Dysphagia associated with esophageal wall thickening in patients with nonspecific high-resolution manometry findings: Understanding motility beyond the Chicago classification version 4.0

BACKGROUND

Previous studies have demonstrated that 50% of patients with normal high-resolution manometry (HRM) findings or ineffective esophageal motility (IEM) may have abnormal functional luminal imaging probe (FLIP) results. However, the specific HRM findings associated with abnormal FLIP results are unknown. Herein, we investigated the relationship between nonspecific manometry findings and abnormal FLIP results.

METHODS

We retrospectively analyzed 684 patients who underwent HRM at a tertiary care center in Seoul, Korea, based on the Chicago Classification version 4.0 protocol.

KEY RESULTS

Among the 684 patients, 398 had normal HRM findings or IEM. Of these 398 patients, eight showed esophageal wall thickening on endoscopic ultrasonography or computed tomography; however, no abnormalities were seen during esophagogastroduodenoscopy. Among these eight patients, seven showed repetitive simultaneous contractions (RSCs) in at least one of the two positions: 61% (±29%) in 10 swallows in the supine position and 51% (±30%) in five swallows in the upright position. Four patients who underwent FLIP had a significantly decreased esophagogastric junction distensibility index (1.0 ± 0.5m m 2 mmHg - 1 at 60 mL). Two of these patients underwent per-oral endoscopic myotomy (POEM) due to a lack of response to medication. Esophageal muscle biopsy revealed hypertrophic muscle with marginal eosinophil infiltration.

CONCLUSIONS & INFERENCES

A subset of patients (2%) with normal HRM findings or IEM and RSCs experienced dysphagia associated with poor distensibility of the thickened esophageal wall. FLIP assessment or combined HRM and impedance protocols may help better define these patients who may respond well to POEM.

Eosinophils Infiltration in Esophageal Muscularis Propria Induces Achalasia-like Esophageal Motility Disorder in Mice

Eosinophil infiltration in esophageal muscularis propria is common in achalasia (AC). This study aims to evaluate the effect of eosinophil infiltration in muscularis propria of the esophagus on esophageal motility in mice. A mouse model with eosinophil infiltration in the esophageal muscle layer was established by long term Ovalbumin (OVA) exposure. The histopathology features of esophageal muscularis propria as well as parameters of esophageal motility, such as lower esophageal sphincter pressure (LESP) and esophageal emptying, were compared between model and control group. In addition, the histopathology and motility of esophagus at each time point in the model group were compared. The esophageal motor function severely deteriorated in the model group, mimicking the abnormal esophageal motility of AC, with more eosinophils and fewer SOX-10-IR cells in esophageal muscularis propria in the model group, compared with control. With the prolongation of OVA treatment, esophageal motility disorder was aggravated, accompanied by increased eosinophils in the the muscle layer of esophagus and decreased SOX-10-IR cells in the model group. In addition, the eosinophil count was negatively correlated with SOX-10-IR cells. Long-term exposure to OVA assisted by alum may induce eosinophil infiltration in esophageal muscularis propria, reduced SOX-10-IR cells and abnormal esophageal motility, which simulates the functional and histopathological features of some AC patients. This suggests that eosinophil infiltration in esophageal muscularis propria may play a role in the pathogenesis of a subgroup of AC.

Use of the Functional Lumen Imaging Probe in Clinical Esophagology

The functional lumen imaging probe (FLIP) measures luminal dimensions using impedance planimetry, performed most often during sedated upper endoscopy. Mechanical properties of the esophageal wall and opening dynamics of the esophagogastric junction (EGJ) can be objectively evaluated in esophageal motor disorders, eosinophilic esophagitis, esophageal strictures, during esophageal surgery and in postsurgical symptomatic states. Distensibility index, the ratio of EGJ cross sectional area to intraballoon pressure, is the most useful FLIP metric. Secondary peristalsis from balloon distension can be displayed topographically as repetitive anterograde or retrograde contractile activity in the esophageal body, similar to high-resolution manometry. Real-time interpretation and postprocessing of FLIP metadata can complement the identification of esophageal outflow obstruction and achalasia, especially when findings are inconclusive from alternate esophageal tests in symptomatic patients. FLIP can complement the diagnosis of achalasia when manometry and barium studies are inconclusive or negative in patients with typical symptoms. FLIP can direct adequacy of disruption of the EGJ in achalasia when used during and immediately after myotomy and pneumatic dilation. Lumen diameter measured using FLIP in eosinophilic esophagitis and in complex strictures can potentially guide management. An abbreviated modification of the Grading of Recommendations Assessment, Development, and Evaluation was used to determine the quality of available evidence and recommendations regarding FLIP utilization. FLIP metrics that are diagnostic or suggestive of an abnormal motor pattern and metrics that define normal esophageal physiology were developed by consensus and are described in this review.

Durability of Esophageal Motor Disorders Identified on High-Resolution Esophageal Manometry: A Case Series

Background/Aim

Diagnosis of esophageal motor disorders using high-resolution esophageal manometry (HREM) may result in medical, endoscopic or surgical intervention. However, prior to any intervention, durability of the HREM findings should be established. The aim of this case series was to assess 25 patients who had undergone HREM twice, at least 6 months apart, and to determine the durability of the initial manometric diagnosis.

Methods and Patients

This is a case series of 25 patients who underwent HREM at least twice, 6 months apart, at a large safety net hospital. All patients were evaluated in between the tests for any clinical intervention. Demographics, patients’ indication for HREM and clinical presentation were documented as well.

Results

Of the 25 patients, HREM results improved in 32%, worsened in 20% and were unchanged in 48%. Some interventions were employed between the first and second HREM diagnosis. Those associated with an improved diagnosis included doubling the proton pump inhibitor (PPI) dose, re-starting a PPI, adding a histamine 2 blocker (H2 blocker) and use of empiric dilation.

Conclusions

In this case series, about half of the patients undergoing two esophageal manometries, at least 6 months apart, demonstrated lack of durability of their initially diagnosed esophageal motor disorder.

Esophagogastric junction outflow obstruction: Where are we now in diagnosis and management?

