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Marques CHD, Lemme EMO, Abrahão-Júnior LJ. Swallow Impairment in Parkinson's Disease: Revelations from High-Resolution Videomanometry. Dysphagia 2023; 38:1371-1381. [PMID: 36884091 DOI: 10.1007/s00455-023-10566-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 02/17/2023] [Indexed: 03/09/2023]
Abstract
Parkinson's disease (PD) is a degenerative disorder that can cause dysphagia and dysphonia. We studied upper esophageal sphincter (UES) function and vocal tests using high-resolution videomanometry (HRVM) in PD. Ten healthy volunteers and 20 patients with PD performed swallowings (5 ml and 10 ml) and vocal tests using HRVM synchronized to the vocal acoustic recording. Mean age of the Parkinson group was 68.7 ± 9.7 years and mean disease stage of 2.7 ± 1.1 (Hoehn & Yahr scale). In videofluoroscopy swallow study (VFSS) for 5 ml, laryngeal elevation was significantly reduced (p = 0.01) in PD and for 10 ml, anteriorization (p = 0.03), elevation (p = 0.03) and total displacement (p = 0.05) were reduced in PD. In high-resolution manometry (HRM) for both volumes, intrabolus pressure was significantly higher in PD (p = 0.0004 and p = 0.001) and a higher NADIR UES relaxation pressure and NADIR UES relaxation at pharyngeal peak contraction in PD (p = 0.00007 and p = 0.0003, p = 0.01 and p = 0.04), respectively. Vocal tests results showed differences between the groups, especially for larynx anteriorization with high pitch /a/ emission (p = 0.06) in VFSS and for UES length with high pitch /i/ with tongue protrusion (p = 0.07) in HRM. Our results demonstrated a reduced compliance and subtle changes in UES function in early and moderate PD stage. We also demonstrated using HRVM that vocal tests can affect UES function. The use of HRVM proved to be an important tool in the description of events related to phonation and swallowing, which can affect the rehabilitation of patients with PD.
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Affiliation(s)
- Charles Henrique Dias Marques
- Medicine College, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
- Digestive Motility Laboratory - Gastroenterology Division of Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255 - Cidade Universitária da Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, 21941-617, Brazil.
- Municipal Secretariat of Health - SMS, Rio de Janeiro City Hall, Rio de Janeiro, RJ, Brazil.
| | - Eponina Maria Oliveira Lemme
- Medicine College, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- Digestive Motility Laboratory - Gastroenterology Division of Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255 - Cidade Universitária da Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, 21941-617, Brazil
| | - Luiz João Abrahão-Júnior
- Medicine College, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- Digestive Motility Laboratory - Gastroenterology Division of Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255 - Cidade Universitária da Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, 21941-617, Brazil
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Saniasiaya J, Kulasegarah J. Dysphonia and reflux in children: A systematic review. Int J Pediatr Otorhinolaryngol 2020; 139:110473. [PMID: 33137676 DOI: 10.1016/j.ijporl.2020.110473] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/12/2020] [Accepted: 10/23/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Aim of this review is to evaluate the relation between reflux (either laryngopharyngeal or gastroesophageal) and dysphonia in children. DATA SOURCES PubMed, Scopus, Embase. REVIEW METHODS A literature search was conducted over a period from January 1990 to March 2020. The following search words were used either individually or in combination: voice disorders, laryngopharyngeal reflux, and gastroesophageal reflux. The search was conducted over a period of a month: April 2020. RESULTS Five clinical research were selected based on our objectives and selection criteria. Four studies were of level III evidence. Altogether, a total of 606 patients were pooled with male predominance of 63%. In all studies, reflux was suggested to have strong relation with dysphonia. Majority of cases used 24-h pH monitoring to confirm reflux which yielded positive results in 69%. The top three most common endoscopic findings include: interarytenoid erythema and edema (32/38), vocal cord erythema and edema (160/231) and postglottic edema (141/337). Vocal cord nodules were found in 28% of our patients. Acoustic analysis and perceptual assessment of voice was performed in only 1 study. No complication from any procedure was mentioned in any of the studies. Outcome of treatment was mentioned in 1 study, whereby after 4.5 months of follow-up, 68% of children showed improvement in symptoms. CONCLUSION Current evidence shows that there is strong relation between reflux and dysphonia in children. Most common laryngoscopic findings suggestive of reflux includes interarytenoid erythema and edema, vocal cord erythema and edema and postglottic edema.
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Affiliation(s)
- Jeyasakthy Saniasiaya
- Department of Otorhinolaryngology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Jeyanthi Kulasegarah
- Department of Otorhinolaryngology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Wilayah Persekutuan, Kuala Lumpur, Malaysia
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Taniguchi H, Aoyagi Y, Matsuo K, Imaeda S, Hirumuta M, Saitoh E. Elicitation of the Swallowing Reflex by Esophageal Stimulation in Healthy Subjects: An Evaluation Using High-Resolution Manometry. Dysphagia 2019; 35:657-666. [PMID: 31630249 DOI: 10.1007/s00455-019-10068-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 09/27/2019] [Indexed: 12/13/2022]
Abstract
The purposes of this human study using high-resolution manometry were to verify whether the swallowing reflex can be evoked by intra-esophageal fluid injection and whether the reflex latency and manometric variables differ depending on the injected location, amount, or speed. Ten healthy individuals participated in this study. The tip of the intranasal catheter for injection was placed at 5 cm (upper), 10 cm (upper-middle), 15 cm (lower-middle), or 20 cm (lower) from the distal end of the upper esophageal sphincter (UES). An intra-esophageal injection of 3 mL or 10 mL of thickened water was administered and controlled at 3 mL/s or 10 mL/s. Latencies from the start of the injection to the onset of UES relaxation were compared regarding injection locations, amounts, and rates. Manometric variables of intra-esophageal injection and voluntary swallowing were compared. The latency became shorter when the upper region was injected. Latency after the 10-mL injection was shorter than that after the 3-mL injection (p < 0.01) when faster injection (10 mL/s) was used. Faster injection induced shorter latency (p < 0.01) when a larger volume (10 mL) was injected. Pre-maximum and post-maximum UES pressures during voluntary swallowing or during spontaneous swallowing when injecting the upper esophageal region were significantly higher than spontaneous swallowing at other regions (p < 0.01). Intra-esophageal fluid injection induces the swallowing reflex in humans. The most effective condition for inducing the swallowing reflex involved a larger fluid amount with a faster injection rate in the upper esophagus.
