Analysis of Spontaneous Gastroesophageal Reflux and Esophageal Acid Clearance in Patients with Reflux Esophagitis

To characterize gastroesophageal reflux episodes and esophageal acid clearance in patients with reflux esophagitis, we obtained 12-hour overnight esophageal pH and manometry recordings in 20 patients with macroscopic reflux esophagitis and in 15 healthy volunteers. Compared to the control subjects, the patients had less pressure in the lower esophageal sphincter (LES) and higher rates of reflux, acid clearance time, and esophageal acid exposure. However, many patients had normal values for one or more of these variables. Transient LES relaxation accounted for 96% of reflux episodes in control subjects and 60% in patients. The remaining 40% of reflux episodes in patients occurred as stress or free reflux. In the control subjects, only one reflux episode occurred during estimated sleep. Of 22 reflux episodes during estimated sleep in patients, most were associated with low basal LES pressure. During esophageal acid clearance, the major esophageal motor event was swallow-induced peristalsis rather than secondary peristalsis. We conclude that esophagitis patients have lower LES pressures, more reflux episodes, impaired esophageal acid clearance, and more esophageal exposure to acid than control subjects. Individual patients, however, exhibit heterogeneous abnormalities with respect to these variables. Transient LES relaxation is the major mechanism of gastroesophageal reflux in both patients and healthy subjects.     

Analysis of Spontaneous Gastroesophageal Reflux and Esophageal Acid Clearance in Patients with Reflux Esophagitis

To characterize gastroesophageal reflux episodes and esophageal acid clearance in patients with reflux esophagitis, we obtained 12-hour overnight esophageal pH and manometry recordings in 20 patients with macroscopic reflux esophagitis and in 15 healthy volunteers. Compared to the control subjects, the patients had less pressure in the lower esophageal sphincter (LES) and higher rates of reflux, acid clearance time, and esophageal acid exposure. However, many patients had normal values for one or more of these variables. Transient LES relaxation accounted for 96% of reflux episodes in control subjects and 60% in patients. The remaining 40% of reflux episodes in patients occurred as stress or free reflux. In the control subjects, only one reflux episode occurred during estimated sleep. Of 22 reflux episodes during estimated sleep in patients, most were associated with low basal LES pressure. During esophageal acid clearance, the major esophageal motor event was swallow-induced peristalsis rather than secondary peristalsis. We conclude that esophagitis patients have lower LES pressures, more reflux episodes, impaired esophageal acid clearance, and more esophageal exposure to acid than control subjects. Individual patients, however, exhibit heterogeneous abnormalities with respect to these variables. Transient LES relaxation is the major mechanism of gastroesophageal reflux in both patients and healthy subjects.     

Reproducibility of esophageal high‐resolution manometry

Background Esophageal high‐resolution manometry (HRM) is a novel method for esophageal function testing that has prompted the development of new parameters for quantitative analysis of esophageal function. Until now, the reproducibility of these parameters has not been investigated. Methods Twenty healthy volunteers underwent HRM on two separate days. Standard HRM parameters were measured. In addition, in conventional (virtual) line tracings, lower esophageal sphincter (LES) resting pressure, relaxation pressure, and relative relaxation pressure were measured. Firstly, for each variable, the mean percentage of covariation (100 × SD/mean: %COV) was derived as a measure of inter‐ and intra‐individual variation. Secondly, Kendall’s coefficients of concordance (W values) were calculated. Thirdly, Bland–Altman plots were used to express concordance graphically. Key Results Statistically significant concordance values were found for upper esophageal sphincter (UES) pressure (W = 0.90, P = 0.02), transition zone length (W = 0.92, P = 0.01), LES length (W = 0.81, P = 0.04), LES pressure (W = 0.75, P = 0.05), LES relaxation pressure (W = 0.75, P = 0.03), relative LES relaxation pressure (W = 0.78, P = 0.05), gastric pressure (W = 0.81, P = 0.04), and contraction amplitude 5 cm above the LES (W = 0.86, P = 0.03). In conventional setting, only LES resting pressure (W = 0.835, P = 0.03) proved significant. In HRM tracings, concordance values for contraction wave parameters, and in conventional line tracings, LES relaxation pressure and relative relaxation pressure did not reach levels of statistical significance. Conclusions & Inferences Esophageal HRM yields reproducible results. Parameters that represent anatomic structures show better reproducibility than contraction wave parameters. The reproducibility of LES resting and relaxation pressure assessed with HRM is better than with conventional manometry and further supports the clinical use of HRM.     

