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Background: Motility disorders are frequently encountered in gastroenterology (GI) practice, yet a national structured training curriculum for GI fellows in motility disorders is lacking. Since GI fellowships vary considerably in opportunities for specialized esophageal motility (EM) training, novel educational technology may be leveraged to provide standardized EM curriculum to train GI fellows in esophageal manometry., Methods: GI fellows participated in an online EM learning program at a single academic center from 2017 to 2022. Fellows answered case-based questions and were provided with evidence-based, corrective feedback related to core EM learning objectives. The primary outcome was change in knowledge and comfort in interpretation and clinical application of EM studies., Results: Sixty-nine fellows actively participated in the online EM curriculum. 65 fellows completed a pre-curriculum test, and 54 fellows completed a post-curriculum test. There was a cumulative improvement between pre-curriculum test and post-curriculum test scores from 70 to 87%, respectively (p < 0.001). Fellows had a mean improvement of 19% in questions as they progressed through the curriculum. Prior to enrolling in the EM course, 26% of fellows felt comfortable in interpreting EM studies compared to 54% of fellows after completion of the program (p < 0.001)., Conclusion: An online, technology-based curriculum was effective in educating GI fellows on core competencies of EM. Fellows demonstrated improvement in proficiency of clinically important EM studies and increased comfort in interpreting EM studies. Further studies are needed to evaluate the use of technology-based learning to widely disseminate a structured training curriculum in EM, particularly in training programs without a motility presence., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Dysphagia lusoria is rare embryologic defect of the aortic arch vasculature characterized by an aberrant retro-esophageal course of the right subclavian artery (RSA), comprising a vascular sling. This may manifest clinically with symptoms of dysphagia or reflux. Given the rarity of this pathology, there remains uncertainty regarding the most effective treatment algorithm. Vascular decompression procedure surgery is often used to rectify the aberrant vascular morphology. However, a low percentage of aberrant arteries result in trachea-esophageal symptoms. As such, we suggest (1) one must exclude co-morbid esophageal motility disorders in patients with dysphagia; and (2) aberrant RSA may be a cause of dysphagia, so-called dysphagia lusoria, but represents an unlikely mechanism, since this morphological arrangement typically does not result in a highly constrictive, circumferential vascular ring. It follows, therefore, that directly addressing the esophageal motility issue should take precedence over complex and potentially noncurative vascular procedures directed to the aberrant RSA. However, the presence of marked aneursymal dilation of the aberrant RSA, and/or the presence of a bicarotid (socalled bovine) trunk, would favor vascular repair in the clinical decision-making due to the elevated risk of rupture and more severe esophageal compression in these specific situations.

Introduction: Ineffective esophageal motility (IEM) is the most commonly diagnosed abnormality on high-resolution manometry (HRM). However, the clinical significance of IEM and associated reflux burden remains unclear., Aim: Our primary aim was to compare reflux patterns between IEM versus normal motility on HRM., Methods: HRM and reflux studies in patients with IEM and normal motility were retrospectively reviewed. Esophageal pressure topography parameters, reflux variables, and patient-reported outcome questionnaires were explored., Results: A total of 239 patients with IEM were explored. Of these, 146 underwent reflux monitoring. Additionally, 100 patients with normal HRM all of whom had undergone reflux monitoring were included. IEM patients were more likely to have an abnormal number of reflux events compared to normal (22.7% vs. 9.0%, p < 0.01). Including only off-proton pump inhibitor (PPI) testing, IEM patients had higher mean total acid exposure time (AET) and total reflux events compared to normal motility (p = 0.02). Within IEM patients, higher AET modestly correlated with increased percentage of impaired swallows. Increased reflux events modestly correlated with higher impaired swallows and decreased lower esophageal sphincter (LES) resting pressure. Reflux burden increased with higher esophagogastric junction (EGJ) subtype, driven mostly by subtype III, although there was no difference in the distribution of EGJ subtypes between the IEM and normal HRM cohorts., Conclusions: Patients with HRM diagnosis of IEM may be more prone to acid reflux while off-PPI and non-acid reflux while on-PPI. Reflux burden appears to be worse in IEM patients who have lower resting LES pressure, higher EGJ subtype, or higher percentage of impaired swallows.

Background: Multiple rapid swallows (MRS) during HREM assess post-deglutitive inhibition, LES relaxation, and subsequent esophageal contraction., Aims: (1) To determine the relationship between MRS and single-swallow (SS) responses and (2) to determine if MRS provides information for symptomatic patients., Methods: Healthy volunteers (HVs) and patients underwent HREM [30-s landmark, ten 5-mL SS, MRS (5 consecutive 2-mL swallows every 2-3 s)] and were analyzed with ManoView software version 3 with CC version 3.0., Results: In 20 HVs, MRS response consisted of: (1) reduction in GEJ pressure; (2) absence of esophageal contractile activity during MRS; and (3) post-MRS peristaltic contraction greater than SS contractions. In 20 HVs and 403 patients, MRS IRP correlated with SS IRP (r = 0.65; p < 0.0001) and post-MRS contraction DCI correlated with SS DCI (r = 0.76; p < 0.0001). Abnormally elevated MRS IRP was seen in 68% type 2 achalasia, 50% type 3 achalasia, 47% EGJOO, and 9% jackhammer. Increased MRS DCI was seen in 53% type 2 achalasia, 92% type 3 achalasia, 10% EGJOO, 22% jackhammer, and 18% DES. Increased DCI post-MRS was seen in 38% patients with jackhammer, 8% type 3 achalasia, 12% EGJOO, and 9% DES. 14 out of 143 (10%) patients with normal or indeterminate results on SS analysis had at least one abnormality on MRS., Conclusions: MRS IRP correlated with SS IRP, and post-MRS DCI correlated with SS DCI. Patients with defined CC disorders have abnormalities on MRS. There were MRS abnormalities in some patients with normal SS studies, most notably suggesting impaired LES relaxation and/or spastic esophageal motility. MRS may complement the baseline SS study analysis.