Esophagogastric junction outflow obstruction (EGJOO) is a major motility disorder based on the Chicago Classification of esophageal motility disorders. This entity involves a heterogenous group of underlying etiologies. The diagnosis is reached by performing high-resolution manometry. This reveals evidence of obstruction at the esophagogastric junction, manifested by an elevated integrated relaxation pressure (IRP) above a cutoff value (IRP threshold varies by the manometric technology and catheter used), with preserved peristalsis. Further tests like endoscopy, timed barium esophagram, and cross-sectional imaging can help further elucidate the underlying etiology and rule out mechanical causes. Treatment is tailored to the underlying cause. Similar to achalasia, treatment targeting lower esophageal sphincter disruption like pneumatic dilation, peroral endoscopic myotomy, and botulinum injection are used in patients with functional EGJOO and persistent symptoms.

Mucosally Expressed Cytokines are Associated with the Esophageal Motility Function

BACKGROUND AND AIM

Although basic research has shown that certain cytokines affect gastrointestinal motility, the clinical evidence is lacking. The objective of this study was to explore the association between mucosally expressed cytokines and the esophageal motility function in humans.

METHODS

We enrolled a total of 57 patients with suspected esophageal motility disorders (EMDs) who underwent high-resolution manometry.

RESULTS

The diagnoses of the patients were as follows: normal esophageal motility (n = 25), ineffective esophageal motility (n = 5), esophagogastric junction outflow obstruction (EGJOO; n = 10), distal esophageal spasm (n = 5), achalasia (n = 10), absent contractility (n = 1), and jackhammer esophagus (n = 1). The expression of tumor necrosis factor (TNF)-α in the esophagogastric junction (EGJ) was significantly higher in EGJOO (14.6, 14.0-15.8, n = 10) than in normal esophageal motility (13.3, 12.8-14.1, n = 25); however, there was no difference in the expression of TNF-α between achalasia (13.4, 13.0-14.1, n = 10) and normal esophageal motility (13.3, 12.8-14.1, n = 25). EGJOO was discriminated from achalasia/normal by a linear discriminant analysis (AUC = 0.917). A multivariable regression analysis revealed that interleukin (IL)-13 and IL-23A were predictive of the distal contractile integral, whereas TNF-α and IL-6 were predictive of the basal EGJ pressure.

CONCLUSIONS

The esophageal motility was associated with mucosally expressed cytokines in humans; these cytokines could be useful targets for the diagnosis and treatment of EMDs.

Impaired Esophageal Mucosal Integrity May Play a Causative Role in Patients With Nongastroesophageal Reflux Disease-Related Noncardiac Chest Pain

Baseline impedance (BI) measurement can be used to evaluate the status of the esophageal mucosa integrity. We hypothesized that impaired esophageal mucosal integrity may play a causative role in patients with nongastroesophageal reflux disease (non-GERD)-related noncardiac chest pain (NCCP). This retrospective study analyzed 24-hour multichannel intraluminal impedance-pH testing data from 77 patients with NCCP and 5 healthy volunteers. BI was calculated at 3 cm (distal esophagus) and 17 cm (proximal esophagus) above the lower esophageal sphincter. GERD was defined by the presence of pathologic acid exposure or reflux esophagitis. Among the 77 patients with NCCP, 16 (20.8%) were classified into the GERD-related NCCP group and 61 (79.2%) into the non-GERD-related NCCP group. BI (median, interquartile range) of the non-GERD-related NCCP group was lower than the control group at the proximal esophagus (2507 Ω, 2156-3217 vs 3855 Ω, 3238-4182, P = 0.001) but was similar at the distal esophagus. The GERD-related NCCP group showed lower BI than the control group at both the distal and proximal esophagus (2024 Ω, 1619-2308 vs 3203 Ω, 2366-3774, P = 0.007 and 2272 Ω, 1896-2908 vs 3855 Ω, 3238-4182, P = 0.003, respectively). At the distal esophagus, BI was lower in the GERD-related NCCP group than the non-GERD-related NCCP group (P = 0.002), whereas it did not differ between the 2 groups at the proximal esophagus. In conclusion, the mucosal integrity is impaired at the proximal esophagus in patients with non-GERD-related NCCP, which might be the pathogenic mechanism of NCCP.

Endoscopy in the diagnosis and management of motility disorders

BACKGROUND

Gastrointestinal illness may result from either an underlying structural abnormality (e.g. neoplastic obstruction), or a functional disorder (e.g. motor diarrhea), or both (e.g. achalasia with squamous esophageal cancer).

AIMS

The purpose of this study was to highlight the potential value and role of endoscopy in the recognition and management of patients with functional and motility disorders.

METHODS

We performed a literature review in PubMed.

RESULTS

Diagnostic and therapeutic endoscopy may be under-used by motility-oriented gastroenterologists; in contrast, motility and other functional studies may be under-used by endoscopists. Yet, many areas of cross-exchange exist.

CONCLUSIONS

This review aims to guide the appropriate indications for the use of endoscopy in diagnosing and treating functional GI and motility disorders and serve as a bridge and a forum of exchange between endoscopists and motility specialists.

Eosinophilic oesophagitis: an enigmatic, emerging disease

Eosinophilic oesophagitis is a disease that has emerged in recent years. It is often associated with dysphagia and oesophageal food impaction in adults. The disease is characterised by infiltration of eosinophilic granulocytes into the oesophageal mucosa. This infiltrate may be responsible for the subtle peristaltic abnormalities that can be found in these patients. Endoscopic findings are usually absent or nonspecific, although a discrete circular ring pattern of the mucosa may be noticed. Occasionally, overt endoscopic abnormalities (such as exudative changes and shearing of the mucosa) can be found. The presence of at least 15 intraepithelial eosinophilic granulocytes per high-power field in random biopsies from the whole length of the oesophagus is considered to be diagnostic. Gastro-oesophageal reflux needs to be excluded as it may lead to eosinophilic infiltration as well. Adequate diagnosis is relevant for treatment and the prevention of unnecessary further investigations. The disease responds well to the ingestion of fluticasone propionate and its long-term prognosis is generally good. But when fluticasone is discontinued recurrent symptoms are common, and some cases are severe, needing treatment with systemic corticosteroids.

