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PubMed2004

Rumination documented by using combined multichannel intraluminal impedance and manometry.

According to the Rome criteria, rumination is considered to be an esophageal functional disorder. Because documentation of rumination is difficult, it has been suggested that rumination is a clinical diagnosis. Even though a clinical diagnosis of rumination can be based only on history, this conclusion often leaves both the patient and the physician dissatisfied. In this article we describe the case of a 26-year-old man referred for evaluation of persistent regurgitation. By using combined multichannel intraluminal impedance and manometry we were able to document the sequence of events leading to regurgitation. These include an increase in intra-abdominal pressure identified in the pressure transducer located in the stomach, which initiates the reflux event identified by both impedance changes as well as common cavity phenomenon, followed by peristaltic fore contractions, which clear the intraesophageal content, a pattern highly suggestive for rumination. The opportunity to review these documented changes visually helps to make the patient aware of the functional aspects of the condition, avoiding unwarranted therapies and providing the opportunity to reinforce behavioral modifications.

Adolescent↗
PubMed2001

Jejunal manometry predicts tube feeding intolerance in the postoperative period.

Postoperative nutrition is best provided enterally; however, patients often develop intolerance to enteral feedings. Our aim was to prospectively identify abdominal examination and jejunal pressure activity associated with postoperative intolerance of enteral feedings. Twenty-nine patients underwent abdominal operation and needle catheter jejunostomy placement. Elemental tube feedings were started on the day after surgery and advanced to the caloric goal rate over three days. Patients whose feedings were slowed at the attending surgeon's discretion were defined as intolerant. Jejunal manometry and a standardized abdominal exam were performed on postoperative days 1, 3, and 5. Fifteen patients (52%) were intolerant of tube feedings and had decreased jejunal motor activity but more active bowel sounds prior to feedings. After feedings, intolerant patients developed abdominal distension, but other abdominal findings were inconsistent. A marked decrease in phase II of the migrating motility complex (MMC) and the lack of a fed response were present in both groups. The overall jejunal motility present on day 1 following surgery identifies patients that will not tolerate enteral feedings. The abdominal examination, MMC parameters, and motor response to feeding did not predict feeding intolerance.

Colectomy↗
PubMed1997

Ambulatory small intestinal manometry. Detailed comparison of duodenal and jejunal motor activity in healthy man.

The aim of this study were to provide a detailed comparison of duodenal and jejunal motor activity in healthy individuals by utilizing prolonged ambulatory manometry in combination with computer-aided analysis. Intraluminal pressure profiles were studied in the duodenum and jejunum of 18 healthy volunteers over 24 hr. The subjects ingested two meals, both of 800 kcal and of equal chemical composition, at two different times of the day. Over the whole interdigestive period, phase III motor activity started more frequently distal than proximal to the ligament of Treitz. However, an increasing time of fasting was linearly related to an increasing number of phase IIIs originating proximal to the ligament of Treitz (r = 0.95). Both meals induced a postprandial motor pattern of similar duration and contractile activity. As compared to the jejunum, individual duodenal contractions during the postprandial period and during phase II had a higher duration and amplitude. Propagated clustered contractions occurred more frequently in the duodenum than in the jejunum, both in the interdigestive and digestive state. Jejunal clusters comprised a higher number of individual contractions of lower amplitude and duration. In healthy man duodenal and jejunal motor activity are different, both in the digestive and interdigestive state. The differences include the number of activity fronts traversing these segments of the gut, the number and organization of propagated clustered contractions, and subtle changes in the amplitude, duration, and coordinated propagation of individual contractions. These changes presumably reflect a regulatory capability of the small intestine to modulate the rate of transit of intraluminal content through different segments of the gut.

Adult↗
PubMed2004

Evaluation of the upper esophageal sphincter (UES) using simultaneous high-resolution endoluminal sonography (HRES) and manometry.

