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Kaniecki T, Hughes M, McMahan Z. Managing gastrointestinal manifestations in systemic sclerosis, a mechanistic approach. Expert Rev Clin Immunol 2024; 20:603-622. [PMID: 38406978 PMCID: PMC11098704 DOI: 10.1080/1744666x.2024.2320205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/14/2024] [Indexed: 02/27/2024]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a connective tissue disease with heterogeneous presentation. Gastrointestinal (GI) complications of SSc are characterized by esophageal reflux, abnormal motility, and microbiome dysbiosis, which impact patient quality of life and mortality. Preventative therapeutics are lacking, with management primarily aimed at symptomatic control. AREAS COVERED A broad literature review was conducted through electronic databases and references from key articles. We summarize the physiology of gastric acid production and GI motility to provide context for existing therapies, detail the current understanding of SSc-GI disease, and review GI medications studied in SSc. Finally, we explore new therapeutic options. We propose a management strategy that integrates data on drug efficacy with knowledge of disease pathophysiology, aiming to optimize future therapeutic targets. EXPERT OPINION SSc-GI complications remain a challenge for patients, clinicians, and investigators alike. Management presently focuses on treating symptoms and minimizing mucosal damage. Little evidence exists to suggest immunosuppressive therapy halts progression of GI involvement or reverses damage, leaving many unanswered questions about the optimal clinical approach. Further research focused on identifying patients at risk for GI progression, and the underlying mechanism(s) that drive disease will provide opportunities to prevent long-term damage, and significantly improve patient quality of life.
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Affiliation(s)
- Timothy Kaniecki
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael Hughes
- Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, US
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Zsuzsanna McMahan
- Division of Rheumatology, UTHealth Houston McGovern Medical School, Houston, TX
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McMahan ZH, Kulkarni S, Chen J, Chen JZ, Xavier RJ, Pasricha PJ, Khanna D. Systemic sclerosis gastrointestinal dysmotility: risk factors, pathophysiology, diagnosis and management. Nat Rev Rheumatol 2023; 19:166-181. [PMID: 36747090 DOI: 10.1038/s41584-022-00900-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 02/08/2023]
Abstract
Nearly all patients with systemic sclerosis (SSc) are negatively affected by dysfunction in the gastrointestinal tract, and the severity of gastrointestinal disease in SSc correlates with high mortality. The clinical complications of this dysfunction are heterogeneous and include gastro-oesophageal reflux disease, gastroparesis, small intestinal bacterial overgrowth, intestinal pseudo-obstruction, malabsorption and the requirement for total parenteral nutrition. The abnormal gastrointestinal physiology that promotes the clinical manifestations of SSc gastrointestinal disease throughout the gastrointestinal tract are diverse and present a range of therapeutic targets. Furthermore, the armamentarium of medications and non-pharmacological interventions that can benefit affected patients has substantially expanded in the past 10 years, and research is increasingly focused in this area. Here, we review the details of the gastrointestinal complications in SSc, tie physiological abnormalities to clinical manifestations, detail the roles of standard and novel therapies and lay a foundation for future investigative work.
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Affiliation(s)
| | - Subhash Kulkarni
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Joan Chen
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Jiande Z Chen
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Ramnik J Xavier
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.,Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - P Jay Pasricha
- Division of Gastroenterology, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA. .,University of Michigan Scleroderma Program, Ann Arbor, MI, USA.
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3
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Cheah JX, Khanna D, McMahan ZH. Management of scleroderma gastrointestinal disease: Lights and shadows. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2022; 7:85-97. [PMID: 35585948 PMCID: PMC9109510 DOI: 10.1177/23971983221086343] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Gastrointestinal symptoms affect the great majority of patients with systemic sclerosis. Management of these complications is often challenging as any region of the gastrointestinal tract may be involved, and significant heterogeneity exists in clinical presentation, kinetics, and outcomes. Here, we highlight new findings relevant to the management of systemic sclerosis-related gastrointestinal disease (lights) and consider areas that we have yet to elucidate (shadows).
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Affiliation(s)
- Jenice X Cheah
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
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4
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Voulgaris TA, Karamanolis GP. Esophageal manifestation in patients with scleroderma. World J Clin Cases 2021; 9:5408-5419. [PMID: 34307594 PMCID: PMC8281422 DOI: 10.12998/wjcc.v9.i20.5408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/22/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Theodoros A Voulgaris
- Department of Gastroenterology and Hepatology, Laiko General Hospital, National and Kapodistian University of Athens, Athens 11527, Greece
| | - Georgios P Karamanolis
- Department of Gastroenterology and Hepatology, Laiko General Hospital, National and Kapodistian University of Athens, Athens 11527, Greece
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Jandee S, Geeraerts A, Geysen H, Rommel N, Tack J, Vanuytsel T. Management of Ineffective Esophageal Hypomotility. Front Pharmacol 2021; 12:638915. [PMID: 34122066 PMCID: PMC8187940 DOI: 10.3389/fphar.2021.638915] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 05/12/2021] [Indexed: 12/13/2022] Open
Abstract
Esophageal hypomotility in general and especially ineffective esophageal motility according to the Chicago criteria of primary motility disorders of the esophagus, is one of the most frequently diagnosed motility disorders on high resolution manometry and results in a large number of patients visiting gastroenterologists. Most patients with esophageal hypomotility present with gastroesophageal reflux symptoms or dysphagia. The clinical relevance of the motility pattern, however, is not well established but seems to be correlated with disease severity in reflux patients. The correlation with dysphagia is less clear. Prokinetic agents are commonly prescribed as first line pharmacologic intervention to target esophageal smooth muscle contractility and improve esophageal motor functions. However, the beneficial effects of these medications are limited and only confined to some specific drugs. Serotonergic agents, including buspirone, mosapride and prucalopride have been shown to improve parameters of esophageal motility although the effect on symptoms is less clear. Understanding on the complex correlation between esophageal hypomotility and esophageal symptoms as well as the limited evidence of prokinetic agents is necessary for physicians to appropriately manage patients with Ineffective Esophageal Motility (IEM).
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Affiliation(s)
- Sawangpong Jandee
- Department of Chronic Diseases, Translational Research Center for Gastrointestinal Disorders (TARGID), Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Annelies Geeraerts
- Department of Chronic Diseases, Translational Research Center for Gastrointestinal Disorders (TARGID), Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
| | - Hannelore Geysen
- Department of Chronic Diseases, Translational Research Center for Gastrointestinal Disorders (TARGID), Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium
| | - Nathalie Rommel
- Department of Chronic Diseases, Translational Research Center for Gastrointestinal Disorders (TARGID), Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium.,Department of Neurosciences, Experimental Otorhinolaryngology, KU Leuven, Leuven, Belgium
| | - Jan Tack
- Department of Chronic Diseases, Translational Research Center for Gastrointestinal Disorders (TARGID), Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, Leuven University Hospitals, Leuven, Belgium
| | - Tim Vanuytsel
- Department of Chronic Diseases, Translational Research Center for Gastrointestinal Disorders (TARGID), Metabolism and Ageing (CHROMETA), KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, Leuven University Hospitals, Leuven, Belgium
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6
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Tack J, Pauwels A, Roman S, Savarino E, Smout A. European Society for Neurogastroenterology and Motility (ESNM) recommendations for the use of high-resolution manometry of the esophagus. Neurogastroenterol Motil 2021; 33:e14043. [PMID: 33274525 DOI: 10.1111/nmo.14043] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/30/2020] [Accepted: 11/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Several patients in gastroenterology practice present with esophageal symptoms, and in case of normal endoscopy with biopsies, high-resolution manometry (HRM) is often the next step. Our aim was to develop a European consensus on the clinical application of esophageal HRM, to offer the clinician guidance in selecting patients for HRM and using its results to optimize clinical outcome. METHODS A Delphi consensus was initiated with 38 multidisciplinary experts from 16 European countries who conducted a literature summary and voting process on 71 statements. Quality of evidence was evaluated using grading of recommendations assessment, development, and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 33 statements. RESULTS The process generated guidance on when to consider esophageal HRM, how to perform it, and how to generate the report. The Delphi process also identified several areas of uncertainty, such as the choice of catheters, the duration of fasting and the position in which HRM is performed, but recommended to perform at least 10 5-ml swallows in supine position for each study. Postprandial combined HRM impedance is considered useful for diagnosing rumination. There is a large lack of consensus on treatment implications of HRM findings, which is probably the single area requiring future targeted research. CONCLUSIONS AND INFERENCES A multinational and multidisciplinary group of European experts summarized the current state of consensus on technical aspects, indications, performance, analysis, diagnosis, and therapeutic implications of esophageal HRM.
