1
|
Sikavi DR, Cai JX, Carroll TL, Chan WW. Prevalence and clinical significance of esophageal motility disorders in patients with laryngopharyngeal reflux symptoms. J Gastroenterol Hepatol 2021; 36:2076-2082. [PMID: 33373479 DOI: 10.1111/jgh.15391] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/12/2020] [Accepted: 12/16/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Esophageal motor dysfunction may underlie impaired bolus/refluxate clearance in laryngopharyngeal reflux (LPR). However, the prevalence of esophageal dysmotility and its correlation with reflux parameters and symptoms in LPR is not well established. The aim of this study was to evaluate the prevalence of coexisting esophageal dysmotility among patients with suspected LPR. METHODS This was a retrospective cohort study of 194 consecutive patients with LPR symptoms referred for high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance and pH testing at a tertiary center in March 2018 to August 2019. Validated symptom surveys were prospectively collected at time of testing, including Reflux Symptom Index, Gastroesophageal Reflux Disease Questionnaire, dominant symptom intensity, and 12-Item Short-Form Health Survey. HRM findings were categorized using Chicago Classification v3.0. RESULTS Abnormal findings on HRM were identified in 84 (43.3%) patients, with ineffective esophageal motility (n = 60, 30.9%) as the most common diagnosis. A disorder of esophagogastric junction outflow or a major disorder of peristalsis was identified in 26 (13.4%) patients, including 2 (1%) with achalasia and 7 (3.6%) with jackhammer esophagus. Reflux burden (distal, proximal, or pharyngeal) on combined hypopharyngeal-esophageal multichannel intraluminal impedance and pH testing did not differ across HRM findings. Patients reporting esophageal symptoms were more likely to have a primary motility disorder (odds ratio 2.34, P = 0.04). However, no significant differences in Reflux Symptom Index, Gastroesophageal Reflux Disease Questionnaire, or 12-Item Short-Form Health Survey were noted across HRM diagnoses. CONCLUSION Esophageal motility disorders are prevalent among patients with LPR symptoms, including up to one in seven with esophagogastric junction outflow or major peristaltic disorder. Patients with abnormal motility more likely report esophageal symptoms. Clinicians should be aware of these coexisting conditions, particularly in those with refractory symptoms.
Collapse
Affiliation(s)
- Daniel R Sikavi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer X Cai
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas L Carroll
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Zerbib F, Rommel N, Pandolfino J, Gyawali CP. ESNM/ANMS Review. Diagnosis and management of globus sensation: A clinical challenge. Neurogastroenterol Motil 2020; 32:e13850. [PMID: 32329203 DOI: 10.1111/nmo.13850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/17/2020] [Accepted: 03/18/2020] [Indexed: 12/20/2022]
Abstract
Globus is a non-painful sensation of a tightness or a lump/foreign body in the throat that is not associated with dysphagia and may actually improve during meals. While several otorhinolaryngologic, thyroid, and esophageal disorders have been linked to globus, cause-and-effect relationships are difficult to establish. Consequently, though part of the evaluation, objective otorhinolaryngologic and esophageal testing is often negative. The presence of alarm symptoms, particularly pain, weight loss, dysphagia, or odynophagia is indications for objective testing. A diagnosis of idiopathic globus requires exclusion of pharyngeal, laryngeal, and esophageal disorders with laryngoscopy, endoscopy, high-resolution manometry, barium radiography, and/or ambulatory reflux monitoring. A trial of acid-suppressive therapy may be reasonable in the absence of alarm symptoms, especially if concurrent reflux symptoms are identified. Ablation of heterotopic gastric mucosa in the proximal esophagus has been reported to improve globus symptoms. Beyond these specific approaches, further management of idiopathic globus consists of reassurance, neuromodulators, and complementary approaches. Globus has a benign course with no long-term consequences, and the overall prognosis is good as the magnitude of symptoms may decline over time.
Collapse
Affiliation(s)
- Frank Zerbib
- Department of Gastroenterology, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - Nathalie Rommel
- Department of Gastroenterology, Neurogastroenterology & Motility, Catholic University of Leuven, Leuven, Belgium
| | - John Pandolfino
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
3
|
Strohl MP, Young VN, Dwyer CD, Bhutada A, Crawford E, Chang JL, Rosen CA, Cheung SW. Novel Adaptation of a Validated Tactile Aesthesiometer to Evaluate Laryngopharyngeal Sensation. Laryngoscope 2020; 131:1324-1331. [PMID: 32735711 DOI: 10.1002/lary.28947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To evaluate laryngopharyngeal sensation at specific subsites using a novel adaptation of a buckling force aesthesiometer for delivery of calibrated tactile stimuli. STUDY DESIGN Cross-sectional. METHODS Twenty-two healthy adults (12 men, 10 women) were tested for responses to tactile forces, using 30-mm 6-0, 5-0, and 4-0 nylon monofilaments to map sensation of the aryepiglottic (AE) fold, lateral pyriform sinus (PS), and medial PS bilaterally. The outcome measures were the laryngeal adductor reflex (LAR) and patient reported rating of perceptual strength. RESULTS Rates of triggered LAR response grew monotonically with increasing tactile force at a mean (SD) stimulus duration of 663 (164) msec across all three subsites. The AE fold and medial PS had similar profiles and were the most responsive, while the lateral PS was the least responsive. Low force (6-0) response rate was ≤14% for all subsites. High force (4-0) response rate was 91% for AE fold and medial PS, and 23% for lateral PS. The perceptual strength gradient was in the lateral to medial trajectory. CONCLUSION Normative data for LAR response rates to low, medium, and high stimulation forces will be useful to assess sensory dysfunction in a variety of laryngopharyngeal disorders, including aspiration, dysphagia, chronic cough, and spasmodic dysphonia. In turn, that information will guide the creation of innovative treatments. LAR response profiles to low and high force stimuli will inform the development of screening tools to diagnose laryngopharyngeal hypersensitivity and hyposensitivity conditions. LEVEL OF EVIDENCE 3b Laryngoscope, 131:1324-1331, 2021.
