Primary disorders of oesophageal motility

Manometric and symptomatic spectrum of motor dysphagia in a tertiary referral center in northern India

BACKGROUND

We studied the spectrum of motor dysphagia in a northern Indian tertiary referral center.

METHODS

In this retrospective study, consecutive patients with motor dysphagia referred to the Gastrointestinal Pathophysiology and Motility Laboratory from 2002 to 2007 were evaluated clinically and with eight-channel water-perfusion manometry. Causes of dysphagia were diagnosed using standard criteria.

RESULTS

Of 250 patients (age 41.3 [15.0] years, 146 men), 193 (77%) had achalasia cardia (AC) and 57 (23%) had other causes (11, 4.4%: diffuse esophageal spasm [DES]; 9, 3.6%: hypertensive lower esophageal sphincter [Hy LES]); manometry was normal in 37 patients. Twenty-seven patients (14%) had vigorous AC. Duration of dysphagia at presentation was longer in those with AC and Hy LES than in normal manometry (NM) (21 months [1-180] vs. 6 [1-360], p = 0.000; 24 months [7-48] vs. 6 [1-360], p = 0.015). Regurgitation and bolus obstruction were more frequent in those with AC than in NM (89/154, 57.79% vs. 3/27, 11.11%, p = 0.000001). Heartburn was less frequent in patients with AC than in others (AC: 4/146, 2.73% vs. normal: 4/27, 14.8% [p = 0.02] and others: 3/15, 20% [p = 0.018]). Chest pain was reported by 74/135 (54.8%) classic and 12/19 (63.2%) vigorous AC (p = NS). Patients with NM had lower LES pressure than those with classic AC, Hy LES and vigorous AC (p < 0.0001 in each case). Patients with DES had lower LES pressure than in classic AC, Hy LES and vigorous AC (p = 0.043, p < 0.0001, and p = 0.002, respectively). Patients with classic AC had lower LES pressure than in Hy LES and vigorous AC (p = 0.024, p = 0.001, respectively).

CONCLUSION

Classic AC was the commonest cause of motor dysphagia in our center. AC was associated with higher LES pressure, longer duration of dysphagia, frequent regurgitation and bolus obstruction.

Automated identification of peristaltic pressure waves in oesophageal manometry investigations using the rolling correlation technique

We have implemented the technique of rolling correlation coefficient as proposed by Buttfield and Bolton (2005 Real time measurement of RR intervals using a digital signal processor J. Med. Eng. Technol. 29 8-13) for ECG R-wave detection in the detection and timing of oesophageal peristalsis. 43 sequential patients attending for oesophageal manometry were retrospectively reviewed. Two expert reviewers visually assessed each swallow for normality of peristaltic amplitude and propagation speed. Automatic assessment was performed using rolling correlation, maximum amplitude, threshold and maximum gradient techniques of identifying onset of peristalsis. Rolling correlation was comparable with the maximum amplitude technique at identifying peristaltic pressure waves visually identified as present. Rolling correlation was most effective at correctly identifying propagation velocity as normal (698 out of 845 normally propagating waves) and highest correlation with expert visual assessment of percentage abnormal propagation for each patient (R value 0.918). In a sub-group of 11 studies assessed as displaying normal motility, rolling correlation gave lowest variation of propagation speed and highest consistency with visual assessment. The rolling correlation technique is effective and accurate at identifying oesophageal peristalsis and characterizing peristaltic propagation in manometric studies even in the presence of abnormally weak peristalsis and other confounding pressure perturbations.

Effect of physical exercise on esophageal motility in patients with esophageal disease

The most common type of esophageal dysfunction associated with chest pain is gastroesophageal reflux, which may be induced by exercise. The effect of exercise on esophageal function has mainly been investigated in normal subjects or trained athletes. Few studies have investigated exercise and esophageal motility disorders. One hundred and thirty-five patients underwent ambulatory esophageal manometry and pH monitoring, before, during and immediately after moderate exercise. Patients were divided into four groups: Normal, nutcracker, diffuse spasm and gastroesophageal reflux disease (GERD). Ambulatory manometry and pH were monitored while exercising on a treadmill during which standardized boluses of water were administered. Nutcracker and diffuse spasm patients demonstrated a significant fall in esophageal wave amplitude during exercise compared to controls, which returned rapidly to pre exercise values after resting. There was no evidence of acid reflux in the non-reflux groups during exercise. Reflux was noted in 13 patients with GERD during exercise, none of whom had evidence of reflux at the onset of exercise. When these patients were classified by reflux type, the majority, 11 patients, were found to come from the combined or supine reflux group. Esophageal amplitude in nutcracker esophagus does not increase during moderate exercise. Moderate exercise provokes reflux in GERD patients with combined or supine reflux.