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Affiliation(s)
- Hiroshige Taniguchi
- Department of Dentistry & Oral-Maxillofacial Surgery, School of Medicine, Fujita Health University, Toyoake, Japan.,Department of Dentistry for the Disability and Oral Health, School of Dentistry, Asahi University, Mizuho, Japan
| | - Yoichiro Aoyagi
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan.
| | - Koichiro Matsuo
- Department of Dentistry & Oral-Maxillofacial Surgery, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Sayuri Imaeda
- Faculty of Rehabilitation, Fujita Health University Hospital, Toyoake, Japan
| | - Makoto Hirumuta
- Faculty of Rehabilitation, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Eiichi Saitoh
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
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Du C, Thayer P, Yan Y, Liu Q, Wang L, Jiang J. Changing Trends of Color of Different Laryngeal Regions in Laryngopharyngeal Reflux Disease. EAR, NOSE & THROAT JOURNAL 2019; 99:543-547. [PMID: 31155940 DOI: 10.1177/0145561319854745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION In our previous study, we demonstrated that there might be correlations between laryngopharyngeal reflux disorder and the hue value of laryngoscopic images. And we found that different regions of larynx have different hue values. It was hypothesized that the degree of inflammation varies between different laryngeal regions, due to an acid reflux pattern. OBJECTIVE The objective of this study was to compare the changing trends of hue values of different laryngeal regions in patients with laryngopharyngeal reflux (LPR) disease. METHODS Ninety-seven patients, including 20 pH-positive, 19 pH-negative were tested for LPR through multichannel intraluminal impedance 24-hour pH monitoring, and 58 controls with reflux symptom index less than 13. Laryngoscopic images of all patients were obtained. The hue values of 7 areas of interest, including both sides of the true vocal folds, the false vocal folds, the arytenoids, and the interarytenoid space, were quantified using a hue calculation. The analysis of variance analysis was applied to find if there was significant difference between different groups within each region. RESULTS (1) In the regions of both sides of the true vocal folds and interarytenoid, there was no significant difference between positive group and negative group; (2) in the regions of both sides of false vocal folds, there was no significant difference between negative group and control group; (3) in the regions of both sides of arytenoids, there was neither significant difference between positive group and negative group nor between negative group and control group; (4) in other comparisons, there were significant differences. CONCLUSION Hue values of separate laryngeal regions are different. In negative group, the hue values of interarytenoid region are similar with positive group, and the sensitivity to the acid are different from different regions. The sensitivity in the true vocal folds may be present.
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Affiliation(s)
- Chen Du
- Department of Otolaryngology, 66482Peking University Third Hospital, Beijing, People's Republic of China
| | - Paige Thayer
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, 5232University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Yan Yan
- Department of Otolaryngology, 66482Peking University Third Hospital, Beijing, People's Republic of China
| | - Qingsong Liu
- Department of Otolaryngology, 66482Peking University Third Hospital, Beijing, People's Republic of China
| | - Li Wang
- Department of Otolaryngology, 66482Peking University Third Hospital, Beijing, People's Republic of China
| | - Jack Jiang
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, 5232University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Wang G, Qu C, Wang L, Liu H, Han H, Xu B, Zhou Y, Li B, Zhang Y, Sun Z, Gong J, Li L, Wu W. Utility of 24-hour pharyngeal pH monitoring and clinical feature in laryngopharyngeal reflux disease. Acta Otolaryngol 2019; 139:299-303. [PMID: 31056040 DOI: 10.1080/00016489.2019.1571280] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND pH monitoring can reflect the changes in H+ in the airway. OBJECTIVES To explore the utility of pharyngeal pH monitoring in the diagnosis of laryngopharyngeal reflux disease (LPRD). MATERIAL AND METHODS Clinical data from 956 suspected LPRD patients from February 2016 to March 2018 were analyzed retrospectively. RESULTS One hundred forty-one patients had positive Ryan score. The positive rates of reflux symptom index (RSI), reflux finding score (RFS), RSI and RFS and RSI or RFS were 14.7%, 32.5%, 21.9%, 7.8% and 46.5%, respectively. The RFS in the positive Ryan score group was higher than that in the negative Ryan score group [(6 ± 3.5) vs. (4.8 ± 2.9)], while the RSI was not significantly different from that in the negative Ryan score group [(10.9 ± 8) vs. (11.3 ± 7.1)]. Regarding Ryan score as the gold standard in the diagnosis of LPRD, the sensitivity, specificity, positive and negative predictive value of identifying LPRD by RSI/RFS were 15.9%, 86.3%, 50.4% and 54%, respectively. CONCLUSIONS Ryan score, RSI and RFS have poor correlation in detecting LPRD. Some patients may be missed with the Ryan score as a diagnostic criterion. SIGNIFICANCE Pharyngeal pH monitoring is useful and more appropriate index is expected.