Collapse
Affiliation(s)
- Madeleine P Strohl
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - VyVy N Young
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Christopher D Dwyer
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Abhishek Bhutada
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Ethan Crawford
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Jolie L Chang
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Clark A Rosen
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Steven W Cheung
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| |
Collapse
|
4
|
Van Daele DJ. Esophageal Manometry, pH Testing, Endoscopy, and Videofluoroscopy in Patients With Globus Sensation. Laryngoscope 2019; 130:2120-2125. [DOI: 10.1002/lary.28289] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/14/2019] [Accepted: 08/19/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Douglas J. Van Daele
- Department of Otolaryngology–Head and Neck SurgeryRoy J. and Lucille A. Carver College of Medicine, University of Iowa Iowa City Iowa U.S.A
| |
Collapse
|
5
|
Finn MTM, McKernan LC. Clinical Hypnosis in Postoperative, Adult-Onset Dysphagia: A 2-Year Empirical Case Study. Int J Clin Exp Hypn 2019; 67:297-312. [PMID: 31251707 DOI: 10.1080/00207144.2019.1612672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Dysphagia, the perceived impediment to swallowing food, is a common postsurgical symptom that can have debilitating consequences. This study presents the successful treatment of severe esophageal dysphagia with a problem-focused and patient-centered approach to hypnosis, informed by long-term empirical follow-up. The authors describe a case history involving significant and persistent difficulty swallowing for which no medical or surgical treatment could be found. Over the course of 10 sessions, the patient was assessed, treated with imaginal exposure, and instructed in self-hypnosis. Outcomes were measured at treatment conclusion, and 6-, 9-, and 18-month follow-ups. Following hypnosis, the patient exhibited significant and reliable change (RC) in visceral hypersensitivity (RC = -3.16, p = .002), emotional distress (RC = -2.21, p= .03), subjective well-being (RC = 4.14, p< .0001), and posttraumatic symptoms (RC = -3.33, p= .001). Gains were maintained at 18-month follow-up.
Collapse
Affiliation(s)
- Michael T M Finn
- a Osher Center for Integrative Medicine , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Lindsey C McKernan
- a Osher Center for Integrative Medicine , Vanderbilt University Medical Center , Nashville , TN , USA
| |
Collapse
|
6
|
Nativ-Zeltzer N, Belafsky PC, Bayoumi A, Kuhn MA. Volitional control of the upper esophageal sphincter with high-resolution manometry driven biofeedback. Laryngoscope Investig Otolaryngol 2019; 4:264-268. [PMID: 31024999 PMCID: PMC6476264 DOI: 10.1002/lio2.255] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 01/13/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction Dysfunction of the upper esophageal sphincter (UES) is associated with swallow dysfunction and globus pharyngeus. Although volitional augmentation of the UES has been previously documented, the ability of individuals to control UES pressure with high‐resolution manometry (HRM) driven biofeedback has not been assessed. Purpose To evaluate the ability of patient driven HRM biofeedback to control UES basal pressure. Methods HRM data was collected from 10 patients undergoing esophageal manometry. Participants were trained on real‐time HRM‐driven biofeedback to both elevate and reduce UES pressure. Measures of baseline UES minimum, mean and maximum pressures (mmHg) were compared to biofeedback‐driven volitional increases and decreases in UES pressures. Pre‐ and post‐biofeedback data were compared with paired sample T‐tests. Results The mean age (± standard deviation) of the cohort was 68 (±12.7) years. Sixty percent (6/10) were female. The mean UES baseline pressure increased from 30.1 (±15.3) mmHg to 44.8 (±25.03) mmHg (P = .02) with biofeedback‐driven UES augmentation (P < .05). Maximum UES pressures were also increased from 63.84 (±24.1) mmHg to 152.4 (±123.7) (P = .04). Although some individuals were able to successfully decrease basal UES tone with the HRM biofeedback, no statistically significant group differences were observed (P > .05). Conclusion Volitional control of UES pressure is possible with HRM‐driven biofeedback. Patients vary in their ability to intentionally control UES pressure and some may require further training aimed at lowering UES pressure with HRM‐guided biofeedback. These data may have significant implications for the future treatment of UES disorders and warrant further investigation. Level of Evidence 4
Collapse
Affiliation(s)
- Nogah Nativ-Zeltzer
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery University of California, Davis Sacramento, California U.S.A
| | - Peter C Belafsky
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery University of California, Davis Sacramento, California U.S.A
| | - Ahmed Bayoumi
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery University of California, Davis Sacramento, California U.S.A
| | - Maggie A Kuhn
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery University of California, Davis Sacramento, California U.S.A
| |
Collapse
|
7
|
Abstract
Globus is an area of interest for many medical specialists including otorhinolaryngologists, gastroenterologist, allergists, and psychiatrists. It may be caused by an organic disease, but it is not uncommon that an underlying etiology remains unidentified even after a full workup has been performed. Patients who suffer from globus usually visit several physicians from different specialties without finding a solution for their symptoms. Identifying the underlying cause of globus is not always a simple task; therefore, structural or functional abnormalities of the thyroid, larynx, pharynx, and esophagus should be investigated. Gastroesophageal reflux disease is commonly considered to be the underlying cause after being identified in an otorhinolarygeal (ear, nose, and throat) evaluation, which is usually the first diagnostic step. In the last few years, an inlet patch in the proximal esophagus has been shown to be associated with globus, and its elimination has resulted in symptom resolution in some patients. Finally, globus can be associated with psychiatric disorders as well as oropharyngeal hypersensitivity that could be either chemical or mechanical. Treatment is directed toward an identified organic cause; in those with a functional disorder, the mainstay of therapy includes neuromodulators and psychiatric/psychological interventions.
