Primary and secondary esophageal contractions in patients with gastroesophageal reflux disease

We studied the primary and secondary esophageal peristalsis in 36 patients with heartburn and acid regurgitation and in 14 asymptomatic volunteers. Primary peristalsis was elicited by ten swallows of a 5-mL bolus of water and secondary peristalsis was elicited by intra-esophageal infusion of 5, 10, and 15 mL water, 0.1 N hydrochloric acid and air. Esophageal contractions were measured by an 8-lumen manometric catheter assembly incorporating a 6-cm sleeve device. Contractions were registered at 3, 9, and 15 cm from the upper margin of the sleeve and the infusion was done through a side hole located at 12 cm. Twenty patients had normal endoscopic esophageal examination, 10 with normal (group I) and 10 with abnormal pH-metric examination (group II), and 16 had esophagitis (group III). The amplitude of contractions after swallows was lower (97.8 ± 10.0 mmHg) in the distal esophagus of group III patients than in controls (142.3 ± 14.0 mmHg). Patients of group III had fewer secondary contractions (water: 25 percent of infusion) than patients of the other groups and controls (67 percent of infusion). Patients of group III also had a lower amplitude of secondary peristalsis in the distal esophagus (water: 70.1 ± 9.6 mmHg) than controls (129.2 ± 18.2 mmHg). We conclude that patients with esophagitis have an impairment of primary and secondary peristalsis in the distal esophagus.

Residence of liquids in the infra-junctional portion of the proximal stomach in patients with gastroesophageal reflux disease

Patients with gastroesophageal reflux disease may have disturbances of gastric motility, which could play a role in the pathophysiology of the disease. Recent studies have suggested that the gastric region just below the gastroesophageal junction may have a distinct physiological behavior. We determined whether patients with gastroesophageal reflux disease have abnormal residence of food in the infra-junctional portion of the stomach after ingesting a liquid nutrient meal. Fasted adult patients with reflux disease (N = 11) and healthy volunteers (N = 10) ingested a liquid meal (320 ml; 437 kcal) labeled with 99m technetium-phytate and their total gastric emptying half-time and regional emptying from the stomach infra-junctional region were determined. In 8 patients, episodes of postprandial acidic reflux to the esophagus were measured for 2 h using pH monitoring. There were no differences between reflux patients and controls regarding total gastric emptying time (median: 68 min; range: 39-123 min vs 65 min and 60-99 min, respectively; P > 0.50). Food residence in the infra-junctional area was similar for patients and controls: 23 percent (range: 20-30) vs 27 percent (range: 19-30 percent; P = 0.28) and emptying from this area paralleled total gastric emptying (Rs = 0.79; P = 0.04). There was no correlation between residence of food in the infra-junctional area and episodes of gastroesophageal reflux (Rs = 0.06; P = 0.88). We conclude that it is unlikely that regional motor disturbances involving the infra-junctional region of the stomach play a relevant role in the pathogenesis of acidic gastroesophageal reflux.

Esophageal striated muscle contractions in patients with Chagas' disease and idiopathic achalasia

Chagas' disease causes degeneration and reduction of the number of intrinsic neurons of the esophageal myenteric plexus, with consequent absent or partial lower esophageal sphincter relaxation and loss of peristalsis in the esophageal body. The impairment of esophageal motility is seen mainly in the distal smooth muscle region. There is no study about esophageal striated muscle contractions in the disease. In 81 patients with heartburn (44 with esophagitis) taken as controls, 51 patients with Chagas' disease (21 with esophageal dilatation) and 18 patients with idiopathic achalasia (11 with esophageal dilatation) we studied the amplitude, duration and area under the curve of esophageal proximal contractions. Using the manometric method and a continuous perfusion system we measured the esophageal striated muscle contractions 2 to 3 cm below the upper esophageal sphincter after swallows of a 5-ml bolus of water. There was no significant difference in striated muscle contractions between patients with heartburn and esophagitis and patients with heartburn without esophagitis. There was also no significant difference between patients with heartburn younger or older than 50 years or between men and women or in esophageal striated muscle contractions between patients with heartburn and Chagas' disease. The esophageal proximal amplitude of contractions was lower in patients with idiopathic achalasia than in patients with heartburn. In patients with Chagas' disease there was no significant difference between patients with esophageal dilatation and patients with normal esophageal diameter. Esophageal striated muscle contractions in patients with Chagas' disease have the same amplitude and duration as seen in patients with heartburn. Patients with idiopathic achalasia have a lower amplitude of contraction than patients with heartburn