Oesophageal dysmotility, delayed gastric emptying and gastrointestinal symptoms in patients with diabetes mellitus

AIMS

Gastroparesis is a common gastrointestinal complication in diabetes mellitus, whereas dysfunction in the other gastrointestinal organs has been less thoroughly investigated. Furthermore, it is not known whether there is any relationship between motility and dysmotility between these organs. The aim of this study was to examine whether diabetic patients with gastrointestinal symptoms also have motility disturbances in the oesophagus and stomach and, if so, whether there are any associations between these disturbances.

METHODS

Thirty-one patients with diabetes mellitus who complained of gastrointestinal symptoms were asked to complete a questionnaire about their symptoms. They were further investigated with oesophageal manometry and gastric emptying scintigraphy.

RESULTS

Fifty-eight per cent of the patients had abnormal oesophageal function, and 68% had delayed gastric emptying. Abdominal fullness was the only symptom that related to any dysfunction, and it was associated with delayed gastric emptying (P = 0.02). We did not find any relationship in motility or dysmotility between the oesophagus and the stomach.

CONCLUSION

Oesophageal dysmotility, as well as gastroparesis, are common in patients with diabetes who have gastrointestinal symptoms. It is important to investigate these patients further, to be able to reach an accurate diagnosis and instigate appropriate treatment. Our findings indicate that the oesophagus and the stomach function as separate organs and that pathology in one does not necessarily mean pathology in the other.

Congenital esophageal stenosis associated with esophageal atresia: new concepts

Congenital esophageal stenosis (CES) is suspected by a fixed intrinsic narrowing of the esophagus that affects the normal swallowing mechanism. The diagnosis is only confirmed by histopathologic picture, which may show fibromuscular disease (FMD) or tracheobronchial remnants (TBR). The latter involves ciliated pseudo stratified columnar epithelium, seromucous glands or cartilage each alone or in combination. The aim of this study is to document the usefulness of histologic picture of surgical specimens obtained from the lower esophageal pouch (LEP) during primary repair in detecting cases of CES associated with esophageal atresia (EA) with or without tracheoesophageal fistula (TEF). Over an 8-year period, 57 consecutive cases operated upon for EA with or without TEF were subjected for histologic examination of surgical specimens obtained from the tip of the LEP. Cases that histologically showed FMD or TBR were included. The usefulness of this histologic picture as a diagnostic and therapeutic aid is assessed. Methods of treatment and outcome were also reviewed. Eight patients out of 57 (14%) had a histologic picture suggestive of CES, two with FMD, four with TBR without cartilage and two with cartilage. Out of 57 patients, 23 developed strictures, six of them had positive biopsies suggestive of CES. One patient with TBR without cartilage did not have stricture. Another case of pure atresia had LEP resection and gastric pull up showed cartilage involving the whole lower esophagus. Excluding the case of pure EA with gastric pull up, all patients suffered from feeding problems and recurrent aspiration. Fluoroscopic barium studies showed late onset minor dysmotility in five patients and late onset major dysmotility in two. All cases studied showed significant gastro-esophageal reflux (GER). Stricture was seen at the anastomotic site extending distally in the two fibromuscular cases and one case with cartilage, at the anastomotic site in three cases with TBR without cartilage. Anti reflux surgical procedures were performed in four patients without benefit in two patients with major dysmotility. Dilatation was successful in the three patients with TBR without cartilage. One patient with cartilage had resection of the anastomotic site and required frequent dilatations and is now doing well. A case of FMD did not improve after frequent dilatations and myotomy together with Nissen's fundoplication and required resection while the other case of FMD responded partially to dilatations. Cartilage in cases of CES requires surgical resection. Those with TBR without cartilage may not develop stricture. If stricture develops, it responds well to dilatation and patients have good clinical outcomes. Unlike isolated CES, GER is a significant feature in CES with EA. Anti reflux procedures should be avoided before definitive surgery for the stricture and if necessary a partial wrap with gastrostomy is recommended. CES should be considered in the etiology of anastomotic stricture. Taking a surgical specimen routinely from the tip of the LEP during primary esophageal repair for histologic studies is highly recommended.

Esophageal dysmotility in young dogs

BACKGROUND

Abnormal esophageal motility can exist without megaesophagus, although its prevalence in dogs is unknown and its cause has not been elucidated.

HYPOTHESIS

Esophageal dysmotility without overt megaesophagus exists in both symptomatic and asymptomatic young dogs, and motility can improve with age.

ANIMALS

Dogs examined at the Department of Veterinary Medicine, University of Cambridge for regurgitation, but without evidence of megaesophagus on radiographs, and a further group of asymptomatic dogs.

METHODS

Dogs underwent an initial and a repeat videofluoroscopic swallowing study. Images were reviewed and 5 criteria of esophageal motility evaluated.

RESULTS

Eight affected dogs were identified (median age 9 months), and terrier dogs predominated (6 terriers of 3 breeds). Esophageal motility was reduced either globally (n = 3) or segmentally (n = 5). Repeat examination at a median of 3 months revealed that regurgitation had reduced or resolved in the majority of terrier dogs, and 4 of 6 cases demonstrated an improvement in esophageal motility. Videofluoroscopic evaluation of young (median age 11 months) asymptomatic dogs of various breeds (n = 22) revealed evidence of esophageal dysmotility in 4 of 5 control terrier dogs. Repeat evaluation demonstrated an improvement in esophageal motility in 3 dogs.

CONCLUSION AND CLINICAL IMPORTANCE

Esophageal dysmotility without overt megaesophagus occurs in young terrier dogs, and affected animals can be symptomatic or asymptomatic. Further, an improvement in esophageal motility occurs with time in some dogs, and might represent a syndrome of delayed esophageal maturation.

Prevalence of increased esophageal muscle thickness in patients with esophageal symptoms

BACKGROUND

Patients with achalasia, diffuse esophageal spasm (DES), and nutcracker esophagus have a thicker muscularis propria than normal subjects. The goal of our study was to determine the prevalence of increased muscle thickness in a group of unselected patients referred to the esophageal function laboratory for evaluation of the symptoms.

