Gastroesophageal reflux disease (GERD) is one of the most commonlyencountered digestive diseases in the world, with the prevalence continuing toincrease. Many patients are successfully treated with lifestyle modificat...Gastroesophageal reflux disease (GERD) is one of the most commonlyencountered digestive diseases in the world, with the prevalence continuing toincrease. Many patients are successfully treated with lifestyle modifications andproton pump inhibitor therapy, but a subset of patients require more aggressiveintervention for control of their symptoms. Surgical treatment with fundoplicationis a viable option for patients with GERD, as it attempts to improve the integrityof the lower esophageal sphincter (LES). While surgery can be as effective asmedical treatment, it can also be associated with side effects such as dysphagia,bloating, and abdominal pain. Therefore, a thorough pre-operative assessment iscrucial to select appropriate surgical candidates. Newer technologies arebecoming increasingly available to help clinicians identify patients with true LESdysfunction, such as pH-impedance studies and high-resolution manometry(HRM). Pre-operative evaluation should be aimed at confirming the diagnosis ofGERD, ruling out any major motility disorders, and selecting appropriate surgicalcandidates. HRM and pH testing are key tests to consider for patients with GERDlike symptoms, and the addition of provocative measures such as straight legraises and multiple rapid swallows to HRM protocol can assess the presence ofunderlying hiatal hernias and to test a patient’s peristaltic reserve prior tosurgery.展开更多
AIM To investigate the behavior of pulsatile pressure zones(PPZ's) as noted on high resolution esophageal impedance manometry(HREIM), and determine their association with dysphagia.METHODS Retrospective, single ce...AIM To investigate the behavior of pulsatile pressure zones(PPZ's) as noted on high resolution esophageal impedance manometry(HREIM), and determine their association with dysphagia.METHODS Retrospective, single center case control design scr-eening HREIM studies for cases(dysphagia) and controls(no dysphagia). Thoracic radiology studies were reviewed further in cases for(thoracic cardiovascular) thoracic cardiovascular(TCV) structures in esophageal proximity to compare with HREIM findings. Manometric data was collected for number, location, axial length, PPZ pressure and esophageal clearance function(impedance). RESULTS Among 317 screened patients, 56% cases and 64% controls had PPZ's. Fifty cases had an available thoracic radiology comparison. The distribution of PPZ's in these 50 cases and 59 controls was similar(average 1.4 PPZ/patient). Controls(mean 31.2 ± SD 12 years) were a significantly younger population than cases(mean 67.3 ± SD 14.9 years) with P < 0.0001. The upright posture PPZ pressure was higher in controls(15.7 ± 10.0 mm Hg) than cases(10.8 ± 9.7 mm Hg). Although statistically significant(P = 0.005), it was a weak predictor using logistic regression and ROC model(AUC = 0.65). Three dysphagia patients had partial compression from external TCV on radiology(1 aberrant subclavian artery, 2 dilated left atrium). The posture(supine vs upright) with more prominent PPZ's impaired bolus clearance in 9 additional cases by > 20%. CONCLUSION Transmitted TCV pulsations observed in HREIM bear no significant impact on swallowing. However, in older adults with dysphagia, evidence of impaired bolus clearance on impedance should be evaluated for external TCV compression. These associations have never been explored previously in literature, and are novel.展开更多
Conventional manometry presents significant challenges,especially in assessment of pharyngeal swallowing,because of the asymmetry and deglutitive movements of oropharyngeal structures.It only provides information abou...Conventional manometry presents significant challenges,especially in assessment of pharyngeal swallowing,because of the asymmetry and deglutitive movements of oropharyngeal structures.It only provides information about intraluminal pressure and thus it is difficult to study functional details of esophageal motility disorders.New technology of solid high resolution impedance manometry(HRIM),with 32 pressure sensors and 6 impedance sensors,is likely to provide better assessment of pharyngeal swallowing as well as more information about esophageal motility disorders.However,the clinical usefulness of application of HRIM in patients with oropharyngeal dysphagia or esophageal dysphagia is not known.We experienced a case of Huntington's disease presenting with both oropharyngeal and esophageal dysphagia,in which HRIM revealed the mechanism of oropharyngeal dysphagia and provided comprehensive information about esophageal dysphagia.展开更多