Upper esophageal sphincter pressure in patients with Chagas' disease and primary achalasia

The most important component of the upper esophageal sphincter (UES) is the cricopharyngeal muscle. During the measurement of sphincter pressure the catheter passed through the sphincter affects the pressure value. In Chagas' disease and primary achalasia there is an esophageal myenteric plexus denervation which may affect UES pressure. We measured the UES pressure of 115 patients with Chagas' disease, 28 patients with primary achalasia and 40 healthy volunteers. We used a round manometric catheter with continuous perfusion and the rapid pull-through method, performed in triplicate during apnea. Pressures were measured in four directions, and the direction with the highest pressure (anterior/posterior) and the average of the four directions were measured. The highest UES pressure in Chagas' disease patients without abnormalities upon radiologic esophageal examination (N = 63) was higher than in normal volunteers (142.8 +/- 47.4 mmHg vs 113.0 +/- 46.0 mmHg, mean +/- SD, P< 0.05). There was no difference in UES pressure between patients with primary achalasia and patients with Chagas' disease and similar esophageal involvement and normal volunteers (P> 0.05). There was no difference between patients with or without esophageal dilation. In the group of subjects less than 50 years of age the UES pressure of primary achalasia (N = 21) was lower than that of Chagas' disease patients with normal radiologic esophageal examination (N = 41), measured at the site with the highest pressure (109.3 +/- 31.5 mmHg vs 149.6 +/- 45.3 mmHg, P<0.01) and as the average of the four directions (64.2 +/- 17.1 mmHg vs 83.5 +/- 28.6 mmHg, < 0.05). We conclude that there is no difference in UES pressure between patients with Chagas' disease, primary achalasia and normal volunteers, except for patients with minor involvement by Chagas' disease, for whom the UES pressure at the site with the highest pressure was higher than the pressure of normal volunteers and patients with primary achalasia.

Gender effects on esophageal motility

It has been suggested that there are no gender effects on esophageal motility. However, in previous studies the subjects did not perform multiple swallows and the quantitative features of esophageal contractions were not evaluated. In order to investigate the gender effects on esophageal motility we studied 40 healthy normal volunteers, 20 men aged 37+15 years (mean + SD), and 20 women aged 38 +14 years. We used the manometric method with an eight-lumen polyvinyl catheter and continuous perfusion. The upper and lower esophageal sphincter pressures were measured by the rapid pull-through method. With the catheter positioned with one lumen opening in the lower esophageal sphincter, and the others at 5, 10 and 15 cm above the sphincter, ten swallows of a 5-ml water bolus alternated with ten dry swallows were performed. Statistical analysis was done by the Student t-test and Mann-Whitney test. Gender differences (P<0.05) were observed for wet swallows in the duration of contractions 5 cm above the lower esophageal sphincter (men: 3.7 + 0.2 s, women: 4.5 + 0.3 s, mean + SEM), and in the velocity of contractions from 15 to 10 cm above the lower esophageal sphincter (men: 4.7 + 0.3 cm/s, women: 3.5 + 0.2 cm/s). There was no difference (P>0.05) in sphincter pressure, duration and percentage of complete lower esophageal sphincter relaxation, amplitude of contractions, or in the number of failed, multipeaked and synchronous contractions. We conclude that gender may cause some differences in esophageal motility which, though of no clinical significance, should be taken into consideration when interpreting esophageal motility tests.