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Affiliation(s)
- Gang Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Chinese People Liberation Army 306th Hospital, Beijing, China
| | - Changmin Qu
- Department of Gastroenterology, Chinese People Liberation Army 306th Hospital, Beijing, China
| | - Lei Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Chinese People Liberation Army 306th Hospital, Beijing, China
| | - Hongdan Liu
- Department of Otorhinolaryngology Head and Neck Surgery, Chinese People Liberation Army 306th Hospital, Beijing, China
| | - Haolun Han
- Department of Otorhinolaryngology Head and Neck Surgery, Chinese People Liberation Army 306th Hospital, Beijing, China
| | - Bingxin Xu
- Department of Otorhinolaryngology Head and Neck Surgery, Chinese People Liberation Army 306th Hospital, Beijing, China
| | - Ying Zhou
- Department of Otorhinolaryngology Head and Neck Surgery, Chinese People Liberation Army 306th Hospital, Beijing, China
| | - Baowei Li
- Department of Otorhinolaryngology Head and Neck Surgery, Chinese People Liberation Army 306th Hospital, Beijing, China
| | - Yiyan Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Chinese People Liberation Army 306th Hospital, Beijing, China
| | - Zhezhe Sun
- Department of Otorhinolaryngology Head and Neck Surgery, Chinese People Liberation Army 306th Hospital, Beijing, China
| | - Jing Gong
- Department of Otorhinolaryngology Head and Neck Surgery, Chinese People Liberation Army 306th Hospital, Beijing, China
| | - Lianyong Li
- Department of Gastroenterology, Chinese People Liberation Army 306th Hospital, Beijing, China
| | - Wei Wu
- Department of Otorhinolaryngology Head and Neck Surgery, Chinese People Liberation Army 306th Hospital, Beijing, China
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Lang IM, Medda BK, Shaker R. Effects of esophageal acidification on esophageal reflexes controlling the upper esophageal sphincter. Am J Physiol Gastrointest Liver Physiol 2019; 316:G45-G54. [PMID: 30308131 PMCID: PMC6383379 DOI: 10.1152/ajpgi.00292.2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Esophageal acid exposure can alter upper esophageal sphincter (UES) function, but the mechanism is unknown. The aim of this study was to determine the effects of esophageal acid exposure on esophago-UES relaxation (EURR) and contractile (EUCR) reflexes. Cats, decrebrate ( n = 27) or chronic ( n = 4), were implanted with electromyographic electrodes on pharynx, larynx, and esophagus. The esophagus was infused with either NaCl (0.9%) or HCl (0.1 N). The EUCR was activated by balloon distension in acute cats and slow air injection in chronic cats, and the EURR was activated by rapid air injection in both sets of cats. We found that NaCl infused for 15 or 30 min had no effect on EUCR or EURR in acute cats. HCl infused for 15, 30, or 45 min significantly ( P < 0.05) decreased the sensitivity to activate EUCR. HCl infused for 15 min significantly ( P < 0.05) increased and for 45 min significantly ( P < 0.05) decreased sensitivity to activate EURR. In chronic cats, HCl infused for 15 min/day increased sensitivity to activate EURR and decreased ( P < 0.05) sensitivity to activate EUCR after 4 days of infusion. EURR occurred spontaneously during HCl infusions on the 3rd and 4th ( P < 0.05) days of HCl infusion. We conclude that esophageal acid exposure initially sensitizes the esophagus to activation of EURR and desensitizes to activation of EUCR, but with longer exposure desensitizes to both. The alteration in sensitivity to activate EURR and EUCR caused by gastroesophageal reflux may play a role in the generation of supraesophageal reflux. NEW & NOTEWORTHY In acute studies, short-term esophageal acid exposure sensitizes esophagus to activation of esophago-upper esophageal sphincter relaxation response (EURR), whereas longer-term exposure inhibits EURR. Short- or long-term esophageal acid exposure decreases sensitivity to activation of esophago-upper esophageal sphincter contractile response (EUCR). In chronic studies, short-term esophageal acid exposure has the same effects on EURR and EUCR as occur acutely, but these effects take days to develop. Alteration in EURR and EUCR caused by gastroesophageal reflux may play a role in reflux disease.
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Affiliation(s)
- Ivan M. Lang
- Dysphagia Research Laboratory, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Bidyut K. Medda
- Dysphagia Research Laboratory, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Reza Shaker
- Dysphagia Research Laboratory, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Nadaleto BF, Herbella FAM, Pinna BR, Patti MG. Upper esophageal sphincter motility in gastroesophageal reflux disease in the light of the high-resolution manometry. Dis Esophagus 2017; 30:1-5. [PMID: 28375485 DOI: 10.1093/dote/dox001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Indexed: 12/11/2022]
Abstract
This study aims to evaluate the upper esophageal sphincter (UES) motility in patients with gastroesophageal reflux disease (GERD) as compared to healthy volunteers. We retrospectively studied the HRM tests of 44 patients (median age: 61 years, 54% females) under evaluation for GERD. The manometric UES parameters of these patients were compared to 40 healthy volunteers (median age: 27 years, 50% females). Almost half of the patients had a short and hypotonic UES. Patients with extraesophageal symptoms had a higher proportion of hypotonic UES as compared to patients with esophageal symptoms. Reflux pattern did not influence manometric parameters. Proximal reflux (any number of episodes) was present in 37(84%) patients (median number of proximal episodes = 6). Manometric parameters are similar in the presence or absence of proximal reflux. There is not a correlation between the UES length and UES basal pressure. In conclusion, our results show that: (1) the manometric profile of the UES in patients with GERD is characterized by a short and hypotonic UES in half of the patients; (2) this profile is more pronounced in patients with extraesophageal symptoms; and (3) neither the presence of proximal reflux nor reflux pattern bring a different manometric profile.
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Affiliation(s)
- B F Nadaleto
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - F A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - B R Pinna
- Department of Ear, Nose and Throat, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - M G Patti
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
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Roman S, Holloway R, Keller J, Herbella F, Zerbib F, Xiao Y, Bernard L, Bredenoord AJ, Bruley des Varannes S, Chen M, Fox M, Kahrilas PJ, Mittal RK, Penagini R, Savarino E, Sifrim D, Wu J, Decullier E, Pandolfino JE, Mion F. Validation of criteria for the definition of transient lower esophageal sphincter relaxations using high-resolution manometry. Neurogastroenterol Motil 2017; 29. [PMID: 27477826 DOI: 10.1111/nmo.12920] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 07/14/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Criteria for transient lower esophageal sphincter relaxations (TLESRs) are well-defined for Dentsleeve manometry. As high-resolution manometry (HRM) is now the gold standard to assess esophageal motility, our aim was to propose a consensus definition of TLESRs using HRM. METHODS Postprandial esophageal HRM combined with impedance was performed in 10 patients with gastroesophageal reflux disease. Transient lower esophageal sphincter relaxations identification was performed by 17 experts using a Delphi process. Four investigators then characterized TLESR candidates that achieved 100% agreement (TLESR events) and those that achieved less than 25% agreement (non-events) after the third round. Logistic regression and decision tree analysis were used to define optimal diagnostic criteria. KEY RESULTS All diagnostic criteria were more frequently encountered in the 57 TLESR events than in the 52 non-events. Crural diaphragm (CD) inhibition and LES relaxation duration >10 seconds had the highest predictive value to identify TLESR. Based on decision tree analysis, reflux on impedance, esophageal shortening, common cavity, upper esophageal sphincter relaxation without swallow and secondary peristalsis were alternate diagnostic criteria. CONCLUSION & INFERENCES Using HRM, TLESR might be defined as LES relaxation occurring in absence of swallowing, lasting more than 10 seconds and associated with CD inhibition.
