Solid swallowing versus water swallowing: manometric study of dysphagia

The aim of the study was to investigate whether a soft solid bolus can induce abnormal manometric patterns in patients with dysphagia and normal standard manometry. The study group comprised 12 normal volunteers and 22 patients with dysphagia. Manometry was performed using 10 wet swallows followed by 10 swallows of marshmallow. The results show: (1) in normal subjects the mean contraction amplitude is significantly greater (P<0.035) and the velocity of propagation significantly slower (P<0.003) for soft solid swallows compared with wet swallows; (2) in normal subjects there are fewer abnormal contractions after soft solid swallows than after wet swallows; (3) in 15 patients, soft solid swallows induced nonperistaltic contractions and/or contractions of extreme amplitude and/or duration that were not observed after wet swallows; 94) in patients, the probability of inducing abnormal contractions after soft solid swallows is significantly greater than after wet swallows (P<0.0001). We conclude that soft solid swallowing is useful in the study of patients with dysphagia.Part of this work was presented by Dr. Argaman as a thesis, to the Technion Medical School, for his MD.     

Effects of mosapride on secondary peristalsis in patients with ineffective esophageal motility

Abstract

Objective. Ineffective esophageal motility is frequently found in patients with gastroesophageal reflux diseases. Secondary peristalsis contributes to esophageal acid clearance. Mosapride improves gastrointestinal (GI) motility by acting on 5-hydroxytrypatamine₄ receptors. The authors aimed to evaluate the effect of mosapride on secondary peristalsis in patients with ineffective esophageal motility. Material and methods. After recording primary peristalsis baseline, secondary peristalsis was stimulated by slowly and rapidly injecting mid-esophageal air in 18 patients. Two separate experiments were randomly performed with 40 mg oral mosapride or placebo. Results. Mosapride had no effect on the threshold volume of secondary peristalsis during slow air distension (9.8 ± 0.97 vs. 10.2 ± 1.0 mL; p = 0.84), but decreased the threshold volume during rapid air distension (4.1 ± 0.2 vs. 4.6 ± 0.3 mL; p = 0.001). The efficiency of secondary peristalsis during rapid air distension increased with mosapride (70% [40–95%]) compared with placebo (60% [10–85%]; p = 0.0003). Mosapride had no effect on the amplitudes of distal pressure wave of secondary peristalsis during slow (94.3 ± 9 vs. 101.9 ± 9.1 mmHg; p = 0.63) or rapid air distension (89.3 ± 9 vs. 95.2 ± 8.3 mmHg; p = 0.24). Conclusions. Mosapride improves esophageal sensitivity of secondary peristalsis by abrupt air distension but has limited effect on the motor properties of secondary peristalsis in ineffective esophageal motility patients. Despite its well-known prokinetic effect, mosapride enhances the efficiency of secondary peristalsis in patients with ineffective esophageal motility through augmenting esophageal sensitivity instead of motility.     

Effects of body position and bolus consistency on the manometric parameters and coordination of the upper esophageal sphincter and pharynx

The development of a solid-state intraluminal sphincter transducer has alleviated many of the problems associated with manometric studies of the upper esophageal sphincter (UES) and pharynx (P). We used this technology to study the effect of position (upright vs. supine) on resting UES pressures and the pressure dynamics of the UES/P complex during both wet and dry swallows in 11 normal volunteers and the effects of foods of different consistencies on the UES/P swallow dynamics in 10 normal volunteers. The UES/P coordination parameters were defined as the 15 time intervals that can be measured between any 2 of 6 pertinent points: the beginning, peak, and end of the pharyngeal contraction and the beginning, nadir, and end of the UES relaxation. Data from both the circumferential transducer used to measure sphincter pressures and a standard microtransducer used to measure pharyngeal pressures were collected on-line by an Apple IIe microcomputer and analyzed by programs written in our laboratory. Significant changes in swallow coordination were measured between upright and supine swallows of the same bolus size, between wet and dry swallows in the same position, and among foods of varying consistencies. Resting UES pressure was unchanged by position and pharyngeal contraction pressure was unchanged by bolus size or consistency.     

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.     

