Effect of aging on the secondary esophageal peristalsis: presbyesophagus revisited

Flip Technology for Assessing Esophageal Structural and Motor Disorders: a Skeptic's View

PURPOSE OF REVIEW

Functional lumen impedance (FLIP) technology has become commercially available to assess structural and motor abnormalities of the esophagus. Increasing numbers of papers have described novel findings with this technology. This review examines the validity of the FLIP technique, how it compares with existing diagnostic modalities, and evidence to date on diagnostic accuracy.

RECENT FINDINGS

FLIP studies require deep sedation at the time of endoscopy to complete. They assess a simulated state of esophageal obstruction in only a distal part of the esophagus rather than deglutitive motor function of the entire esophagus. The available normative dataset is small and not matched to the older age of patients typically being evaluated. The test-retest agreement in health and disease is unknown, as is the operator dependence on performing and interpreting findings. Studies to date have largely excluded patients with structural disorders, which FLIP cannot reliably distinguish from motor disorders. FLIP is an expensive technology that has been made clinically available without its true utility being established. For FLIP to be deemed a device ready for widespread clinical use, additional studies on validity, diagnostic accuracy, and outcomes need to be performed. Prospective clinical studies need to include all patients and assess the incremental cost-effectiveness of FLIP over more innovative use of existing technology, such as high-resolution manometry with provocative challenges.

Effects of Age on Esophageal Motility: Use of High-resolution Esophageal Impedance Manometry

Background/Aims

Disturbances of esophageal motility have been reported to be more frequent the aged population. However, the physiology of disturbances in esophageal motility during aging is unclear. The aim of this study was to evaluate the effects of age on esophageal motility using high-resolution esophageal impedance manometry (HRIM).

Methods

Esophageal motor function of 268 subjects were measured using HRIM in 3 age groups, < 40 years (Group A, n = 32), 40–65 years (Group B, n = 185), and > 65 years (Group C, n = 62). Lower esophageal sphincter (LES) and upper esophageal sphincter (UES) pressures, integrated relaxation pressure, distal contractile integral, contractile front velocity, distal latency, and pressures and duration of contraction on 4 positions along the esophagus, and complete bolus transit were measured.

Results

Basal UES pressure was lower in Group C (P < 0.001) but there was no significant difference in the LES pressure among groups. Contractile duration on position 3 (10 cm from proximal LES high pressure zone) was longer in Group C (P = 0.001), and the contractile amplitude on position 4 (5 cm from proximal LES high pressure zone) was lower in Group C (P = 0.005). Distal contractile integral was lower in Group C (P = 0.037). Contractile front velocity (P = 0.015) and the onset velocity (P = 0.040) was lower in Group C. There was no significant difference in impedance values.

Conclusions

The decrease of UES pressure, distal esophageal motility, and peristaltic velocity might be related with esophageal symptoms in the aged population.

Effect of aging on hypopharyngeal safe volume and the aerodigestive reflexes protecting the airways

OBJECTIVES/HYPOTHESIS

Studies on young volunteers have shown that aerodigestive reflexes are triggered before the maximum volume of fluid that can safely collect in the hypopharynx before spilling into the larynx is exceeded (hypopharyngeal safe volume [HPSV]). The objective of this study was to determine the influence of aging on HPSV and pharyngo-glottal closure reflex (PGCR), pharyngo-UES contractile reflex (PUCR), and reflexive pharyngeal swallow (RPS).

STUDY DESIGN

Comparison between two groups of different age ranges.

METHODS

Ten young (25 ± 3 standard deviation [SD] years) and 10 elderly (77 ± 3 SD years) subjects were studied. PGCR, PUCR, and RPS were elicited by perfusing water into the pharynx rapidly and slowly. HPSV was determined by abolishing RPS with pharyngeal anesthesia.

RESULTS

Frequency-elicitation of PGCR and PUCR were significantly lower in the elderly compared to the young during slow water perfusion (47% vs. 97% and 40% vs. 90%, respectively, P < .001). RPS was absent in five of the 30 (17%) slow injections in the elderly group. In these elderly subjects, HPSV was exceeded and laryngeal penetration of the water was seen. The threshold volume to elicit PGCR, PUCR, and RPS was significantly lower than the HPSV during rapid injections. Except for RPS, these volumes were also significantly lower than HPSV during slow injections.