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Affiliation(s)
- S Roman
- Digestive Physiology, Hospices Civils de Lyon, and Lyon I University, Lyon, France.,Inserm U1032, LabTAU, Lyon, France
| | - R Holloway
- Gastroenterology and Hepatology, Royal Adelaid Hospital, Adelaide, SA, Australia
| | - J Keller
- Department of Internal Medicine, Israelitic Hospital, University of Hamburg, Hamburg, Germany
| | - F Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - F Zerbib
- Gastroenterology, CHU Bordeaux and Bordeaux II University, Bordeaux, France
| | - Y Xiao
- Department of Gastroenterology and Hepatology, The First affiliated Hospital, Sen Yat-sen University, Guangzhou, China
| | - L Bernard
- Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Unité de recherche clinique, Lyon, France
| | - A J Bredenoord
- Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - S Bruley des Varannes
- Institut des Maladies de l'Appareil Digestif, CHU Nantes and Nantes University, Nantes, France
| | - M Chen
- Gastroenterology and Hepatology, Royal Adelaid Hospital, Adelaide, SA, Australia
| | - M Fox
- iDigest Clinic and Laboratory for Disorders of GI Motility and Function, Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland
| | - P J Kahrilas
- Division of Gasotrenterology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - R K Mittal
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - R Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi, Milan, Italy
| | - E Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - D Sifrim
- Center for Digestive Diseases, Bart's and the London School and Dentistry, London, UK
| | - J Wu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - E Decullier
- Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Unité de recherche clinique, Lyon, France
| | - J E Pandolfino
- Division of Gasotrenterology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - F Mion
- Digestive Physiology, Hospices Civils de Lyon, and Lyon I University, Lyon, France.,Inserm U1032, LabTAU, Lyon, France
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Abstract
Eructation is composed of three independent phases: gas escape, upper barrier elimination, and gas transport phases. The gas escape phase is the gastro-LES inhibitory reflex that causes transient relaxation of the lower esophageal sphincter, which is activated by distension of stretch receptors of the proximal stomach. The upper barrier elimination phase is the transient relaxation of the upper esophageal sphincter along with airway protection. This phase is activated by stimulation of rapidly adapting mechanoreceptors of the esophageal mucosa. The gas transport phase is esophageal reverse peristalsis mediated by elementary reflexes, and it is theorized that this phase is activated by serosal rapidly adapting tension receptors. Alteration of the receptors which activate the upper barrier elimination phase of eructation by gastro-esophageal reflux of acid may in part contribute to the development of supra-esophageal reflux disease.
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10
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Babaei A, Venu M, Naini SR, Gonzaga J, Lang I, Massey B, Jadcherla S, Shaker R. Impaired upper esophageal sphincter reflexes in patients with supraesophageal reflux disease. Gastroenterology 2015; 149:1381-91. [PMID: 26188682 PMCID: PMC4628603 DOI: 10.1053/j.gastro.2015.07.007] [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] [Received: 06/25/2014] [Revised: 06/22/2015] [Accepted: 07/07/2015] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Normal responses of the upper esophageal sphincter (UES) and esophageal body to liquid reflux events prevent esophagopharyngeal reflux and its complications, however, abnormal responses have not been characterized. We investigated whether patients with supraesophageal reflux disease (SERD) have impaired UES and esophageal body responses to simulated reflux events. METHODS We performed a prospective study of 25 patients with SERD (age, 19-82 y; 13 women) and complaints of regurgitation and supraesophageal manifestations of reflux. We also included 10 patients with gastroesophageal reflux disease (GERD; age, 32-60 y; 7 women) without troublesome regurgitation and supraesophageal symptoms and 24 healthy asymptomatic individuals (controls: age, 19-49 y; 13 women). UES and esophageal body pressure responses, along with luminal distribution of infusate during esophageal rapid and slow infusion of air or liquid, were monitored by concurrent high-resolution manometry and intraluminal impedance. RESULTS A significantly smaller proportion of patients with SERD had UES contractile reflexes in response to slow esophageal infusion of acid than controls or patients with GERD. Only patients with SERD had abnormal UES relaxation responses to rapid distension with saline. Diminished esophageal peristaltic contractions resulted in esophageal stasis in patients with GERD or SERD. CONCLUSIONS Patients with SERD and complaints of regurgitation have impaired UES and esophageal responses to simulated liquid reflux events. These patterns could predispose them to esophagopharyngeal reflux.
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Affiliation(s)
| | | | | | | | | | | | | | - Reza Shaker
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin.
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11
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Lang IM, Medda BK, Shaker R. Mechanism of UES relaxation initiated by gastric air distension. Am J Physiol Gastrointest Liver Physiol 2014; 307:G452-8. [PMID: 24970778 PMCID: PMC4137114 DOI: 10.1152/ajpgi.00120.2014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The aim of this study was to determine the mechanism of initiation of transient upper esophageal sphincter relaxation (TUESR) caused by gastric air distension. Cats (n = 31) were decerebrated, EMG electrodes were placed on the cricopharyngeus, a gastric fistula was formed, and a strain gauge was sewn on the lower esophageal sphincter (n = 8). Injection of air (114 ± 13 ml) in the stomach caused TUESR (n = 18) and transient lower esophageal sphincter relaxation (TLESR, n = 6), and this effect was not significantly (P > 0.05) affected by thoracotomy. Free air or bagged air (n = 6) activated TLESR, but only free air activated TUESR. Closure of the gastroesophageal junction blocked TUESR (9/9), but not TLESR (4/4), caused by air inflation of the stomach. Venting air from distal esophagus during air inflation of the stomach prevented TUESR (n = 12) but did not prevent air escape from the stomach to the esophagus (n = 4). Rapid injection of air on the esophageal mucosa always caused TUESR (9/9) but did not always (7/9) cause an increase in esophageal pressure. The time delay between the TUESR and the rapid air pulse was significantly more variable (P < 0.05) than the time delay between the rapid air pulse and the rise in esophageal pressure. We concluded that the TUESR caused by gastric air distension is dependent on air escape from the stomach, which stimulates receptors in the esophagus, but is not dependent on distension of the stomach or esophagus, or the TLESR. Therefore, the TUESR caused by gastric air distension is initiated by stimulation of receptors in the esophageal mucosa.