Short‐ and long‐term effects of balloon dilatation on esophageal motility in achalasia

OBJECTIVE: To explore the effect of balloon dilatation on esophageal motility in patients with achalasia. METHODS: In 48 patients diagnosed with achalasia based on clinical observations, barium radio­graphy, endoscopy and esophageal manometry, the following parameters were evaluated before dilatation, and 4 and 12?24 weeks after dilatation: symptom score, maximal width of esophagus (MWE), lower esophageal sphincter pressure (LESP), lower esophageal sphincter relaxation rate (LESRR), and contraction amplitude of esophageal body. RESULTS: The symptom score and MWE decreased significantly after dilatation (P < 0.05). The LESP decreased (P < 0.05) and LESRR increased (P < 0.05) significantly 4 weeks and 12?24 weeks after dilatation. The percentages of patients with LESP <2.67 kPa were 45.41% before dilatation, and 82.48% and 85.87% 4 weeks and 12?24 weeks after dilatation, respectively (P < 0.05). The percentages of patients with LESRR ≥80% were 6.74% before dilatation, and 55.97% and 43.78% 4 weeks and 12?24 weeks after dilatation, respectively (P < 0.05). Peristaltic waves were not observed after dilatation in any patient. CONCLUSIONS: Balloon dilatation may significantly improve the symptoms of achalasia and reduce esophageal distention by decreasing LESP and increasing LESRR. The mechanism by which balloon dilatation increases LESRR needs to be further studied.     

Different effects of electroacupuncture on esophageal motility and serum hormones in cats with esophagitis

SUMMARY.  We aim to investigate the effects of different electroacupuncture (EA) frequencies at ST-36 on esophageal motility, and to compare the effect of EA on serum gastrin (GAS), motilin (MTL), and vasoactive intestinal peptide (VIP). Thirty-two cats were divided into four equal groups. All animals underwent a Heller myotomy. After esophagitis developed two frequencies (2/15 Hz or 2/100 Hz) of EA were delivered into ST-36 (LEA group [low EA], HEA group [high EA]). Animals submitted to EA on a non-point region (EANP) were used as controls (LEANP group, HEANP group), respectively. Esophageal motility was continuously monitored. The lower esophageal sphincter pressure (LESP) decreased significantly after myotomy. The LESP decreased in both LEA and LEANP cats, and in LEA cats the pressure decrease was greater. The LESP increased in the HEA group, which was higher than that in the HEANP group ( P  < 0.05). High-frequency EA significantly increased the peak amplitude in esophageal peristalsis. There was a decrease in serum GAS and MTL in LEA cats compared with LEANP cats (both P  < 0.01). GAS and MTL were higher in the HEA group than in the HEANP group (both P  < 0.01). Serum VIP decreased in the HEA group ( P  < 0.05), while it increased in the LEA group ( P  < 0.05), compared with EANP groups, respectively. EA with a high frequency at ST-36 enhances LESP as well as esophageal motility, while EA with a low frequency decreases LESP. The effect of EA is acupoint-specific, and this effect appears to be mediated through GAS, MTL and VIP.     

Effect of hiatal hernia on esophageal manometry and pH-metry in gastroesophageal reflux disease

An increased frequency of reflux events and a prolonged acid clearance have been shown in gastroesophageal reflux (GER) patients with a hiatal hernia as compared to those without. The objective of the present study was to further investigate esophageal motility and patterns of reflux in GER patients, in relation to the presence or absence of hiatal hernia. Esophageal manometry and ambulatory 24-hr esophageal pH-metry were used in 42 patients with GER and 18 controls. Eighteen of the patients were considered to have a nonreducing hiatal hernia on endoscopy. Hiatal hernia patients showed a higher extent of reflux (total composite score,P=0.016; total reflux time,P=0.008, reflux time in supine position,P=0.024; reflux time in upright position,P=0.008), a lower frequency of reflux events (P=0.005), a more severe esophagitis on endoscopy (P<0.01) and a lower amplitude of peristalsis at 5 cm proximal to LES (P=0.0009) as compared to patients without hiatal hernia. The amplitude of peristalsis at the distal esophagus was inversely related to the extent of reflux (P=0.024). Acid clearance was also significantly prolonged in the hernia subgroup (P=0.011). Although LES resting pressure did not differ significantly between the two subgroups of patients, it was inversely related to the extent of reflux in the patients with hiatal hernia (P=0.0005). It is concluded, that GER patients with hiatal hernia present with an increased amount of reflux and more severe esophagitis, which results in more severely impaired esophageal peristalsis as compared to patients without hernia. Prolonged acid clearance and impaired esophageal emptying observed in patients with hiatal hernia could be the result of both the presence of the hernia itself and the reduced peristaltic activity of the esophagus.     