METHODS

We studied 40 normal subjects and 94 consecutive patients. Manometry and ultrasound images were recorded concurrently, using a special custom-built catheter. Esophageal muscle thickness and muscle cross-sectional area were measured at 2 and 10 cm above the lower esophageal sphincter (LES). Patients were assigned manometric diagnosis and determination was made if they had increased muscle thickness and muscle cross-sectional area.

RESULTS

Nearly all patients with well-defined spastic motor disorders, i.e., achalasia, DES, and nutcracker esophagus, revealed (a) an increase in the muscle thickness/cross-sectional area, (b) increase in esophageal muscle thickness/cross-sectional area was also seen, albeit at a lower prevalence rate, in patients with less well-characterized manometric abnormalities, i.e., hypertensive LES, impaired LES relaxation, and ineffective esophageal motility, and (c) 24% of patients with esophageal symptoms but normal manometry were also found to have an increase in muscle thickness/cross-sectional area. Dysphagia was more likely, and heartburn less likely in patients with increased muscle thickness, but there were no differences in chest pain and regurgitation symptoms between the groups.

CONCLUSION

We describe, for the first time, increased muscle thickness in patients with esophageal symptoms and normal manometry. We suggest that increased esophageal muscle thickness is likely to be an important marker of esophageal motor dysfunction.

Gastroesophageal reflux disease-associated esophagitis induces endogenous cytokine production leading to motor abnormalities

BACKGROUND & AIMS

Gastroesophageal reflux disease is a condition frequently associated with esophagitis and motor abnormalities. Recent evidence suggests that proinflammatory cytokines, such as interleukin (IL)-1beta and IL-6, may be implicated because they reduce esophageal muscle contractility, but these results derive from in vitro or animal models of esophagitis. This study used human esophageal cells and tissues to identify the cellular source of cytokines in human esophagitis investigate whether cytokines can be induced by gastric refluxate, and examine whether esophageal tissue- or cell-derived mediators affect muscle contractility.

METHODS

Endoscopic mucosal biopsy specimens were obtained from patients with and without esophagitis, organ-cultured, and undernatants were assessed for cytokine content. The cytokine profile of esophageal epithelial, fibroblast, and muscle cells was analyzed, and esophageal mucosa and cell products were tested in an esophageal circular muscle contraction assay.

RESULTS

The mucosa of esophagitis patients produced significantly greater amounts of IL-1beta and IL-6 compared with those of control patients. Cultured esophageal epithelial cells produced IL-6, as did fibroblasts and muscle cells. Epithelial cells exposed to buffered, but not denatured, gastric juice produced IL-6. Undernatants of mucosal biopsy cultures from esophagitis patients reduced esophageal muscle contraction, as did supernatants from esophageal epithelial cell cultures.

CONCLUSIONS

The human esophagus produces cytokines capable of reducing contractility of esophageal muscle cells. Exposure to gastric juice is sufficient to stimulate esophageal epithelial cells to produce IL-6, a cytokine able to alter esophageal contractility. These results indicate that classic cytokines are important mediators of the motor disturbances associated with human esophageal inflammation.

Esophageal ultrasonography: A new view on esophageal motility

Esophageal manometry has long been the gold standard for assessment of esophageal motility. Recently, high-frequency intraluminal ultrasonography (HFIUS) has been introduced to measure esophageal contractility and the thickness of esophageal muscle. Greater esophageal muscle thickness has been reported in patients with achalasia, diffuse spasm, and hypertensive peristalsis. In this issue of the Journal, Mittal and colleagues report additional observations in patients with esophageal symptoms referred for esophageal manometry. Their findings confirm earlier observations in patients with spastic motor disorders and report new findings of greater muscle thickness in patients with nonspecific motor disorders as well as normal manometry. Greater muscle thickness was associated with a greater prevalence of dysphagia suggesting the possibility that symptoms may be related, at least in part, to alterations in the biomechanics of the esophagus. The place of HFIUS in the assessment of esophageal function remains to be determined, but it offers the possibility of greater insights into esophageal physiology as well as clinical esophageal motor disorders.

Functional MRI in the evaluation of oesophageal motility: feasibility, MRI patterns of normality, and preliminary experience in subjects with motility disorders

PURPOSE

The aim of this study was to introduce functional magnetic resonance imaging (fMRI) with T1-weighted turbo fast low-angle shot (FLASH) sequences in the evaluation of oesophageal motility and morphology, to formulate MRI patterns of normality in healthy subjects and to demonstrate the feasibility of the method by obtaining a preliminary experience in the study of subjects affected by oesophageal motility disorders.

MATERIALS AND METHODS

Thirty healthy volunteers and seven patients with radiological and manometric diagnoses of oesophageal motility disorders underwent fMRI with dynamic T1- weighted turbo-FLASH (TFL) sequences during the administration of oral contrast material.

RESULTS

Evaluation of oesophageal function and morphology proved possible in all subjects, as well as the formulation of normality patterns. In patients with motility disorders, fMRI correctly visualised the typical alterations in agreement with radiological and manometric findings.

CONCLUSIONS

Functional MRI sequences acquired during the administration of oral contrast material can evaluate oesophageal transit, providing information on motility and morphology; furthermore, this modality can properly visualise the typical functional and morphological alterations of motility disorders.

Oesophageal dysmotility, delayed gastric emptying and autonomic neuropathy correlate to disturbed glucose homeostasis

AIMS/HYPOTHESIS

Among diabetic patients, glucose homeostasis may be affected by abnormal gastrointestinal motility and autonomic neuropathy. This study analysed whether oesophageal dysmotility, delayed gastric emptying or autonomic neuropathy affect glucose homeostasis.

MATERIALS AND METHODS

Oesophageal manometry and gastric emptying scintigraphy were performed in 20 diabetic patients. Heart-rate variation during deep breathing (expiration/inspiration [E/I] ratio) and continuous subcutaneous glucose concentrations for a period of 72 h were also monitored in the same patients.

