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PubMed1987

Scintigraphic detection of metoclopramide esophageal stimulation in progressive systemic sclerosis.

Supine radionuclide esophageal scintigraphy (RES) and manometry were used to prospectively evaluate metoclopramide effect on esophageal function and pressure amplitudes in 14 patients (12 females and two males; median time since diagnosis: 2 yr) with progressive systemic sclerosis (PSS). Quantitation of RES included calculation of percent emptying at 30 sec, and standard manometric measurements were obtained. RES and manometry were performed before and 10 min following the i.v. administration of metoclopramide. RES showed a significant increase in mean percent emptying from 36% to 46% after drug administration (p less than 0.01), while mean lower esophageal pressure (end-expiratory) increased from 2 to 11 mm of Hg (p less than 0.001). Manometry failed to reveal a significant increase in either distal or proximal mean esophageal contractile amplitude, and no correlation was found between the increase in percent emptying at RES and the change in lower esophageal pressure in the individual patient. RES is the only quantitative method presently available to evaluate bolus propagation in the esophagus, and it documented improved esophageal function after metoclopramide administration in a PSS population. When drug therapy is directed at augmentation of esophageal emptying, RES is an ideal method to evaluate drug response.

Adult↗
PubMed1987

The ergometrine test: effects on esophageal motility in patients with chest pain and normal coronary arteries.

Ergometrine can evoke coronary spasm in patients with variant angina. The cause of ergometrine-induced chest pain in the absence of coronary spasm is not clear. To determine whether ergometrine produced esophageal dysfunction and chest pain, we evaluated 28 patients by esophageal manometry. Six had chest pain in response to ergometrine during cardiac catheterization (group I) and 22 did not (group II). Results of cardiac catheterization were normal in all patients. Seven volunteers with no history of chest pain formed a control group (group III). Esophageal manometry was performed before and after ergometrine administration (0.4 mg I.V.). Ergometrine provocation during esophageal manometry caused significant deterioration in esophageal motility associated with familiar pain in 5/6 group 1 patients. The motility disorders were characterized by repetitive contracts of high amplitude and long duration in the distal esophagus. No patient from group II or III experienced chest pain after ergometrine and only 2 from group II developed long duration contractions. Thus, we conclude that in patients with normal coronary angiograms, ergometrine-induced chest pain without associated coronary spasm suggests that esophageal motility disorders originate chest pain.

Angina Pectoris↗
PubMed1987

Radionuclide esophageal emptying and manometric studies in diabetes mellitus.

Esophageal function was prospectively studied in 50 consecutive insulin-requiring diabetes mellitus patients. The patients were stratified in three groups: A) 18 without peripheral neuropathy (PN); B) 20 with PN but no autonomic neuropathy; C) 12 with PN and autonomic neuropathy. Twelve patients (four B, eight C) had gastrointestinal symptoms including six with dysphagia. Radionuclide esophageal emptying was abnormal in 55, 70, and 83% of patients in groups A, B, and C, respectively. Eleven of the 12 (92%) symptomatic and 23 of the 38 (60%) asymptomatic diabetes mellitus patients had abnormal emptying. Five of six patients with dysphagia had abnormal emptying. Esophageal manometry was also performed in 15 patients. Twelve patients had abnormal manometry. These included nutcracker esophagus in two, achalasia in one, and increased percentage of multipeaked and simultaneous contractions in nine. There were no significant correlations between radionuclide esophageal emptying, manometric changes and symptoms. Gastrointestinal symptoms were more common in the presence of autonomic neuropathy. Delayed esophageal emptying was more profound in the presence of PN, but abnormal esophageal emptying was present in patients with neuropathy as commonly as patients without. Furthermore, the presence of diabetic retinopathy, duration or control of diabetics, and fasting blood sugar did not influence the frequency of abnormal esophageal emptying. Our data indicate that esophageal dysfunction is common in male diabetics even in the absence of clinical PN and retinopathy, suggesting that diabetic gastroenteropathy can occur in the absence of significant diabetic complications. Commonly observed abnormal esophageal manometry in diabetics is not necessarily accompanied by significant functional disturbances or symptoms.