Background: Gastric and esophageal dysmotility syndromes are some of the most common motility diagnoses, but little is known about their interrelationship., Aims: The aim of our study was to determine if a correlation exists between gastric and esophageal dysmotility syndromes., Methods: We reviewed the records of all patients who underwent both solid gastric emptying scintigraphy (GES) and high-resolution esophageal manometry (HRM) within a 2 year period, with both done between August 2012 and August 2017. All GESs were classified as either rapid, normal, or delayed. All HRMs were classified according to the Chicago Classification 3.0. Correlations were assessed using Fisher's exact test and multiple logistic regression., Results: In total, 482 patients met inclusion criteria. Of patients with a normal, delayed, and rapid GES, 53.1, 64.5, and 77.3% had an abnormal HRM, respectively (p < 0.05 vs. normal GES). Likewise, patients with an abnormal HRM were more likely to have an abnormal GES (54.9 vs. 41.8%, p = 0.005). Multiple logistic regression showed abnormal GES [odds ratio (OR) 2.14], age (OR 1.013), scleroderma (OR 6.29), and dysphagia (OR 2.63) were independent predictors of an abnormal HRM. Likewise, an abnormal HRM (OR 2.11), diabetes (OR 1.85), heart or lung transplantation (OR 2.61), and autonomic dysfunction (OR 2.37) were independent predictors of an abnormal GES., Conclusions: The correlation between an abnormal GES and HRM argues for common pathogenic mechanisms of these motility disorders, and possibly common future treatment options. Clinicians should have a high index of suspicion for another motility disorder if one is present.

Esophageal high-resolution manometry (HRM) has advanced the understanding of esophageal motor function and the ability to diagnose and manage disorders of esophageal motility. In this review, we describe the indications for and the technical performance of HRM. The Chicago classification of esophageal motor function, now in its third iteration, streamlines and standardizes the nomenclature and basic interpretation of HRM data depicted as Clouse topographic plots. In clinical practice, HRM is an important diagnostic test for patients with dysphagia as well as patients with suspected gastroesophageal reflux disease (GERD), particularly in those patients with a suboptimal symptomatic response to antisecretory therapy. HRM can support diagnoses such as achalasia, as well as provide evidence for behavioral disorders such as rumination syndrome or supragastric belching with the assistance of postprandial HRM with impedance. Further, the GERD classification of motor function introduces a three-part hierarchical evaluation of esophageal motor function in GERD, highlighting the value of assessment of esophageal contractile reserve through provocative maneuvers during HRM such as multiple rapid swallows.

Background: Using manometry, the classification of motility-related disorders in the esophagus is vague and overlapping. We present a new method, which combines manometry and axial force measurements in a single catheter., Aim: The aim was to examine the manometric and axial force recordings during swallows., Methods: Recordings from 20 patients suffering from diffuse esophageal spasms (DES) (8), achalasia (5) and other diseases including gastro-oesophageal reflux (7) were compared to recordings made in ten healthy subjects. The probe was capable of measuring axial force 6.5-cm proximal to the lower esophageal sphincter (LES) and pressures 8-, 10- and 12-cm proximal to the LES. After insertion, five dry and five wet swallows were made. Swallows were repeated with 0, 2, 4 and 6 ml of water in a bag mounted distal to the axial force recording site. Each contraction was analysed for duration and amplitude, and was categorised according to its configuration., Results: The number of failed contractions measured with axial force was lower for the achalasia (P < 0.001) and DES groups (P < 0.001) compared to the healthy volunteers. The number of multi-peaked contractions was unchanged for the achalasia and DES groups while it increased for the group of healthy volunteers. On several occasions a negative traction force was encountered though the manometric pattern appeared normal., Conclusions: Measurements of axial force generated by primary peristalsis provide additional information about esophageal neuromuscular function in different diseases that is not demonstrable with manometry alone.

Background and Aims: The evolution of nonspecific esophageal motility disorders remains unclear. The aim of this study was to investigate whether nonspecific esophageal motility disorders progress into specific motility disorders and whether such progression is predictable., Methods: Seventy-six symptomatic patients (49 males, 27 females, mean age 57 ± 16 years) with newly diagnosed nonspecific esophageal motility disorders were prospectively registered and followed-up. Follow-up visits, with structured interviews and manometric re-evaluation, were recommended biannually and whenever symptoms exacerbated., Results: Forty-three patients were followed for up to 4 years, symptoms worsened in 30% of patients, resolved in 26%, improved in 14% and were unchanged in 30%. Twenty-eight patients agreed to undergo manometric re-evaluation. Fifteen (53.6%) of these patients showed a progression to achalasia. The remaining patients continued to display features of nonspecific esophageal motility disorders (32%) or had normal motility (11%). The only significant association could be determined between age and progression to achalasia reaching nearly 100% in patients' ≤46 years of age. In contrast, none of the patients' ≥68 years progressed., Conclusion: More than half of the patients in our cohort with nonspecific esophageal motility disorders showed a transition into achalasia. Neither manometric nor clinical findings predicted the progression of nonspecific esophageal motility disorders. However, young patients were more likely to progress to achalasia.