CONCLUSIONS

PGCR, PUCR, and RPS reflexes are triggered at a threshold volume significantly lower than the HPSV in both young and elderly subjects. Lower frequency-elicitation of PGCR, PUCR, and RPS in the elderly can predispose them to the risks of aspiration.

Aspiration and infection in the elderly : epidemiology, diagnosis and management

Aspiration of the oropharyngeal or gastric contents by elderly persons often leads to lower respiratory tract infections, such as aspiration pneumonia or pneumonitis. The existence of dysphagia and aspiration in elderly patients are important factors in the occurrence of aspiration pneumonia, but are not sufficient to cause aspiration pneumonia in the absence of other risk factors. Salivary flow and swallowing can eliminate Gram-negative bacilli from the oropharynx in healthy persons. However, elderly persons may have diminished production of saliva as a result of medications and oral/dental disease, leading to poor oral hygiene and oropharyngeal colonisation with pathogenic organisms. When dysphagic patients aspirate pathogenic bacteria while swallowing food or liquids, they must also have decreased defences, such as impaired immunity or pulmonary clearance, in order to develop aspiration pneumonia.Elderly patients with cerebrovascular disease often have dysphagia that leads to an increased incidence of aspiration. It was previously reported that patients with silent cerebral infarction affecting the basal ganglia were more likely to experience subclinical aspiration and an increased incidence of pneumonia. Basal ganglia infarction leads to the impairment of dopamine metabolism and, as a consequence, a decrease of substance P in the glossopharyngeal nerve and sensory vagal nerves. Therefore, dysphagia and a decreased cough reflex may be induced by the impairment of dopamine metabolism in some elderly patients with cerebrovascular disease, suggesting that pharmaceutical agents which modulate dopamine metabolism may be able to improve swallowing and the cough reflex in patients with basal ganglia infarction. The main strategy for controlling aspiration and aspiration-related pulmonary infection in the elderly is to prevent aspiration of pathogenic bacteria along with the oropharyngeal or gastric contents. Because aspiration pneumonia in the elderly is related to certain risk factors, including dysphagia and aspiration, effective preventive measures involve various approaches, such as pharmacological therapy, swallowing training, dietary management, oral hygiene and positioning.

Medical management of nocturnal symptoms of gastro-oesophageal reflux disease in the elderly

Elderly patients with nocturnal symptoms of gastro-oesophageal reflux disease (GORD) usually experience a more aggressive and complicated disease course compared with younger patients, resulting in impaired quality of life. The severity of disease and possible complications should be evaluated with upper endoscopy once the diagnosis is suspected. Elderly patients with nocturnal symptoms of GORD and evidence of endoscopic complications (oesophagitis, Barrett's oesophagus, etc.) and those with severe endoscopically negative reflux disease (ENRD) should be treated with proton pump inhibitors. Histamine H(2) receptor antagonists are suitable for mild-to-moderate ENRD. Antacids and lifestyle modifications may be incorporated into the management as adjuncts to more potent and durable therapeutic agents. Effective treatment of nocturnal GORD symptoms in the elderly will result in relief of symptoms, healing of oesophagitis and improved quality of life, and should be maintained indefinitely to prevent relapses of the disease.

Esophageal body and upper esophageal sphincter motor responses to esophageal provocation during maturation in preterm newborns

OBJECTIVES

We studied the maturation of esophageal body and upper esophageal sphincter (UES) motor responses that protect against reflux in newborns.

STUDY DESIGN

The responses of esophageal body and UES on midesophageal provocation were quantified using a micromanometric water perfusion system and a specially designed catheter with a UES sleeve and 5 side-hole recording sites. Eighteen healthy premature infants were studied twice, at 33.4 weeks' and 35.7 weeks' mean postmenstrual ages (PMAs).

RESULTS

Mean threshold volumes and the distribution of responses including secondary peristalsis, UES pressure increase, and primary peristalsis were similar for air and liquids. Secondary peristalsis and UES pressure increases were volume dependent for both studies, but their characteristics changed as PMA increased in that (1) completely propagated secondary peristalsis with liquids increased; (2) proximal esophageal contraction duration was shorter for air and liquids; and (3) propagating velocity for liquids was faster.

