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Dantas RO. Effects of Increased Intra-abdominal Pressure on the Gastroesophageal Junction of Children and Adults. J Clin Gastroenterol 2023; 57:324. [PMID: 36728658 DOI: 10.1097/mcg.0000000000001820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/17/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Roberto O Dantas
- Medical School of Ribeirão Preto-University of São Paulo, Ribeirão Preto SP, Brazil
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Lei WY, Liang SW, Omari T, Chang WC, Wong MW, Hung JS, Yi CH, Liu TT, Lin L, Gyawali CP, Chen CL. Transient Hiatal Separation During Straight Leg Raise Can Predict Reflux Burden in Gastroesophageal Reflux Disease Patients With Ineffective Esophageal Motility. J Neurogastroenterol Motil 2022; 28:589-598. [PMID: 36250366 PMCID: PMC9577578 DOI: 10.5056/jnm21189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/26/2021] [Accepted: 01/10/2022] [Indexed: 11/20/2022] Open
Abstract
Background/Aims Straight leg raise (SLR) can be utilized to evaluate the integrity of the esophagogastric junction during high-resolution manometry (HRM). We aim to assess the value of transient hiatal separation during SLR in symptomatic reflux patients. Methods Consecutive reflux patients undergoing esophageal HRM and pH monitoring were included. Transient hiatal separation was defined by a ≥ 1 cm separation between the lower esophageal sphincter and crural diaphragm during SLR. We compared esophageal motor patterns and reflux monitoring parameters between patients with normal, transiently abnormal and consistently abnormal esophagogastric junction morphology during SLR. Results Of 85 (56.3% female, mean age: 46.7 ± 12.3 years) completed SLR, esophagogastric junction morphology was normal in 31 (36.5%), transient hiatal separation in 19 (22.3%), and consistently hiatal hernia in 35 (41.2%). The values of total acid exposure time (P = 0.016), longest acid reflux episodes (P = 0.024), and DeMeester scores (P = 0.016) were higher in hiatal hernia compared to patients with non-transient hiatal separation, but there were no differences between those with and without transient hiatal separation. Within ineffective esophageal motility, the presence of transient hiatal separation during SLR significantly associated with a higher total acid exposure time (P = 0.014), higher DeMeester scores (P = 0.019), higher total acid reflux events (P = 0.037), and higher longest acid reflux episodes (P = 0.006). Conclusion Our work suggests that SLR may have value as a provocative test during HRM, and future outcome studies are warranted to elucidate the clinical relevance of motor abnormalities depicted from SLR.
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Affiliation(s)
- Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Shu-Wei Liang
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Taher Omari
- College of Medicine and Public Health Flinders University, Adelaide, Australia
| | - Wei-Chuan Chang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Lin Lin
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan.,Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
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Nikaki K, Sifrim D. Pathophysiology of Pediatric Gastroesophageal Reflux Disease: Similarities and Differences With Adults. J Clin Gastroenterol 2022; 56:99-113. [PMID: 34560757 DOI: 10.1097/mcg.0000000000001604] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Gastroesophageal reflux (GOR) is defined as "the passage of gastric contents into the esophagus with or without regurgitation and vomiting" and gastroesophageal reflux disease (GORD) is defined "when GOR leads to troublesome symptoms affecting the daily functioning and/or complications." This definition was first developed in 2006 by the Montreal consensus group (1) and later on adopted by pediatric gastroenterology societies such as ESPGHAN and NASPGHAN in 2009 (2). The definition of gastroesophageal reflux reveals little about its pathophysiology and is focused on symptomatology. In this way, it acts as an umbrella term for the multifactorial causes of the disease and the various phenotypes encountered; from functional heartburn to hypersensitive esophagus and nonerosive reflux disease, to erosive esophagitis and Barrett's esophagus. This article is devoted to the pathophysiology of pediatric GORD in comparison to adult GORD and is divided in 2 parts. In the first part, we will systematically describe the different mechanisms for the generation and clearance of reflux events, while on the second part we will discuss the mechanisms involved in symptoms generation. Finally, we will discuss the similarities and differences between pediatric and adult GORD.
