The reproducibility of the station pullthrough technique for measuring lower oesophageal sphincter pressure

Blowing time ratio and high-resolution manometry to evaluate swallowing function of patients with oral and oropharyngeal cancer

OBJECTIVE

The blowing time ratio, which is the ratio of the blowing time when the nostrils are open and closed, is significantly correlated with velopharyngeal pressure, not only during speech but also during swallowing. This study aimed to further evaluate the usefulness of the blowing time ratio as a screening tool to evaluate the swallowing pressure of patients treated for oral and oropharyngeal cancers using high-resolution manometery (HRM).

METHODS

Ten patients treated for oral or oropharyngeal cancer were recruited for this study. Swallowing pressures at the velopharynx, oropharynx, and upper esophageal sphincter (UES) were measured using HRM. Their correlations with the blowing time ratio were analyzed.

RESULTS

The blowing time ratio was significantly correlated with the swallowing pressures of the oropharynx (CC = 0.815, p = 0.004) and the velopharynx (CC = 0.657, p = 0.039), but not of the UES.

CONCLUSIONS

The present results further support our previous finding that the blowing time ratio is a useful screening tool to evaluate velopharyngeal and oropharyngeal swallowing pressures in patients treated for oral and oropharyngeal cancer.

Irritable bowel syndrome and organic diseases: A comparative analysis of esophageal motility

AIM: To assess the esophageal motility in patients with irritable bowel syndrome (IBS) and to compare those with patients with autoimmune disorders.

METHODS: 15 patients with IBS, 22 with systemic lupus erythematosus (SLE) and 19 with systemic sclerosis (SSc) were prospectively selected from a total of 115 patients at a single university centre and esophageal motility was analysed using standard manometry (Mui Scientific PIP-4-8SS). All patients underwent esophago-gastro-duodenoscopy before entering the study so that only patients with normal endoscopic findings were included in the current study. All patients underwent a complete physical, blood biochemistry and urinary examination. The grade of dysphagia was determined for each patient in accordance to the intensity and frequency of the presented esophageal symptoms. Furthermore, disease activity scores (SLEDAI and modified Rodnan score) were obtained for patients with autoimmune diseases. Outcome parameter: A correlation coefficient was calculated between amplitudes, velocity and duration of the peristaltic waves throughout esophagus and patients’ dysphagia for all three groups.

RESULTS: There was no statistical difference in the standard blood biochemistry and urinary analysis in all three groups. Patients with IBS showed similar pathologic dysphagia scores compared to patients with SLE and SSc. The mean value of dysphagia score was in IBS group 7.3, in SLE group 6.73 and in SSc group 7.56 with a P-value > 0.05. However, the manometric patterns were different. IBS patients showed during esophageal manometry peristaltic amplitudes at the proximal part of esophagus greater than 60 mmHg in 46% of the patients, which was significant higher in comparison to the SLE (11.8%) and SSc-Group (0%, P = 0.003). Furthermore, IBS patients showed lower mean resting pressure of the distal esophagus sphincter (Lower esophageal sphincter, 22 mmHg) when compared with SLE (28 mmHg, P = 0.037) and SSc (26 mmHg, P = 0.052). 23.5% of patients with SLE showed amplitudes greater as 160 mmHg in the distal esophagus (IBS and SSc: 0%) whereas 29.4% amplitudes greater as 100 mmHg in the middle one (IBS: 16.7%, SSc: 5.9% respectively, P = 0.006). Patients with SSc demonstrated, as expected, in almost half of the cases reduced peristalsis or even aperistalsis in the lower two thirds of the esophagus. SSc patients demonstrated a negative correlation coefficient between dysphagia score, amplitude and velocity of peristaltic activity at middle and lower esophagus [r = -0.6, P < 0.05].

CONCLUSION: IBS patients have comparable dysphagia-scores as patients with autoimmune disorders. The different manometric patterns might allow differentiating esophageal symptoms based on IBS from other organic diseases.