Effect of Cold Stress on Esophageal Peristalsis in Healthy Humans During the Postprandial Period

The effect of cold stress on esophageal peristalsis was assessed in nine healthy subjects after ingestion of a 700-kcal meal. All subjects underwent a control stimulus (immersion of the nondominant hand in water at 37° C) and a stressful stimulus (immersion in water at 4°C) on separate days and in randomized order. When compared to the control stimulus, stress increased blood pressure (p < 0.01) and pulse rate (p < 0.05). It also determined an increase of 9 ± 3 mm Hg (mean ± SEM) in amplitude (p < 0.05), of 0.2 ± 0.1 seconds in duration (p < 0.1), and of 0.3 ± 0.1 cm per second in propagation velocity (p < 0.05) of peristalsis, as assessed after water swallows. Percentage of failed peristalsis was unaffected by stress. We conclude that cold stress exerts only minor effects on variables of the peristaltic wave and does not induce dysmotility in the esophagus of healthy subjects during the postprandial period.     

Long-Term pH and Manometric Evaluation of the Distal Esophagus After Endoscopic Sclerotherapy of Esophageal Varices

Endoscopic sclerotherapy (ES) of esophageal varices is widely used as an effective treatment for recurrent esophageal bleeding. Retrosternal pain, dysphagia, and esophageal strictures are frequently reported after ES. Alterations in esophageal motility have also been described. In this study, the motility pattern of the esophagus and lower esophageal sphincter (LES) competence were evaluated in a group of 11 patients with portal hypertension and esophageal varices treated by means of ES. Esophageal manometry and pH monitoring of the distal esophagus were carried out before starting ES of esophageal varices, and 2 months and 6 months later. The results of the study demonstrated that ES does not affect LES competence or reduce the amplitude of esophageal motor contractions, but does induce esophageal motility changes consisting of a reduction of esophageal coordination, an increase in the percentage of contraction abnormalities (multipeaked contractions), an increase of the average contraction duration, and an alteration in LES relaxation after swallowing. These motor abnormalities are evident at both early and late control evaluations. However, since only few patients, in the authors' experience, develop esophageal symptoms after ES, these findings represent a minor side effect of the procedure, without clinical implications.     

Dysphagia in olivopontocerebellar atrophy

Clinical, radiological and manometric studies on thirteen patients with olivopontocerebellar atrophy were performed in order to investigate the characteristics of dysphagia. As a clinical study, a detailed history of dysphagia was taken to distinguish two types of dysphagia, that is to say swallowing disturbance in a narrow sense and passage disturbance. In the radiological study, each phase of swallowing was observed by X-rays with contrast medium (Dionosil). In the manometric study, intraluminal resting pressure in the esophagus and pressure of esophageal contraction after swallowing were measured. The results were as follows: Eight patients had the sensation of swallowing disturbance in a narrow sense and five patients has the feeling of passage disturbance. In X-ray studies four patients had pooling in piriformis sinus and six patients had slight dilatation of the lower esophagus. In manometric studies, six patients had low intraluminal resting pressure of the upper esophageal sphincter, but almost all patients had normal intraluminal resting pressure throughout the esophagus and in the lower esophageal sphincter. Two patients, who had suffered for five and seven years, had loss of both negative and positive wave in the upper esophageal sphincter after swallowing. Another three patients, who had suffered for two, six and seven years, respectively had loss of negative wave in the upper esophageal sphincter after swallowing. Regarding peristaltic wave, eight patients had low amplitude of the wave. Two patients, who had suffered for five and six years, had diphasic shape of the wave. One patient, who had suffered for nine years, had synchronous wave. Nine patients had loss of negative wave in the lower esophageal sphincter.(ABSTRACT TRUNCATED AT 250 WORDS)     

Neural Contribution to Interdigestive Lower Esophageal Sphincter Pressure Phenomena in the Conscious Opossum