Background: Systemic sclerosis (SS) patients with severe esophageal affection have impaired peristalsis. However, motor function evaluated in vivo by manometry and fluoroscopy does not provide detailed information about the individual contraction cycles., Aims: To apply, for the first time in gastrointestinal (GI) patients, a method and principles modified from cardiac research to study esophageal muscle behavior in SS patients., Methods: Muscle contraction cycles were analyzed using pressure-cross-sectional area (P-CSA) loops during distension pressure up to 5 kPa. The probe with bag and electrodes for CSA measurements was positioned 7 and 15 cm above the lower esophageal sphincter (LES) in eleven healthy volunteers and eleven SS patients. The P-CSA, the wall tension, Δtension (afterload tension - preload tension), contraction velocity, work output (area of the tension-CSA loops), and power output (preload tension × CSA rate) were analyzed., Results: The P-CSA loops consisted of phases with relaxation and contraction behavior. The tension-stretch ratio loops in patients were shifted to the left at both distension sites, indicative of a stiffer wall in patients. Lower contraction amplitudes and smaller P-CSA loops were observed for the SS patients. The work output, power output, Δtension, and contraction velocity were lower in patients (P < 0.001). Association was found between disease duration and the work output, Δtension, and velocity at pressure steps higher than 3 kPa (P < 0.05)., Conclusions: Distension-evoked esophageal contraction can be studied in vivo and analyzed with advanced methods. Increased esophageal stiffness and impaired muscle function that depended on disease duration were observed for SS patients. The analysis may be useful for characterization of other diseases affecting GI function.

Background: An association between eosinophilic esophagitis (EoE) and esophageal motility disorders has been described in small studies., Aims: The aim of this study was to describe the prevalence of esophageal motor disorders in a large cohort of adults with EoE and examine whether an association exists between esophageal dysmotility and dysphagia., Methods: A retrospective review of esophageal manometry studies in adult EoE patients was performed. Tracings were reviewed for abnormalities including nutcracker esophagus and ineffective swallows, defined as low amplitude peristalsis (<30 mmHg) or non-propagating contractions. Ineffective esophageal motility (IEM) was categorized as mild (30-40% ineffective swallows), moderate (50-60% ineffective swallows), and severe (≥70% ineffective swallows). Dysphagia was graded on a 0-3 scale for frequency and severity., Results: Seventy-five tracings from EoE patients were reviewed (85% male, mean age 41 ± 12 years). IEM was identified in 25 patients and categorized as mild (n = 13), moderate (n = 6), and severe (n = 6). Nutcracker esophagus was found in three patients. There was no significant difference in eosinophil count among the motility groups: normal 46.5 ± 3.1, mild IEM 56.9 ± 36.9, moderate IEM 45.5 ± 23.7, severe IEM 34.3 ± 12.6 (P = 0.157)., Conclusions: In this cohort of EoE patients, the majority had normal esophageal motility studies, although a subset of these patients had some esophageal dysmotility. It is unlikely that esophageal dysmotility is a major contributing factor to dysphagia, although it is reasonable to consider esophageal manometry testing in EoE patients to identify potential abnormalities of the smooth muscle esophagus.

Background: Slow transit constipation (STC) is associated with upper gastrointestinal tract motor abnormalities in a subset of patients. This could influence the clinical approach, particularly in those rare cases where surgical management is considered., Aims: To identify factors that predict proximal gut dysmotility in patients with STC., Methods: Esophageal and small bowel motor function were evaluated in 77 patients with STC. Severity and pattern of colonic transit delay, prevalence of a co-existent rectal evacuatory disorder, and type (if present), and duration, and onset of constipation symptoms were compared., Results: Of the 77 patients studied, 43% exhibited altered motor function in the esophagus and/or small bowel. Frequency of defecation was lower in these patients than in those without upper gastrointestinal dysmotility (0.5 +/- 0.1 vs. 1.3 +/- 0.3 bowel movements/per week, respectively; P = 0.04). Severity and patterns of colonic transit delay and the mechanism associated with the onset of constipation symptoms or with their duration were similar in subjects with or without upper gastrointestinal tract dysmotility. Small bowel but not esophageal motor dysfunction was more frequently associated with a co-existent rectal evacuatory disorder (P = 0.01)., Conclusion: Upper gastrointestinal tract dysmotility in patients with STC is frequent, but prediction on the basis of clinical history and characteristics of colonic transit is problematic.