Different effects of an oral anticholinergic drug on gastroesophageal reflux in upright and supine position in normal, ambulant subjects: a pilot study

OBJECTIVE: There is controversy in the literature on the effects of anticholinergic drugs on gastroesophageal reflux. Our aim was to study more extensively the effects of an oral anticholinergic drug on esophageal motility and gastroesophageal reflux in normal ambulant subjects under different circumstances: upright, supine, fed, and fasted state. METHODS: Fifteen healthy subjects (seven men, eight women), mean age 34 yr (range, 22-61 yr) underwent randomized placebo-controlled 16-h evening and overnight ambulatory esophageal motility/pH study. After a 3-day loading dose of either oral dicyclomine (Dic) 20 mg four times daily or placebo (Pla), an ambulatory esophageal motility/pH study was performed while taking medication or placebo. Each study was analyzed for meal, first and second h postprandial, upright and supine periods, and first 2 h supine after bedtime snack. RESULTS: The mean number of reflux episodes decreased with dicyclomine during the first h postprandial (Dic, 1.9 vs Pla, 2.5; p < 0.05). During the first 2 h supine, mean number of reflux episodes increased with dicyclomine (Dic, 1.4 vs Pla, 0.8; p < 0.09), as did mean percent time pH < 4 (Dic, 2.6 vs Pla, 0.5; p < 0.04), with an increase in clearance time (Dic, 0.9 vs Pla, 0.3; p < 0.05; in min). Mean peristaltic amplitude decreased with dicyclomine during the 2nd h postprandial (Dic, 48.8 vs Pla, 56.3; p < 0.04). CONCLUSIONS: Oral dicyclomine caused a decrease in early postprandial upright reflux episodes, but also significantly increased the percent time pH < 4 during the first two h supine. Therefore, its effects are dependent on body position and fasted or fed state. Our results justify additional studies with oral anticholinergic agents in patients with gastroesophageal reflux disease.     

Influence of everyday bolus consistencies in different body positions on high‐resolution esophageal pressure topography (HREPT) parameters

The standard protocol for esophageal manometry involves placing the patient in the supine position with head turned to left (supine head left [SHL]) while evaluating liquid bolus swallows. Routinely, semisolid or solid boluses are not evaluated. Currently, the daily American diet includes up to 40% solid or semisolid texture. Thus far, the data on the effect of different bolus on high‐resolution esophageal pressure topography (HREPT) parameters are scarce. This study aims to evaluate the effect of every day bolus consistencies in different body positions on HREPT variables. HREPT was performed on healthy volunteers with a modified protocol including liquid swallows in the SHL position followed by applesauce (semisolid), cracker (solid), and marshmallow (soft solid) in three different positions (SHL, sitting, and standing). A total of 38 healthy adult subjects (22 males and 16 females, median age = 27, and mean body mass index = 25) were evaluated. The resting upper esophageal sphincter pressure was significantly different while subjects swallowed crackers, applesauce, and marshmallows in most positions compared with liquid SHL (P < 0.05). The lower esophageal sphincter, contractile front velocity, and distal contractile integral pressures did not differ in all different consistencies compared with SHL. The integrated relaxation period was significantly higher with solid bolus compared with liquid bolus only in SHL position. The intrabolus pressure was significantly different with solid and soft solid boluses in all postures compared to liquid SHL. The American diet consistency affects upper esophageal sphincter pressure and partially integrated relaxation period and intrabolus pressure in various positions. Semisolid bolus swallows do not cause substantial pressure changes and are safe for evaluation and maintaining adequate caloric intake in patients with dysphagia who cannot tolerate solids.     

