[Increased occurrence of esophageal hypermotility disorders in patients with arterial hypertension]

BACKGROUND AND OBJECTIVE

It has been noted in previous manometric examinations of the oesophagus in patients with chest pain that abnormal motility was often associated with arterial hypertension. A systematic study of this relationship was therefore undertaken.

PATIENTS AND METHODS

In 40 patients with chest pain (18 women and 22 men, mean age 54.7 [24-70] years) and in 20 healthy volunteers (12 men, 8 women, mean age 50.8 [22-63] years) standardized oesophageal manometry and arterial blood pressure monitoring were performed over 24 hours. Coronary heart disease and gastrointestinal lesions had been excluded by angiography and endoscopy, respectively.

RESULTS

20 patients (group H) had hypertension (median 24-hour blood pressure > 135/85 mmHg), while 20 patients (group N) and the normal controls (group K) were normotensive. Oesophageal manometry data differed significantly between the three groups regarding distal pressure amplitude (in hPa [hectopascals]; group H: 62 hPa*,**, group N 44 hPa* and group K 36 hPa**; [*P < 0.0005]) and the proportion of simultaneous contractions (group H 23%, group N 22%**, group K 10%***; ***P < 0.001). The hypertensive patients had significantly more frequent motility abnormalities than normal controls (13/20 vs 4/20, P < 0.001); while normotensive patients had more frequent episodes of abnormal propulsion in the oesophagus (proportion of propulsive contractions in group H: 53%, in N: 44%, in K: 59%; P < 0.01).

CONCLUSION

Oesophageal motility differed significantly in patients with chest pain from that in healthy controls. Patients with chest pain and hypertension more frequently had oesophageal hypermotility. This suggests a generalized abnormality of smooth muscle.

Gastroesophageal reflux, motility disorders, and psychological profiles in the etiology of globus pharyngis

The aim of this study was to investigate the origin of globus pharyngis with particular reference to esophageal disorders such as gastroesophageal reflux disease (GERD), motility disorders, structural abnormalities, other gastrointestinal tract diseases, and psychological profile. Previous studies on this subject using 24-hour pH monitoring give conflicting results and are hampered by the high background prevalence of asymptomatic GERD in the normal Western population. The local Chinese population is known to have a very low background level of GERD and therefore is an ideal study population. Twenty-six patients with globus pharyngis underwent 24-hour ambulatory pH monitoring, esophageal manometry, and esophagogastroduodenoscopy with lower esophageal biopsy. A control group of 20 patients presenting with non-ulcer dyspepsia was similarly investigated. Personality profiles of the globus pharyngis subjects and an appropriate control group were assessed. Eight of the globus pharyngis group (30.7%) had evidence of GERD, whereas only one of the controls (5%) demonstrated GERD on 24-hour esophageal pH monitoring (P < 0.05). The manometric and personality profile studies did not show significant differences between study and control groups. We concluded that the finding of GERD in patients with globus pharyngis is not a coincidental finding but that there is a true association between GERD and globus pharyngis.

Mechanisms responsible for gastroesophageal reflux in children

BACKGROUND & AIMS

There is limited information about the motor mechanisms responsible for gastroesophageal reflux (GER) in children. The aim of this study was to evaluate the relationship between esophageal body and lower esophageal sphincter (LES) motor events and the occurrence of GER.

METHODS

Concurrent esophageal manometry and pH monitoring was conducted for 4 hours postprandially in 37 children referred for evaluation of suspected pathological GER. Presence of esophagitis and/or abnormal esophageal acid exposure was used to classify patients into two groups: those with pathological GER (group A; n = 24) and those in whom GER was not confirmed (group B; n = 13).

RESULTS

GER occurred during LES relaxations unassociated with swallowing within 5 seconds before and 2 seconds after the onset of LES relaxation in 58% (group A) and 69% (group B) of the analyzable episodes. These swallow-independent sphincter relaxations satisfied criteria for classification as transient LES relaxations. An additional 23% (group A) and 19% (group B) of reflux episodes could have been a result of transient LES relaxation associated with swallowing by chance. Persistent absence of LES tone was an infrequent association of reflux and was confined to group A patients (8% of episodes).