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Affiliation(s)
- Ivan M. Lang
- MCW Dysphagia Research Institute, Division of Gastroenterology and Hepatology, and Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Bidyut K. Medda
- MCW Dysphagia Research Institute, Division of Gastroenterology and Hepatology, and Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Reza Shaker
- MCW Dysphagia Research Institute, Division of Gastroenterology and Hepatology, and Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Schindler A, Mozzanica F, Alfonsi E, Ginocchio D, Rieder E, Lenglinger J, Schoppmann SF, Scharitzer M, Pokieser P, Kuribayashi S, Kawamura O, Kusano M, Zelenik K. Upper esophageal sphincter dysfunction: diverticula-globus pharyngeus. Ann N Y Acad Sci 2013; 1300:250-260. [PMID: 24117647 DOI: 10.1111/nyas.12251] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The following discussion of upper esophageal sphincter dysfunction includes commentaries on the role of the cricopharyngeus muscle in reflux disease; the etiology and treatment of Zenker diverticulum; the use of videofluoroscopy in patients with dysphagia, suspicion of aspiration, or globus; the role of pH-impedance monitoring in globus evaluation; and treatment for reflux-associated globus.
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Affiliation(s)
- Antonio Schindler
- Department of Biomedical and Clinical Sciences "L. Sacco,", University of Milan, Milan, Italy
| | - Francesco Mozzanica
- Department of Biomedical and Clinical Sciences "L. Sacco,", University of Milan, Milan, Italy
| | - Enrico Alfonsi
- Spinal and Cranial Reflexes Laboratory, Fondazione Istituto Neurologico C Mondino IRCCS, Pavia, Italy
| | - Daniela Ginocchio
- Department of Audiology, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - Erwin Rieder
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | | | - Peter Pokieser
- Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Shiko Kuribayashi
- Department of Gastroenterology, Gunma University Hospital, Gunma, Japan
| | - Osamu Kawamura
- Department of Gastroenterology, Gunma University Hospital, Gunma, Japan
| | - Motoyasu Kusano
- Department of Gastroenterology, Gunma University Hospital, Gunma, Japan
| | - Karol Zelenik
- Department of Otorhinolaryngology, University Hospital Ostrava, Ostrava, Czech Republic
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Kim HI, Hong SJ, Han JP, Seo JY, Hwang KH, Maeng HJ, Lee TH, Lee JS. Specific movement of esophagus during transient lower esophageal sphincter relaxation in gastroesophageal reflux disease. J Neurogastroenterol Motil 2013; 19:332-7. [PMID: 23875100 PMCID: PMC3714411 DOI: 10.5056/jnm.2013.19.3.332] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 05/07/2013] [Accepted: 05/09/2013] [Indexed: 01/04/2023] Open
Abstract
Background/Aims Transient lower esophageal sphincter relaxation (TLESR) is the main mechanism of gastroesophageal reflux disease (GERD). The aim of this study was to investigate the characteristics of transient lower esophageal sphincter movement in patients with or without gastroesophageal reflux by high-resolution manometry (HRM). Methods From June 2010 to July 2010, we enrolled 9 patients with GERD (GERD group) and 9 subjects without GERD (control group), prospectively. The manometry test was performed in a semi-recumbent position for 120 minutes following ingestion of a standardized, mixed liquid and solid meal. HRM was used to identify the frequency and duration of TLESR, esophageal shortening length from incomplete TLESR, upper esophageal sphincter (UES) response, and the related esophageal motor responses during TLESR. Results TLESR occurred in 33 in the GERD group and 34 in the control group after 120 minutes following food ingestion. Duration of TLESR and length of esophageal shortening did not differ between 2 groups. UES pressure increase during TLESR was mostly detected in patients with GERD, and UES relaxation was observed frequently in the control group during TLESR. TLESR-related motor responses terminating in TLESR were predominantly observed in the control group. Conclusions Increased UES pressure was noted frequently in the GERD group, suggesting a mechanism for preventing harmful reflux, which may be composed mainly of fluid on the larynx or pharynx. However, patients with GERD lacked the related motor responses terminating in TLESR to promote esophageal emptying of refluxate.
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Affiliation(s)
- Hoon Il Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Gyeonggi-do, Korea
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14
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Shepherd K, Hillman D, Eastwood P. CPAP-induced aerophagia may precipitate gastroesophageal reflux. J Clin Sleep Med 2013; 9:633-4. [PMID: 23772202 DOI: 10.5664/jcsm.2776] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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15
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Lang IM, Medda BK, Shaker R. Digestive and respiratory tract motor responses associated with eructation. Am J Physiol Gastrointest Liver Physiol 2013; 304:G1044-53. [PMID: 23578784 PMCID: PMC3680682 DOI: 10.1152/ajpgi.00043.2013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We studied the digestive and respiratory tract motor responses in 10 chronically instrumented dogs during eructation activated after feeding. Muscles were recorded from the cervical area, thorax, and abdomen. The striated muscles were recorded using EMG and the smooth muscles using strain gauges. We found eructation in three distinct functional phases that were composed of different sets of motor responses: gas escape, barrier elimination, and gas transport. The gas escape phase, activated by gastric distension, consists of relaxation of the lower esophageal sphincter and diaphragmatic hiatus and contraction of the longitudinal muscle of the thoracic esophagus and rectus abdominis. All these motor events promote gas escape from the stomach. The barrier elimination phase, probably activated by rapid gas distension of the thoracic esophagus, consists of relaxation of the pharyngeal constrictors and excitation of dorsal and ventral upper esophageal sphincter distracting muscles, as well as rapid contraction of the diaphragmatic dome fibers. These motor events allow esophagopharyngeal air movement by promoting retrograde airflow and opening of the upper esophageal sphincter. The transport phase, possibly activated secondary to diaphragmatic contraction, consists of a retrograde contraction of the striated muscle esophagus that transports the air from the thoracic esophagus to the pharynx. We hypothesize that the esophageal reverse peristalsis is mediated by elementary reflexes, rather than a coordinated peristaltic response like secondary peristalsis. The phases of eructation can be activated independently of one another or in a different manner to participate in physiological events other than eructation that cause gastroesophageal or esophagogastric reflux.
