Lilian Rose Otoboni Aprile

Perception of dysphagia: lack of correlation with objective measurements of esophageal function

Background  The mechanism underlying increased perception of food bolus passage in the absence of esophageal mechanical obstruction has not been completely elucidated. A correlation between the intensity of the symptom and the severity of esophageal dysfunction, either motility (manometry) or bolus transit (impedance) has not been clearly demonstrated. The aim of this study was to analyze the correlation between objective esophageal function assessment (with manometry and impedance) and perception of bolus passage in healthy volunteers (HV) with normal and pharmacologically‐induced esophageal hypocontractility, and in patients with gastro‐esophageal reflux disease (GERD) with and without ineffective esophageal motility (IEM).

Diminished retention of food in the proximal stomach correlates with increased acidic reflux in patients with gastroesophageal reflux disease and dyspeptic symptoms.

This work aimed at evaluating the intragastric distribution of food in patients with GERD and dyspepsia and its relationship to acidic reflux episodes. Gastric emptying and food retention in the proximal stomach were evaluated by scintigraphy in 12 healthy subjects and 19 patients with GERD and dyspepsia after a liquid test meal. Patients also underwent 24-hr esophageal pH monitoring, which included a 2-hr postprandial period following a similar test meal. Total gastric emptying was similar in patients and controls, whereas proximal gastric retention (AUCprox/AUCtot) was significantly decreased in patients (mean ± SD: 0.48 ± 0.07 vs. 0.56 ± 0.06; P = 0.02). Within the GERD–dyspepsia group, a significant negative correlation was found between proximal gastric retention and the number of acidic reflux episodes. We concluded that abnormally decreased retention of gastric contents in the proximal stomach after a liquid meal may contribute to the pathogenesis of acidic reflux episodes in patients with GERD and dyspepsia.

Esophageal Striated Muscle Contractions in Patients with Gastroesophageal Reflux Symptoms

Although there are studies showing that the amplitude of contraction in the distal esophageal body may be lower in gastroesophageal reflux (GER) disease than in asymptomatic subjects, there are no data about proximal striated muscle contraction in this disease. We studied the esophageal contraction 2 or 3 cm below the upper esophageal sphincter in response to swallowing a 5-ml bolus of water in 122 consecutive patients submitted to esophageal manometry who complained of heartburn and acid regurgitation. Sixty-nine had esophagitis seen at endoscopy. Thirty-three also complained of dysphagia. No patients had esophageal stenosis, esophageal motility abnormalities in distal esophagus, chest pain, or extraesophageal manifestations of GER. We also studied 20 patients with systemic sclerosis (SSc), a disease with no involvement of striated muscle. When we measured the amplitude, duration, and area under the curve (AUC) of the proximal esophageal contraction, we did not find any differences (P > 0.05) between patients with esophagitis (N = 69) or without esophagitis (N = 53), with dysphagia (N = 33) or without dysphagia (N = 89), with mild (N = 55) or severe (N = 14) esophagitis, or younger than 40 years (N = 45) or older than 60 years (N = 19). There was also no difference between patients with GER symptoms and patients with SSc (P > 0.05). We conclude that patients with GER symptoms with or without esophagitis and with or without dysphagia have similar esophageal striated muscle contractions.

Gastric motility in patients with presinusoidal portal hypertension

OBJECTIVE:The aim of this study was to evaluate the consequences of portal hypertension (PH) for the motor functions of the human stomach.METHODS:The PH model used was the hepatosplenic form of mansonic schistosomiasis, as this is a condition characterized by PH but with considerably preserved hepatocellular function. The study included 15 patients with PH and 25 healthy volunteers who served as controls. The adaptive relaxation of the stomach was studied in 12 patients with PH and in 10 controls by a manometric method during rapid insufflation (25–30 s) of 700 ml of air into the gastric fundus. The gastric emptying of a liquid solution (15 patients with PH and 20 controls) and of a solid-liquid meal (nine patients with PH and 12 controls) was determined by gamma scintigraphy. The thickness of the gastric antrum wall was measured by ultrasonography in 12 patients with PH and in 10 controls.RESULTS:Patients with PH showed the following: 1) reduction of the adaptive relaxation of the stomach (p < 0.0001); 2) acceleration of gastric emptying of the test solution (T1/2, p = 0.0316), which became particularly expressive 25, 30, 40, and 50 min after ingestion (p = 0.0181, 0.0215, 0.0181, and 0.0215, respectively); 3) no alteration in gastric emptying of the solid-liquid meal as judged by T1/2 values (p = 0.9170) or lag-phase values (p = 0.7544); and 4) a conspicuous increase in gastric wall thickness as determined by antrum wall measurements (p = 0.0008).CONCLUSIONS:The reduced gastric adaptive relaxation demonstrated in patients with PH and normal hepatocellular function leads us to consider this condition as a cause of diastolic dysfunction of the stomach. In this disease, the motor alteration may be explained as a consequence of the reduction of gastric wall compliance, probably resulting from edema and vascular ectasia, which were indirectly detected by the increase thickness of the gastric antrum wall. The discrete acceleration of liquid gastric may be also related to the reduced gastric wall compliance.