CONCLUSIONS

Transient LES relaxation is the most important cause of GER in children. Absent basal LES pressure is a relatively infrequent cause of reflux and only in children with pathological GER.

Chest pain at rest in patients with coronary artery disease. Myocardial ischemia, esophageal dysfunction, or panic disorder?

Severe nonexertional (resting) chest pain may be due to myocardial ischemia, esophageal dysfunction, psychiatric disorder, or any combination thereof and frequently poses a difficult diagnostic challenge. Our aim was to investigate causes of chest pain in patients with coronary artery disease. Forty-five patients with angiographically proven obstructive coronary lesions and recurrent chest pain at rest were studied; 18 had refractory pain despite cardiac therapy (problem group), and 27 had documented myocardial ischemia (control group). Esophageal manometry, edrophonium provocation, 24-hr pH studies, and psychiatric interview were performed in all patients. The clinical evolution and the outcome of specific treatment during follow-up was used to establish the etiology of chest pain. Esophageal dysfunction was identified in all problem patients and in 52% of controls, and the esophagus was incriminated as the source of pain in 8 (44%) and 5 (18.5%), respectively. After a mean follow-up of 49 months (range 24-76 months), the cause of chest pain in the problem group was identified as panic disorder in 9 patients (50%), gastroesophageal reflux in 6 (33%), esophageal dysmotility in 2 (11%), and gallstone disease in 1 (6%). Of the control patients, 18 (67%) had ischemic pain alone, while 9 had concurrent causes: panic disorder in 5 (19%) and esophageal dysfunction in 4 (15%). Esophageal dysfunction and psychiatric disturbances are common in patients with coronary artery disease presenting with resting chest pain, and may contribute to patients' symptoms.

Esophageal dysmotility and gastroesophageal reflux in intrinsic asthma

This study was undertaken to determine the prevalence of esophageal motor abnormalities, the incidence of gastroesophageal reflux, and the coexistence of gastroesophageal reflux with esophageal dysmotility in patients with intrinsic asthma. Based on clinical criteria, 34 consecutive asthmatics, 15 patients with gastroesophageal reflux, and 10 subjects with upper gastrointestinal symptoms with normal results of esophageal manometry and 24-hr esophageal pH test (controls) were studied. Esophageal motor disorders were noted in 23 of 34 asthmatics, and in 10 of 15 patients with acid reflux but in none of the subjects of the control group. A positive result of the prolonged esophageal pH study (pH in the distal esophagus less than 4 for more than 4.2% of the recording time) was obtained in 14 of 17 patients with asthma (only 17 of the original patients were tested because the others did not give informed consence for this test) and in all patients with gastroesophageal reflux. None of the members of the control group had positive test results. The findings of this study show that: (1) it is possible to identify a group of subjects with nonallergic asthma presenting with esophageal dysmotility, (2) the 24-hr esophageal pH study must be properly done in such patients; (3) esophageal motor abnormalities are often associated with positive pH results; and (4) more reflux was observed while in a supine position (especially during the night) than that observed either in control or reflux patients. Based on these results, patients with intrinsic asthma with reflux can benefit from both acid suppressive and prokinetic drugs with notable clinical implications regarding standard treatment for asthma, and those with prevalent supine compared to upright reflux could even benefit from surgery.

Spastic disorders of the esophagus

Spastic disorders of the esophagus are found in up to 50% of patients referred for manometry, therapy representing the most prevalent motility disorders in clinical practice. They share in common their manifestations of hypermotility, one of two principal types of esophageal motor dysfunction. Diffuse esophageal spasm is segregated from the nonspecific spastic disorders because of its demonstrated interference with bolus transit. However, the overlap among the spastic disorders in manifestation, course, and management is great; segregation of any disorder within this group is not of paramount importance. Spastic disorders, pain reproduction with provocative testing, and psychological abnormalities are coprevalent in patients with unexplained symptoms, but a cause-effect relationship of the motor abnormalities with the other findings is not established. The physician's charge in determining the relevance of a spastic disorder to the clinical presentation and for creating a treatment plan is to establish a direct relationship of motor dysfunction with symptoms-a task that may require correlation of transit abnormalities with symptoms using tests other than manometry. A variety of treatment options, invasive and noninvasive, are available today for patients who have spastic disorders, and each is effective in appropriately selected candidates.