Collapse
|
8
|
Tang Y, Huang J, Zhu Y, Qian A, Xu B, Yao W. Comparison of esophageal motility in gastroesophageal reflux disease with and without globus sensation. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 109:850-855. [PMID: 29082739 DOI: 10.17235/reed.2017.4449/2016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUNDS AND AIMS This study aimed to compare the esophageal motility between gastroesophageal reflux disease (GERD) patients with typical symptoms but without globus sensation and GERD patients only with globus symptoms. METHODS A total of 57 consecutive GERD patients diagnosed by endoscopy or by 24-hour pH monitoring between May 2013 and September 2015 were included retrospectively into the study. The patients were grouped based on the presence or absence of globus. Thirty patients presented with typical reflux symptoms but without globus were assigned to the typical GERD group and 27 patients only with globus symptom were assigned to the globus GERD group. All patients underwent esophageal high resolution manometry (HRM) and the differences in esophageal motility between the two groups were analyzed. RESULTS The globus GERD group showed a significantly greater lower esophageal sphincter (LES) length, LES basal pressure and upper esophageal sphincter (UES) residual pressure than that of the typical GERD group (3.47 ± 0.76 vs. 2.65 ± 0.62 cm, 21.71 ± 9.68 vs. 16.04 ± 8.49 mmHg, 7.30 ± 4.42 vs. 4.12 ± 2.92 mmHg, all p < 0.05). There was no significant difference between the two groups in terms of the distal wave amplitude, mean wave duration, distal contractile integral (DCI), contractile front velocity (CFV), distal latency (DL), integrated relaxation pressure (IRP) and UES basal pressure. The incidence of esophageal dysmotility in the globus GERD group (33.3%) was higher than in the typical GERD group (23.3%). There was no significant difference in esophageal acid exposure of the non-erosive gastroesophageal reflux disease (NERD) patients between the two groups. CONCLUSIONS Globus GERD patients have a higher UES residual pressure, longer LES length, higher LES basal pressure and greater esophageal dysmotility than typical GERD patients. HRM is useful in evaluating esophageal motility of GERD patients.
Collapse
Affiliation(s)
- Yuming Tang
- Department of Gastroenterology, Ruijin Hospital, China
| | - Jia Huang
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, China
| | - Ying Zhu
- Department of Gastroenterology, Ruijin Hospital, China
| | - Aihua Qian
- Department of Gastroenterology, Ruijin Hospital, China
| | - Bin Xu
- Department of Gastroenterology, Ruijin Hospital, China
| | - Weiyan Yao
- Department of Gastroenterology, Ruijin Hospital, China
| |
Collapse
|
9
|
Harvey PR, Theron BT, Trudgill NJ. Managing a patient with globus pharyngeus. Frontline Gastroenterol 2018; 9:208-212. [PMID: 30046425 PMCID: PMC6056082 DOI: 10.1136/flgastro-2017-100844] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/26/2017] [Accepted: 07/03/2017] [Indexed: 02/04/2023] Open
Abstract
A woman aged 47 years reported the feeling of a lump in her throat for the past year. The sensation was present intermittently and usually improved when she ate. She noted it was worse with dry swallows when she felt like a tablet was stuck in her throat. The sensation had become more persistent in recent weeks leading her to worry that she had cancer. She had no cough, sore throat or hoarseness. There were no precipitating factors and no symptoms of weight loss, dysphagia, odynophagia or change in her voice. She had smoked previously and rarely had heartburn. She had no other anxieties and was not under any unusual stress. She was initially assessed by an ear, nose and throat surgeon, who found no abnormalities on examination of her neck, throat and oral cavity. Nasolaryngoscopy was normal. An upper gastrointestinal endoscopy was organised and reported a hiatus hernia, but a 3-month trial of a proton pump inhibitor did not have any impact on her symptoms. The benign nature of her symptoms was discussed at her gastroenterology follow-up appointment. She was discharged back to primary care with a final diagnosis of 'globus'. A trial of speech therapy, cognitive behavioural therapy or amitriptyline would be recommended if her symptoms became more troublesome in future.
Collapse
Affiliation(s)
- Philip R Harvey
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, Birmingham, UK
| | - Byron T Theron
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, Birmingham, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, Birmingham, UK
| |
Collapse
|
10
|
Brink GJ, Lei WY, Omari TI, Singendonk MMJ, Hung JS, Liu TT, Yi CH, Chen CL. Physiological augmentation of esophageal distension pressure and peristalsis during conditions of increased esophageal emptying resistance. Neurogastroenterol Motil 2018; 30:e13225. [PMID: 29063658 DOI: 10.1111/nmo.13225] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 09/14/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Abdominal compression has been implemented as a provocative maneuver in high-resolution impedance manometry (HRIM) to "challenge" normal esophageal physiology with the aim of revealing abnormal motor patterns which may explain symptoms. In this study, we measured the effects of abdominal compression on esophageal functioning utilizing novel pressure-impedance parameters and attempted to identify differences between healthy controls and globus patients. METHODS Twenty-two healthy volunteers (aged 23-32 years, 41% female) and 22 globus patients (aged 23-72 years, 68% female) were evaluated with HRIM using a 3.2-mm water perfused manometric and impedance catheter. All participants received 10 × 5 mL liquid swallows; healthy controls also received 10 × 5 mL liquid swallows with abdominal compression created using an inflatable cuff. All swallows were analyzed to assess esophageal pressure topography (EPT) and pressure-flow metrics, indicative of distension pressure, flow timing and bolus clearance were derived. KEY RESULTS The effect of abdominal compression was shown as a greater contractile vigor of the distal esophagus by EPT and higher distension pressure based on pressure-flow metrics. Age and body mass index also increased contractile vigor and distension pressure. Globus patients were similar to controls. CONCLUSIONS AND INTERFERENCES Intrabolus pressure and contractile vigor are indicative of the physiological modulation of bolus transport mechanisms. Provocative testing by abdominal compression induces changes in these esophageal bolus dynamics.