Effects of body position and liquid meal ingestion on esophageal acid exposure time in healthy subjects

We investigated the effect of body position and ingestion of a test liquid meal on esophageal acid exposure time in 20 asymptomatic healthy subjects. Intraesophageal pH monitoring was performed for 1 h before meals and 3 h postprandially with the subject in the supine (n = 10) or sitting position (n = 10). The test meal had a total volume of 800 ml and an energy content of 500 kcal. Esophageal acid exposure time was defined as the percentage of time at pH < 4.0. There was no difference in preprandial or postprandial esophageal acid exposure time between the supine and sitting positions. Esophageal acid exposure time for the 3-h postprandial period was significantly greater than that for the preprandial period in both the supine and the sitting positions. The difference in body position did not influence preprandial or postprandial esophageal acid exposure time, but ingestion of the liquid meal significantly increased the esophageal acid exposure time in both the supine and sitting positions in asymptomatic healthy subjects. (Received Feb. 3, 1997; accepted July 25, 1997)     

Effects of oral erythromycin on esophageal pH and pressure profiles in patients with gastroesophageal reflux disease

Erythromycin, a possible motilin agonist, is a potent gastrokinetic agent that may increase the lower esophageal sphincter pressure. Therefore, we assessed the effects of erythromycin in two dosages (250 and 500 mgper os four times a day) on esophageal pH and pressure profiles in reflux patients using prolonged ambulatory monitoring systems. Studies were blinded, placebo-controlled with randomized crossover design. Patients took each drug for three days prior to studies, with erythromycin serum levels obtained the day of esophageal studies. Erythromycin 250 mg four times a day had no effect on esophageal contraction pressures or peristalsis during the day or meal periods. In the supine position, however, erythromycin significantly (P=0.012) decreased esophageal contraction velocity and showed a strong trend (P=0.059) towards increasing the percentage of peristaltic waves. Despite these potentially beneficial effects on esophageal clearance, no significant difference in acid exposure times during 24-hr pH studies were observed between placebo and low-dose erythromycin. High-dose erythromycin (500 mg four times a day) was associated with drug levels in the typical antibiotic efficacy range (normal 1–3 µg/ml; patients 1.7–7.0 µg/ml), but, here again, there was no significant difference in all acid reflux parameters between placebo and erythromycin phases. Therefore, standard doses of erythromycin have no important clinical effects on esophageal pressures or acid reflux parameters.     

Original article: The effect of argon plasma coagulation ablation on esophageal motility and chemoreceptor sensitivity in Barrett's esophagus patients

Patients with Barrett's esophagus usually demonstrate impaired esophageal motility, which affects acid clearance, together with reduced chemo‐receptor sensitivity and symptom severity. Ablative endoscopic techniques are now used to eliminate Barrett's cells. The hypothesis for this study was that ablation with argon plasma coagulation (APC) may affect esophageal sensitivity and motility in patients with Barrett's esophagus, and the aim of this study was to assess differences in these parameters before and after APC treatment. Twenty patients with Barrett's esophagus were investigated before and after APC therapy. After standard pull through manometry, water bolus aliquots were given to assess primary peristalsis and rapid water and air bolus injections to assess secondary peristalsis. Sensitivity studies were carried out using weak solutions of either hydrochloric acid or sodium hydroxide, together with saline washouts. Onset time for typical symptoms (t), sensory intensity rating (I), and a sensory score (SS) = (t) × (I)/100 was observed. There were no significant differences in the lower esophageal sphincter pressures (13.6 mm Hg versus 12.6 mm Hg, P= 0.8) and successful test swallows (3 mm Hg versus 5 mm Hg, P= 0.5) before and after treatment, but there was a trend for secondary peristalsis to improve (air bolus 0 versus 2, P= 0.05, water bolus 0 versus 1, P= 0.07). Sensitivity studies showed a smaller sensitivity intensity rating to both acid (61 versus 31, P= 0.02) and alkaline (91 versus 64, P= 0.03) after treatment. In conclusion, we have shown no substantive changes in esophageal motility after ablation of Barrett's esophagus cells, but have demonstrated reduced sensitivity to reflux type solutions.     

