Gloria Lacima

Deterioration of esophageal motility with age : A manometric study of 79 healthy subjects

OBJECTIVES:Data are limited on the effect of age on esophageal function. We evaluated whether aging influences the motor activity of the esophagus.METHODS:Standard esophageal manometry was performed in 79 healthy, nonpaid volunteers of both sexes, 18–73 yr of age. Lower (LES) and upper esophageal sphincter (UES) characteristics and the properties of esophageal peristaltic waves were assessed by age groups: ≤25 yr, 26–35 yr, 36–45 yr, 46–55 yr, 56–65 yr, and >65 yr.RESULTS:Age correlated inversely with LES pressure and length, UES pressure and length, and peristaltic wave amplitude and velocity, and correlated directly with the proportion of simultaneous contractions. Age was inversely correlated with the upper limits of normality (95th percentiles) of LES pressure (r =−0.943, p= 0.005), UES pressure (r =−0.943, p= 0.005), middle and lower peristaltic wave amplitude (r =−0.947, p= 0.004, and r =−0.844, p= 0.035, respectively), upper/middle peristaltic progression speed (r =−0.943, p= 0.005), and the proportion of simultaneous contractions (r = 0.926, p= 0.008), but not with the lower normal limits (5th percentiles) of these variables. Gender did not affect esophageal motility variables. The 95th percentiles of LES pressure differed by 20 mm Hg, those of lower peristaltic amplitude by 82 mm Hg, and those of percent simultaneous contractions by a factor of 2, between the younger and the older age groups.CONCLUSIONS:The results suggest that normal esophageal motility deteriorates with advancing age. Thus, age-related normality limits of esophageal pressures should be considered before establishing the manometric diagnosis of hypercontractile esophageal motility disorders.

Patología del suelo pélvico

Resumen La incontinencia fecal y urinaria estan frecuentemente asociadas, junto con el prolapso de los organos pelvicos. El parto vaginal y el estrenimiento cronico son los factores de riesgo mas importantes en la patologia del suelo pelvico. Sea cual sea el sintoma por el que acude la paciente al especialista, es necesario investigar la existencia de sintomas de otros compartimentos, porque las pacientes raramente los refieren de forma espontanea. Las pacientes con una enfermedad del suelo pelvico deberian ser evaluadas por un grupo multidisciplinario de especialistas. Se recomienda, en la mayoria de los casos, una evaluacion completa que incluya urodinamica, manometria anal, ecografia endoanal y estudios neurofisiologicos del suelo pelvico, dado que las afecciones del suelo pelvico tienen una compleja patofisiologia multifactorial, y deben detectarse todas las anormalidades anatomicas y funcionales para proporcionar el tratamiento mas adecuado. El tratamiento conservador permite la curacion o mejoria de un gran numero de pacientes con sintomatologia le-ve-moderada. La cirugia debe indicarse en pacientes seleccionadas y correctamente evaluadas, de forma que se hayan identificado preoperatoriamente todos los defectos anatomicos y funcionales que puedan ser corregidos quirurgicamente. Identificar factores de riesgo, conocer mejor la prevalencia y la patofisiologia de este problema de salud, permitira establecer estrategias preventivas y mejorar los resultados terapeuticos.

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<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.

Electrophysiologic Studies and Clinical Findings in Females With Combined Fecal and Urinary Incontinence: A Prospective Study

PurposeSeveral clinical, urodynamic, and manometric findings suggest neurologic damage as a contributing factor in the development of combined fecal and urinary incontinence. In this study, we wanted to test the hypothesis of pudendal nerve neuropathy being a more frequent lesion in patients with double incontinence compared with patients with isolated fecal incontinence.PatientsNinety-three females with combined fecal and urinary incontinence and 36 females with isolated fecal incontinence were investigated. All patients underwent anal manometry, endoanal ultrasound, electromyography, and pudendal nerve terminal motor latency.ResultsNo statistically significant differences were found in the age, history of vaginal delivery, and chronic straining between both groups. However, the rate of postmenopausal females was higher in the combined fecal and urinary incontinence group (85 vs. 67 percent; P = 0.02). Menopause was an independent risk factor of having double incontinence (odds ratio, 1.4; P = 0.02). Concentric needle electromyography of the external anal sphincter revealed increased duration of the motor unit potentials in 43 and 53 percent of patients with combined fecal and urinary incontinence and isolated fecal incontinence, respectively (P = 0.28). An increased number of polyphasic motor unit potentials was detected in 52 and 58 percent (P = 0.6). There was no statistically significant difference in the prevalence of bilateral (20 vs. 27 percent) or unilateral (23 vs. 14 percent) prolonged mean pudendal nerve terminal motor latency between both groups (P = 0.3).ConclusionsPudendal neuropathy is not a distinct characteristic of patients with double incontinence. The prevalence of pudendal neuropathy in these patients is similar to that observed in patients with isolated fecal incontinence. Others factors should be investigated to explain the common association of both types of incontinence.

