Esophageal motor function

Conclusion Esophageal motility studies provide an innocuous and relatively uncomplicated method for evaluating esophageal function in both health and disease. In addition to their investigative potential, intraluminal pressure tracings are of significant help in clinical medicine when used to supplement data accruing from the more conventional technics of roentgenologic and endoscopic evaluation. They are particularly useful in evaluating loss of esophageal motor function such as occurs in scleroderma, in detecting early and subtle cases of achalasia, and in documenting disordered peristalsis in individuals with chest pain and other symptoms secondary to esophageal spasm.Supported in part by Research Grant A-4097 from the National Institute of Arthritis and Metabolic Diseases, National Institutes of Health, Bethesda, Md.Presented at a postgraduate course, Current Therapy in Gastroenterology (Nov. 16–17, 1963), sponsored by Louisiana State University School of Medicine, New Orleans. La.     

Esophageal function in humans

We determined the effect of increased bolus consistency on esophageal motor function in 11 healthy volunteer subjects. Further, we sought to define the esophageal response to boluses with a wide range of temperatures in nine healthy volunteers. Intraluminal pressure events were measured with an infused catheter system, and lower esophageal sphincter pressure was monitored continuously with a Dent sleeve. Boluses (10 swallows each) consisting of 5 ml of a solid suspension (yogurt), 5 cm³ of a soft solid (gelatin), and 5 ml of water were given in a randomized order. In a separate study, boluses with temperatures of 1° C, 5° C, 10° C, 15° C, room temperature, 30° C, 40° C, 50° C, and 60° C were given in a randomized fashion. Compared to the water bolus, the solid boluses elicited a significant (P<0.05) reduction in peristaltic wave velocity, which was accompanied by significant (P< 0.05) increments in the durations of wave contraction and lower esophageal sphincter relaxation. The magnitude of the response elicited by the solid boluses was comparable to that noted with boluses of high viscosity suggesting that the esophagus responds to increments in bolus viscosity and consistency in a similar fashion. Alterations in bolus temperature did not elicit any significant changes in the parameters of esophageal peristalsis. It is concluded that bolus temperature does not have a significant role in the modulation of human esophageal peristalsis except under conditions that cause a change in esophageal wall temperature.     

Esophageal function in chronic alcoholics

We determined whether there are abnormalities in esophageal motility or acid clearance in chronic alcoholics since alterations in these parameters have been implicated in the pathogenesis of esophagitis after chronic ingestion of ethanol. In addition to esophageal manometry, we also performed acid-clearance studies and examined salivary output, acid-neutralizing capacity, and bicarbonate concentration. We found an increased lower esophageal sphincter pressure which reverted to normal after withdrawal from ethanol. Except for a significantly larger number of tertiary contractions, no other abnormality of esophageal motility was found. Salivary flow, acid-neutralizing capacity, and bicarbonate concentration were not significantly different from that in control subjects. However, in contrast to findings in controls, there was no correlation between salivary bicarbonate concentration and acid-neutralizing capacity in the alcoholics. Our results indicate that chronic ethanol ingestion alters some aspects of esophageal function and salivary composition but that these alterations are unlikely to explain the increased risk of esophagitis in alcoholics.     

Esophageal function in duodenal ulcer

We examined 21 patients with duodenal ulcer confirmed by endoscopy for disturbances of esophageal function, using manometric techniques and long-term pH measurement. Pathological manometric findings, largely of a mild degree, were obtained in 48 per cent of the patients examined, and a pathological gastro-esophageal reflux was found in 81 per cent, with only 33 per cent suffering from reflux esophagitis as confirmed by endoscopy and/or histological examination. Although duodenal ulcer and disturbed esophageal function often appear simultaneously, a causal connection seems unlikely. Alcohol and nicotine stimulate reflux, with the degree of severity depending on the amount.     

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.     

Esophageal function testing with combined multichannel intraluminal impedance and manometry: multicenter study in healthy volunteers.

BACKGROUND & AIMS: Combined multichannel intraluminal impedance and manometry (MII-EM) assesses esophageal function by simultaneous measurement of both pressure and bolus transit. Normative data for this method have not been published. The aim of this study was to establish normative data for combined MII-EM and to correlate liquid and viscous bolus transit by impedance with esophageal contractions by manometry. METHODS: Forty-three normal volunteers recruited from 4 centers (15 women, 28 men; age range, 21-72 years) underwent combined MII-EM with a catheter containing 4 impedance-measuring segments and 4 solid-state pressure transducers. Each center recruited and analyzed subjects independently, according to pre-established criteria. Each subject received 20 x 5 mL swallows, 10 liquid and 10 viscous material. Tracings were analyzed manually for bolus presence time, bolus head advance time, segmental transit times, total bolus transit time, contraction amplitude, duration, and onset velocity. RESULTS: Ninety-seven and four-tenths percent of manometrically normal liquid and 96.1% of manometrically normal viscous swallows had complete bolus transit by impedance. Almost half (47.2%) of manometrically ineffective liquid and 34.7% of ineffective viscous swallows had complete bolus transit, whereas 91.7% of manometric simultaneous liquid swallows and 54.5% of simultaneous viscous swallows had complete bolus transit. More than 93% of normal individuals had at least 80% complete liquid or at least 70% complete viscous bolus transit. CONCLUSIONS: This study establishes normative data for combined MII-EM. Combined MII-EM may be a more sensitive tool in assessing esophageal function compared to standard manometry because impedance can distinguish different bolus transit patterns. Studies in patients with manometrically defined esophageal motility abnormalities should help clarify the functional importance of manometric ineffective and simultaneous swallows.     

