Correlation between esophageal contraction amplitude and lower esophageal sphincter pressure in patients with nutcracker esophagus

Nutcracker esophagus (NE) is a primary esophageal motility disorder characterized by high-wave amplitude at the distal esophagus. The aim of this study was to analyze patients with NE and determine the relationship between distal esophageal contraction amplitude and lower esophageal sphincter (LES) pressure. Esophageal manometry tracings of patients with NE, defined as the presence of distal contraction amplitude of more than 182 mmHg after wet swallow, were analyzed. LES pressure was measured as the mean end-expiratory value. Spearman's correlation coefficient analysis was used to compare esophageal contraction amplitude with LES pressure. This comparison was also performed in patients with isolated hypertensive LES (HLES) and in subjects with normal manometry. Forty patients (25 female, 15 male; mean age 54 years) with NE were included in the study. Mean (SD) distal esophageal contraction amplitude was 230 (35.7) mmHg and mean LES pressure was 27.3 (5.7) mmHg. Esophageal contraction amplitude showed a positive correlation with LES pressure (r = 0.49, P < 0.01). In contrast, no correlation was found in patients with HLES (r = 0.21, P > 0.05) and in those with a normal manometric study (r = 0.18, P > 0.05). It is concluded that in patients with nutcracker esophagus a positive correlation exists between distal esophageal contraction amplitude and LES pressure, suggesting a diffuse hypertensive pattern involving smooth muscle at the distal esophagus and adjacent LES.     

Esophageal body length, lower esophageal sphincter length, position and pressure in health and disease

We compared esophageal dimensions in control subjects and patients with differing motility disorders and severities of reflux disease. Patients (1108) and healthy controls (36) underwent manometry and 24-h pH monitoring. Subjects were grouped according to pH and manometry data into seven groups. Mean (s.e.m.) esophageal body length is greatest in achalasia [22.41 (0.27) cm] and least in reflux disease [20.06 (0.13) cm, p < 0.05]. Lower esophageal sphincter (LES) pressure is greatest in achalasia [17.46 (1.06) mmHg] and least in reflux disease [6.57 (0.24) mmHg, p < 0.05]. LES length is least in achalasia patients and control subjects. The ratio of intra-abdominal to intrathoracic LES is greatest in achalasia (1.29), no reflux and normal motility group, and controls and least in reflux disease (1.04, p < 0.05). In conclusion, esophageal body length is greatest in achalasia and least in reflux disease. This is associated with caudal movement of the LES in achalasia and cranial movement of the LES in reflux disease, relative to the diaphragm.     

Influence of age on lower esophageal sphincter pressure]

We studied the effect of aging on lower esophageal sphincter (LES) pressure of 52 normal subjects, 129 patients with Chagas' disease and 63 patients with systemic sclerosis. Three groups were compared: with ages between 10 to 29 years, 30 to 49 years and 50 to 70 years. We used a perfused catheter and the station pull-through (SPT) technique, at end expiratory phase. There was no difference in LES pressure between the three groups in normal subjects (p = 0.72) and patients with systemic sclerosis (p = 0.33). In Chagas' disease the patients with ages between 50 to 70 years had LES pressure (17 +/- 8 mmHg, mean +/- SD) lower (p = 0.03) than patients with ages between 10 to 29 years (22 +/- 9 mmHg). We conclude that in Chagas' disease the patients with ages over 50 years have LES pressure lower than patients with ages under 30 years, what does not happen with normal subjects nor systemic sclerosis patients.     

Manometric patterns using esophageal body and lower sphincter characteristics

In order to determine the actual spectrum of abnormal esophageal motility, manometric patterns in 1013 consecutive tracings were established using a classification method that employs esophageal body and lower esophageal sphincter (LES) characteristics. Peristaltic performance and contraction wave parameters were measured in the esophageal body; basal pressure and relaxation were included for the LES. Nine hundred thirty (92%) of the tracings could be completely classified, and 33 different patterns were observed (15 occurring at a rate >1%). Abnormalities were most common in contraction wave parameters (661 tracings, 65%), and least common in LES relaxation (105 tracings, 10%). Patterns most typical of achalasia and diffuse esophageal spasm were found in 6.4% and 5.0% of tracings, respectively. Statistical analysis of the patterns demonstrated that significant bidirectional predictive associations between categories were restricted to features representing pathology-based motor disorders (ie, achalasia and sclerodermaesophagus). This systematic classification method is capable of recognizing and cataloging common findings of motor dysfunction in the esophageal body and LES as well as uncommon patterns representing traditional motility disorders. Our findings provide reference data for clinical esophageal manometry.Supported in part by a grant (AMO7130) from the United States Public Health Service.     

