Proximal and distal esophageal contractions in patients with vigorous or classic esophageal Chagas' disease

BACKGROUND: Some patients with achalasia have distal esophageal contraction amplitude in the normal range, a condition called vigorous achalasia, and others have low contraction amplitude, a condition named classic achalasia. The difference in distal contraction amplitude may also be associated with a difference in proximal contraction amplitude. AIM: To study the proximal and distal esophageal contractions in patients with Chagas' disease. MATERIAL AND METHODS: We studied 28 patients with Chagas' disease, all with dysphagia and an esophageal radiologic examination with retention without dilation, and 18 controls. The patients with Chagas' disease had vigorous achalasia (distal amplitude over 34 mm Hg, n = 13) or classic achalasia (distal amplitude below 34 mm Hg, n = 15). We measured the contractions by the manometric method with continuous perfusion at 2, 7, 12 and 17 cm below the upper esophageal sphincter after five swallows of a 5 mL bolus of water. RESULTS: There was no difference in proximal amplitude of contractions between classic or vigorous achalasia, and controls. In the proximal esophagus there was also no difference in duration or area under curve of contractions. In the distal esophagus, duration and area under curve were lower in classic than vigorous disease. Failed and simultaneous contractions were more frequent in patients than controls. Simultaneous contractions were seen more frequently in classic disease, and peristaltic contractions were seen more frequently in vigorous disease. CONCLUSION: We did not find differences in proximal esophageal contractions of patients with classical or vigorous esophageal Chagas' disease, except for the higher number of simultaneous contractions seen in classic disease.     

Vigorous achalasia in Chagas'' disease

The study investigated the esophageal motility of 98 patients with Chagas' disease and 40 asymptomatic volunteers, with the objective of comparing patients with vigorous achalasia (distal amplitude contractions >/= 37 mmHg) and patients with classical achalasia (amplitude < 37 mmHg). The Chagas' disease patients had normal esophageal radiologic transit (n=60) or esophageal slow transit and retention without dilation (n=38). The manometric method with continuous perfusion was used to study esophageal motility. Comparison of classical and vigorous achalasia showed no difference in duration of contractions, lower and upper esophageal sphincter pressure, proportion of patients with dysphagia, or the number of multipeaked contractions. The number of failed contractions was higher in patients with classic achalasia than in patients with vigorous achalasia. We conclude that the distinction between classical and vigorous achalasia does not seem to be important for the classification of Chagas' disease.     

Hypocontraction of the esophagus in patients with Chagas' disease and with primary achalasia

The esophageal contraction amplitude is low in patients with Chagas' disease and patients with primary achalasia but not every swallow is followed by low contraction amplitude. We evaluated the number of low contraction amplitude in 40 normal volunteers, 99 Chagas' disease patients and 14 patients with primary achalasia. Each subject performed 10 swallows of a 5 mL bolus of water and the esophageal motility was measured at 5, 10 and 15 cm above the lower esophageal sphincter by the manometric method with continuous perfusion. The amplitude of contraction was considered to be low when its value was below 30 mm Hg. There was a hypotensive contraction when the amplitude was low or when the contraction failed. The number of hypotensive contractions was higher in patients with Chagas' disease and patients with achalasia than in healthy volunteers (P < 0.05). Patients with Chagas' disease and abnormal esophageal radiological examination but without dilation had more frequent hypotensive contraction than patients with normal esophageal radiologic examination (P < 0.01). The same results were obtained for subjects with three or more hypotensive contractions (P < 0.01). The patients with Chagas' disease and dysphagia had more hypotensive contractions than patients without dysphagia (P < 0.05). We conclude that patients with Chagas' disease and patients with primary achalasia have a higher number of hypotensive contractions following wet swallows than normal volunteers, a fact that should influence the symptomatology of the patients.     