Collapse
Affiliation(s)
- G J Brink
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, AMC, Amsterdam, The Netherlands
| | - W Y Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - T I Omari
- School of Medicine, Flinders University, South Australia
| | - M M J Singendonk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, AMC, Amsterdam, The Netherlands
| | - J S Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - T T Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - C H Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - C L Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| |
Collapse
|
11
|
Lei WY, Hung JS, Liu TT, Yi CH, Chen CL. Altered oesophageal mechanosensitivity of secondary peristalsis as a pathophysiological marker in patients with globus sensation. Clin Otolaryngol 2017; 43:306-311. [PMID: 28881108 DOI: 10.1111/coa.12978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Secondary peristalsis is important for clearance of retained food bolus and refluxate from the oesophagus. We aimed to investigate whether patients with globus sensation have altered physiological characteristics of secondary peristalsis. DESIGN Prospective case-controlled study SETTING: Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan. PARTICIPANTS Seventeen globus patients and 18 healthy controls. MAIN OUTCOME MEASURES After a baseline recording of primary peristalsis, secondary peristalsis was stimulated with slow and rapid mid-oesophageal injections of air. Distension thresholds and peristaltic activities of secondary peristalsis were analysed and compared between the patients and healthy controls. RESULTS The threshold volume for generating secondary peristalsis during slow air distension did not differ between the patient and control groups (P = .55). The threshold volume for generating secondary peristalsis during rapid air distension was significantly greater in patients with globus than healthy controls (7.0 ± 0.9 vs 5.0 ± 0.3 mL, P = .04). Secondary peristalsis was triggered less frequently in globus patients as compared with healthy control after rapid air distension (40% [30%-65%] vs 60% [60%-83%], P = .001). There was no difference in any of peristaltic parameters for primary and secondary peristalsis between the groups. CONCLUSIONS Our work identifies functional defects of oesophageal secondary peristalsis in patients with globus sensation and such defects are characterised with defective triggering of secondary peristalsis during rapid air distension. Whether current findings have therapeutic implication in the management of patients with globus sensation warrants further investigation.
Collapse
Affiliation(s)
- W-Y Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
| | - J-S Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
| | - T-T Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
| | - C-H Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
| | - C-L Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
| |
Collapse
|
12
|
Abstract
Functional heartburn (FH) is defined as a functional esophageal disorder characterized by symptoms of chronic heartburn with no apparent correlation to acid or nonacid reflux. In addition, its symptoms persist despite the lack of organic abnormalities or inflammation, esophageal motility disorders, or metabolic disorders. Although conditions presenting with esophageal symptoms without endoscopic abnormalities were previously categorized as nonerosive reflux disease, such conditions are now classified into 3 categories under Rome IV criteria: nonerosive reflux disease, reflux hypersensitivity, and FH. Although many aspects of FH remain unclear, its onset mechanism is considered to be strongly associated with peripheral or central sensitization, given the fact that its symptoms seem to be unrelated to gastroesophageal reflux. In addition, the cause of such hypersensitivity is an interesting topic in itself, and psychological factors, such as stress followed by increasing esophageal permeability are gaining attention as factors that can potentially influence this condition. There is a great unmet clinical need for therapeutic drugs that can be used to treat FH, and the development of novel drugs, diagnostic tests and biomarkers is eagerly awaited.
Collapse
|
13
|
The effects of paroxetine and amitriptyline on the upper esophageal sphincter (UES) pressure and its natural history in globus pharyngeus. Dig Liver Dis 2017; 49:757-763. [PMID: 28258931 DOI: 10.1016/j.dld.2017.02.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 02/02/2017] [Accepted: 02/02/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antidepressant agents have been shown to be an effective and safe treatment method for patients with globus. However, there are few clinical trials dedicated to studying the effects of antidepressant agents on the natural history and upper oesophageal sphincter (UES) pressure of treated globus patients. AIMS To evaluate the effect of paroxetine and amitriptyline to prevent relapses in patients with globus, the simultaneous relationship between changes in UES pressure and improvement of globus symptoms were measured. METHODS Globus patients were randomised into amitriptyline, paroxetine and lansoprazole groups for a 6-week treatment period, and follow-up was extended to 12 additional months. Efficacy was evaluated in terms of the Glasgow-Edinburgh Throat Scale (GETS), and UES pressure was measured by standard oesophageal manometry. RESULTS Paroxetine therapy resulted in a higher withdrawal rate due to symptom relapse (15.9% vs 44.1%, P=0.01; 15.9% vs 64.7, P=0.001) than amitriptyline and lansoprazole. Furthermore, globus symptoms were alleviated with the decrease of UES pressure after paroxetine and amitriptyline treatment (r=0.620, P=0.02; r=0.575, P=0.03) CONCLUSIONS: This follow-up study indicates that paroxetine may alter the natural history of globus and can effectively be used for the long-term management of patients with the disease. Apart from the clinical benefits, paroxetine and amitriptyline can potentially decrease UES pressure.