The supersensitive hypertensive lower esophageal sphincter. Precipitation of pain by small doses of intravenous pentagastrin

The clinical and investigative features of eight patients with attacks of epigastric pain believed due to a hypertensive lower esophageal sphincter (LES) are described. Radionuclide esophageal transit studies were normal in all but one patient. Two patients had positive acid perfusion studies. Only three had an abnormal baseline esophageal manometry, but after small intravenous doses of pentagastrin all subjects experienced their presenting pain coincident with increases in LES pressure ranging from 75 to 140 mmHg. Five patients eventually required surgical myotomy of the LES, but pain relief which was immediate and complete in all proved permanent in only one. Two of the operated patients continued to experience severe attacks of pain refractory to medical therapy. The diagnosis of a hypertensive LES is best made by pentagastrin stimulation of the sphincter, but cutting the sphincter may not cure the patient.     

Effect of tense ascites on esophageal body motility and lower esophageal sphincter pressure.

BACKGROUND: Esophageal motility and lower esophageal sphincter (LES) pressure change with rapid changes in intraabdominal pressure (IAP); the response of these to slow change in IAP is not known. AIMS: To study esophageal body motility and LES pressures in patients with cirrhosis with tense ascites in the basal state and after paracentesis. METHODS: Twenty four patients with cirrhosis of liver and tense ascites and 13 with cirrhosis without ascites (controls) were studied. Basal intragastric (IGP) and LES pressures, and esophageal body response to water swallows, were recorded using a water perfusion system; IAP was measured in patients with ascites. In patients with ascites, the study was repeated twice: after paracentesis of two liters of fluid and after adequate control of ascites. RESULTS: Basal IGP (p = 0.002) and duration of esophageal contraction (p = 0.01) were lower in controls, but basal LES pressures were similar in the two groups. After control of ascites, IAP (p = 0.02) and IGP (p = 0.005) decreased; amplitude and duration of distal esophageal contraction decreased (p < 0.05). The frequency of high-amplitude waves also decreased (p = 0.04). LES pressure remained unaltered. CONCLUSIONS: Esophageal contraction duration is increased in the presence of ascites, and decreases after control of ascites; LES pressure is not affected by ascites.     

The hypertensive lower esophageal sphincter

Controversy exists as to whether the hypertensive lower esophageal sphincter (HLES) represents a clinical motility disorder of the esophagus or is merely the right-sided expression of a normal distribution curve. In the present study we describe 16 patients with HLES, defined as a lower esophageal sphincter (LES) pressure of 40 mm Hg (mean +3sd of controls) with normal peristalsis. All of the patients suffered from chest pain and nine from dysphagia. Delayed bolus transit at the gastroesophageal junction was demonstrated in four patients by radiography. Manometric studies showed that during swallowing the LES residual pressures were significantly greater (9.2±5.0 mm Hg) than observed in normal controls (1.8±2.2 mmHg) (mean±1sd). However, the percent LES relaxation in patients did not differ significantly from controls. Clinical improvement was associated with pharmacological or mechanical reduction of resting LES pressure with an accompanying fall in the nadir pressure. These observations suggest that HLES may have clinical and pathophysiological significance and that evidence for the entity should be sought during manometric studies in the clinical laboratory.     

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...     

The effect of terbutaline sulfate, nitroglycerin, and aminophylline on lower esophageal sphincter pressure and radionuclide esophageal emptying in patients with achalasia