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Affiliation(s)
- Jan Tack
- Division of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Ans Pauwels
- Universitaire Ziekenhuis Gasthuisberg, Leuven, Belgium
| | - Sabine Roman
- Department of Digestive Physiology, Hospices Civils de Lyon, Lyon University, Lyon, France
| | | | - André Smout
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
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Dhar SI, Nativ-Zeltzer N, Mehdizadeh OB, Ramaswamy AT, Nachalon Y, Belafsky PC. Effects of Pyridostigmine on Esophageal and Pharyngeal Motility in Dysphagic Patients Undergoing High-Resolution Manometry. Dysphagia 2021; 37:4-10. [PMID: 33452552 DOI: 10.1007/s00455-020-10243-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/30/2020] [Indexed: 02/07/2023]
Abstract
Weak or absent peristalsis of the esophageal musculature is a common finding in ambulatory patients suffering from dysphagia and frequently associated with gastroesophageal reflux. There is currently no pharmacologic intervention that reliably improves esophageal contractility in patients suffering from various esophageal motility disorders. Our objective was to evaluate the acute effects of pyridostigmine on high-resolution manometry parameters in patients suffering from dysphagia with evidence of esophageal dysmotility. Pyridostigmine is an acetylcholinesterase inhibitor which increases effective concentrations of acetylcholine at the neuromuscular junction of both striated and smooth muscle cells. We conducted a prospective crossover study of five patients with dysphagia and proven esophageal dysmotility. Three patients had baseline ineffective esophageal motility and two had achalasia. Patients underwent pharyngeal and esophageal manometry before and after pyridostigmine administration. The median distal contractile integral (DCI), a marker of esophageal contractile vigor, was significantly higher post pyridostigmine administration 3001 (1950.3-3703.2) mmHg × s × cm compared to pre-pyridostigmine DCI of 1229.9 (956.2-2100) mmHg × s × cm; P < 0.001. Pre-pyridostigmine 18/25 (72%) of the patient's swallows was peristaltic compared to 25/25 (100%) post-pyridostigmine; P < 0.005. No other pharyngeal or esophageal high-resolution manometry parameter differed significantly after pyridostigmine administration. The results of this pilot study demonstrate that pyridostigmine acutely improves esophageal contractile vigor in patients suffering from dysphagia with esophageal dysmotility. Further investigation with larger sample size, longer follow-up, side effect profile, and patient-reported outcome measures is still needed to determine the clinical usefulness of pyridostigmine in specific disorders of esophageal motility.
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Affiliation(s)
- Shumon I Dhar
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD, 21287, USA.
| | - Nogah Nativ-Zeltzer
- Department of Otolaryngology-Head and Neck Surgery, Davis, Medical Center, University of California, 2521 Stockton Blvd., Suite 7200, Sacramento, CA, 95817, USA
| | - Omid B Mehdizadeh
- Pacific Eye, Ear, and Skull Base Center, Pacific Neuroscience Institute, 11645 Wilshire Blvd., 6th Floor, Los Angeles, CA, 90025, USA
| | - Apoorva T Ramaswamy
- Department of Otolaryngology-Head and Neck Surgery, Davis, Medical Center, University of California, 2521 Stockton Blvd., Suite 7200, Sacramento, CA, 95817, USA
| | - Yuval Nachalon
- Department of Otolaryngology-Head and Neck Surgery, Davis, Medical Center, University of California, 2521 Stockton Blvd., Suite 7200, Sacramento, CA, 95817, USA
| | - Peter C Belafsky
- Department of Otolaryngology-Head and Neck Surgery, Davis, Medical Center, University of California, 2521 Stockton Blvd., Suite 7200, Sacramento, CA, 95817, USA
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Abstract
PURPOSE OF REVIEW This narrative review focuses on the presentation, contributing factors, diagnosis, and treatment of non-acid reflux. We also propose algorithms for diagnosis and treatment. RECENT FINDINGS There is a paucity of recent data regarding non-acid reflux. The recent Porto and Lyon consensus statements do not fully address non-acid reflux or give guidance on classification. However, recent developments in the lung transplantation field, as well as older data in the general population, argue for the importance of non-acid reflux. Extrapolating from the Porto and Lyon consensus, we generally classify pathologic non-acid reflux as impedance events > 80, acid exposure time < 4%, and positive symptom correlation on a standard 24-h pH/impedance test. Other groups not meeting this criteria also deserve consideration depending on the clinical situation. Potential treatments include lifestyle modification, increased acid suppression, alginates, treatment of esophageal hypersensitivity, baclofen, buspirone, prokinetics, and anti-reflux surgery in highly selected individuals. More research is needed to clarify appropriate classification, with subsequent focus on targeted treatments.
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Affiliation(s)
- Thomas A Zikos
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street, Pavilion C, 3rd Floor, GI suite, Redwood City, CA, 94063, USA.
| | - John O Clarke
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street, Pavilion C, 3rd Floor, GI suite, Redwood City, CA, 94063, USA
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9
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Kim SE, Park MI, Park SJ, Moon W, Kim JH, Jung K, Kwon HJ, Kim GM, Joo HK. Mosapride Improves Lower Esophageal Sphincter and Esophageal Body Function in Patients With Minor Disorders of Esophageal Peristalsis. J Neurogastroenterol Motil 2020; 26:232-240. [PMID: 32235030 PMCID: PMC7176494 DOI: 10.5056/jnm19062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/02/2019] [Accepted: 09/20/2019] [Indexed: 11/20/2022] Open
Abstract
Background/Aims High-resolution manometry (HRM) has broadened the awareness of minor esophageal peristaltic disorders. However, the treatments for these minor disorders are limited and the role of prokinetics has been controversial. This study evaluates the effect of mosapride in patients with minor peristaltic disorders. Methods This study prospectively enrolled 21 patients with esophageal symptoms who were diagnosed with minor peristaltic disorders by gastroscopy and HRM using the Chicago classification version 3.0. Patients received mosapride 30 mg daily for 2 weeks. Symptoms were assessed using the abbreviated World Health Organization quality of life scale (WHOQOL-BREF) and a HRM study was performed before and after 2 weeks of treatment. Results HRM metrics of lower esophageal sphincter (LES) respiratory mean pressure (median 14.6 mmHg vs 17.3 mmHg; interquartile range [IQR] 8.7-22.5 mmHg vs 12.5-25.9 mmHg; P = 0.004) and distal contractile integral (median 343.8 mmHg·sec·cm vs 698.1 mmHg·sec·cm; IQR 286.5-795.9 mmHg·sec·cm vs 361.0-1127.6 mmHg·sec·cm; P = 0.048) were significantly increased after treatment. Complete response (≥ 80.0%), satisfactory response (≥ 50.0%), partial response (< 50.0%), and refractory response rates were 19.0%, 52.4%, 14.3%, and 14.3%, respectively. However, there was no statistical difference in all WHOQOL-BREF scores before and after treatment. Univariate analysis showed LES respiratory mean pressure (P = 0.036) was associated with symptom improvement (complete + satisfactory group). However, no statistical difference was found in other factors after multivariate analysis. Conclusions Mosapride improved esophageal symptoms and significantly increased LES respiratory mean pressure and distal contractile integral. Therefore, mosapride could enhance LES and esophageal body contraction pressures in patients with minor peristaltic disorders.
