Danos anatômicos ao esfíncter esofágico inferior após gastrectomia subtotal / Anatomic damage of the lower esophageal sphincter after subtotal gastrectomy

RESUMO - RACIONAL: Disfunção do esfíncter esofágico inferior (EEI), doença do refluxo gastroesofágico e esofagite erosiva em pacientes submetidos à gastrectomia subtotal são ocorrências comumente reconhecidas, mas até agora as causas permanecem obscuras. OBJETIVO: A hipótese deste estudo é que a gastrectomia subtotal provoque alterações na pressão de repouso do EEI e na sua competência, devido ao dano anatômico desta, visto que as fibras oblíquas "Sling", um dos componentes musculares do EEI, são seccionadas durante este procedimento cirúrgico. MÉTODOS: Sete cães adultos sem raça definida (18-30 kg) foram anestesiados e submetidos à transecção do estômago proximal. Em seguida, o remanescente gástrico proximal foi fechado por sutura. No intraoperatório, manometria lenta foi realizada em cada cão, em condições basais (com estômago intacto) e no remanescente gástrico proximal fechado. A média dessas medidas é apresentada, com cada cão servindo como seu próprio controle. RESULTADOS: A pressão média do EEI medida no remanescente gástrico proximal, em comparação com a pressão do EEI no estômago intacto, foi diminuída em cinco cães, aumentada em um cão e sem alterações no outro cão. CONCLUSÃO: A secção transversa superior do estômago e o fechamento do remanescente do estômago por sutura provocam alterações na pressão do EEI. Sugerimos que essas mudanças na pressão do EEI são secundárias à secção das fibras oblíquas "Sling" do esfíncter, um de seus componentes musculares. A sutura e o fechamento do remanescente gástrico proximal, reancora essas fibras com mais, menos ou a mesma tensão, modificando ou não a pressão do EEI.

ABSTRACT - BACKGROUND: Dysfunction of the lower esophageal sphincter (LES), gastroesophageal reflux disease, and erosive esophagitis in patients undergoing subtotal gastrectomy are commonly recognized occurrences, but until now the causes remain unclear. AIM: The hypothesis of this study is that subtotal gastrectomy provokes changes on the LES resting pressure and its competence, due to the anatomical damage of it, given that the oblique "Sling" fibers, one of the muscular components of the LES, are transected during this surgical procedure. METHODS: Seven adult mongrel dogs (18-30 kg) were anesthetized and admitted for transection of the proximal stomach. Later, the proximal gastric remnant was closed by a suture. Intraoperatively, slow pull-through LES manometries were performed on each dog, under basal conditions (with the intact stomach), and in the closed proximal gastric remnant. The mean of these measurements is presented, with each dog serving as its control. RESULTS: The mean LES pressure (LESP) measured in the proximal gastric remnant, compared with the LESP in the intact stomach, was decreased in five dogs, increased in one dog, and remained unchanged in other dogs. CONCLUSION: The upper transverse transection of the stomach and closing the stomach remnant by suture provoke changes in the LESP. We suggested that these changes in the LESP are secondary to transecting the oblique "Sling" fibers of the LES, one of its muscular components. The suture and closing of the proximal gastric remnant reanchor these fibers with more, less, or the same tension, whether or not modifying the LESP.

Experimental study of animal esophageal motility using sonic wave device / 天津医药

Objective To investigate a sonic wave device including micro-oscillator and microphone for real-time monitoring the situation of the esophageal motility of lower esophageal sphincter (LES). Methods A micro-oscillator that can actively send sound waves was located at one side of LES, and a microphone located at the other side can be to capture the sound generated from the oscillator. This device was tested in vitro by utilizing a LES simulator in quiet and noisy environment, as well as in vivo in a pilot model corresponding to moments A-D. Results In the in vitro test, the sound can be captured by the microphone, and its power strength was correlated with closing and opening of LES. The measurements showed statistically significant Pearson correlation coefficients. In the in vivo test, the LES was open and closed by an endoscope, which was monitored in real-time by another endoscope inserted into the distal stomach from the duodenum. The sound power strength corresponding to moments A-D were (-89.63 ± 0.79) dB, (-84.74 ± 0.97) dB, (-82.37 ± 1.93) dB and (-89.86 ± 0.75) dB. Conclusion The LES dynamics can be monitored by the acoustic interrogation device, which has the potential to become an effective minimally-invasive technique for studying LES dysfunction.