The genesis of lower esophageal sphincter (LES) pressure in anesthetized opossums is a myogenic phenomenon without excitatory neural input. The mechanism responsible for generating phasic LES pressure phenomena in unanesthetized opossums, however, is not established. In this study, we evaluated the effects of potential pharmacological antagonists on LES pressure phenomena in unanesthetized opossums. We also compared LES responses to pharmacological excitatory agonists in anesthetized and unanesthetized animals. In awake animals the LES exhibited substantial tone as well as characteristic phasic activity. The tonic, or basal, LES pressure did not change during cycling of the migratory motor complex (MMC). However, atropine, 4-diphenylacetoxy-N-methylpiperidine methiodide, and hexamethonium abolished the phasic, MMC-related LES contractions while having no effect on basal pressure. Pirenzepine, prazosin, propranolol, pyrdamine, naloxone, and haloperidol did not affect either phasic or tonic LES pressure phenomena. Anesthesia substantially reduced the excitatory LES response to motilin but not to bethanechol, cholecystokinin-octapeptide, pentagastrin, or phenylephrine. The results suggest that phasic LES contractions related to the MMC cycle are mediated by postganglionic cholinergic nerves with nicotinic ganglionic transmission. Basal LES tone, however, is maintained by a myogenic phenomenon. Anesthesia reduces excitatory LES responses induced by motilin, which acts via excitatory nerves, but has no effect on excitatory responses induced by agents that act mainly or exclusively on LES smooth muscle.     

Short-term electrical stimulation of the lower esophageal sphincter increases sphincter pressure in patients with gastroesophageal reflux disease

Background Electrical stimulation (ES) of the lower esophageal sphincter (LES) increases resting LES pressure (LESP) in animal models. Our aims were to evaluate the safety of such stimulation in humans, and test the hypothesis that ES increases resting LESP in patients with gastroesophageal reflux disease (GERD). Methods A total of 10 subjects (nine female patients, mean age 52.6 years), with symptoms of GERD responsive to PPIs, low resting LES pressure, and abnormal 24‐h intraesophageal pH test were enrolled. Those with hiatal hernia >2 cm and/or esophagitis >Los Angeles Grade B were excluded. Bipolar stitch electrodes were placed longitudinally in the LES during an elective laparoscopic cholecystectomy, secured by a clip and exteriorized through the abdominal wall. Following recovery, an external pulse generator delivered two types of stimulation for periods of 30 min: (i) low energy stimulation; pulse width of 200 μs, frequency of 20 Hz and current of 5–15 mA (current was increased up to 15 mA if LESP was less than 15 mmHg), and (ii) high energy stimulation; pulse width of 375 ms, frequency of 6 cpm, and current 5 mA. Resting LESP, amplitude of esophageal contractions and residual LESP in response to swallows were assessed before and after stimulation. Symptoms of chest pain, abdominal pain, and dysphagia were recorded before, during, and after stimulation and 7‐days after stimulation. Continuous cardiac monitoring was performed during and after stimulation. Key Results All patients were successfully implanted nine subjects received high frequency, low energy, and four subjects received low frequency, high energy stimulation. Both types of stimulation significantly increased resting LESP: from 8.6 mmHg (95% CI 4.1–13.1) to 16.6 mmHg (95% CI 10.8–19.2), P < 0.001 with low energy stimulation and from 9.2 mmHg (95% CI 2.0–16.3) to 16.5 mmHg (95% CI 2.7–30.1), P = 0.03 with high energy stimulation. Neither type of stimulation affected the amplitude of esophageal peristalsis or residual LESP. No subject complained of dysphagia. One subject had retrosternal discomfort with stimulation at15 mA that was not experienced with stimulation at 13 mA. There were no adverse events or any cardiac rhythm abnormalities with either type of stimulation. Conclusions & Inferences Short‐term stimulation of the LES in patients with GERD significantly increases resting LESP without affecting esophageal peristalsis or LES relaxation. Electrical stimulation of the LES may offer a novel therapy for patients with GERD.     