Collapse
|
14
|
Esophageal Sensorimotor Function and Psychological Factors Each Contribute to Symptom Severity in Globus Patients. Am J Gastroenterol 2016; 111:1382-1388. [PMID: 27481312 DOI: 10.1038/ajg.2016.302] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 06/02/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Altered upper esophageal sphincter (UES) and esophageal body (EB) sensorimotor function and psychosocial factors may both be involved in symptom generation in globus, but their common impact is not yet assessed. The aim of the study is (1) to compare UES and EB sensitivity and compliance of globus patients with healthy controls (HC); (2) to study the association of globus symptom severity (GSS) with UES and EB sensitivity and compliance, UES motor function and psychosocial factors. METHODS In 58 globus patients, GSS, somatization, and anxiety disorders were determined using validated questionnaires. In 26 HC and 42/58 patients, UES and EB sensitivity and compliance were assessed twice using barostat measurements. UES function of 27 globus patients was evaluated using high-resolution manometry. Bivariate correlations and a general linear model tested the association of these factors with GSS. RESULTS UES and EB compliance did not differ between globus patients and HC. Upon repeated distension, UES habituation was seen in both groups, whereas EB sensitization (23.3±1.3 vs. 19.5±1.5 mm Hg, P<0.0001) only occurred in globus patients, (P=0.038). UES compliance (ρ=0.37, P=0.04), change in EB compliance upon repeated distension (ρ=0.45, P=0.007), somatization (ρ=0.43, P=0.003), panic disorder (t=3.04, P=0.004), and post-traumatic stress severity (ρ=0.40, P=0.005) were associated with GSS. UES compliance and somatization were independently associated with GSS. A trend (P=0.061) was found for the association of GSS with change in EB compliance. CONCLUSIONS UES compliance, change in EB compliance, and somatization explain 40% of the variance in GSS. This indicates that globus is a complex disorder of the brain-gut axis rather than a "psychosomatic" disorder or a peripheral esophageal disorder.
Collapse
|
15
|
Manabe N, Tsutsui H, Kusunoki H, Hata J, Haruma K. Pathophysiology and treatment of patients with globus sensation--from the viewpoint of esophageal motility dysfunction. J Smooth Muscle Res 2016; 50:66-77. [PMID: 26081369 PMCID: PMC5137314 DOI: 10.1540/jsmr.50.66] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
"Globus sensation" is often described as the sensation of a lump in the throat associated
with dry swallowing or the need for dry swallowing, which disappears completely during
eating or drinking and for which no organic cause can be established. Due to the uncertain
etiology of "globus sensation", it remains difficult to establish standard treatment
strategies for affected patients. Lately most attention has been focused on
gastroesophageal reflux disease and several reports have indicated that there is a close
relationship between esophageal acid reflux and globus sensation. Nowadays, empirical
therapy with a high dose of a proton pump inhibitor (PPI) is considered to be indicated
for patients with globus sensation, after excluding organic diseases such as pharyngeal
cancer, Zenker's diverticulum, or thyroid enlargement. If patients are nonresponsive to
PPI therapy, evaluation of esophageal motility should be done. In our recent study, 47.9%
had abnormal esophageal motility, with the most common esophageal motility abnormality
being an ineffective esophageal motility in PPI-resistant patients with globus sensation.
This suggests that prokinetics alone or adding prokinetics to PPI should be the treatment
to be considered, although few studies have investigated the efficacy of prokinetics in
the treatment of patients with globus sensation. If patients without any esophageal
motility dysfunctions are nonresponsive to PPI therapy, either cognitive-behavioral
therapy, anti-depressants, or gabapentin could be helpful, although further well-designed,
randomized controlled large-scale studies will be necessary to determine the effectiveness
of each treatment strategy on patients with globus sensation.
Collapse
Affiliation(s)
- Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Kurashiki, Japan
| | | | | | | | | |
Collapse
|
16
|
Abdel Jalil AA, Katzka DA, Castell DO. Approach to the patient with dysphagia. Am J Med 2015; 128:1138.e17-23. [PMID: 26007674 DOI: 10.1016/j.amjmed.2015.04.026] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 04/15/2015] [Accepted: 04/16/2015] [Indexed: 12/17/2022]
Abstract
Dysphagia is a fascinating symptom. It is ostensibly simple when defined by trouble swallowing, yet its subtleties in deciphering and its variations in pathophysiology almost mandate a thorough knowledge of medicine itself. With patience and careful questioning, a multitude of various disorders may be suggested before an objective test is performed. Indeed, the ability to diligently and comprehensively explore the symptom of dysphagia is not only rewarding but also a real test for a physician who prides himself or herself on good history taking.
Collapse
Affiliation(s)
- Ala' A Abdel Jalil
- Esophageal Disorders Program, Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston.
| | - David A Katzka
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minn
| | - Donald O Castell
- Esophageal Disorders Program, Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston
| |
Collapse
|
17
|
Peng L, Patel A, Kushnir V, Gyawali CP. Assessment of upper esophageal sphincter function on high-resolution manometry: identification of predictors of globus symptoms. J Clin Gastroenterol 2015; 49:95-100. [PMID: 24492407 PMCID: PMC4117818 DOI: 10.1097/mcg.0000000000000078] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Globus is commonly encountered in clinical practice, but high-resolution manometry (HRM) characteristics are incompletely characterized. We evaluated HRM metrics in globus subjects, compared with age-matched and sex-matched dysphagia subjects and healthy controls. STUDY Twenty-four subjects with globus (53.3 ± 2.3 y, 58% female) were compared with 24 age-matched and sex-matched subjects with nonobstructive dysphagia (52.5 ± 2.5 y, 58% female), and 21 healthy controls (27.6 ± 0.6 y, 52% female). Sphincter and segment anatomy, and pressure volume metrics assessed skeletal (proximal contractile integral) and smooth muscle contraction (distal contractile integral). Parameters significantly different across groups on univariate analysis were subjected to multivariate logistic regression and receiver-operating characteristic analysis to identify HRM predictors of globus. RESULTS Upper esophageal sphincter (UES) postswallow residual pressures were highest in globus (2.6 ± 0.5 vs. 2.3 ± 0.5 mm Hg in dysphagia and 0.6 ± 0.6 mm Hg in controls, P = 0.03); 66.7% had recordable UES residual pressure, in contrast to 9.5% of controls, and 37.5% of dysphagia patients (P = 0.0002). Although different from controls, UES length and basal pressure, and segment 1 parameters did not differ from dysphagia controls. In a multivariate model, measurable UES residual pressure (odds ratio, 6.33; 95% confidence interval, 1.79-25.96) independently predicted globus. Receiver-operating characteristic analysis identified a threshold of 0.4 mm Hg UES residual pressure in segregating globus (sensitivity 66.7%, specificity 71.5%, positive predictive value 55.2%, and negative predictive value 80.0%). CONCLUSION HRM with measurement of UES residual pressure allows objective assessment of patients with globus sensation, and has potential to complement current diagnostic strategies.
