occurred in the context of a collagen disease. A transhiatal esophageal resection was performed in 6, a transthoracic procedure in 2 patients. RESULTS: Outcome assessment was done after a follow-up of 43.5 (3-92) months in median. The resection and reconstruction of the esophagus in advanced and decompensated esophageal motility disorders led to a marked functional improvement with disappearance of dysphagia. Despite previous therapeutic failures, alimentation could be restored in all patients. CONCLUSION: Favourable long-term results with significant improvement of symptoms can be achieved by esophageal resection even if endoscopic therapy or non-resecting surgical measures are unsuccessful. Transhiatal esophagectomy with gastric pull-up should be the preferred procedure and can be performed with low morbidity.     

Nutcracker esophagus: clinical evaluation of 97 patients]

Nutcracker esophagus is a manometric abnormality classified as a primary esophageal motor disorder, characterized by high pressure peristaltic waves in distal esophagus and related to non-cardiac chest pain. Further studies observed nutcracker esophagus in dysphagic patients and recently in gastroesophageal reflux disease. However, there is controversy about the meaning of this motor disorder and there are few clinical studies involving a great number of patients. A retrospective study involving 97 patients with manometric criteria of nutcracker esophagus according a control group was undertaken. Most of the patients were female (63.9%), mean age 54.3 years. The chief complaint was chest pain, followed by dysphagia and heartburn. Clinical findings, as a whole were chest pain (53.6%), dysphagia (52.6%), heartburn (52.6%), regurgitation (21.6%), otorhinolaryngologic symptoms (15.4%), dyspepsia (15.4%) and odynophagia (4.1%). The majority of patients had multiple symptoms, however in 28% just a single one was observed. Endoscopic examination observed erosive esophagitis in 8% of the patients, while signs of esophageal motor disorders were showed by esophagogram in 16.4%. Esophageal pH recordings indicated abnormal gastroesophageal reflux in 41.2% of the cases reported. We concluded that there are other symptoms in nutcracker esophagus patients besides chest pain and dysphagia and the use of esophageal pH recordings is helpful to establish its association with acid reflux and guide the appropriate therapy.     

Cardiospasm,a generalized disorder of esophageal motility

In four patients with cardiospasm the esophageal motility as studied by balloonkymograph records presented the following deviations from normal: decreased tone, lack of propulsion and irregular phasic activity of variable intensity. These abnormalities involved the lower two-thirds of the esophagus.     

The ringed esophagus: histological features of GERD

OBJECTIVE: The "ringed" or "corrugated" esophagus is a cause of chronic dysphagia and recurrent food impactions in young men. It was previously believed to be a congenital condition, but recent case series have documented histological esophagitis in these patients. We have treated 19 patients with a ringed esophagus and are impressed that this represents an acquired condition with gastroesophageal reflux disease (GERD) as its etiology. Our goals are to present the largest case series to date of ringed esophagus, discuss the evidence for GERD, and suggest a strategy for its diagnosis and management. METHODS: The charts of 19 patients with a ringed esophagus were reviewed. A single pathologist interpreted all available esophageal biopsy specimens and graded them for the presence of GERD-related abnormalities. Phone interviews were conducted to assess response to therapy and confirm historical features obtained from medical records. RESULTS: The typical patient is a young man (median age 35, M:F 17:2) with long-standing dysphagia and multiple food impactions. Endoscopy revealed multiple concentric rings that persisted despite air insufflation and caused significant stenosis. Of the 11 patients with available histology, all had basal cell hyperplasia, papillomatosis, and an increased number of intraepithelial eosinophils. Other clinical features of GERD such as heartburn, endoscopic esophagitis, and hiatal hernia were often absent. Response to dilation and acid suppression was good. CONCLUSIONS: The uniform presence of histological esophagitis with intraepithelial eosinophils, basal cell hyperplasia, and papillary lengthening strongly implicates GERD in the pathogenesis of the adult ringed esophagus. In addition to a series of gradual esophageal dilations, we suggest using a proton pump inhibitor to provide acid suppression.     

Exercise-provoked esophageal motility disorder in patients with recurrent chest pain

AIM:To investigate the relationship between exerciseprovoked esophageal motility disorders and the prognosis for patients with chest pain.METHODS:The study involved 63 subjects with recurrent angina-like chest pain non-responsive to empirical therapy with proton pump inhibitor(PPI).In all,a coronary artery angiography,panendoscopy,24-h esophageal pH-metry and manometry,as well as a treadmill stress test with simultaneous esophageal pH-metry and manometry monitoring,were performed.Thirtyfive subjects had no ...     

