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PubMed2005

Effect of lower esophageal sphincter distension and acidification on esophageal pressure and electromyographic activity: the identification of the "sphinctero-esophageal excitatory reflex".

BACKGROUND: The mechanism of esophageal acid clearance through augmenting esophageal peristalsis in response to gastroesophageal reflux (GER) is not exactly known. We investigated the hypothesis that lower esophageal sphincter (LES) dilatation rather than the refluxed acid affected reflex increase in the esophageal peristaltic activity aiming at clearing the esophagus of the refluxed acid. METHODS: The esophageal pressure and electromyographic (EMG) activity response to esophageal sphincter balloon distension in increments of 2 mL of saline was recorded in 17 healthy volunteers (10 men, 7 women, mean age 43.6 +/- 11.2 years). The test was repeated in 10 of 17 volunteers while the esophageal sphincter was being anesthetized. The response of the esophageal pressure and electromyographic activity to lower esophageal acidification was also tested. RESULTS: Lower esophageal sphincter balloon distension with 2 mL of saline produced esophageal pressure increase to a mean of 34.2 +/- 5.3 cm H2O (p < 0.001). Increase of the balloon distending volume produced results similar to the 2-mL distension (p > 0.05). The esophageal electrical activity increased on esophageal balloon distension; the increase was similar with distensions of 2 mL up to 10 mL. There was no esophageal pressure or electrical activity response to distension of the anesthetized lower esophageal sphincter or to lower esophageal sphincter acidification. CONCLUSIONS: During gastroesophageal reflux episodes, the lower esophageal sphincter dilatation and not acidification appears to initiate increased esophageal peristalsis, which clears the esophagus of the refluxed acid. The increased esophageal peristalsis on lower esophageal sphincter dilatation is suggested to be reflex in nature and is mediated through the "sphincteroesophageal excitatory reflex." This reflex may be of diagnostic significance in esophageal motility disorders; however, this point needs further studies.

Adult↗

PubMed1990

Healing or amelioration of esophagitis does not result in increased lower esophageal sphincter or esophageal contractile pressure.

There is conflicting evidence regarding whether lower esophageal sphincter and esophageal contractile pressures are affected by changes in the severity of gastroesophageal reflux disease. We compared the manometric and endoscopic findings from 30 patients before and after treatment for esophagitis. Before treatment, the grade of esophagitis (I-III) was significantly correlated (r = -0.37; p less than 0.05) with lower esophageal sphincter pressure, but not with esophageal contractile pressure. After treatment, the grade of esophagitis did not change or became worse in 15 patients, and became better in 15 patients. Of these, seven healed. The group that showed no endoscopic improvement demonstrated no change in lower esophageal sphincter or esophageal contractile pressures. The group that did show endoscopic improvement also demonstrated no increase in lower esophageal sphincter or esophageal contractile pressures, and this was particularly evident in those whose esophagitis healed. These data suggest that healing of esophagitis does not result in improvement of esophageal motor function.

Adult↗

PubMed2003

Expressions of PCNA, p53, p21(WAF-1) and cell proliferation in fetal esophageal epithelia: comparative study with adult esophageal lesions from subjects at high-incidence area for esophageal cancer in Henan, North China.