Most studies on the effect of aging on esophageal motor function have shown that peristaltic function deteriorates with age. Esophageal motor function is traditionally studied by means of manometry and radiography. Distension of the esophagus with evaluation of active and passive mechanical parameters have become available during recent years. In this study, we did a manometric swallow analysis and used the distension method to study esophageal properties and function during aging. An impedance planimetric probe with a bag for distension was placed in the distal esophagus of 25 healthy volunteers with a median age of 35 (range 23-86) years. Distensions were done at an infusion rate of 25 ml min(-1) with and without relaxation of neuromuscular activity with butylscopolamine. The infusion was reversed when moderate pain was experienced by the subjects. Swallow-induced contraction amplitudes decreased as function of age for persons older than 40 years (P < 0.05). The total and passive tension showed an exponential increase as function of the change in radius, whereas the active tension increased until it reached a local maximum point. The maximum active tension deteriorated as a function of age after the age of 40 years (P < 0.05). Furthermore, esophagus became stiffer with age. In conclusion, age-related changes of increased stiffness and reduced primary and secondary peristalsis were found in the human esophagus with a deterioration of esophageal function after the age of 40 years. Such changes may contribute to the high prevalence of reflux disease in elderly.

The hypothesis that non-erosive reflux disease (NERD) patients comprise various subgroups is gaining popularity. This study was conducted to investigate the possibility of categorizing NERD patients according to symptom types and response to acid-suppressive drug rabeprazole (RPZ) 10 mg/day. NERD patients were classified as grade N (endoscopically normal), M (minimal change), or erosive GERD, and answered a 51-item, yes-or-no questionnaire pre and post-treatment. Compared to erosive GERD, clear differences existed in pretreatment prevalence of symptoms and responsiveness to RPZ in grades N and M; the results suggested stomachaches (especially at night) were significant symptoms in grade N and dysmotility-like symptoms like bloated stomach were significant in grade M while gastroesophageal reflux symptoms were significant in erosive GERD. Clinical significance of classifying NERD was indicated from different symptoms and responsiveness to PPI.

Obesity has increased dramatically in the last 30 years, affecting 33% of the adult population in the United States. Increase in body mass index has been shown to be associated with the increase in the prevalence of gastroesophageal reflux disease (GERD) symptoms, esophageal mucosal injury, and GERD complications. The putative mechanisms responsible for the close relationship between GERD and increased body mass index include increased intragastric pressure, increased gastroesophageal pressure gradient, esophageal motor and sensory abnormalities, increase in prevalence of hiatal hernia, increase in serum female hormonal levels, diet, and increase in comorbidities. Whilst the current efforts are to focus on one major underlying mechanism, it is highly likely that multiple factors contribute to the increased prevalence of GERD in the obese patient.

Background: Conventional esophageal manometry evaluating liquid swallows in the recumbent position measures pressure changes at a limited number of sites and does not assess motility during solid swallows in the physiologic upright position., Aim: To evaluate esophageal motility abnormalities during water and bread swallows in the upright and recumbent positions using high-resolution manometry (HRM)., Methods: Thirty-two-channel HRM testing was performed using water (10 ml each) and bread swallows in the upright and recumbent positions. The swallows were considered normal if the distal peristaltic segment >30 mmHg was >5 cm, ineffective if the 30-mmHg pressure band was <5 cm, and simultaneous if the onset velocity of the 30 mmHg pressure band was >8 cm/s. Abnormal esophageal manometry was defined as the presence of > or =30% ineffective and/or > or =20% simultaneous contractions., Results: The data from 96 patients (48 F; mean age 51 years, range 17-79) evaluated for dysphagia (56%), chest pain (22%), and gastroesophageal reflux disease (GERD) symptoms (22%) were reviewed. During recumbent water swallows, patients with dysphagia, chest pain, and GERD had a similar prevalence of motility abnormalities. During upright bread swallows, motility abnormalities were more frequent (p = 0.01) in patients with chest pain (71%) and GERD (67%) compared to patients with dysphagia (37%)., Conclusions: Evaluating bread swallows in the upright position reveals differences in motility abnormalities overlooked by liquid swallows alone.

This paper describes multiple intraluminal impedance (MII) in 50 children with typical and atypical gastroesophageal reflux (GER) symptoms and discusses the possible clinical significance of objective numeric data provided by MII computed analysis. Patients underwent 24-hr pH/MII monitoring. Reflux parameters were analyzed with relation to age and reported symptoms. Nonacidic MII events occurred as frequently as acidic ones. A Pathologic Bolus Exposure Index associated with a normal pH Reflux Index was detected in 26% of our series. Significant correlations were found regarding acid and bolus clearing times and their ratio. We conclude that the low rate of symptom occurrence in the pediatric population represents a limit on MII evaluation. Our study confirmed that nonacid GER is at least as frequent as acid GER. As MII provides interesting objective data that could be used in clinical practice, we suggest further research to define normal ranges in the pediatric population.

The aim of this study was to examine if edrophonium provocative testing is useful for evaluating upper gastrointestinal hypersensitivity in patients with nonulcer dyspepsia (NUD). A questionnaire rating dyspeptic symptoms was done for 58 patients with NUD. The patients were then given an intravenous infusion of saline followed by 5 mg of edrophonium. Baseline esophageal manometry was also done. Patients whose usual symptoms were reproduced (48.3%) had significantly higher symptom scores (13.0 [8.5, 17.0] vs. 8.5 [6.0, 11.0]; P = 0.015) and a significantly higher number of symptoms (4.0 [2.5, 6.0] vs. 3.0 [1.0, 4.0]; P = 0.010) than patients whose usual symptoms were not reproduced. The presence of an esophageal motility disorder was not significantly different between the two groups. These findings suggest upper gastrointestinal hypersensitivity in the patients whose symptoms were reproduced. Edrophonium provocative testing might be useful for evaluating upper gastrointestinal hypersensitivity in patients with NUD.