Characterization of Esophageal Striated Muscle in Patients with Achalasia

Many studies have been conducted analyzing the manometric properties of patients with achalasia, but the striated portion of the esophagus has never been analyzed and is often overlooked. We retrospectively reviewed 120 manometric tracings (20 achalasia, 100 controls) performed between 1994 and 1997 and excluded tracings from patients with chronic cough and nutcracker esophagus. The data were assessed for age, sex, symptoms, duration of symptoms, lower esophageal sphincter pressure, gastroesophageal gradient, upper esophageal sphincter pressure, smooth muscle contraction amplitude and duration, striated muscle contraction amplitude and duration, length from upper esophageal sphincter to maximal striated muscle contraction, and esophageal length. The maximum striated muscle contraction amplitude was significantly decreased in achalasia patients with a median amplitude of 45 mm Hg (range 12–95) vs 76 mm Hg (range 30–210) in the control group (P = 0.002). Although the wave forms were similar, the maximum striated muscle contraction duration and the distance from the upper esophageal sphincter in achalasia patients was not significantly different from controls. The length of the esophagus was significantly longer in achalasia patients with a median value of 25 cm (range 21–30) vs 21 cm (range 17–26) in the control group (P < 0.001). Patients with achalasia have significantly lower maximum striated muscle contraction amplitudes and longer esophagi, but the duration of the contractions and the configuration of the wave forms are not different.     

Esophageal Motility of Patients with Chagas' Disease and Idiopathic Achalasia

Chagas' disease and idiopathic achalasia have the same neuropathic lesion—the loss of ganglion cells within the esophageal myenteric plexus—with similar clinical, radiologic, and manometric features. However, it is suggested that there are some differences between them. We studied the esophageal motility of 45 patients with Chagas' disease (seven with esophageal dilation), 27 patients with idiopathic achalasia (13 with esophageal dilation), and 40 asymptomatic volunteers. We used the manometric method with continuous perfusion. The lower esophageal sphincter (LES) pressure was measured by the rapid pull-through method. Esophageal contractions was evaluated at 5, 10, and 15 cm above the LES, after 10 swallows of a 5-ml bolus of water alternated with 10 dry swallows. LES pressure was higher in achalasia than in Chagas' disease patients and controls (P < 0.05). Amplitude of contraction was lower in all patient groups compared with controls (P < 0.01) and lower in patients with dilation compared with patients without dilation (P < 0.05). The contraction duration was longer in patients with achalasia than in patients with Chagas' disease and controls (P < 0.05). The percentage of failed contractions was higher in Chagas' disease than in achalasia and controls (P < 0.05), and the percentage of simultaneous contractions was higher in patients with idiopathic achalasia than in patients with Chagas' disease and controls (P < 0.05). The results suggest the possibility that the extent of impairment of esophageal innervation differs between Chagas' disease and idiopathic 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.     

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.     

Bethanechol increases the diagnostic yield in patients with esophageal chest pain

The diagnostic yield of routine esophageal manometrics in evaluating noncardiac chest pain is low. To determine if bethanechol stimulation would increase the diagnostic yield, we examined 87 patients with chest pain but no gastroesophageal reflux, 47 patients with gastroesophageal reflux but no chest pain, and 20 normal subjects. All subjects underwent standard esophageal manometrics before and after two doses of 50 micrograms/kg body wt bethanechol administered subcutaneously 15 min apart. Mean amplitude and duration of contractions and percentage of abnormal contractions were measured in the distal 7 cm of the esophageal body. Pathologic manometric parameters were defined as mean +/- 2 SD of values obtained in normal patients. Patients with chest pain had pathological responses for amplitude of contraction, duration of contraction, and percentage of abnormal contractions of 31%, 14%, and 22%, respectively, in the basal period. This increased to 43%, 66%, and 40%, respectively, after the first dose of bethanechol and to 53%, 85%, and 82% after the second dose of bethanechol. Chest pain was reproduced with new manometric abnormalities in 46% of patients after the first dose of bethanechol and in 77% after the second dose. Our conclusions are that: sequential bethanechol administration significantly increases the diagnostic yield of standard esophageal manometrics in the evaluation of noncardiac chest pain and duration of contraction after pharmacologic provocation with bethanechol is the best parameter to segregate patients with chest pain from normal subjects and gastroesophageal reflux patients.     