Autonomic Nervous System Diseases↗
PubMed1987

Specificity and sensitivity of objective diagnosis of gastroesophageal reflux disease.

To evaluate the diagnostic value of different tests for gastroesophageal reflux disease, a test population was constructed from 45 patients with symptoms of heartburn and regurgitation with or without esophagitis and 45 healthy subjects, who never experienced heartburn, regurgitation, or swallowing discomfort. The test population underwent esophagoscopy, standard acid reflux test, 24-hour pH monitoring, and manometry of the lower esophageal sphincter. Sensitivity, specificity, positive predictive value, negative predictive value, and the accuracy of the tests and test combinations were calculated. Esophagoscopy had a sensitivity of 62%, that is, only 62% of patients with the disease have evidence of mucosal damage on endoscopy. Manometric measurements of the lower esophageal sphincter had a sensitivity of 84%, a specificity of 89%, and an accuracy of 87%. Twenty-four hour esophageal pH monitoring had a sensitivity, specificity, and accuracy of 96%. The results show that 24-hour pH monitoring can detect gastroesophageal reflux disease with an accuracy of 96% by measuring an increase in esophageal acid exposure. Manometry of the lower esophageal sphincter can detect a mechanically deficient sphincter as a cause of the disease with an accuracy of 87%. The test combination of 24-hour monitoring and motility studies can select patients with an accuracy of 91% who have an increase in esophageal exposure to gastric juice because of a deficient cardia. Antireflux surgery is designed to reduce esophageal exposure to gastric juice in patients with a deficient sphincter by creating a mechanical antireflux mechanism at the cardia. Therefore it is necessary to determine the mechanical status of the sphincter with manometry before surgery in such patients. Thus the indications for antireflux surgery are (1) uncontrolled symptoms of increased esophageal exposure to gastric juice; (2) a documented increase in esophageal exposure to gastric juice by 24-hour pH monitoring; and (3) a mechanically defective sphincter on motility with a pressure of 6 mm Hg or less, an overall length of 2 cm or less, and an abdominal length of 1 cm or less.

Esophagoscopy↗
PubMedDate not supplied

Esophageal dysfunction in patients with progressive systemic sclerosis and mixed connective tissue diseases.

Esophageal motility was studied in 37 patients with progressive systemic sclerosis (PSS), 12 patients with mixed connective tissue disease (MCTD) and 40 controls by the manometry method, using an open tube and continuous perfusion, and by radiological examination. Radiology was normal in 17 patients with PSS and five patients with MCTD, and abnormal in 15 patients with PSS and three with MCTD. The most frequent abnormality was slow transit time of barium. Manometry of the esophageal body was normal in 20 patients with PSS and six patients with MCTD, and abnormal in 17 patients with PSS and six with MCTD. Lack of contraction in the middle lower segments of the esophagus was the abnormality most frequently observed. Lower esophageal sphincter pressure was significantly lower among patients with PSS and MCTD than among the controls. Dysphagia was reported by ten patients with PSS and by six patients with MCTD. Radiology and manometry showed similar changes in PSS and MCTD, but dysphagia was more frequent among patients with MCTD.

Adolescent↗
PubMed1985

Radionuclide esophageal transit in progressive systemic sclerosis.

Twenty-three patients with progressive systemic sclerosis (PSS) were studied by radionuclide esophageal transit (RT) and esophageal manometry. Twenty-two patients had abnormal manometry ranging from lower esophageal sphincter incompetence to aperistaltism. Of these 22 patients, twenty (91%) had abnormal RT with prolongation of transit time. A characteristic RT pattern showing stagnation of the radionuclide in the distal and middle segments of the esophagus was demonstrated in 82% of the patients with advanced sclerodermatous involvement of the esophagus. Fifteen of the 19 controls (79%) studied had a normal RT. Four showed prolongation of transit time without stagnation. We conclude that RT is a safe, noninvasive, highly sensitive method which might be used as an alternative to esophageal manometry. However, it may lack specificity.