RESULTS

Oesophageal dysmotility was found in eight of 14 patients. Eleven of 20 patients had delayed gastric emptying (abnormal gastric emptying half-time [T (50)]) and nine of 18 had an abnormal E/I ratio. Complaints of abdominal fullness were predictive of delayed gastric emptying. A low peristaltic speed of the oesophagus was associated with impaired T (50) (r ( s )=-0.67; p=0.02). One hour after breakfast, subcutaneous glucose levels decreased in patients with delayed gastric emptying but continued to rise in those with normal emptying. Consequently, the median glucose level 2.5 h after breakfast was lower in the former (9.1 [4.2-12.5] vs 14.3 [11.2-17.7] mmol/l; p<0.05). Glucose fluctuations during the 72 h were significantly higher in patients with an abnormal E/I ratio than in those with a normal E/I ratio (coefficient of variation: 41 [46-49] vs 28 [27-34]%; p=0.008).

CONCLUSIONS/INTERPRETATION

Abdominal fullness predicted delayed gastric emptying that was associated with diminished glucose uptake after breakfast. Low oesophageal peristaltic speed was associated with slow gastric emptying whereas parasympathetic neuropathy was associated with increased glucose variations.

Initial experience with magnetic resonance fluoroscopy in the evaluation of oesophageal motility disorders. Comparison with manometry and barium fluoroscopy

The aim of this paper was to assess the diagnostic value of magnetic resonance (MR) fluoroscopy in the study of oesophageal motility disorders and to compare MR fluoroscopy results with those of manometry and barium contrast radiography. Twenty-five subjects referred for dysphagia and three patients in follow-up after pneumatic dilatation of the lower oesophageal sphincter to treat severe achalasia underwent esophageal manometry, barium contrast radiography and MR fluoroscopy. Examinations were performed on a 1.5 T scanner. Dynamic turbo- fast low angle shot (turbo-FLASH) sequences acquired during oral contrast agent administration were used to perform MR fluoroscopy. MR fluoroscopy correctly diagnosed achalasia in nine patients, uncoordination of esophageal body motility in ten and scleroderma oesophagus in one. Diagnostic performance was satisfactory, with a sensitivity of 87.5% and a specificity of 100% in the general depiction of motility alterations. Our work demonstrates that MR fluoroscopic examination in subject affected by oesophageal motility disorders is feasible and can properly depict motility and morphology alterations, achieving correct diagnosis in the majority of cases. Studies on larger populations are necessary to obtain statistically significant results.

High prevalence of oesophageal involvement in patients with undifferentiated connective tissue disease using radionuclide oesophageal transit scintigraphy

AIM

To look for the frequency of oesophageal dysfunction using radionuclide oesophageal transit scintigraphy in 145 patients with undifferentiated connective tissue disease (UCTD); to seek the correlation between the clinical/laboratory data and scintigraphic alterations; and to determine predictive value of radionuclide oesophageal transit scintigraphy for evolution to established connective tissue disease (CTD).

METHOD

One hundred and forty-five patients with UCTD were examined by 99mTc-DTPA oesophageal transit scintigraphy. The intraoesophageal transport of the radiopharmaceutical was followed and imaged by a gamma camera, a series of 128 x 128 images were stored and evaluated. The correlation between the scintigraphic data and clinical and laboratory parameters was analysed statistically.

RESULTS

Unequivocally positive scintigraphy, indicative of motor abnormality was found in 46% of patients (66), 71% (47) of whom were totally asymptomatic. Significant correlation was found between the presence and severity of scintigraphic alterations and antinuclear antibodies, the anti-beta2GPI, IgM, IgG, the aCL antibody positivity, and the skin symptoms. Scintigraphic positivity was significantly more frequent in patients evolving to definitive CTD (P = 0.0178), and abnormal scan predisposed to transition into the definitive CTD (odds ratio, 2.292; CI, 1.610-4.525). Its cumulative positive predictive value was found to be 43% and cumulative negative predictive value 73% with regard to the development of a definitive CTD.

CONCLUSION

Our results show that scintigraphic alterations together with clinical and laboratory alterations can help the clinician in the prediction of final outcome.

Histology of esophageal mucosa from patients with achalasia

When achalasia becomes far advanced and leads to esophageal resection, inflammation of the esophageal mucosa is almost universal. The histology of the esophageal mucosa in less advanced cases of achalasia has not been firmly established. We have studied endoscopic biopsies obtained during evaluation of patients with achalasia. Two to four endoscopic biopsies from the lower esophagus of 26 patients with manometrically verified achalasia were mounted on mesh, serially sectioned, stained, coded and interpreted by two independent observers using recognized criteria. The histological findings were correlated with clinical data. Ten of 26 patients had at least one abnormal biopsy. Five of these 10 patients had a previous Heller myotomy; another patient had several pneumatic dilatations, and two other patients had endoscopically proven candida infections. Of the 16 patients with normal histology, four had prolonged stasis, five had heartburn and one patient had both heartburn and stasis. Unless the patient with achalasia has had a Heller myotomy, balloon dilatation, or a candida infection, the esophageal mucosa on biopsy appears to be within normal limits, even in patients with years of esophageal stasis or complaints of heartburn.

[Esophageal resection for non-specific esophageal motility disorder]

A 47-year-old patient presented with a history of dysphagia for solid food for almost 10 years and weight loss of more than 50 kg. Non-resecting surgical as well as endoscopic procedures (laparoscopic cardiomyotomy with secondary antireflux operations, balloon dilation, Botulinum-toxin injection) were without success. A barium esophagogram showed a confinement of the distal esophagus with a filiform passage of the contrast medium and undigested food in the prestenotic dilated esophageal corpus. Manometry displayed a hypertensive lower esophageal sphincter with a resting pressure of 43.8 mmHg - although completely relaxing. The tubular esophagus was aperistaltic with 100 % simultaneous and repetitive contractions. As all attempts of previous therapy had failed, a transhiatal esophagectomy with gastric pull-up and cervical esophagogastrostomy ensued. Neuropathological examination of the esophagus showed that degeneration of the myenteric plexus was not severely involved, whereas inflammatory and fibrotic changes were obvious. Esophageal resection provided the only chance of a long-term benefit for our patient with relief of dysphagia.