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Affiliation(s)
- Kornilia Nikaki
- Gastroenterology Department, Great Ormond Street Hospital for Children
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, The Blizard Institute, QMUL, London, UK
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Rogers BD, Gyawali CP. Making Sense of Nonachalasia Esophageal Motor Disorders. Gastroenterol Clin North Am 2021; 50:885-903. [PMID: 34717877 DOI: 10.1016/j.gtc.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Achalasia is the prototypical obstructive motor disorder diagnosed using HRM, but non-achalasia motor disorders are often identified in symptomatic patients. The clinical relevance of these disorders are assessed using ancillary HRM maneuvers (multiple rapid swallows, rapid drink challenge, solid swallows) that augment the standard supine HRM evaluation by challenging peristaltic function. Finding obstructive motor physiology in non-achalasia motor disorders may raise the option of invasive management akin to achalasia. Certain non-achalasia disorders, particularly hypermotility disorders, may manifest as epiphenomena seen with esophageal hypersensitivity. Symptomatic management is offered for superimposed reflux disease, psychological disorders, functional esophageal disorders, and behavioral disorders.
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Affiliation(s)
- Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA; Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, 550 South Preston Street, Louisville, KY 40202, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA.
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Lei WY, Gyawali CP, Chang WC, Roman S, Wong MW, Yi CH, Liu TT, Hung JS, Liang SW, Chen CL. Application of a novel straight leg raise test during high-resolution manometry can predict esophageal contractile reserve in patients with gastroesophageal reflux disease. Neurogastroenterol Motil 2021; 33:e13996. [PMID: 33006260 DOI: 10.1111/nmo.13996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/02/2020] [Accepted: 09/02/2020] [Indexed: 12/06/2022]
Abstract
BACKGROUND/AIM Increased intra-abdominal pressure from abdominal compression augments esophageal peristalsis during high-resolution manometry (HRM), and straight leg raise (SLR) while supine increases intra-abdominal pressure. We determined if water swallows performed during SLR can mimic contraction reserve seen with multiple rapid swallows (MRS). METHODS Consecutive patients evaluated for GERD symptoms completed validated GERD questionnaires, esophageal HRM, and upper endoscopy. Distal contractile integral (DCI) was analyzed during single water swallows (10 × 5 mL), MRS (5 × 2 mL), and during SLR (5x5 mL). Peristaltic breaks were measured using software tools with a 20 mm Hg isobaric contour. Univariate correlational analyses were performed to compare esophageal motor patterns and DCI values during single water swallows, MRS, and SLR. RESULTS Of 103 study patients (mean age: 46.7 ± 12.3 years, 56.3% female), 50 (48.5%) had ineffective esophageal motility (IEM). Contraction reserve was observed on MRS in 62% with IEM, and 35.8% with normal motility (p = 0.008). DCI was significantly higher during SLR compared to mean single swallow DCI in both IEM and normal motility patients (p < 0.001 for each comparison). In IEM patients, SLR significantly reduced swallows with peristaltic breaks (6.1 ± 3.7 vs 3.6 ± 3.6; p < 0.001) and shortened the length of the largest break (4.8 ± 3.4 vs 3.0 ± 3.0 cm; p < 0.001). DCI response following MRS correlated with DCI with swallows during SLR, with a correlational coefficient (Pearson's r) of 0.70 (p < 0.001). CONCLUSIONS Swallowing against the resistance of increased intra-abdominal pressure from SLR improves esophageal body peristaltic performance and predicts esophageal body contraction reserve.
