Esophageal function testing: role of combined multichannel intraluminal impedance and manometry

Combined multichannel intraluminal impedance and manometry (MII-EM) is a relatively new technique that allows simultaneous measurement of intraesophageal pressures and bolus transit. Combined MII-EM has the ability to identify what percentage of manometric normal/peristaltic, ineffective, and simultaneous swallows have complete or incomplete bolus transit. Predictors of normal bolus transit in patients with ineffective esophageal motility are the distal esophageal amplitude, the number of sites with low amplitudes, and the overall number of manometric ineffective contractions. Outcome studies are necessary to evaluate whether combined MII-EM is superior to traditional manometry in evaluating patients with nonobstructive dysphagia and in identifying patients at risk for developing dysphagia after antireflux surgery.     

反流性食管炎患者食管动力学改变对疗效的影响

目的探讨反流性食管炎（RE）患者不同食管动力障碍对抑酸剂及促胃肠动力剂的治疗反应，为临床RE的治疗提供方法学选择。方法对临床及胃镜诊断为RE的104例患者进行食管压力测定，并同时进行14d的埃索美拉唑及莫沙比利分散片治疗，观察不同食管动力障碍患者的疗效。结果经14d治疗，104例患者临床症状改善情况：显效64例，有效32例，总有效率为92．3％，其中治疗A组（LESP降低或正常，伴食管蠕动减弱者）疗效明显优于治疗B组（LESP增高或正常，或伴食管腔压力增高）（P〈0．01）。结论对抑酸剂及促动力药物疗效欠佳的RE患者，可能存在不同的食管动力障碍，食管测压可能对此有一定的鉴别意义，而在治疗时不应常规给予治RE药物，应体现个体化治疗原则。     

évaluation des anomalies motrices oesophagiennes au cours de la dysphagie avec endoscopie digestive haute normale

Aims

Dysphagia is considered, rightly, as an alarm symptom requiring upper endoscopy which is sometimes normal. Esophageal manometry is the second examination performed to explore this symptom. The aims of this study are to evaluate the frequency and to identify the type of oesophageal motility disorders in patients with dysphagia with a normal endoscopy.

Patients and methods

It was a retrospective study including patients with dysphagia with normal upper endoscopy and referred to our department for esophageal manometry. The variables assessed were: age; gender; dysphagia duration; LES pressure and relaxation on swallowing; amplitude, duration and propagation of peristaltic contractions.

Results

226 patients were included: 114 women (50.4 %) and 112 men (49.6 %) whose mean age was 44.23 ± 16.50 years. The median duration of dysphagia was 12 months [6.25–48]. Dysphagia was isolated in 38 cases (16.8 %). Esophageal manometry was abnormal in 144 patients (63.7 %). The inadequate relaxation (achalasia) was the most frequent primary motor disorder in these patients (36.3 %).

Conclusion

In patients with dysphagia with normal upper endoscopy, esophageal manometry should be routinely performed to diagnose esophageal motility disorders. These are noted in 2 of 3 patients. Achalasia is a primary motor disorder most often frequent.     

Pharmacologic treatment of eosinophilic esophagitis

There are several treatment options available for patients who have eosinophilic esophagitis (EE). These options include dilatation for mechanical esophageal abnormalities, pharmacologic therapy, and dietary management. Providing the appropriate therapy depends on the significance of clinical symptoms, association of abnormal anatomy, and histologic involvement of underlying the esophageal tissue. This article focuses on the pharmacotherapy of EE.     

Diagnosis of esophageal motor disorders: A prospective study comparing barium swallow,food barium mixture,and continuous swallows with manometry

Radiography and manometry of the esophagus were compared in 77 patients consecutively referred for manometric investigation on suspicion of esophageal motility disorder. Radiography and manometry were carried out simultaneously, and the results were assessed blindly. The examination comprised barium swallow, bread barium swallow, and barium swilling. Considering manometry as the standard, the overall sensitivity and specificity of the radiologic examinations were 90.4% and 92.0%, respectively. We conclude that radiology is an excellent investigation for the separation of patients with and without esophageal motility disorders, but correct subclassification often required manometry.     