Effects of Metoclopramide on Esophageal Motor Activity and Esophagogastric Junction Compliance in Healthy Volunteers

BACKGROUND/AIMS: Prokinetic drugs such as metoclopramide are frequently used as second-line therapy for patients with gastroesophageal reflux disease. However, their beneficial effects remain unclear. Esophageal motor activities and compliance of the esophagogastric junction (EGJ) are important for prevention of gastroesophageal reflux. Although metoclopramide has been reported to increase lower esophageal sphincter (LES) pressure, its effects on EGJ compliance have not been evaluated. In the present study, we investigated the effects of metoclopramide on esophageal motor activities and EGJ compliance. METHODS: Nine healthy male volunteers without abdominal symptoms were enrolled. Peristaltic esophageal contractions and LES pressure were examined using high-resolution esophageal manometry, while EGJ compliance was evaluated with an endoluminal functional lumen-imaging probe. After obtaining baseline values for esophageal motor activities and EGJ compliance, metoclopramide (10 mg) was intravenously administered, then all measurements were repeated at 15 minutes after administration in each subject. RESULTS: Following administration of metoclopramide, mean resting LES pressure was significantly increased as compared with the baseline (13.7 +/- 9.2 vs 26.7 +/- 8.8 mmHg, P < 0.05). In addition, metoclopramide significantly augmented peristaltic contractions, especially in the distal esophageal segment (P < 0.05). On the other hand, distensibility index did not change after administration (4.5 +/- 0.5 vs 4.1 +/- 0.5 mm2/mmHg), suggesting no significant effect of metoclopramide on EGJ compliance. CONCLUSIONS: Metoclopramide augmented esophageal contractions without changing EGJ compliance in healthy adults.

Effect of Electrical Stimulation on Anti-reflux of Gastroesophageal Junction and Preliminary Exploration of Related Neural Pathway / 胃肠病学

Background:As a new concept of treatment for gastroesophageal reflux disease(GERD),local electrical stimulation on lower esophageal sphincter(LES)is still in a preliminary stage. Aims:To explore the ideal local electrical stimulation parameters for LES contraction and the local neural reflex path that inhibits LES contraction. Methods: Anti-gastroesophageal reflux model with electrical stimulation in vivo was established. The changes of gastroesophageal reflux were observed to explore the ideal electrical stimulation parameters for LES contraction. Effects of different drugs on gastroesophageal reflux in condition with ideal electrical stimulation parameters were observed. Results:When frequency was 10 Hz and pulse was 0. 4 ms,gastroesophageal reflux in voltage 10 V or 15 V groups was significantly decreased(P <0. 001). When voltage was 10 V and pulse was 0. 4 ms,gastroesophageal reflux in frequency 10 Hz group was significantly decreased(P < 0. 001). When voltage was 10 V and frequency was 10 Hz,gastroesophageal reflux in pulse 0. 4 ms group was significantly decreased(P < 0. 001). Local infiltration of tubocurarine or capsaicin on LES could significantly increase gastroesophageal reflux(P < 0. 05). The administration of NK1 receptor blocker L-732,138 or NO synthase inhibitor L-NAME could significantly decrease gastroesophageal reflux(P < 0. 05). Conclusions:In view of the injury of electrical energy on tissue,the ideal electrical stimulation parameters are voltage of 10 V,frequency of 10 Hz and pulse of 0. 4 ms. Local neural reflex path consisted of primary TRPV-1-positive tachykininergic neurons and nitrergic neurons in the muscle layer of esophagus could inhibit LES contraction evoked by electrical stimulation.

