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SUMMARY The primary role of the esophagus is to propel swallowed food or fluid into the stomach and to prevent or clear gastroesophageal reflux. This function is achieved by an organized pattern that involves a sensory pathway, neural reflexes, and a motor response that includes esophageal tone, peristalsis, and shortening. The motor function of the esophagus is controlled by highly complex voluntary and involuntary mechanisms. There are three different functional areas in the esophagus: the upper esophageal sphincter, the esophageal body, and the LES. This article focused on anatomy and physiology of the esophageal body. [ABSTRACT FROM AUTHOR]

Background: Gastrointestinal (GI) disturbances are often reported by long distance runners and are more common in women, particularly after prolonged high intensity exercise. Objectives: To determine whether these symptoms could be associated with alterations in GI motility. Methods: Small bowel and colonic transit were measured using pH telemetry in a group of 11 female athletes (age 22 to 53 years), six of whom experienced lower GI symptoms during exercise. Subjects participated in two experimental sessions: a control measurement, where small bowel transit was estimated during a rest period (R) of six hours; and an exercise session (E), where small bowel transit was measured during a one hour period of high intensity exercise (cross country running) at >70% VO2max. Colonic transit was estimated indirectly from determinations of whole gut transit time by radio-opaque marker. Results: Small bowel transit time was 3.5 to 10.6 h (R) and 3.0 to 8.7 h (E) in asymptomatic athletes, versus 4.0 to 6.6 h (R) and 4.6 to 7.3 h (E) in symptomatic athletes (NS). Colonic transit time was 35.0 to 62.5 h (R) and 30.5 to 70.9 h (E) in asymptomatic athletes versus 20.4 to 42.9 h (R) and 21.5 to 67.2 h (E) in symptomatic athletes (NS). Conclusions: Small bowel and colonic transit times were similar in the two groups in the rest and exercise sessions. The diarrhoea seen in this study did not result from accelerated colonic transit. Other mechanisms must be sought. [ABSTRACT FROM AUTHOR]

30 to 65% of long distance runners experience gastrointestinal (GI) symptoms related to exercise. Several hypotheses have been postulated; however, the aetiology and pathophysiology are far from clear. The mechanical effect of running on the viscera must be involved in the development of GI symptoms in this sport. Reduction of splanchnic blood flow due to visceral vasoconstriction is another widely supported theory; nevertheless, it does not explain many of the clinical findings. Examination of the GI tract during exercise is a difficult task, and measurements of both orocaecal and whole-gut transit time have shown equivocal results. GI hormones, and especially prostaglandins, may be of crucial importance for the production of symptoms. Intestinal absorption, secretion and permeability may also be altered during exercise, provoking intestinal dysfunction. Factors such as stress, diet, dehydration, infections and other factors need to be analysed in order to present a global view of the hypotheses regarding the aetiology of this common and often overlooked problem. [ABSTRACT FROM AUTHOR]

Introduction Persistent reflux symptoms occur in a subgroup of patients following antireflux surgery. These symptoms can be due failure of the antireflux barrier. GI physiology studies are performed to evaluate the OGJ function and anatomy in these patients. Recent studies with high resolution manometry (HRM) have shown the presence of a dual high pressure zone (HPZ) at the OGJ as an expression of persistent hiatus hernia. However, the relation between dual high pressure zone, oesophageal hypomotility and persistent symptoms is unclear. The aim of this study was to evaluate reflux parameters and oesophageal motility patterns with HRM in a group of symptomatic patients after fundoplication. Methods Ten patients (5 male, 5 female; mean age 55 years) were selected based on the presence of persistent typical reflux symptoms post-Nissen fundoplication. The patients underwent HRM and impedance-pH monitoring ‘off’ PPI. The existence of dual HPZ, oesophageal hypomotility and amplitude of the after-contraction post multiple rapid swallowing (MRS) were evaluated together with acid and non-acid reflux parameters. Increased number of reflux events (post Nissen) was considered if >30/24 h. Results Six out of ten patients had a dual HPZ on HRM. Acid exposure time and number of acid reflux events in these patients was significantly higher than those with a single HPZ (12.7% vs 0.5%, p=0.01). The patients with a dual HPZ more commonly exhibited oesophageal hypomotility and poor response to MRS compared to the patients with a single HPZ (4/6 vs 1/4). In addition more of the patients with a dual HPZ showed impaired acid reflux clearance compared to patients with single HPZ (5/5 vs 1/3). Conclusion HRM and impedance-pH measurement allows a precise assessment of patients with symptoms postfundoplication. Our study suggests that the presence of a dual HPZ on oesophageal HRM is associated with impairment of oesophageal motility and impaired oesophageal acid clearance, and hence may be important in the persistence of GORD symptoms postoperatively. [ABSTRACT FROM PUBLISHER]