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Affiliation(s)
- Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Wei-Chuan Chang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Sabine Roman
- Digestive Physiology, Hospital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France
| | - Ming Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Shu-Wei Liang
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
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Abstract
The esophagogastric junction (EGJ) is a complex barrier between the thoracic and abdominal luminal gut compartments, comprised primarily of the lower esophageal sphincter (LES) and crural diaphragm. Although closed at rest, the EGJ relaxes to allow antegrade bolus transit and retrograde venting of air. Abnormal relaxation is the hallmark of achalasia spectrum disorders, while increased frequency of transient lower esophageal sphincter relaxations and/or EGJ disruption are seen in gastroesophageal reflux disease. High resolution manometry (HRM) is the modern day gold standard for assessment of EGJ morphology and function, with better performance characteristics compared with endoscopy and barium esophagography. Conventional LES metrics defining EGJ function include resting LES pressure as well as postswallow residual pressures. Newer HRM-based metrics include EGJ contractile integral, which measures static barrier function at rest, and EGJ morphology, which characterizes the relationship between LES and crural diaphragm. Provocative maneuvers assess dynamic EGJ function during physiological or pharmacologic stress. The most useful of these maneuvers, the rapid drink challenge, assesses for latent obstruction, while multiple rapid swallows evaluate adequacy of deglutitive inhibition. Amyl nitrate and cholecystokinin administration can segregate motor from structural obstruction. Newer provocative tests (straight leg raise maneuver, abdominal compression) and novel diagnostic tools (functional lumen imaging probe) complement HRM evaluation of the EGJ. Although current HRM metrics and maneuvers show promise in identifying clinically relevant EGJ abnormalities, future investigations evaluating management outcomes will improve segregation of normal from abnormal EGJ morphology and function.
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Abstract
Esophageal high-resolution manometry (HRM) assesses esophageal motor function and is indicated both for evaluation of esophageal symptoms and before antireflux interventions. HRM studies are interpreted and esophageal motor diagnoses made according to the Chicago Classification, version 3.0 algorithm, which is based on ten 5 mL supine water swallows. However, this practice of single liquid swallows performed in the supine position does not reflect typical "real-life" swallowing, and may not reproduce the patient's presenting symptoms. Therefore, provocative maneuvers at HRM-beyond these 10 standard swallows-can afford additional insights into esophageal motor function with clinically significant implications, and represent areas of exciting investigation and innovation. Accordingly, the 2020 American College of Gastroenterology Guidelines on Esophageal Physiologic Testing conditionally recommend their inclusion in the HRM protocol. In this clinical review, we discuss the supporting data for and clinical utility of provocative maneuvers at HRM that include changes in body position or accessories (upright swallows, "bridge" position, straight leg raise, abdominal compression), bolus consistency (solid swallows, test meals, postprandial high-resolution impedance manometry), bolus frequency (multiple rapid swallows), the volume of bolus (rapid drink challenge/multiple water swallows), and the use of pharmacological agents.
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Effects of Diaphragmatic Breathing on the Pathophysiology and Treatment of Upright Gastroesophageal Reflux: A Randomized Controlled Trial. Am J Gastroenterol 2021; 116:86-94. [PMID: 33009052 DOI: 10.14309/ajg.0000000000000913] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/17/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Uncontrolled results suggest that diaphragmatic breathing (DB) is effective in gastroesophageal reflux disease (GERD) but the mechanism of action and rigor of proof is lacking. This study aimed to determine the effects of DB on reflux, lower esophageal sphincter (LES), and gastric pressures in patients with upright GERD and controls. METHODS Adult patients with pH proven upright GERD were studied. During a high-resolution impedance manometry, study patients received a standardized pH neutral refluxogenic meal followed by LES challenge maneuvers (Valsalva and abdominal hollowing) while randomized to DB or sham. After that, patients underwent 48 hours of pH-impedance monitoring, with 50% randomization to postprandial DB during the second day. RESULTS On examining 23 patients and 10 controls, postprandial gastric pressure was found to be significantly higher in patients compared with that in controls (12 vs 7 mm Hg, P = 0.018). Valsalva maneuver produced reflux in 65.2% of patients compared with 44.4% of controls (P = 0.035). LES increased during the inspiratory portion of DB (42.2 vs 23.1 mm Hg, P < 0.001) in patients and healthy persons. Postprandial DB reduced the number of postprandial reflux events in patients (0.36 vs 2.60, P < 0.001) and healthy subjects (0.00 vs 1.75, P < 0.001) compared with observation. During 48-hour ambulatory study, DB reduced the reflux episodes on day 2 compared with observation on day 1 in both the patient and control groups (P = 0.049). In patients, comparing DB with sham, total acid exposure on day 2 was not different (10.2 ± 7.9 vs 9.4 ± 6.2, P = 0.804). In patients randomized to DB, esophageal acid exposure in a 2-hour window after the standardized meal on day 1 vs day 2 reduced from 11.8% ±6.4 to 5.2% ± 5.1, P = 0.015. DISCUSSION In patients with upright GERD, DB reduces the number of postprandial reflux events pressure by increasing the difference between LES and gastric pressure. These data further encourage studying DB as therapy for GERD.