The aim of this study was to characterize the motion, morphology, and pressure of the upper esophageal sphincter (UES). The UES and its surrounding structures were evaluated in seven normal subjects and four human cadavers, using simultaneous high-resolution endoluminal sonography and manometry. The UES musculature on ultrasound is a C-shaped structure with an angle of 107 +/- 19 degrees. The mean peak resting UES pressure was 74 mm Hg, with a total cross-sectional area (CSA) of 0.87 +/- 0.33 cm2. During swallowing, the UES moved in an orad direction. Localizing the UES sonographically, the peak UES pressure in the cadavers was 19.7 +/- 10.0 mm Hg. The UES has a greater muscular CSA and resting pressure than the upper esophageal body. In the cadaver studies, the UES was imaged in conjunction with a significant increase in pressure, indicating that the pressure is due to passive mechanical conformational changes.

Adult↗
PubMed1997

Heretical thoughts about food hypersensitivity: small bowel manometry as an objective way to document gut reactions.

BACKGROUND: Food hypersensitivity is a frequent complaint by both pediatric and adult subjects. However, notwithstanding patient' belief about 'allergies' related to food stuffs, only a minority of them have actually such a diagnosis substantiated. Moreover, the diagnostic approach to these problems is cumbersome and unsatisfactory, and the objectivation of a food hypersensitivity is often difficult. PATIENTS AND METHODS: For these reasons we studied by means of small bowel manometry a small group of patients with food hypersensitivity, and showed abnormal fasting and postprandial findings in those with the gut as a target organ on clinical grounds. RESULTS: Manometric abnormalities were somewhat similar to those previously described in celiac disease, a well recognized food allergy disease. The possible usefulness of this technique in the investigative approach of food hypersensitivity is discussed.

Adult↗
PubMed1997

Ambulatory long-term jejunal manometry in diabetic patients with cardiac autonomic neuropathy.

Concerning alteration of small bowel motility in diabetic patients with autonomic neuropathy controversial data were obtained with stationary manometry and over a limited period of time. The aim of our study was to examine ambulatory 24 h jejunal motility in 15 diabetic patients with cardiac autonomic neuropathy compared with data obtained in 50 healthy controls. Twenty-four hour motility was recorded in the proximal jejunum with a portable datalogger and tube-mounted miniature pressure sensors. Diurnal and nocturnal fasting motility and the motor response to a standardized evening meal of 600 kcal were evaluated by visual and computer-aided analysis. The following abnormalities were found during fasting motility (n = number of patients): absence of phase III over 24 h (n = 2), retrograde migration or simultaneous occurrence of phase III (n = 5). During postprandial motility irregular bursts with tonic baseline elevation (n = 3) and contraction frequencies below the range of controls (n = 8) occurred. Furthermore patients exhibited an inversion of the normal relationship between phase I and phase II during nocturnal MMC-cycles, and discrete clustered contractions were diminished (P < 0.01) in the fasting and digestive state. All patients showed at least one abnormal manometric finding. We conclude that small bowel motility in diabetic autonomic neuropathy is characterized by disturbances in the generation and aboral migration of phase III, an altered circadian variability of the MMC cycle and by postprandial hypomotility.

Adult↗
PubMed2002

Periodic colonic motor activity identified by 24-h pancolonic ambulatory manometry in humans.

The pattern of colonic motor activity in healthy humans has not been fully elucidated to date. The aim of this study was to evaluate colorectal motor activity employing 24-h ambulant pancolonic manometry. Ten healthy volunteers (6F, 4M), aged 19-31 years were studied. Motor activity was measured using two custom-made silicone coated catheters, each with five solid-state pressure transducers. No bowel preparation or sedation was used. The study period was 24 h. A total of 232 h of recording was obtained. Sixty-three high amplitude propagated contractions were observed, median six per 24-h period. Low-amplitude colonic contractile activity showed regional and diurnal variations. Frequency of contraction was highest in the right colon [median 5.26 cpm (cycles per minute)], and transverse colon and splenic flexure (median 5.15 cpm). The interval between colonic motor complexes was shortest in the transverse colon and splenic flexure. This study introduces a new technique for the evaluation of colorectal motor activity. Subjects were studied in an ambulant setting in their own environment ensuring that this method of study is as physiological as possible. This study demonstrates that colonic motor activity has two main components: high amplitude propagated contractions and low amplitude colonic contractile activity.

