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Abnormal esophageal motility
GASTROEh’TEROLOGY 1991;101:344-354
Abnormal Esophageal Motility An Analysis of Concurrent Mariometric Findings BENSON T. MASSEY, JAMES G. BRASSEUR,
Radiographic
WYLIE J. DODDS, WALTER and JAMES F. HELM
and
J. HOGAN,
Departments of Medicine and Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin; and Department of Mechanical Engineering, School of Engineering, Pennsylvania State University, University Park, Pennsylvania _
The findings of concurrent esophageal videofluoroscopy and manometry in 15 patients with major disturbances of esophageal motor function were evaluated and the data were analyzed from a fluid mechanical perspective. Each of 153 fluoroscopic barium swallow sequences was analyzed on a swallow-by-swallow basis. Two distinct pressure domains were identified: intrabolus pressure and pressure within a bolus-free contracting esophageal segment. Analyses in terms of these pressure domains showed specific and consistent correlations between the radiographic and manometric findings. Radiography was insensitive to contractions occurring in esophageal segments devoid of bolus fluid, whereas manometry was insensitive to contractions that did not occlude the lumen. It is concluded that using fluid mechanical principles of bolus transport allows meaningful comparison of esophageal motility as recorded by radiography and intraluminal manometry. However, the inherent limitations in the range of physical phenomena recorded by each modality make these techniques complementary for evaluating esophageal motor function. adiography and manometry are the two diagnostic modalities used most commonly for the evaluation of patients with suspected esophageal motor disturbances. These two modalities record different parameters of esophageal motor function, thereby raising the possibility that they may not be equally useful in detecting all facets of disturbances in esophageal motor function. However, recent analysis of fluid mechanical models of esophageal bolus transport suggests that some parameters measured by manometry and radiography may have a predictable correspondence (1).Previously, we evaluated the relationship between concurrent manometric and radiographic findings in subjects with normal or only
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mildly abnormal esophageal motor function (2,s). Our aims in this study were to (a) obtain concurrent manometric and radiographic recordings in patients with substantial abnormalities of esophageal motor function and (b) analyze the data from a fluid mechanical perspective to determine if correlates exist between the two recording modalities when such abnormalities are present. Methods We performed concurrent esophageal videofluoroscopy and manometry in 15 patients (seven men and eight women, aged 39-83 years) with diverse esophageal motor disorders. The patients were referred to our manometry laboratory for evaluation of dysphagia and/or chest pain. The final diagnoses in the 15 patients included hypertensive peristalsis (Z patients), achalasia (4 patients], diffuse esophageal spasm (3 patients), myotonic dystrophy (1 patient), and unclassified esophageal motor disorders (5 patients). The study was approved by the Medical College of Wisconsin Institutional Review Board. For i&alumina1 manometry we used an eight-lumen recording catheter, described previously (3,~). Eight orifices, cut at 3-cm intervals, beginning 1 cm from the assembly tip, gave a span of 21 cm. A metal marker immediately distal to each recording orifice enabled radiographic localization of each recording site. After the subjects fasted 6-12 hours, the manometric assembly was passed transnasally and positioned with the distal recording orifice [site 1) 1-2 cm proximal to the lower esophageal sphincter (LES). During recordings each manometric recording orifice was perfused with water (0.5 mL/min) by a minimally compliant perfusion system (5). Each recording lumen was connected to an external transducer (model 23Db; Gould Inc., Oxnard, CA). Pressures were recorded with an eight-channel polygraph recorder (SensorMedics
o 1991bytheAmericanGastroenterologicalAssociation 0016-5005/91/$3.00
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CONCURRENT ESOPHAGEAL RADIOGRAPHYAND h4ANOMETRY 345
