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PubMed1975

[Manometric study of esophageal involvement in progressive systemic sclerosis (author's transl)].

In 15 patients with progressive systemic sclerosis esophageal function was examined radiologically and by manometry. Only one third of the patients had experienced dysphagia, while radiologically esophageal motility was abnormal in 8 patients (55%) and by manometry even in 11 patients (73%). Therefore the absence of symptoms does not exclude extensive involvement of the esophagus. Furthermore the manometric results indicate that involvement of the esophagus in the edematous-indurative stage of scleroderma should be suspected more frequently than assumed generally on the base of radiological studies alone.

Aged↗
PubMed1986

[Sphincter function following colo-anal anastomosis].

The effect of colo-anal anastomosis (CAA) on the function of the anal sphincters was assessed in 27 cases by interview, sphincter manometry and a retention test. During an observation period of 3-12 months after closure of colostomy, the percentage of patients with perfect continence increased from 50 to 80%, of those with solid stool consistency from 30 to 90% and of those with solid stool consistency from 30 to 90% and of those with less than 5 b.o./day from 30 to 80%. The operation resulted in a significant reduction of the length of the anal canal from 4.0 +/- 0.3 to 1.7 +/- 0.2 cm (p less than 0.001) and a significant reduction of the resting tone from 85.5 +/- 7.9 to 30.3 +/- 6.1 cm H2O (p less than 0.001). The contraction pressure was hardly influenced, the recto-anal inhibition reflex was temporarily lost. Minute preoperative assessment of a normal sphincter function with anal manometry is an essential prerequisite for the evaluation of the indication for a CAA.

Anal Canal↗
PubMed1992

Gastroesophageal pH step-up inaccurately locates proximal border of lower esophageal sphincter.

Limiting the widespread use of 24-hr pH monitoring is the necessity of manometrically placing the pH probe 5 cm above the proximal lower esophageal sphincter (LES) border. Therefore, we prospectively compared LES localization by gastroesophageal pH step-up with manometry in 71 patients and 14 asymptomatic volunteers. The gastroesophageal pH step-up significantly correlated with the proximal LES border in patients (r = 0.53, P less than 0.0001) and volunteers (r = 0.91, P less than 0.0001). Based on previously published criteria, the pH step-up value was considered acceptably accurate if it was within +/- 3 cm (6 cm total span) of the manometrically determined proximal LES border. In 58% of patients and 29% of volunteers the pH step-up occurred outside this accuracy range. Esophagitis (P = 0.015) and abnormal reflux parameters (P = 0.002) were variables contributing to this error. Subsequent analysis found that the pH step-up overestimated the proximal LES border and occurred at the midportion of the sphincter. The pH step-up still inaccurately located the mid LES in 34% of patients. Therefore, manometry should remain the standard for accurate LES localization prior to placing the pH probe.

Adolescent↗
PubMed1991

Abnormalities of gastrointestinal motility in children with nonulcer dyspepsia and in children with gastroesophageal reflux disease.

In 11 children (mean age 44.2 months) with symptoms suggesting upper intestinal dysfunction (nonulcer dyspepsia), in nine children (mean age 27.3 months) with gastroesophageal reflux (GER) disease, and in seven controls (mean age 20.4 months) we investigated fasting [for 3 hr or until two migrating motor complexes (MMC) were observed] and fed (90 min) antroduodenal motility by means of perfused catheter system; furthermore, we measured both gastric emptying of a radiolabeled milk formula and fasting duodenogastric reflux during manometry by assessing bile salt concentration in gastric aspirates. No structural abnormalities of gastrointestinal tract and organic disorders were detected in the patients. In a high proportion of both groups of patients we found manometric abnormalities of interdigestive and fed motor patterns that were not seen in the controls: absence of antral phase III of MMC; significant decrease of antral and/or duodenal motor activity during fasting and/or fed periods; abnormal propagation or configuration of MMC phase III that was significantly shorter than in controls; bursts of sustained fasting and/or fed phasic duodenal activity, frequently uncoordinated with adjacent gut segments. When compared to controls, the mean intragastric concentration of bile salts during all MMC phases and the mean 1-hr percent gastric activity of the radiolabeled milk were significantly higher in the two groups of patients. We conclude that in a high proportion of children with nonulcer dyspepsia and of children with GER disease, gastrointestinal manometry may reveal significant irregularities of antral and duodenal motility, which are associated with increased duodenogastric reflux and delayed gastric emptying.

Bile Acids and Salts↗
PubMed1979

Efficacy of the morphine-prostigmin test for evaluating patients with suspected papillary stenosis.