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Affiliation(s)
- Ivan M. Lang
- Dysphagia Research Institute, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Bidyut K. Medda
- Dysphagia Research Institute, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Reza Shaker
- Dysphagia Research Institute, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
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16
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Szczesniak MM, Fuentealba SE, Zhang T, Cook IJ. Modulation of esophageal afferent pathways by 5-HT3 receptor inhibition. Neurogastroenterol Motil 2013; 25:383-8, e293. [PMID: 23360084 DOI: 10.1111/nmo.12074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The study aims were to investigate whether neural pathways involving 5-HT3 receptors mediate: (i) distension-induced upper esophageal sphincter (UES) relaxation reflex, (ii) esophageal sensitivity to acid and electrical stimuli, and (iii) viserosomatic sensitization following acid exposure. METHODS In Study I, in a double-blind crossover trial (n = 9) esophageal sensory and pain thresholds to electrical stimulation were measured in the esophagus, midsternum, and the foot, before subjects were randomized to receive either Ondansetron (8 mg i.v.) or NaCl (0.9% w/v). HCl (0.15 mol L(-1)) was then infused into distal esophagus and electrical thresholds were reassessed. Following electrical sensory threshold testing, subjects received a second esophageal infusion of HCl to evaluate esophageal sensitivity to acid. In Study II (N = 10), frequencies of distension-induced UES relaxation responses were scored before and after treatment with Ondansetron and NaCl in a double-blind crossover trial. KEY RESULTS In Study I, ondansetron had no effect on esophageal sensitivity to HCl or acid-induced sensitization. However, blockade of 5-HT3 receptors did reduce midsternum somatic pain thresholds. Sixty minutes after esophageal acid exposure, pain thresholds were significantly lower in the ondansetron arm (mean Δ-1.36 ± 0.4 mA) when compared with NaCl (mean Δ-0.14 ± 0.58 mA) (P < 0.05). In Study II, 5-HT3 receptor blockade had no significant effect on UES relaxation reflex. CONCLUSIONS & INFERENCES This study does not support the hypothesis that in health, 5-HT3 receptors play a significant role in esophago-UES distention-induced relaxation reflex and esophageal sensitivity to acid or electrical stimulation. It does provide new evidence for involvement of 5-HT3 receptors in viscerosomatic sensitization.
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Affiliation(s)
- M M Szczesniak
- Department of Gastroenterology, St George Hospital, University of New South Wales, Sydney, NSW, Australia.
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17
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Kessing BF, Bredenoord AJ, Smout AJPM. Mechanisms of gastric and supragastric belching: a study using concurrent high-resolution manometry and impedance monitoring. Neurogastroenterol Motil 2012; 24:e573-9. [PMID: 23072402 DOI: 10.1111/nmo.12024] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Esophageal impedance monitoring has made it possible to distinguish two types of belches, designated gastric and supragastric. We aimed to compare the esophageal pressure characteristics during supragastric belches and gastric belches using combined high-resolution manometry and impedance monitoring. METHODS We included 10 patients with severe and frequent belching. Combined high-resolution manometry and impedance monitoring was performed. KEY RESULTS Whereas gastric belching was relatively rare in all patients (median incidence 2 per 90-min period), nine of the 10 patients exhibited excessive supragastric belching (36 in 90 min). Supragastric belches were characterized by: (i) movement of the diaphragm in aboral direction and increased esophagogastric junction (EGJ) pressure, (ii) decrease in esophageal pressure, (iii) upper esophageal sphincter (UES) relaxation, (iv) antegrade airflow into the esophagus, and (v) increase in esophageal and gastric pressure leading to expulsion of air out of the esophagus in retrograde direction. In contrast, gastric belches were characterized by: (i) decreased or unchanged EGJ pressure, which was significantly lower than during supragastric belches, (ii) absence of decreased esophageal pressure preceding entrance of air into the esophagus (iii) retrograde airflow into the esophagus, (iv) common cavity phenomenon, and (v) upper esophageal sphincter relaxation after the onset of the retrograde airflow. CONCLUSIONS & INFERENCES In gastric belching UES relaxation is a late event, allowing efflux of air that entered the esophagus from the stomach. In most patients with supragastric belching air is brought into the esophagus by movement of the diaphragm in aboral direction, creation of negative esophageal pressure, and UES relaxation.
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Affiliation(s)
- B F Kessing
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands.
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18
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Babaei A, Dua K, Naini SR, Lee J, Katib O, Yan K, Hoffmann R, Shaker R. Response of the upper esophageal sphincter to esophageal distension is affected by posture, velocity, volume, and composition of the infusate. Gastroenterology 2012; 142:734-743.e7. [PMID: 22248662 PMCID: PMC3327135 DOI: 10.1053/j.gastro.2012.01.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 12/21/2011] [Accepted: 01/03/2012] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Studies of the pressure response of the upper esophageal sphincter (UES) to simulated or spontaneous gastroesophageal reflux have shown conflicting results. These discrepancies could result from uncontrolled influence of variables such as posture, volume, and velocity of distension. We characterized in humans the effects of these variables on UES pressure response to esophageal distension. METHODS We studied 12 healthy volunteers (average, 27 ± 5 years old; 6 male) using concurrent esophageal infusion and high-resolution manometry to determine UES, lower esophageal sphincter, and intraesophageal pressure values. Reflux events were simulated by distal esophageal injections of room temperature air and water (5, 10, 20, and 50 mL) in individuals in 3 positions (upright, supine, and semisupine). Frequencies of various UES responses were compared using χ(2) analysis. Multinomial logistical regression analysis was used to identify factors that determine the UES response. RESULTS UES contraction and relaxation were the overriding responses to esophageal water and air distension, respectively, in a volume-dependent fashion (P < .001). Water-induced UES contraction and air-induced UES relaxation were the predominant responses among individuals in supine and upright positions, respectively (P < .001). The prevalence of their respective predominant response significantly decreased in the opposite position. Proximal esophageal dp/dt significantly and independently differentiated the UES response to infusion with water or air. CONCLUSIONS The UES response to esophageal distension is affected by combined effects of posture (spatial orientation of the esophagus), physical properties, and volume of refluxate, as well as the magnitude and rate of increase in intraesophageal pressure. The UES response to esophageal distension can be predicted using a model that incorporates these factors.