AIM: To characterize the expression of p53, p21(WAF-1) and proliferation-cell-nuclear-antigen (PCNA) in fetal esophageal epithelia and to determine the role of these genes in proliferation of fetal and adult esophageal epithelial cells. METHODS: Immunohistochemical avdin-biotin peroxidase complex (ABC) method was applied to 31 cases of fetal esophageal specimens and 194 cases of adult esophageal specimens to detect the expression of p53, p21(WAF-1) and PCNA in fetal and adult esophageal epithelia. RESULTS: Both the PCNA positive immunostaining cell number and PCNA positive immunostaining rate in fetal esophageal epithelia (506+/-239) were significantly higher those that in adults, including normal epithelia (200+/-113) and epithelia with basal cell hyperplasia (BCH) (286+/-150) (P<0.05, t test). However, the number of PCNA positive immunostaining cells in adult esophageal dysplasia (719+/-389) and squamous cell carcinoma(SCC) (1261+/-545) was apparently higher than that in fetal esophageal epithelia (506+/-239) (P<0.05, t test). The positive immunostaining rate of P53 was 10 % (3/31) in fetal esophageal epithelia, which was significantly lower than that in adult normal esophageal epithelia (50 %), adult epithelia with basal cell hyperplasia (62 %), dysplasia (73 %) and squamous cell carcinoma (86 %) (P<0.05, Fisher's exact test). No p21(WAF-1) positive immunostaining cells were observed in fetal esophageal epithelia. However, p21(WAF-1) positive immunostaining cells were observed in adult esophagus with 39 % (11/28) in normal, 38 % (14/37) in BCH, 27 % (3/11) in DYS and 14 % (1/7) in SCC. CONCLUSION: PCNA could act as an indicator accurately reflecting the high proliferation status of fetal esophageal epithelium. p53 may play an important role in growth and differentiation of fetal esophageal epithelium. p21(WAF-1) may have no physiological function in development of fetal esophageal epithelium.

Adult↗

PubMed2000

Transient lower esophageal sphincter relaxations and esophageal body muscular contractile response in reflux esophagitis.

In patients with gastroesophageal reflux disease (GERD), transient lower esophageal sphincter relaxations (TLESRs) are more frequently accompanied by acid reflux than in normals. The role of esophageal tone during gastroesophageal reflux events is unknown. We studied the tonic motor activity in the body of the esophagus during TLESRs with and without acid reflux in 11 patients with erosive esophagitis and compared the results with those previously obtained in healthy subjects. Esophageal peristaltic contractions were recorded 13, 8, and 3 cm above a sleeve that measured LES pressure. An intraluminal balloon was inflated 8 cm above the sleeve to induce an esophageal tonic contraction [artificial high pressure zone (HPZ)]. The percentage of TLESRs with acid reflux was significantly higher in patients with esophagitis than in healthy controls (58.3% vs 37.3%, P < 0.05). TLESRs per se were not associated with an inhibition or increase in esophageal body contractility, which, however, changed substantially immediately after reflux. In patients with esophagitis the esophageal body tonic contractility was inhibited in 59.5% of TLESRs vs 36% in controls (P < 0.05). Esophageal contractions during TLESRs traveled down the esophagus in 77% of the instances in patients vs 96.5% in controls (P < 0.05). In conclusion, gastroesophageal reflux during TLESRs was more frequently associated with inhibition of esophageal body tonic contractility in patients with esophagitis than in normals. The different response of the esophageal body to reflux observed in GERD patients may partially contribute to the higher prevalence of reflux during TLESRs in these patients.

Adult↗

PubMed2004

Mid-esophageal ulceration and candidiasis-associated distal esophagitis as two distinct clinical patterns of tetracycline or doxycycline-induced esophageal injury.

BACKGROUND: Tetracyclines may cause esophageal injury. GOALS: The aims of this study are to describe 2 distinct clinical patterns of esophageal injury induced by tetracycline or its derivate doxycycline and to compare these patterns with respect to demographic, endoscopic, and clinical characteristics of the patients. STUDY: Forty-eight patients with the diagnosis of doxycycline- or tetracycline-induced esophageal injury by endoscopy were analyzed retrospectively. The patients were considered in 2 groups according to the type and the location of esophageal lesions (Group A: mid-esophageal ulceration, n = 18; Group B: distal esophagitis, n = 30). RESULTS: Patients in Group A were significantly younger than in Group B (P = 0.0014). In Group A, 15 patients (83%) had single ulceration, 2 (11%) double, and 1 (6%) circumferential at the mid-esophagus. In Group B, all patients had multiple micro-ulcerations in the distal esophagus. Development of mid-esophageal ulceration was induced predominantly by doxycycline, whereas distal esophagitis was induced by tetracycline. The description of drug ingestion with little or no water by patients in Group A was significantly more frequent than in Group B (94% vs. 10%, P < 0.001). Associated medical and benign gastric diseases and esophageal candidiasis were significantly more frequent in Group B (P = 0.006, P < 0.001, P < 0.001, respectively). Prompt response to medical therapy was observed in both groups with no significant difference (P = 0.093). CONCLUSIONS: The type of tetracyclines used by patients may give some clues to physicians on the pattern of esophageal injury because mid-esophageal ulceration seems to be more frequently associated with doxycycline and distal esophagitis with or without candidiasis with tetracycline.