The morphine-Prostigmin test (MPT) has been advocated as a diagnostic test for identifying patients with papillary stenosis. We studied 14 patients referred for possible papillary stenosis with the MPT and ERCP sphincter of Oddi manometry. The response to the MPT (symptoms, serum amylase/lipase values) was evaluated by multiple criteria. The MPT was also done on 6 volunteer control subjects. Operative evaluation of the sphincter of Oddi was obtained in 8 of the 14 patients. There was no correlation between the results of the MPT and ERCP manometry or operative findings. There was good correlation, however, between ERCP manometric findings and operative assessment of the sphincter of Oddi. Fifty percent of the volunteer subjects had a significantly positive enzyme response to the MPT. In our experience the MPT does not reliably detect patients with papillary stenosis.

Ampulla of Vater↗
PubMed1993

Scintigraphic studies of rectal emptying in patients with constipation and defecatory difficulty.

We prospectively evaluated 38 adult patients with chronic constipation with and without defecatory difficulties using a newly described scintigraphic test to measure rectal emptying and compared them to 20 healthy controls. All patients underwent anorectal manometry, and 30 who complained of infrequent defecation underwent a colonic transit study using radiopaque markers. Control subjects promptly evacuated both 100 ml and 200 ml artificial stool in a characteristic fashion, but three evacuated none of the 100-ml volume and two had no evacuation of the 200-ml stool (inhibited controls). Constipated patients exhibited three patterns of emptying: (1) normal emptying of both volumes (47%); (2) poor emptying of both volumes or inhibited defecation (29%); and (3) normal emptying of the 200-ml but abnormal evacuation of the 100-ml volume (24%). An abnormal expulsion pattern during manometry occurred in 21% of patients and was strongly associated with the inhibited defecation pattern. However, defecation patterns could not be predicted on the basis of age, gender, symptoms, duration of complaints, colonic transit, or other rectal manometric parameters. Although rectal scintigraphy has potential advantages as a diagnostic test in terms of quantitation and decreased radiation exposure, the inability of the test to distinguish patients with slow transit constipation and defecatory complaints makes the potential utility of this test of uncertain value in clinical and investigative settings.

Adult↗
PubMed1992

Solid swallowing versus water swallowing: manometric study of 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.

Adult↗
PubMed1991

Medical treatment of esophageal achalasia. Double-blind crossover study with oral nifedipine, verapamil, and placebo.

Calcium channel blockers have been previously shown to decrease lower esophageal sphincter (LES) pressure and improve symptoms in achalasia. We performed a placebo-controlled, double-blind, crossover study to assess the effects of oral nifedipine and verapamil on LES pressure, amplitude of esophageal body contraction, and clinical symptomatology in eight patients with symptomatic achalasia diagnosed by endoscopy, barium swallow, and manometry. Patients were randomized to receive up to 20 mg nifedipine, 160 mg verapamil, or placebo and underwent esophageal manometry before (baseline) and after four weeks on each drug. Diary cards were kept to record and grade symptoms and drug plasma level determinations were correlated with manometric and clinical findings. Both nifedipine and verapamil caused a statistically significant decrease in mean LES pressure, but only nifedipine caused a significant decrease in the amplitude of contractions of the smooth muscle portion of the esophagus. No statistically significant differences in the overall clinical symptomatology were noted with any of the drugs, although some individual improvements in dysphagia and chest pain were noted. We conclude that, despite the reduction in LES pressure and contraction amplitude of the distal esophageal body, oral nifedipine and verapamil do not significantly alter the clinical symptomatology of patients with achalasia.

Administration, Oral↗
PubMed1989

Recurrent autonomous esophageal peristalsis in patients with chest discomfort.

Routine esophageal manometry revealed a novel pattern of esophageal motility, recurrent autonomous peristalsis, in five patients evaluated for chest discomfort and heartburn. In the absence of swallowing, esophageal peristalsis occurred at frequencies of 4-8 peristaltic sequences per minute for periods of 2-8 min. The recurrent peristaltic sequences developed spontaneously during manometry and were associated with the onset of vague chest discomfort in four patients; one patient reported no symptoms during recurrent peristalsis. Duration and propagation velocity of the recurrent peristaltic contractions differed significantly from primary peristalsis in four patients. Recurrent autonomous esophageal peristalsis is an unusual motor pattern that may be associated with vague chest discomfort. The circuit(s) mediating recurrent autonomous peristalsis are unknown.

Adult↗
PubMed1990

Peristaltic dysfunction associated with nonobstructive dysphagia in reflux disease.