Collapse
Affiliation(s)
- Lihua Peng
- Chinese PLA General Hospital, Beijing, China,Department of Medicine, Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | - Amit Patel
- Department of Medicine, Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | - Vladimir Kushnir
- Department of Medicine, Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | - C. Prakash Gyawali
- Department of Medicine, Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| |
Collapse
|
18
|
Abstract
Globus is a topic of interest for many specialties including otorhinolaryngology, gastroenterology and psychiatry/psychosomatic medicine, but, although many hypotheses have been suggested, key questions about its aetiology remain. This Review provides an overview of the extensive literature concerning this topic and discusses the quality of the evidence to date. Globus has been associated with oropharyngeal structural lesions, upper oesophageal sphincter disorders, oesophageal disorders, GERD, psychosocial factors and psychiatric comorbidity. However, findings are often contradictory and the literature remains highly inconclusive. Indeed, with the exception of patients with structural-based globus, the Rome III criteria for functional globus only apply to a subgroup of patients with idiopathic globus. In clinical reality, there exists a group of patients who present with idiopathic (nonstructural) globus, but nevertheless have dysphagia, odynophagia or GERD-exclusion criteria for globus diagnosis according to Rome III. The symptomatology of patients with globus might be broader than previously thought. It is therefore crucial to approach globus not from one single perspective, but from a multifactorial point of view, with focus on the coexistence and/or interactions of different mechanisms in globus pathogenesis. This approach could be translated to clinical practice by adopting a multidisciplinary method to patients presenting with globus.
Collapse
|
19
|
Brodsky MB, Gellar JE, Dinglas VD, Colantuoni E, Mendez-Tellez PA, Shanholtz C, Palmer JB, Needham DM. Duration of oral endotracheal intubation is associated with dysphagia symptoms in acute lung injury patients. J Crit Care 2014; 29:574-9. [PMID: 24631168 DOI: 10.1016/j.jcrc.2014.02.015] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 02/14/2014] [Accepted: 02/20/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE The purpose of this study is to evaluate demographic and clinical factors associated with self-reported dysphagia after oral endotracheal intubation and mechanical ventilation in patients with acute lung injury (ALI). MATERIALS AND METHODS This is a prospective cohort study of 132 ALI patients who had received mechanical ventilation via oral endotracheal tube. RESULTS The primary outcome was binary, whether clinically important symptoms of dysphagia at hospital discharge were reported by patients, using the Sydney Swallowing Questionnaire score 200 or more. Of 132 patients, 29% reported clinically important symptoms of dysphagia. Of 18 relevant demographic and clinical variables, only 2 were found to be independently associated with clinically important symptoms of dysphagia in a multivariable logistic regression model: upper gastrointestinal comorbidity (odds ratio, 2.82; 95% confidence interval, 1.09-7.26) and duration of oral endotracheal intubation (odds ratio, 1.79; [95% confidence interval, 1.15-2.79] per day for first 6 days, after which additional days of intubation were not associated with a further increase in the odds of dysphagia). CONCLUSIONS In ALI survivors, patient-reported, postexubation dysphagia at hospital discharge was significantly associated with upper gastrointestinal comorbidity and a longer duration of oral endotracheal intubation during the first 6 days of intubation.
Collapse
Affiliation(s)
- Martin B Brodsky
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD; Outcomes After Critical Illness and Surgery Research Group, Johns Hopkins University, Baltimore, MD
| | - Jonathan E Gellar
- Outcomes After Critical Illness and Surgery Research Group, Johns Hopkins University, Baltimore, MD; Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery Research Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Elizabeth Colantuoni
- Outcomes After Critical Illness and Surgery Research Group, Johns Hopkins University, Baltimore, MD; Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Pedro A Mendez-Tellez
- Outcomes After Critical Illness and Surgery Research Group, Johns Hopkins University, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Carl Shanholtz
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore, MD
| | - Jeffrey B Palmer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD; Department of Otolaryngology-Head and Neck Surgery and Center for Functional Anatomy and Evolution, Johns Hopkins University, Baltimore, MD
| | - Dale M Needham
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD; Outcomes After Critical Illness and Surgery Research Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD.