Adult↗
PubMed2002

Human duodenal phase III migrating motor complex activity is predominantly antegrade, as revealed by high-resolution manometry and colour pressure plots.

Abstract Late phase III migrating motor complex activity has been said to be primarily retroperistaltic but has not been assessed with high resolution manometry or three-dimensional colour pressure plots (pressure/time/distance). Duodenal phase III was examined in healthy young volunteers (seven male, two female) with a 20-lumen assembly. With the most proximal sidehole in the distal antrum, after a 4.5-cm interval 18 sideholes at 1.5-cm intervals spanned the duodenum with a final sidehole 3 cm beyond. Fasting pressures were recorded until phase III occurred. Comparisons were made between proximal (P) and distal (D) duodenum during early (E) (first 0.5-1 min) and late (L) (last 0.5-1 min) phase III. With colour pressure analysis, 121 of 180 pressure wave (PW) sequences were purely antegrade, two purely retrograde and 57 bidirectional. Ten of fifty-seven bidirectional PW sequences were complex, branching to become two separate sequences. Bidirectional sequences occurred more frequently in late than early phase III (L 43 vs. E 14 of 57), but their occurrence did not differ between proximal and distal duodenum (P31 vs. D 24 of 57). Antegrade propagation velocity was faster in late compared with early phase III (L 28.50 vs. E 17.05 mm s(-1); P = 0.006), but did not differ between proximal and distal duodenum. Colour pressure analysis also indicated an intermittent segmental pattern to phase III, with each subject exhibiting a change in velocity or direction, or a relative failure of peristalsis somewhere along the duodenum during part of phase III. Duodenal phase III is not homogenous and, in contrast with previous studies, does not primarily constitute a retroperistaltic pump. Colour pressure analysis is useful in interpreting intraluminal pressure profiles and may improve the sensitivity and specificity of clinical studies.

Adult↗
PubMed2003

Colonic motor activity in slow-transit idiopathic constipation as identified by 24-h pancolonic ambulatory manometry.

Colorectal motor activity in slow-transit idiopathic constipation has not been fully evaluated under physiological conditions. The aim of this study was to evaluate colorectal motor activity in chronic idiopathic constipation using 24-h ambulant pancolonic manometry. Ten healthy volunteers (six females) 19-31 years of age, and eight females 25-46 years of age with slow-transit idiopathic constipation were studied. Motor activity was measured using two custom-made silicone-coated catheters, each with five solid-state pressure transducers. Bowel preparation or sedation was not used. Frequency of high-amplitude propagated contractions was reduced in chronic idiopathic constipation, median 1.9/24 h vs 6/24 h (P = 0.01). Contractile frequency of low-amplitude complexes was reduced throughout the colon in slow-transit idiopathic constipation (P < 0.0001). The interval between contractile complexes was reduced in the transverse colon and splenic flexure (P < 0.0001). This study demonstrates that colonic motor activity is abnormal in slow-transit idiopathic constipation; decreased motor activity leads to a reduction in propulsion of intraluminal contents.

Adult↗
PubMed2004

Effect of interval between swallows on oesophageal pressures and bolus movement in normal subjects - Studies with combined multichannel intraluminal impedance and oesophageal manometry.