The article comments on the paper "Proton pump inhibition prevents gastrointestinal bleeding in ultramarathon runners: a randomised, double blinded, placebo controlled study," by M. Thalmann and colleagues in this issue. The findings offer an important message to clinicians who see athletes with gastrointestinal problems. However, the impact of physical exercise on the gastrointestinal tract is not yet clear.

This article focuses on a study related to manometric visualisation of lower oesophageal sphincter (LOS) at flexible endoscopy. Identification of LOS by visual inspection at endoscopy is unreliable and often impossible. Knowledge of the sphincter position detected by station pull through monometry can not be effectively utilized for endoscopic therapeutic procedures as is normally carried out by nasal intubation. Endoscopic monometry is a valid and reliable technique which can be carried out safely and quickly. Identification of LOS at flexible endoscopy may have potential diagnostic and therapeutic applications.

This article focuses on a study related to upper oesophageal sphincter (UOS) manometry and 24 hour pH measurements in patients with globus sensation. Patients with globus sensation are usually referred to an ENT specialist for possible malignancy. However, in most patients, flexible laryngoscopy shows no abnormalities, and further management is often unclear. UOS manometry and 24 hour pH measurements have detected pathology in high proportion of patients with globus sensation. These investigations are therefore useful for managing patients with globus who had normal laryngoscopy.

Background: Small bowel manometry (SBM) has widely been used to investigate adult patients with gastrointestinal motility disorder. However, the use of this technique to paediatrics is uncommon. The aim of this study was to evaluate feasibility of SBM on paediatric patients with suspected small intestinal motility disorder. Methods: We have performed SBM on 14 paediatric patients (age range 2-10 years) who had symptom(s) including recurrent abdominal pain (n = 10), nausea (n = 5), vomiting (n = 7), abdominal distension (n = 2) and constipation (n = 2). A 3-channel manometry catheter was introduced nasally and placed in the proximal small bowel under fluoroscopic control. Ambulatory recordings were made for 24 hours using a portable recorder. Recorded data were analysed using dedicated software. Results: Four had normal motility when applied to the normal ranges in adults. At least one of the following abnormalities was found in eight patients; possible neuropathy findings including excess of motor activity (n = 3), prolonged Phase III (n = 2), Phase III-like prolonged bursts (n = 3), non-propagated Phase III (n = 2), retrograde propagation of Phase III (n = 2), and Iow-amplitude Phase III (n = 1) suggesting possible myopathy. Intubation failed in two patients due to no migrations of the catheter into the small intestine. Summary: In this study a high proportion of the patients had abnormal small intestinal motility and this suggests that SBM can be used to evaluate those conditions. Normal values during infant and childhood development need establishing before adopting the technique for clinical diagnosis. [ABSTRACT FROM AUTHOR]