Corp., Anaheim, CA), at a paper speed of 10 mm/s. Pressures were recorded only from the distal seven sideholes of the manometric catheter while the eighth polygraph channel was used to record a timing signal. After placement of the manometric assembly, the subject lay in a supine position, rotated 15” left side down, so that the esophagus projected slightly to the left of the spine. The output from the videofluoroscopic image intensifier was transmitted to a Betamax videorecorder (Sony model SLHF 900) with a 0.5-in tape recording at 30 frames per second. The video and manometric recordings were synchronized using a modified timer (model VC-436; Thalner Electronics Laboratories Inc., Ann Arbor, MI) that encoded digital time on each videoframe and sent a signal each second to the eighth channel of the polygraph (3). For each patient, a median of 10 fluoroscopic sequences were recorded, each initiated by a single 5-mL or 10&L barium swallow (40% wt/vol, SG 1.6). For most sequences, the fluoroscope was swept over the entire esophagus, whereas on other sequences the fluoroscope was fixed over the proximal or distal half of the esophagus. Spontaneous or requested dry swallows were recorded during some of the fluoroscopic sequences. Some sequences were recorded after the patient was given IV edrophonium (80 pg/kg) or atropine (3 or 6 l&g). Data analysis was performed by slow motion and freezeframe playback of the videorecordings with reference to the concurrent manometric tracings. Each sequence and swallow was analyzed individually. The analysis was conducted to identify (a) what manometric correlates existed for a given radiographic phenomenan and, conversely, (b) what radiographic appearances existed for a given manometric phenomenon. For example, the manometric correlates were determined for the radiographic appearances of tertiary contractions (shallow, sawtooth indentations along the barium bolus), corkscrew (curling) configurations, and rosary beading (barium saculation separated by segmental luminal occlusions). Conversely, the radiographic appearances were established for hypertensive peristaltic pressure waves, simultaneous spastic esophageal contractions, and retrograde waves.
imparted an inverted-V configuration to the tail of the barium bolus and traversed the entire esophagus (6). With manometry this peristaltic action was identified as a peristaltic pressure wave that passed each recording site successively in an aboral direction, traversing the entire esophagus at an average speed of 2-4 cm/s (7). As described previously (3,6) the tail peristaltic stripping wave seen radiologically close temporal relationship with the onset upstroke of the pressure wave (Figure 1). Two Domains of Intraluminal
of the had a of the
Pressure
Initial review confirmed, as suggested previously (l), that when a lumen-obliterating contraction is present after a wet swallow, intraluminal pressure is segregated into two distinct domains: that of intrabolus pressure and that within the contracted esophageal segment which is devoid of bolus fluid. As illustrated in Figure 1, these two pressure domains are separated spatially and temporally from one another.
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Results For the 15 patients, 153 fluoroscopic sequences containing 165 barium swallows and 125 dry swallows as well as intervals of nondeglutitive motor activity were analyzed. Initial review showed several important principles concerning the relationship between manometrically recorded pressure phenomena and intraluminal bolus transport recorded by radiography. These principles were then used to correlate specific radiographic and manometric patterns. General Observations Relationship Between Bolus Tail and Peristaltic Pressure Wave
On fluoroscopy, esophageal peristaltic bolus transport was seen as a stripping wave that generally
T3
Figure 1. Schematic illustration of the two domains of intrabolus pressure and pressure within a lumen-occluded esophageal segment. The left side of the illustration shows the position of the bolus relative to three manometry recording sites (PI-P,) at three different times (T,-T,) corresponding to the passage of the bolus tail past these manometric sites. The right side of the illustration shows the pressure tracings from the three manometric sites. The shaded areas under the pressure curves represent the interval during which pressure is recorded from within the fluid-filled esophageal lumen (i.e., intrabolus pressure). The upstroke of the pressure wave at each site is closely associated with passage of the bolus tail past that site. Between times T, and T,, recording sites P, and P, are within the fluid continuum of the bolus and are segregated from site P, by a contracted esophageal segment. Hence, during this time interval the elevated contractile pressure at P, is not transmitted to either sites P, or P,, both of which record similar low-amplitude intrabolus pressures.