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Affiliation(s)
- Sung Eun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea.,Department of Internal Medicine, Kosin University Gospel Hospital, Busan, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea.,Department of Internal Medicine, Kosin University Gospel Hospital, Busan, Korea
| | - Seun Ja Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea.,Department of Internal Medicine, Kosin University Gospel Hospital, Busan, Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea.,Department of Internal Medicine, Kosin University Gospel Hospital, Busan, Korea
| | - Jae Hyun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea.,Department of Internal Medicine, Kosin University Gospel Hospital, Busan, Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea.,Department of Internal Medicine, Kosin University Gospel Hospital, Busan, Korea
| | - Hye Jung Kwon
- Department of Internal Medicine, Kosin University Gospel Hospital, Busan, Korea
| | - Gyung Mi Kim
- Department of Internal Medicine, Kosin University Gospel Hospital, Busan, Korea
| | - Hee Kyoung Joo
- Department of Internal Medicine, Kosin University Gospel Hospital, Busan, Korea
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10
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Zhao Q, Chen P, Wang X, Ye H, Zhang X, Song Y, Zhang X. Is Peroral Endoscopic Myotomy a Potential Therapy for Esophageal Absent Contractility? Surg Laparosc Endosc Percutan Tech 2020; 30:129-133. [PMID: 32168166 PMCID: PMC7147407 DOI: 10.1097/sle.0000000000000770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/02/2020] [Indexed: 11/26/2022]
Abstract
AIM Peroral endoscopic myotomy (POEM) is recommended for the endoscopic treatment of achalasia and esophageal junction outflow obstruction (EGJOO); however, absent contractility, a subtype of peristalsis disorders classified by the Chicago Classification of esophageal motility v3.0, has no effective treatment. The purpose of this study was to assess the efficacy of POEM in absent contractility, in the part of the patients presents with dysphagia. METHODS We conducted a single-center retrospective study at a tertiary referral center. We included 30 patients who mainly complain with dysphagia, and they underwent POEM from January 2013 to December 2018. The data of high-resolution esophageal manometry was collected before and after POEM. They were divided into 3 groups: EGJOO, Achalasia, and Absent contractility according to the Chicago Classification of esophageal motility v3.0 before POEM. Telephone follow-up was made in February 2019 to obtain Eckardt scores and weight changes. RESULTS We found that both Eckardt scores and integrated relaxation pressure decreased post-POEM in the 3 groups (P<0.05). Eckardt score was significantly lower in the EGJOO group than in the Absent contractility group (P=0.004) post-POEM. The difference of Eckardt Score was higher in the EGJOO group (P=0.010) and the Achalasia group (P=0.007) than in the Absent contractility group, as was weight gain (P=0.023; P=0.002). CONCLUSIONS These findings suggest that POEM is an effective endoscopic procedure for patients with EGJOO and achalasia. Furthermore, POEM can significantly improve symptoms in patients with absent contractility, although less so than for the other 2 groups. POEM is a potential therapy for absent contractility patients presenting with dysphagia.
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Affiliation(s)
| | | | | | - Hua Ye
- Departments of Gastroenterology
| | | | | | - Xie Zhang
- Pharmacy, Ningbo Medical Center Li Huili Hospital, Zhejiang, China
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11
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Le syndrome de motricité œsophagienne inefficace. Presse Med 2019; 48:897-903. [DOI: 10.1016/j.lpm.2019.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 04/23/2019] [Accepted: 07/03/2019] [Indexed: 12/12/2022] Open
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12
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Tétreault MP, Kahrilas P. GI Manifestations With a Focus on the Esophagus: Recent Progress in Understanding Pathogenesis. Curr Rheumatol Rep 2019; 21:42. [PMID: 31270707 DOI: 10.1007/s11926-019-0841-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Esophageal dysfunction is common in systemic sclerosis (SSc) patients. Limited treatment options are available for scleroderma esophageal disease. Here, we discuss recent updates on the diagnosis, treatment, and characterization that have been made in patients with scleroderma esophageal disease. RECENT FINDINGS In the past few years, novel diagnostic tools have provided insight into esophageal dysmotility in SSc patients. New drugs are being tested and might improve symptoms and quality of life in SSc patients with esophageal dysfunction. Molecular stratification methods have facilitated the identification of molecular signatures in the esophagus of SSc patients. The Friend leukemia integration 1 (Fli1) conditional knockout mouse is the first animal model to report an esophageal phenotype with SSc features. The clinical presentation in SSc patients with esophageal dysfunction is heterogeneous, complicating diagnosis and management. The improvement of diagnostic tools for esophageal symptoms and dysfunction and the use of molecular approaches in SSc mouse models and patient biopsies offer an opportunity to improve the characterization of SSc esophageal disease, which should help improve management and treatment decisions.
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Affiliation(s)
- Marie-Pier Tétreault
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, 15-753 Tarry Building, 300 East Superior Street, Chicago, IL, 60611-3010, USA.
| | - Peter Kahrilas
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, 15-753 Tarry Building, 300 East Superior Street, Chicago, IL, 60611-3010, USA
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13
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Browne PD, Nagelkerke SCJ, van Etten-Jamaludin FS, Benninga MA, Tabbers MM. Pharmacological treatments for functional nausea and functional dyspepsia in children: a systematic review. Expert Rev Clin Pharmacol 2018; 11:1195-1208. [PMID: 30360666 DOI: 10.1080/17512433.2018.1540298] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/22/2018] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Chronic idiopathic nausea (CIN) and functional dyspepsia (FD) cause considerable strain on many children's lives and their families. Areas covered: This study aims to systematically assess the evidence on efficacy and safety of pharmacological treatments for CIN or FD in children. CENTRAL, EMBASE, and Medline were searched for Randomized Controlled Trials (RCTs) investigating pharmacological treatments of CIN and FD in children (4-18 years). Cochrane risk of bias tool was used to assess methodological quality of the included articles. Expert commentary: Three RCTs (256 children with FD, 2-16 years) were included. No studies were found for CIN. All studies showed considerable risk of bias, therefore results should be interpreted with caution. Compared with baseline, successful relief of dyspeptic symptoms was found for omeprazole (53.8%), famotidine (44.4%), ranitidine (43.2%) and cimetidine (21.6%) (p = 0.024). Compared with placebo, famotidine showed benefit in global symptom improvement (OR 11.0; 95% CI 1.6-75.5; p = 0.02). Compared with baseline, mosapride versus pantoprazole reduced global symptoms (p = 0.011; p = 0.009). One study reported no occurrence of adverse events. This systematic review found no evidence to support the use of pharmacological drugs to treat CIN or FD in children. More high-quality clinical trials are needed. ABBREVIATIONS AP-FGID: Abdominal Pain Related Functional Gastrointestinal Disorders; BART: Biofeedback-Assisted Relaxation Training; CIN: Chronic Idiopathic Nausea; COS: Core Outcomes Sets; EPS: Epigastric Pain Syndrome; ESPGHAN: European Society for Pediatric Gastroenterology Hepatology and Nutrition; FAP: Functional Abdominal Pain; FD: Functional Dyspepsia; GERD: Gastroesophageal Reflux Disease; GES: Gastric Electrical Stimulation; H2RAs: H2 Receptor Antagonists; IBS: irritable bowel syndrome; NASPGHAN: North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition; PDS: Postprandial Distress Syndrome; PPIs: Proton Pump Inhibitor; PROMs: Patient Reported Outcome Measures; RCTs: Randomized Controlled Trials; SSRIs: selective serotonin reuptake inhibitors; TCAs: tricyclic antidepressants.