Different criteria have been used for the diagnosis of nutcracker esophagus, but the clinical importance of this is largely unknown. To this end, 45 patients with hypertensive esophageal peristalsis were identified from 572 esophageal investigations, and thereafter explored with regard to diagnostic criteria and clinical background data. The numbers of patients classified as having nutcracker esophagus with different criteria were 25 (by Richter criteria), 39 (by Achem criteria), and 45 (by Gothenburg criteria). In comparison with patients with segmental hypertensive peristalsis, patients with diffuse hypertensive peristalsis were more often referred for chest pain (P < 0.05), less often for reflux symptoms (P < 0.05), and tended to have arterial hypertension less often (P < 0.08). In conclusion, the choice of criteria for the diagnosis of nutcracker hypertensive peristalsis has prominent effects on the number of patients receiving this diagnosis. Moreover, a diffuse nutcracker peristaltic pattern appears more strongly linked to chest pain.

It was the aim of this study to analyze whether a shorter measuring period would render the same diagnostic information on esophageal motility as a circadian measuring period in ambulatory esophageal manometry. In an investigation on normal volunteers (n = 10), patients with gastroesophageal reflux disease without esophageal motility disorders (n = 13), and patients with esophageal motility disorders (n = 14), a comparison was performed between a 5-hr and a 24-hr motility study. An analysis was performed on inter- and intraindividual reproducibility of time periods, prandial phases, and motility sequences (Wilcoxon and Spearman test). There was no significant difference between the two analyzed measuring periods in all three groups with regard to the diagnostic information on esophageal motility in 44 of 45 comparisons for intraindividual variability. A measuring period restricted to 5 hr offers the same diagnostic information on esophageal peristaltic activity as a 24-hr motility study.

To simplify assessment of gastric emptying, we have developed a radiopaque barium marker method. The subjects were 11 healthy volunteers, 30 patients with progressive systemic sclerosis, 16 patients with dysmotility-like dyspepsia, 7 patients with irritable bowel syndrome, and 6 patients with diabetes mellitus. We tested three types of radiopaque markers with manometry by a three-channel strain gauge transducer. The 4.5-mm ring-shaped markers with a specific gravity of 1.2 were emptied from the stomach in correlation with the number of high-amplitude (>50 mm Hg) antral contractions. The percentage of residual markers at 2 hr was significantly (P < 0.05) lower in patients with irritable bowed syndrome than in normal controls, and at 5 hr it was significantly (P < 0.05) higher in patients with systemic sclerosis with esophageal dysmotility, dysmotility-like dyspepsia, or diabetes than in normal controls. This radiopaque barium marker method may be useful as a screening test for determining whether gastric emptying is rapid or delayed.

Subtypes of functional dyspepsia (FD), including refluxlike dyspepsia, ulcerlike dyspepsia, dysmotility-like dyspepsia, and nonspecific dyspepsia, have been described and are widely used clinically. However, these symptom patterns often overlap, and the terms are insufficient for indicating all FD symptoms. In this study, we divided 71 FD patients into two groups: patients with or without pain. Group I, the pain dyspepsia group, included patients in whom the main symptoms were epigastralgia and/or chest pain. Group II, the painless dyspepsia group, included patients without pain, in whom the symptoms were nausea, vomiting, and heartburn. We examined the relationship between esophageal function and psychiatric factors in the test groups and compared them with a control group. Of the FD patients, 19.7% [8 (25%) of 32 group I patients, 6 (15.4%) of 39 group II patients] had esophageal motility disorders, such as nutcracker esophagus and diffuse esophageal spasm. The LES pressure of group I was higher than that of group II by esophageal manometry (P < 0.05). In 17 (53.1%) of 32 group I patients and 31 (79.5%) of 39 group II patients, psychiatric disorders (38.0% had depressive disorder and 21.1% had an anxiety disorder) were diagnosed following DSM III-R criteria. Group II tended to be more depressive than group I (P = 0.0508). Psychological assessment scores, STAI-I and STAI-II, were higher in groups I and II than in the control group (P < 0.001). Long-term distress, anxiety, and depression seem to influence the symptoms of FD patients. Esophageal dysmotility may be an important functional abnormality of FD.

We report a case of documented transient segmental aperistalsis of the distal esophagus following an accidental electrical injury. There are no other reports in the literature demonstrating this phenomenon. A review of gastrointestinal injury secondary to electrical injury is presented.