| |
Collapse
|
20
|
Choi WS, Kim TW, Kim JH, Lee SH, Hur WJ, Choe YG, Lee SH, Park JH, Sohn CI. High-resolution Manometry and Globus: Comparison of Globus, Gastroesophageal Reflux Disease and Normal Controls Using High-resolution Manometry. J Neurogastroenterol Motil 2013; 19:473-8. [PMID: 24199007 PMCID: PMC3816181 DOI: 10.5056/jnm.2013.19.4.473] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Revised: 06/10/2013] [Accepted: 06/12/2013] [Indexed: 11/20/2022] Open
Abstract
Background/Aims Globus is a foreign body sense in the throat without dysphagia, odynophagia, esophageal motility disorders, or gastroesophageal reflux. The etiology is unclear. Previous studies suggested that increased upper esophageal sphincter pressure, gastroesophageal reflux and hypertonicity of esophageal body were possible etiologies. This study was to quantify the upper esophageal sphincter (UES) pressure, contractile front velocity (CFV), proximal contractile integral (PCI), distal contractile integral (DCI) and transition zone (TZ) in patient with globus gastroesophageal reflux disease (GERD) without globus, and normal controls to suggest the correlation of specific high-resolution manometry (HRM) findings and globus. Methods Fifty-seven globus patients, 24 GERD patients and 7 normal controls were studied with HRM since 2009. We reviewed the reports, and selected 5 swallowing plots suitable for analysis in each report, analyzed each individual plot with ManoView. The 5 parameters from each plot in 57 globus patients were compared with that of 24 GERD patients and 7 normal controls. Results There was no significant difference in the UES pressure, CFV, PCI and DCI. TZ (using 30 mmHg isobaric contour) in globus showed significant difference compared with normal controls and GERD patients. The median values of TZ were 4.26 cm (interquartile range [IQR], 2.30-5.85) in globus patients, 5.91 cm (IQR, 3.97-7.62) in GERD patients and 2.26 cm (IQR, 1.22-2.92) in normal controls (P = 0.001). Conclusions HRM analysis suggested that UES pressure, CFV, PCI and DCI were not associated with globus. Instead increased length of TZ may be correlated with globus. Further study comparing HRM results in globus patients within larger population needs to confirm their correlation.
Collapse
Affiliation(s)
- Won Seok Choi
- Division of Gastroenterology, Department of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Choi WS, Kim TW, Kim JH, Lee SH, Hur WJ, Choe YG, Lee SH, Park JH, Sohn CI. High-resolution Manometry and Globus: Comparison of Globus, Gastroesophageal Reflux Disease and Normal Controls Using High-resolution Manometry. J Neurogastroenterol Motil 2013. [PMID: 24199007 DOI: 10.5056/jnm.2013.19.4.47] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS Globus is a foreign body sense in the throat without dysphagia, odynophagia, esophageal motility disorders, or gastroesophageal reflux. The etiology is unclear. Previous studies suggested that increased upper esophageal sphincter pressure, gastroesophageal reflux and hypertonicity of esophageal body were possible etiologies. This study was to quantify the upper esophageal sphincter (UES) pressure, contractile front velocity (CFV), proximal contractile integral (PCI), distal contractile integral (DCI) and transition zone (TZ) in patient with globus gastroesophageal reflux disease (GERD) without globus, and normal controls to suggest the correlation of specific high-resolution manometry (HRM) findings and globus. METHODS Fifty-seven globus patients, 24 GERD patients and 7 normal controls were studied with HRM since 2009. We reviewed the reports, and selected 5 swallowing plots suitable for analysis in each report, analyzed each individual plot with ManoView. The 5 parameters from each plot in 57 globus patients were compared with that of 24 GERD patients and 7 normal controls. RESULTS There was no significant difference in the UES pressure, CFV, PCI and DCI. TZ (using 30 mmHg isobaric contour) in globus showed significant difference compared with normal controls and GERD patients. The median values of TZ were 4.26 cm (interquartile range [IQR], 2.30-5.85) in globus patients, 5.91 cm (IQR, 3.97-7.62) in GERD patients and 2.26 cm (IQR, 1.22-2.92) in normal controls (P = 0.001). CONCLUSIONS HRM analysis suggested that UES pressure, CFV, PCI and DCI were not associated with globus. Instead increased length of TZ may be correlated with globus. Further study comparing HRM results in globus patients within larger population needs to confirm their correlation.
Collapse
Affiliation(s)
- Won Seok Choi
- Division of Gastroenterology, Department of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Association between swallow perception and esophageal bolus clearance in patients with globus sensation. Dig Dis Sci 2013; 58:1042-8. [PMID: 23108530 DOI: 10.1007/s10620-012-2463-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 10/08/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Globus sensation is common, but its pathogenesis is not yet clear. AIMS Our purpose was to investigate subjective perception of swallowing and esophageal motility by combined multichannel intraluminal impedance and manometry (MII-EM) for patients with globus sensation. METHODS Combined MII-EM was performed for 25 globus patients and 15 healthy controls. Swallows were abnormal if hypocontractivity or simultaneous contractions occurred. Esophageal bolus transit was incomplete if bolus exit was not found at one or more of all measurement sites. Perception of each swallow was assessed by use of a standardized scoring system, and was enhanced if the score was >1. RESULTS Few globus patients reported enhanced perception during viscous or solid swallows. Incomplete bolus transit and enhanced perception occurred similarly between viscous and solid boluses. Agreement between enhanced perception and proximal bolus clearance was greater during solid swallows (κ = 0.45, 95 % CI: 0.32-0.58) than during viscous swallows (κ = 0.13, 95 % CI: 0-0.25) (P < 0.05). Similarly, agreement between enhanced perception and total bolus clearance was greater during solid swallows (κ = 0.46, 95 % CI: 0.34-0.58) than during viscous swallows (κ = 0.11, 95 % CI: 0-0.22) (P < 0.05). CONCLUSIONS Enhanced swallow perception is uncommon in patients with globus sensation, although there is a significant association between enhanced esophageal perception and solid bolus clearance. Application of a solid bolus may help better delineation of the interrelationship between the subjective perception of bolus passage and the objective measurement of bolus clearance.