The participatinn of the nitrergic pathway in icreased rate of transitory relaaxation of lower esophageal sphincter induced by rectal distension in dogs / A participação da via nitrérgica no aumento da taxa de relaxamento transitório do esfíncter esofágico inferior induzida pela distensão retal em cães

Context The rectal distension in dogs increases the rate of transitory lower esophageal sphincter relaxation considered the main factor causing gastroesophageal reflux. Objectives The aim of this study was evaluate the participation of the nitrergic pathway in the increased transitory lower esophageal sphincter relaxation rate induced by rectal distension in anesthetized dogs. Methods Male mongrel dogs (n = 21), weighing 10-15 kg, were fasted for 12 hours, with water ad libitum. Thereafter, they were anesthetized (ketamine 10 mg.Kg-1 + xylazine 20 mg.Kg-1), so as to carry out the esophageal motility evaluation protocol during 120 min. After a 30-minute basal period, the animals were randomly intravenous treated whith: saline solution 0.15M (1ml.Kg-1), L-NAME (3 mg.Kg-1), L-NAME (3 mg.Kg-1) + L-Arginine (200 mg.Kg-1), glibenclamide (1 mg.Kg-1) or methylene blue (3 mg.Kg-1). Forty-five min after these pre-treatments, the rectum was distended (rectal distension, 5 mL.Kg-1) or not (control) with a latex balloon, with changes in the esophageal motility recorded over 45 min. Data were analyzed using ANOVA followed by Student Newman-Keuls test. Results In comparison to the respective control group, rectal distension induces an increase in transitory lower esophageal sphincter relaxation. Pre-treatment with L-NAME or methylene blue prevents (P<0.05) this phenomenon, which is reversible by L-Arginine plus L-NAME. However, pretreating with glibenclamide failed to abolish this process. Conclusions Therefore, these experiments suggested, that rectal distension increases transitory lower esophageal sphincter relaxation in dogs via through nitrergic pathways. .

Contexto A distensão retal aumenta a taxa de relaxamento transitório do esfíncter esofágico inferior em cães, sendo o relaxamento transitório do esfíncter esofágico inferior considerado o principal fator responsável pelo refluxo gastroesofágico. Objetivos Avaliar a participação da via nitrérgica no aumento da taxa relaxamento transitório do esfíncter esofágico inferior induzida por distensão retal em cães anestesiados. Métodos Cães sem raça definida, machos (n = 21), pesando entre 10-15 kg, foram mantidos em jejum durante 12 horas, no entanto, com água ad libitum. Depois disso, eles foram anestesiados (cetamina 10 mg.Kg-1 + xilazina 20 mg.Kg-1), para a realização do protocolo de avaliação da motilidade esofágica durante 120 minutos. Após um período basal de 30 minutos, os animais foram aleatoriamente tratados intravenosa com: solução salina 0,15 (1 ml.Kg-1), L-NAME (3 mg.Kg-1), L-NAME (3 mg.Kg-1) + L-arginina (200 mg.Kg-1), glibenclamida (1 mg.Kg-1) e azul de metileno (3 mg.Kg-1). Quarenta e cinco minutos após os pré-tratamentos, o reto foi distendido com um balão de látex (DR, 5 mg.Kg-1) ou não (grupo controle), e as variações da motilidade esofágica foram registradas e gravadas ao longo dos 45 minutos seguintes. Os dados foram analisados utilizando-se ANOVA seguido pelo teste de Student Newman-Keuls. Resultados Em comparação com o respectivo grupo controle, a distensão retal demonstrou induzir um aumento na taxa de relaxamento transitório do esfíncter esofágico inferior. O pré-tratamento com L -NAME ou azul de metileno impediu (P<0,05) este fenômeno, que foi reversível após a administração de L-Arginina + L-NAME. No entanto, o pré-tratamento com a glibenclamida não ...

Study on Pathology and Neurotransmitters of Esophageal Sphincter after Radiofrequency Thermocoagulation in Dogs / 天津医药

Objective To investigate the effects of radiofrequency thermocoagulation (RFT) on pathological features and the expressions of choline acetyltransferase (ChAT), vasoactive intestinal peptide (VIP) and nitric oxide synthase (NOS) at lower esophageal sphincter (LES) in family dogs. Methods A total of 15 dogs were randomly divided into three groups. Sham group underwent gastroscopy and was fed for 3 months (n=5). Dogs were given RFT and were fed for 24 h after RFT (n=5, RFT+24 h group). Dogs were given RFT and were fed for 3 months after RFT (n=5, RFT+3m group). The pathological changes of LES were observed after HE staining in three groups. The expressions of ChAT, VIP and NOS were detected by immunohistochemical method in three groups. Results Results of HE staining showed nearly the same tissues in Sham group and control group. There were active inflammatory reaction and structural damage in RFT+24 h group. The chronic in-flammatory reaction and structural remodeling were found in RFT+3m group. Immunohistochemistry showed that ChAT was significantly increased in RFT+3m group compare than that of Sham group. Values of VIP and NOS were significantly de-creased in RFT+3m group compare than that of Sham group (P<0.01). Conclusion The thickness and increased pressure of LES were found after RFT,which also caused changes in neurotransmitters of local tissues in dogs.