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Rogers BD, Rengarajan A, Ali IA, Hasak SL, Hansalia V, Gyawali CP. Straight leg raise metrics on high-resolution manometry associate with esophageal reflux burden. Neurogastroenterol Motil 2020; 32:e13929. [PMID: 32633016 DOI: 10.1111/nmo.13929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/25/2020] [Accepted: 06/02/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Straight leg raise (SLR) is a provocative maneuver that assesses esophagogastric junction (EGJ) barrier function during high-resolution manometry (HRM). We evaluated the value of SLR in symptomatic reflux patients undergoing ambulatory reflux monitoring. METHODS Adult patients being evaluated for reflux symptoms with esophageal physiologic testing off antisecretory therapy over a 12 month period were studied. Demographics, clinical presentation, HRM studies, and reflux monitoring studies were analyzed. Intra-abdominal and intra-esophageal pressures were extracted at baseline and during SLR from HRM studies. Acid exposure time (AET) was derived from reflux monitoring studies, and EGJ morphology and tone from HRM studies. SLR pressure metrics predicting abnormal AET were evaluated. KEY RESULTS Of 122 patients, 70 (57.4%) had ≥50% peak intra-abdominal pressure increase during SLR (58.0 ± 1.4 years, 75.7% female). Peak intra-esophageal pressure gradient between baseline and SLR predicted pathologic AET when ≥100% (AUC 0.78, sensitivity 71%, specificity 75%, P < .001), seen in 60.7% with AET > 6%, but only 23.7% with AET < 4% (P = .01). Peak intra-esophageal pressure gradient ≥100% was most discriminative in identifying abnormal acid burden in type 1 EGJ morphology (P = .005) but trended toward significance in type 2 and type 3 morphology (P = .1). Normal and abnormal EGJ contractile integral did not associate with peak intra-esophageal pressure gradient either collectively or when subdivided by EGJ morphology (P ≥ .2). CONCLUSIONS & INFERENCES Analysis of intra-esophageal pressure gradients during SLR, a simple HRM maneuver, may augment evaluation of symptomatic GERD, and provide adjunctive evidence supporting GERD.
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Affiliation(s)
- Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Arvind Rengarajan
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Ijlal A Ali
- Section on Digestive Diseases and Nutrition, University of Oklahoma School of Medicine, Oklahoma City, OK, USA
| | - Stephen L Hasak
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Vivek Hansalia
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
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Rogers BD, Gyawali CP. Enhancing High-Resolution Esophageal Manometry: Use of Ancillary Techniques and Maneuvers. Gastroenterol Clin North Am 2020; 49:411-426. [PMID: 32718561 DOI: 10.1016/j.gtc.2020.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
High-resolution manometry evaluates esophageal motor function using 10 supine water swallows. Superimposing impedance over high-resolution manometry pressure topography assesses the relationship between contraction and bolus propulsion and identifies inadequate clearance. Ancillary techniques and maneuvers augment the standard supine high-resolution manometry evaluation by challenging peristaltic function. Increasing bolus volume (rapid drink challenge) and altering bolus consistency (standardized test meal, solid swallows) enhance identification of esophageal outflow obstruction syndromes. Physiologic maneuvers (multiple rapid swallows, abdominal compression) address the ability of the esophageal smooth muscle to augment contraction vigor. Pharmacologic challenge is less commonly used clinically, and elucidates pathophysiology of esophageal motor disorders.