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Affiliation(s)
- Arash Babaei
- Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Sohrab Rahimi Naini
- Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Justin Lee
- Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Omar Katib
- Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ke Yan
- Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Raymond Hoffmann
- Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Reza Shaker
- Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Han SH, Hong SJ. [Transient lower esophageal sphincter relaxation and the related esophageal motor activities]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2012; 59:205-10. [PMID: 22460568 DOI: 10.4166/kjg.2012.59.3.205] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Transient lower esophageal sphincter (LES) relaxation (TLESR) is defined as LES relaxation without a swallow. TLESRs are observed in both of the normal individuals and the patients with gastroesophageal reflux disorder (GERD). However, TLESR is widely considered as the major mechanism of the GERD. The new equipments such as high resolution manometry and impedance pH study is helped to understand of TLESR and the related esophageal motor activities. The strong longitudinal muscle contraction was observed during development of TLESR. Most of TLESRs are terminated by TLESR related motor events such as primary peristalsis and secondary contractions. The majority of TLESRs are associated with gastroesophageal reflux. Upper esophageal sphincter (UES) contraction is mainly associated with liquid reflux during recumbent position and UES relaxation predominantly related with air reflux during upright position. The frequency of TLESR in GERD patients seems to be not different compared to normal individuals, but the refluxate of GERD patients tend to be more acidic during TLESR.
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Affiliation(s)
- Seung Hyo Han
- Department of Internal Medicine, Soonchunhyang University College of Medicine, 1174 Jung-dong, Wonmi-gu, Bucheon 420-767, Korea
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20
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Jung WJ, Yang HJ, Min TK, Jeon YH, Lee HW, Lee JS, Pyun BY. The efficacy of the upright position on gastro-esophageal reflux and reflux-related respiratory symptoms in infants with chronic respiratory symptoms. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2011; 4:17-23. [PMID: 22211166 PMCID: PMC3242055 DOI: 10.4168/aair.2012.4.1.17] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 09/20/2011] [Indexed: 12/14/2022]
Abstract
Purpose Gastro-esophageal reflux (GER), particularly non-acid reflux, is common in infants and is a known cause of chronic respiratory symptoms in infancy. Recent guidelines recommended empirical acid suppression therapy and the head-up position in patients with suspected GER. However, the efficacy of the upright position in relieving GER and reflux-related respiratory symptoms in infants is unclear. We conducted this study to investigate the efficacy of the upright position on GER and reflux-related respiratory symptoms in infants with chronic respiratory symptoms. Methods Thirty-two infants (21 male; median age, 5 months; range, 0 to 19 months) with unexplained chronic respiratory symptoms underwent multi-channel intraluminal esophageal impedance and pH monitoring. We retrospectively compared the frequencies of GER and reflux-related symptoms according to body position. Results A mean of 3.30 episodes of reflux per hour was detected. Overall, refluxes were more frequent during the postprandial period than the emptying period (3.77 vs. 2.79 episodes/hour, respectively; P=0.01). Although there was no significant difference in the total refluxes per hour between the upright and recumbent positions (6.12 vs. 3.77 episodes, P=0.10), reflux-related respiratory symptoms per reflux were significantly fewer in infants kept in an upright position than in a recumbent position during the postprandial period (3.07% vs. 14.75%, P=0.016). Non-acid reflux was the predominant type of reflux in infants, regardless of body position or meal time. Conclusions The upright position may reduce reflux-related respiratory symptoms, rather than reflux frequency. Thus, it may be a useful non-pharmacological treatment for infantile GER disease resistant to acid suppressants.
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Affiliation(s)
- Woo Jin Jung
- Pediatric Allergy and Respiratory Center, Department of Pediatrics, Soonchunhyang University Hospital, Seoul, Korea
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21
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Pandolfino JE, Lin Z, Roman S, Kahrilas PJ. The time course and persistence of "concurrent contraction" during normal peristalsis. Am J Physiol Gastrointest Liver Physiol 2011; 301:G679-83. [PMID: 21799184 PMCID: PMC3191553 DOI: 10.1152/ajpgi.00214.2011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Whereas conventional manometry depicts peristalsis as pressure variation over time, high-resolution manometry makes it equally feasible to depict pressure variation along the lumen (spatial pressure variation plots). This study analyzed the characteristics of spatial pressure variation plots during normal peristalsis. High-resolution manometry studies of 72 normal subjects were analyzed with custom MATLAB programs. A coordinate-based strategy was used to normalize both timing of peristalsis and esophageal length. A spatial pressure variation function was devised to localize the proximal (P) and the distal troughs (D) on each subject's composite pressure topography and track the length within the P-D segment contracting concurrently in the course of peristalsis. The timing at which this function peaked was compared with that of the contractile deceleration point (CDP). The length of concurrent contraction during normal peristalsis had an average span of 9.3 cm, encompassing 61% of the distal P-D length of the esophagus. The timing of the CDP position closely matched that of maximal length within the P-D segment contracting concurrently (r = 0.90, P < 0.001). The pressure morphology of the maximal concurrent contraction was that of a smooth curve, and it was extremely rare to see multiple peaks along the vertical axis (seen in 4 of 72 subjects). Concurrent contraction involving ∼60% of the P-D span occurred with normal peristalsis. The segment of concurrent contraction progressively increased as peristalsis progressed, peaked at the CDP, and then progressively decreased. How abnormalities of the extent or timing of concurrent contraction relate to clinical syndromes requires further investigation.