Esophageal motility disorders in critically ill patients: a 24-hour manometric study

OBJECTIVE: Impaired tubular esophageal motility is involved in the pathogenesis of gastroesophageal reflux disease, which, in turn, has been shown to cause nosocomial pneumonia in critically ill patients. As multiple factors are involved, this pilot study was undertaken to evaluate whether, similarly, impaired esophageal motility may contribute to nosocomial infections by determining esophageal motility in critically ill patients undergoing mechanical ventilation and sedation in comparison to that of a healthy control group. DESIGN: Open, single-centered study. PATIENTS AND METHODS: Fifteen consecutive ventilated intensive care unit (ICU) patients with different diseases and three regimens of analgo-sedation were included: group 1: no analgo-sedation, group 2: ketamine and benzodiazepines, and group 3: fentanyl and benzodiazepines. Six healthy volunteers were studied as controls. Twenty-four hour esophageal anterograde (propulsive) and retrograde motility changes were assessed by a manometry system. RESULTS: The frequencies of contractions were 0.67 +/- 0.1/min (no analgo-sedation) 0.093 +/- 0.02 (ketamine) and 0.076 +/- 0.01 (fentanyl) (p < 0.05 as compared to controls). The amplitudes (% of maximum) were 98 % (control), 58 % (analgo-sedation), 38 % (ketamine) and 42 % (fentanyl; p < 0.05 for the comparison of fentanyl and ketamine with controls). Whereas the percentage of propulsive contractions was significantly decreased in patients (no sedation: 45 %, ketamine: 34 %; fentanyl: 35 %, p < 0.05) as compared to controls (72 %), the percentage of retrograde contractions increased: no sedation: 29 %, ketamine: 34 % and fentanyl: 37 % as compared to controls: 10 %, p < 0.05. Analysis according to the underlying diseases showed marked inhibition of motility parameters within any disease group in comparison with controls. CONCLUSIONS: Irrespective of the underlying disease, propulsive motility of the esophageal body is significantly reduced during any kind of sedation in critically ill patients. Possibly central as well peripheral drug-related effects are involved in such a depression. Twenty-four hour motility recordings appear to be a valuable and feasible method to quantify and analyze esophageal motor disorders in critically ill patients.     

Autonomic dysfunction and upper digestive functional disorders in untreated adult coeliac disease

There is recent evidence that upper-gut motor abnormalities may be present in coeliac disease. However, to date, the pathophysiological mechanisms responsible for the above have not been explored. The purpose of the present study was to investigate upper-gut motor activity in coeliac disease and explore the role played by the autonomic nervous system in motility disturbances. Thirty untreated adult coeliac patients were recruited into the study. Oesophageal manometry and cardiovascular autonomic tests were performed in all patients; oesophageal pH-metry was carried out in 20 patients, gastrointestinal manometry in eight and scintigraphic gastric emptying in 13. Oesophageal motor abnormalities were detected in about 50% of patients, pH-metry was abnormal in 30% of them, and up to 75% of coeliac patients displayed gastrointestinal motility alterations. Delayed gastric emptying was documented in about 50% of patients and was correlated with manometric post-prandial hypomotility. Autonomic tests were positive in 45% of patients as a group, and reached pathological score in 19% of them. Autonomic score correlated significantly with the percentage of bi-peaked waves and with the number of fasting intestinal clusters. This study confirms that upper-gut motor abnormalities are frequently present in adult coeliac disease. Extrinsec autonomic neuropathy may play a role, although other pathophysiological mechanisms are likely to occur.     

Relationship of radionuclide liquid bolus transport and esophageal manometry

Using simultaneous esophageal manometry and radionuclide transit studies, we compared liquid bolus transport with the various parameters of esophageal contractions. Study subjects included seven normal individuals, six patients with the "nutcracker esophagus" (mean distal peristaltic amplitude greater than 180 mm Hg), and three patients with spastic motility disorders. Manometric studies were performed when the subjects were in the basal state and after intravenous administration of edrophonium and atropine. Simultaneous radionuclide studies were done with subjects in the supine position by swallows of 250 mu Ci technetium Tc 99m sulfur colloid in 10 ml water. We found that normal liquid bolus transport (less than 15 seconds) is primarily dependent on the presence of a peristaltic wave front throughout the esophagus. Above a threshold pressure of 30 mm Hg, liquid transport was not affected by amplitude (33 to 500 mm Hg) or duration (3 to 15 seconds) of esophageal contractions. Repetitive wave forms also gave normal transit times as long as the wave front was peristaltic in onset. There was a significant inverse correlation (-0.65; P less than 0.001) between liquid transit time and peristaltic velocity. Prolonged radionuclide transport (30 to less than 50 seconds) was observed only with nonperistaltic contractions and very low amplitude (15 to 30 mm Hg) peristaltic waves.     