Nonspecific esophageal motility disorder (NEMD) is a vague category used to include patients with poorly defined esophageal contraction abnormalities. The criteria include "ineffective" contraction waves, ie, peristaltic waves that are either of low amplitude or are not transmitted. The aim of this study was to identify the prevalence of ineffective esophageal motility (IEM) found during manometry testing and to evaluate esophageal acid exposure and esophageal acid clearance (EAC) in patients with IEM compared to those with other motility findings. We analyzed esophageal manometric tracings from 600 consecutive patients undergoing manometry in our laboratory following a specific protocol from April 1992 through October 1994 to identify the frequency of ineffective contractions and the percentages of other motility abnormalities present in patients meeting criteria for NEMD. Comparison of acid exposure and EAC was made with 150 patients who also had both esophageal manometry and pH-metry over the same time period. Sixty-one of 600 patients (10%) met the diagnostic criteria for NEMD. Sixty of 61 (98%) of these patients had IEM, defined by at least 30% ineffective contractions out of 10 wet swallows. Thirty-five of these patients also underwent ambulatory esophageal pH monitoring. Patients with IEM demonstrated significant increases in both recumbent median percentage of time of pH <4 (4.5%) and median distal EAC (4.2 min/episode) compared to those with normal motility (0.2%, 1 min/episode), diffuse esophageal spasm (0%, 0.6 min/episode), hypertensive LES (0%, 1.8 min/episode), and nutcracker esophagus (0.4% 1.6 min/episode). Recumbent acid exposure in IEM did not differ significantly from that in patients with systemic scleroderma (SSc) for either variable (5.4%, 4.2 min/episode). We propose that IEM is a more appropriate term and should replace NEMD, giving it a more specific manometric identity. IEM patients demonstrate a distinctive recumbent reflux pattern, similar to that seen in patients with SSc. This finding indicates that there is an association between IEM and recumbent GER. Whether IEM is the cause or the effect of increased esophageal acid exposure remains to be determined.

The purpose of this study was to determine if botulinum toxin injection at the lower esophageal sphincter improves symptoms in patients with nonachalasia spastic esophageal motility disorders. Fifteen patients with nonachalasia spastic esophageal motility disorders (diffuse esophageal spasm, nonspecific esophageal motility disorders, and lower esophageal sphincter dysfunction) unresponsive to medical therapy underwent endoscopic injection of botulinum toxin at the level of the gastroesophageal junction. Symptoms were scored (0 = no symptoms, 1 = mild, 2 = moderate, 3 = severe and 4 = very severe) before treatment, at seven days and every 30 days after treatment. There was significant improvement in chest pain, dysphagia, and regurgitation at 7,30,60 and 90 days after treatment. At one month after treatment, 11 of 15 (73%) patients had a good or excellent response to treatment. At the last patient interview (mean follow-up of 10.6 months), five (33%) patients continued to have a good to excellent response, whereas 10 (67%) underwent subsequent treatment with repeat botulinum toxin, pneumatic dilation, or bougienage. We conclude that botulinum toxin injection at the gastroesophageal junction leads to significant symptom improvement in patients with nonachalasia esophageal motility disorders. These results suggest that botulinum toxin may be an effective treatment option in some of these patients not responsive to conventional medical therapy.

Our aims were to determine the long-term clinical and manometric follow-up of 11 children with previously documented esophageal dysmotility, who had been breast-fed by mothers with silicone breast implants, their response to prokinetic agents, and to analyze changes in macrophage activation. Seven of 11 children had subjective clinical improvement. Weight/ height ratios remained the same or improved in 9/11. Biopsies at follow-up endoscopy were either normal or demonstrated mild esophagitis in 8/10. LES and UES pressures and percent propagation were not significantly different at follow-up, while wave amplitude significantly increased. Following intravenous metoclopramide, LES pressure, percent propagation, and wave amplitude significantly increased while UES pressure was unchanged. Urinary neopterin significantly decreased at follow-up, while urinary nitrates were unchanged. Esophageal dysmotility is chronic in this group of children, suggesting persistent autonomic nervous system dysfunction. Prokinetic agents may be useful in long-term management. The decreasing urinary neopterin levels suggest that, ultimately, there may be improvement in esophageal motility.

Recent studies of the peristaltic pressure wave have suggested the presence of two sequential but overlapping contraction segments in the distal esophageal body. In this report, propagation velocity of esophageal peristalsis was determined in these segments in normal subjects (N = 35) and in patients with high-amplitude peristalsis (nutcracker esophagus, N = 25) to see if intersegment differences were present in the normal or abnormal setting. Velocity measurements were made from conventional manometric tracings in two 4-cm regions representing the distal smooth-muscle segments. A novel method of velocity measurement was employed that used regression lines established from contraction onset times. In normal subjects, propagation velocity decreased significantly from the proximal to distal segment (4.9 +/- 0.5 cm/sec, vs 3.2 +/- 0.2 cm/sec, P < 0.01). Velocity also decreased across segments in nutcracker-esophagus patients (5.3 +/- 0.6 cm/sec, vs 3.6 +/- 0.7 cm/sec, P = 0.06), but the difference reached statistical significance only when the subset with highest amplitudes (> or = 180 mm Hg) was analyzed separately. Greater variance in velocity in the distal smooth-muscle segment of nutcracker-esophagus patients (P < 0.01) was, in part, responsible for this statistical observation. We conclude that normal propagation velocity decreases across regions corresponding to the smooth-muscle contraction segments defined by recent studies of peristalsis, supporting the assumption that they represent separate neuromuscular units. The mechanisms responsible for contraction wave abnormalities in the nutcracker esophagus have a minimal effect on propagation velocity, an effect that is restricted to the distal smooth-muscle segment of the esophageal body.