Adult↗

PubMed1979

Esophageal scintigraphy to quantitate esophageal transit (quantitation of esophageal transit).

None of the tests employed currently to investigate esophageal transit is quantitative. The purpose of this study was to evaluate normal subjects and patients with a variety of esophageal disorders using a scintigraphic technique to quantitate esophageal transit. After oral administration of a bolus of water labeled with 99mTc-sulfur colloid, isotopic count rates were measured over the esophagus employing a gamma-camera on line to a digital computer. Esophageal transit was expressed as the percent emptying for each of the first 15-sec after the initial swallow and for 15-sec intervals after serial swallows. Sixty-two subjects were studied, including: normal volunteers; patients with motor disorders of the esophagus such as achalasia, diffuse esophageal spasm, and scleroderma; and patients with symptomatic gastroesophageal reflux both with and without esophageal motor dysfunction on manometic testing. Esophageal transit was decreased significantly after single and multiple swallows in patients with motor disorders of the esophagus. In addition, esophageal transit was abnormal in patients with reflux disease accompanied by abnormal motor function. In contrast, esophageal transit was normal after a single swallow, but incomplete after serial swallows in patients with reflux associated with normal esophageal motor function on manometry. We conclude that esophageal scintigraphy may be used to evaluate esophageal transit.

Adult↗

PubMed2005

Esophageal motor activity in children with gastro-esophageal reflux disease and esophagitis.

OBJECTIVE: To evaluate esophageal body motor contractions occurring during esophageal reflux in pediatric patients with gastro-esophageal reflux disease (GERD). METHODS: Patients referred for the evaluation of GERD who were evaluated with combined 24-hour pH probe and esophageal manometry test (MP24) were included. Patients were separated into the following groups: Group C -- normal pH probe and normal EGD; Group 1 -- abnormal pH probe and normal EGD; and Group 2 -- abnormal pH probe and EGD with histologic esophagitis. Esophageal motor function during reflux episodes was analyzed. RESULTS: Twenty-five patients were included. All had a normal stationary esophageal manometry. Patients in Groups 1 and 2 had significantly more gastroesophageal reflux by pH probe than Group C (P < 0.01). During the MP24, patients in Group 1 and 2 had significantly fewer contractions per minute pre-, during, and post-GER (P < 0.05). There were significant differences in the number of isolated and prolonged contractions (>7 sec) during prolonged GERD episodes >5 minutes (P < 0.05). CONCLUSION: Children with GERD have a decreased number and abnormal esophageal body contractions with esophageal reflux. This suggests that children with GERD with and without esophagitis have impaired esophageal body acid clearance.

Adolescent↗

PubMed1989

Lower esophageal sphincter pressure, esophageal body motor functioning, and esophageal acid sensitivity.

Esophageal acid sensitivity is believed to develop as a result of esophageal acid exposure, contributing factors being gastroesophageal reflux and delayed esophageal acid clearance. The relationship among lower esophageal sphincter pressure, motor functioning of the body of the esophagus, and esophageal acid sensitivity was examined by comparing the results from 912 patients and normal subjects studied with both esophageal manometric and Bernstein acid infusion tests. Positive acid infusions were statistically more closely associated with hypotensive lower esophageal sphincter pressures than with any motor abnormality in the body of the esophagus. Of the several esophageal body motor abnormalities considered, only feeble peristalsis had significantly more positive Bernstein tests than did normal esophageal body motor functioning. The findings from this study demonstrate that hypotensive lower esophageal sphincter pressure is more closely associated with an acid-sensitive esophagus than is impaired esophageal body motor functioning.