Esophageal motility disorders with thoracic pain of unknown origin

35 patients with angina-like chest pain underwent esophageal manometry after a coronary artery disease had been ruled out by angiography. Furthermore, patients after gastric or esophageal surgery, with pathologic upper gastrointestinal endoscopy or with pathologic gastroesophageal reflux as seen on 24-hour-pH-metry were excluded from this study. 29 out of 35 patients (83%) had a normal manometric study, six patients (17%) had a motility disorder; five of these showed an unspecific dismotility pattern and were asymptomatic while the study was done; only one patient presented with esophageal spasm. Since only this latter patient was symptomatic while the study was done, a correlation between symptoms and this motility disorder seems likely. --If pathologic gastroesophageal reflux has been ruled out, esophageal manometry can establish a diagnosis in only 3% of patients with angina-like chest pain without esophageal symptoms (dysphagia, odynophagia, heartburn or regurgitation). We conclude that this complicated examination should not be done in these patients.     

Esophageal manifestation in patients with scleroderma

The esophagus is the most commonly affected part of the gastrointestinal system in patients with systemic sclerosis (SSc). Esophageal involvement may lead to a significant reduction in patient quality of life. The exact pathophysiology is complex and not yet fully elucidated. Ultimately, esophageal smooth muscle becomes atrophied and replaced by fibrous tissue leading to severe motility disturbance of the distal esophagus. Symptoms are mainly attributed to gastroesophageal reflux disease and to esophageal dysmotility. Compelling evidence has correlated esophageal involvement to the severity of pulmonary disease. No formed guidelines exist about the diagnostic modalities used to assess esophageal disease in patients with SSc, though upper gastrointestinal endoscopy is the first and most important modality used as it can reveal alterations commonly observed in patients with SSc. Further exploration can be made by high resolution manometry and pH-impedance study. Proton pump inhibitors remain the mainstay of treatment, while prokinetic agents are commonly used as add-on therapy in patients with symptoms attributed to gastroesophageal reflux disease not responding to standard therapy as well as to motility disturbances. Gastroesophageal reflux disease symptoms in patients with SSc are frequently difficult to manage, and new therapeutic modalities are emerging. The role of surgical treatment is restricted and should only be preserved for resistant cases.     

Traitement endoscopique de l’achalasie : dilatation pneumatique, chirurgie ou myotomie pérorale endoscopique ?

Achalasia is an esophageal motility disorder defined by the absence of propagated contractions (aperistalsis) in the body of the esophagus and failure of relaxation of the lower esophageal sphincter. Thanks to high resolution manometry and study of the esophageal pressure topography, three subtypes, according to the classification of Chicago, have a direct interest in the choice of treatment to use: type I of achalasia presents the same result with pneumatic dilatation (81%) and surgery (85%); type II of achalasia presents the best result with pneumatic dilatation (100%); type III of achalasia called “spastic”, which is the more resistant, have the best result with Heller-Dor myotomy (86%). More recently appeared the peroral endoscopic myotomy, which remains to study in France, but with the preliminary results, this technic could become the treatment of choice for achalasia, particularly in the type III which is the most resistant.     

24h食管pH监测和食管测压及奥美拉唑治疗试验在食管原性胸痛中的应用

目的 :探讨 2 4 h食管 p H监测和食管测压及奥美拉唑治疗试验在食管原性胸痛中的诊断价值。方法 :对食管原性胸痛 6 8例行内镜、食管测压、2 4 h食管 p H监测及 7d的奥美拉唑 (2 0 mg,2次 / d)治疗试验 ,治疗后症状评分比治疗前降低超过 75 %者则为治疗试验阳性。结果 :食管原性胸痛 6 8例中 5 5例 (81% )符合胃食管反流病 (GERD) ,胡桃夹食管 2例 ,早期贲门失驰缓症 3例 ,弥漫性食管痉挛 3例 ,无效食管运动 (IEM) 5例。GERD5 2例测压分析 ,35例(6 7% )符合 IEM诊断标准。奥美拉唑治疗试验对诊断 GERD的敏感性为 93% ,特异性为 85 %。结论 :GERD是食管原性胸痛的主要原因。 2 4 h食管 p H监测和食管测压是诊断食管原性胸痛的主要检查手段 ,奥美拉唑治疗试验是临床诊断GERD简便而实用的方法。     