Naturally occurring fruit juices dislodge meat bolus obstruction in vitro*

Oesophageal meat bolus obstruction is often removed endoscopically/surgically with attendant morbidity and mortality. Anecdotal evidence suggests that fruit juices' enzymes may dissolve meat boluses. To assess this, an in vitro study was carried out. Cooked chicken was tightly packed between 10 and 8 mL markers of 80, 10 mL syringes. Two millilitres of fresh juice from lemons, papaya, kiwi fruits, pineapples, frozen and then thawed pineapple juice, processed pineapple juice, Coca-Cola and saliva were added to 10 syringes each. By 4 h, the meat boluses significantly moved in the pineapple juice both fresh and frozen and kiwi juice groups (P < 0.001), little movement in the Coca-Cola group (P < 0.05), and no movement in the saliva, processed pineapple juice, lemon juice and papaya groups. In conclusion, pineapples and kiwi fruits contain enzymes which can dislodge meat boluses. Freezing does not denature the enzyme and provides a convenient way of storing the juice.

[Epiglottic anteversion in the etiology of globus pharyngeus and its surgical management]

OBJECTIVES

To define the role of epiglottic anteversion in the etiology of globus pharyngeus (GP) and to evaluate the effectiveness of laser partial epiglottectomy in its treatment.

PATIENTS AND METHODS

Four patients who admitted to our clinic between 2001 and 2003 with the complaint of GP underwent laryngoscopic examination, which revealed a structurally anteverted epiglottis that was in contact with the tongue base and vallecula. After ruling out other etiologic factors of GP, the patients were operated on under general anesthesia and laser partial epiglottectomy was carried out. In this procedure, the part of the epiglottis 1 cm from the free margin, forming the contact points with the tongue base and vallecula was excised with laser.

RESULTS

Three patients were symptom-free totally, while one patient reported a partial cure.

CONCLUSION

Epiglottic anteversion should be kept in mind in the etiology of GP. Laser partial epiglottectomy may be helpful in the treatment of selected cases.

Subtotal esophageal resection in motility disorders of the esophagus

BACKGROUND

Esophagectomy for motility disorders is performed infrequently. It is indicated after failed medical therapy, pneumatic dilation, non-resecting surgical and redo procedures. Patient selection in this group is challenging and the operative risk has to be weighted carefully against the poor quality of life with persistent or recurrent dysphagia.

PATIENTS AND METHODS

Between September 1985 and April 2004, subtotal esophageal resections for advanced esophageal motility disorders of the esophagus not responding to previous therapy were carried out in 8 patients (6 females, 2 males). The median age of these patients was 59.5 (43-78) years. Six patients had a megaesophagus secondary to achalasia; 1 patient had a non-specific esophageal motility disorder with a stenosis of the distal esophagus, and a further patient displayed a recurrent huge epiphrenic diverticulum, which occurred in the context of a collagen disease. A transhiatal esophageal resection was performed in 6, a transthoracic procedure in 2 patients.

RESULTS

Outcome assessment was done after a follow-up of 43.5 (3-92) months in median. The resection and reconstruction of the esophagus in advanced and decompensated esophageal motility disorders led to a marked functional improvement with disappearance of dysphagia. Despite previous therapeutic failures, alimentation could be restored in all patients.

CONCLUSION

Favourable long-term results with significant improvement of symptoms can be achieved by esophageal resection even if endoscopic therapy or non-resecting surgical measures are unsuccessful. Transhiatal esophagectomy with gastric pull-up should be the preferred procedure and can be performed with low morbidity.

Hypertrophy of the muscularis propria of the lower esophageal sphincter and the body of the esophagus in patients with primary motility disorders of the esophagus

OBJECTIVES

Patients with diffuse esophageal spasm (DES) and nutcracker esophagus/high amplitude esophageal contraction (HAEC) have a thicker esophageal muscularis propria than do healthy subjects. The goals of this study were to determine the esophageal muscle cross-sectional area (MCSA), a measure of muscle mass, in patients with achalasia of the esophagus; and to compare it with that in patients with DES, patients with HAEC, and normal subjects.

METHODS

Using a high-frequency ultrasound probe catheter, concurrent manometry and ultrasound images of the esophagus were recorded in four subject groups: normal volunteers, patients with HAEC, patients with DES, and patients with achalasia of the esophagus. Recordings were obtained from the lower esophageal sphincter (LES) and multiple sites in the esophagus 2, 4, 6, 8, and 10 cm above the LES.

RESULTS

The LES and esophageal muscle thickness as well as esophageal MCSA were greater in all three patient groups than in the normal subject group. Muscle thickness and MCSA were observed to be greatest in patients with achalasia, which were greater than in patients with DES, which were greater than in those with HAEC, which in turn were greater than in normal subjects.

CONCLUSIONS

We propose that an increase in the MCSA is an important feature of patients with primary motility disorders of the esophagus. The degree of increase in muscle mass may be an important determinant of the type and the severity of esophageal motor dysfunction.

[Ineffective motility in lower third of esophagus. Length of involved esophagus and severity of gastroesophageal reflux disease]

Ineffective esophageal motility (IEM) has been described in patients with gastroesophageal reflux disease (GERD). Exact prevalence of IEM is unknown; however, it is associated with more severe forms of GERD. There are no studies of IEM in patients with non-erosive GERD (NERD). Traditionally, IEM is identified by manometry at 3 and 8 cm above lower esophageal sphincter. Studies evaluating each cm of distal third of esophagus to detect IEM have not been carried out to date.

AIM

To determine frequency of an IEM in NERD and erosive GERD as well as in mild and severe esophagitis, and to compare traditional criteria of IEM vs. manometry of each cm of distal third of esophagus.

MATERIAL AND METHODS

Healthy controls and patients with NERD and mild and severe esophagitis were studied. Manometry of each cm of lower third of esophagus was performed. Amplitude of esophageal contractions and frequency of IEM were compared between different groups of subjects and patients. The ability to detect IEM by traditional criteria and proposed criteria was determined.