There have been some breakthroughs in the diagnosis and treatment of esophageal achalasia in the past few years.First,the introduction of high-resolution manometry with pressure topography plotting as a new diagnostic...There have been some breakthroughs in the diagnosis and treatment of esophageal achalasia in the past few years.First,the introduction of high-resolution manometry with pressure topography plotting as a new diagnostic tool has made it possible to classify achalasia into three subtypes.The most favorable outcome is predicted for patients receiving treatment for type Ⅱ achalasia (achalasia with compression).Patients with typeⅠ(classic achalasia) and type Ⅲ achalasia (spastic achalasia) experience a less favorable outcome.Second,the first multicenter randomized controlled trial published by the European Achalasia Trial group reported 2-year follow-up results indicating that laparoscopic Heller myotomy was not superior to endoscopic pneumatic dilation (PD).Although the follow-up period was not long enough to reach a convincing conclusion,it merits the continued use of PD as a generally available technique in gastroenterology.Third,the novelendoscopic technique peroral endoscopic myotomy is a promising option for treating achalasia,but it requires increased experience and cautious evaluation.Despite all this good news,the bottom line is a real break-through from the basic studies to identify the actual cause of achalasia that may impede treatment success is still anticipated.展开更多
AIM To investigate the relationship between pathological oropharyngeal(OP) acid exposure and esophageal motility in patients with extra-esophageal syndromes.METHODS In this prospective study we enrolled consecutive ou...AIM To investigate the relationship between pathological oropharyngeal(OP) acid exposure and esophageal motility in patients with extra-esophageal syndromes.METHODS In this prospective study we enrolled consecutive outpatients with extra-esophageal symptoms suspected to be related to gastroesophageal reflux disease(GERD). We enrolled only patients with a reflux symptom index(RSI) score-higher than 13 and with previous lung, allergy and ear, nose and throat evaluations excluding other specific diagnoses. All patients underwent 24-h OP pH-metry with the Dx probe and esophageal highresolution manometry(HRM). Patients were divided into two groups on the basis of a normal or pathological p H-metric finding(Ryan Score) and all manometric characteristics of the two groups were compared.RESULTS We examined 135 patients with chronic extra-esophageal syndromes. Fifty-one were considered eligible for the study. Of these, 42 decided to participate in the protocol. Patients were divided into two groups on the basis of normal or pathological OP acid exposure. All the HRM parameters were compared for the two groups. Significant differences were found in the median upper esophageal sphincter resting pressure(median 71 mmH g vs 126 mmH g, P = 0.004) and the median proximal contractile integral(median 215.5 cm·mmH g·s vs 313.5 cm·mmH g·s, P = 0.039), both being lower in the group with pathological OP acid exposure, and the number of contractions with small or large breaks, which were more frequent in the same group. This group also had a larger number of peristaltic contractions with breaks in the 20 mm Hg isobaric contour(38.7% vs 15.38%, P < 0.0001).CONCLUSION In patients with suspected GERD-related extraesophageal syndromes pathological OP acid exposure was associated with weaker proximal esophageal motility.展开更多
Esophageal achalasia is a chronic and progressive motility disorder characterized by absence of esophageal body peristalsis associated with an impaired relaxation of lower esophageal sphincter(LES) and usually with an...Esophageal achalasia is a chronic and progressive motility disorder characterized by absence of esophageal body peristalsis associated with an impaired relaxation of lower esophageal sphincter(LES) and usually with an elevated LES pressure, leading to an altered passage of bolus through the esophago-gastric junction. A definitive cure for achalasia is currently unavailable. Palliative treatment options provide only food and liquid bolus intake and relief of symptoms. Endoscopic therapy for achalasia aims to disrupt or weaken the lower esophageal sphincter. Intra-sphincteric injection of botulinum toxin is reserved for elderly or severely ill patients. Pneumatic dilation provides superior results than botulinum toxin injection and a similar mediumterm efficacy almost comparable to that attained after surgery. Per oral endoscopic myotomy is a promising option for treating achalasia, but it requires increased experience and further objective and long-term follow up. This article will review different endoscopic treatments in achalasia, and summarize the short-term and long-term outcomes.展开更多