High amplitude contractions in the middle third of the oesophagus: a manometric marker of chronic alcoholism?

BACKGROUND--Oesophageal motor abnormalities have been reported in alcoholism. AIM--To investigate the effects of chronic alcoholism and its withdrawal on oesophageal disease. PATIENTS--23 chronic alcoholic patients (20 men and three women; mean age 43, range 23 to 54). METHODS--Endoscopy, manometry, and 24 hour pH monitoring 7-10 days and six months after ethanol withdrawal. Tests for autonomic and peripheral neuropathy were also performed. Motility and pH tracings were compared with those of age and sex matched control groups: healthy volunteers, nutcracker oesophagus, and gastro-oesophageal reflux disease. RESULTS--14 (61%) alcoholic patients had reflux symptoms, and endoscopy with biopsy showed oesophageal inflammation in 10 patients. One patient had an asymptomatic squamous cell carcinoma. Oesophageal motility studies in the alcoholic patients showed that peristaltic amplitude in the middle third was > 150 mm Hg (95th percentile (P95) of healthy controls) in 13 (57%), the ratio lower/ middle amplitude was < 0.9 in 15 (65%) (> 0.9 in all control groups), and the lower oesophageal sphincter was hypertensive (> 23.4 mm Hg, P95 of healthy controls) in 13 (57%). All three abnormalities were present in five (22%). Abnormal reflux (per cent reflux time > 2.9, P95 of healthy controls) was shown in 12 (52%) alcoholic patients, and was unrelated to peristaltic dysfunction. Subclinical neuropathy in 10 patients did not effect oesophageal abnormalities. Oesophageal motility abnormalities persisted at six months in six patients with ongoing alcoholism, whereas they reverted towards normal in 13 who remained abstinent; reflux, however, was unaffected. CONCLUSIONS--Oesophageal peristaltic dysfunction and reflux are frequent in alcoholism. High amplitude contractions in the middle third of the oesophagus seem to be a marker of excessive alcohol consumption, and tend to improve with abstinence.

Effects of Red Wine on 24-Hour Esophageal pH and Pressures in Healthy Volunteers

The purpose of this study was to assess theeffects of red wine taken with meals on esophagealmotility, esophageal exposure to acid, and gastric pH.Following a randomized design, 14 healthy malevolunteers (mean age 25 years, range 18 -35 years weregiven 360 ml of red wine or tap water during lunch ordinner. All subjects underwent ambulatory 24-hresophageal motility and esophagogastric pH monitoringstudies. Three different periods were analyzed: duringmeals (30 min), postprandial (3 hr), and 8-hr supine.Two volunteers complained of heartburn after wineingestion. An increase in the number of high amplitude waves (>125 mm Hg, 95th percentile of ourmotility unit controls) was observed during mealsaccompanied by wine: water 1.2 (0-10.2), wine 1.6(0-32.6), P = 0.02 [median (range)]. No other esophagealmotility changes occurred. Percent reflux time increasedduring the postprandial period after wine ingestion incomparison with water: 1.7 (0-14.9) vs 0.1 (0- 0.8), P< 0.05. Gastric pH was unaffected by the type of drink. Ingestion of moderate amounts of redwine with meals increases postprandial esophagealexposure to gastric acid in healthy persons.

Long-term Control of Gastroesophageal Reflux Disease Symptoms After Laparoscopic Nissen-Rosetti Fundoplication

Laparoscopic fundoplication is the gold standard surgical treatment for gastroesophageal reflux disease, although some patients develop recurrence or collateral symptoms related to surgery. The aims of this study were to describe the long-term symptoms control in patients undergoing laparoscopic fundoplication, to analyze the patterns of failure and to correlate postoperative symptoms with anatomic and physiologic findings. Extensive preoperative and postoperative work-up including symptom questionnaire, barium meal, endoscopy, manometry, and 24-hour pH-metry were performed in 130 consecutive patients undergoing laparoscopic fundoplication. Mean follow-up was 52 months. After laparoscopic fundoplication, 117 patients (90%) were asymptomatic with Visick grade I and II symptoms reported by 124 patients (95%). On evaluation, 119 (92%) patients were satisfied and willing to repeat surgery. Two failure patterns, anatomic abnormalities (wrap migration into the chest or down onto the stomach with or without repair disruption) and functional (incompetence of antireflux mechanism), were reported in 17 patients. Reflux can be controlled in up to 90% of patients with gastroesophageal reflux disease with relatively few complications and a high degree of patient satisfaction. The most common cause of recurrent symptoms is an anatomic failure of the fundoplication.