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Affiliation(s)
- Benjamin D Rogers
- Division of Gastroenterology, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO 63110, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO 63110, USA.
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Rogers B, Hasak S, Hansalia V, Gyawali CP. Trans-esophagogastric junction pressure gradients during straight leg raise maneuver on high-resolution manometry associate with large hiatus hernias. Neurogastroenterol Motil 2020; 32:e13836. [PMID: 32163648 DOI: 10.1111/nmo.13836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/17/2020] [Accepted: 02/24/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Straight leg raise (SLR) while supine increases intra-abdominal pressure. We hypothesized that elevations in intra-abdominal pressure would transmit into the thoracic cavity if the esophagogastric junction (EGJ) was disrupted. METHODS Consecutive patients undergoing esophageal HRM were included if they had adequate SLR (hip flexion with knees extended for ≥ 5 seconds while supine). EGJ morphology was subtyped based on lower esophageal sphincter (LES) and crural diaphragm (CD) location (type 1: LES and CD overlap; type 2: separation of < 3 cm; type 3: separation of ≥ 3 cm). EGJ tone was assessed using EGJ contractile integral (EGJ-CI). HRM studies were analyzed according to Chicago Classification v3.0. Mean and peak intra-thoracic and abdominal pressures were measured at baseline and during SLR using on-screen software tools. Trans-EGJ gradients were compared, and pressure gradient < 1 mmHg denoted the equalization of pressures. KEY RESULTS Of 430 patients, 248 (57.5 ± 0.9 years, 69.4% F) completed SLR. EGJ morphology was type 1 in 122 (49.2%), type 2 in 56 (22.6%) and type 3 in 40 (16.1%). In types 1 and 2 EGJ, neither the mean nor peak trans-EGJ pressure gradient changed with SLR (P ≥ .17 for each). In contrast, in type 3 EGJ, peak pressure gradient decreased significantly following SLR (3.5 ± 1.8 mmHg vs. -8.6 ± 4.8 mmHg, P = .01). More type 3 EGJ patients equalized peak (65%) pressures across EGJ compared with types 1 and 2 (27%, P < .001). CONCLUSIONS AND INFERENCES The evaluation of intra-abdominal and intra-thoracic pressures with SLR during esophageal HRM can provide evidence of physiological disruption of the EGJ barrier.
