Richard Heddle

Swallowing dysfunction in healthy older people using pharyngeal pressure-flow analysis

Age‐related loss of swallowing efficiency may occur for multiple reasons. Objective assessment of individual dysfunctions is difficult and may not clearly differentiate these from normal. Pharyngeal pressure‐flow analysis is a novel technique that allows quantification of swallow dysfunction predisposing to aspiration risk based on a swallow risk index (SRI). In this study, we examined the effect of ageing on swallow function.

Age and gender affect likely manometric diagnosis: Audit of a tertiary referral hospital clinical esophageal manometry service

Background and Aim:u2002 Awareness of patient demographics, common diagnoses and associations between these may improve the use and interpretation of manometric investigations. The aim of the present study therefore was to determine whether age and/or gender affect manometric diagnosis in a clinical motility service.

Stimulation of pyloric contractions by intraduodenal triglyceride is persistent and sensitive to atropine

Intraduodenal lipid infusion stimulates phasic and tonic pyloric contractions and suppresses antral contractions. This study determined: (i) whether this response is sustained over 90 min; and (ii) the role of muscarinic mediation of this response. Antropyloroduodenal motility was recorded in 17 healthy volunteers with a sleeve/sidehole manometric assembly. Subjects received either a 90 min intraduodenal infusion of saline or triglyceride (20% Intralipid) at a rate of 1 mL/min; 30 min after the start of this infusion, the eight subjects who received triglyceride were given intravenous atropine 15 μg/kg over 30 s, followed by a maintenance infusion of 4 μg/kg/h until the study was completed.

Lower esophageal sphincter relaxation is impaired in older patients with dysphagia

AIMnTo characterize the effects of age on the mechanisms underlying the common condition of esophageal dysphagia in older patients, using detailed manometric analysis.nnnMETHODSnA retrospective case-control audit was performed on 19 patients aged ≥ 80 years (mean age 85 ± 0.7 year) who underwent a manometric study for dysphagia (2004-2009). Data were compared with 19 younger dysphagic patients (32 ± 1.7 years). Detailed manometric analysis performed prospectively included basal lower esophageal sphincter pressure (BLESP), pre-swallow and nadir LESP, esophageal body pressures and peristaltic duration, during water swallows (5 mL) in right lateral (RL) and upright (UR) postures and with solids. Data are mean ± SE; a P-value < 0.05 was considered significant.nnnRESULTSnElderly dysphagic patients had higher BLESP than younger patients (23.4 ± 3.8 vs 14.9 ± 1.2 mmHg; P < 0.05). Pre-swallow LESP was elevated in the elderly in both postures (RL: 1 and 4 s P = 0.019 and P = 0.05; UR: P < 0.05 and P = 0.05) and solids (P < 0.01). In older patients, LES nadir pressure was higher with liquids (RL: 2.3 ± 0.6 mmHg vs 0.7 ± 0.6 mmHg, P < 0.05; UR: 3.5 ± 0.9 mmHg vs 1.6 ± 0.5 mmHg, P = 0.01) with shorter relaxation after solids (7.9 ± 1.5 s vs 9.7 ± 0.4 s, P = 0.05). No age-related differences were seen in esophageal body pressures or peristalsis duration.nnnCONCLUSIONnBasal LES pressure is elevated and swallow-induced relaxation impaired in elderly dysphagic patients. Its contribution to dysphagia and the effects of healthy ageing require further investigation.

Is esophageal dysphagia in the extreme elderly (≥80 years) different to dysphagia younger adults? A clinical motility service audit

Dysphagia in elderly patients has major effects on nutrition and quality of life. Although aging itself is associated with changes in esophageal motility, the impact of this on symptoms such as dysphagia is unclear. Data in the extreme elderly are also limited. Symptoms and manometric diagnoses from 23 consecutive older patients (older dysphagia [OD]) >or=80 reporting esophageal dysphagia (12 female, mean age 83 (range 80-93) were compared with those from 23 gender matched younger patients (young dysphagia [YD]) also with dysphagia (mean age 35, range [17-46]). More older patients reported dysphagia as their primary symptom (OD 22/23 vs YD 14/23, P = 0.005). Overall, dysphagia was most common for solids only (OD 16/23 vs YD 15/23) and rare for liquids only (OD 1/23 vs YD 3/23). Dysphagia for both liquids and solids was more frequent in older patients (OD 6/23 vs YD 1/23, P < 0.05). Fewer older patients reported heartburn (OD 3/23 vs YD 14/23, P = 0.001). Manometric diagnoses were generally similar between OD and YD patients with the most common diagnoses being nonspecific esophageal motility disorder (nine each) and ineffective peristalsis (OD = 6, YD = 7). There was a trend for diagnoses related to lower esophageal sphincter failure to be more frequent in younger subjects (OD 1 vs YD 7, P = 0.053). Despite differences in symptom patterns, broad manometric diagnoses in the extreme elderly with dysphagia are similar to younger dysphagia patients. Further studies are required to determine whether this relates to insensitivity in recording or reporting of esophageal manometry (or perceptual differences associated with aging).