Dynamic Changes in Esophageal Manometry of Achalasia Patients Receiving Peroral Endoscopic Myotomy / 胃肠病学

Background:The goals for treatment of achalasia are reducing lower esophageal sphincter pressure (LESP)and alleviating esophageal obstruction and its related symptoms.Peroral endoscopic myotomy (POEM)is a promising option for treating achalasia.Aims:To assess the short-term efficacy of POEM for treating achalasia by analyzing the dynamic changes in esophageal manometry.Methods:A retrospective study was conducted in 39 achalasia patients receiving POEM in Nanjing Drum Tower Hospital from Dec.2011 to Oct.2012.Data of water-perfusion esophageal manometry and one-month follow up were collected and analyzed.Results:Thirty-eight patients accomplished the POEM procedure and esophageal manometry three days after treatment.The post-POEM LESP was significantly reduced as compared with the pre-POEMones (P <0.01),while no significant difference was seen in LES relaxation rate before and after POEM.With regard to the motility of esophageal body,absence of peristalsis and increased synchronous contraction were observed both pre-and post-operatively.One month after POEM,LESP was still significantly lower than that before treatment (P <0.05).Thirty-seven patients had their dysphagia alleviated with an efficacy rate of 94.9%.Conclusions:POEM can reduce LESP and alleviate clinical symptoms of achalasia patients but has no effect on esophageal peristalsis during the short-term follow up.Esophageal manometry is useful for evaluating the short-term outcome postoperatively.

Electrical Stimulation Therapy for Gastroesophageal Reflux Disease

Electrical stimulation therapy (EST) of the lower esophageal sphincter is a relatively new technique for the treatment of gastroesophageal reflux disease (GERD) that may address the need of GERD patients, unsatisfied with acid suppressive medication and concerned with the potential risks of surgical fundoplication. In this paper we review available data about EST for GERD, including the development of the technique, implant procedure, safety and results from open-label trials. Two short-term temporary stimulation and long-term open-label human trials each were initiated to investigate the safety and efficacy of EST for the treatment of GERD and currently up to 2 years follow-up results are available. The results of EST are promising as the open-label studies have shown that EST is a safe technique with a significant improvement in both subjective outcomes of symptoms and objective outcomes of esophageal acid exposure in patients with GERD. However, long-term data from larger number of patients and a sham-controlled trial are required before EST can be conclusively advised as a viable treatment option for GERD patients.

Study on the risk factors that are related to gastroesophageal reflux disease / 中国医师杂志

Objective To investigate the pathogenesis of gastroesophageal reflux (GERD) diseaserelated risk factors.Methods A questionnaire survey of 1213 patients in our hospital gastroenterology clinic visits was conducted,including irregular feeding time,eating too full,eating before going to bed,like greasy food,spicy food and alcohol consumption,and smoking.The results of the investigation were rated;95 patients were selected as the observation group,another 30 healthy volunteers were selected as the control group.Esophageal and gastric pressures were measured on the observation group and control subjects,respectively.Results Multivariate logistic regression analysis showed that often eating to satiety (OR =11.5322,P =0.0135),before going to bed eating (OR =14.6537,P =0.0005),like greasy food (OR =11.6547,P =0.0089),spicy food (OR =12.5674,P =0.0031),heavy drinking (OR =10.9874,P =0.0003),and smoking (OR =10.3846,P =0.0013) were important factors affecting the incidence of GERD; length of lower esophageal sphincter (LESL) mean of the observation group was (3.27 ±0.29)cm,intragastric pressure (GP) mean (1.63 ± 1.12) kPa,lower esophageal sphincter pressure/intragastric pressure (LESP/GP) =0.55 ±0.41,LESP-GP mean (-0.33 ±0.34) kPa,with the control group [(3.90 ± 0.42) cm,(1.12 ± 0.94) kPa,1.72 ± 0.82,(0.88 ± 0.41) kPa] were statistically significant (t' =8.99,P ＜0.05,t =2.43,P ＜0.05,t' =8.18,P ＜0.05,t =7.91,P ＜0.01).Conclusions Eating too full,eating before going to bed,like greasy food,spicy food,heavy drinking,smoking,and other bad diet and lifestyle were important risk factors of GERD.The lower esophageal sphincter dysfunction and esophageal clearance capacity play important role in the pathogenesis of gastroesophageal reflux disease.