Oesophageal reflex responses: abnormalities of the enteric nervous system in patients with oesophageal symptoms

An intraluminal balloon was used to study the peristaltic reflex, which is mediated by the intrinsic nerves of the oesophagus. Serial balloon distension was performed in nine asymptomatic volunteers and 133 patients with oesophageal symptoms. Eight of the volunteers had a normal response with proximal stimulation and distal inhibition of motility. Only 42 patients (31.6 per cent) had a normal response. The commonest abnormal response (39.1 per cent) was some form of failure of the distal inhibitory reflex. Other patterns of abnormality were an unresponsive oesophagus (15.8 per cent) with no motility change during balloon inflation, or spasm (13.5 per cent) proximal to the balloon. These alterations of secondary peristaltic activity suggest that there are abnormalities of the intrinsic (enteric) nerves of the oesophagus. Different abnormalities were found in patients with similar symptoms. Awareness of this difference might allow a more rational approach to treatment. This hypothesis was tested in a small pilot study treating functional dysphagia with cisapride. Three of nine patients had marked symptomatic improvement within 4 weeks and all three had an unresponsive oesophagus. The remaining six patients, who had failure of distal inhibition or a normal response, did not improve.

Improved lower esophageal sphincter manometry: application of the end-hole recording technique in vivo

The recommendation to use a thin end-hole catheter for lower esophageal (LES) manometry has a strong theoretic background supported by previous in vitro studies. The pressure in the closed sphincter is measured, and the problem of pressure asymmetry eliminated. In this study the advantage and applicability of an end-hole catheter compared with the composite side-hole catheter for LES manometry was tested in vivo in dogs and human subjects. Pull-through manometry was performed with a continuously infused composite four-lumen catheter with one central channel and three side-hole channels enabling simultaneous end-hole and side-hole recording of LES pressure. A pull-through produced one end-hole and three side-hole pressure registrations. The end-hole recorded resting sphincter pressure was 19.7 +/- 4.5 cm H2O in 6 dogs and 9.9 +/- 6.8 cm H2O in 89 human subjects (volunteers and patients). The side holes recorded higher pressures, longer high-pressure zones, and obvious differences--asymmetry--between the three channels. The correlation between the side-hole and end-hole recordings was equally poor with regard to both pressure and length, with r values from 0.48 to 0.61. The relative difference between the end hole and side holes was most pronounced in low-pressure sphincters. In the dogs the end-hole and one side-hole channel always recorded LES pressure close to the expected 0 pressure during reflux, whereas the other two side-hole channels recorded high pressures. The present study proved the applicability of the end-hole technique for LES manometry in vivo in man. The end hole seemed to record true sphincter pressure.

Gastro-oesophageal reflux in the irritable bowel syndrome

Symptomatic assessment and oesophageal investigations were done in 25 consecutive patients with the irritable bowel syndrome attending a gastroenterological clinic. Symptoms of gastro-oesophageal reflux, dysphagia, and a globus sensation were significantly commoner than in a control group of fracture clinic patients. Ambulatory oesophageal pH monitoring showed clearly abnormal reflux in 11 of 22 patients (50%). Nine patients had macroscopic endoscopic changes and a further 11 biopsy changes alone, of oesophagitis which was thus present in 80% overall. Lower oesophageal sphincter pressure was significantly less in irritable bowel patients than in age and sex matched controls, but upper oesophageal sphincter pressure was comparable in the two groups and disordered peristalsis was not found. Oesophageal symptoms in the irritable bowel syndrome are mainly caused by gastro-oesophageal reflux predisposed to by a subnormal lower oesophageal sphincter pressure, rather than by oesophageal spasm.