Oesophageal motility disorders in patients with psychiatric disease

Clinical and experimental observations indicate that the motility of the oesophagus may be affected by emotional stimuli. The aim of this study was to evaluate the incidence of oesophageal contractility impairment in patients suffering from a psychiatric disorder. Fifty-one patients admitted to the psychiatric department were submitted to an oesophageal transit study by means of krypton-81m. All patients with an abnormal oesophageal transit underwent manometry and endoscopy. The level of depression and anxiety was evaluated by the treating psychiatrist, using the Hamilton Depression and Anxiety Rating Scales. The oesophageal transit was abnormal in 13 patients. Two of these 13 patients refused manometric investigation. In ten of the 11 remaining patients, the manometry revealed functional motor abnormalities. Endoscopy, performed in all these ten patients, was normal. In conclusion, a high percentage of oesophageal contractility disturbances was found in psychiatric patients complaining of anxiety and/or depression. These abnormalities were detected by scintigraphy as well as by manometry. Owing to the normal endoscopic findings, these contraction abnormalities are likely to reflect a functional motor impairment.

Functional abnormalities of the esophagus: a prospective analysis of radiographic findings relative to age and symptoms

OBJECTIVE

The prevalence and severity of functional abnormalities of the esophagus seen on fluoroscopic examination were compared with the age and symptoms of the patients.

SUBJECTS AND METHODS

The esophagus was examined radiographically in 139 consecutive outpatients 19-84 years old. All patients completed a data sheet about their symptoms, and medical records were reviewed to determine the main indication for the examination. Videofluoroscopy was used to evaluate primary peristalsis, proximal escape, and tertiary activity in the esophagus. The severity of proximal escape and activity was classified.

RESULTS

Patients were categorized into three age groups: 39 years old or younger (n = 33); from 40 to 60 years old (n = 55); and 61 years old or older (n = 51). Abnormal esophageal motility, defined as disruption of peristalsis on two or more of five swallows, was found in 24% of patients 39 years old or younger, 36% of patients from 40 to 60 years old, and in 49% of patients 61 years old or older (p > .05). However, evaluation of the number of disrupted peristaltic swallows by age revealed 18% abnormal swallows in patients 39 years old or older, 27% in patients from 40 to 60 years old, and 37% in patients 61 years old or older (p < .01). Proximal escape and tertiary contractions increased significantly with the age of the patient. Regardless of age, proximal escape was seen in 79% of swallows and tertiary contractions were seen in 48% of swallows with disrupted peristalsis. The prevalence and severity of proximal escape and tertiary contractions increased in the older patients. Symptoms had no correlation with status of esophageal motility (p > .05). In 22 patients with secondary diseases, including rheumatoid arthritis and diabetes mellitus, those diseases showed no correlation with the status of esophageal motility.

CONCLUSION

The prevalence of functional abnormalities of the esophagus increased with age. Most patients with abnormal swallows showed proximal escape with or without tertiary activity. Patients' symptoms and other diseases did not correlate with the status of their esophageal motility.

Clinical spectrum of esophageal aperistalsis in the elderly

OBJECTIVES

Our inability to explain the swallowing difficulty that is associated with esophageal motor dysfunction in a number of otherwise healthy elderly patients prompted us to assess the prevalence of esophageal aperistalsis among an elderly population and to investigate prospectively how frequently aperistalsis can be explained by factors other than age.

METHODS

During the 5-yr period from 1987 to 1992 we performed esophageal manometry in 562 patients. Recordings were assessed for the presence of complete esophageal aperistalsis. As an effort to explain the aperistalsis, patients then underwent a battery of clinical, radiological, and laboratory studies.

RESULTS

Complete aperistalsis was present in 121 patients; 73 of them were 65 yr or older, and 48 were 40 yr or younger. Further investigations into the cause of the aperistalsis in the aged group revealed achalasia in 31, vigorous achalasia in six, symptomatic diffuse spasm in four, systemic sclerosis in one, and diabetes mellitus in five. In the younger group, 40 cases of achalasia, one case of vigorous achalasia, one case of diffuse esophageal spasm, two cases of systemic sclerosis, and one case of diabetes were identified. In 29 patients, 26 of the aged group and three of the younger group, no explanation for aperistalsis was found. Aperistalsis of obscure origin was significantly more common in the aged group (p < 0.05).