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This distinction is essential because contractile pressures within the bolus-free segment are not transmitted directly to the bolus itself, because fluid must be present for pressure to be transmitted axially along the length of the esophageal lumen. Hence, for a peristaltic stripping wave, when the contractile pressure wave is recorded from a lumen-occluded esophageal segment, the peak wave pressure is never observed concurrently at manometric recording sites located distally within the bolus-filled esophagus.
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Isobaric Versus Nonisobaric
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An essential distinction exists on manometry between what we call isobaric waves and nonisobaric waves. Previously, isobaric waves have been termed simultaneous waves and nonisobaric waves had been referred to as simultaneous contractions. However, we believe that this new terminology of isobaric and nonisobaric waves avoids misconceptions about the underlying fluid mechanics of the observed manometric phenomena. We define isobaric waves as pressure waves of similar amplitude and waveform that are recorded concurrently from two or more adjacent recording sites. Isobaric, or simultaneous waves, were recorded only when two or more manometric sites were located within a fluid-filled, open-lumened esophageal segment in which there was negligible fluid flow. This observation is illustrated schematically in Figure 2A, in which intraluminal pressure waves resulting from contraction of any portion of the esophageal wall bounding the trapped bolus are transmitted uniformly to all recording sites located within the bolus, so long as the esophageal lumen is not occluded between the two recording sites. This phenomenon of isobaric waves which erroneously has been referred to as simultaneous contractions as well as simultaneous waves is in contrast tothe phenomenon of nonisobaric waues, which we define as the simultaneous occurrence of pressure waves of adifferent amplitude and configuration recorded from adjacent recording sites. When nonisobaric waves are present (Figure 2B), the recording sites are located within (a) bolus-depletea, contracted esophageal segments, (b) two or more regions of bolus fluid that are segregated by a lumen-occluded segment of esophagus, or (c) fluid-filled esophageal segments experiencing appreciable fluid 40~.
Correlation of Videofluoroscopic and Manometric Findings Analysis of the. tideofluoroscopic and manometric recordings showed that some patients (e.g., those with achalasia) showed similar radiographic
Figure 2. Schematic illustration of the difference baric waves and nonisobaric waves.
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A. Isobaric waves. The left part of the diagram represents the radiographic appearance at time A corresponding to the manometric tracings recorded from sites P,-P, located within the esophageal lumen, At time A (verkal dotted line), P, and P, are located within a fluid continuum (shaded area) that is bounded by segments of the esophagus where the lumen is occluded. When the bolus is not in motion, pressures transmitted from the esophageal wall to the fluid are transmitted uniformly throughout the fluid [i.e., P, = PJ. Thus, isobaric or simultaneous waves of similar form and amplitude are recorded at P, and P,. Such waves do not require the simultaneous contraction of the esophagus at P, and P,; therefore, these waves should not be called simultaneous contractions. B. Nonisobaric waves. At time B, sites P, and P, are both within portions of the bolus separated by a lumen-occluded segment of esophagus devoid of bolus fluid. Pressures generated at P,, therefore, cannot be transmitted to P,, so that nonisobaric waves having different forms and amplitudes exist at these two sites, indeed, at all 4 sites. Nonisobaric waves generally result from contractions occurring simultaneously at several sites along an esophageal segment, although they may also be seen if a nonperistaltic contraction at one site only causes appreciable fluid flow.