Chest pain and dysphagia in patients with prolonged peristaltic contractile duration of the esophagus

Dysphagia and chest pain are well-described symptoms in subjects with achalasia, diffuse esophageal spasm (DES), and high-amplitude peristaltic contractions, a subset of nonspecific motor disorders (NEMD). We observed a high incidence of chest pain and dysphagia in a different NEMD subgroup characterized by prolonged peristaltic contractile duration (PPCD) and normal contractile amplitude. We compared the manometric characteristics of patients with PPCD to healthy controls and compared the clinical profile of PPCD patients to that of patients with achalasia, DES, and high-amplitude peristalsis. In 2o patients with PPCD, mean contractile duration was 7.4±0.3 sec, significantly greater than healthy controls (3.7±0.1 sec) (P<0.001). PPCD was associated with an 85% incidence of chest pain and 65% incidence of dysphagia. These symptoms were similar to those observed in patients with achalasia, DES, and highamplitude peristalsis. In PPCD patients, chest pain was more frequently of long duration in comparison to achalasia and DES. PPCD was encountered more frequently than either achalasia or DES in patients referred to our laboratory. This study suggests that in symptomatic NEMD patients, abnormal duration of peristaltic contractions, rather than abnormal amplitude, may be a distinguishing manometric feature.This study was presented in part at the annual meeting of the American Gastroenterological Association, 1981, and published as an abstract inGastroenterology 80:1173, 1981.This study was supported solely by a grant from the Alton Ochsner Medical Foundation.     

Manometric diagnosis of diffuse esophageal spasm

There are no requirements concerning the amplitude of simultaneous contractions among the present criteria for the manometric diagnosis of diffuse esophageal spasm. The purpose of this investigation was to determine whether the current criteria effectively identify an appropriately homogeneous patient population. Sixty consecutive motility tracings that met the criteria for diffuse esophageal spasm were evaluated. A bimodal distribution of the highest simultaneous esophageal contraction for each patient was observed. One group's (N=29) highest simultaneous esophageal contractile amplitude was 74 mm Hg, the other's (N=31) highest simultaneous esophageal contractile amplitude was 100 mm Hg. Group 1 had significantly decreased lower esophageal sphincter pressure, lower peristaltic amplitude, more aperistalsis, fewer simultaneous contractions, and fewer complaints of chest pain. These comparisons suggest that consideration be given to the amplitude of simultaneous esophageal contractions in the manometric diagnosis of diffuse esophageal spasm.     

Manometric and Radiologic Correlations in Achalasia

Achalasia is an esophageal motor disorder distinguished by clinical, radiologic, and manometric features. To evaluate the correlation among these features, we studied 109 achalasia patients. The four most common clinical complaints, the four most commonly encountered radiologic findings, and two manometric parameters were analyzed with a correlation matrix test and a multiple regression analysis. Significant correlation existed among symptoms of dysphagia, regurgitation, and weight loss. In contrast, chest pain inversely correlated with these symptoms. Dysphagia and weight loss significantly correlated with a bird-beak deformity but not with esophageal dilatation or a sigmoid esophagus. Moreover, no significant relationship between lower esophageal sphincter pressure and esophageal dilatation or sphincter pressure and sigmoid esophagus was found. However, in those patients with a resting lower esophageal sphincter pressure greater than 45 mm Hg, a reasonable correlation among clinical, radiologic, and manometric parameters did exist. In conclusion, although in a subset of patients with markedly increased lower esophageal sphincter pressure, a good correlation between clinical, radiologic, and manometric findings exists, such a correlation cannot be established in all of the achalasia patients; esophageal dilatation or a sigmoid esophagus may not be due to a hypertensive sphincter, and their presence must not necessarily be interpreted as an indication of severity of the disease; there is an inverse correlation between chest pain and symptoms of dysphagia, regurgitation, and weight loss; and finally, achalasia and hiatal hernia may coexist in 6% of the patients.     