Healing of erosive esophagitis with sucralfate and cimetidine: Influence of pretreatment lower esophageal sphincter pressure and serum pepsinogen I levels

Forty-eight patients with erosive reflux esophagitis were allocated to either sucralfate tablets, 4 g/day, or cimetidine, 1.6 g/day, for 8 weeks in a randomized, prospective, single-blind, cross-over therapeutic trial. Pretreatment lower esophageal sphincter (LES) pressure and serum pepsinogen I (PG-I) levels were investigated as possible predictors of healing with either drug. The trial was completed by 41 patients (21 in the sucralfate group and 20 in the cimetidine group); one patient in each group was removed because of side effects. Symptom improvement occurred to a similar extent in both groups. Endoscopic results after 8 weeks of treatment with sucralfate revealed complete healing of esophageal erosions in 48% (cimetidine, 55%) and improvement in an additional 19% (cimetidine, 20%). Neither of these differences was statistically significant. Some patients refractory to one drug had endoscopic healing of esophagitis when treated with the other drug after crossover. LES pressure did not influence outcome in patients treated with sucralfate, whereas significantly (p = 0.024) more patients refractory to cimetidine had an LES pressure less than 7 mm Hg than did those with a good response to the histamine-2 (H2)-receptor blockade. Patients whose esophagitis healed or improved after sucralfate tended to have lower serum PG-I levels than those with treatment failure (104 +/- 35 ng/mL vs 125 +/- 45 ng/mL), whereas the opposite occurred in patients treated with cimetidine (132 +/- 58 ng/mL in responders vs 78 +/- 27 ng/mL in nonresponders, p = 0.048). The results confirm that sucralfate is a valuable alternative to H2-receptor inhibitors for the treatment of reflux esophagitis. They also provide preliminary evidence that LES pressures and serum PG-I levels may have predictive value of the response to one or the other of these two drugs.

Comparison of stationary vs ambulatory 24-hour pH monitoring systems in diagnosis og gastroesophageal reflux disease

Twenty-four-hour intraesophageal pH monitoring is presently considered the most reliable diagnostic test for gastroesophageal reflux. Prolonged esophageal pH measurements can be obtained in hospitalized patients with a stationary technique and in ambulant outpatients by means of a portable device; however, there have been no studies that have examined whether the two approaches provide a similar diagnostic accuracy. We performed a prospective study to compare stationary and ambulatory pH-metry in the diagnosis of gastroesophageal reflux. Seventy-seven control subjects and 178 patients with proven gastroesophageal reflux disease were randomized to either ambulant or static pH-metry, which was performed with standard pH electrodes, sensors, and recorders. Reflux events (intraesophageal pH<4.0) analyzed were: number of episodes; total, upright, and supine reflux time; number of episodes lasting >5 min; and duration of the longest episode. A composite score of all reflux events according to DeMeester was also calculated. The limits of normality were defined as the 95th percentiles of the control groups. Both controls and patients assigned to either pH monitoring method were comparable. Of 255 studies attempted, 243 (95%) were completed successfully. The results showed similar median values of reflux events for the two control groups and for the two patients groups. Percent total reflux time provided a good separation between normal and abnormal reflux, with a sensitivity of 0.92 for static pH-metry and 0.68 for the ambulant procedure (respective 95th percentiles, 3.4 and 4.6). The lower sensitivity of ambulatory pH-metry compared to the stationary method could not be attributed to the higher normal limit in the former; circumstantial evidence suggests that dietary restrictions by the patients to minimize symptoms during home monitoring were probably responsible of this relatively high false negative rate. In conclusion, the results confirm the accuracy of stationary pH monitoring in the diagnosis of gastroesophageal reflux and show that the ambulatory procedure is less reliable; its sensitivity could probably be improved by strict dietary standardization.

Is electromyography a predictive test of patient response to biofeedback in the treatment of fecal incontinence

Biofeedback is effective in more than 70% of patients with fecal incontinence. However, reliable predictors of successful treatment have not been identified. The aim was to identify clinical variables and diagnostic tests, particularly electromyography, that could predict a successful outcome.