Diagnostic value of lower esophageal sphincter and diaphragm separation in patients with hiatus hernia / 中华消化杂志

Objective To analyze the endoscopic features of patients with the lower esophageal sphincter (LES) and crural diaphragm (CD) separation and explore its significance in hiatus hernia (HH) diagnosis.Methods From January 2011 to June 2012,the data of patients underwent esophagus high resolution manometry (HRM) examination were retrospectively analyzed and of which the patients with LES-CD separation were selected.Patients who received digestive tracts operation or lack of complete endoscopic date were excluded.A total of 93 cases were enrolled for analysis.According to Chicago Criteria,the cases were divided into three groups.There were 21 cases in type Ⅰ group (LES-CD separation＜1 cm),37 cases in type Ⅱ group (LES-CD separation≥l cm and ＜2 cm),35 cases in type Ⅲ group (LES-CD separation≥2 cm).The differences among groups in endoscopic features were analyzed.HRM were taken as golden standard,the sensitivity and specificity of endoscopy in HH diagnosis were analyzed.Measurement data were expressed as x ± s,one-way ANOVA was performed for multi-groups comparisons,LSD method or Dunnett T3 test for pairwise comparisons and chi-square test or Fisher's exact test for two groups' comparisons.Results There were no significant differences in the distance between esophagus gastric junction (EGJ) and foreteeth of the three groups (P＞0.05).Distances between EGJ and diaphragmatic HH pressure impression in type Ⅲ group,type Ⅱ group and type Ⅰ group were (3.57±0.78) cm,(1.89±0.81) cm and (1.14±0.67) cm,respectively and the differences were significant (LSDt=9.26,11.44,3.57; all P＜0.05).The percentage of continuously-open cardia and showing pressure impression of the gastric pouch of type Ⅲ group was higher than that of type Ⅱ group and the percentage of continuously-open cardia and showing pressure impression of gastric poach of type Ⅱ group was higher than that of type Ⅰ group (80.0％,40.5％ and 4.8％,x2 =11.64,29.76 and 8.59; 91.4％,27.0％ and 4.8％,x2 =30.69,40.73 and 4.32' all P＜0.05).The occurrence rates of the His angle blunting and sac of type Ⅲ group were higher than those of typeⅡ group and type Ⅰ group (74.3％ and 77.1％,24.3％ and 24.3％,4.8％ and 4.8％,x2 =17.97 and 25.41,both P＜0.05),there was no significant difference between type Ⅱ group and type Ⅰ group (P＞0.05).The rates of esophagitis of type Ⅲ group and type Ⅱ group were higher than that of type Ⅰ group (71.4％,59.5％ and 14.3％,x2 =17.14 and 11.15,both P＜0.05),there was no significant difference between type Ⅲ group and type Ⅱ group (P＞0.05).There was one case of Barrett's esophagus in each group.The sensitivity and specificity of endoscopy in HH diagnosis were 91.4％ and 81.0％,respectively.Conclusions The distance between EGJ and hiatal pressure impression,continuously-open cardia,the His angle blunting,hiatal pressure impression of the gastric pouch and hernia sac were important indicators of HH endoscopic features.The sensitivity of endosocopy is higher than the spcificity of endosocopy in HH diagnosis.