Stress induces alteration of esophageal pressures in healthy volunteers and non-cardiac chest pain patients

The present study was designed to explore the relationship between psychological stress and esophageal motility disorders. Nineteen non-cardiac chest pain patients (10 with the nutcracker esophagus and nine with normal baseline manometry) and 20 healthy control subjects were administered two acute stressors: intermittent bursts of white noise and difficult cognitive problems. The results indicated that the esophageal contraction amplitudes and levels of anxiety-related behaviors of non-cardiac chest pain patients and control subjects were significantly greater during the stressors than during baseline periods. All patients demonstrated significantly greater (P<0.01) increases in contraction amplitude and anxiety-related behavior during cognitive problems than during the noise stressor. The nutcracker esophagus patients showed a greater increase in contraction amplitude during the problems (23.50±9.42 mm Hg, ¯X ±SE) than control subjects (P<0.01), while the amplitude changes of chest pain patients with normal baseline manometry were not significantly greater than that of control subjects (9.00±1.91 mm Hg). The present results identified an increase in contraction amplitude as the primary esophageal response to stress. The possible interaction of esophageal contraction abnormalities, psychological stress, and the perception of chest pain is discussed.This work was supported by Public Health Services grant AM 34200-01AI from NIADDK.     

Nutcracker esophagus: GERD or an esophageal motility disorder

A retrospective study was performed to determine the frequency of acid-related esophageal dysfunction in an unselected group of patients with nutcracker esophagus (NE). Five hundred seventy-two consecutive patients who underwent esophageal manometry and pH testing at one institution were evaluated. Forty-one percent were referred for evaluation of chest pain, 39% for reflux symptoms, and 20% for dysphagia, nausea, or epigastric pain. Esophageal manometry and 24-h pH monitoring were performed using standard methods. NE was defined as amplitude of phasic contractions of ≥180 mm Hg in any manometric tracing at any level of the esophagus. Abnormal total reflux was defined as >4% of the time with the esophageal pH < 4. A positive symptom index was defined as >50% of periods with pH < 4 coinciding with symptoms of chest pain or heartburn. Esophagitis was defined as an unequivocal mucosal defect if esophagogastroduodenoscopy was performed.
Forty-five patients met criteria for NE, with acid-related abnormalities found in 77%. Forty-nine percent had abnormal acid exposure time, 16% had positive symptom indexes with normal acid exposure, and 5% had endoscopic esophagitis. An additional 7% had only an increased number of reflux episodes with normal acid exposure and symptom indexes. The prevalence of NE was significantly higher in patients referred for chest pain than for typical reflux symptoms (14.3% vs 4.5%). Seventy-four percent of the patients with NE and chest pain did not have classic reflux symptoms. Seventy-six percent of 34 evaluable subjects who had been started on acid suppression were either improved or symptom free at an average of 10.7 months of follow-up.     

Peppermint oil improves the manometric findings in diffuse esophageal spasm.

BACKGROUND: Diffuse esophageal spasm (DES) is an uncommon condition that results in simultaneous esophageal contractions. Current medical treatment of DES is frequently unsatisfactory. We hypothesized that, as a smooth muscle relaxant, peppermint oil may improve the manometric findings in DES. STUDY: Eight consecutive patients with chest pain or dysphagia and who were found to have DES were enrolled during their diagnostic esophageal manometry. An eight-channel perfusion manometry system was used. Lower esophageal sphincter pressure and contractions of the esophageal body after 10 wet swallows were assessed before and 10 minutes after the ingestion of a solution containing five drops of peppermint oil in 10 mL of water. Each swallow was assessed for duration (seconds), amplitude (mm Hg), and proportion of simultaneous and multiphasic esophageal contractions. RESULTS: Lower esophageal sphincter pressures and contractile pressures and durations in both the upper and lower esophagus were no different before and after the peppermint oil. Peppermint oil completely eliminated simultaneous esophageal contractions in all patients (p < 0.01). The number of multiphasic, spontaneous, and missed contractions also improved. Because normal esophageal contractions are characteristically uniform in appearance, variability of esophageal contractions was compared before and after treatment. The variability of amplitude improved from 33.4 +/- 36.7 to 24.9 +/- 11.0 mm Hg (p < 0.05) after the peppermint oil. The variability for duration improved from 2.02 +/- 1.80 to 1.36 +/- 0.72 seconds (p < 0.01). Two of the eight patients had chest pain that resolved after the peppermint oil. CONCLUSIONS: This data demonstrates that peppermint oil improves the manometric features of DES.     