术中食管测压在外科治疗贲门失弛缓症中的应用

[目的]利用食管测压技术,监测贲门失弛缓症患者行改良Heller手术术前、术中、术后食管动力学的改变,探讨改良Heller手术的机制及疗效.[方法]对21例贲门失弛缓症患者行经腹改良Heller手术,对患者术前、术中、术后食管测压,术前、术后24 h pH值检测及术后并发症、远期疗效等进行观察.[结果]21例均手术顺利,无手术死亡,食管测压显示术后食管下括约肌压力（LESP）、吞咽后食管下括约肌松弛百分比等指标明显改善,术后随访19例,1例偶有进食不畅,优良率达94.7%.[结论]经腹改良Heller术在治疗贲门失弛缓症中机制合理,并发症少,疗效满意.附加抗反流术式是防止反流的有效措施.术中食管测压对提高手术疗效有一定的指导作用.     

Effects of two oral erythromycin ethylsuccinate formulations on the motility of the small intestine in human beings.

Fourteen-membered macrolides are known to produce alterations in digestive tract motor activity; these include the induction of strong gastric contractions and a decrease in the motility of the small intestine. The aim of the study was to compare the effects of two different formulations of erythromycin ethylsuccinate (EE) on duodenojejunal motility. Compared with the more commonly used crystalline formulation of EE (CEE), the amorphous formulation (AEE) has previously been described to have greater bioavailability and to induce significantly fewer gastrointestinal side effects when given at therapeutic and what have been considered to be equivalent oral doses (i.e., CEE, 1,000 mg every 12 h; AEE, 500 mg every 12 h). In a crossover double-blind study, duodenojejunal manometric recordings were performed for 10 volunteers treated with placebo, CEE at 1,000 mg, or AEE at 500 mg. Recordings for each volunteer were obtained for a fed period after a standard dinner and then for a nocturnal fasting period. When compared with the placebo, CEE significantly decreased the motility index of the duodenum during the 30 min after the peak serum erythromycin concentrations, shortened the duration of the fed state, and had no effect during the fasting state. In contrast, AEE did not significantly modify any motility parameter. Because AEE produced significantly lower concentrations in serum than CEE, these results do not necessarily imply that the two formulations of EE act differently on the motility of the small intestine.     

功能性消化不良者心理因素与食管动力的关系

目的探讨心理因素与功能性消化不良(FD)食管动力的关系。方法使用高分辨率旁道灌注测压系统对20例健康对照组及121例FD进行食管动力测定,同时以焦虑自评量表及抑郁自评量表评定两组的心理状态,并观察食管动力与心理状态的联系。结果9.8%(24/121)的FD患者有食管动力障碍,主要表现为非特异性食管动力障碍70.8%(17/24);胡桃夹食管2例、弥漫性食管痉挛5例;60.7%(73/121)的FD者有心理障碍,其中抑郁障碍38.0%(46/121)、焦虑障碍48.8%(59/121),对照组1例有轻度的抑郁障碍,P<0.01。有心理障碍FD者食管动力障碍发生率(26.0%,19/73)比非心理障碍FD者(10.4%,5/48)显著增高(P<0.05),且前者LES压力、食管体蠕动波幅、持续时间均显著高于后者(P<0.05)。结论食管动力障碍是FD重要功能紊乱之一,长期抑郁或焦虑可能影响FD食管动力。     

Management of diffuse esophageal spasm with balloon dilatation

Of 1200 patients referred to the esophageal laboratory at Guy's Hospital for investigation of suspected esophageal motility disorders, 61 (5.1%) were diagnosed as diffuse esophageal spasm. Twenty of these patients whose symptoms were severe did not respond to conservative treatment and were treated by balloon dilatation. Results were good in 14 and poor in six patients, which included one esophageal perforation. Diffuse esophageal spasm was diagnosed where more than 30% nonperistaltic activity was demonstrated by manometry. Lower esophageal sphincter pressure and relaxation were normal in all cases except one. Gastroesophageal reflux was present in four of five poor responders who were examined by 24-h ambulatory pH monitoring, and in only one of 10 good responders. Three of the six patients in whom balloon dilatation was successful proceeded to full-length myotomy, with relief of symptoms in two. The indications for, and results of, balloon dilatation in this condition are discussed, and a new radiological sign is described.     