Maximum Upper Esophageal Sphincter (UES) Admittance: A Non-Specific Marker of UES Dysfunction

Assessment of upper esophageal sphincter (UES) motility is challenging, as functionally, UES relaxation and opening are distinct. We studied novel parameters, UES admittance (inverse of nadir impedance), and 0.2‐s integrated relaxation pressure (IRP), in patients with cricopharyngeal bar (CPB) and motor neuron disease (MND), as predictors of UES dysfunction.

Incidence of Achalasia in South Australia Based on Esophageal Manometry Findings

BACKGROUND & AIMS Achalasia is a disorder of esophageal motility with a reported incidence of 0.5 to 1.6 per 100,000 persons per year in Europe, Asia, Canada, and America. However, estimates of incidence values have been derived predominantly from retrospective searches of databases of hospital discharge codes and personal communications with gastroenterologists, and are likely to be incorrect. We performed a cohort study based on esophageal manometry findings to determine the incidence of achalasia in South Australia. METHODS We collected data from the Australian Bureau of Statistics on the South Australian population. Cases of achalasia diagnosed by esophageal manometry were identified from the 3 adult manometry laboratory databases in South Australia. Endoscopy reports and case notes were reviewed for correlations with diagnoses. The annual incidence of achalasia in the South Australian population was calculated for the decade 2004 to 2013. Findings were standardized to those of the European Standard Population based on age. RESULTS The annual incidence of achalasia in South Australia ranged from 2.3 to 2.8 per 100,000 persons. The mean age at diagnosis was 62.1 ± 18.1 years. The incidence of achalasia increased with age (Spearman rho, 0.95; P < .01). The age‐standardized incidence ranged from 2.1 (95% CI, 1.8–2.3) to 2.5 (95% CI, 2.2–2.7). CONCLUSIONS Based on a cohort study of esophageal manometry, we determined the incidence of achalasia in South Australia to be 2.3 to 2.8 per 100,000 persons and to increase with age. South Australias relative geographic isolation and the populations access to manometry allowed for more accurate identification of cases than hospital code analyses, with a low probability of missed cases.

Impaired bolus clearance in asymptomatic older adults during high-resolution impedance manometry.

Dysphagia becomes more common in old age. We performed high‐resolution impedance manometry (HRIM) in asymptomatic healthy adults (including an older cohort >80 years) to assess HRIM findings in relation to bolus clearance.

Dysphagia lusoria: A late onset presentation

Dysphagia lusoria is a term used to describe dysphagia secondary to vascular compression of the oesophagus. The various embryologic anomalies of the arterial brachial arch system often remain unrecognised and asymptomatic, but in 30%-40% of cases can result in tracheo-oesophageal symptoms, which in the majority of cases manifest as dysphagia. Diagnosis of dysphagia lusoria is via barium swallow and chest Computed tomography scan. Manometric abnormalities are variable, but age-related manometric changes may contribute to clinically relevant dysphagia lusoria in patients who present later in life. Our report describes a case of late-onset dysphagia secondary to a right aortic arch with an aberrant left subclavian artery, which represents a rare variant of dysphagia lusoria. The patient had proven additional oesophageal dysmotility with solid bolus only and a clinical response to dietary modification.

Evaluation of outcome after cardiomyotomy for achalasia using the Chicago classification.

Achalasia can be subdivided into manometric subtypes according to the Chicago classification. These subtypes are proposed to predict outcome after treatment. This hypothesis was tested using a database of patients who underwent laparoscopic Hellers cardiomyotomy with anterior fundoplication.