Beta adrenergic influence on esophageal and colonic motility in man

Gastrointestinal (GI) motility is centrally controlled through the sympathetic and parasympathetic nerves, sympathetic effects being partly mediated by beta adrenoceptors. Although beta adrenoceptor agonists and antagonists are widely used for different disorders, little is known about the influence of these agents on GI motility. The present study was initiated to investigate whether there is a physiological, beta adrenergic influence on human GI motility and to describe the effects of selective beta adrenoceptor stimulation on motility in the proximal and distal parts of the GI tract. Esophageal peristalsis was measured in healthy subjects using electronic catheters. Distal colonic motility was measured with an open-tipped, water-perfused catheter in the sigmoid colon and from an air-filled balloon in the rectum in healthy subjects and in patients with the irritable bowel syndrome (IBS). In one study, colonic motility was stimulated with continuous infusion of the octapeptide of cholecystokinin (CCK-OP). Esophagus: Peristaltic amplitude was increased in the distal smooth muscle part of the esophageal body after infusion of both the nonselective beta blocker propranolol and the beta-1 selective blocker metoprolol. After infusion of the beta-1 agonist prenalterol and the beta-2 selective agonist terbutaline, a profound decrease in esophageal peristaltic amplitude was seen. Pretreatment with metoprolol selectively blocked the response to a moderate dose of prenalterol but did not block the response to terbutaline. The latter response was blocked by propranolol. Peristaltic velocity in the proximal part of the esophagus was decreased by beta-1 stimulation and in the distal part by beta-2 stimulation. Distal colon: In healthy subjects the sigmoid motility index showed a dose-dependent increase after metoprolol and propranolol, respectively. The increase was more marked after propranolol infusion. Terbutaline decreased the sigmoid motility index both in healthy subjects and in patients with the IBS. Furthermore, the rectal motility index was decreased in the group of healthy subjects. The effects of prenalterol on rectal and sigmoid motility did not differ from those of placebo. The IBS patient group showed larger intraindividual variations in sigmoid motility from day to day and also lower rectal motility indices than the healthy subjects. Infusion of CCK-OP increased the sigmoid motility index compared to non-stimulated conditions. No effects on CCK-OP stimulated motility were seen after either terbutaline, prenalterol or placebo.(ABSTRACT TRUNCATED AT 400 WORDS)

A study of factors responsible for the efficacy of fundoplication in the treatment of gastro-oesophageal reflux

Forty-one patients were followed up for a median 14 months after Nissen fundoplication. Patients were questioned regarding their symptoms and 83% considered the surgery a complete success. Oesophageal manometry was performed before and after surgery. Median pre-operative lower oesophageal sphincter pressure (LOSP) was 5.5 mmHg; following operation median LOSP was 14 mmHg. The ability of the lower oesophageal sphincter (LOS) to relax with swallow was impaired by fundoplication; the median residual lower oesophageal sphincter pressure (RLOSP) was 0 mmHg prior to surgery and 3.5 mmHg following operation. Fundoplication appears to superimpose a zone of constant pressure on the lower oesophageal sphincter and this may be a further factor responsible for the efficacy of surgery.

Effective of highly selective vagotomy upon the lower oesophageal sphincter

Recently highly selective vagotomy has been suggested as both a cause of gastro-oesophageal reflux and a potential cure. This study was designed to investigate whether this operation produced any change in the resting pressure or the length of the lower oesophageal sphincter in patients undergoing highly selective vagotomy. A group of patients undergoing truncal vagotomy and drainage were also studied for comparison. No alteration in the resting pressure or length of the lower oesophageal sphincter was noted after either operation. It is therefore unlikely that interference with the sphincter is responsible for post-vagotomy reflux.

Oesophageal motility in the irritable bowel syndrome

Oesophageal motility was assessed in 30 patients with the irritable bowel syndrome and controls matched for age and sex. Lower oesophageal sphincter pressure was significantly lower in the patients than their controls (mean pressures 13.8 and 23.8 cm H2O respectively), and the same degree of difference between patients and controls was maintained in all age groups. In addition, spontaneous activity, repetitive contractions, and the presence of variable-amplitude and simultaneous waves were significantly more common in the patients, who were also more likely to have more than one abnormal pattern of motility. There was no difference in upper oesophageal sphincter pressure between the two groups. These findings may help to explain why patients with the irritable bowel syndrome may complain of upper gastrointestinal symptoms, including heartburn and dysphagia. The results suggest that the syndrome may be a more widespread disorder of smooth muscle, or its innervation, than was previously thought.

Assessment of the rapid pullthrough technique in oesophageal manometry

The lower oesophageal sphincter pressure was measured by infusion manometry using the rapid pullthrough technique in two studies designed to evaluate this technique. The first study performed was an assessment of its reproducibility in individual subjects on separate occasions. We conclude that the rapid pullthrough technique does not give reproducible results. The second study compared the lower oesophageal sphincter pressure obtained by this technique with that by the standard station pullthrough technique. We conclude that the results are not comparable.