Inspiration closure reflex: The effect of respiration on intrinsic sphincters

Introduction: The functions of the lower esophageal sphincter (LES) and internal urethral sphincter (IUS) have not been reported during voluntary and involuntary respiratory maneuvers. Methods: In this study we performed a prospective barium videofluoroscopy study (BSV) of the LES on 4 healthy adult men during voluntary cough (VC), laryngeal expiration reflex (LER), breath‐hold maneuvers, and normal inspiration. One subject had fiber‐optic pressure catheters placed in the LES and IUS, and electromyographic recording of the right T7–8 intercostals during respiration. Results: BSV showed closure and relaxation of the LES corresponding to the inspiration and expiration of VC. The LES was patent during the LER. There was closure of the LES during the deep inspiration/breath‐hold event. Pressure catheters in the LES and IUS showed increased pressure during inspiration. Conclusions: These observations suggest that pulmonary inspiration afferents elicit a patterned reflex motor response in the LES and IUS, referred to as the inspiration closure reflex (ICR). Muscle Nerve 47:424‐431, 2013     

Ambulatory Esophageal Manometry: Comparison of Expert and Computer-Aided Analyses

This study describes the validation of a computer program for automated analysis of ambulatory 24-hour two-channel esophageal manometry. The program's ability to characterize contractions and to calculate their duration and amplitude was validated against manual evaluation. An independent reference standard for the identification and classification of contractions was established by submitting representative recordings to a group of 14 experts in upper gastrointestinal motility; the program's ability to identify and classify contractions was then validated against the majority verdict of the experts. The results show an excellent correlation between the manual and computer evaluations of both contraction amplitude (p = 0.9957) and duration (p = 0.8241). The concordance between the experts was also excellent: 97 (72%) of 135 pressure events were classified identically by 12 or more experts. Computer-aided manometry analysis (CAMA) had a sensitivity of 98.9% and a specificity of 93.5% for the detection of contractions, with sensitivities of 94.7% and 84.4% and specificities of 94.9% and 94.2% for the classification of propagated and nonpropagated contractions, respectively.     

Ambulatory high-resolution manometry, lower esophageal sphincter lift and transient lower esophageal sphincter relaxation

Background Lower esophageal sphincter (LES) lift seen on high‐resolution manometry (HRM) is a possible surrogate marker of the longitudinal muscle contraction of the esophagus. Recent studies suggest that longitudinal muscle contraction of the esophagus induces LES relaxation. Aim Our goal was to determine: (i) the feasibility of prolonged ambulatory HRM and (ii) to detect LES lift with LES relaxation using ambulatory HRM color isobaric contour plots. Methods In vitro validation studies were performed to determine the accuracy of HRM technique in detecting axial movement of the LES. Eight healthy normal volunteers were studied using a custom designed HRM catheter and a 16 channel data recorder, in the ambulatory setting of subject’s home environment. Color HRM plots were analyzed to determine the LES lift during swallow‐induced LES relaxation as well as during complete and incomplete transient LES relaxations (TLESR). Key Results Satisfactory recordings were obtained for 16 h in all subjects. LES lift was small (2 mm) in association with swallow‐induced LES relaxation. LES lift could not be measured during complete TLESR as the LES is not identified on the HRM color isobaric contour plot once it is fully relaxed. On the other hand, LES lift, mean 8.4 ± 0.6 mm, range: 4–18 mm was seen with incomplete TLESRs (n = 80). Conclusions & Inferences Our study demonstrates the feasibility of prolonged ambulatory HRM recordings. Similar to a complete TLESR, longitudinal muscle contraction of the distal esophagus occurs during incomplete TLESRs, which can be detected by the HRM. Using prolonged ambulatory HRM, future studies may investigate the temporal correlation between abnormal longitudinal muscle contraction and esophageal symptoms.     

Esophageal Manometry in Patients with Unilateral Hemispheric Cerebrovascular Accidents or Idiopathic Parkinsonism

The relative importance of cortical and infracortical neural control of deglutition was investigated in nine patients with unilateral cortical or internal capsule stroke, six patients with idiopathic parkinsonism, and seven healthy volunteers. Ten dry then 10 wet swallows were requested, during a right and left electromyographic recording of the mylohyoideus muscles, coupled to a manometric recording of the pharynx, upper esophageal sphincter, esophageal body, and lower esophageal sphincter (LES). Six hemiplegic patients, but no patient with Parkinson's disease, had asynchronous contractions of the mylohyoideus muscle at the onset of swallowing. Four hemiplegic patients and one with Parkinson's disease were unable to trigger dry swallows, but wet swallows were always initiated in all subjects. Four hemiplegic patients and one with Parkinson's disease had nonperistaltic esophageal contractions with either dry or wet swallows. LES relaxation was complete after dry swallows in none of the hemiplegic patients and in two with Parkinsons disease, and after wet swallows in six hemiplegic patients and four with Parkinson's disease. We conclude that a unilateral stroke may abolish the synchronism of mylohyoideus muscle contractions during swallowing, and that both pharyngeal and esophageal stages of deglutition are impaired in either cortical or striatonigral lesions.     