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Affiliation(s)
- John E. Pandolfino
- Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Zhiyue Lin
- Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sabine Roman
- Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Peter J. Kahrilas
- Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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22
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Roman S, Zerbib F, Belhocine K, des Varannes SB, Mion F. High resolution manometry to detect transient lower oesophageal sphincter relaxations: diagnostic accuracy compared with perfused-sleeve manometry, and the definition of new detection criteria. Aliment Pharmacol Ther 2011; 34:384-93. [PMID: 21651594 DOI: 10.1111/j.1365-2036.2011.04728.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Inhibition of transient lower oesophageal sphincter relaxations (tLESRs) has become one of the most relevant therapeutic objectives in patients with reflux symptoms resistant to proton pump inhibitors. tLESRs are currently detected by oesophageal perfused-sleeve manometry (PSM), but oesophageal high resolution manometry (HRM), which combines closely spaced pressure sensors and oesophageal pressure topography plots, may prove to be a better tool. AIM To evaluate the efficacy, reproducibility and interobserver agreement of HRM for the detection of tLESRs, in comparison with PSM. METHODS Twenty-four healthy volunteers underwent HRM alone and on a separate occasion with PSM simultaneously. LES pressure was monitored for 1 h during fasting and 2 h postprandial. Criteria for tLESRs were defined by characterising spontaneous LES relaxation associated with common cavity and then applied to all spontaneous LES relaxations. Interobserver agreement and the rates of tLESRs detected by HRM and PSM were compared. RESULTS New HRM criteria for the detection of tLESRs have been established. A similar number of tLESRs were identified during the two HRM recordings (median per subject 15 and 13 (P = 0.07) and less with PSM (median per subject 11, P < 0.01). The overall concordance rate between the two procedures was substantial (kappa = 0.61). The interobserver agreement was almost perfect (kappa = 0.83) with HRM and only fair (kappa = 0.38) with PSM. CONCLUSIONS High resolution manometry is reproducible and more sensitive than PSM to detect tLESRs. HRM provides a better interobserver agreement. These results confirm that HRM is the gold standard for detecting tLESRs (NTC00931593).
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Affiliation(s)
- S Roman
- Hospices Civils de Lyon, Edouard Herriot Hospital, Digestive Physiology and Université Claude Bernard Lyon 1, Lyon, France
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Rohof WOA, Boeckxstaens GEE, Hirsch DP. High-resolution esophageal pressure topography is superior to conventional sleeve manometry for the detection of transient lower esophageal sphincter relaxations associated with a reflux event. Neurogastroenterol Motil 2011; 23:427-32, e173. [PMID: 21199174 DOI: 10.1111/j.1365-2982.2010.01654.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Transient lower esophageal sphincter relaxations (TLESRs) are the main mechanism underlying gastro-esophageal reflux and are detected during manometric studies using well defined criteria. Recently, high-resolution esophageal pressure topography (HREPT) has been introduced and is now considered as the new standard to study esophageal and lower esophageal sphincter (LES) function. In this study we performed a head-to-head comparison between HREPT and conventional sleeve manometry for the detection of TLESRs. METHODS A setup with two synchronized MMS-solar systems was used. A solid state HREPT catheter, a water-perfused sleeve catheter, and a multi intraluminal impedance pH (MII-pH) catheter were introduced in 10 healthy volunteers (M6F4, age 19-56). Subjects were studied 0.5 h before and 3 h after ingestion of a standardized meal. Tracings were blinded and analyzed by the three authors according to the TLESR criteria. KEY RESULTS In the HREPT mode 156 TLESRs were scored, vs 143 during sleeve manometry (P = 0.10). Hundred and twenty-three TLESRs were scored by both techniques. Of all TLESRs (177), 138 were associated with reflux (78%). High-resolution esophageal pressure topography detected significantly more TLESRs associated with a reflux event (132 vs 119, P = 0.015) resulting in a sensitivity for detection of TLESRs with reflux of 96% compared to 86% respectively. Analysis of the discordant TLESRs associated with reflux showed that TLESRs were missed by sleeve manometry due to low basal LES pressure (N = 5), unstable pharyngeal signal (N = 4), and residual sleeve pressure >2 mmHg (N = 10). CONCLUSIONS & INFERENCES The HREPT is superior to sleeve manometry for the detection of TLESRs associated with reflux. However, rigid HREPT criteria are awaited.
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Affiliation(s)
- W O A Rohof
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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25
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Babaei A, Mittal RK. Cardiovascular compression of the esophagus and spread of gastro-esophageal reflux. Neurogastroenterol Motil 2011; 23:45-51, e3. [PMID: 20939848 DOI: 10.1111/j.1365-2982.2010.01606.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Factors that determine the spread of gastro-esophageal reflux (GER) along the length of the esophagus are not known. We investigated if cardiovascular (CV) compressions on the esophagus may determine the spread of refluxate into the proximal esophagus. METHODS High-resolution manometry (HRM) and multi-channel intra-luminal impedance recording (MIIR) were performed simultaneously in 10 normal subjects in the recumbent and upright positions. Pulsatile pressure increases on the esophagus (marker of CV compression) were identified on the HRM. Spread of refluxate into the esophagus was determined by the MIIR. KEY RESULTS Cardiovascular compression zones were observed in the esophagus in 9 out of 10 subjects in recumbent position. Forty percent of GER episodes were limited to the distal esophagus in the recumbent position and CV compression pressure was greater than distal esophageal pressure at the time of GER in all such cases. On the other hand, distal esophageal pressure was greater than CV compression pressure when the refluxate extended into the proximal esophagus. In the upright position, CV compression was less frequent than recumbent position and only 12% of GER episodes were limited to the distal esophagus. CONCLUSIONS & INFERENCES Cardiovascular compression of the esophagus is frequently observed in normal healthy subject and restricts the spread of refluxate into the proximal esophagus.
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Affiliation(s)
- A Babaei
- Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
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