CONCLUSION

In a distinct minority of otherwise healthy elderly patients, no significant disease process can explain dysphagia and complete esophageal aperistalsis. In this context, aging remains as a possible factor.

Esophageal motility disorders in the rheumatic diseases: a review of 150 patients

OBJECTIVE

Rheumatic diseases are a group of systemic disorders that may be concurrent with Raynaud's phenomenon and involvement of the internal organs, in particular the esophagus. Esophageal motor abnormalities have been widely described in systemic sclerosis, but have not frequently been reported in other diseases. In the present study we have examined the prevalence and pattern of esophageal motility disorders in different rheumatic diseases.

METHODS

Esophageal manometry was performed on 150 patients, 21 males and 129 females, suffering from different rheumatic diseases (SSc, RA, SLE, MCTD, undifferentiated CTD, or DM/PM) and on 30 healthy controls.

RESULTS

Functional involvement of the esophagus was demonstrated in all the rheumatic diseases considered, although at varying percentages. The frequencies of the functional abnormalities differed when each disease was considered separately. In SSc patients abnormalities were found more frequently in the lower esophageal sphincter (81.8%) and in the esophageal body (84.8%); data for the DM/PM and MCTD patients broadly overlapped. On the contrary, in SLE the lower sphincter appeared to be less (or even not at all) impaired, while the most specific disorder was an isolated abnormal peristalsis. RP did not always correlate with manometric changes in all of the groups studied.

CONCLUSIONS

Three conclusions derive from our study: i) motor disorders affecting the esophagus were not only found in SSc, but also in all forms of non-lupus CTD; ii) the simultaneous involvement of the esophageal body and the lower esophageal sphincter is discriminant between non-lupus CTD and SLE; and iii) RP may be regarded as a condition pathogenetically unrelated to manometrically detected esophageal motor abnormalities.

Pharyngeal pouch: link with reflux and oesophageal dysmotility

Twenty patients aged 56-92 years who underwent surgical correction of pharyngeal pouches at Queen Alexandra Hospital, Portsmouth were asked to fill in a detailed questionnaire. They were then interviewed and barium swallow studies performed from 3 months to 4 years post-operatively. Nineteen patients in the sample were found to have reflux and 20 had dysmotility. These findings suggest that pharyngeal pouches are not a purely localized inco-ordination of the cricopharyngeal sphincter but are associated with a generalized oesophageal muscle dysfunction.

The effect of symptoms and nonspecific motility abnormalities on outcomes of surgical therapy for gastroesophageal reflux disease

The outcome of Nissen fundoplication in patients with a nonspecific motility abnormality compared with the outcome in patients with normal motility is unknown. One hundred consecutive patients who underwent primary Nissen fundoplication were evaluated before and a median of 50 months after operation, with emphasis on the presence of a preoperative motility disorder and its relationship to preoperative and postoperative symptoms. Compared with patients who had normal motility, patients with a nonspecific motility abnormality had a greater prevalence and severity of heartburn and regurgitation before operation. These patients also had a greater esophageal exposure to gastric juice on pH monitoring as a result of poorer esophageal clearance function. The prevalence and severity of preoperative dysphagia was not related to the presence of a motility disorder. A 90% or a 95% actuarial success rate was achieved in the relief of heartburn and regurgitation over a 96-month period in patients with and without a motility abnormality. The overall actuarial success rate was 93%. Dysphagia was rarely caused or made more severe by the procedure; if present before the operation, it was relieved in most patients. The prevalence of persistent postoperative dysphagia was similar in patients with and without a motility abnormality. The success of Nissen fundoplication in properly selected patients is not affected by the presence of a nonspecific motility disorder.

Esophageal motility disorders in patients with Sjögren's syndrome

Esophageal motility was studied in 21 patients with Sjögren's syndrome, and in 25 normal volunteers, in order to record the prevalence and type of esophageal motor abnormalities. Esophageal motor abnormalities were detected in seven of the 21 patients (33.3%). These esophageal abnormalities did not correlate with the presence of dysphagia, the extraglandular involvement, or the presence of autoantibodies.