Collapse
|
23
|
Abstract
Alexander disease is a rare leukodystrophy that most often presents in infancy but also includes neonatal, juvenile, and adult variants. Juvenile Alexander disease presents primarily with bulbar symptoms between 2 and 12 years of age. The diagnosis is often suggested by the clinical course and brain magnetic resonance image pattern and then confirmed by the presence of a mutation in the glial fibrillary acidic protein gene. A young girl presented with globus sensation and magnetic resonance imaging of the brain revealed abnormalities mainly involving white matter tracts of the medulla oblongata and cerebellum. The presence of a mutation in the glial fibrillary acidic protein gene confirmed the diagnosis of juvenile Alexander disease. A high index of clinical suspicion is necessary for the diagnosis of late-onset presentations of Alexander disease.
Collapse
Affiliation(s)
- Maria Joana Osorio
- Children's Hospital of Pittsburgh, Division of Child Neurology, Department of Pediatrics, University of Pittsburgh School of Medicine, PA, USA.
| | | | | |
Collapse
|
24
|
The hypersensitive esophagus: pathophysiology, evaluation, and treatment options. Curr Gastroenterol Rep 2011; 12:417-26. [PMID: 20669058 DOI: 10.1007/s11894-010-0122-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Visceral hypersensitivity plays a key role in the pathogenesis of esophageal functional disorders such as functional heartburn and chest pain of presumed esophageal origin (noncardiac chest pain). About 80% of patients with unexplained noncardiac chest pain exhibit lower esophageal sensory thresholds when compared to controls during esophageal sensory testing (ie, esophageal barostat, impedance planimetry). Such information has led to prescription of peripherally and/or centrally acting therapies for the management of these patients. This review summarizes and highlights recent and significant findings regarding the pathophysiology, evaluation, and treatment of the hypersensitive esophagus, a central factor in functional esophageal disorders.
Collapse
|
25
|
Hori K, Kim Y, Sakurai J, Watari J, Tomita T, Oshima T, Kondo C, Matsumoto T, Miwa H. Non-erosive reflux disease rather than cervical inlet patch involves globus. J Gastroenterol 2010; 45:1138-45. [PMID: 20582442 DOI: 10.1007/s00535-010-0275-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 06/07/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gastroesophageal reflux is the most favored etiology for globus; however, recent studies suggest that a cervical inlet patch (heterotopic gastric mucosa in the cervical esophagus) involves globus. This study aimed to reveal whether these two conditions were associated with globus. METHODS A prospective cross-sectional survey was conducted for 2116 consecutive patients who underwent esophagogastroduodenoscopy in our hospital. Patients were interviewed about globus sensations and reflux symptoms prior to endoscopy. Non-erosive reflux disease was considered with reflux symptoms without reflux esophagitis. Inlet patch was detected using narrow-band imaging. RESULTS Sixty-three patients were excluded, and of the remaining 2053 patients (1117 male, 61 years old on average), 120 (5.8%) and 284 (13.8%) had globus and inlet patch, respectively. Multivariate analysis (n = 1584) following the exclusion of proton pump inhibitor users revealed that female gender, younger age (<60), inlet patch, and reflux symptoms were independent risk factors for the development of globus; however, reflux esophagitis was an independent factor for reducing the development of globus. In a reanalysis of non-erosive reflux disease instead of reflux symptoms, inlet patch and non-erosive reflux disease were independent risk factors for the development of globus (odds ratio, 2.9 and 12.1, respectively). CONCLUSIONS Non-erosive reflux disease was more closely associated with globus than an inlet patch. Our controversial results indicating a strong association of globus with non-erosive reflux disease and an inverse association of globus with reflux esophagitis may suggest that mechanisms other than gastroesophageal reflux as the etiology, such as an esophageal visceral hypersensitivity, involve globus.
Collapse
Affiliation(s)
- Kazutoshi Hori
- Department of Intestinal Inflammation Research, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Kiebles JL, Kwiatek MA, Pandolfino JE, Kahrilas PJ, Keefer L. Do patients with globus sensation respond to hypnotically assisted relaxation therapy? A case series report. Dis Esophagus 2010; 23:545-53. [PMID: 20459447 DOI: 10.1111/j.1442-2050.2010.01064.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Globus sensation is a bothersome and difficult symptom to treat. The aims of this study were to evaluate the acceptability and utility of hypnotically-assisted relaxation (HAR) in decreasing the perception of globus sensation and the effect of HAR on interdeglutitive upper esophageal sphincter (UES) pressure. Sixteen subjects with persistent globus sensation unresponsive to therapy for reflux disease and with normal esophageal/laryngeal imaging studies were invited to participate in a 7-session clinical protocol. Before and after HAR, subjects completed standard questionnaires including the esophageal symptoms questionnaire. High-resolution manometric assessment of respiratory augmentation and average resting UES pressure were assessed before and after HAR. Ten of the 16 subjects agreed to participate in the protocol. All participants were women with median age 51.5 (range 30-72 years). The participants found HAR acceptable and completed the entire 7-session trial. Globus symptom severity varied widely pre-treatment (median=52.5, range 16-72), and 9 of 10 subjects reported a reduction in globus symptomatology following treatment (median=14.0, range 3-19; P=.007). Only 1 subject exhibited abnormal respiratory augmentation of UES pressure (>27 mm Hg) prior to treatment and was normal following treatment (9.9 mm Hg). Resting UES pressure was normal in all subjects (<118 mm Hg). Group respiratory augmentation and average resting UES pressure were unaffected by HAR (P=.48, .89). This case series suggests that HAR can provide a substantial improvement in globus sensation irrespective of cause. UES function was unaffected. We suggest that HAR therapy is an acceptable and useful intervention for patients with globus sensation.
Collapse
Affiliation(s)
- J L Kiebles
- Center for Psychosocial Research in GI, and Esophageal Disorders Research Center, Northwestern University, Feinberg School of Medicine, Division of Gastroenterology, Chicago, IL, USA
| | | | | | | | | |
Collapse
|