How to Perform and Interpret Timed Barium Esophagogram

Timed barium esophagogram (TBE) is a simple and objective method for assessing the esophageal emptying. The technique of TBE is similar to usual barium swallow with some modifications, which include taking multiple sequential films at pre-decided time interval after a single swallow of a fixed volume of a specific density barium solution. While many authors have used height and width of the barium column to assess the esophageal emptying, others have used the area of the barium column. TBE is being used in patients with suspected or confirmed achalasia and to follow-up those who have been treated with pneumatic dilation or myotomy. This review discusses technique of performing TBE, interpretation and its utility in clinical practice.

Normative values of the esophageal manometry and its influential factors in the healthy subjects: a multiple center study in China / 中华消化杂志

ObjectiveTo establish normative values of esophageal manometry in different age groups and standard test method.Methods The values of esophageal manometry were tested in healthy subjects of 3 different age groups (Group Ⅰ: 18-39 years,Group Ⅱ: 40-59 years,Group Ⅲ:≥60 years) with pneumohydraulic capillary perfusion system.The repeatability and stability of this method in lower esophageal sphincter (LES) testing were observed. Results There were no significant differences of LES length (LESL),LES pressure (LESP) at the end of expiration,average LESP,residual pressure of LES and LES relaxation rate (LESRR) in three groups (P＞0.05).The LESP at the end of inspiration in Group Ⅰ (28.98± 1.11 ) mm Hg was significantly lower than that of Group Ⅲ (34.35±1.96) mm Hg (P＜0.05).Trandiaphragmatic pressure (Pdi) in Group Ⅰ (9.55±0.62) mm Hg was significantly lower than that of Group Ⅱ (13.05±0.76) mm Hg (P＜0.05).There were no significant differences in contraction amplitude and duration of proximal and distant esophagus in 3 groups (P＞0.05).UES pressure (UESP) of Group Ⅲ was significantly lower than that of Group Ⅰ and Ⅱ (P＜0.05).As for repeatability,the second recording of LESP in Group Ⅰ and Ⅱ were significantly higher than first recording (P＜0.05).Amplitude of distant esophageal peristaltic contraction (DEPC) of female was significantly higher than of male (P＜0.05).However,there was no significant difference in amplitude of proximal esophageal peristaltic contraction (PEPC)between femal and male (P＞0.05).ConclusionsThe normative values of esophageal manometry in different age groups have been obtained.The dynamic parameters of LES do not change with age.Between age 40 to 59 years old,the contraction of esophageal body is strongest.UESP decreases significantly in old people.If the subjects have enough time to adapt before test,it will help to get accurate and reliable dynamic parameters of LES.

Effects of Rikkunshito (TJ-43) on Esophageal Motor Function and Gastroesophageal Reflux

BACKGROUND/AIMS: Rikkunshito (TJ-43), an herbal medicine, has been demonstrated to relieve gastroesophageal reflux symptoms. However, the effects of TJ-43 on esophageal motor functions have not been fully determined. This double-blind crossover study was performed to investigate the effects of TJ-43 on esophageal motor functions and gastroesophageal reflux. METHODS: The subjects were 10 normal male volunteers. Lower esophageal sphincter pressure and esophageal body peristaltic contractions with and without 1-week administration of TJ-43 were examined in a crossover fashion. Post-prandial gastroesophageal reflux was also determined using a multi-channel impedance pH dual monitor. RESULTS: TJ-43 at a standard dose of 7.5 g/day did not significantly augment esophageal peristaltic contraction pressure measured in the proximal, middle and distal segments of the esophagus, whereas increment of resting lower esophageal sphincter pressure was observed in a supine position. In addition, TJ-43 administration did not decrease post-prandial gastroesophageal acid, non-acid reflux events or accelerate esophageal clearance time. CONCLUSIONS: TJ-43 at a standard dose did not have a significant effect on esophageal motor activity or gastroesophageal reflux in healthy adults.