and manometric patterns during most swallows. However, the majority (e.g., patients with nonspecific esophageal motor disorders) showed considerable variation in manometric and radiographic patterns from swallow to swallow. Because of this variation, the recorded sequences were more appropriately analyzed on a swallow-by-swallow basis, rather than by averaging results within diagnostic categories. Analysis of the recorded sequences showed that a limited range of manometric findings was associated with a specific motor pattern observed fluoroscopically and vice versa. These relationships are outlined in Tables 1 and2. Peristaltic Contractions
From the 15 patients we recorded 69 sequences with hypertensive peristalsis (e.g., distal esophageal pressures waves > 200 mm Hg in amplitude), 22 sequences with hypotensive peristalsis (esophageal
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Table 2. Esophageal Manometric Patterns and Their Radiographic Correlates
Table 1. Esophageal Radiographic Patterns and Their Manometric Correlates Radiographic
Peristaltic contractions Normal peristalsis
Normal peristaltic wave, hypertensive peristalsis, nonisobaric waves following a leading peristaltic front Hypotensive peristalsis Elevated basal pressure, isobaric, and/or nonisobaric waves Retrograde peristalsis
Proximal escape Non-lumen-obliterating peristaltic contraction Retrograde peristalsis Nonperistaltic contractions Tertiary contractions
Elevated basal pressure, lowamplitude isobaric waves Isobaric waves, nonisobaric waves (with appreciable fluid flow) Nonisobaric waves
Curling (corkscrew) contractions Rosary bead (lumenoccluding) contractions Sacculations Transient diverticulum
Nonperistaltic movement
Nonisobaric waves Nonisobaric waves, no pressure wave if orifice facing diverticulum neck Antegrade successive relaxation of nonisobaric waves Regional pressure gradient
bolus
Radiographic findings
Manometric findings
Manometric findings
findings
347
Peristaltic waves Normal peristalsis or hypertensive peristalsis
Hypotensive
peristalsis
Retrograde peristalsis Nonperistaltic waves Isobaric waves or elevated basal pressure
Nonisobaric waves
Initial isobaric or nonisobaric waves with subsequent sequential, nonsimultaneous relaxation
FLUOROBCOPY 41k
Normal stripping wave, possible tertiary contractions along bolus ahead of bolus tail, occasional residual barium in sacculations or diverticula Regional bolus escape, occasional normal stripping wave Retrograde stripping wave
Continuous fluid column within open lumen; possible tertiary contractions, curling, or nonlumen-obliterating peristalsis Bolus absent or bolus portions segregated by lumen-occluded segments [rosary beading, sacculations, transient diverticula), fluid continuum present but appreciable fluid flow occurs Nonperistaltic bolus flow (generally retrograde] along pressure gradient
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Figure 3. Example of hypertensive peristalsis. As with peristaltic waves of normal amplitude, the tail of the barium bolus passes each mauometric recording site coincident with the onset of the peristaltic pressure wave at that site. The prolonged high-pressure contractions are not evident radiographically because barium has been cleared from each site before the maximal pressure waves are recorded.
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pressures waves <3O mm Hg) and proximal bolus escape, 22 sequences with non-lumen-obliterating peristaltic contractions, and 20 sequences with retrograde peristalsis. Manometric
correlates of radiographic
findings.
When the fluoroscopic image showed an intact stripping wave, the leading edge of the manometrically recorded contraction wave always showed peristaltic progression and its initial upstroke was closely associated temporally with passage of the bolus tail (Table 1). Because intact stripping waves did not generally leave any residual barium in the esophagus, videofluoroscopy did not show motor events occurring in the esophagus after the stripping wave had passed that region of the esophagus. In our patients with hypertensive peristaltic contractions, an effective stripping wave was seen radiographically (Figure 3). Because the bolus is propelled ahead of the peristaltic contraction wave, there is no radiographic image from within the region of elevated pressures that follows the bolus. In episodes of retrograde peristalsis, the pressure
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wave upstroke was associated with the retrograde passage of the bolus tail at that site (Figure 4). Contractions following the leading edge of a peristaltic contraction wave were evident radiographically only when residual barium was left in the esophageal body, because of retention in sacculations or transient diverticula or because of proximal bolus escape caused by hypotensive peristalsis. In the case of barium becoming trapped within sacculations or transient diverticula, termination of the contraction wave at that site corresponded fluoroscopically to escape of the trapped barium, thus allowing fluoroscopic determination of contraction duration at that site. When videofluoroscopy recorded proximal escape of a portion of the bolus (usually in the region of the aortic arch), manometry recorded hypotensive peristaltic pressure waves in the region of escape, as described previously (3). In several sequences, videofluoroscopy recorded a non-lumen-obliterating peristaltic contraction that traversed part of the esophagus without occluding its
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MANOMETRY Figure 4. Example of retrograde peristalsis in a patient with an unclassified esophageal motility disorder. At the beginning of this sequence, barium remains in the esophagus after a failed swallow. Starting at 25.8 seconds, tertiary contractions, seen along the contour of the barium bolus, correspond to the onset of low-amplitude isobaric waves recorded manometrically throughout the esophagus’(note differences in scale on different channels). These waves peak at 28.8 seconds. Starting at 27’.9 seconds, a retrograde peristaltic stripping wave is seen. The aborad passage of the barium bolus tail past the three distal recording sites (vertical arrows) corresfionds closely With the onset of the contraction wave at each site. The retrograde peristaltic pressure wave is not seen at the fourth manometric site, corresponding to the failure of the retrograde stripping wave to carry the bolus tail past that site.