Segmental versus diffuse nutcracker esophagus: an intermittent motility pattern

The most common esophageal motility abnormality in patients with noncardiac chest pain is nutcracker esophagus. Most investigators regard nutcracker esophagus as a diffuse process involving the distal esophagus. Others consider it a segmental disturbance affecting isolated regions of the distal esophageal smooth muscle. This study compared the prevalence, clinical features, consistency, and manometric course of patients with either segmental high-amplitude peristaltic contractions (SHAPC) or those with the traditional diffuse contraction abnormalities termed nutcracker esophagus (NE). We particularly sought to determine whether patients with SHAPC represent an early spectrum evolving into a more diffuse contraction disorder--NE. The prevalence and clinical features of patients with either motility disturbance were similar. Thirty-nine percent of our patients had abnormally high peristaltic amplitude in locations of the proximal esophagus not previously described. Follow-up manometric studies demonstrated that only 53% of patients in the NE and 20% with SHAPC retained the same manometric diagnosis. In addition, 33% of patients in the NE group and 40% of the SHAPC group permutated into each other. These findings indicate that patients with SHAPC do not represent an early process subsequently evolving into a more diffuse contraction abnormality. Rather, the motility pattern of high-amplitude peristaltic contractions--segmental or diffuse--constitutes a labile marker associated with noncardiac chest pain.

Esophageal function in systemic sclerosis: a prospective evaluation of motility and acid reflux in 36 patients

Systemic sclerosis (SSc) is a connective tissue disorder which frequently involves the esophagus, with severe gastroesophageal reflux (GER) and dysphagia as clinical consequences of esophageal dysmotility. The relationship between the severity and extent of esophageal acid exposure and the specific manometric disturbances has received little attention. Similarly, a paucity of manometric data exists regarding pharyngeal/upper esophageal sphincter (UES) function in SSc patients. We prospectively studied 36 SSc patients using computerized solid-state manometric and ambulatory dual-pH (upper and lower esophageal) monitoring, to define further the relationship between esophageal dysmotility and severity of GER in these patients. Patients were separated for analysis into two subgroups based on the absence (group 1, N = 25) or presence (group 2, N = 11) of distal esophageal peristalsis. SSc disease variant (diffuse vs. limited) and duration of illness were inaccurate predictors of the presence and severity of esophageal involvement. The mean lower esophageal sphincter (LES) pressure for the SSc patients (15.8 +/- 1.2 mm Hg, mean +/- SE) was significantly lower (p < 0.01) than that for a control group (26.0 +/- 2.1 mm Hg). There was no significant difference between the mean LES pressure for group 1 (15.0 +/- 1.6 mm Hg) and group 2 (17.5 +/- 1.6 mm Hg) patients. Although distal esophageal aperistalsis was noted in 70% of patients, normal proximal esophageal contraction pressures were documented in all cases. Mean UES pressure was significantly (p < 0.01) lower in group 1 (52.5 +/- 4.6 mm Hg) than in group 2 (80.5 +/- 10.6 mm Hg). The mean duration of UES relaxation and the mean time interval between the onset of UES relaxation and onset of pharyngeal contraction were significantly (p < 0.05) shorter for group 1 than group 2 patients. Pharyngeal pressures, peristalsis, and other aspects of pharyngeal/UES coordination were normal. Excessive distal esophageal acid exposure was often seen in patients in both subgroups, but it was significantly (p < 0.01) greater in group 1. Excessive proximal esophageal acid exposure was documented only in patients with absent distal peristalsis. Linear regression analysis revealed a poor correlation between the severity of esophageal acid exposure and the LES pressure. Thus, the severity and extent of GER in SSc is most closely related to the integrity of distal esophageal peristalsis.

Disturbed esophageal motility after total gastrectomy

Esophageal manometry with a catheter microtransducer was performed as a functional diagnostic method on 30 patients after total gastrectomy because of gastric cancer (18 men, 12 women with a mean age of 64 +/- 3.7 years). Subsequently their symptoms were recorded. 21 of the patients (70%) complained of reflux discomfort and symptoms of disturbed peristalsis (dysphagia, odynophagia). 29 patients (93%) showed pathological patterns of contraction (repetitive, simultaneous, deformed, multipeak contractions) especially in the distal part of the esophagus. The contractile force was decreased on average by 10 mmHg in that area. The resting pressure of the upper sphincter was also decreased by about 10 mmHg. These results can be explained by an increased postoperative reflux (absence of the lower sphincter) and the changed biomechanics of the esophagus (decreased longitudinal tension) caused by the operation. The results of this study demonstrate the importance of postoperative manometry in total gastrectomized patients.