Influence of Full-body Water Immersion on Esophageal Motor Function and Intragastric Pressure

BACKGROUND/AIMS: In Japan, it is customary to take a daily bath during which the body is immersed in water to the neck. During full-body immersion, hydrostatic pressure is thought to compress the chest and abdomen, which might influence esophageal motor function and intra-gastric pressure. However, whether water immersion has a significant influence on esophageal motor function or intragastric pressure has not been shown. The aim of this study was to clarify the influence of full-body water immersion on esophageal motor function and intragastric pressure. METHODS: Nine healthy male volunteers (mean age 40.1 +/- 2.8 years) were enrolled in this study. Esophageal motor function and intragastric pressure were investigated using a high-resolution 36-channel manometry device. RESULTS: All subjects completed the study protocol. Intragastric pressure increased significantly from 4.2 +/- 1.1 to 20.6 +/- 1.4 mmHg with full-body water immersion, while the lower esophageal high pressure zone (LEHPZ) value also increased from 20.5 +/- 2.2 to 40.4 +/- 3.6 mmHg, with the latter being observed regardless of dietary condition. In addition, peak esophageal peristaltic pressure was higher when immersed as compared to standing out of water. CONCLUSIONS: Esophageal motor function and intragastric pressure were altered by full-body water immersion. Furthermore, the pressure gradient between LEHPZ and intragastric pressures was maintained at a high level, and esophageal peristaltic pressure was elevated with immersion.

Achalasia - An Update

Achalasia is an esophageal motility disorder of unknown cause, characterized by aperistalsis of the esophageal body and impaired lower esophageal sphincter relaxation. Patients present at all ages, primarily with dysphagia for solids/liquids and bland regurgitation. The diagnosis is suggested by barium esophagram and confirmed by esophageal manometry. Achalasia cannot be cured. Instead, our goal is to relieve symptoms, improve esophageal emptying and prevent the development of megaesophagus. The most successful therapies are pneumatic dilation and surgical myotomy. The overall success rate of graded pneumatic dilation is 78%, with women and older patients responding best. Laparoscopic myotomy, usually combined with a partial fundoplication, has an overall success rate of 87%. Young patients, especially men, are the best candidates for surgical myotomy. Botulinum toxin injection into the lower esophageal sphincter and smooth muscle relaxants are usually reserved for older patients or those with co-morbid illness. The prognosis for achalasia patients to return to near normal swallowing is good, but the disease is rarely "cured" with a single procedure and intermittent touch-up procedures may be required.

Estudo prospectivo comparativo de duas modalidades de posicionamento do sensor de phmetria esofágica prolongada: por manometria esofágica e pela viragem do Ph / Comparative prospective study of two positioning modes of 24-hour esophageal pH monitoring: by esophageal manometry and by the pH step-up technique

RACIONAL: Por padronização aceita internacionalmente, posiciona-se o sensor distal de pHmetria esofágica a 5 cm acima da borda superior do esfíncter inferior do esôfago, localizado por manometria esofágica. Porém, vários autores sugerem técnicas alternativas de posicionamento que prescindem da manometria. Dentre essas, destaca-se a da viragem do pH, tema este controverso pela sua duvidosa confiabilidade. OBJETIVO: Avaliar a adequação do posicionamento do sensor distal de pHmetria pela técnica de viragem do pH, considerando-se a presença, o tipo e o grau de erro de posicionamento que tal técnica proporciona, e também estudar a influência da posição adotada pelo paciente durante a técnica da viragem. MÉTODOS: Foram estudados de modo prospectivo, durante o período de 1 ano, 1.031 pacientes. Durante entrevista clínica, foram registrados os dados demográficos e as queixas clínicas apresentadas. Todos foram submetidos a manometria esofágica para localização do esfíncter inferior do esôfago e a técnica da viragem do pH. A identificação do ponto de viragem foi realizada de dois modos distintos, caracterizando dois grupos de estudo: com o paciente sentado (grupo I - 450 pacientes) e com o paciente em decúbito dorsal horizontal (grupo II - 581 pacientes). Após a identificação do ponto de viragem, o sensor distal de pHmetria era posicionado na posição padronizada, baseada na localização manométrica do esfíncter. Registrava-se onde seria posicionado o sensor de pH se fosse adotada a técnica da viragem. Para avaliação da adequação do posicionamento, considerou-se que o erro é representado pela diferença (em centímetros) entre a localização padronizada (manométrica) e a localização que seria adotada caso fosse empregada a técnica da viragem. Considerou-se que o erro seria grosseiro se fosse maior que 2 cm. Analisou-se também o tipo de erro mais freqüente (se acima ou abaixo da posição padronizada). Foram incluídos todos pacientes que aceitaram participar...