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Affiliation(s)
- Benjamin Rogers
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Stephen Hasak
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Vivek Hansalia
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
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Assessment of esophageal function using provocative tests during high resolution manometry: A single-center experience. J Formos Med Assoc 2019; 118:244-248. [DOI: 10.1016/j.jfma.2018.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 03/30/2018] [Accepted: 04/25/2018] [Indexed: 11/16/2022] Open
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13
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Cho YK. Which Provocation Test Will Be Added to Routine High-resolution Manometry Protocol in Unexplained Dysphagia? J Neurogastroenterol Motil 2018; 24:329-330. [PMID: 29969853 PMCID: PMC6034663 DOI: 10.5056/jnm18111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 06/17/2018] [Indexed: 12/27/2022] Open
Affiliation(s)
- Yu Kyung Cho
- Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea
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Brink GJ, Lei WY, Omari TI, Singendonk MMJ, Hung JS, Liu TT, Yi CH, Chen CL. Physiological augmentation of esophageal distension pressure and peristalsis during conditions of increased esophageal emptying resistance. Neurogastroenterol Motil 2018; 30:e13225. [PMID: 29063658 DOI: 10.1111/nmo.13225] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 09/14/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Abdominal compression has been implemented as a provocative maneuver in high-resolution impedance manometry (HRIM) to "challenge" normal esophageal physiology with the aim of revealing abnormal motor patterns which may explain symptoms. In this study, we measured the effects of abdominal compression on esophageal functioning utilizing novel pressure-impedance parameters and attempted to identify differences between healthy controls and globus patients. METHODS Twenty-two healthy volunteers (aged 23-32 years, 41% female) and 22 globus patients (aged 23-72 years, 68% female) were evaluated with HRIM using a 3.2-mm water perfused manometric and impedance catheter. All participants received 10 × 5 mL liquid swallows; healthy controls also received 10 × 5 mL liquid swallows with abdominal compression created using an inflatable cuff. All swallows were analyzed to assess esophageal pressure topography (EPT) and pressure-flow metrics, indicative of distension pressure, flow timing and bolus clearance were derived. KEY RESULTS The effect of abdominal compression was shown as a greater contractile vigor of the distal esophagus by EPT and higher distension pressure based on pressure-flow metrics. Age and body mass index also increased contractile vigor and distension pressure. Globus patients were similar to controls. CONCLUSIONS AND INTERFERENCES Intrabolus pressure and contractile vigor are indicative of the physiological modulation of bolus transport mechanisms. Provocative testing by abdominal compression induces changes in these esophageal bolus dynamics.
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Affiliation(s)
- G J Brink
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, AMC, Amsterdam, The Netherlands
| | - W Y Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - T I Omari
- School of Medicine, Flinders University, South Australia
| | - M M J Singendonk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, AMC, Amsterdam, The Netherlands
| | - J S Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - T T Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - C H Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - C L Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
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Carlson DA, Roman S. Esophageal provocation tests: Are they useful to improve diagnostic yield of high resolution manometry? Neurogastroenterol Motil 2018; 30:e13321. [PMID: 29603510 DOI: 10.1111/nmo.13321] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/30/2018] [Indexed: 12/13/2022]
Abstract
High resolution manometry (HRM) is the gold standard to diagnose esophageal motility disorders but has some limitations. The inclusion of provocative tests might enhance the diagnostic yield of HRM. These tests are easy to perform and to add to the regular manometry protocol. Multiple rapid swallows (MRS; 5 2-mL swallows) is useful to assess the contractile reserve and deglutitive inhibition. The optimal number of MRS to perform might be 3 as suggested by Mauro et al. in this issue of Neurogastroenterology & Motility. The absence of contractile reserve might be associated with gastro-esophageal reflux disease and with an increased risk of post fundoplication dysphagia. Single viscous and solid swallows might enhance the detection of esophageal motility disorders but are not significantly associated with symptom occurrence. Test meal has the advantage to represent a real-life scenario and is promising to depict significant motility findings responsible for esophageal symptoms. Post-prandial recording might also be of interest to diagnose rumination and belching disorders. The best indication of rapid drink challenge test (free drinking of 200 mL) is currently the diagnosis of esophago-gastric junction obstruction. Finally, abdominal compression might be an option to evaluate response of esophageal peristalsis in a context of outflow resistance as proposed by Brink et al. in this issue. These provocative maneuvers appear to provide a complementary role in the evaluation of esophageal motility but require prospective studies to determine the validity of the findings and whether they will lead to changes in clinical practice.
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Affiliation(s)
- D A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - S Roman
- Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hopital E Herriot, F-69437 LYON, France.,Université de Lyon, Lyon I University, Digestive Physiology, F-69008 LYON, France.,Université de Lyon, Inserm U1032, F-69008 LYON, France
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Abstract
This article reviews the mechanisms responsible for gastroesophageal reflux disease (GERD), available techniques for diagnosis, and current medical management. In addition, it extensively discusses the surgical treatment of GERD, emphasizing the use of minimally invasive techniques.