Esophagitis↗

PubMed1998

[Effects of Yunqitang on both esophageal mucosal morphology and esophageal motility in reflux esophagitis patients].

OBJECTIVE: To observe the effects of Yunqitang (YQT) on both esophageal mucosal morphology and esophageal motility in patients with reflux esophagitis (RE). METHODS: According to Syndrome Differentiation of TCM, 42 RE patients were divided into three groups: Disharmony of Liver and Stomach (D) group, Deficiency-Cold of Spleen and Stomach (DC) group, Heat Syndrome caused by depression of Liver Qi (H) group. No. I, II, III of YQT were taken respectively for 4 weeks. Before and after treatment scores of typical symptoms were collected, gastroscope and esophageal motility were measured. RESULTS: (1) The symptom remission rate was 81.1%, there were significant differences between the group DC with group D and Group H (P < 0.01). (2) The esophageal mucosal healing rate was 61.9%, the effective rate was 90.5%, and the ineffective rate 9.5%. There weren't significant difference of effective rates among the three groups (P < 0.05). (3) The changes of esophageal motility: lower esophageal sphictor pressure (LESP), average peristaltic pressure (APP) of group D were higher (P < 0.05), LESP, gastro-esophageal barrier pressure (GEBP) and peristaltic conduct speed (PCS) of group DC were remarkably higher (P < 0.05), GEBP of group H was improved (P < 0.05). CONCLUSIONS: YQT has a good therapeutical effect, it's not only resolving reflux symptoms, healing esophageal mucosa, but also improving esophageal motile function.

Adult↗

PubMed1992

Lack of effect of metoclopramide and domperidone on esophageal peristalsis and esophageal acid clearance in reflux esophagitis. A randomized, double-blind study.

The acute effects of oral metoclopramide (40 mg/day) and domperidone (80 mg/day) on esophageal motor activity and acid reflux were assessed in a randomized, double-blind, placebo-controlled study in 20 patients with erosive reflux esophagitis. Esophageal motor function was assessed by standard manometry with wet swallows, and reflux events were evaluated by ambulatory 24-hr pH-monitoring. Both drugs caused a significant (P less than 0.05) increase in lower esophageal sphincter pressure lasting at least 120 min. However, neither esophageal body motility, duration of esophageal exposure to acid, nor esophageal clearance were effected by drug administration in comparison to placebo. Side effects were reported in two patients who received metoclopramide, while no adverse effects occurred after domperidone intake. In conclusion, the so-called motility agents metoclopramide and domperidone have few acute effects on esophageal motility in patients with erosive reflux esophagitis.

Adult↗

PubMed2003

Comparison of the esophageal manometric characteristics of idiopathic and reflux-associated esophageal spasm: evaluation by 24-hour ambulatory esophageal motility and pH monitoring.

Diffuse esophageal spasm (DES) is a typical esophageal dysfunction, but its cause is unknown. DES has been classified into reflux-associated esophageal spasm (RDES), caused by acid exposure, and idiopathic esophageal spasm (IDES), of unknown causes. The differences in esophageal motility pattern between the RDES and IDES are clues to elucidating the pathogenesis of DES. Although 24-hr ambulatory esophageal motility and pH monitoring is considered a feasible method for evaluating gastroesophageal reflux and esophageal function, most researchers previously defined the RDES as DES accompanied by esophagitis and heartburn using standard manometry over a short time frame. To clarify the pathogenesis of RDES, we did this research using 24-hr ambulatory esophageal motility and pH monitoring. The investigation included 25 normal controls and 116 patients with upper digestive symptoms. Among the 116 patients, 45 had DES (11 RDES, 30 IDES, and DES-GERD coexistence). Patients with RDES showed a significantly higher frequency of simultaneous contractions than did patients with IDES. Heartburn has been said to be peculiar to RDES, but also occurred in 12.5% of IDES. No significant differences in the mean pH of the esophagus during acid reflux were found between the RDES and IDES patients. Based on the results, we have proposed a refined definition of RDES.