Modulation of upper and lower esophageal sphincter tone during sleep

BACKGROUND AND PURPOSE: The pressures generated within the upper esophageal sphincter (P(UES)) and lower esophageal sphincter (P(LES)) reflect the integrity of these barriers to gastroesophageal and pharyngoesophageal reflux, respectively. This study sought to describe the effects of sleep, respiration and posture on the function of the UES and the LES and the pressure differentials developed across them. METHODS: Ten healthy volunteers (7M, 3F: 38+/-10 yr) without a history of sleep-disordered breathing or reflux underwent overnight polysomnography with simultaneous measurement of P(LES) and P(UES) using a purpose-built sleeve device (Dentsleeve). Posture was recorded but not controlled. RESULTS: Subjects slept for 4.3+/-1.6h. Compared to waking values, both end-inspiratory and end-expiratory Pues were significantly less during slow wave sleep (SWS) (p<0.05). However, P(LES) was unaffected by sleep stage. During wakefulness and all stages of sleep, both P(UES) and P(LES) were greater at end-inspiration than end-expiration (p<0.05). Similar relationships were observed whether subjects were supine or in the lateral decubitus position. CONCLUSION: Sleep decreases the effectiveness of the UES to act as a barrier to pharyngoesophageal reflux, particularly during slow wave sleep (SWS). UES pressure varies with respiration, with minimal values observed during expiration. Hence, barrier function of the UES appears most impaired during SWS, in the expiratory phase of the respiratory cycle. The LES pressure and its barrier pressure also vary with respiration, being least during expiration. However, unlike the UES, the function of the LES was unaffected by sleep.     

Actomyosin, Collagen, and Succinate Dehydrogenase Determinations in Opossum Esophageal Muscles

The contractile activities of the lower esophageal sphincter (LES), esophageal body smooth muscle (SM), and esophageal body striated muscle (ST) of the opossum differ in their dependence on oxygen. One possible explanation for this difference in oxygen dependence is that the muscles differ in their oxidative capacities. The purpose of this study was to estimate the oxidative. capacity of these muscles by measuring the activity of succinate dehydrogenase (SDH). Since the muscles are structurally as well as functionally distinct, we also determined the amount of actin, myosin, collagen, and total protein in the tissues. LES contained less total protein and more collagen than SM and ST. The actin contents per unit of total protein of all three tissues were similar. The myosin contents and the actin: myosin ratios, however, were significantly different among all three muscles. The interpretation of the values of the SDH activity depended on the manner in which the data were expressed. When SDH activity was expressed relative to the tissue content of myosin, the values were different among all three muscles. These findings support the hypothesis that there is biochemical variability in these three esophageal muscles that may account in, part for their differences in contractile behavior.     

Effect of Intraesophageal Electrode Position on Signal Amplitude of the Crural Diaphragm Electromyogram

We studied the effect of electrode position relative to the lower esophageal sphincter (LES) on the crural diaphragm electromyogram (EMG) recording in 15 healthy human subjects. Three coil electrodes, each 1 cm in axial length and spaced 1 cm apart, were positioned on the distal 5 cm of a 6-cm-long Dent sleeve device. Bipolar EMG signals were recorded simultaneously from proximal and distal pairs of electrodes during spontaneous respiration, maximum inspiration with open airway, and maximum inspiration with closed airway. The catheter was positioned so that the side hole at the proximal margin of the sleeve recorded esophageal pressure just above the upper end of the LES. During spontaneous inspiration, the amplitude of the proximal diaphragm EMG signal was significantly higher than the distal. There was a significant difference in the amplitude of the two diaphragm EMG signals during maximum inspiration with open airway, and nearly significant differences in the two EMG signals during maximum inspiration with closed airway. We found that electrode position strongly influences the amplitude of the crural diaphragm EMG signals as measured by intraesophageal electrodes. Assessment of the crural diaphragm EMG with only one pair of electrodes may underestimate the signal amplitude.     