Vagal afferent dysfunction in naturally occurring canine esophageal motility disorder

Few studies have examined the vagal afferent innervation of the esophagus in naturally occurring esophageal motility disorders. The present study assessed the integrity of distension-sensitive vagal afferents innervating the esophagus in naturally occurring canine megaesophagus. In the dog, esophageal distension induces reflex inhibition of crural diaphragm electromyographic activity that is mediated by vagal afferents innervating esophageal mechanoreceptors. This reflex was measured during stepwise esophageal distension in six dogs with congenital idiopathic megaesophagus, two dogs with megaesophagus secondary to esophageal striated muscle disease, and eight matched controls. In contrast to control dogs, inhibition of crural electromyographic activity was not observed in megaesophagus dogs with esophageal distension within the control volume range. With esophageal distensions far in excess of the control volume range, inhibition of crural electromyographic activity was not observed in five of six dogs with congenital idiopathic megaeosphagus, while crural inhibition was observed in the two dogs with secondary megaesophagus. These findings indicate that a defect is present in the vagal afferent innervation to the esophagus in a majority of dogs with congenital idiopathic megaesophagus.The present study was funded by a Clive and Vera Ramaciotti Foundations research grant. Christopher T. Holland was the recipient of a Jean Walker Trust Fellowship from the University of Sydney.     

The esophageal motility disorder of polymyositis. A prospective study

A prospective study of 12 patients with the diagnosis of polymyositis or dermatomyosiois was initiated to determine the characteristics of the esophageal manometric patterns in this group. All of the patients were women between the ages of 30 to 80 years and met three of four of Bohan's diagnostic criteria for these diseases. The patients' conditions were classified according to Rose and Walton's muscle weakness index. Almost two thirds of our patients exhibited distal esophageal dysfunction by manometry. Based on our roentgenographic and manometric data, we conclude that in addition to the well-described abnormalities in the striated portion of the esophagus, smooth-muscle dysfunction occurs with a high frequency in this patient population.     

Functional chest pain: esophageal or overlapping functional disorder

BACKGROUND: Whether patients with functional chest pain have an esophageal or overlapping functional disorder of the gut is unclear. We investigated the prevalence of functional gastrointestinal disorders in patients with functional chest pain. METHODS: One hundred patients with functional chest pain and normal cardiac, endoscopic, and manometric studies were evaluated for esophageal hypersensitivity with a balloon distension test. Subsequently, a modified Rome II functional bowel disorder questionnaire was mailed to these subjects. Prevalence of irritable bowel syndrome (IBS) and other functional disorder were determined using the Rome II criteria. In addition, we assessed the prevalence of chest pain in 81 patients with functional constipation. RESULTS: There were 69 responders (54 women); 2 were excluded. Fifty-five patients (82%) fulfilled criteria for other functional disorders besides chest pain. Although there was an overlap, IBS (27%) and abdominal bloating (22%) were most common; dyspepsia (7%), dysphagia (7%), nonspecific bowel disorder (7%), constipation (4%), abdominal pain (3%), and diarrhea (1%) were less common. Among responders, 52 (78%) had esophageal hypersensitivity and 15 (22%) had normosensitivity, with similar prevalence of functional disorders. Thirty-two (39%) of the subjects with functional constipation reported chest pain occasionally, and 5 (6%) frequently. CONCLUSIONS: Approximately 80% of patients with functional chest pain exhibit features of other functional disorders including IBS suggesting an overlap. This association is independent of esophageal hypersensitivity. Recognition of this overlap may facilitate better management of these patients.     

Esophageal motility disorders (Distal esophageal spasm, nutcracker esophagus, and hypertensive lower esophageal sphincter): Modern management

Opinion statement The group of hypercontractile esophageal motility disorders includes distal esophageal spasm (DES), nutcracker esophagus (NE), and hypertensive lower esophageal sphincter (LES). The clinical relevance of these abnormalities identified during esophageal manometry is debated, and their management can be challenging. Hypercontractile esophageal motility abnormalities are defined through specific manometric criteria. Current pathophysiologic concepts for these abnormalities include defects in the nitronergic neural pathways and imbalances between the cholinergic and nitronergic pathway. Proposed treatments for NE, DES, and hypertensive LES include proton-pump inhibitors, nitrates, calcium channel blockers, phosphodiasterase inhibitors, and tricyclic antidepressants or serotonin reuptake inhibitors. Small case series reported benefits after botulinum toxin injections, dilatations, and myotomies. The optional management of esophageal spasm, NE, and hypertensive LES is still debated. Treatment recommendations are based on controlled studies with small numbers of patients or on case series. Medical treatment, including acid suppression, smooth muscle relaxants, and visceral analgesics, should be tried first. In nonresponding patients, botulinum toxin injections or balloon dilatations can be tried. Pneumatic dilatations or myotomies should be regarded as last-option treatments for nonresponding patients.