The effect of closely spaced swallows to decrease peristalsis ('deglutitive inhibition') is believed to be due to both central inhibitory impulses and smooth muscle refractoriness. Ten volunteers (three females, age 26-65) were given both four pairs and two series of four swallows at 5-, 10-, 15-s intervals and control swallows at 30-s intervals. Oesophageal function was assessed using combined multichannel intraluminal impedance and oesophageal manometry (MII-OM). Swallows were considered manometrical effective if distal oesophageal pressures >/=30 mmHg. Complete bolus transit was defined as bolus exiting from all three distal impedance segments. During swallowing at 5-s intervals the majority of initial swallows were ineffective with incomplete bolus transit while the last swallow in both series and pairs was manometrically effective with complete bolus transit. During swallowing at 10-15-s intervals the number of manometric ineffective swallows and swallows with incomplete bolus transit progressively increased with the number of swallows. The functional information obtained by MII-OM indicates pooling of liquid in the distal oesophagus that is cleared by the last swallow determined by, previously reported, neural inhibition occurring during swallowing spaced 5 s apart whereas incomplete bolus transit is related to manometrically ineffective swallows resulting from muscle refractoriness occurring during swallowing at 10-15-s intervals.

Adult↗
PubMed2001

Gastrointestinal transit and anorectal manometry in children with colonic substance P deficiency.

BACKGROUND AND AIMS: Severe intractable constipation in children may be associated with a reduction of substance P (SP)- containing fibers in colonic circular muscle. The aim of this study was to characterize gastrointestinal transit (GIT), anorectal manometry (ARM) and electromyographic (EMG) changes in these children. METHODS: Seromuscular laparoscopic biopsies of the colon were obtained from 35 children with severe constipation. Immunofluorescent staining for SP and vasoactive intestinal peptide (VIP) were then performed on these specimens. The cohort of patients studied included a SP-deficient group (SPD, n = 25) who had reduced numbers of SP-immunoreactive nerve fibers. The other group consisted of patients with normal staining for both SP and VIP (SPN, n = 10). Gastrointestinal transit studies (gastric emptying, orocecal and colonic transit) suitable for analysis were available for 17 patients (SPD, n = 9 and SPN, n = 8). The colon was divided into segments and radioactivity counts in each segment were expressed as a percentage of the total colonic count at each time point (6, 24, 32 and 48 h). The geometric center (GC), ARM, EMG, clinical and demographic data characteristics of both groups of patients were compared. RESULTS: There were no differences in demographic data, gastric emptying, orocecal transit or geometric center of transit in the colon between the two patient groups. The ARM and EMG studies suggested that the SPN group have a higher mean threshold volume of balloon distension required to initiate a rectoanal inhibitory reflex, and a higher incidence of anismus; however, this did not reach statistical significance. CONCLUSIONS: These data suggest a trend that the SPN patients have a greater problem with obstructive defecation and abnormal rectal sensation than those with SPD. We were unable to confirm any defect in colonic transit in the SPD patients compared with the SPN group.

Anal Canal↗
PubMed2006

Transient lower esophageal sphincter relaxations and reflux: mechanistic analysis using concurrent fluoroscopy and high-resolution manometry.

BACKGROUND & AIMS: The aim of this study was to perform a detailed analysis of the mechanics leading to esophagogastric junction (EGJ) opening during transient lower esophageal sphincter relaxations (tLESRs) using high-resolution manometry coupled with simultaneous fluoroscopy. METHODS: Six subjects without hiatus hernia had endoclips placed at the squamocolumnar junction and 10 cm proximal. A 36-channel solid-state manometric assembly was placed spanning from stomach to pharynx, and subjects were studied for 2 hours after a high-fat meal. An esophageal pH electrode also was placed and fluoroscopy was initiated at the onset of a tLESR. Axial clip movement was measured during replay of the videotaped fluoroscopy and was correlated with manometric data. RESULTS: Ninety-three tLESRs were recorded, 62 tLESRs of which had good fluoroscopic visualization. Seventy-eight tLESRs had manometric evidence of flow and the majority had evidence of a common cavity (88%), but few were detected by the pH electrode. Esophageal shortening and crural diaphragm inhibition always preceded EGJ opening and common cavity. A positive pressure gradient between the stomach and the EGJ lumen of 7.1 mm Hg (interquartile range, 4.1-9.1 mm Hg) preceded the EGJ opening. CONCLUSIONS: Key events leading to the EGJ opening during tLESRs were LES relaxation, crural diaphragm inhibition, esophageal shortening, and a positive pressure gradient between the stomach and the EGJ lumen. The manometric signature of opening was pressure equalization within the EGJ, but this only occasionally was associated with pH evidence of reflux. Future investigations will need to analyze how this delicately balanced anatomic-physiologic system is perturbed in subjects with reflux disease.