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Pediatric esophageal high-resolution manometry: utility of a standardized protocol and size-adjusted pressure topography parameters. Am J Gastroenterol 2010; 105:460-7. [PMID: 19953088 DOI: 10.1038/ajg.2009.656] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Esophageal high-resolution manometry (EHRM) has evolved rapidly from a research tool to a routine investigation in adult clinical practice. This study proposes and evaluates a standardized EHRM protocol for use in pediatric clinical practice. METHODS Thirty pediatric patients underwent unsedated EHRM. Indications for EHRM were dysphagia, feeding difficulty, or pre-fundoplication assessment. Two 20-channel customized water-perfused silicone catheters, with an outside diameter of 3.8 mm (MuiScientific, Ontario, CA), were used. The catheters had one distal gastric channel, five channels 0.5 cm apart for the e-sleeve, and 14 proximal channels either 1 cm (for children <5 years) or 2 cm apart (for children >5 years). Single wet swallows, multiple rapid swallows (MRS), and solid swallows were systematically studied. RESULTS The median age was 10 years (range 6 months-15 years). The esophageal motor findings were normal peristalsis (n=15), peristaltic dysfunction (n=12), achalasia (n=3), and spasm on consumption of solid food (n=2). The distal contractile integral adjusted for esophageal length (DCIa) of patients with peristaltic dysfunction was significantly lower than that of patients without peristaltic dysfunction (P<0.001). On MRS, aperistalsis with lack of esophagogastric junction (EGJ) relaxation was observed in patients with achalasia, and aperistalsis with complete EGJ relaxation was observed in patients with severe peristaltic dysfunction. On consumption of solid food, esophageal spasm associated with bolus impaction was observed in two patients. CONCLUSIONS This study provides objective information with regard to topography pressure parameters in esophageal motility disorders of childhood while using a standardized EHRM protocol. The new DCIa variable may be useful for the assessment of patients with peristaltic dysfunction.
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Sathesh-Kumar T, Rollins H, Cheslyn-Curtis S. General paediatric surgical provision of percutaneous endoscopic gastrostomy in a district general hospital--a 12-year experience. Ann R Coll Surg Engl 2009; 91:404-9. [PMID: 19344554 DOI: 10.1308/003588409x391749] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION A small, but significant, number of children require long-term nutritional support. The aim of this study was to demonstrate the safety and efficacy of providing a percutaneous endoscopic gastrostomy (PEG) service for children in a district general hospital and to raise awareness of the suitability of the procedure to be performed on paediatric surgery lists in similar hospitals across the UK. PATIENTS AND METHODS A multidisciplinary paediatric nutrition team was established and all children accepted for PEG insertion between 1995 and 2007 were entered onto a database prospectively and are included in this study. PEG tubes were inserted by the standard pull-through technique under general anaesthetic. RESULTS A total of 172 procedures were performed in 76 children. The median age at first tube insertion was 3 years (range, 0.5-18 years). Length of follow-up ranged from 1 month to 12.6 years. Fifty-eight children (76%) had a neurological abnormality, the commonest being cerebral palsy. All but one procedure were performed successfully, of which 63 (37%) were new insertions, 99 change of tube, 4 changed from surgical gastrostomy and 6 from PEG to button gastrostomy. The median hospital stay was 2 days (range, 2-7 days) for new insertions and 1 day for tube changes. There were 10 (6%) early complications within 30 days, the commonest being peritubal infection (6). The 39 late complications included 16 peritubal infection/granulomata, 9 'buried bumpers', 4 worsening of gastro-oesophageal reflux disease, 2 gastrocolic fistulae, 3 gastrocutaneous fistulae and 4 tubal migration. There was no mortality. CONCLUSIONS We have demonstrated that paediatric PEG procedures and continuing management by a supporting team can be successfully and efficiently provided in the district general hospital. It should be possible for the majority of similar hospitals to provide local access and increase the availability of PEG feeding for children.