We assessed the relationship of lower esophageal sphincter pressure (LESP) to presence and absence of lower esophageal mucosal ring (LEMR) in 66 patients to determine if the LEMR was more likely related to prolonged sphincter hypotension. This potential relationship is of interest because LEMR may be due to reflux esophagitis. Each patient had radiographic and manometric studies, and both examinations were done within one week of each other. The mean LESP in patients with LEMR was 23.8 mm Hg (range 4.2-64 mm Hg) compared to 28.7 mm Hg (range 8-59 mm Hg) in patients without LEMR; the difference was not statistically significant. Patients with LEMR were also divided into three subgroups according to the diameter of the rings (< or = 13 mm, 14-19 mm, > or = 20 mm). There was no significant relationship between the caliber of LEMR and LESP (P > 0.05). Presence of LEMR did not affect the amplitude or duration of primary esophageal peristalsis. These results do not support a relationship between LEMR and prolonged LESP hypotension or abnormal esophageal motility. However, other pathogenetic mechanisms involved in producing reflux esophagitis not related to prolonged sphincter hypotension were not studied.

Normal swallowing requires the close functional coordination of the mouth, pharynx, and esophagus, and if one of these components becomes functionally impaired, it is likely that the others may be affected. Using videofluoroscopy and manometry in this study, we examined the esophageal phase of swallowing in 12 patients with oropharyngeal dysphagia (group A) and the oropharyngeal components of swallowing in 29 patients with esophageal motor dysfunction and nonobstructive dysphagia (group B). A wide range of esophageal function abnormalities was seen in the first group, including delayed esophageal body peristalsis, spontaneous or simultaneous (tertiary) contractions, esophageal body dilation, proximal bolus redirection, and poor lower esophageal sphincter relaxation. Manometrically, 92% of group A patients were classified as having nonspecific esophageal motility disorder (NSEMD). In a similar fashion, group B patients exhibited many oropharyngeal function abnormalities on videofluorography including disturbed lingual peristalsis, slowed pharyngeal transit time with poor constriction of pharyngeal muscles, and laryngeal vestibular and tracheal bolus penetration. Manometrically, group B patients were classified as having NSEMD, achalasia, diffuse esophageal spasm, nutcracker esophagus, scleroderma, and chronic intestinal pseudoobstruction. In conclusion, oropharyngeal function is significantly altered in patients with esophageal motility disorders and dysphagia, and esophageal motor dysfunction occurs in patients with oropharyngeal dysphagia. These changes may represent either a compensatory mechanism or concomitant involvement of the oropharynx or the esophagus by the underlying neuromotor disorder. We suggest that assessment by esophageal motility and videofluoroscopy of both the oropharyngeal and esophageal phases of swallowing may improve diagnosis and therapy in patients with nonobstructive dysphagia.

The aim of the study was to investigate whether a soft solid bolus can induce abnormal manometric patterns in patients with dysphagia and normal standard manometry. The study group comprised 12 normal volunteers and 22 patients with dysphagia. Manometry was performed using 10 wet swallows followed by 10 swallows of marshmallow. The results show: (1) in normal subjects the mean contraction amplitude is significantly greater (P less than 0.035) and the velocity of propagation significantly slower (P less than 0.003) for soft solid swallows compared with wet swallows; (2) in normal subjects there are fewer abnormal contractions after soft solid swallows than after wet swallows; (3) in 15 patients, soft solid swallows induced non-peristaltic contractions and/or contractions of extreme amplitude and/or duration that were not observed after wet swallows; (4) in patients, the probability of inducing abnormal contractions after soft solid swallows is significantly greater than after wet swallows (P less than 0.0001). We conclude that soft solid swallowing is useful in the study of patients with dysphagia.

It is known that primary (swallow-induced) esophageal contractions are abnormal in alcoholics. Data concerning acid-induced esophageal contractions, which appear to be important in cleansing refluxed acid from the esophagus, are lacking. To determine whether acid-induced esophageal contractions are also affected by chronic ethanol exposure, we studied secondary (acid or saline-induced) esophageal motor events in 19 male alcoholics [6 actively drinking (ADA), 13 withdrawing (WA)]. Esophageal motility was performed in response to wet swallows (5 ml of water) and to intraesophageal injection of 5 ml of 0.1 N HCl (0.1 N) or saline. Lower esophageal sphincter pressure (LESP), amplitude (ECA), duration (ECD), and velocity (ECV) of esophageal contractions in response to swallowing and injection of acid or saline were similar in controls and alcoholics. There were more simultaneous and double-peaked contractions in response to acid and saline than to swallows in both alcoholics and controls. However, there was no difference between HCl- and NaCl-induced contractions. ECA in alcoholics was significantly higher than in controls. ECD in alcoholics was significantly more prolonged than in controls. There was no significant different between alcoholics and controls in ECV, LESP, or LES relaxation. These data indicate that similar to primary esophageal contractions, secondary esophageal contractions are also abnormal in both actively drinking and withdrawing alcoholics.