Saliva transport to the distal esophagus

Objective. During esophageal acid clearance, saliva should reach the most distal esophagus. The mechanisms responsible for saliva transport are not completely understood but it is assumed that normal peristalsis plays a significant role. The aim of this study was to assess the role of esophageal peristalsis and gravity in saliva transport to the distal esophagus. Material and methods. Esophageal transit and presence times of a 2-ml bolus of radiolabeled artificial saliva were assessed using concurrent scintigraphy and manometry in 10 healthy volunteers in the upright and supine positions before and after disruption of esophageal motility with sildenafil (50 mg). Results. With normal peristalsis, there was no difference in saliva transit to the distal esophagus between supine and upright positions 3.9 (1.5– > 60.0) versus 3.3 s (1.3–8.3). Low amplitude contractions did not affect saliva transit but the disappearance of contractions after sildenafil was associated with prolonged saliva transit in supine position 7.4 (1.0– > 60.0). Saliva presence time was significantly prolonged in both the upright and supine positions by esophageal dysmotility. Conclusions. Saliva transport to the distal esophagus does not require complete normal peristalsis or gravity and mainly depends on an efficient pharyngeal pump. However, subjects in supine position with severe esophageal dysmotility might have both impaired volume clearance and delayed saliva transport, leading to abnormal acid clearance and esophagitis.

Abnormally Rapid Gastric Emptying of an Isosmotic Liquid Meal in Patients with Megaduodenum

Duodenal resistance to gastric outflow is known to participate in the regulation of gastric emptying of liquids in animals, but the role of this mechanism in humans has not been extensively investigated. In this work we studied the gastric emptying of liquids in patients with megaduodenum, who putatively have increased duodenal receptivity to gastroduodenal transfer of liquids. Subjects included eight patients with megaduodenum and eight healthy volunteers. Since megaduodenum in all cases was associated with Chagas’ disease, a further reference group consisting of 11 chagasic patients without megaduodenum was also studied. Fasted subjects ingested 200 ml of an isotonic dextrose solution labeled with 15 MBq of technetium-99m coupled to sulfur colloid, as an unabsorbable marker. Images of the anterior aspect of the stomach were taken immediately after test meal ingestion and thereafter up to 1 hr. Decay-corrected counts over the gastric region along time yield the calculation of early (5 min) and late (60 min) gastric retention as well as gastric emptying half-times (T1/2). Early gastric retention in patients with megaduodenum (median; range: 48%; 18–64%) was significantly lower (P < 0.05) than in both patients without megaduodenum (59%; 40–86%) and controls (82%; 68–99%). T1/2 values in patients with megaduodenum (5 min; 3–17 min) were also significantly lower (P < 0.01) than in patients without megaduodenum (23 min; 4 to >60 min) and controls (29 min; 13–60 min). There were no significant differences between the three groups concerning late gastric retention. We conclude that the early phase of gastric emptying of liquids is abnormally accelerated in patients with megaduodenum, which suggests that increased duodenal receptivity may have a significant effect on the gastroduodenal transfer of liquids in humans.

Esophageal contractions, bolus transit and perception of transit after swallows of liquid and solid boluses in normal subjects

CONTEXT Esophageal dysphagia is the sensation that the ingested material has a slow transit or blockage in its normal passage to the stomach. It is not always associated with motility or transit alterations. OBJECTIVES To evaluate in normal volunteers the possibility of perception of bolus transit through the esophagus after swallows of liquid and solid boluses, the differences in esophageal contraction and transit with these boluses, and the association of transit perception with alteration of esophageal contraction and/or transit. METHODS The investigation included 11 asymptomatic volunteers, 4 men and 7 women aged 19-58 years. The subjects were evaluated in the sitting position. They performed swallows of the same volume of liquid (isotonic drink) and solid (macaroni) boluses in a random order and in duplicate. After each swallow they were asked about the sensation of bolus passage through the esophagus. Contractions and transit were evaluated simultaneously by solid state manometry and impedance. RESULTS Perception of bolus transit occurred only with the solid bolus. The amplitude and area under the curve of contractions were higher with swallows of the solid bolus than with swallows of the liquid bolus. The difference was more evident in swallows with no perception of transit (n = 12) than in swallows with perception (n = 10). The total bolus transit time was longer for the solid bolus than for the liquid bolus only with swallows followed by no perception of transit. CONCLUSION The results suggest that the perception of esophageal transit may be the consequence of inadequate adaptation of esophageal transit and contraction to the characteristics of the swallowed bolus.