Adult↗
PubMed1977

A new catheter for endoscopic manometry of Oddi's sphincter.

With a newly designed manometry catheter and a modified pull-through maneuver a high presure zone can reproducibly be recorded between the duodenum and the pancreato-biliary tree corresponding to Oddi's sphincter. Catheter marking allows in addition calculation of the length of this zone. Since the sealed end of the catheter remains during pressure recording within the ductal system repeated push-and-pull maneuvres can be performed through the sphincter area.

Ampulla of Vater↗
PubMed2006

Nonendoscopic transnasal placement of a wireless capsule for esophageal pH monitoring: feasibility, safety, and efficacy of a manometry-guided procedure.

BACKGROUND AND STUDY AIMS: The aim of the study was to evaluate the safety, feasibility, and efficacy of transnasal placement of the Medtronic Bravo capsule for wireless esophageal pH monitoring. PATIENTS AND METHODS: Forty patients with symptomatic gastroesophageal reflux disease were prospectively evaluated. All patients underwent upper gastrointestinal endoscopy and esophageal manometry. The Bravo capsule was then introduced transnasally and released 5 cm above the upper margin of the lower esophageal sphincter. Serial radiographs were performed weekly until capsule release. RESULTS: Of the 40 patients who were evaluated, 38 (95 %) were eligible to undergo the procedure. Transnasal placement proved impossible in one patient (2.5 %). Overall, a total of 39 procedures were performed in 38 patients (the procedure was repeated in one patient because of accidental intragastric fixation). Esophageal placement was successful in 36/39 procedures (92.3 %). The mean duration of the procedure was 10 minutes (range 5 - 16 minutes). Adverse events were noted in five of the 39 procedures (12.8 %), mild epistaxis in two patients (5.1 %) and pharyngeal irritation in three patients (7.7 %). After the procedure, a slight "foreign body" sensation was reported by 20 of the 36 patients (55.5 %) who had undergone successful esophageal placement; two patients (5.5 %) experienced severe retrosternal pain necessitating endoscopic removal of the capsule. At the end of the study, 34 of the 38 patients (89.5 %) stated that they would be willing to undergo the test again if necessary. CONCLUSIONS: Transnasal placement of the Bravo pH capsule is safe, well tolerated, does not require sedation, and avoids endoscopy and its complications.

Adult↗
PubMed1994

Dynamic endoscopic manometry of the response to secretin in patients with chronic pancreatitis.

Endoscopic manometry of the sphincter of Oddi and the main pancreatic duct (MPD) was performed before and after intravenous injection of secretin (1 CU/kg) in 15 control subjects and 19 patients with chronic pancreatitis. Secretin significantly but transiently enhanced the MPD pressure in the controls, whereas chronic pancreatitis patients had an elevated basal MPD pressure and a manometric pattern of sphincter of Oddi dyskinesia. The secretin-induced MPD pressure was also elevated and more sustained in chronic pancreatitis patients compared to controls. No influence of the etiology or MPD ductal diameter was found, but the duration of the disease correlated significantly to the pressure response to secretin in patients. The pressure enhancement was most impressive in chronic pancreatitis of recent onset (less than four years), whereas it was minimal or normal in later stages of the disease. This dynamic manometric test reliably demonstrates sphincter of Oddi dysfunction and an altered response to secretin. The test could have a role to play in the explanation of progressive MPD dilatation as well as in the early diagnosis of chronic pancreatitis.