An evaluation was done of 325 consecutive patients who underwent esophageal manometry to investigate the relationship between solid food dysphagia and peristaltic dysfunction in gastroesophageal reflux disease. All patients with dysphagia were endoscoped to evaluate for mechanical obstruction. Manometry was done focusing on the incidence of peristaltic dysfunction (failed peristaltic sequences or sequences characterized by foci of hypotensive peristalsis). The major finding was that the severity of manometrically demonstrated peristaltic dysfunction in reflux patients correlated with the prevalence of dysphagia. After excluding patients with esophageal rings or strictures from the analysis, the overall prevalence of dysphagia was 39% among the 157 reflux patients. Within this group, 29% of patients with minimal peristaltic dysfunction experienced dysphagia compared to 78% of patients with severe peristaltic dysfunction. We conclude that peristaltic dysfunction should be considered along with mechanical obstruction as a potential cause of dysphagia in patients with gastroesophageal reflux disease.

Deglutition Disorders↗
PubMed1989

Detection of esophageal motor disorders by radionuclide transit studies. A reappraisal.

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.

Adult↗
PubMed1985

Portal hypertension due to jejunal vascular malformation.

We report a case of hepatic portal venous hypertension secondary to a small-bowel vascular malformation in a 24-year-old man with anemia. Preoperative diagnostic evaluation included gastrointestinal barium studies and endoscopy (showing esophageal varices), hepatic panangiography, peroral small-bowel biopsy, percutaneous transhepatic portal venography, and manometry. Preoperative injection of methylene blue dye into the jejunal arteries supplying the malformation resulted in easy localization of the lesion at surgery. Direct manometry at the time of segmental jejunal resection yielded a portal pressure of 35 mmHg, with subsequent reduction to 21 mmHg.

Adult↗
PubMed1993

Sonographic, manometric, and myographic evaluation of the anal sphincters morphology and function.

PURPOSE: A direct comparison of anal sphincter physiology (muscle performance and anatomy-muscle thickness) has not yet been undertaken but may be of importance in patients with defecation disorders. METHODS: We evaluated 15 healthy volunteers by means of anorectal manometry to determine pressure functions of the internal and external and sphincter. Transcutaneous electromyography was recorded to assess the electrical activity of the external anal sphincter. Thickness of the anal sphincter muscles was measured sonographically from within the anal canal with dorsal projection using a 7.5-MHz 360 degrees rectal panorama scanner. RESULTS: It was shown that neither is the muscle thickness of the external anal sphincter during rest (6.26 +/- 1.02 mm) or during squeezing (7.40 +/- 1.39 mm) correlated to its squeeze pressure (138.8 +/- 15.2 mmHg), nor is the diameter of the internal anal sphincter (2.09 +/- 0.58 mm) correlated to its resting pressure (61.1 +/- 15.2 mmHg). Finally, the thicker the internal and sphincter muscle, the lower the electrical activity of the external anal sphincter during squeezing (r = 0.74, P < 0.001). CONCLUSION: It is concluded that both manometry to assess sphincter function and sonography to determine sphincter morphology are important measures in the evaluation of continence function.

Adult↗
PubMed1994

Long-term efficacy of biofeedback training for fecal incontinence.

PURPOSE: Biofeedback therapy in fecal incontinence has been reported to improve continence in more than 70 percent of patients, but most studies have followed patients for less than two years. METHODS: Patients treated by biofeedback training between 1985 and 1986 were given a questionnaire in 1991, as were incontinent patients who had not entered this treatment program. All were asked for the occurrence, frequency, and severity of incontinence events in the past two weeks. Anamnestic and anorectal manometry data from the initial visit were also compared. RESULTS: Eighteen of 24 treated patients and 40 of 71 untreated patients responded. Of those treated by biofeedback, 78 percent reported episodes of fecal incontinence as compared with 77.5 percent of those not treated by biofeedback. Severity of incontinence, however, was significantly less (P < 0.02) in the treatment group (mean number of events, 0.2/day) than in those without treatment (1/day). In biofeedback-treated patients, it was identical with the frequency and severity reported immediately after therapy. No differences were found with respect to initial clinical data and anorectal manometry between both groups. CONCLUSION: Biofeedback training improves continence in patients not only during treatment and within the first two years but also for several years after therapy.

Adolescent↗
PubMed1996

Unilateral pudendal neuropathy. Significance and implications.