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Affiliation(s)
- Pamela D Browne
- a Emma Children's Hospital, Amsterdam UMC , University of Amsterdam, Pediatric Gastroenterology , Amsterdam , The Netherlands
| | - Sjoerd C J Nagelkerke
- a Emma Children's Hospital, Amsterdam UMC , University of Amsterdam, Pediatric Gastroenterology , Amsterdam , The Netherlands
| | | | - Marc A Benninga
- a Emma Children's Hospital, Amsterdam UMC , University of Amsterdam, Pediatric Gastroenterology , Amsterdam , The Netherlands
| | - Merit M Tabbers
- a Emma Children's Hospital, Amsterdam UMC , University of Amsterdam, Pediatric Gastroenterology , Amsterdam , The Netherlands
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Manini ML, Camilleri M, Grothe R, Di Lorenzo C. Application of Pyridostigmine in Pediatric Gastrointestinal Motility Disorders: A Case Series. Paediatr Drugs 2018; 20:173-180. [PMID: 29243034 DOI: 10.1007/s40272-017-0277-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Gastrointestinal (GI) motility disorders are common in children. Treatment is challenging with limited medical and surgical options. Pyridostigmine, an acetyl cholinesterase inhibitor, increases acetylcholine at the neuromuscular junction promoting intestinal contractions. Little is known about the role and dosing of pyridostigmine in pediatric GI motility disorders. METHODS We present a case series of children with GI dysmotility managed with oral pyridostigmine. Patients' diagnoses include chronic intestinal pseudo-obstruction, gastroparesis with delayed small bowel transit, chronic constipation with failure to thrive, and prolonged ileus after pelvic surgery with chronic opioid use. RESULTS Pyridostigmine was effective and safe in all cases. Pyridostigmine decreased abdominal distention, increased bowel movement frequency, and improved enteral feeding tolerance. Effective dosing ranged between 0.25-2.0 mg/kg/day. One patient experienced cramping abdominal pain while on pyridostigmine, but pain resolved after medication was discontinued. CONCLUSION We found oral pyridostigmine to be helpful in children with different GI motility problems. Pyridostigmine should be considered in such patients when other treatment interventions have not been beneficial.
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Affiliation(s)
- Mhd Louai Manini
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | | | - Rayna Grothe
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Carlo Di Lorenzo
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
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Rangan V, George NS, Khan F, Geng Z, Gabbard S, Kichler A, Gittleman H, Fass R. Severity of ineffective esophageal motility is associated with utilization of skeletal muscle relaxant medications. Neurogastroenterol Motil 2018; 30:e13235. [PMID: 29027725 DOI: 10.1111/nmo.13235] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 09/19/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Ineffective esophageal motility (IEM) is the most common finding on high-resolution esophageal manometry (HREM). The underlying mechanisms for IEM remain to be fully elucidated. The aim of this study was to determine if utilization of skeletal muscle relaxants is associated with IEM, and with more severe subtypes of the disorder. METHODS Patients with diagnosis of IEM were gender and age matched to patients with normal HREM. Demographic information, symptoms, endoscopic findings, medication usage and medical comorbidities were recorded. Patients with a diagnosis of IEM were divided into subgroups based on mean distal contractile integral (DCI) and percentage of ineffective swallows, and assessed for clinically significant differences among patients with varying severity of underlying IEM. KEY RESULTS A total of 118 patients were included in each group. There were no significant clinical differences between the group of patients with IEM and the group of patients with normal manometry. Within the group of IEM patients, those with mean DCI < 250 mm Hg/s/cm were more likely to be prescribed skeletal muscle relaxants (27.8% vs 11.0%, P = .044), and those using skeletal muscle relaxants had a larger mean percentage of ineffective swallows (81.1% vs 71.5%, P = .029). There were no significant differences across mean DCI subgroups in usage of any other medication, or in any of the demographic variables or disease comorbidities examined in this study. CONCLUSIONS & INFERENCES Use of skeletal muscle relaxants is associated with more severe IEM, which may suggest a causal association between this class of medications and weaker esophageal peristalsis.
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Affiliation(s)
- V Rangan
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - N S George
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - F Khan
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Z Geng
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - S Gabbard
- The Esophageal Center, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A Kichler
- The Esophageal Center, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - H Gittleman
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - R Fass
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
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16
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Aggarwal N, Thota PN, Lopez R, Gabbard S. A randomized double-blind placebo-controlled crossover-style trial of buspirone in functional dysphagia and ineffective esophageal motility. Neurogastroenterol Motil 2018; 30. [PMID: 28884884 DOI: 10.1111/nmo.13213] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 08/19/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Studies suggest that Ineffective Esophageal Motility (IEM) is the manometric correlate of Functional Dysphagia (FD). Currently, there is no accepted therapy for either condition. Buspirone is a serotonin modulating medication and has been shown to augment esophageal peristaltic amplitude in healthy volunteers. We aimed to determine if buspirone improves manometric parameters and symptoms in patients with overlapping IEM/FD. METHODS We performed a prospective, double-blind, placebo-controlled, crossover-style trial of 10 patients with IEM/FD. The study consisted of two 2-week treatment arms with a 2-week washout period. Outcomes measured at baseline, end of week 2, and week 6 include high resolution esophageal manometry (HREM), the Mayo Dysphagia Questionnaire-14 (MDQ-14), and the GERD-HRQL. RESULTS The mean age of our 10 patients was 53 ± 9 years and 70% were female. After treatment with buspirone, 30% of patients had normalization of IEM on manometry; however, there was 30% normalization in the placebo group as well. Comparing buspirone to placebo, there was no statistically significant difference in the HREM parameters measured. There was also no statistically significant difference in symptom outcomes for buspirone compared to placebo. Of note, patients had a statistically significant decrease in the total GERD-HRQL total score when treated with placebo compared to baseline levels. DISCUSSION Despite previous data demonstrating improved esophageal motility in healthy volunteers, our study shows no difference in terms of HREM parameters or symptom scores in IEM/FD patients treated with buspirone compared to placebo. Further research is necessary to identify novel agents for this condition.
