[Etiopathogenetic hypothesis on the course of esophageal dyskinesias regarding particularly the transitional forms between esophageal spasm, vigorous achalasia and decompensated achalasia]. / Ipotesi eziopatogenetica sull'evoluzione delle discinesie esofagee con particolare riguardo alle forme di transizione tra spasmo esofageo, acalasia vigorosa e acalasia scompensata.

The aetiology of oesophageal motor disturbances (OMD) including achalasia is unknown. Many causes have been hypothesised including: autoimmune inflammatory lesions, mechanical obstruction, degeneration of the dorsal nucleus of the vagus etc. to explain the anatomopathological lesions of Auerbach's plexus. On the basis of the manometric studies carried out so far on motor disturbances of the oesophagus, it is considered that dyskinesia develop into decompensated achalasia. The disturbance would appear to begin as an oesophageal spasm, turn into vigorous achalasia and finally reach the point of decompensated achalasia characterised by hypotonic, synchronous waves and the absence of relaxation of the lower oesophageal sphincter. A personal series of 76 cases of OMD chosen from among 420 monometries carried out from 1980 to 1987 showed that the duration of the wave, namely the length of time the abnormal pressure is maintained is as important as the pressure of the peristaltic wave and the lower oesophageal sphincter. In fact, wave pressure is generally greater than the systolic pressure of the patient and hence, during contraction, the oesophageal walls are ischaemic and this ischaemia might be the cause of the anatomopathological lesions of Auerbach's plexus observed in decompensated achalasia.

Relationships between diaphragmatic hiatus and infra-diaphragmatic esophagus: a combined X-ray and manometry study.

The relationship between the diaphragmatic hiatus, the infra-diaphragmatic esophagus and a manometric tube were examined in 10 patients not suffering from hiatal hernia or gastroesophageal reflux. During surgery, two metal markers were attached to the diaphragmatic hiatus and two others were fixed at the vertex of the angle of His. X-ray examinations were taken during manometric recordings of the high pressure zone (HPZ) both at rest and during relaxation. Comparison between the radiographs showed that during swallowing the manometric tube did not move with respect to the vertebral bodies; contraction of the esophagus caused complete disappearance of the infra-diaphragmatic esophagus. It was also observed that during pressure drop in the HPZ (so-called lower esophageal sphincter relaxation), the manometric recording site is located below the vertex of the angle of His, i.e. in the gastric cavity. These findings provide the basis for a hypothesis to explain the passage of a solid bolus through the lower esophagus into the stomach.

[Manometric study of the upper esophageal sphincter in normal subjects and in patients with achalasia of the cardia]. / Studio manometrico dello sfintere esofageo superiore nei soggetti normali e in pazienti con acalasia del cardias.

The authors explored the motor behavior of the upper esophageal sphincter in normal subjects and in patients with achalasia of the cardia, in a manometric investigation involving the measurement of intraluminal pressure both with axial and with radial catheters. The former were used to assess motor coordination between the various segments of the esophagus; the latter for recording basal pressure along various diameters. The data concerning pressure at rest, relaxation time, and motor coordination relative to adjacent segments, were then compared with the corresponding data obtained in a group of patients treated surgically by Heller cardiomyotomy and Dor, antireflux esophagoplasty, and then with those obtained in a group of normal subjects. Statistical processing of data by the T test of STUDENT failed to reveal any significant differences between the three groups being compared. This is taken to mean complete motor independence of the upper esophageal sphincter in achalasia in relation to the remaining segments of the esophagus, whereas these segments are themselves subject to considerable variations of pressure and motility.