Adolescent↗
PubMed1983

Gastroesophageal reflux--reassessment of the value of fluoroscopy based on manometric evaluation of the lower esophageal segment.

The value of fluoroscopic gastroesophageal reflux examination by barium swallow was assessed in 51 symptomatic patients. Using electronic esophageal manometry, these patients were divided in groups with frank reflux, intermittent reflux, and symptoms of other etiology. Although a high incidence between presence of an hiatal hernia and manometric reflux (0.86) was apparent, fluoroscopy was only able to identify 33% of patients suffering from reflux disease diagnosed on clinical grounds and by electronic manometry. It is concluded that the fluoroscopic test is insufficient to separate patients with reflux disease from those with similar symptoms of other etiology which may be done reliably by esophageal manometry. The role of fluoroscopy is limited to the morphological evaluation of the gastroesophageal junction.

Adult↗
PubMed1983

Biofeedback for neurogenic fecal incontinence: rectal sensation is a determinant of outcome.

Fifteen subjects (ages 5-33 years) with meningomyelocele and fecal incontinence underwent anorectal manometry followed by biofeedback conditioning of the external anal sphincter or nearby gluteal muscles. Seven of the 15 subjects undergoing biofeedback had improvement, defined as a 75% or greater decrease in the frequency of soiling, with a mean follow-up period of 23.1 months (range, 8-30 months). The seven subjects who improved with biofeedback had significantly lower thresholds of rectal sensation (smallest volume of distension perceived) than did the eight nonresponders; all responders had a sensory threshold less than or equal to 20 ml, whereas five of eight nonresponders had thresholds exceeding this level. Twenty-one children (ages 4-17 years) also underwent anorectal manometry, but not biofeedback conditioning, in order to evaluate the relationship of rectal sensation and peripheral neurological deficits. Fifteen of the 36 subjects with meningomyelocele had absent rectal sensation or thresholds exceeding 20 ml; there was no correlation of anorectal manometric parameters and peripheral sensorimotor levels. Response to biofeedback by children with meningomyelocele strongly correlates with rectal sensory thresholds which do not correlate with peripheral sensorimotor levels. If children with meningomyelocele and fecal incontinence are motivated and have adequate strength and coordination of the muscles of the lower extremities, anorectal manometry is the most accurate test to identify those who may benefit from biofeedback conditioning.

Adolescent↗
PubMed1982

Esophageal potential difference measurements in esophageal disease.

To determine if esophageal transmural electrical potential difference measurements are of use for evaluating esophageal disease, we recorded potential difference in 129 patients with one or more of the following: heartburn, dysphagia, and chest pain. All potential difference studies were performed at the time of esophageal manometry using a Ringer-perfused catheter technique which yields accurate and reproducible results in healthy subjects. In 103 of the 129 patients, esophageal potential difference measurements could be correlated with findings at manometry, endoscopy, and biopsy. The remaining 26 patients had primary esophageal motor disease and were not biopsied. The results of this investigation showed: (a) that 94% of patients with gross endoscopic lesions have an abnormal esophageal potential difference, (b) that an abnormal esophageal potential difference (found in only 1 of 24 patients with normal mucosa) is highly specific for the presence of esophageal mucosal disease, (c) that the type of potential difference abnormality may suggest the nature of the mucosal abnormality, for example high potential difference with Barrett's esophagus and low potential difference with esophagitis or invasive carcinoma, and (d) that while an abnormal esophageal potential difference is highly sensitive for detecting gross esophagitis (38 of 40 patients), it is less sensitive for diagnosing microscopic esophagitis (8 of 16 patients). Based on these findings we conclude that the measurement of esophageal potential difference at the time of manometry can provide additional valuable information about the state of the esophageal mucosa.

Action Potentials↗
PubMed1995

[Heller's myotomy by laparoscopic approach for megaesophagus].