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Affiliation(s)
- Nitin Aggarwal
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, 44195, USA
| | | | - Rocio Lopez
- Department of Biostatistics, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Scott Gabbard
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, 44195, USA
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17
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Pyridostigmine for the treatment of gastrointestinal symptoms in systemic sclerosis. Semin Arthritis Rheum 2018; 48:111-116. [PMID: 29397195 DOI: 10.1016/j.semarthrit.2017.12.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 11/18/2017] [Accepted: 12/18/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND/PURPOSE Symptoms of gastrointestinal dysmotility are common among patients with systemic sclerosis (SSc), and the management of severe cases is often limited by a relative lack of effective interventions. The objective of this case series was to review our experience with pyridostigmine as a treatment for patients with SSc and symptomatic gastrointestinal disease. METHODS This study evaluated rates of symptom improvement, side effects, medication adherence, and dose ranges for SSc patients prescribed pyridostigmine for refractory gastrointestinal symptoms over a 10-year period at a quaternary referral center. Patients were defined as responders if they remained on pyridostigmine for at least 4 weeks and clinical benefit was documented by the recorded response of the patient or by the treating physician RESULTS: Of 31 patients treated with pyridostigmine for at least 4 weeks, 51.6% reported symptomatic improvement. Constipation was the most commonly improved symptom based on prevalence prior to therapy (noted by 6/20 patients suffering with constipation). Fifteen of 31 patients reported adverse effects, most commonly diarrhea. Throughout the duration of follow-up (median 126 days, range: 28-506 days), pyridostigmine was continued by 81.3% of patients who reported symptomatic benefit and 58.1% of patients overall. CONCLUSIONS Pyridostigmine holds promise for the treatment of various gastrointestinal symptoms in SSc patients, particularly in patients with refractory constipation. Though side effects may limit its use, most patients who experienced benefit chose to continue therapy.
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Aggarwal N, Lopez R, Gabbard S, Wadhwa N, Devaki P, Thota PN. Spectrum of esophageal dysmotility in systemic sclerosis on high-resolution esophageal manometry as defined by Chicago classification. Dis Esophagus 2017; 30:1-6. [PMID: 28881879 DOI: 10.1093/dote/dox067] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 05/19/2017] [Indexed: 12/11/2022]
Abstract
The classic manometric findings in systemic sclerosis are aperistalsis of the esophageal body with hypotensive lower esophageal sphincter. These changes contribute to gastroesophageal reflux disease in these patients. With widespread use of high-resolution esophageal manometry, diverse abnormalities are seen. The aim of this study is to characterize esophageal dysmotility in patients with systemic sclerosis undergoing high-resolution esophageal manometry and compare demographic features and diagnostic test results among patients with varying degrees of esophageal dysmotility. Patients with systemic sclerosis who underwent high-resolution esophageal manometry between January 2008 and October 2014 at our institution were identified. High-resolution esophageal manometry studies were reinterpreted using the Chicago Classification, v3.0 criteria. We also reviewed the patient charts for demographic data, indications for manometry, esophagogastroduodenoscopy findings, pH studies, medication use, and autoantibody panel. The cohort consisted of 122 patients with a mean age of 53.3 ± 15.3 years. High-resolution esophageal manometry was normal in 23, showed ineffective esophageal motility in 22, absent contractility in 73, and one case each of type II achalasia, esophagogastric junction outflow obstruction, hypercontractile esophagus, and distal esophageal spasm. Patients with absent contractility were younger and more likely to have erosive esophagitis, hiatal hernia, and esophageal strictures than patients with ineffective esophageal motility or normal manometry. There were no statistically significant differences in the groups based on autoantibodies or indications for manometry. Diverse esophageal motility abnormalities were noted in systemic sclerosis with ineffective esophageal motility or absent contractility observed in over three-fourth of the patients. Patients with absent contractility were younger and had more severe reflux. The severity of gastroesophageal reflux disease related endoscopic findings correlated with the degree of esophageal dysmotility on high-resolution esophageal manometry.
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Affiliation(s)
- N Aggarwal
- Departments of Gastroenterology and Hepatology
| | - R Lopez
- Biostatistics, Cleveland Clinic, Cleveland, Ohio, USA
| | - S Gabbard
- Departments of Gastroenterology and Hepatology
| | - N Wadhwa
- Departments of Gastroenterology and Hepatology
| | - P Devaki
- Departments of Gastroenterology and Hepatology
| | - P N Thota
- Departments of Gastroenterology and Hepatology
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19
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Eker A, Kaymakamzade B, Akpinar S. Treatment of Wallenberg's Syndrome related dysphagia with pyridostigmine. Acta Neurol Belg 2017; 117:329-331. [PMID: 27424039 DOI: 10.1007/s13760-016-0664-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/20/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Amber Eker
- Department of Neurology, Faculty of Medicine, Near East University, Nicosia, Cyprus.
| | - Bahar Kaymakamzade
- Department of Neurology, Faculty of Medicine, Near East University, Nicosia, Cyprus
| | - Suha Akpinar
- Department of Radiology, Faculty of Medicine, Near East University, Nicosia, Cyprus
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Abdel Jalil AA, Castell DO. Ineffective Esophageal Motility (IEM): the Old-New Frontier in Esophagology. Curr Gastroenterol Rep 2016; 18:1. [PMID: 26685862 DOI: 10.1007/s11894-015-0472-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Ineffective esophageal motility (IEM) is characterized by distal esophageal contraction amplitude of <30 mmHg on conventional manometry (Blonski et al. Am J Gastroenterol. 103(3):699-704, 2008), or a distal contractile integral (DCI) < 450 mmHg*s*cm on high-resolution manometry (HRM) (Kahrilas et al. Neurogastroenterol Motil. 27(2):160-74, 2015) in≥50 % of test swallows. IEM is the most common abnormality on esophageal manometry, with an estimated prevalence of 20-30 % (Tutuian and Castell Am J Gastroenterol. 99(6):1011-9, 2004; Conchillo et al. Am J Gastroenterol. 100(12):2624-32, 2005). Non-obstructive dysphagia has been considered to be frequently associated with severe esophageal peristaltic dysfunction. Defective bolus transit (DBT) on multichannel intraluminal impedance testing was found in more than half of IEM patients who presented with dysphagia (Tutuian and Castell Am J Gastroenterol. 99(6):1011-9, 2004), highlighting the functional defect of this manometric finding. Treatment of IEM has been challenging because of lack of promotility agents that have a definite effect on esophageal function.
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Affiliation(s)
- Ala' A Abdel Jalil
- Division of Gastroenterology & Hepatology, University of Missouri-Columbia, One Hospital Dr., CE 405, Columbia, MO, 65212, USA.
| | - Donald O Castell
- Esophageal Disorders Program, Gastroenterology & Hepatology Division, Medical University of South Carolina (MUSC), 114 Doughty St. Suite 249, MSC 702, Charleston, SC, 29425, USA.