Studies of Small Intestinal Myoelectrical Activity and Intraluminal Pressure Changes in the Unrestrained Conscious Rat

Our aim was to develop and validate a methodology to permit chronic recordings of small intestinal intraluminal pressure changes in the conscious rat and thereby to study regional variations in motor activity. A low-flow (0.014 cc/min) perfusion system permitted reliable intraluminal pressure recordings at four sites along the small intestine from unrestrained animals. Comparison of overall patterns of fasted and fed motor activity and the various parameters of the migrating motor complex (MMC) from these recordings with those obtained from another group of animals prepared with serosal electrodes provided similar results in the proximal small intestine (MMC frequency 3.4 ± 0.5 vs. 3.9 ± 0.3 cycles/h, phase II duration 3.8 ± 0.7 vs. 4.7 ± 0.4 min, and phase III duration 4.0 ± 0.2 vs. 3.5 ± 0.2 min for duodenal catheters vs. electrodes, all NS). However, the distal deal phase II was considerably shorter in catheter than electrode recordings (6.0 ± 0.8 vs. 15.7 ± 2.4 min, p < 0.0001). Both methodologies confirmed significant regional variations in small intestinal motor parameters: the incidence of interdigestive myoelectrical complex (IDMEC) cycles was lower and phase II of the IDMEC was considerably prolonged in the distal Hewn. In summary, a system to permit chronic recordings of small intestinal intraluminal pressure has been developed and validated by comparison to myoelectrical recordings. Motor specialization was evident in the rat distal ileum.     

Mechanisms of gastroesophageal reflux in children with sequelae of birth asphyxia

Patterns of childhood gastroesophageal reflux (GER) have been studied extensively; however, the mechanisms underlying its occurrence in neurologically impaired children (NIC) are poorly understood. Concurrent esophageal manometry and pH monitoring was conducted in 10 un-operated children (7 male; mean age: 59.5 months) with sequelae birth asphyxia and esophagitis. Reflux episodes were scored when esophageal pH decreased to <4 for at least 5s. When the rate of decrease of lower esophageal sphincter (LES) pressure was >1mmHg/s, the decrease of LES pressure was defined as LES relaxation. The time relationship of the pharyngeal manometric swallowing signal to LES relaxation onset was then evaluated in order to distinguish between LES relaxations associated with swallowing (type II or III, associated with one or more swallows, respectively) and those that occurred independently of swallowing (type I). Results: Esophageal manometry and pH monitoring were conducted for a mean duration of 91.5min. Basal LES pressure averaged (+/-SD) 9.2+/-4.8mmHg; in 4 of 10 patients (40%) the LES pressure was largely undetectable, varying between 0 and 2mmHg. Mean LES pressure was inversely correlated with age (r=0.7, P=0.02). The total number of reflux episodes/h averaged 32.1+/-12.1 LES pressure reached 0mmHg in 98% of reflux episodes. Type I LES relaxations were present in 3.15+/-1.1 reflux episodes/h, whereas type II LES relaxation occurred in 2.3+/-2.4 episodes/h. Acid reflux episodes appeared during absent basal LES tone periods, without phasic LES relaxations, in 74%. Conclusions: Absent basal LES tone is the main mechanism of GER in a subgroup of NIC, especially in older children. Transient LES relaxation, the most common known event associated with acid reflux in neurologically normal children, seems to precede a minority of reflux events in NIC.     