BACKGROUND: By internationally accepted standardization, the esophageal pH-meter distal sensor is positioned 5 cm above the superior border of the lower esophageal sphincter, identified by esophageal manometry. However, several authors suggest alternative positioning techniques that leave out the manometry; among such techniques, the pH step-up is the one to be pointed out. This subject is controversial; some publications state that the step-up technique is not reliable while some others consider it reliable. AIMS: Considering the existent controversy and the small number of prospective works with suitable sample and methodology, we have idealized the present study, that aims the evaluation of the suitability of the pH-meter distal sensor positioning based on the step-up technique, by analyzing the presence, the type and the degree of the error of positioning that such technique provides and the influence of the position adopted by the patient during the procedure. METHODS: One thousand and thirty one patients conducted to the esophageal pH-meter procedure were studied in a prospective way. During the clinical interview, the demographic data and the presented clinical complaints were registered. All the patients were submitted to both esophageal manometry in order to localize the lower esophageal sphincter and the pH step-up technique, that consists of the introduction of the pH-meter sensor in the gastric chamber and in the sensor's gradual traction until the pH steps up to levels over 4. The step-up point was identified by two distinct ways, characterizing two study groups: with the sitting patient (group I - 450 patients) and with the patient in supine position (group II - 581 patients). After the step-up point identification, the pH-meter distal sensor was placed in the standard position (based on the sphincter manometric placement). It was registered where the pH sensor would be positioned if the step-up technique were adopted. To...

The enhancement effect of domperidene on esophagus and lower esophageal sphincter / 中华消化杂志

Objective To observe the prokinetic effect of domperidone on esophagus and lower esophageal sphincter (LES), and compare its effect with that of mosapride and cisapride. Methods In vivo experiments: forty rats were divided into control, domperidone, mosapride, and eisapride groups. Strain gauges were planted in proximal esophagus, distal esophagus and LES to record the activities of esophagus and LES in conscious rat. In vitro experiments: in the thermostatic muscle bath, the prokinetic effect of domperidone, mosapride, and cisapride on the contractility of rat muscle strips from esophagus body and LES were recorded by tone-transducers. Results In vivo experiments, ① In the interdigestive period of resting conscious rats, only mild contraction activities were recoded in esophagus bodies. In LES, typical interdigestive migrating motor complex (MMC) with phase Ⅰ,Ⅱ,Ⅲ,and Ⅳ was recorded. The contraction amplitude of LES was much greater than esophagus body. ② Domperidone significantly enhanced the contraction of esophagus body and LES. The mean contraction amplitude of proximal esophagus, distal esophagus, and LES increased by 63.24%±7.17%, 75.54%±5.27%, and 85.81%±6.02%, respectively, compared with controls. The prokinetic effect showed a dose-effect relation. Mosapride at the same dosage increased the mean contraction amplitude of proximal esophagus, distal esophagus, and LES by 29. 71%±4.15%, 40.15%±3.30%, and 35.24%±5.36%, respectively, compared with controls. The prokinetic effects of mosapride on esophagus and LES were much less than domperidone. Cisapride at the same dosage increased the mean contraction amplitude of proximal esophagus, distal esophagus, and LES by 59.84%±6.55%, 70.11%±5.62%, and 75.13%± 5.10%, respectively, compared with controls. The prokinetic effects of cisapride were similar as domperidone. In vitro experiments. ① Domperidone perfusion could significantly increase the contraction of esophagus body and LES muscle strips by 87.74%±7.65% and 92.44±7.17%, respectively, compared with Krebs-Ringer (KR) solution perfuslon. Mosapride at the same dosage increased the mean contraction amplitude by 35.42%±5.02% and 31.12%±4.32%, respectively, compared with KR controls. The prokinetic effects of mosapride were much less than domperidone. Cisapride of the same dosage showed a similar prokinetic effect as domperidone. ② Atropine and tetrodotoxin could block the prokinetic effects of domperidone on esophagus and LES. Conclusions Domperidone can significantly enhance the esophagus body contraction and LES motility. The effects of domperidone are similar as cisapride and much greater than mosapride. The prokinetic effects of domperidone on esophagus and LES are not only through well-known dopaminergic receptor blockade, but also through the cholinergic nerves of the enteric nervous system.