Tempo de trânsito faringeano medido através dos métodos cintilográfico e biomagnético / Pharyngeal transit time measured by of scintilographic and biomagnetic methods

Apesar do método Cintilográfico se mostrar o melhor estabelecido para o estudo do trânsito digestivo, recentemente o método Biomagnético vem sendo utilizado, possuindo algumas vantagens em relação ao Cintilográfico. O objetivo deste estudo é comparar ambos os métodos para a medida de tempo de trânsito faringeano. Foram estudados 3 voluntários, obtendo-se valores consideravelmente diferentes do método Cintilográfico, possivelmente devido a resolução do detetor biomagnético.

Abstract - The Scintigrafic method is well established to study the digestive tract motility. Nevertheless, the Biomagetic method has recently been employed and it does have some advantages over the Scintigraphic one. The aim of this study is to compare pharyngeal transit time measured by both methods. Our preliminary results indicate that there is a difference between the values obtained with each method, probabily due to the Biomagnetic detector resolution

Comparison of methods for recording esophageal sphincter pressures in Chagas’ disease

We measured the lower (LES) and upper esophageal sphincter (UES) pressure in 22 Chagas’ disease patients with dysphagia and abnormal radiologic esophageal examination, and in 12 normal volunteers. We compared the station pull-through (SPT) and rapid-through (RPT) techniques of sphincter pressure measurement, using an infused round catheter 5 mm in outer diameter, and with four side orifices at the same level. The LES pressure was higher when measured by RPT than by SPT and at inspiration than expiration (P/0.05). In Chagas’ disease patients, LES pressure was lower than in volunteers, with significance when measured by RPT at expiration (P/0.05). In normal volunteers, but not in patients, the UES pressure was higher when measured by RPT at expiration than when measured by SPT. When measured by RPT the UES pressure of Chagas’ disease patients was lower than in volunteers. In conclusion, LES pressure was higher when measured at inspiration and by the RPT technique. There was a considerable overlap of LES individual pressures between patients and volunteers, but the pressure was lower in patients when we used RPT at expiration. In normal volunteers the RPT technique recorded higher UES pressures than the SPT, and higher pressures than in Chagas’ disease patients.

Effect of bolus volume and consistency on swallow-induced submental and infrahyoid electromyographic activity

The effect of the volume of swallowed bolus and the form of barium delivered (liquid vs paste) on the timing of bolus transit, submental and infrahyoid electromyographic activity and hyoid movement during the oral and pharyngeal phase of swallowing was studied in 9 healthy volunteers. Using videofluoroscopy, we recorded concurrent submental electromyographic (EMG) activity from over the mylohyoid, geniohyoid and anterior digastric muscle complex (SM EMG) and from over the infrahyoid muscles, which consisted mainly of the thyrohyoids (IH EMG). Bolus volume (2 to 20 ml) did not change the timing or the duration of SM EMG and IH EMG activity, transit of the bolus tail through the mouth and pharynx, or the onset and duration of hyoid movement, for either liquid or paste. Although not volume dependent, the magnitude of SM EMG (2 ml, 79 + or 9% vs 44 + or - 6%, mean + or - SEM) and IH EMG (2 ml, 73 + or - 15% vs 42 + or - 8%) was greater for barium paste than for liquid barium. Large bolus volumes increased the duration of barium flow through the upper esophageal sphincter (UES), for both liquid (0.30 s, 0.40 s, 0.46 s, 0.50 s for 2, 5, 10, 20 ml) and paste (0.32 s, 0.43 s, 0.53 s, 0.61 s for 2, 5, 10, 20 ml). Barium paste was associated with a delay in the timing of events of about 0.2 s and a longer duration of bolus transit (0.91 + or - 0.03 vs 1.14 + or - 0.6 s, 5 ml), hyoid movement (1.21 + or - 0.08 vs 1.42 + or - 0.11 s, 5 ml), EMG activity (1.02 + or - 0.08 vs 1.30 + or - 0.10 s...