The development of laparoscopic surgery has allowed the indications of this technique to be extended to the management of achalasia. Four patients were operated for achalasia confirmed by esophageal manometry. The procedure consisted of laparoscopic Heller's myotomy. The purpose of this paper is to detail the technical principles of this procedure and to evaluate its feasibility. There were no intra-operative incident and no conversion to open procedure. The postoperative course was uneventful in every case. The mean postoperative stay was 5 days. The postoperative manometry (n = 3), performed an average of 14.5 months after the operation, showed a normal lower esophageal sphincter pressure in all cases. Only one patient complained of intermittent dysphagia without food restriction and with normal postoperative manometry. The feasibility of laparoscopic Heller's myotomy is therefore obvious. Consequently, this procedure could replace repeated balloon dilatations in the management of achalasia.

Adult↗
PubMed1994

Endosonography of the anal sphincters: incontinent and continent patients and healthy controls.

It has previously been shown that in healthy subjects anal sphincter functions as assessed by anorectal manometry and anal sphincter anatomy as measured by endoluminal ultrasound are poorly correlated. It remains to be shown, however, whether this is true for a larger series of patients with anorectal dysfunctions such as incontinence, and what is the clinical relevance of anal sonography. Anal sonography was performed in 42 consecutive patients with fecal incontinence, in 19 patients with constipation and/or anal pain, and in 15 healthy volunteers to determine anal sphincter integrity and the dorsal diameter of the internal and external anal sphincter muscles. Conventional multilumen anorectal manometry was performed in all subjects and patients to determine, among others, external and internal sphincter (EAS, IAS) performance at rest and during squeezing. It was shown that healthy subjects exhibit significantly higher muscle diameters of the IAS than both patient groups, but the EAS was similar in all groups. In 11/42 cases of incontinent patients, in 3/19 constipated patients, but in none of the controls a muscle defect of the EAS was found with sonography. Thirteen of these 14 patients were women with previous birth traumas. EAS but not IAS muscle thickness and muscle performance (squeezing and resting, respectively) were significantly correlated. Across all groups, women had smaller EAS muscle diameters than men. It is concluded, that in incontinent patients anal sonography may reveal additional information of clinical relevance in a substantial fraction of patients, and, thus, both anal manometry and anal ultrasound are of clinical value.

Adult↗
PubMed1994

Globus pharyngis, commonly associated with esophageal motility disorders.

OBJECTIVES: To evaluate the role of gastrointestinal and psychiatric etiology in globus sensation. METHODS: The study population consisted of 32 consecutive patients with globus sensation without dysphagia referred to the Department of Otorhinolaryngology in Helsinki University Hospital. Eleven patients were excluded from the study: two because of advanced age, one prisoner, and six patients refused further studies. Only two patients (6%) were found to have abnormal otorhinolaryngological status. These patients were also excluded from the study. Esophagogastroduodenoscopy, 24-h pH recording, esophageal manometry, and Bernstein acid perfusion test were carried out in 21 patients (13 females, eight males, mean age 49 yr). Psychiatric evaluation was done in 20 patients; one patient refused the psychiatric consultation. RESULTS: Abnormal endoscopy was found in 12/21 (57%) of the patients, with antral gastritis and hiatal hernia being the most common findings. Two patients had esophagitis. Sixty-seven percent demonstrated abnormalities in esophageal manometry, the most frequent finding being a nonspecific esophageal motility disorder (29%). pH monitoring was normal in 16/21 of patients (76%), whereas the Bernstein test showed positive results in 13/21 (62%). With DSM IIIR as the diagnostic tool, five of 20 patients (25%) received a psychiatric diagnosis. CONCLUSIONS: Globus sensation has a multiple etiology, and local reasons are rare but should first be ruled out. Abnormalities in esophageal motility are commonly found, and these patients seem to be sensitive to esophageal acidity. Esophageal manometry and ambulatory 24-h pH recording should be included in the evaluation of a globus patient. The number of psychiatric disorders does not differ from that in the general population. Treatment of globus sensation should be directed toward the abnormality found behind the symptom.

Conversion Disorder↗
PubMed1993

[Does manometric megarectum have a symptomatic role in patients complaining of dyschezia?].