文摘Gastroesophageal reflux disease (GERD) is one of the most commonlyencountered digestive diseases in the world, with the prevalence continuing toincrease. Many patients are successfully treated with lifestyle modifications andproton pump inhibitor therapy, but a subset of patients require more aggressiveintervention for control of their symptoms. Surgical treatment with fundoplicationis a viable option for patients with GERD, as it attempts to improve the integrityof the lower esophageal sphincter (LES). While surgery can be as effective asmedical treatment, it can also be associated with side effects such as dysphagia,bloating, and abdominal pain. Therefore, a thorough pre-operative assessment iscrucial to select appropriate surgical candidates. Newer technologies arebecoming increasingly available to help clinicians identify patients with true LESdysfunction, such as pH-impedance studies and high-resolution manometry(HRM). Pre-operative evaluation should be aimed at confirming the diagnosis ofGERD, ruling out any major motility disorders, and selecting appropriate surgicalcandidates. HRM and pH testing are key tests to consider for patients with GERDlike symptoms, and the addition of provocative measures such as straight legraises and multiple rapid swallows to HRM protocol can assess the presence ofunderlying hiatal hernias and to test a patient’s peristaltic reserve prior tosurgery.
文摘AIM To investigate the behavior of pulsatile pressure zones(PPZ's) as noted on high resolution esophageal impedance manometry(HREIM), and determine their association with dysphagia.METHODS Retrospective, single center case control design scr-eening HREIM studies for cases(dysphagia) and controls(no dysphagia). Thoracic radiology studies were reviewed further in cases for(thoracic cardiovascular) thoracic cardiovascular(TCV) structures in esophageal proximity to compare with HREIM findings. Manometric data was collected for number, location, axial length, PPZ pressure and esophageal clearance function(impedance). RESULTS Among 317 screened patients, 56% cases and 64% controls had PPZ's. Fifty cases had an available thoracic radiology comparison. The distribution of PPZ's in these 50 cases and 59 controls was similar(average 1.4 PPZ/patient). Controls(mean 31.2 ± SD 12 years) were a significantly younger population than cases(mean 67.3 ± SD 14.9 years) with P < 0.0001. The upright posture PPZ pressure was higher in controls(15.7 ± 10.0 mm Hg) than cases(10.8 ± 9.7 mm Hg). Although statistically significant(P = 0.005), it was a weak predictor using logistic regression and ROC model(AUC = 0.65). Three dysphagia patients had partial compression from external TCV on radiology(1 aberrant subclavian artery, 2 dilated left atrium). The posture(supine vs upright) with more prominent PPZ's impaired bolus clearance in 9 additional cases by > 20%. CONCLUSION Transmitted TCV pulsations observed in HREIM bear no significant impact on swallowing. However, in older adults with dysphagia, evidence of impaired bolus clearance on impedance should be evaluated for external TCV compression. These associations have never been explored previously in literature, and are novel.
文摘Conventional manometry presents significant challenges,especially in assessment of pharyngeal swallowing,because of the asymmetry and deglutitive movements of oropharyngeal structures.It only provides information about intraluminal pressure and thus it is difficult to study functional details of esophageal motility disorders.New technology of solid high resolution impedance manometry(HRIM),with 32 pressure sensors and 6 impedance sensors,is likely to provide better assessment of pharyngeal swallowing as well as more information about esophageal motility disorders.However,the clinical usefulness of application of HRIM in patients with oropharyngeal dysphagia or esophageal dysphagia is not known.We experienced a case of Huntington's disease presenting with both oropharyngeal and esophageal dysphagia,in which HRIM revealed the mechanism of oropharyngeal dysphagia and provided comprehensive information about esophageal dysphagia.