RESULTS

Forty-four subjects were included, 13 controls, 10 patients with NERD, 12 with mild esophagitis, and nine with severe esophagitis. Amplitude of contractions was significantly different between groups. Controls showed higher amplitude than patients with severe esophagitis. Frequency of IEM was 0% in controls, 20% in NERD, 17% in mild esophagitis, and 33% in severe esophagitis. Frequency of IEM was similar when traditional criteria and proposed criteria were compared.

CONCLUSIONS

IEM occurs in NERD as well as in mild and severe esophagitis, and IEM is associated with GERD severity. Traditional manometry detects similar proportion of patients with IEM as well as manometry of each cm of lower third of esophagus.

Myenteric plexus in spastic motility disorders

Previous studies have often revealed an absence or reduction of ganglia in Auerbach's plexus in many patients with achalasia, which has been postulated to be related to the elevated lower esophageal sphincter pressure in these patients. We undertook a prospective study to determine whether microscopic changes were present in the myenteric plexus of patients with hypertensive lower esophageal sphincter, nutcracker esophagus, and diffuse esophageal spasm and if there was a correlation with lower esophageal sphincter pressure. Nine patients (3 men and 6 women; ages 49 to 72 years, mean 58 years) underwent a laparoscopic esophagomyotomy with fundoplication for symptomatic spastic motility disorder. A 10 mm x 5 mm segment of esophageal muscle was removed from the border of the myotomy incision, fixed in formalin, and examined under light microscopy for the presence or absence of ganglia and inflammation. Correlation between the presence of ganglia and lower esophageal sphincter pressure was tested by Pearson's bivariant correlation. Manometry revealed three patients with hypertensive lower esophageal sphincter, four patients with nutcracker esophagus, and two patients with diffuse esophageal spasm. All three patients with a hypertensive lower esophageal sphincter revealed an absence of ganglia, whereas the six patients with nutcracker esophagus and diffuse esophageal spasm exhibited ganglia despite an elevated lower esophageal sphincter pressure in four. Hypertensive lower esophageal sphincter resembled achalasia in its absence of ganglia in Auerbach's plexus, whereas nutcracker esophagus and diffuse esophageal spasm exhibited ganglia. There was no significant correlation in our series between the presence of ganglia and an elevated lower esophageal sphincter pressure in spastic motility disorders.

Oesophageal diverticula

BACKGROUND

Oesophageal pulsion diverticula, excluding pharyngeal types, are uncommon sequelae of oesophageal dysmotility. Current opinion favours myotomy as effective therapy, but the role of diverticulectomy, myotomy selection and placement, and the need for fundoplication remain unresolved.

METHODS

A Medline search and review of references identified relevant English language articles. Data on epidemiology, aetiology, oesophageal motility, pathology, symptomatology, investigations, surgical management and outcome were examined.

RESULTS

Data were largely retrospective. Significant morbidity and mortality were associated with pulmonary aspiration and diverticulectomy site leaks. Surgical outcome was similar whether or not a diverticulectomy was added to a myotomy, but a myotomy clearly reduced the risk of leaks. Fundoplication reduced the incidence of postcardiomyotomy reflux symptoms. Results from minimally invasive techniques were similar to those of open surgery.

CONCLUSION

Surgery should be reserved for symptomatic patients; asymptomatic patients may benefit from surveillance. Pulmonary aspiration mandates surgical intervention. Myotomy remains the mainstay of treatment and an adequate subdiverticular extension is crucial in relieving obstruction. A partial fundoplication is preferred in selected patients. Minimally invasive techniques should become the routine approach for oesophageal pulsion diverticula.

Esophagitis-related esophageal shortening in opossum is associated with longitudinal muscle hyperresponsiveness

Acute intraluminal acid perfusion induces esophageal shortening in humans and opossums. Lower esophageal sphincter (LES) hypotension and peristaltic dysfunction occur in patients and animal models of reflux esophagitis. This study examined whether similar shortening and motor dysfunction occur in anesthetized opossums after repeated esophageal acid exposure and whether this is associated with longitudinal muscle (LM) hyperresponsiveness. Manometry used before and after 3 consecutive days of 45-min perfusion with 100 mmol/l HCl or normal saline measured esophageal length and motor responses to induced swallows. LM electrical and mechanical responses were assessed using standard isometric tension and intracellular recording techniques. Compared with controls, repeated acid perfusion induced erosive esophagitis and significant esophageal shortening, associated with enhanced LM responses to carbachol, a significantly depolarized resting membrane potential, and abnormal spike patterns. LES resting pressure and swallow-induced peristalsis were unaffected. In this model of reflux esophagitis, marked persistent esophageal shortening and associated LM hyperresponsiveness occur before significant LES or peristaltic dysfunction, suggesting that esophageal shortening is the earliest motor disorder induced by acid injury.

Esophageal motility and outcomes following laparoscopic paraesophageal hernia repair and fundoplication

BACKGROUND

The addition of an antireflux procedure to all giant paraesophageal hernia (PEH) repairs remains controversial. In addition there are no series evaluating the impact of hernia repair and fundoplication on esophageal physiology. This study examines the outcomes of PEH repair with fundoplication and examines the results of preoperative and postoperative motility and pH testing.

METHODS

An analysis of a data base containing all patients undergoing PEH repair between September 1994 and December 1997. Patients underwent laparoscopic sac reduction, hernia repair, and fundoplication. Follow-up was performed under protocol and consisted of a symptoms assessment form, 24 hour pH, and manometry.

RESULTS

Fifty-two patients (mean age 63) were treated: 59% complained of heartburn, 50% dysphagia, and 27% chest pain; 26% had a body motility disorder. Complete manometry was not possible in 41%. Mean operative time was 4 hours. There were 48 Nissen, 4 Toupet, and 7 Collis-Nissen procedures. There were 3 (6%) intraoperative and 3 (6%) postoperative complications. There were no operative mortalities. Hospital stay was 3 days (1 to 29). Late follow-up (18 months) was available for 96% of patients and showed dysphagia in 6%, heartburn in 10%, and recurrent herniation in 8%. Objective postoperative testing was available in 61 % of the patients at a mean of 8 months. Twenty-four hour pH tests were abnormal in 4 patients (2 asymptomatic and 2 with a Collis). Lower esophageal sphincter pressures increased 63% and functioned well in 71% of patients; 50% of preoperative motility disorders improved following repair.