Adolescent↗

PubMed2003

Severe complications in advanced esophageal cancer treated with radiotherapy after intubation of esophageal stents: a questionnaire survey of the Japanese Society for Esophageal Diseases.

PURPOSE: A questionnaire survey was performed to evaluate the complications and prognosis of esophageal cancer treated with esophageal intubation before or during radiotherapy. METHODS AND MATERIALS: Clinical data were accumulated on a total of 47 patients treated at 17 institutions in Japan. Five patients had Stage II, 30 Stage III, and 11 Stage IV, and the stage was unknown in 1 patient. Covered expandable metallic stents were inserted in 30 patients, uncovered expandable metallic stents in 13, plastic or silicon prosthesis in 3, and an unknown type in 1 patient. Esophageal stenting was performed before the start of RT for 23 patients and during the course of RT for 24 patients. The reasons for the stenting were severe stricture in 32 patients (Group 1) and esophageal fistula in 15 patients (Group 2). RESULTS: The most frequent toxicity was formation or worsening of esophageal fistulas in 13 patients (28%), followed by massive hematemesis or GI bleeding in 10 patients (21%). In total, 24 patients (51%), including 10 patients with possible treatment-related deaths (Grade 5), had nonhematologic toxicities of Grade 3-5. The interval from the start of RT to the nonhematologic toxicity ranged from 16 to 312 days (median 78). The incidence of toxicities was higher for Group 1 (59%) than for Group 2 (33%), although the difference was not statistically significant. The median survival time for those with Stage II-III and Stage IV was 5 and 3.5 months, respectively. CONCLUSIONS: Patients with esophageal intubation before or during RT have a high risk of life-threatening complications, especially for those with severe esophageal stricture. Because long survival is expected for a substantial proportion of patients with locally advanced esophageal cancer after chemoradiotherapy, palliative intubation should be delayed until radiotherapy or chemoradiotherapy appears to have failed.

Aged↗

PubMed1988

Esophageal manometrical assessment after esophageal circular myotomy for wide-gap esophageal atresia.

We treated 3 children with wide-gap esophageal atresia by a circular myotomy of Livaditis technique, after which no postoperative complaints, such as heartburn, vomiting or dysphagia, were seen. Esophageal manometry, performed to evaluate the postoperative esophageal motor function revealed; (1) that lower esophageal sphincter pressure (LESP) increased gradually with time, (2) esophageal contraction waves (ECW) were evident at the site of the circular myotomy with swallowing, though these contractions were simultaneous; and (3) relaxation of the LES with swallowing was evident. These findings, as determined by the esophageal manometrical assessments, indicate that there is no difference between the postoperative esophageal function after either repair with a circular myotomy or primary anastomosis for esophageal atresia.

Adolescent↗

PubMed2000

[Esophageal motility disorders in patients with esophageal reflux disease without pathologic reflux by 24 h esophageal pH monitoring].

BACKGROUND: In a high proportion of patients with symptomatic gastroesophageal reflux disease, 24 h esophageal pH monitoring is normal. AIM: To study esophageal motility in patients with symptomatic gastroesophageal reflux disease and normal 24 h esophageal pH monitoring. PATIENTS AND METHODS: Fourteen patients (12 women, aged 28 to 74 years old) with esophageal reflux disease and normal 24 pH monitoring and 14 asymptomatic controls (8 women, aged 19 to 69 years old), were studied. Symptoms were evaluated using an analog scale and all subjects underwent a barium meal, upper gastrointestinal endoscopy and a standard esophageal manometry. RESULTS: Lower esophageal sphincter was normal in 11 patients, hypotonic in one and displaced to the thorax in two. Esophageal wave amplitude was lower in patients than in asymptomatic controls (10 to 50 and 13 to 70 mm Hg respectively). The proportion of hypotonic waves was Grade I and II in seven patients, Grade III in three and grade IV in four cases. Four patients had localized aperistalsis (that can be considered normal) and four had more severe forms of aperistalsis, along with severe hypotonia. CONCLUSIONS: Patients with gastroesophageal reflux disease without alterations in 24 h pH monitoring, have alterations in esophageal motility.