Pulmonary function in systemic lupus erythematosus is related to distinct clinical, serologic, and nailfold capillary patterns

PURPOSE

The purpose of this study was to investigate whether systemic lupus erythematosus (SLE) patients with interstitial lung disease represent a particular subset of patients characterized by the presence of clinical, serologic, and nailfold capillary patterns overlapping scleroderma.

PATIENTS AND METHODS

In 57 consecutive patients with SLE, a standardized detailed history was obtained and a physical examination performed, directed at signs and symptoms of connective tissue diseases, in particular scleroderma. Additionally, pulmonary function testing, chest radiography, radionuclide transit studies of the esophagus, nailfold capillary microscopy, and detailed serologic studies directed at the antigenic specificities of antinuclear antibodies were performed. Patients were divided into three groups based on the results of pulmonary function testing, i.e., normal lung function, restriction, or isolated impairment of diffusion. Clinical, serologic, and nailfold capillary microscopic findings were compared among these three groups.

RESULTS

Twenty patients had normal lung function, 19 had restrictive lung function loss, and 9 had an isolated impairment of the diffusing capacity (T1,CO). Patients with obstructive lung disease (n = 9) were excluded from analysis. Sclerodermatous changes of the hands were associated with a restrictive lung function pattern. Interstitial changes on chest radiograph were associated with isolated impairment of T1,CO. Nailfold capillary abnormalities correlated with decreased T1,CO and Dm, the component of T1,CO representing the diffusing capacity of the alveolocapillary membrane. Antibodies to U1-RNA were associated with restrictive lung function and decreased T1,CO.

CONCLUSION

We conclude that interstitial lung disease is present in a subset of SLE patients characterized by an increased prevalence of scleroderma traits and anti-(U1)RNA antibodies. Microvascular changes may contribute to the development of interstitial lung disease in SLE as well as in scleroderma.

Spectrum of esophageal disorders in children with chest pain

The charts of 83 children with chest pain who underwent esophageal manometry followed by esophagogastroscopy were reviewed. Forty-seven (57%) had normal esophageal histology and normal motility (group I). Esophagitis and normal motility were demonstrated in 15 children (group II), normal esophageal histology and esophageal dysmotility in 13 (group III), and both esophagitis and abnormal motility in 8 (group IV). Diffuse esophageal spasm and achalasia were the most common motility disorders identified (in seven and four patients, respectively). The presence and duration of symptoms, the age, and the gender were not different among the four patient groups. After six months of H2-receptor blockade, 12 of 15 group II patients were asymptomatic, whereas a significantly smaller percentage (five of 18) of patients with abnormal esophageal motility responded to esophageal dilation or treatment with calcium channel blockade, H2-receptor antagonist, and/or prokinetic agents (P less than 0.01). These data suggest that the evaluation of children with chest pain should include esophageal motility testing and esophagoscopy, even in the absence of other gastrointestinal-associated symptoms, and that while treatment of esophagitis results in resolution of symptoms, motility disorders were relatively refractory to therapy.

High incidence of esophageal motor disorders in consecutive patients with globus sensation

Thirty consecutive patients with globus sensation who were referred to a psychosomatic clinic prospectively underwent otolaryngological, videokinematographic, and manometric examinations of pharynx and esophagus to evaluate whether morphological abnormalities or motility disorders underlay their symptom. When indicated by findings, 24-hour pH-metry, scintigraphy of bolus transport, and esophagogastroscopy were performed. Seven patients were shown to have achalasia, 10 had "hypochalasia" (lower esophageal sphincter relaxation less than 75% with esophageal contraction abnormalities but no complete distal aperistalsis), and 1 had diffuse esophageal spasms; 2 patients had also hyperplastic lingual tonsils, 1 had tonsillitis, and 1 had a cervical spondylophyte. Nutcracker esophagus and nonspecific contraction abnormalities were found in 7 patients, and gastroesophageal reflux with esophagitis and a low lower esophageal sphincter resting pressure was found in 1; only 3 patients had normal esophageal motility. None had volunteered dysphagic symptoms at primary evaluation. Psychometric investigations in consenting patients showed no higher mean scores for state and trait anxiety, depression, hysteria, and hypochondriasis than in general medical outpatients. Esophageal motor disorders may, before giving rise to dysphagia, be sensed more vaguely and induce the globus sensation. However, only disappearance of the sensation after treatment allows inferring an etiological significance of such a disorder.