Adolescent↗
PubMed1993

The clinical need for sphincter of Oddi manometry in gastrointestinal endoscopy units.

The clinical need for sphincter of Oddi manometry (SOM) was investigated by retrospective analysis of 736 consecutive endoscopic retrograde cholangiopancreatography (ERCP) referrals (1985-89). During this period SOM was not performed in any unit in Greece including our own. Assuming a conservative or a more liberal policy in the utilization of SOM, a biliary and a pancreatic group of patients were established respectively, depending on the clinical presentation. ERCP was diagnostic in 168/194 (86.6%) of patients referred for post-cholecystectomy symptoms, but SOM was considered to be necessary to establish a diagnosis in the remaining 26 (13.4%) patients (biliary group). ERCP revealed pancreatic and/or biliary pathology in 46/69 (66.7%) patients, referred for symptoms attributed to pancreatitis, but 11/69 (15.9%) patients with pancreas divisum and 12/69 (17.4%) with acute recurrent idiopathic pancreatitis may have benefitted from SOM for planning endoscopic therapy (pancreatic group). Thus, only 5 patients from each group per 147 ERCP annual referrals were candidates for SOM. When taking into account that to run a SOM service the minimum annual number of investigations should be 50 and that the provision of ERCP in the UK is 50 per 100,000 of population per year, it is extrapolated that such a Gastrointestinal Endoscopy Unit should serve a population of 1.5 to 3 million.

Aged↗
PubMed1991

Endoscopic manometry of the sphincter of Oddi and pancreatic duct in patients with papillary stenosis.

The function of the sphincter of Oddi (SO) in patients with papillary stenosis was evaluated using endoscopic manometry to determine its possible contribution to pancreatic dysfunction. A total of 30 patients with papillary stenosis were divided into two groups according to the pattern of narrowing of the sphincter zone observed in ERCP studies: group A, a mild form, and group B, a severe form. Group C (control) comprised 12 subjects with no abnormality of the pancreas or biliary system. The SO contraction pressure was significantly higher in group A (115.1 mmHg) than in groups B (79.2) and C (91.1). The SO basal pressure in groups A (11.5 mmHg) and B (10.3) was significantly higher than in group C (5.8). The pancreatic duct pressure in group A (15.5 mmHg) was significantly higher than in group C (9.7), while group B (11.1) showed an intermediate value. The increase in pancreatic duct pressure following intravenous secretin was significantly greater in groups A and C than in B. The BT-PABA test in groups A and C revealed a normal value in contrast to group B. A significant correlation was observed between these two factors. The function of both the SO and the pancreas thus appears to be abnormal in patients with severe narrowing of the SO and papillary stenosis.

Adult↗
PubMed1982

The presence of a positive pressure gradient from pancreatic duct to choledochal cyst demonstrated by duodenoscopic microtransducer manometry: clue to pancreaticobiliary reflux.

A case of choledochal cyst is presented. The diagnosis was established by endoscopic retrograde cholangiopancreatography, which also demonstrated that the common bile duct joined the pancreatic duct at an abnormally long distance from the papilla. Duodenoscopic manometry using a microtransducer catheter showed that the pressure in the pancreatic duct was higher than that in the choledochal cyst by 1.1 mmHg. The cyst-to-duodenum pressure gradient of 3.5 mmHg was not different from the common duct-to-duodenum gradient in patients with other common biliary tract diseases, making the presence of a stenosis as an etiology of this entity unlikely. The bile aspirated from the gallbladder had an extremely high amylase content, suggesting influx of the pancreatic juice into the biliary system. The pancreaticobiliary reflux caused by the positive pressure gradient from the pancreatic duct to the choledochal cyst may be related to the development of the disease.

Bile Reflux↗