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21
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Karamanolis GP, Panopoulos S, Denaxas K, Karlaftis A, Zorbala A, Kamberoglou D, Ladas SD, Sfikakis PP. The 5-HT1A receptor agonist buspirone improves esophageal motor function and symptoms in systemic sclerosis: a 4-week, open-label trial. Arthritis Res Ther 2016; 18:195. [PMID: 27586891 PMCID: PMC5009650 DOI: 10.1186/s13075-016-1094-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 08/16/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Acute administration of the oral 5-HT1A receptor agonist buspirone, which is commonly used as an anxiolytic drug, may improve compromised lower esophageal sphincter function. In an open-label trial we assessed the effects of buspirone on esophageal motor function and symptoms in patients with esophageal involvement associated with systemic sclerosis (SSc). METHODS Thirty consecutive patients with SSc and symptomatic esophageal involvement, despite treatment with proton pump inhibitors, underwent high resolution manometry and chest computed tomography for assessment of motor function and esophageal dilatation, respectively. Regurgitation, heartburn, dysphagia, and chest pain severity was subjectively scored by visual analog scales. Manometric parameters (primary endpoint) and symptom severity (secondary endpoint) were re-examined after 4-week daily administration of 20 mg buspirone. Other medications remained unchanged. RESULTS Eight patients did not complete the trial because of buspirone-associated dizziness (n = 2), or nausea (n = 2), or reluctancy to undergo final manometry. In the remaining 22 patients lower esophageal sphincter (LES) resting pressure increased from 7.7 ± 3.9 to 12.2 ± 4.6 mmHg (p = 0.00002) after buspirone administration; other manometric parameters did not change. Statistical analysis revealed negative correlation between individual increases in resting LES pressure and supra-aortic esophageal diameter (r = -0.589, p = 0.017), suggesting a more beneficial effect in patients with less severely affected esophageal function. Heartburn and regurgitation scores decreased at 4 weeks compared to baseline (p = 0.001, and p = 0.022, respectively). CONCLUSION Our findings warrant more conclusive evaluation with a double-blind controlled study; however, buspirone could potentially be given under observation for objective improvement in all patients with SSc who report reflux symptoms despite undergoing standard treatment. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02363478 Registered: 21-02-2014.
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Affiliation(s)
- George P Karamanolis
- Academic Department of Gastroenterology, "Laiko" Hospital, Athens Medical School National and Kapodistrian University, Athens, Greece.
| | - Stylianos Panopoulos
- Joint Academic Rheumatology Programme, Athens Medical School National and Kapodistrian University, Athens, Greece
| | - Konstantinos Denaxas
- Academic Department of Gastroenterology, "Laiko" Hospital, Athens Medical School National and Kapodistrian University, Athens, Greece
| | - Anastasios Karlaftis
- Academic Department of Gastroenterology, "Laiko" Hospital, Athens Medical School National and Kapodistrian University, Athens, Greece
| | - Alexandra Zorbala
- Joint Academic Rheumatology Programme, Athens Medical School National and Kapodistrian University, Athens, Greece
| | - Dimitrios Kamberoglou
- Academic Department of Gastroenterology, "Laiko" Hospital, Athens Medical School National and Kapodistrian University, Athens, Greece
| | - Spiros D Ladas
- Academic Department of Gastroenterology, "Laiko" Hospital, Athens Medical School National and Kapodistrian University, Athens, Greece
| | - Petros P Sfikakis
- Joint Academic Rheumatology Programme, Athens Medical School National and Kapodistrian University, Athens, Greece
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Abstract
Ingestion and digestion of food as well as expulsion of residual material from our gastrointestinal tract requires normal propulsive, i.e. motor, function. Hypomotility refers to inherited or acquired changes that come with decreased contractile forces or slower transit. It not only often causes symptoms but also may compromise nutritional status or lead to other complications. While severe forms, such as pseudo-obstruction or ileus, may have a tremendous functional impact, the less severe forms of hypomotility may well be more relevant, as they contribute to common disorders, such as functional dyspepsia, gastroparesis, chronic constipation, and irritable bowel syndrome (IBS). Clinical testing can identify changes in contractile activity, defined by lower amplitudes or abnormal patterns, and the related effects on transit. However, such biomarkers show a limited correlation with overall symptom severity as experienced by patients. Similarly, targeting hypomotility with pharmacological interventions often alters gut motor function but does not consistently improve symptoms. Novel diagnostic approaches may change this apparent paradox and enable us to obtain more comprehensive information by integrating data on electrical activity, mechanical forces, patterns, wall stiffness, and motions with information of the flow of luminal contents. New drugs with more selective effects or more specific delivery may improve benefits and limit adverse effects. Lastly, the complex regulation of gastrointestinal motility involves the brain-gut axis as a reciprocal pathway for afferent and efferent signaling. Considering the role of visceral input in emotion and the effects of emotion on visceral activity, understanding and managing hypomotility disorders requires an integrative approach based on the mind-body continuum or biopsychosocial model of diseases.
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Affiliation(s)
- Klaus Bielefeldt
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ashok Tuteja
- Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Salman Nusrat
- Department of Medicine, Oklahoma University Medical Center, Oklahoma City, OK, USA
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Abstract
BACKGROUND The use of psychotropic medications, particularly antidepressants, is common in patients with inflammatory bowel disease (IBD) in spite of a lack of their robust efficacy in this population. This review provides an overview of the use trends of different classes of antidepressant and anti-anxiety medication and their effects on mood, nervous system function, gastrointestinal physiology and immunity drawing from the literature available in the general population, other medical conditions, and when available, patients with IBD. It also covers the evidence base for the actions, efficacy, and potential complications of antidepressants organized by different classes. METHODS We conducted a PubMed search of articles relating the different drug classes probed to the terms above in different populations of interest. All types of articles were accepted including case reports and series, open and randomized trials, reviews, and expert opinion. We also examined the reference lists of the publications found. RESULTS Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) are the most commonly prescribed agents for anxiety and depression in patients with IBD, though their efficacy for these conditions in the general population are mild to moderate at best. SSRIs are generally well tolerated, though at higher doses, they, like most antidepressant classes, can be associated with activation, serotonergic syndrome, and increased suicidal ideation. TCAs have many more serious side effects but have some shown efficacy for functional GI symptoms. A newer class, the serotonin noradrenergic reuptake inhibitors (SNRIs), can be effective for refractory depression, anxiety and chronic pain syndromes with a side effect profile similar to both SSRIs and more mild manifestations of TCAs. Mirtazapine has moderate efficacy for depression if sedation and weight gain side effects are tolerated and some small support for use in nausea and vomiting. Bupropion targets dopamine and noradrenaline reuptake and has moderate efficacy for depression, and some small support for use in fatigue and smoking cessation. Buspirone has an indication for generalized anxiety disorder though studies show only a minimal benefit. It has some growing evidence for use in functional dyspepsia. Most of these agents have physiological effects on the brain, immune system, and gastrointestinal tract (with the exception of bupropion) hence their therapeutic and side effects manifested in these systems. CONCLUSION Antidepressant medications are frequently prescribed for depression, anxiety disorders, and chronic pain syndromes, but overall support for their efficacy is modest at best. Psychological interventions have growing support for having much more robust effects without the side effects of antidepressants and should be considered first-line treatment or at least an adjunct to psychotropic medications for these conditions.
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Ruiz de León San Juan A, Ciriza de los Ríos C, Pérez de la Serna Bueno J, Canga Rodríguez-Valcárcel F, Estremera Arévalo F, García Sánchez R, Huamán Ríos JW, Pérez Fernández MT, Santander Vaquero C, Serra Pueyo J, Sevilla Mantilla C, Barba Orozco E, Bosque López MJ, Casabona Francés S, Carrión Bolorino S, Castillo Grau P, Delgado Aros S, Domínguez Carbajo AB, Fernández Orcajo P, García-Lledó J, Gigantó Tomé F, Iglesias Picazo R, Lacima Vidal G, López López P, Llabrés Rosselló M, Mas Mercader P, Mego Silva M, Mendarte Barrenetxea MU, Miliani Molina C, Oreja Arrayago M, Sánchez Ceballos F, Sánchez Prudencio S. Practical aspects of high resolution esophageal manometry. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 109:91-105. [DOI: 10.17235/reed.2016.4441/2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Scheerens C, Tack J, Rommel N. Buspirone, a new drug for the management of patients with ineffective esophageal motility? United European Gastroenterol J 2015; 3:261-5. [PMID: 26137300 DOI: 10.1177/2050640615585688] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 04/14/2015] [Indexed: 01/05/2023] Open
Abstract
Ineffective esophageal motility (IEM) is the most frequently encountered esophageal motility disorder. Patients may present with a variety of symptoms, such as dysphagia, heartburn, odynophagia, and regurgitation. Over the past years, the landscape of esophageal motility testing has been revolutionized; however, our current treatment options for IEM still remain limited. Previous studies have suggested that buspirone, a serotonin receptor agonist, enhances esophageal peristalsis and lower esophageal sphincter (LES) function. Recent work provides the first evidence that buspirone may influence LES resting pressure in patients with systemic sclerosis. Future research should evaluate whether the beneficial effects of buspirone also apply to the broad clinical entity of esophageal dysphagia patients with IEM.