Esophageal involvement in mixed connective tissue disease

A study of esophageal symptoms and function was performed in 21 patients with mixed connective tissue disease (MCTD). Esophageal involvement was found in 18 cases (85%), in 14 (66%) with typical symptoms, in 15 (71%) with manometric abnormalities and in 11 (57%) with both. The manometric pattern was characterized by reduction of amplitude and coordination of peristaltic waves throughout the esophageal body and reduction of lower esophageal sphincter (LES) competency. In comparison, 38 patients with systemic sclerosis showed a similar but more severe pattern, particularly at the level of the distal esophagus and LES. Thus, although similar, the esophageal involvement in MCTD was not exactly the same as that of systemic sclerosis. Furthermore, in MCTD a correlation between manometric abnormalities and cutaneous involvement was lacking, and this suggests that esophageal disorders are not always linked with clinically evident scleroderma-like features of this disease. Since the diagnosis of MCTD is made in the presence of the clinical picture of more than one connective tissue disease, the detection of esophageal involvement by a sensitive technique such as esophageal manometry in a patient with suspected MCTD may be a useful diagnostic aid.

Esophageal motility, heartburn, and gastroesophageal reflux: variations in clinical presentation of esophageal dysphagia

Dysphagia is a potentially important symptom, often leading to the finding of an anatomical or motility disorder of the esophagus. Dysphagia and heartburn represent two of the most common symptoms associated with esophageal motility disorders. To explore the relationship of symptomatic esophageal dysphagia and heartburn and their association with primary esophageal motor disorders, we have performed a retrospective assessment of 1035 patient evaluations performed at our gastrointestinal laboratory. A clear statistical association of symptomatic dysphagia and heartburn was established; however, no pattern diagnostic of a specific motility disorder was discernible. A sizable fraction of our patient population with dysphagia demonstrated normal esophageal motility. A significant portion of dyspeptic patients exhibited both normal motility and acid exposure. The differences observed between the incidence of subjective symptoms and objective dysfunction may be explained in part by an altered or increased esophageal sensitivity of these patients.

Radionuclide esophageal transit study in detection of esophageal motor dysfunction: comparison with motility studies (manometry)

Radionuclide esophageal transit study (RETS) has been developed to assess motor function of the esophagus. The purpose of this study was to compare RETS to esophageal motility studies (EMS) in detection of motility disorders. A total of 109 consecutive patients without previous history of surgery on the esophagus underwent both RETS and EMS within one month of each other. Final diagnosis was divided into three categories: I--primary esophageal motor disorders (n = 39); II--reflux disease (n = 48); and III--non-cardiac chest pain and/or dysphagia (n = 22). Using EMS as the standard, the results of RETS were as follows: sensitivity for detection of motor dysfunction was 97%, 92%, and 77% for Groups I, II, and III, respectively, while specificity was 91% for Group II and 100% for Group III. Global sensitivity was 92% and specificity was 88%. No clinically significant motor disorders were missed by RETS. In conclusion, RETS is a useful noninvasive test for the screening of patients with symptoms thought to be of esophageal origin.

Studies in esophageal motility: five year clinical experience in a Canadian tertiary care hospital

A total of 661 esophageal motility studies were performed in 568 patients over a five year period in a tertiary care hospital. Patients referred for investigation generally presented with one of three symptoms: dysphagia, reflux or chest pain. Dysphagia was more closely identified with organic esophageal dysfunction than other symptoms. Normal studies were recorded in 201 instances (30%). Studies demonstrating either a major or minor non-specific motor disorder were found in 380 cases (58%). Achalasia was found in 48 patients who underwent 65 procedures (10%). Scleroderma was diagnosed in 7 patients (1%). Elderly patients were not found to have diminished esophageal function when compared to a young group.