Gastrointestinal endoscopic ultrasonography

Although conventional endoscopy provides excellent visualization of gastrointestinal mucosa, it provides little information about intramural or nearby extramural lesions. The imaging of intraabdominal structures by conventional transabdominal ultrasound is degraded by ultrasound energy attenuation with distance. The provision of an ultrasound probe on a flexible gastrointestinal endoscope, to form an echoendoscope, provides excellent imaging of the gastrointestinal wall and of adjacent extramural structures. During the last two decades, endoscopic ultrasound, using an echoendoscope, has revolutionized the diagnosis and treatment of gastrointestinal diseases that affect the submucosa, deep bowel wall, and adjacent extramural structures. This article reviews the role of endoscopic ultrasound in the diagnosis and treatment of gastrointestinal disease, including standard and promising new applications, as well as standard and emerging new technology.

Perception of esophageal manometry

Esophageal manometry is an important investigation method but its direct impact on patients' well-being has not been studied. A structured questionnaire was given to all patients (n=92) after the manometry during one calendar year. The response rate was 91%. A total of seventy-one patients also reported their health status during the next 24 h. No serious side-effects were recorded. About half of the respondents regarded manometry as an easy or fairly easy investigation. The most common problems were irritation of nose and throat. In total, 48% of the respondents had mild to moderate late symptoms after manometry, usually soreness of the throat or nose lasting for some hours. The manometry was more troublesome to women than to men. It is concluded that esophageal manometry is generally a benign and fairly tolerated investigation, and the high level of anxiety that many patients show before the manometry is not well justified.

Does previous endoscopic treatment affect the outcome of laparoscopic Heller myotomy?

STUDY AIM

Aim of this study was to assess symptomatic and objective outcome in patients undergoing laparoscopic Heller myotomy after unsuccessful endoscopic treatment, compared to patients having primary surgery.

PATIENTS AND METHOD

Between November 1992 and December 1998, 92 patients with esophageal achalasia underwent laparoscopic Heller myotomy and Dor fundoplication. Intraoperative endoscopy was routinely performed. Sixty patients had primary surgery (PS); 32 patients had surgery after unsuccessful pneumatic dilatation (PD) (n = 22), or botulinum toxin (Botox) injection (n = 10).

RESULTS

The mean operative time and the incidence of postoperative dysphagia were similar in the two groups. The incidence of intraoperative mucosal tears was 5% in the PS group and 12.5% in the PD/Botox group (P = NS). Mucosal tears occurred more frequently during the first 30 operations (17% vs 3.2%, P < 0.05). Median follow-up was 28 months (range 4-76). An abnormal esophageal acid exposure was documented in 2 patients in the PS group (7.7%), and in two patients in the PD/Botox group (13.3%) (P = NS). Lower esophageal sphincter pressure significantly decreased in both groups (P < 0.01). The mean percentage of radionuclide residual activity in the esophagus at 1 and 10 minutes significantly decreased in both groups (P < 0.01).

CONCLUSION

There is only a trend, although not statistically significant, towards an increased risk of complications and adverse effects in patients previously treated by PD and/or Botox. The higher incidence of mucosal tears during the first 30 operations suggests the effect of the learning curve.