PURPOSE: Obstetric trauma and excessive defecatory straining with perineal descent may lead to pudendal neuropathy with bilateral increase in pudendal nerve terminal motor latencies (PNTML). We have frequently observed unilateral prolongation of PNTML. Diagnostic and therapeutic implications of unilateral pudendal neuropathy are discussed. METHODS: Records of 174 patients referred to pelvic floor laboratory for anorectal manometry and PNTML testing were reviewed. Computerized and manometry was performed using dynamic pressure analysis, and PNTML was determined using a pudendal (St. Mark's) electrode. RESULTS: No response was elicited from pudendal nerves to electric stimulation from both sides in 14 patients (8 percent) and from one side in 24 patients (13.8 percent). Bilateral PNTML determination was possible in only 136 patients (78 percent), of whom 83 patients (61 percent) had no evidence of neuropathy, revealing normal PNTML on both sides. Of 53 patients (39 percent) with delayed conduction in pudendal nerves, in 15 patients (28 percent), PNTML was abnormally prolonged on both sides, with an abnormal mean value for PNTML. In the remaining 38 patients (72 percent), PNTML was abnormal on one side; in 27 patients with an abnormal mean PNTML and in 11 patients with a normal mean PNTML. CONCLUSIONS: A significant number of patients with pelvic floor disorders have only unilateral pudendal neuropathy. Patients with unilaterally prolonged PNTML should be considered to have pudendal neuropathy, despite normal value for mean PNTML. This fact may be relevant in planning surgical treatment and in predicting prognosis of patients with sphincter injuries.

Constipation↗
PubMed1991

Autotransplantation of the pylorus sphincter at the terminal abdominal colostomy. Experimental study in dogs.

A method for constructing a continent colostomy has been tried in dogs. The pylorus sphincter with blood supply by the left gastroepiploic vessels was transposed around or anastomosed to the terminal abdominal colostomy in five dogs. One dog had a colostomy without pylorus transplantation. Evaluation was by clinical (consistency and weight of fecal material and number of defecations per day), radiologic, and manometry studies. There was no difference in the clinical data. In all the dogs, the radiologic study demonstrated emptying of the contrast medium to the peristomal skin. By manometry one high-pressure zone was demonstrated, and, in all dogs with a transposed or anastomosed pyloric segment, the average resting pressure was superior to that of the control dog. However, the transposed pylorus sphincter alone was not sufficient to control continence.

Animals↗
PubMed1991

Neurophysiologic assessment of the anal sphincters.

One hundred twenty consecutive patients with either fecal incontinence (60 patients), chronic constipation (41 patients), or idiopathic intractable pelvic pain (19 patients) were prospectively assessed. Patients underwent concentric needle electromyography (EMG), bilateral pudendal nerve terminal motor latency evaluation, anorectal manometry, and cinedefecography. The most common EMG finding in patients with fecal incontinence was decreased recruitment of motor units with squeezing and polyphasic motor unit potentials; these are consistent with an injury pattern. The most common EMG finding in the constipated patients was paradoxical puborectalis contraction. This latter abnormality was also a frequent finding in patients with rectal pain, as was prolongation of pudendal nerve latency. Paradoxical puborectalis contraction was diagnosed more frequently with EMG than with cinedefecography. Inter-examination correlation was best in the incontinent group between EMG and manometry. Cinedefecography had poor correlation with EMG in all patient groups but was valuable in the detection of additional pathology such as rectoanal intussusception and anterior rectocele. Electromyography including pudendal nerve terminal motor latency assessment is a valuable adjunct in the evaluation of disorders of evacuation. The information it yields is complementary to that offered by more routine physiologic examinations.

Anal Canal↗
PubMed1991

The role of sphincteroplasty for fecal incontinence reevaluated: a prospective physiologic and functional review.

Sixteen female patients (mean age 54.1 years; range 34-74 years) with a 9.8-year (range 1-25 years) history of incontinence to solid stool underwent overlapping sphincteroplasty with internal sphincter imbrication without fecal diversion. All patients were prospectively evaluated with preoperative anorectal manometry, electromyography, and pudendal nerve motor latency assessment, postoperative anorectal manometry, and preoperative and postoperative functional evaluation. Mean and maximal resting pressures increased from 30 mm Hg and 49 mm Hg preoperatively to 40 mm Hg and 57 mm Hg, respectively, postoperatively. Likewise, mean and maximal squeeze pressures increased from 27 mm Hg and 48 mm Hg preoperatively to 39 mm Hg and 73 mm Hg, respectively, postoperatively (P less than 0.01). Furthermore, anal canal high pressure zone length was increased by sphincteroplasty from a mean of 0.9 cm (range 0-3 cm) to a mean of 2.1 cm (range 1-4 cm). These objective physiologic improvements correlated well with subjective functional improvement. Subjectively, functional outcome was rated by patients as excellent in 38 percent, good in 38 percent, fair in 19 percent, and poor in only 5 percent of cases. Overlapping sphincteroplasty with internal sphincter imbrication improves both the anal sphincter physiologic profile and fecal continence.

Adult↗