文摘There have been some breakthroughs in the diagnosis and treatment of esophageal achalasia in the past few years.First,the introduction of high-resolution manometry with pressure topography plotting as a new diagnostic tool has made it possible to classify achalasia into three subtypes.The most favorable outcome is predicted for patients receiving treatment for type Ⅱ achalasia (achalasia with compression).Patients with typeⅠ(classic achalasia) and type Ⅲ achalasia (spastic achalasia) experience a less favorable outcome.Second,the first multicenter randomized controlled trial published by the European Achalasia Trial group reported 2-year follow-up results indicating that laparoscopic Heller myotomy was not superior to endoscopic pneumatic dilation (PD).Although the follow-up period was not long enough to reach a convincing conclusion,it merits the continued use of PD as a generally available technique in gastroenterology.Third,the novelendoscopic technique peroral endoscopic myotomy is a promising option for treating achalasia,but it requires increased experience and cautious evaluation.Despite all this good news,the bottom line is a real break-through from the basic studies to identify the actual cause of achalasia that may impede treatment success is still anticipated.
文摘AIM To investigate the relationship between pathological oropharyngeal(OP) acid exposure and esophageal motility in patients with extra-esophageal syndromes.METHODS In this prospective study we enrolled consecutive outpatients with extra-esophageal symptoms suspected to be related to gastroesophageal reflux disease(GERD). We enrolled only patients with a reflux symptom index(RSI) score-higher than 13 and with previous lung, allergy and ear, nose and throat evaluations excluding other specific diagnoses. All patients underwent 24-h OP pH-metry with the Dx probe and esophageal highresolution manometry(HRM). Patients were divided into two groups on the basis of a normal or pathological p H-metric finding(Ryan Score) and all manometric characteristics of the two groups were compared.RESULTS We examined 135 patients with chronic extra-esophageal syndromes. Fifty-one were considered eligible for the study. Of these, 42 decided to participate in the protocol. Patients were divided into two groups on the basis of normal or pathological OP acid exposure. All the HRM parameters were compared for the two groups. Significant differences were found in the median upper esophageal sphincter resting pressure(median 71 mmH g vs 126 mmH g, P = 0.004) and the median proximal contractile integral(median 215.5 cm·mmH g·s vs 313.5 cm·mmH g·s, P = 0.039), both being lower in the group with pathological OP acid exposure, and the number of contractions with small or large breaks, which were more frequent in the same group. This group also had a larger number of peristaltic contractions with breaks in the 20 mm Hg isobaric contour(38.7% vs 15.38%, P < 0.0001).CONCLUSION In patients with suspected GERD-related extraesophageal syndromes pathological OP acid exposure was associated with weaker proximal esophageal motility.
文摘Esophageal achalasia is a chronic and progressive motility disorder characterized by absence of esophageal body peristalsis associated with an impaired relaxation of lower esophageal sphincter(LES) and usually with an elevated LES pressure, leading to an altered passage of bolus through the esophago-gastric junction. A definitive cure for achalasia is currently unavailable. Palliative treatment options provide only food and liquid bolus intake and relief of symptoms. Endoscopic therapy for achalasia aims to disrupt or weaken the lower esophageal sphincter. Intra-sphincteric injection of botulinum toxin is reserved for elderly or severely ill patients. Pneumatic dilation provides superior results than botulinum toxin injection and a similar mediumterm efficacy almost comparable to that attained after surgery. Per oral endoscopic myotomy is a promising option for treating achalasia, but it requires increased experience and further objective and long-term follow up. This article will review different endoscopic treatments in achalasia, and summarize the short-term and long-term outcomes.