Incomplete Lower Esophageal Sphincter Relaxation in Subjects with Peristalsis: Prevalence and Clinical Outcome

Incomplete lower esophageal sphincter relaxation is recognized in achalasia and has been reported in subjects with esophageal spasm. We reviewed 500 consecutive manometric studies from a 3-yr period to determine the prevalence of this manometric finding, its association with other motility abnormalities, and the clinical outcome of subjects without associated aperistalsis (i.e., without achalasia). We identified 60 subjects with incomplete lower sphincter relaxation, 17 of whom had at least some normal peristalsis (3.4% of the total). Mean lower sphincter residual pressure for these 17 subjects (4.5 +/- 2.8 mm Hg) was intermediate between those with achalasia (11.7 +/- 6.8 mm Hg) and those with normal relaxation (0.1 +/- 0.2 mm Hg). Both peristaltic and contraction abnormalities in the esophageal body were prevalent in the 17 subjects compared with those who had normal relaxation. Outcome with conservative medical therapy after a mean follow-up of 3.3 yr was not significantly related to presence of peristaltic or contraction abnormalities at presentation, and 71% of subjects with or without these concomitant findings had improvement or complete resolution of symptoms. Only one subject worsened and was treated with pneumatic dilation. We conclude that incomplete relaxation of the lower esophageal sphincter without aperistalsis is uncommon, symptom regression occurs with conservative therapy, and pneumatic dilation appears rarely required over a modest follow-up period.     

Manometry during Food Ingestion Aids in the Diagnosis of Diffuse Esophageal Spasm

It has been shown that food ingestion can provoke esophageal motor abnormalities in patients with otherwise normal manometry. Such motor abnormalities are usually nonspecific in character. We now report water swallow and food ingestion data on 12 patients with a history of dysphagia and/or chest pain who satisfied strict manometric diagnostic requirements for diffuse esophageal spasm. Three of these patients had normal water swallow manometry, yet, during food ingestion, showed manometric evidence of diffuse esophageal spasm. In the other nine patients, the occurrence of nonperistaltic contractions was greater, and there was a greater incidence of nonperistaltic contractions of 100 mm Hg or more after ingestion of food. We conclude that food ingestion increases the diagnostic yield of manometric testing for diffuse esophageal spasm and, not infrequently, magnifies an abnormality seen during standard water-swallow testing.     

Segmental High Amplitude Peristaltic Contractions in the Distal Esophagus

High amplitude peristaltic contractions in the distal esophagus ("nutcracker esophagus") is the most common manometric disorder seen in patients with noncardiac chest pain. Although this abnormality is found in the distal esophagus, the definition regarding its precise level in the esophagus is unclear. A careful analysis of 99 consecutive manometric tracings performed during a 1-yr period revealed that in patients with noncardiac chest pain and/or dysphagia, the location of the abnormal esophageal contractions varied: 1) in 11 patients the esophageal contractions were abnormal at 2 cm, as well as 7 cm, above the lower esophageal sphincter (LES); 2) the abnormality was limited to the 2-cm location above the LES in six patients; and 3) was confined to the 7-cm location above the LES in five patients. If the conventional criteria of averaging the distal esophageal contraction amplitudes at 2 and 7 cm above the LES were adopted, six of the 11 patients with segmental esophageal contraction abnormality would not have been identified. We suggest that, by inspection of each location of the distal esophagus separately, localized high amplitude contractions can be identified, and the distal 2 cm segment of the esophagus should be routinely included in the manometric evaluation.     

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.     

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.