We studied the effects of three smooth muscle relaxants on lower esophageal sphincter (LES) pressure and radionuclide esophageal emptying in 15 untreated patients with achalasia. LES pressures were determined before and after the administration of normal saline subcutaneously, terbutaline sulfate subcutaneously, nitroglycerin sublingually, and aminophylline intravenously. All smooth muscle relaxants significantly decreased LES pressures when compared with normal saline controls and pretreatment baseline pressures (p less than 0.01). However, in normal saline controls, LES pressure actually increased over time (p less than 0.01). Control radionuclide esophageal emptying studies were performed in all patients. Subsequent esophageal emptying studies were carried out only in patients responding to smooth muscle relaxants by decreasing LES pressures by greater than or equal to 25% (terbutaline sulfate, n = 8; nitroglycerin, n = 7; and aminophylline, n = 4). Significant improvement in esophageal emptying was observed after nitroglycerin and terbutaline sulfate (p less than 0.05) but not after aminophylline. We conclude that in patients with achalasia (a) terbutaline sulfate, nitroglycerin, and aminophylline can significantly decrease LES pressure; (b) resting LES pressures vary over time; and (c) terbutaline sulfate and nitroglycerin significantly improve esophageal emptying in some subjects.     

The effect of laparoscopic partial fundoplication on dysphagia, esophageal and lower esophageal sphincter motility

It has been suggested that dysphagia is less common after partial versus complete fundoplication. The mechanisms contributing to postoperative dysphagia remain unclear. The objective of the present prospective study was to investigate esophageal motility and the prevalence of dysphagia in patients who have undergone laparoscopic partial fundoplication. Symptoms, lower esophageal sphincter (LES) characteristics and esophageal body motility were evaluated prospectively in 62 patients before and after laparoscopic partial fundoplication: 33 women and 29 men with a mean age of 44 +/- 1.5 years (range, 21-71). The patients filled in symptom questionnaires and underwent stationary and ambulatory manometry and 24-h pH-metry before and after operation. A small but significant increase in LES pressure from 14.8 +/- 0.9 to 17.8 +/- 0.8 mmHg was seen after laparoscopic partial fundoplication. Further, LES characteristics and esophageal body motility were not different post- versus preoperation. Three months after surgery, dysphagia was present in eight patients. No differences in LES characteristics or body motility were present between patients with and without dysphagia. Six months after the operation dysphagia was present in only three patients (3.2% mild and 1.6% severe dysphagia). Adequate reflux control was obtained in 85% of the patients. Laparoscopic partial fundoplication offers adequate reflux control without affecting esophageal body motility and with a very low incidence of postoperative dysphagia.     

Role of the diaphragm in the genesis of lower esophageal sphincter pressure in the cat

To determine the role of the diaphragm in the genesis of the high-pressure zone at the lower esophageal sphincter (LES) we studied the effect of diaphragmatic contraction on lower esophageal sphincter pressure in 10 anesthetized adult cats. Despite anchoring the pressure recording assembly within the LES to prevent axial movement of the sphincter during respiration relative to the pressure recording ports, there was an average oscillation in LES pressure of 17.4 +/- 5.5 mmHg, the frequency of which was the same as the respiratory rate. Peak LES pressure occurred at end-inspiration corresponding with peak diaphragmatic electromyogram. During periods of central apnea induced by manual hyperventilation there was absence of both diaphragmatic electromyogram and the oscillations in LES pressure. Lower esophageal sphincter pressure during apnea was equal to end-expiratory pressure during spontaneous respiration. Following complete neuromuscular blockade with pancuronium, artificial respiration with increasing tidal volumes resulted in increasing oscillations in pressure. However, the magnitude of the pressure oscillation even at tidal volumes four times normal was always significantly below that observed during spontaneous eupnic respiration. Furthermore, progressive augmentation of diaphragmatic electromyogram activity by breathing 5% CO2 in air revealed a linear correlation between the magnitude of the respiratory-induced pressure oscillations of the LES and peak integrated diaphragmatic electromyogram in individual animals. It is concluded, therefore, that (a) intrinsic LES tone is best approximated by end-expiratory pressure during spontaneous respiration, (b) the respiratory-induced oscillations in LES pressure are primarily the result of active diaphragmatic contraction, and (c) the level of diaphragmatic electrical activity directly influences the magnitude of the pressure oscillation.     