坐位下体负压对人体心脑血管系统的影响

目的探讨坐位下体负压对人体心脑血管系统的影响。方法15名健康青年男性在-4.00 kPa、-6.67 kPa坐位下体负压下,分别测试负压前、负压暴露0.5、1、2、3、4、5 m in和卸压后1、3、5 m in的大脑中动脉的搏动指数（PI）、阻力指数（R I）、血流速度（VMCA）,心率（HR）,血氧饱和度（SaO2）,血压（BP）及主观症状和客观体征。结果在-4.00 kPa下体负压作用下,PI、R I、BP、SaO2无明显改变,VMCA在负压作用4、5 m in时减慢（P<0.05）;HR在负压作用3、4、5 m in时增快（P<0.05）。在-6.67 kPa下体负压作用下,PI、R I在负压作用4、5 m in时增大（P<0.05）;VMCA在负压作用2、3 m in时显著减慢（P<0.05）,在4、5 m in时非常显著减慢（P<0.01）,卸压后1 m in尚未恢复（P<0.05）,随后恢复至对照水平;负压作用各时间点HR均显著增快（P<0.01）;SaO2在负压暴露5 m in时显著下降（P<0.05）;收缩压与负压前无明显变化,舒张压显著升高（P<0.05）。结论坐位下体负压造成血液在下肢淤积,搏动指数和阻力指数升高,大脑中动脉血流速度减慢,引起大脑血供减少,为空中晕厥和立位耐力不良的医学鉴定提供了人体实验依据。     

Impact of body mass index on postoperative complications and long‐term survival in patients with esophageal squamous cell cancer

Undernutrition and cachexia have been suggested to be risk factors for postoperative complications and survival in cancer patients. The aim of this study was to investigate whether body mass index (BMI) is related to the short‐term and long‐term outcomes in patients who undergo an esophagectomy for the resection of esophageal squamous cell cancer (ESCC). Three hundred forty patients who underwent an esophagectomy for the resection of ESCC between 2003 and 2008 were retrospectively reviewed. The patients were divided into two groups: an L‐BMI group characterized by a BMI < 18.5 kg/m² and an N‐BMI group characterized by a BMI ≥ 18.5 kg/m². Clinical and pathological outcome were compared between groups. The study included 40 patients in the L‐BMI group and 300 patients in the N‐BMI group. A clinicopathological assessment showed that nodal involvement was seen more frequently in the L‐BMI group (P = 0.016). Pulmonary complications seemed to occur more frequently in the L‐BMI group (P = 0.006). The 5‐year overall survival rate was higher in the N‐BMI group (63.6%) than in the L‐BMI group (32.3%) (P < 0.001). The 5‐year disease‐free survival rate was also higher in the N‐BMI group (58.0%) than in the L‐BMI group (33.6%) (P = 0.001). In multivariate analysis, the BMI (hazard ratio, 2.154; 95% CI, 1.349–3.440, P = 0.001) was found to be an independent prognostic factor for overall survival. Our data suggested that a lower BMI not only increased pulmonary complications but also impaired overall and disease‐free survival after an esophagectomy for the resection of ESCC.     

Comparison of effects of isometric and supine bicycle exercise on left ventricular performance in patients with aortic regurgitation and normal ejection fraction at rest

The effects of handgrip and supine bicycle exercise on hemodynamics and left ventricular (LV) performance were compared in 25 patients with moderate to severe aortic regurgitation (AR) and normal LV ejection fraction at rest (greater than or equal to 50%) and in 10 control subjects. In both groups, heart rate, systolic blood pressure, rate-pressure product, and LV output were higher during supine bicycle exercise. Compared with the controls, in patients with AR, stroke volume was unchanged during supine bicycle exercise. LV end-diastolic volume increased during handgrip exercise but was unchanged during supine bicycle exercise. LV end-systolic volume increased and ejection fraction decreased during both forms of exercise. Of 25 patients with AR, 15 (60%) during handgrip exercise and 19 (76%) during supine bicycle exercise had an abnormal ejection fraction response (p less than 0.05). In patients with moderate to severe AR and normal LV ejection fraction at rest, both handgrip and supine bicycle exercise induced LV dysfunction. An abnormal LV ejection fraction response occurred more often with supine bicycle exercise. Handgrip exercise may be a useful alternative method for detecting LV dysfunction in patients with AR in whom adequate bicycle exercise cannot be accomplished.