Adult↗

PubMed1995

Simultaneous two-level esophageal 24-hour pH monitoring in patients with mild and severe esophagitis. Does probe position influence results of esophageal monitoring?

Simultaneous ambulatory esophageal pH monitoring was performed in 10 patients (group 1) with normal distal acid exposure and in 40 patients (group 2) with pathological distal reflux. The probes were placed 5 and 10 cm above the lower esophageal sphincter to quantify variations of pH values that can be due to a displacement of pH sensor. In group 1 the median percent time with pH < 4 for total and upright monitoring periods and composite score were significantly lower at the proximal than the distal level. In group 2 all pH data were significantly lower at the proximal than the distal level. The patients with pathological reflux were subdivided into two subgroups based on endoscopic findings (mild and severe esophagitis). The patients with severe esophagitis showed a proximal acid reduction higher than in patients with mild esophagitis. Nine patients with mild esophagitis showed normal values at 10 cm, but all patients with severe esophagitis had abnormal proximal acid exposure.

Adolescent↗

PubMed1999

[Use of color Doppler esophageal ultrasonography for assessing hemodynamics of the lower esophageal veins before and after endoscopic esophageal variceal ligation].

Using color Doppler esophageal ultrasonography(CDEUS) with water balloon, we examined the lower esophageal veins of 24 patients with portal hypertension and esophageal varices. The results showed that CDEUS with water balloon could clearly display the lower esophageal veins and could effectively evaluate the changes of hemodynamics of the lower esophageal veins before and after endoscopic esophageal variceal ligation. The maximum blood velocity of peri-esophageal vein in the active bleeding group was higher than that in the non-active bleeding group.

Endoscopy, Digestive System↗

PubMed1984

Functional evaluation of distal esophagus and lower esophageal sphincter after esophagogastric devascularization, esophageal transection and antireflux procedure for bleeding esophageal varices.

Distal esophageal function and LES competence were evaluated in 21 patients by means of esophageal manometry and standard pHmetry after Sujura mod. operation for bleeding esophageal varices. This operation involves complete devascularization of 10-12 cm. of distal esophagus, disruption of anatomic anti-reflux mechanism, excision of nearly one cm. of muscular tissue at lower esophageal sphincter level. Intraoperative manometry was performed in 8 patients and demonstrated a significant shortening of high pressure zone, while lower esophageal sphincter pressure did not show significant variations. Postoperatively gastroesophageal reflux at pHmetry was not observed (five patients had pathological reflux preoperatively). No significant variations of resting lower esophageal sphincter pressure and no peristaltic alterations were observed. In conclusion despite the marked anatomic alterations related to this procedure, sphincter dynamics and distal esophageal function remain nearly normal.

Adult↗

PubMed1979

Esophageal-atrial perforation due to recurrent esophagitis 18 years after esophageal bypass surgery.

A 62-year-old man presented with a grand mal seizure, progressive abdominal distention, and refractory hypotension 18 years after colonic bypass of a benign stricture of the low middle third of the esophagus. He died 3 hours after admission to the hospital. The patient had a history of liniment ingestion in childhood plus a long history of dysphagia and substernal pain. Autopsy disclosed a large ulcer of the anterior wall of the distal esophagus, which had eroded through the posterior wall of the left atrium. Histologic examination revealed chronic esophagitis with fibrous obliteration of the esophageal wall, pericardium, and left atrial myocardium near the site of perforation. Foreign material was present within small arteries of multiple viscera, and in several of these fragments transverse striations were demonstrated. Esophageal-atrial perforation is a rare but fatal complication of chronic esophageal ulceration. The clinical and pathological features of this and previously reported cases of nontraumatic esophageal-atrial perforation are reviewed.

Esophageal Fistula↗