Effect of caffeine on lower esophageal sphincter pressure in Thai healthy volunteers

Caffeine affects many aspects of body function including the gastrointestinal system. A single-blinded experimental study was performed to evaluate the effect of caffeine on lower esophageal sphincter (LES) and esophageal peristaltic contractions in healthy Thai adults. The volunteers were six men and six women aged 19-31 years. Subjects drank 100 mL of water. Five wet swallows were performed 30 min after the drink. The basal LES pressure was continuously measured using esophageal manometric technique. They then consumed another 100 mL of water containing caffeine at the dose of 3.5 mg/kg body weight. The swallows and basal LES pressure monitoring were repeated. The results showed no change in basal LES pressure after a water drink while caffeine consumption significantly lowered the pressure at 10, 15, 20 and 25 min. The mean amplitude of contractions and peristaltic velocity were decreased at the distal esophagus at 3 and 8 cm above LES. The mean duration of contraction was decreased at the distal part but increased at the more proximal esophagus. The heart rate, systolic and diastolic blood pressures were increased significantly at 10-20 min after caffeine ingestion. This study indicated that caffeine 3.5 mg/kg affected esophageal function, resulting in a decrease in basal LES pressure and distal esophageal contraction, which is known to promote the reflux of gastric contents up into the esophagus.     

Experimental esophagitis in cats impairs lower esophageal sphincter pressure.

We studied the effect of esophageal inflammation on lower esophageal sphincter (LES) pressure in cats by measuring LES pressure and taking mucosal biopsies before and after the development of experimental esophagitis, as well as after a 3 1/2-week recovery period. Perfusion of the esophagus with 0.1 N HCl for either 1 hr or 1/2 hr per day for 4 days produced inflammatory changes by mucosal biopsy and was associated with a marked decline in LES pressure. Upon resolution of the inflammation, LES pressure returned to normal. Biopsies were normal in control groups which underwent either esophageal perfusion with distilled water or intragastric perfusion with acid, 1 hr per day for 4 days, and LES pressures in these groups remained unchanged from pre-perfusion values. These studies indicate that lower esophageal inflammation per se adversely affects LES pressure in cats, and that experimental esophagitis may be a useful model for the study of LES function and its relation to esophageal inflammation.     

Effect of phenylalanine-vasopressin on the lower esophageal sphincter. Possible implications in the treatment of bleeding esophageal varices]

Vasopressin and its analogs are used inthe treatment of bleeding esophageal varices. Since gastrointestinal reflux may have a deleterious effect on variceal hemorrhage, the effect of 2,3-phenylalanine-8-lysine-vasopressin upon the lower esophageal sphincter (LES) was studies by rapid pull-through manometry in 24 persons. PLV infusion up to a dosis of 2.7 mU/kg/h raised LES pressure from 15.1 +/- 1.3 (SEM) to 17.9 +/- 2.0 mm Hg. Higher doses lowered LES pressure progressively to 12.1 +/- 0.7 mmHg at 54 mU/kg/h. The serum gastrin level did neither correlate with basal LES pressure not with LES pressure changes during PLV infusion. Therefore, PLV does not appear to act indirectly through serum gastrin. Because of the danger of systemic side effects and of the undesirable in LES pressure with the usual high doses of vasoactive substances, a continuous infusion of lower doses of vasopressin analogs appears to be advantageous.     

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.     

Integrity of cholinergic innervation to the lower esophageal sphincter in achalasia

The human lower esophageal sphincter (LES) is believed to be innervated by nonadrenergic, noncholinergic inhibitory nerves, and cholinergic excitatory nerves. In idiopathic achalasia, LES relaxation is abnormal because the inhibitory nerves to the sphincter are either absent or functionally impaired. The integrity of cholinergic excitatory nerves to the LES, however, has not been thoroughly evaluated. In 27 patients with untreated idiopathic achalasia, and 21 healthy volunteers, we investigated the hypothesis that postganglionic cholinergic nerves to the LES are functionally intact in achalasia. The LES responses to atropine, edrophonium, methacholine, amyl nitrite, and pentagastrin were assessed. In 2 achalasia patients, patterns of fasting motor activity in the LES were investigated during overnight manometric studies. Resting LES pressure was significantly greater in the achalasia patients, 41 +/- 4 mmHg (mean +/- SE), than in the normal subjects, 20 +/- 2 mmHg. Atropine significantly reduced LES pressure in both groups by 30%-75%. Edrophonium increased LES pressure in the achalasia patients but had negligible effect on the normal subjects. The LES in achalasia patients exhibited an increased sensitivity to both methacholine and pentagastrin compared with the normal subjects. In both patients who underwent an overnight manometric study, the LES exhibited cyclic phasic contractile activity synchronous with gastric contractions during the migrating motor complex. We conclude that the study findings support the hypothesis that postganglionic cholinergic LES innervation in achalasia patients is either normal or only minimally impaired, in contrast to the marked impairment of the inhibitory nerves governing LES relaxation.     