Esophageal testing: What we have so far

Gastroesophageal reflux disease(GERD) is a common disorder of the gastrointestinal tract. In the last few decades, new technologies have evolved and have been applied to the functional study of the esophagus, allowing for the improvement of our knowledge of the pathophysiology of GERD. High-resolution manometry(HRM) permits greater understanding of the function of the esophagogastric junction and the risks associated with hiatal hernia. Moreover, HRM has been found to be more reproducible and sensitive than conventional water-perfused manometry to detect the presence of transient lower esophageal sphincter relaxation. Esophageal 24-h p H-metry with or without combined impedance is usually performed in patients with negative endoscopy and reflux symptoms who have a poor response to anti-reflux medical therapy to assess esophageal acid exposure and symptom-reflux correlations. In particular, esophageal 24-h impedance and p H monitoring can detect acid and non-acid reflux events. Endo FLIP is a recent technique poorly applied in clinical practice, although it provides a large amount of information about the esophagogastric junction. In the coming years, laryngopharyngeal symptoms could be evaluated with up and coming non-invasive or minimally invasive techniques, such as pepsin detection in saliva or pharyngeal p H-metry. Future studies are required of these techniques to evaluate their diagnostic accuracy and usefulness, although the available data are promising.     

Esophageal function in chronic alcohol abuse

1. In our patients the chronic overindulgence in alcohol led to an increased appearance of a pathological gastrooesophageal reflux. Thereby the group with normal liver findings or steatosis showed a slightly pathological, the group with alcoholic liver cirrhosis a severe pathological reflux behaviour. 2. The manometric findings in form of a decreased resting pressure in the inferior oesophageal sphincter, a slightly increased duration as well as of a decreased speed of the contraction wave were certainly insignificant in functional respect. They could not explain the pathological reflux behaviour. 3. The chronic abuse of alcohol did not lead to erosive changes of the mucous membrane in the distal oesophagus.     

Esophageal motor function in Graves' disease

Esophageal motor function was studied in 10 patients with untreated Graves' disease and 15 healthy volunteers who served as controls. A noncompliant recording system with a triple-lumen assembly was used. Resting upper- and lower-esophageal-sphincter pressures, amplitude, duration, and velocity of peristaltic contractions in the body of the esophagus, and the number of repetitive and simultaneous contractions were measured. There was no significant difference in peristaltic amplitude and duration between the controls and the patients with Graves' disease. However, there was a significant increase in velocity of contractions in Graves' disease as compared with controls. On restudy of 5 patients who became euthyroid after treatment with¹³¹I, all the measured parameters were unchanged except for velcity of the peristaltic contractions. The value for this measurement decreased essentially to the same as that found in the control subjects. It is conclueded that: (1) thyrotoxicosis increases the propagation velocity of esophageal contraction, and (2) thyroid hormones may play a physiologic role in the control of esophageal motor function.     

Esophageal function in progressive systemic sclerosis.

A prospective study was performed in 13 consecutive patients with systemic progressive sclerosis (PSS). For the diagnosis of impaired esophageal peristalsis cineradiography and manometry are equally useful. Esophageal suction biopsy allows the diagnosis of esophagitis but not of scleroderma. Mild to severe esophageal involvement was observed in 12 patients. In only one patient the esophagus was virtually normal. Dysfunction of the esophageal body may occur early in the course of the disease while incompetence of the lower esophageal sphincter is observed on an average after 7 to 8 years. Both impairment of peristalsis and pressure of the lower esophageal sphincter may lead to delayed esophageal clearance. Relaxation of LES is normal even in the absence of primary peristalsis. Extensive esophageal damage including severe gastroesophageal reflux may be present in the absence of esophageal symptoms.     

Esophageal submucosal glands: structure and function

A three-tiered defense system exists in the esophagus, which serves a dual purpose of both limiting the degree of gastroesophageal reflux and minimizing the risk of acid-induced mucosal injury. The antireflux barrier, composed of both the lower esophageal sphincter and the diaphragmatic pinchcock, is the first line of defense and serves to limit the frequency and volume of refluxed gastric contents. When the antireflux barrier fails, the second line of defense, esophageal clearance, comes into play and serves to limit the duration of contact between gastric contents and the esophageal epithelium. Mechanisms involved in esophageal clearance include gravity and esophageal peristalsis, which remove volume, and secretions from swallowed saliva and esophageal submucosal glands, which neutralize acid. The third line of defense, tissue resistance, is necessary when acid contact time is prolonged such as when esophageal clearance is either ineffective or not operative (e.g., during sleep). Most studies that have examined esophageal clearance mechanisms have focused on the roles of esophageal peristalsis and salivary secretion, but the role of submucosal gland secretions is less well understood. This article reviews the structure and function of esophageal submucosal glands and discusses the potential role of their secretory products in esophageal clearance and tissue resistance.