Esophageal manometric studies in children with achalasia before and after operative treatment

This study manometrically assessed and compared esophageal function in 16 children with achalasia before and after surgical treatment (anterior esophagomyotomy with antireflux partial fundoplication). Manometric examinations were done in 10 children preoperatively and in 12, 3 months to 8 years postoperatively. Both pre- and postoperative examinations were done in 6 patients. The following parameters were measured: lower esophageal sphincter (LES) pressure and length, spontaneous motility of the esophageal body, and motility provoked by swallowing of fluids. Preoperative examinations confirmed disturbances typical for achalasia: increased LES pressure (mean 39.4 mmHg), lack of relaxation upon swallowing, and various types of anomalous esophageal motility (lack of propulsive waves, segmental waves, breaks in propagation of contractions, tonic contractions, etc.). Postoperative examinations showed normalization of LES pressure; however, relaxation did not appear in any patient. Esophageal motility improved after surgery in most patients and was already noticeable 3-6 months postoperatively, but motility never returned to normal. Clinically, all but 1 patient with reflux esophagitis were doing well despite persistent motility disturbances. Our study confirms that achalasia is a complex motor disorder of the entire esophagus. The improvement of esophageal contractility after esophagomyotomy suggests both primary and significant secondary damage to motility of the esophageal body in most patients. It appears that secondary disturbances are reversible to some extent in children after surgical treatment.

Onset of oesophageal peristalsis after surgery for idiopathic achalasia

Twenty-seven patients were treated with a Heller myotomy and Dor fundoplication; some peristaltic contractions occurred in seven after operation. When clinical, radiological and manometric data in the seven patients developing peristalsis were compared with findings in the other 20, there were no differences in symptoms, lower oesophageal sphincter pressures and lengths, relief of dysphagia or oesophageal calibre reduction. Oesophageal resting pressure was lower and oesophageal contraction amplitudes were statistically higher in patients with restored peristalsis, which correlated only with the amplitude of contractions 5 cm above the lower oesophageal sphincter (P < 0.05, 95 percent confidence interval). Peristaltic contractions probably exist before treatment, but are concealed by the dilated oesophagus and the common cavity phenomenon. Achalasia is not necessarily associated with complete aperistalsis. No difference was found in the outcome of surgical treatment, and the return to peristalsis appears to be clinically relevant.

Secondary oesophageal peristalsis in patients with non-obstructive dysphagia

Secondary peristalsis was investigated in 30 patients with non-obstructive dysphagia and 20 age matched controls. Oesophageal motility was recorded at 3 cm intervals along the oesophageal body. Primary peristalsis was tested with 5 ml water swallows. Secondary peristalsis was stimulated with 10 ml boluses of air and water injected in the mid-oesophagus and by distensions (5 seconds duration) with a 3 cm balloon at the same level. Primary peristalsis was normal in 19 of the 20 control subjects and in nine of the 30 patients with dysphagia; 11 patients had diffuse spasm and 10 had non-specific abnormalities of primary peristalsis. Secondary peristalsis was triggered significantly less frequently by air and water distension in dysphagia patients (median success rate of 10% for the air boluses and 0% for the water boluses) than in control subjects (50% and 30% respectively, p < 0.005), and was abnormal in six of nine patients with normal primary peristalsis, nine of 11 patients with diffuse spasm and eight of 10 patients with non-specific motor abnormalities. The median frequency of balloon induced secondary peristalsis, however, was not significantly different in the two groups (0% controls, 40% non-obstructive dysphagia, p = 0.22). For each stimulus, there were no significant differences in the response rate in the three subgroups of patients. The major pattern of failure of secondary peristalsis in response to the air and water boluses was the complete absence of any oesophageal response. The amplitude of complete secondary peristalsis triggered by the water boluses and the balloon was greater in the patients with dysphagia (p = 0.03) than in normal subjects, while the amplitude of the secondary peristaltic responses triggered by the air boluses was similar in the two groups. Secondary peristaltic velocity was also similar in normal subjects and patients with non-obstructive dysphagia. Patients with non-obstructive dysphagia show a noticeable defect in the triggering of secondary peristalsis which may make an important contribution to the delayed oesophageal bolus transit and dysphagia seen in this condition.

Achalasia of the oesophagus: results of treatment

Achalasia of the oesophagus is an uncommon neuromuscular disorder characterized by symptoms of dysphagia and regurgitation of undigested food. The results of treatment of 43 patients with achalasia over 10 years are presented. Clinical data on presenting complaints and duration, and all subsequent treatments, were recorded. Patients were contacted to assess their current symptomatic status.