UNLABELLED: Adults with dyschezia are occasionally diagnosed as having megarectum when anorectal manometry identifies rectal sensory disturbances. It remains difficult however to ascertain whether this state represents a part of the pathophysiological process responsible for symptoms, or just an associated phenomenon. The aim of this study was to highlight the symptomatic and functional features encountered in patients with dyschezia and megarectum, and to compare them with those obtained in an asymptomatic group and in a group of patients complaining of dyschezia without manometric megarectum. PATIENTS AND METHODS: The maximum tolerable volume (MTV) was defined as the highest tolerable volume which induced painful and irrepressible repletion upon inflation of the rectum with air. The upper normal range of MTV (330 mL) was obtained from rectal manometry performed in a group of 18 healthy volunteers and asymptomatic patients (mean age: 37.8 +/- 14 years, 12 F, 6 M). Between February 90 and February 92, 27 consecutive adults (48 ans +/- 15 years, 26 F, 1 M) suffering from dyschezia were found to have abnormally increased MTV, and were compared to a group of 35 patients (47 +/- 15.3 years, 34 F, 1 M) with dyschezia with MTV within normal ranges. Symptomatic patients underwent detailed interrogation, clinical examination, anorectal manometry, and evacuation proctography. RESULTS: Parity, prevalence of hysterectomy, symptoms and natural history did not differ between the two groups except for increased use of antidepressive agents in the megarectum group.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

Manual verification of computer analysis of 24-hour esophageal motility.

The application of solid-state technology to intraesophageal pressure monitoring over an entire circadian cycle has resulted in large amounts of data that require computer analysis. Recently available commercial software has yet to be validated. The aim of this study was to compare the analysis of ambulatory esophageal manometry by an automated computer program with manual analysis and make the software modifications necessary to validate the automated system for clinical use. Computer-aided analysis of a large number of esophageal contractions recorded during ambulatory esophageal manometry was compared with manual analysis by four experienced physicians. Good correlations were found between manual and computerized measurements of contraction amplitude and duration (r = 0.99 and r = 0.73, respectively). Software modifications resulted in correct identification of 94% of contractions and correct classification of 93.3% of these waves as peristaltic or simultaneous. These results demonstrate that the evaluated program for automated analysis of ambulatory esophageal manometry is accurate and reliable for research and clinical applications.

Circadian Rhythm↗
PubMed1996

Yield pressure: a new concept in the evaluation of GERD?

This study evaluates the yield pressure at the gastroesophageal junction in a group of 73 patients undergoing diagnostic endoscopy and in another group of 82 patients during the course of manometry for suspected GERD. The group included 17 patients who had previously undergone a successful Nissen fundoplication and eight patients who had a failed Nissen fundoplication. Air is insufflated into the stomach, and a water perfused pressure transducer is used to detect intragastric pressure. The pressure at which the cardia was seen to open at endoscopy, or when a common cavity phenomenon was detected at manometry, was taken as the opening pressure. Yield pressure was calculated as the difference between the opening pressure of the cardia and the resting gastric pressure. Results indicated a significant decrease in yield pressure in 65 patients with esophagitis compared with 65 patients with no evidence of reflux or esophagitis. A significant inverse correlation was found between yield pressure and the size of the hiatus hernia noted in these patients. There was also a correlation between valvular appearance of the cardia at endoscopy and the yield pressure. A progressive decrease in yield pressure occurred with an increasing deterioration in the physical appearance of the valve. There was no significant relationship found between yield pressure and lower esophageal sphincter (LES) pressure or intra-abdominal length. A small but significant relationship was found between yield pressure and acid exposure of the lower esophagus. The 17 patients with a successful Nissen showed a significantly increased yield pressure to supranormal values. In contrast, the eight patients with a failed Nissen had yield pressures within the range of the patients with esophagitis. In eight patients, yield pressure was measured by both manometry and endoscopy and showed no significant differences between the two methods.

Esophagogastric Junction↗
PubMedDate not supplied

Manometric assessment of Heller-Dor operation for esophageal achalasia.