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Affiliation(s)
- Charlotte Scheerens
- KU Leuven -- University of Leuven, Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, Leuven, Belgium ; KU Leuven -- University of Leuven, Research Group Experimental Otorhinolaryngology (ExpORL), Department of Neurosciences, Leuven, Belgium
| | - Jan Tack
- KU Leuven -- University of Leuven, Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, Leuven, Belgium ; UZ Leuven -- University Hospitals Leuven, Neurogastroenterology and Motility Clinic, Department of Internal Medicine, Division of Gastroenterology, Leuven, Belgium
| | - Nathalie Rommel
- KU Leuven -- University of Leuven, Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, Leuven, Belgium ; KU Leuven -- University of Leuven, Research Group Experimental Otorhinolaryngology (ExpORL), Department of Neurosciences, Leuven, Belgium ; UZ Leuven -- University Hospitals Leuven, Neurogastroenterology and Motility Clinic, Department of Internal Medicine, Division of Gastroenterology, Leuven, Belgium
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26
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Karamanolis GP, Panopoulos S, Karlaftis A, Denaxas K, Kamberoglou D, Sfikakis PP, Ladas SD. Beneficial effect of the 5-HT1A receptor agonist buspirone on esophageal dysfunction associated with systemic sclerosis: A pilot study. United European Gastroenterol J 2015; 3:266-71. [PMID: 26137301 DOI: 10.1177/2050640614560453] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/15/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Esophageal involvement in systemic sclerosis (SSc) carries significant morbidity and is empirically managed with domperidone, albeit with questionable efficacy. The oral 5-HT1A receptor agonist buspirone may enhance esophageal peristalsis and lower esophageal sphincter (LES) function in healthy volunteers. AIM We aimed to test the hypothesis that buspirone may exert a beneficial acute effect on esophageal motor dysfunction in symptomatic patients with SSc. METHODS Twenty consecutive patients with SSc reporting esophageal symptoms underwent high-resolution manometry before and 30 minutes after administration of buspirone (10 mg). Ten other patients received domperidone (10 mg) and served as control group. Changes in LES resting and residual pressure, amplitude, duration, and velocity of distal esophageal body contractions were examined. RESULTS Esophageal hypomotility and hypotensive LES was found in 63% and 67% of patients, respectively. Demographic and clinical characteristics, including baseline manometric parameters, were comparable between groups. Resting pressure of LES increased after buspirone from 9.42 ± 2.6 to 11.53 ± 3.4 mmHg (p = 0.0002 by paired t-test), but not after domperidone; a trend for increase of amplitude of contractions was also observed after buspirone (p = 0.09). Comparison of the individual changes revealed that buspirone was superior to domperidone in enhancing LES pressure ( + 2.11 ± 2.0 versus -0.45 ± 2.3 mmHg, p = 0.006). No significant effects of either drug were noted on other examined parameters of esophageal function. CONCLUSION The beneficial acute effect of buspirone on impaired LES function associated with SSc suggests a role of 5-HT1A receptor-mediated interactions in these patients. Prospective studies to examine whether buspirone is of long-term therapeutic value for SSc-associated esophageal disease are warranted.
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Affiliation(s)
- George P Karamanolis
- Academic Department of Gastroenterology, Athens Medical School, "Laiko" GH, Athens, Greece
| | - Stylianos Panopoulos
- Rheumatology Unit, First Department of Propaedeutic and Internal Medicine, Athens Medical School "Laiko" GH, Athens, Greece
| | - Anastasios Karlaftis
- Academic Department of Gastroenterology, Athens Medical School, "Laiko" GH, Athens, Greece
| | - Konstantinos Denaxas
- Academic Department of Gastroenterology, Athens Medical School, "Laiko" GH, Athens, Greece
| | - Dimitrios Kamberoglou
- Academic Department of Gastroenterology, Athens Medical School, "Laiko" GH, Athens, Greece
| | - Petros P Sfikakis
- Rheumatology Unit, First Department of Propaedeutic and Internal Medicine, Athens Medical School "Laiko" GH, Athens, Greece
| | - Spiros D Ladas
- Academic Department of Gastroenterology, Athens Medical School, "Laiko" GH, Athens, Greece
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27
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Abstract
High-resolution manometry enables the categorization of patients with oesophageal dysphagia caused by oesophageal motility disorders into diagnostic categories according to the Chicago Classification. This Review provides an overview of the literature concerning treatment options for patients with dysphagia associated with achalasia, hypercontractile disorders and hypocontractility disorders of the oesophagus. In achalasia, pharmacotherapy and botulinum toxin are less effective than pneumatic dilation or surgical Heller myotomy, which had comparable efficacy in the largest controlled trial to date. Peroral endoscopic myotomy is a novel therapeutic modality that is currently being evaluated in controlled trials versus pneumatic dilation or surgical myotomy. A variety of medical treatments have been evaluated in hypermotility disorders, but only botulinum toxin injection yielded favourable results in a single controlled trial. Few studies have addressed the treatment of dysphagia in patients with oesophageal hypomotility. A variety of prokinetic agents have been studied, but there is no evidence of clinically relevant efficacy from controlled trials.
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Affiliation(s)
- Jan Tack
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Giovanni Zaninotto
- Imperial College, Department of Surgery and Cancer, St Mary's Hospital, Praed Street, Paddington, London W2 1NY, UK
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Omari T, Tack J, Rommel N. Impedance as an adjunct to manometric testing to investigate symptoms of dysphagia: What it has failed to do and what it may tell us in the future. United European Gastroenterol J 2014; 2:355-66. [PMID: 25360313 DOI: 10.1177/2050640614549096] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 07/31/2014] [Indexed: 12/17/2022] Open
Abstract
Dysphagia is a common reason for referral for investigations of oesophageal motility. Impedance measurement has now been incorporated into commercially available diagnostic manometry systems for more than a decade. This innovation, which offered the ability to record patterns of bolus transport without the need for simultaneous radiology, has for the most part failed to live up to expectations, offering few additional diagnostic insights. This review examines the potential pitfalls related to how impedance patterns are currently analysed and introduces and discusses the new concept of pressure-flow analysis integrating pressure and impedance measurements to derive new metrics linked to the pressures occurring within and around the bolus as it is being transported.