In order to determine the actual spectrum of abnormal esophageal motility, manometric patterns in 1013 consecutive tracings were established using a classification method that employs esophageal body and lower esophageal sphincter (LES) characteristics. Peristaltic performance and contraction wave parameters were measured in the esophageal body; basal pressure and relaxation were included for the LES. Nine hundred thirty (92%) of the tracings could be completely classified, and 33 different patterns were observed (915 occurring at a rate greater than 1%). Abnormalities were most common in contraction wave parameters (661 tracings, 65%), and least common in LES relaxation (105 tracings, 10%). Patterns most typical of achalasia and diffuse esophageal spasm were found in 6.4% and 5.0% of tracings, respectively. Statistical analysis of the patterns demonstrated that significant bidirectional predictive associations between categories were restricted to features representing pathology-based motor disorders (ie, achalasia and "scleroderma-esophagus"). This systematic classification method is capable of recognizing and cataloging common findings of motor dysfunction in the esophageal body and LES as well as uncommon patterns representing traditional motility disorders. Our findings provide reference data for clinical esophageal manometry.

Fifty-three patients suffering from dysphagia because of suspected esophageal motor disorders were treated by pneumatic dilatation using the Rider-Moeller technique. Fifteen had achalasia demonstrated by manometric studies. Forty-nine of them had remarkable clinical improvement after the procedure. During the mean period of follow-up (average 5 years, range 1-11), 75% of the patients needed a new dilatation, with a delay of two years. The results of the dilatation were excellent or good in 80% of the cases. Early complications consisted in two esophageal perforations surgically treated. There was no mortality. We did not observe late complications of the procedure. We conclude that pneumatic dilatation should be the initial procedure in the treatment of dysphagia in suspected esophageal motor disorders.

Nutcracker esophagus is essentially a manometric diagnosis characterized by high-amplitude, often prolonged duration of peristaltic contractions in the distal two thirds of the esophagus. Its association with noncardiac chest pain and/or dysphagia has been recognized and reported by numerous esophageal motility laboratories. There are very few long-term studies of the natural history of this abnormality. We report a patient who presented with dysphagia and, on initial investigation, was found to have classical nutcracker esophagus. On reinvestigation three years later, however, he had developed achalasia of the cardia. The transition from nutcracker esophagus to achalasia has not previously been reported.

We performed esophageal investigations in 20 patients suffering from noncardiac chest pain in order to assess the diagnostic value of short- versus long-term manometric and pH studies. Patients had baseline esophageal manometry with two provocative tests: a Bernstein test and an intravenous injection of edrophonium. On a separate occasion they had a 24-hr ambulatory esophageal pH and motility recording. The Bernstein test provoked chest pain in two patients, while edrophonium injection did not elicit pain in any of the patients. The ambulatory pH study helped to establish the esophagus as the likely source of pain in one patient, and the ambulatory motility one in another. In our experience, ambulatory pH and motility recordings have a low diagnostic yield in the evaluation of patients with noncardiac chest pain.

The present study was designed to explore the relationship between psychological stress and esophageal motility disorders. Nineteen non-cardiac chest pain patients (10 with the nutcracker esophagus and nine with normal baseline manometry) and 20 healthy control subjects were administered two acute stressors: intermittent bursts of white noise and difficult cognitive problems. The results indicated that the esophageal contraction amplitudes and levels of anxiety-related behaviors of non-cardiac chest pain patients and control subjects were significantly greater during the stressors than during baseline periods. All patients demonstrated significantly greater (P less than 0.01) increases in contraction amplitude and anxiety-related behavior during cognitive problems than during the noise stressor. The nutcracker esophagus patients showed a greater increase in contraction amplitude during the problems (23.50 +/- 9.42 mm Hg, X +/- SE) than control subjects (P less than 0.01), while the amplitude changes of chest pain patients with normal baseline manometry were not significantly greater than that of control subjects (9.00 +/- 1.91 mm Hg). The present results identified an increase in contraction amplitude as the primary esophageal response to stress. The possible interaction of esophageal contraction abnormalities, psychological stress, and the perception of chest pain is discussed.

Radionuclide measurement of esophageal transit has been proposed as a screening test for esophageal motor dysfunction. In this study we evaluated the radionuclide esophageal transit test in 49 consecutive patients undergoing esophageal manometry for esophageal motor disorders. Esophageal transit was assessed using a 10-ml water bolus labeled with 250 microCi technetium-99m sulfur colloid. In preliminary studies in 14 healthy controls, mean transit time was 9.6 +/- 2.1 (SD) sec. Prolonged transit (greater than 15 sec) was observed in two of 28 swallow sequences in the control subjects. Transit times were prolonged in all patients with achalasia or diffuse esophageal spasm, and in five of seven patients with nonspecific abnormalities of peristaltic progression. The test was abnormal in only three of seven patients with high-amplitude peristalsis (nutcracker esophagus) and in none of three patients with hypertensive lower esophageal sphincter. Additionally, prolonged transit was seen in two of 18 patients with normal manometry. We conclude that the radionuclide transit test using a liquid bolus successfully identifies motor disorders characterized by defective peristaltic progression but not disorders in which peristalsis is intact. A major limiting factor appears to be the small number of swallow sequences tested. The test may not, therefore, be accurate enough to consider adopting as a sensitive and noninvasive screening test in the evaluation of patients with suspected esophageal motor disorders.