Summary Background Acid infusion in humans induces primary and secondary oesophageal hypersensitivity. The effects of pregabalin, a centrally-acting modulator of voltage-sensitive calcium channels, on development of acid-induced oesophageal hypersensitivity remain unknown. Aim To study the effects of pregabalin on development of secondary oesophageal hypersensitivity in healthy humans. Methods Placebo-controlled, double-blind, randomised, cross-over study of 15 healthy volunteers (six women, age 21-56 years). After oesophageal manometry, baseline pain thresholds (PTs) to proximal oesophageal electrical stimulation were determined using bipolar ring electrodes. A 30-min infusion of HCl was performed in the distal oesophagus followed by PT measurements at 30 and 90 min. This protocol was repeated after administration of pregabalin (dosing schedule: 75 mg twice daily for 3 days then 150 mg twice daily for 1 day and then 150 mg on the morning of study) or placebo. Results T0 PTs were similar in patients after receiving placebo or pregabalin [mean (s.d.) 32.9 mA (20.5) vs. 34.1 (15.7), P = 0.42]. Pregabalin reduced development of acid-induced hypersensitivity in the proximal oesophagus at 30 min [mean change in PT (C.I.) placebo −6.2 mA (−11.3 to +1.3) vs. pregabalin +0.20 mA (−2.7 to +3.3)] and 90 min [placebo −3.7 mA (−10.0 to +2.0) vs. pregabalin +0.7 mA (−4.7 to 7.3)] overall P = 0.001. Pregabalin reduced median visual analogue scale score for acid-induced pain (1/10 vs. placebo 3/10, P = 0.027). Conclusions Pregabalin attenuates development of secondary hypersensitivity in the proximal oesophagus after distal oesophageal acidification; it may thus have a role in treatment of patients with proven oesophageal pain hypersensitivity. [ABSTRACT FROM AUTHOR]

Enteral feed given as a bolus has a half emptying time of 90 mm. No data are available on gastric emptying patterns during continuous nasogostric infusion. The gold standard for measuring gastric emptying (GE) is gamma scintigraphy (GS). GS does not measure gastric secretions and exposes subjects to radiation. Electric impedance tomography (EIT) is a new non-invasive, non-isotopic method which measures both feed and gastric secretions. The aim of this study was to compare EIT with GS in volunteers and to establish normal patterns of GE during continuous infusion.

Interdigestive human small bowel motility is characterized by the migrating motor complex (MMC). The aims of this study were to: (i) establish the normal range of variables of the nocturnal jejunal MMC and (ii) incorporate these data in a subsequent meta-analysis. Eighty-one recordings were performed by prolonged (24 h) ambulatory manometry in 51 subjects in two centres. Quantitative analysis was undertaken of 419 Phase III and 332 Phase II episodes. Adjusted mean values of seven variables were calculated using a mixed-effects model. Meta-analysis of pooled published data to generate a reliable 95% reference range was also performed. Adjusted mean values and confidence intervals are presented for all seven variables. Intrasubject variances were large in comparison with intersubject. Meta-analysis of 19 studies (356 pooled patients) meeting inclusion criteria produced wide reference ranges. At least five such ranges are useful for the detection of abnormality in the individual. This is the largest study of normal volunteers presented to date, with ranges for many variables produced using appropriate statistical methodology. A model for definition of abnormality has been proposed. We recommend that these data may be used by investigators in this field as a complement to other existing indicators of small bowel dysmotility. [ABSTRACT FROM AUTHOR]

Compares the symptomatic and physiological response to the treatment of gastro-esophageal reflux disease (GORD) by proton pump inhibitors and by laparoscopic antireflux surgery. Relationship between symptom severity and objective evidence of GORD after medical and surgical treatment; Relationship between the patient's subjectiveand objective response to treatment of GORD.

: ObjectiveSmall bowel dysmotility has previously been demonstrated in some patients with slow transit constipation (STC), suggesting a generalized intestinal disorder. However, no study has addressed whether the incidence of small intestinal dysfunction differs between subgroups of patients in this heterogeneous population. Using appropriate methodology, we aimed to determine prospectively the proportion of individuals with abnormal small bowel motility, and to assess whether heterogeneity in terms of pattern of colonic transit delay (based on 111In diethylene-triamine-pentaacetic acid (DTPA) isotope scintigraphy), or mode of onset (based on clinical history) is of importance.: MethodsThirty-seven patients with STC underwent 24-h ambulatory jejunal manometry; data were compared with those obtained in 38 healthy controls. Automated quantitative analysis of seven variables of the nocturnal migrating motor complex was performed, to assess whether differences existed between groups, and whether individual patients had evidence of small intestinal dysmotility, defined as two or more measures of migrating motor complex variables outside the normal range.: ResultsFour variables differed significantly between STC patients and controls: in phase III, propagation was slower, duration was longer, and contraction amplitude was higher; in phase II, contraction frequency was increased. Seven of 24 patients with a generalized pattern of colonic transit delay had abnormal small bowel motility compared with none of 13 with a left-sided delay (p < 0.04). These included four patients with chronic idiopathic symptoms and three with acquired symptoms.: ConclusionsApproximately one third of patients with a generalized delay in colonic transit had evidence of jejunal enteric neuromuscular dysfunction. Individual patients with a left-sided colonic delay did not satisfy the criteria for nocturnal small bowel dysmotility, but as a group, some differences were noted from controls. In contrast to previous reports, evidence of generalized enteric dysmotility may be present irrespective of the mode of onset. [Copyright &y& Elsevier]