3D‐high resolution manometry of the esophagogastric junction

Background The esophagogastric junction (EGJ) is a complex structure that challenges accurate manometric recording. This study aimed to define EGJ pressure morphology relative to the squamocolumnar junction (SCJ) during respiration with 3D‐high resolution manometry (3D‐HRM). Methods A 7.5‐cm long 3D‐HRM array with 96 independent solid‐state pressure sensors (axial spacing 0.75 cm, radial spacing 45°) was used to record EGJ pressure in 15 normal subjects. Concurrent videofluoroscopy was used to localize the SCJ marked with an endoclip. Ex vivo experiments were done on the effect of bending the probe to match that seen fluoroscopically. Key Results 3D‐high resolution manometry EGJ pressure recordings were dominated by an asymmetric pressure peak superimposed on the lower esophageal sphincter (LES) attributable to the crural diaphragm (CD). Median peak CD pressure at expiration and inspiration (51 and 119 mmHg, respectively) was much greater in 3D‐HRM than evident in HRM with circumferential pressure averaging. Esophagogastric junction length, defined as the zone of circumferential pressure exceeding that of adjacent esophagus or stomach was also substantially shorter (2.4 cm) than evident in conventional HRM. No consistent circumferential EGJ pressure was evident distal to the SCJ in 3D‐HRM recordings and ex vivo experiments suggested that the intra‐gastric pressure peak seen contralateral to the CD related to bending the assembly rather than the sphincter per se. Conclusions & Inferences 3D‐high resolution manometry demonstrated a profoundly asymmetric and vigorous CD component to EGJ pressure superimposed on the LES. Esophagogastric junction length was shorter than evident with conventional HRM and the distal margin of the EGJ sphincteric zone closely correlated with the SCJ.     

The Rectal Motor Complex

To identify patterns of motility in the rectum of humans during the day while awake and at night during sleep, and to correlate the patterns with interdigestive duodenal motor complexes and sleep cycles, intraluminal rectal pressure was recorded in 12 healthy subjects (five female, seven male; mean age, 28 years) using a flexible, noncompliant, silastic catheter and an Arndorfer system with a single perfused rectal port 6 cm above the anorectal junction, duodenal motility was recorded via a perfused oroduodenal tube, and sleep stages were determined electroencephalographically. Discrete bursts of rectal motor waves, called rectal motor complexes (RMCs), were identified on 72 occasions in 11 of the 12 subjects during 157 hours of recording. The RMCs were found in daytime during fasting or after feeding (0.2 ± 0.1 RMCs/hour), but were more easily and frequently identified at night during sleep (0.8 RMCs/hour, p < .01). The complexes had a distinct onset, a mean duration ± SEM of 9.5 ± 1.0 minutes, and a distinct decline. Within each complex, the waves had a mean frequency of 3.8 ± 0.3 per minute and a mean amplitude of 19 ± 2.7 mm Hg. Complex-to-complex intervals at night averaged 74 ± 15 minutes. No clear-cut temporal association was present between the complexes and phase III of interdigestive duodenal motor complex or the REM stage of sleep.     

Multiple rapid swallow responses segregate achalasia subtypes on high‐resolution manometry

Background Multiple rapid swallows (MRS) inhibit esophageal peristalsis and lower esophageal sphincter (LES) tone; a rebound excitatory response then results in an exaggerated peristaltic sequence. Multiple rapid swallows responses are dependent on intact inhibitory and excitatory neural function and could vary by subtype in achalasia spectrum disorders. Methods Consecutive subjects with incomplete LES relaxation on high‐resolution manometry (HRM) (Sierra Scientific, Los Angeles, CA, USA) in the absence of mechanical obstruction were prospectively identified. Achalasia spectrum disorders were classified and HRM plots reviewed according to Chicago criteria. Esophageal peristaltic performance and LES function were assessed after 10 wet swallows and MRS (five 2 mL water swallows 2–3 s apart). Findings were compared with 18 healthy controls (28.5 ± 0.6 years, 44% women). Key Results A total of 46 subjects (57.1 ± 2.1 years, 52.2% women) met inclusion criteria. There was complete failure of peristalsis with MRS in all subjects with achalasia subtypes 1 and 2. In contrast, 80% of achalasia subtype 3 and incomplete LES relaxation (EGJ outflow obstruction) with preserved esophageal body peristalsis had a contractile response to MRS (P < 0.001 compared with subtypes 1 and 2); controls demonstrated 94.4% peristalsis. Percent decrease in LES residual pressure during MRS (compared to wet swallows) segregated achalasia subtypes; those with aperistalsis (subtypes 1 and 2) had a lesser decline (22.6%) compared to those with retained esophageal body peristalsis (40.5%) and controls (51.3%, P < 0.001 across groups). Conclusions & Inferences Multiple rapid swallow responses segregate achalasia spectrum disorders into two patterns differentiated by presence or absence of esophageal body contraction response to wet swallows. These findings support subtyping of achalasia, with pathophysiologic implications.