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Affiliation(s)
- T Omari
- School of Medicine, Flinders University, Bedford Park, Australia ; The Robinson Institute, University of Adelaide, Adelaide, Australia ; Translational Research Center for Gastrointestinal Diseases, University of Leuven, Belgium
| | - J Tack
- Translational Research Center for Gastrointestinal Diseases, University of Leuven, Belgium
| | - N Rommel
- Translational Research Center for Gastrointestinal Diseases, University of Leuven, Belgium ; Neurosciences, ExpORL, University of Leuven, Belgium
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29
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Maradey-Romero C, Gabbard S, Fass R. Treatment of esophageal motility disorders based on the chicago classification. ACTA ACUST UNITED AC 2014; 12:441-55. [PMID: 25263532 DOI: 10.1007/s11938-014-0032-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OPINION STATEMENT The Chicago Classification divides esophageal motor disorders based on the recorded value of the integrated relaxation pressure (IRP). The first group includes those with an elevated mean IRP that is associated with peristaltic abnormalities such as achalasia and esophagogastric junction outflow obstruction. The second group includes those with a normal mean IRP that is associated with esophageal hypermotility disorders such as distal esophageal spasm, hypercontractile esophagus (jackhammer esophagus), and hypertensive peristalsis (nutcracker esophagus). The third group includes those with a normal mean IRP that is associated with esophageal hypomotility peristaltic abnormalities such as absent peristalsis, weak peristalsis with small or large breaks, and frequent failed peristalsis. The therapeutic options vary greatly between the different groups of esophageal motor disorders. In achalasia patients, potential treatment strategies comprise medical therapy (calcium channel blockers, nitrates, and phosphodiesterase 5 inhibitors), endoscopic procedures (botulinum toxin A injection, pneumatic dilation, or peroral endoscopic myotomy) or surgery (Heller myotomy). Patients with a normal IRP and esophageal hypermotility disorder are candidates for medical therapy (nitrates, calcium channel blockers, phosphodiesterase 5 inhibitors, cimetropium/ipratropium bromide, proton pump inhibitors, benzodiazepines, tricyclic antidepressants, trazodone, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors), endoscopic procedures (botulinum toxin A injection and peroral endoscopic myotomy), or surgery (Heller myotomy). Lastly, in patients with a normal IRP and esophageal hypomotility disorder, treatment is primarily focused on controlling the presence of gastroesophageal reflux with proton pump inhibitors and lifestyle modifications (soft and liquid diet and eating in the upright position) to address patient's dysphagia.
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Affiliation(s)
- Carla Maradey-Romero
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Case Western Reserve University, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH, 44109 -1998, USA
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Bolkhir A, Gyawali CP. Treatment Implications of High-Resolution Manometry Findings: Options for Patients With Esophageal Dysmotility. ACTA ACUST UNITED AC 2014; 12:34-48. [DOI: 10.1007/s11938-013-0003-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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31
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O'Rourke A, Weinberger P, Morrison M, Conklin J, Postma G. Topical bethanechol for the improvement of esophageal dysmotility: a pilot study. Ann Otol Rhinol Laryngol 2013; 122:481-6. [PMID: 24027856 DOI: 10.1177/000348941312200801] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We studied a case series to evaluate the effect of topical bethanechol chloride on esophageal function in individuals with ineffective esophageal motility. METHODS Five subjects with ineffective esophageal motility underwent high resolution esophageal manometry. Ten 5 mL liquid swallows were performed to establish a baseline. Five milligrams of topical bethanechol was then administered. After 10 minutes, the subjects completed 10 additional liquid swallows. This procedure was repeated with 10 mg of bethanechol in 4 subjects. RESULTS After administration of 5 mg of topical bethanechol, the mean (+/- SD) distal contractile integral, an index of esophageal contractility, increased from 178.3 +/- 83.1 mm Hg x s x cm to 272.3 +/- 216.9 mm Hg x s x cm (p = 0.69). The percentage of failed swallows decreased from 52.8% +/- 33.2% to 29.4% +/- 18.3% (p = 0.14). The percentage of peristaltic swallows increased from 28.0% +/- 26.8% to 67.2% +/- 15.3% (p = 0.04). The contractile front velocity was essentially unchanged. After administration of 10 mg of bethanechol,the distal contractile integral decreased from 349.3 +/- 371.0 mm Hg x s x cm to 261.8 +/- 293.5 mm Hg x s x cm (p = 0.72). The percentage of failed swallows increased from 57.5% +/- 37.7% to 66.8% +/- 24.9% (p = 0.46). The percentage of peristaltic swallows increased from 17.5% +/- 23.6% to 28.3% +/- 19.1% (p = 0.29). The contractile front velocity decreased from 11.6 +/- 5.2 cm/s to 4.9 +/- 3.0 cm/s (p = 0.32). No adverse side effects occurred. CONCLUSIONS The results of this pilot study support the need for further investigation with larger sample sizes and dose escalation.
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Affiliation(s)
- Ashli O'Rourke
- Department of Otolaryngology-Head and Neck Surgery, Center for Voice, Airway and Swallowing Disorders, Georgia Regents University, Augusta, Georgia, USA
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Di Stefano M, Papathanasopoulos A, Blondeau K, Vos R, Boecxstaens V, Farré R, Rommel N, Tack J. Effect of buspirone, a 5-HT1A receptor agonist, on esophageal motility in healthy volunteers. Dis Esophagus 2012; 25:470-6. [PMID: 22050410 DOI: 10.1111/j.1442-2050.2011.01275.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There are limited data concerning the effects of 5-HT(1A) receptor activation on esophageal motility. Sumatriptan, a 5-HT(1A) receptor agonist, was recently reported to enhance esophageal peristalsis after intravenous administration. Buspirone, an orally available 5-HT(1A) receptor agonist, was shown to modulate gastroduodenal motor function. Our aim was to evaluate the effect of buspirone on esophageal motility of healthy volunteers. On two separate visits, 20 healthy volunteers aged 21-29 years (nine women) underwent esophageal manometry before and 10, 30, and 60 minutes after the administration of buspirone 20-mg or placebo capsule, according to a double-blind crossover design. At each time point, we compared buspirone and placebo effects on: resting pressure of the lower esophageal sphincter (LES); residual pressure and duration of LES relaxation; amplitude, duration, and onset velocity of esophageal body contractions, during 10 swallows of 5 mL of water. Significant analysis of variance differences (P < 0.05) are presented as mean ± standard deviation. Buspirone significantly increased mean distal esophageal wave amplitude (151 vs. 87 mmHg, P < 0.05) and duration (6.1 vs. 4.2 seconds, P < 0.05). Similarly, buspirone significantly increased mean LES resting pressure (26 vs. 21 mmHg, P < 0.05) and mean residual LES pressure (7.9 vs. 2 mmHg, P < 0.05), whereas reduced mean LES relaxation duration (7.2 vs. 8.0 seconds, P < 0.05) and mean distal onset velocity (7.6 vs. 14.7 cm/second, P < 0.05). Buspirone enhances esophageal peristalsis and LES function in healthy volunteers. Further study is warranted on the effects of buspirone on esophageal function and symptoms in patients with ineffective esophageal motility.
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Affiliation(s)
- M Di Stefano
- Department of Internal Medicine, Division of Gastroenterology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
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Abstract
BACKGROUND Weak and absent esophageal peristalsis are frequently encountered esophageal motility disorders, which may be associated with dysphagia and which may contribute to gastroesophageal reflux disease. Recently, rapid developments in the diagnostic armamentarium have taken place, in particular, in high-resolution manometry with or without concurrent intraluminal impedance monitoring. PURPOSE This article aims to review the current insights in the terminology, pathology, pathophysiology, clinical manifestations, diagnostic work-up,and management of weak and absent peristalsis.
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Affiliation(s)
- André Smout
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands.
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