Introduction Many patients attending GI physiology units for assessment of dysphagia and GORD also complain of postprandial bloating and/or belching. Excessive fasting aerophagia has been recently described in patients with severe continuous bloating and belching. Exaggerated air swallowing might be more relevant for postprandial symptoms but, thus far, objective assessment of prandial aerophagia and normal values are lacking. Oesophageal impedance can detect air swallowing. We aimed to quantify aerophagia during meals in asymptomatic subjects and patients with postprandial bloating and belching. Methods We assessed aerophagia during meals using ambulatory impedance-pH monitoring in 39 healthy, asymptomatic controls (from the US-Belgian MII-pH Normal value study, Shay . 2004; mean age in original study 39, range 22–62) to establish normal 95% confidence intervals. We identified 38 patients (mean age 43, range 17–74) with postprandial bloating and/or belching who attended the GI physiology unit for assessment of dysphagia or GORD as primary symptoms. Mealtime air swallows were visually identified when swallows were associated with antegrade flow and fast impedance increase (at least 3000 Ω from baseline) in the most distal recording segment. A score of air swallows/10 min mealtime was calculated for each subject. In patients with mealtime exaggerated air swallowing (above 95th percentile of normal values) we examined for evidence of concomitant fasting aerophagia. Results The 95% percentile range of mealtime aerophagia in normal subjects was 6.8 to 9.4 episodes/10 min, mean 8.1. Patients had significantly higher mealtime air swallowing rates than controls (mean 11.8 episodes/10 min, SEM 1.0, p = ). There was no significant difference between predominant bloating and belching subgroups. Only 4 of 23 patients with exaggerated mealtime air swallowing had concomitant fasting aerophagia. OC-054 Prandial aerophagia in normal controls and patients with belching and bloating Conclusion We established normal values of mealtime air swallowing using oesophageal impedance. Patients with postprandial bloating and/or belching exhibit increased aerophagia during meals. Most of these patients do not have fasting aerophagia. Exaggerated air swallowing during meals can now be objectively detected and biofeedback techniques can be attempted to modify such behaviour as a potential therapeutic strategy for these patients with functional GI symptoms. [ABSTRACT FROM PUBLISHER]

This article focuses on a study related to botulinum toxin as a diagnostic tool in sphincter of Oddi dysfunction. Sphincter of Oddi dysfunction (SOD) represents a difficult diagnostic challenge. Sphincter of Oddi manometry is the gold standard diagnostic method, but this is technically difficult, carries significant risk, and possibly under diagnoses SOD as sphincter hypertension may be an intermittent phenomenon. BTX is a very effective means of anticipating response to ES when manometry is equivocal or in difficult cases.