Effect of pentagastrin and gastric alkalinization on lower esophageal sphincter pressure in diffuse esophageal spasm.

The purpose of this study was to evaluate the effect of intravenous pentagastrin and gastric alkalinization on the lower esophageal sphincter (LES) pressure in seven patients with diffuse esophageal spasm as compared to nine normal controls. Intravenous injections of 0.2 and 0.4 mug pentagastrin/kg body weight increased LES pressure significantly more in patients than in control subjects (p less than 0.05, p less than 0.01). Following gastric alkalinization both groups showed increases in LES pressure, but these were significantly greater for patients with diffuse esophageal spasm (p less than 0.05) than for controls. The results of our study indicate that the LES in patients with diffuse esophageal spasm is supersensitive to pentagastrin and gastric alkalinization.     

Altered lower esophageal sphincter function during early pregnancy

To determine whether lower esophageal sphincter (LES) function was normal during early pregnancy, studies were performed in 8 pregnant women before and after abortion. Resting LES pressures were 22.1 +/- 2.4 and 22.6 +/- 2.3 mm Hg before and after abortion, respectively. During early pregnancy the LES pressure responses to pentagastrin were inhibited significantly. The LES responses to edrophonium and methacholine were decreased also. Finally, LES pressure responses to a protein meal were diminished in an additional 5 pregnant women. Serum concentrations of estrogen and progesterone were elevated during pregnancy, but the serum concentration of gastrin was unchanged. It can be concluded that in early pregnancy the basal LES pressure was within normal limits, but the LES pressure responses to hormonal, pharmacological and physiological stimulation were reduced (during demonstrated elevations of serum concentrations of estrogen and progesterone). These studies suggest that during early pregnancy, when no clinical symptoms of reflux are present, altered LES function may be demonstrated.     

Stimulation of the incompetent lower esophageal sphincter

The primary function of the lower esophageal sphincter (LES) is to prevent the reflux of gastric contents into the esophagus. We have studied the effect of hormonal and pharmacologic stimuli on LES pressure in patients with symptomatic gastroesophageal reflux due to LES incompetence. Gastric alkalinization, subcutaneous pentagastrin, intravenous edrophonium, and subcutaneous bethanecol each resulted in marked increases in LES pressure. In all studies, pressure rose to a level occurring in normal subjects. Subsequently, the patients were given 25 mg bethanecol orally and pressure monitored for 2 hours. The LES pressure increased from a mean basal pressure of 5.6±0.8 mmHg to a peak of 16.9±2.8 mmHg at 50 minutes. Pressure remained elevated for the full 2-hour study period. Both subcutaneous and oral bethanecol successfully increased LES pressure in all patients with symptomatic reflux to the level of resting pressure seen in normal subjects. These studies suggest a potential role for cholinergic agents in the therapy of symptomatic gastroesophageal reflux.The opinions expressed herein are those of the authors and cannot be construed as reflecting the views of the Navy Department or of the Naval Service at large.Presented at the 53 rd Annual Session of the American College of Physicians, April 19, 1972, Atlantic City, New Jersey.     

Prognostic value of the lower esophageal sphincter gradient and acid exposure in the follow-up of antireflux operations

Eighty-eight consecutive patients with antireflux fundoplication had manometry and pH recording pre- and post-operatively at 6 months and 1, 3 and 5 years for a mean follow-up of 30.6 months. Failure occurred in nine patients (11.4%). For the whole group of patients, surgery produced a significant increase in the lower esophageal sphincter (LES) pressure gradient from 9.5 +/- 6.3 to 14.6 +/- 6.7 mmHg and a significant decrease in acid exposure from 20.6% +/- 17.6% to 5.5% +/- 8.8% at 6 months. There was a similar change in pressure (p < 0.0005) and pH (p < 0.002) in the successful but not in the failure group. Over time, the values remained stable in both groups. Post-operative LES pressure was significantly correlated with the outcome at 6 months (p < 0.02), and the pH was inversely correlated at 5 years (p < 0.039). This study confirms the early predictive value of the post-operative LES pressure. Esophageal acid exposure remains a reliable marker of the outcome. However, recurrences remain unexplained by LES pressure measurement and long-term follow-up using manometry and pH recording does not bring additional valuable data.