CONCLUSIONS

Esophageal and UES motor responses to abrupt midesophageal provocation are present as early as 33 weeks' PMA, and the response-characteristics improve during development. Reflexes that may facilitate esophageal clearance include (1) secondary peristalsis; (2) esophago-UES-contractile reflex; and (3) esophago-deglutition response.

Aging and neural control of the GI tract: IV. Clinical and physiological aspects of gastrointestinal motility and aging

The gastrointestinal motility changes that occur as a function of age are reviewed herein. Careful attention must be given in any review of aging phenomena to exclude, or at least be cognizant of, the many comorbid conditions that can alter physiological functioning in older adults. The dramatic increase in life expectancy over the past 10-15 years demands that clinicians be aware of the various physiological and clinically relevant changes that occur with age. Gastrointestinal motility changes associated with age are relatively subtle, and in many instances only conflicting data exist. As the older adult population increases, and as the control of disease is improved, much more work needs to be done to understand the true effects of aging on gastrointestinal functioning.

Presbyesophagus: a reappraisal

The gastrointestinal tract undergoes change with aging, and the esophagus is not exempt from those changes. Failure of peristalsis in the older esophagus was labeled "presbyesophagus" over 35 years ago. Modern manometric techniques and classification systems have challenged this concept, yet there are clearly age-related changes in the esophagus. The lower esophageal sphincter changes little. Esophageal peristalsis (body) is more likely to fail in older patients, but some of this failure may be caused by damage from gastroesophageal reflux disease. The pharynx and upper esophageal sphincter also undergo age-related changes in health and disease. The ability to sense events in the esophagus fails with aging, which may cause patients with severe mucosal disease to present with less severe symptoms. Failure of the esophagus thus does not appear to be an inevitable consequence of aging, but the esophagues does undergo change with aging, and these changes should be considered in evaluation of older patients with esophageal complaints.

Swallowing disorders in the elderly

Changes that occur as a natural part of senescence in the complex action of deglutition predispose us to dysphagia and aspiration. As the "baby-boomers" begin to age, the onset of swallowing difficulties will begin to manifest in a greater number of our population. Recent advances in the evaluation of normal and abnormal swallowing make possible more precise anatomical and physiological diagnoses. Coupled with an understanding of swallowing physiology, such detailed evaluation allows greater opportunity to safely manage dysphagia with directed therapy and appropriate surgical intervention. The current study is a discussion of the changes that occur in deglutition with normal aging, contemporary evaluation of swallowing function, and some of the common causes of dysphagia in elderly patients.

Gastro-Oesophageal reflux in the elderly: role of drug therapy in management

Gastro-oesophageal reflux disease (GORD) is common in the elderly. The presenting symptoms of heartburn and regurgitation, so common in the young, are less frequent in the elderly. Common symptoms of GORD in the elderly are dysphagia, vomiting and respiratory problems. Because of the higher risk of associated pathological oesophageal lesions in the older person presenting with symptoms suggestive of GORD, oesophagogastroduodenoscopy must be performed earlier in their clinical course. There is only a poor correlation between the severity of the symptoms and the severity of the associated oesophagitis. Whereas lifestyle modifications are important in individuals with GORD, the use of proton pump inhibitors is recommended to heal the underlying pathology, to resolve the patient's symptoms, to prevent complications, and to improve the quality of life.

Airway protective mechanisms: current concepts

There are at least eight mechanisms identified that result either in volume clearance of the pharynx and esophagus (secondary peristalsis and pharyngeal swallow) or prevent entry of the gastric content into the esophagus and pharynx (LES and UES), accentuate these barriers (esophago-UES and pharyngo-UES contractile reflexes), or induce closure of the vocal cords and introitus to the trachea (esophagoglottal and pharyngoglottal reflexes). The sum effect of various combinations of these mechanisms is suggested to help prevent retrograde aspiration. In other words, airway protective mechanisms against retrograde aspiration are multifactorial and involve delicate interaction between upper GI and upper airway tracts. Although the existence of these mechanisms in normal volunteers has been documented, their function in patients with retrograde aspiration and supraesophageal complications of gastroesophageal reflux disease currently awaits investigation.