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3cm _____/_3cm -_L_. 1 m & /; Figure 5. Example of a non-lumen-obliterating peristaltic contraction. In this patient, hypertensive contractions were diminished by 6 pgkg atropine. Bolus transport proceeds normally in the proximal, striated muscle portion of the esophagus, but retrograde bolus escape and a slight delay in the peristaltic wave are observed at the aortic arch, in the region of the junction between the striated and smooth muscle parts of the esophagus. By the time the peristaltic wave reaches site 4, as determined by fluoroscopy (7.5 seconds), it is no longer lumen obliterating. Note that starting at about 6.8 seconds isobaric waves are initially seen in channels 1-4. The passage of the non-lumen-obliterating peristaltic wave (horizontal arrows) is marked only by a slight indentation of the barium bolus that moves distally. In effect, the non-lumen-obliterating peristaltic contraction is seen as a ripple along the barium-filled esophagus. Its arrival at recording sites Z-4 has no distinct manometric correlates, because pressures are recorded within an open lumen of a relatively motionless fluid continuum, Because of extensive retrograde escape of the bolus, minimal barium enters the stomach. The relaxation phase of the pressure wave has slightly different amplitades and waveforms at the different distal recording sites (i.e., they have changed to nonisobaric waves), corresponding to net retrograde axial flow in the esophagus as it relaxes.
lumen. Such contractions did not effectively transport the bolus distally. In such instances, the manometric tracings from within the bolus transiently showed isobaric waveforms that appeared nonperistaltic. The example shown in Figure 5 shows a nonlumen-obliterating peristaltic contraction in a patient with hypertensive peristalsis who had received atropine. Atropine decreased peristaltic pressure wave amplitude in the distal esophagus, and the recorded pressures initially displayed the pattern of isobaric waves. The upstrokes of these waves do not correspond temporally to the passage of the nonlumenoccluding peristaltic contraction wave past the respective recording sites. Radiographic correlates of manometric findings. When manometry recorded a peristaltic pressure wave, several other videofluoroscopic appearances were observed in addition to the normal stripping wave pattern (Table 2). Figure 6 shows a hypotensive pressure wave proximally, which is associated with partial escape of the barium bolus. Manometry was insensitive to the feeble non-lumen-obliterat-
ing contractions occurring in the bolus-filled esophageal segment distal to the peristaltic stripping wave located at the bolus tail. This phenomenon is shown in Figure 7, in which tertiary contraction waves occur along the edge of the barium bolus. The only manometric finding is an increase in basal intrabolus pressure. Nonperistaltic
Contractions
We recorded 98 fluoroscopic sequences with nonperistaltic tertiary contractions, 33 sequences with corkscrew (curling) contractions, 72 with sacculations or rosary beading, and 27 with transient diverticulum formation. Of these nonperistaltic contractions, 69 sequences were associated with concurrent isobaric waves and 62 with concurrent nonisobaric waves. Manometric correlates of radiographic findings. Because barium was generally completely stripped from the esophagus when a normal peristaltic sequence occurred, many abnormal fluoroscopic appear-
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MAlOHETRY Figure 6. Example of hypertensive peristalsis with proximal bolus escape. Although hypertensive peristaltic pressure waves are recorded distally, retrograde escape of the barium bolus from the stripping wave is seen at the region of the aortic arch, where a low-amplitude pressure wave is recorded. After clearance of the bolus from the distal esophagus, long-duration repetitive contractions are recorded manometrically from this region, and the pressure complexes at each recording site have different amplitudes and waveforms (i.e., they are nonisobaric waves). In this case, the nonisobaric waves represent “simultaneous” contractions of the esophageal wall that are not acting on a continuous fluid column.