CONCLUSIONS

Laparoscopic repair of giant PEH is technically difficult but feasible. Routine addition of a fundoplication is advised, as preoperative testing is unreliable for a selective approach and fundoplications are well tolerated in this group of patients.

Medical treatment of gastroesophageal reflux disease does not prevent the development of Barrett's metaplasia and poor esophageal body motility

OBJECTIVE

Duodenal contents refluxing into the esophagus may be involved in the pathophysiology of gastroesophageal reflux disease (GERD). This study was performed to investigate whether medical treatment of GERD aimed at suppression of gastric acid production can prevent the development of complications, such as Barrett's metaplasia or poor esophageal body motility.

DESIGN

Retrospective study.

SETTING

University hospital.

PATIENTS

138 GERD patients were analyzed regarding the development of Barrett's metaplasia or poor esophageal body motility, despite intermittent or continuous treatment with H2 blockers or omeprazole.

MAIN OUTCOME MEASURES

The rate of patients with Barrett's metaplasia or poor esophageal body motility with or without effective medical treatment.

RESULTS

Barrett's metaplasia was found in 33.8% of patients receiving medical treatment, although it was not present when treatment was induced. This rate was 21.9% among patients who were not receiving therapy (not significant). In all, 41.9% of patients with medication had impaired esophageal body motility compared with 59.3% of patients not receiving treatment (P < 0.05), but these patients had a significantly shorter history of GERD.

CONCLUSIONS

Medical treatment with H2 blockers or omeprazole does not prevent the development of Barrett's metaplasia or poor esophageal body motility.

[Imaging and pathological studies on the esophageal dysfunction in patients with myotonic dystrophy]

The purpose of this study is to clarify a correlation between the esophageal dysfunction and suffocation after meals in patients with myotonic dystrophy (MD) and to find how to prevent such accidents. Using imaging methods, we examined eight patients with MD (six of them had difficulty in swallowing), four patients with other neuromuscular diseases (Fukuyama-type congenital muscular dystrophy, congenital myopathy, Machado-Joseph disease, and Duchenne's muscular dystrophy), and two healthy control subjects. We also investigated material from an autopsy of another patient with MD who died of suffocation. In all patients with MD, fluoroscopy and computed tomography showed dilatation of the esophagus, particularly in the proximal third, and residual contrast media in the esophagus 15 to 40 minutes after swallowing. In histologic studies, morphologic changes were confined to the esophageal striated muscle in a patient with MD. These results indicate that regurgitation from the esophagus to the trachea happens more than 40 minutes after swallowing in patients with MD and that histological alterations of striated muscle are primary causes of the esophageal dysfunction. From these findings, we propose that patients with MD should not lie down at least 40 minutes after meals whether they complain of difficulty in swallowing or not.

Morphological changes of myenteric neurons in the partially obstructed opossum esophagus

We have previously described a model of partial esophageal obstruction which leads to hypertrophic and degenerative changes in the smooth muscle cells. In the present communication we describe changes occurring in the myenteric plexus including increased thickness, varicosities and irregular angulations of nerve fiber bundles. The perikarya of myenteric neurons in the obstructed esophagus showed elongated mitochondria, dilated cisternae of the endoplasmic reticulum and increased numbers of secondary lysosomes and multimembranous dense bodies. In myenteric axons, there was infiltration of Schwann cell subunit by collagen fibrils.

[Pharyngo-esophageal motility disorders in Steinert's myotonic dystrophy. Description of a case presenting with dysphagia]

In Myotonic Dystrophy symptoms of gastrointestinal dysfunction may dominate the clinical picture or they may be manifested long before the musculoskeletal disturbances become apparent. A case of Myotonic Dystrophy in a 26-year-old woman with dysphagia as the symptom of clinical presentation is reported. Manometric investigations demonstrated motor dysfunctions in pharynx and in proximal, middle and distal portions of the esophageal body, indicating both striated and smooth muscle involvement. The pathophysiology of the esophageal motility disorders in Myotonic Dystrophy and the related therapeutic problems are briefly discussed.

Esophageal motor dysfunction years after radiation therapy

Well-known complications of radiation to the esophagus are acute esophagitis and strictures. Although radiologic studies have demonstrated motor abnormalities after radiation treatment, clinical aspects have not been described adequately, nor have manometric evaluations been reported. Clinical presentation of dysphagia long after treatment also has not been reported. We describe herein three patients who presented with dysphagia years after radiation therapy. Radiographic, endoscopic, histologic, and manometric studies supported our conclusion that these patients suffered from radiation-induced esophageal motor dysfunction. This report indicates the need, in the proper setting, to consider radiation-induced motor dysfunction as a cause of dysphagia even decades after radiation treatment.

Pharyngoesophageal dysmotility in globus sensation

Ambulatory esophageal pH monitoring, radiologic examination, endoscopy, and manometry were undertaken in 142 patients with globus. The results demonstrate that abnormal gastroesophageal reflux occurred in 23% of patients, implying that, while reflux may be responsible for globus in some patients, it is not the cause of globus sensation in the majority of individuals with this symptom. Comparing patients with globus and control subjects, there were no differences in lower esophageal sphincter pressures, esophageal body motility, or tonic upper esophageal sphincter pressures, but patients with globus exhibited higher pharyngeal and upper esophageal sphincter after-contraction pressures during deglutition. The physiological significance of this pharyngeal and upper esophageal dysmotility is not clear and it may be no more than a secondary phenomenon. Alternatively, it may contribute to the generation of globus, perhaps in combination with other physical and psychological triggers.

Use of endoscopic ultrasound in patients with esophageal motility disorders

New technology has combined the endoscope with ultrasound in an effort to enhance the visualization of the gastrointestinal tract. With a modified standard endoscope that has an ultrasound transducer built into the tip, high frequency ultrasonic beams can be targeted in close proximity to existing lesions. This results in better quality resolution which enhances the evaluation of the targeted lesion. In addition, esophageal wall thickness can be evaluated and assessed as to its role in esophageal function.