Radiographic evaluation of esophageal function

Radiologic studies can be helpful when evaluating patients who are suspected of having esophageal motility disorders. Performing studies of the highest technical quality yields the most definitive results. The esophagus should be assessed for anatomic and functional abnormalities that may account for presenting symptoms. Motility disorders such as achalasia and scleroderma have specific radiographic findings that are described in this article; however, some motility disorders of the esophagus have nonspecific radiographic findings. In those cases, it is imperative that clinical and manometric information be combined with radiographic findings to provide accurate diagnoses. The radiographic examinations that are most commonly used include barium esophagography and nuclear medicine examinations. This article emphasizes the use of barium examinations to assess esophageal motility.     

Apport des nouvelles méthodes d’exploration pour la classification des troubles moteurs œsophagiens

The development of high resolution manometry has modified the diagnostic approach of esophageal motility disorders. The use of a high number of electronic sensors together with the pressure variations displayed as esophageal pressure topography have greatly facilitated data interpretation. The diagnostic yield for dysphagia has increased by 10-20% thanks to these improvements. The Chicago classification is based on both relaxation of the esophago-gastric junction and the pattern of esophageal contractility. This diagnostic algorithm allows classifying esophageal motor disorders as achalasia, hypercontractile, or hypocontractile disorders. Whether this classification will positively impact the outcome of patients with esophageal motor disorders remains to be determined.     

Comparison of investigation modalities for evaluation of esophageal peristaltic function

We reviewed the recent literature concerning investigations of esophageal peristaltic function. The gold standard for the assessment of esophageal peristaltic function is manometry with pH monitoring. Even with this investigation modality, however, we are in fact doing no more than estimating esophageal peristaltic function from the manometry and pH results. With esophageal fluoroscopy and scintigraphy, where we observe esophageal motility, there are problems with radiation exposure and handling of radioactive agents that make widespread use difficult. In recent years, the development of multichannel intraluminal impedance (MII) manometry has allowed simultaneous measurement of intraesophageal pressure and assessment of esophageal peristalsis. Using MII it is also possible to distinguish whether gas or liquid is passing down the esophagus. When manometry is performed in conjunction with transnasal esophagogastroduodenoscopy, with this unique combination it is possible to measure the intraesophageal pressure while actually observing the swallowing motion at the same time. Assessment of esophageal peristaltic function is now moving from simple measurement of intraesophageal pressure to simultaneous impedance manometry and endoscopic observation of esophageal peristalsis itself.     

Distal esophageal spasm:Update on diagnosis and management in the era of high-resolution manometry

Distal esophageal spasm(DES)is a rare major motility disorder in the Chicago classification of esophageal motility disorders(CC).DES is diagnosed by finding of≥20%premature contractions,with normal lower esophageal sphincter(LES)relaxation on high-resolution manometry(HRM)in the latest version of CCv3.0.This feature differentiates it from achalasia type 3,which has an elevated LES relaxation pressure.Like other spastic esophageal disorders,DES has been linked to conditions such as gastroesophageal reflux disease,psychiatric conditions,and narcotic use.In addition to HRM,ancillary tests such as endoscopy and barium esophagram can provide supplemental information to differentiate DES from other conditions.Functional lumen imaging probe(FLIP),a new cutting-edge diagnostic tool,is able to recognize abnormal LES dysfunction that can be missed by HRM and can further guide LES targeted treatment when esophagogastric junction outflow obstruction is diagnosed on FLIP.Medical treatment in DES mostly targets symptomatic relief and often fails.Botulinum toxin injection during endoscopy may provide a temporary therapy that wears off over time.Myotomy through peroral endoscopic myotomy or via surgical Heller myotomy can provide long term relief in cases with persistent symptoms.