Louis P. Leite

Ineffective Esophageal Motility (IEM) (The Primary Finding in Patients with Nonspecific Esophageal Motility Disorder)

Nonspecific esophageal motility disorder (NEMD)is a vague category used to include patients with poorlydefined esophageal contraction abnormalities. Thecriteria include “ineffective” contractionwaves, ie, peristaltic waves that are either of lowamplitude or are not transmitted. The aim of this studywas to identify the prevalence of ineffective esophagealmotility (IEM) found during manometry testing and to evaluate esophageal acid exposure andesophageal acid clearance (EAC) in patients with IEMcompared to those with other motility findings. Weanalyzed esophageal manometric tracings from 600consecutive patients undergoing manometry in our laboratoryfollowing a specific protocol from April 1992 throughOctober 1994 to identify the frequency of ineffectivecontractions and the percentages of other motility abnormalities present in patients meetingcriteria for NEMD. Comparison of acid exposure and EACwas made with 150 patients who also had both esophagealmanometry and pH-metry over the same time period. Sixty-one of 600 patients (10%) met thediagnostic criteria for NEMD. Sixty of 61 (98% ) ofthese patients had IEM, defined by at least 30%ineffective contractions out of 10 wet swallows.Thirty-five of these patients also underwent ambulatoryesophageal pH monitoring. Patients with IEM demonstratedsignificant increases in both recumbent medianpercentage of time of pH 4 (4.5%) and median distal EAC (4.2 min/episode) compared to those with normalmotility (0.2%, 1 min/episode), diffuse esophageal spasm(0%, 0.6 min/episode), hypertensive LES (0%, 1.8min/episode), and nutcracker esophagus (0.4% 1.6 min/episode). Recumbent acid exposure inIEM did not differ significantly from that in patientswith systemic scleroderma (SSc) for either variable(5.4%, 4.2 min/episode). We propose that IEM is a more appropriate term and should replace NEMD,giving it a more specific manometric identity. IEMpatients demonstrate a distinctive recumbent refluxpattern, similar to that seen in patients with SSc. This finding indicates that there is anassociation between IEM and recumbent GER. Whether IEMis the cause or the effect of increased esophageal acidexposure remains to be determined.

Mucosal acid exposure sensitizes a subset of normal subjects to intra-oesophageal balloon distension.

Object: To assess the effect of acid infusion on the response of normal subjects to progressive intra-oesophageal balloon distension (IOBD). Methods: Twenty-one volunteers underwent slow IOBD. Subjects were asked to indicate the first perception of sensation (S1) and the onset of pain (S2), balloon volumes being recorded at both points. A 15-min infusion of 0.1 M HCl (8ml/min) was then instilled proximal to the balloon. Subjects were designated as acid-sensitive if they reported chest pain or heartburn during the acid infusion. Thereafter S1 and S2 were assessed again in the same manner. Results: Nine subjects were acid-sensitive, 12 were acid-insensitive. The subgroup of 12 acid-insensitive subjects had an increase of pain threshold after acid infusion (P<0.05), whereas the nine acid-sensitive subjects showed a decrease of pain threshold after acid infusion (P<0.05). No change of the threshold for sensation occurred in either of these groups after acid infusion. Conclusion: Individuals showing mucosal acid sensitivity have a lower threshold for mechanoreceptor stimulation after acid exposure.

Effects of octreotide on esophageal visceral perception and cerebral evoked potentials induced by balloon distension

Objective: Octreotide, a somatostatin analog, is antinociceptive and increases perception threshold in the rectum. The aim of this study was to determine whether octreotide alters esophageal sensory thresholds and cortical evoked potentials (CEPs) resulting from intraesophageal balloon distension. Methods: Twelve healthy volunteers (six men and six women, median age 25 yr, range 21–60 yr) underwent a randomized, double-blind, placebo-controlled trial of octreotide 100 μg s.c. versus saline. A 30-mm balloon was inserted 5 cm above the lower esophageal sphincter without topical anesthesia. The balloon was inflated at a rate of 170 cc/s to a maximum of 30 cc in 2 cc steps. Both pressure and volume were recorded. Patients reported first sensation (S1) and maximally tolerated pain (S2). Two cycles were performed both preinjection and 40 min postinjection. Evoked potentials were recorded from Cz to linked ears over 50 balloon inflation cycles (volume = S2). Results: Threshold volume to first sensation (S1) was significantly increased after octreotide injection [median (interquartile range): 24 (14–26) cc vs 13 (9–21) cc, p < 0.02]. No significant alteration in volume causing pain (S2) was noted after octreotide injection [29 (25–30+) cc vs 22 (19–29) cc]. Neither were volumes causing either first sensation [18 (11–24) cc vs 13 (9–18) cc] or pain [27 (23–30) cc vs 23 (21–25) cc] significantly altered by placebo injection. Neither amplitude nor latency of any of the three peaks of the evoked potential recordings differed significantly between postplacebo and postoctreotide recordings. Conclusion: Octreotide significantly increased esophageal perception thresholds to balloon distension. It did not alter pain thresholds, nor were cortical evoked potentials to painful stimulation altered in normal subjects.

Ambulatory Esophageal Manometry in the Evaluation of Unexplained Chest Pain

Ambulatory esophageal manometry is a relatively new technology, widely accepted as a research tool in the study of esophageal motility disorders. Its role as a clinical tool has been more controversial. This paper reviews current opinions regarding the use of this diagnostic tool, and attempts to summarize the advantages and shortcomings of this technology as it has been employed in the evaluation of unexplained chest pain.

CorrespondenceOmeprazole for the treatment of posterior laryngitis

purpose: To determine whether the patients with refractory posterior laryngitis respond to treatment with omeprazole. patients and methods: Sixteen consecutive patients with persistent posterior laryngitis despite prior therapy with H2 blockers were recruited from outpatient university otolaryngology and gastroenterology practices. Patients received 6 to 24 weeks of omeprazole 40 mg qhs, which was increased to 40 mg twice a day for 6 weeks in four patients with continuing symptoms. Laryngoscopy, esophagoscopy, and esophageal/laryngeal symptom questionnaire were completed at entry to the study. Laryngoscopy and the questionnaire were repeated at the conclusion of the study. A follow-up questionnaire was completed at 6 weeks. results: Laryngoscopy scores improved from 4.44 to 1.94 (nonblinded otolaryngologist) and 4.31 to 1.88 (blinded otolaryngologist) (P <0.05). Laryngeal and esophageal symptom indices improved from 13.94 and 9.00 to 3.00 and 0.38, respectively (P <0.05). Symptom indices increased to 7.00 and 7.33, respectively, after the discontinuation of therapy (P <0.05 compared with the conclusion of the study). One patient intolerant of omeprazole underwent fundoplication and was asymptomatic 6 weeks after surgery. Only 3 patients had esophagitis at entry. conclusions: The signs and symptoms of posterior laryngitis improve with the administration of omeprazole and symptoms recur after discontinuation of therapy, suggesting that reflux is the underlying etiology. Patients with refractory symptoms, but intolerant of omeprazole, may benefit from antireflux surgery. Laryngoscopic findings of posterior laryngitis are often subtle, and many patients with posterior laryngitis do not have esophagitis.