Introduction: Circadian rhythms for protein transcription have recently been identified in the gut? Environmental synchronizers may reset biological clocks, leading to alteration in gut functions, but alteration in bowel transit due to time zone shifts experienced in long haul flight is yet to be reported. Methods: Six men (Age 33.2 +/- 10.6 years) and 3 women (36.7 +/- 7.2) (mean +/- 1 SD) flew from London to California, USA, and back. As a pre-condition to joining the study, they were on no drugs for digestive diseases. We elicited responses pre-, in-, and post-flight and during foreign stay about their bowel habit, stool form scale and abdominal symptoms using validated questionnaires. Paired t-tests were used to examine significant changes in sleep and stool form scale from the pre-flight level. Stool form scale may be used as o guide to intestinal transit time. Results: Sleep duration and times pre-flight, during foreign stay and post flight were not significantly different (p > 0.05). Additionally, there was no reason to believe that the stool changes were attributable to a drastic change in diet. Abdominal symptoms were unremarkable and did not change during foreign stay or on return home from abroad. All our subjects were normal and had an uneventful stay abroad. Average stool consistency changed significantly (p < 0.01) from a lumpy to smooth consistency to a smooth to soft consistency during foreign stay and persisted 4-5 days into post-flight. The respective stool form sca[es were pre-flight 2.8 +/- 1.0, foreign stay 3.5 +/-1.1, post-flight 3.7 +/-1.2. Summary and Conclusion: During a time zone shift of +/- 8h, while the sleep clock was synchronized with the external chock, gut transit, as measured by the stool form scale, failed to synchronize with the external clock, leading to altered bowel habit. Biologic clocks that regulate gut functions may not adapt as readily to time shifts, as does the sleep clock. [ABSTRACT FROM AUTHOR]

Sphincter of Oddi dysfunction (SOD) is a cause of postcholecystectomy pain. Current gold-standard diagnosis is by measurement of basal pressure by sphincter of Oddi manometry (SOM), and if elevated an endoscopic sphincterotomy (ES) is performed. Both these procedures carry significant complication rates. Hepatobiliary scintigraphy has been promoted as a means of assisting management. Aim: to evaluate hepatobiliary scintigraphy (HBS) as a means of screening for SOD and predicting treatment response. Methods: 21 post-cholecystectomy patients were screened by HBS prior to standard evaluation with SOM during ERCP. HBS was performed using a standard protocol. A semi-quantitative scoring system classified scans as positive (SOD) or negative (no SOD). Two observers reviewed all 21 scintigrams. SOM was regarded as diagnostic of SOD if sphincter base pressure was > 40 mm Hg. If elevated, an ES was performed and a successful result was defined as an improvement in symptoms. Results: 17 of our patients were female, average age 42.4 + 4.0 years. Agreement was 100% between observers. Conclusions: HBS can be interpreted reliably between observers. HBS is a poor screening tool in isolation, but may prove a useful adjunct to manometry in predicting ES outcome. [ABSTRACT FROM AUTHOR]

23 Children aged between 11 months and 15.5 years were seen in our clinic within the period October 01 2001-2002. They presented with feeding difficulties that required oesophageal manometry, among other diagnostic investigations. The commonest symptoms were dysphagia for solids, regurgitation, and vomiting, in order of frequency. Lower Oesophageal Sphincter (LOS) pressure and body motility were measured using a standard eight channel, water perfused adult catheter (3.9 mm diameter) or a 2.3 mm catheter purpose designed for paediatric use (Mediplast). LOS pressure and oesophageal body motility were measured using a Flexilog 4000 recording system. Nine out of 23 patients had a hypertensive LOS (pressure > 26 mm Hg). These patients with hypertensive LOS but without achalasia often had regurgitation and vomiting as major presenting symptoms. Only 2 out of 23 patients had achalasia and only one of the two had a hypertensive LOS. Non-specific motility disorder (7/23), in which there were few peristaltic waves with a majority of simultaneous contractions, was the commonest cause of dysphagia. Of significance was a subgroup (4/23) with a partially relaxing LOS (residual pressure 6-11 mm Hg) but who did not have achalasia. This group had varied symptoms such as vomiting, regurgitation, and dysphagia for solids. A large hiatus hernia (7 cm) was the only finding in an adolescent girl with unexplained vomiting, normal oesophageal body motility, and "normal" OGD. in summary, children with feeding problems who present with regurgitation, vomiting, and dysphagia for solids are most likely to have a hypertensive LOS or non-specific oesophageal dysmotility rather than achalasia. Unexplained vomiting with normal LOS function and body motility may be due to hiatus hernia, which could be missed during OGD. In conclusion, oesophageal manometry is an essential diagnostic tool in the investigation of upper gastrointestinal manifestations. From our experience, it is best suited to... [ABSTRACT FROM AUTHOR]