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Affiliation(s)
- T Sathesh-Kumar
- Department of Surgery, Luton and Dunstable Hospital, Luton, UK.
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Abstract
Gastroesophageal reflux disease (GERD) is one of the most common disorders in the general population. In recent years, a marked increase in the occurrence of the disease worldwide has been noted. Intense exercise belongs to factors that are known to exacerbate symptoms of GERD. Episodes of reflux seem to be associated with the length and the intensity of the physical activity undertaken. Experimental studies suggest that the gastroesophageal reflux may be increased in athletes due to: decreased gastrointestinal blood flow; alterations of hormone secretion; changes in the motor function of the oesophagus and the ventricle; and the constrained body position during exercise. Disturbances of the balance between two areas of opposite pressure: intra-abdominal and intrathoracic, have also been proven to influence GERD events. GERD is found in sportspeople of various disciplines, but specific types of exercise may have significantly different impacts on the gastroesophageal reflux.Basic prevention of GERD comprise lifestyle and dietary interventions. Adjustments of the exercise load and avoiding meals and drinks about the time of physical effort may ease the symptoms. Unfortunately, in most patients, pharmacological measures are necessary. These include occasional application of antacids and blockers of histamine H2 receptors in mild forms of the disease, and a regular therapy with proton pump inhibitors (PPI) in the majority of other cases. An average dose of PPI varies from 20 to 40 mg/day and should be continued for 4-8 weeks. Unfortunately, symptoms of GERD frequently return and in these situations long-term acid suppression with PPI is usually necessary. As regular physical activity exerts beneficial health effects, the necessity of establishing associations between moderate, recreational exercise and GERD is needed.
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Affiliation(s)
- Pawel Jozkow
- Department of Sports Medicine, Wroclaw University of Physical Education, Wroclaw, Poland.
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Goldani HAS, Silveira TRD, Rocha R, Celia L, Dalle Molle L, Barros SGSD. [Predominant respiratory symptoms in indications for prolonged esophageal pH-monitoring in children]. ARQUIVOS DE GASTROENTEROLOGIA 2005; 42:173-7. [PMID: 16200254 DOI: 10.1590/s0004-28032005000300009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND An increasing prevalence of extraesophageal complications of gastroesophageal reflux (GER) has been seen. Evaluation of clinical profiles of patients submitted to prolonged esophageal pH monitoring could help to identify the patients who could benefit from the early diagnosis of GER. OBJECTIVE To evaluate the population, indications and results of esophageal pH-monitoring for the diagnosis of GER in a pediatric gastroenterology clinic. PATIENTS AND METHODS Data from 190 children and adolescents who had esophageal pH-monitoring were analyzed. A descriptive analysis of the population was performed and the children were categorized in five groups according to the age. The equipment used was a Digitrapper MKIII (Synetics) and all data were analyzed by using a software EsopHogram 5.7. Reflux index was established for analysis. RESULTS The most frequent indications for the exam were: asthma (26.8%), apnea/cyanosis (20%), recurrent pulmonary infections (18.4%), wheezing infant syndrome (15.8%) and chronic cough/horseness (11%). The most frequent groups of age for the respiratory symptoms were: asthma--above 5 years (92.2%); apnea/cyanosis--under 3 months (55.3%); recurrent pulmonary infections and wheezing infant syndrome--3 to 12 months (31.4% and 83.3%). Reflux index of patients with positive exam for GER was significantly higher in patients under 2 years than above 2 years of age. CONCLUSION Respiratory symptoms were predominant among the indications for esophageal pH-monitoring in children. The knowledge of the clinical profile of the patients who had esophageal pH monitoring could help to improve the technical quality of the exam.
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Affiliation(s)
- Helena Ayako Sueno Goldani
- Unidade de Gastroenterologia Pediátrica, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS.
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