Effect of swallowed bolus viscosity and body position on esophageal transit, contraction and perception of transit

BACKGROUND The esophagus has a different response in relation to the characteristics of a swallowed bolus. Bolus viscosity and body position may affect esophageal contraction and transit. Objectives To investigate the effect of bolus viscosity and body position on esophageal contraction, transit and perception. METHODS Esophageal contraction, transit and perception of transit were evaluated in 26 asymptomatic volunteers, 13 men and 13 women aged 18-60 years, mean: 33.6 (12.2) years. Esophageal contraction (manometry) and transit (impedance) were measured with a solid state catheter with sensors located 5, 10, 15, and 20 cm from the lower esophageal sphincter. Each volunteer swallowed in duplicate and in random sequence a 5 mL low viscous (LV) liquid bolus of an isotonic drink with pH 3.3, and a 5 mL high viscous (HV) paste bolus, which was prepared with 7.5 g of instant food thickener diluted in 50 mL of water (pH: 6.4). RESULTS Total bolus transit time, in the sitting position, was longer with the HV bolus than with the LV bolus. Esophageal transit was longer in the supine position than in the sitting position. Bolus head advance time was longer with the HV bolus than with the LV bolus in both positions. Contraction esophageal amplitude was higher in the supine position than in the sitting position. The perception of bolus transit was more frequent with the HV bolus than with the LV bolus, without differences related to position. CONCLUSIONS The viscosity of the swallowed bolus and body position during swallows has an influence on esophageal contractions, transit and perception of transit.

High-resolution manometry for the evaluation of gastric motility

This review focus on the utility of HRM for the evaluation of gastric motility. The evaluation of gastric motility has clinical implications for the study of a myriad of diseases. Disordered motility represents a spectrum of dysfunction ranging from delayed gastric emptying to abnormally rapid gastric transit. Gastric motility may be measured by a variety of methods with different efficacy and different variables that may be obtained. High-resolution manometry was created and added to the diagnostic armamentarium. The methods and outcomes for the study of proximal motility that may be useful to assess the thoracoabdominal pressure gradient, gastric filling and accommodation are described. Also, studies on antroduodenal manometry are reviewed. High-resolution manometry allows gastric manometry without technical limitations found on conventional manometry; however, studies are still on the phase of understanding the normal findings.

Postprandial gastric antral contractions in patients with gastro‐oesophageal reflux disease: a scintigraphic study

Abstract  Disturbed gastric contractility has been found in manometric studies in patients with gastro‐oesophageal reflux disease (GORD), but the pathophysiological role of this abnormality is unclear. We aimed at assessing postprandial gastric antral contractions and its relationships with gastric emptying and gastro‐oesophageal reflux in GORD patients. Fasted GORD patients (n = 13) and healthy volunteers (n = 13) ingested a liquid meal labelled with 72 MBq of 99mTechnetium‐phytate. Gastric images were acquired every 10 min for 2 h, for measuring gastric emptying half time. Dynamic antral scintigraphy (one frame per second), performed for 4 min at 30‐min intervals, allowed estimation of both mean dominant frequency and amplitude of antral contractions. In GORD patients (n = 10), acidic reflux episodes occurring 2 h after the ingestion of the same test meal were determined by ambulatory 24‐h oesophageal pH monitoring. Gastric emptying was similar in GORD patients and controls (median; range: 82 min; 58–126 vs 80 min; 44–122 min; P = 0.38). Frequency of antral contractions was also similar in both groups (3.1 cpm; 2.8–3.6 vs 3.2 cpm; 2.4–3.8 cpm; P = 0.15). In GORD patients, amplitude of antral contractions was significantly higher than in controls (32.7%; 17–44%vs 23.3%; 16–43%; P = 0.01), and correlated positively with gastric emptying time (Rs = 0.58; P = 0.03) and inversely with the number of reflux episodes (Rs = −0.68; P = 0.02). Increased amplitude of postprandial gastric antral contractions in GORD may comprise a compensatory mechanism against delayed gastric emptying and a defensive factor against acidic gastro‐oesophageal reflux.