BACKGROUND/AIMS: The aim of this study was to evaluate changes occurring in esophageal motility through a systematic manometric study performed before, during and after Heller-Dor operation (8) and to correlate the possible post-operative symptoms to the manometric and pH-recording patterns detected, in order to provide useful elements that may optimize surgical therapy for esophageal achalasia. MATERIALS AND METHODS: Between January 1981 and January 1991, 27 patients affected by esophageal achalasia underwent Heller's operation with Dor's anti-reflux procedure. Assessment involved clinical, radiological and manometric investigations. RESULTS: Intra-operative manometry was performed on 11 patients, in whom LES pressure reached values lower than 5 mmHg. Post-operative control, performed 2 years after operation on 25 patients, showed the complete absence of dysphagia in 22 (88%) and occasional dysphagia in 3 (12%). Post-operative manometry in all the patients showed a decreased LES resting pressure (from 32.6 to 7.2 mmHg, p < 0.001), LES residual pressure (from 16.4 to 5.0 mmHg, p < 0.001) and esophageal tone (from 4.8 to -3.5 mmHg, p < 0.001). Patients free of dysphagia presented LES basal and residual pressures lower than the other patients (6.2 and 4.6 vs 15.1 and 7.7 mmHg respectively, p < 0.01 and p < 0.05). 24-hour-esophageal pH-metry showed pathologic reflux in 3 patients with reflux symptoms and in 1 without symptoms. All had LES basal and residual pressures equivalent to non refluxing patients (5.7 and 5.0 vs 7.5 and respectively 4.9 mmHg, p = n.s. and p = n.s.). On the contrary, a difference was found in abdominal LES length between the two groups (0.5 vs 1.6 cm, p < 0.01). Patients with intra-operative manometry presented a lower incidence of residual dysphagia than patients without it (0% vs 21.5%), but a higher incidence of reflux (18.2% vs 7.3%). CONCLUSION: Heller-Dor operation induces a definitive disappearance of dysphagia when it is complete in depth and length. Prevention of gastro-esophageal reflux requires the preservation of a sufficiently long portion of esophagus in the abdomen.

Adolescent↗
PubMed1996

[Indications and outcome of anal sphincter myectomy in childhood].

Anal sphinctermyectomy according to Lynn is an established therapy for chronic constipation in children. However, no consensus on indications exists and, according to the literature, results are contradictory. In order to clarify this problem, 33 children were examined and divided into two groups: I (n = 12) chronic constipation, and II (n = 21) dysganglionosis. All children were treated conservatively for at least a 6-month period and showed elevated anal resting tone in manometry. The operative results were assessed by anorectal manometry and a physical examination; subjective opinion was evaluated using a questionnaire. Anorectal manometry showed a marked decrease of anal resting tone of 30%, correlating to subjective relief of the symptoms.

Adolescent↗
PubMed1997

Manometric evaluation of defecation disorders: Part II. Fecal incontinence.

Fecal incontinence is a silent affliction that often leads to self-imposed ostracism. For many years, a lack of understanding regarding its pathophysiology and a lack of empathy among many physicians has bedeviled this problem. However, during the last two decades, remarkable strides have been made, both in the evaluation and in the treatment of incontinence. These advances stem from the ability to perform a detailed and comprehensive assessment of anorectal physiology. Anorectal manometry has spearheaded this renaissance. Manometry is not a single test but consists of a series of measurements that include an assessment of anal sphincter function, rectal sensation, rectoanal reflexes, and rectal compliance. Electrophysiological assessments such as pudendal nerve terminal latency can provide additional information regarding neuromuscular integrity. Newer techniques such as vectography, saline continence test, impedance planimetry, and prolonged ambulatory anorectal manometry have added a new dimension to the overall assessment. Radiological tests such as defecography and anal endosonography can provide complimentary information. These tests of anorectal function have advanced immensely our understanding of the pathophysiological mechanisms that are responsible for fecal incontinence. Equipped with sound objective information, today, it is possible to treat most incontinent patients with novel treatments that include medical, biofeedback, or surgical therapies. This is the second article in a two-part evaluation of defecation disorders that discusses the manometric evaluation of fecal incontinence.

Adult↗