antes were seen between swallows when residual barium was left in the esophagus after failure of peristalsis (Table 1).Contraction abnormalities were then commonly observed spontaneously or in response to a subsequent dry swallow. The fluoroscopic abnormalities observed were tertiary waves, corkscrew deformities, rosary beading, sacculations, and transient diverticula (Figures 4,7,and 8). Again, there was a limited range of manometric correlates for specific fluoroscopic appearances. When abnormal radiographic features were present and effective peristaltic bolus transport was absent, the manometric recordings never showed a normal peristaltic sequence. In general, the peak pressures recorded were progressively higher during tertiary wave (lo-95 mm Hg), corkscrew (25-l50 mm Hg), and rosary bead (40-630mm Hg) formation. However, considerable overlap existed in the range of peak pressures recorded during these different phenomena, depending on the recording site, recording sequence, and subject. An important finding was that hypertensive and/or prolonged pressure waves were not necessary for corkscrew or rosary bead deformities to occur. Conversely, hypertensive pressure waves were never recorded from sites located with regions of corkscrew or tertiary wave bolus deformation.
When tertiary waves were seen on radiography, the manometric tracing usually showed a slight increase in basal pressure or low-amplitude isobaric waves. When a corkscrew deformity was present and negligible axial flow was present, the manometric finding was generally that of isobaric waves. This finding was in contrast to corkscrew deformities with appreciable fluid flow or rosary beading, in which the manometric pattern was one of nonisobaric waves. Frequently, the corkscrew deformity progressed into rosary beading. This occurrence was heralded by a change in the manometric pattern from isobaric waves to nonisobaric waves, as is seen at 32.9 seconds in Figure 8. Isolated transient diverticula or sacculations iYere seen in the setting of nonperistaltic contractions. In such instances, nonisobaric waves were recorded manometrically. During some epigdes of nonperistaltic esophageal contractions, barium bolus transport was observed. When this phenomenon occurred, bolus flow was along a gradient of spatially decreasing pressure as seen in Figure 8 during the interval from 41.3 to 42.4 seconds. Radiographic correlates of manometric findings. The two broad categories of manometric waveforms present when peristalsis was absent were isobaric and nonisobaric waves. These two different
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MANOMETRY Figure 7. Example of a failed swallow with subsequent tertiary contractions. The initial barium swallow (SW) resulted in a failed peristaltic sequence, marked by the failure of the bolus tail to progress past site 6, at the level of the aortic arch. After a subsequent spontaneous dry swallow (DS), the peristaltic sequence is observed radiugraphically only when it reaches the tail of the bolus. Starting at 12.0 seconds, sawtooth tertiary contractions are seen deforming the holus column ahead of the leading edge of the peristaltic wave. The only manometric activity recorded fi-om this region during the tertiary contractions is a slight elevation in baseline pressure. Note that at 16.1 seconds a small amount of barium is trapped in a sacculation (orrow) in the vicinity of site 2 following the passage of the leading edge of the peristaltic wave. Subsequent escape of barium from this sacculation (not shown) occurred at the termination of contractile activity in this region.
pressure phenomena, in some instances, occurred concurrently in different regions of the esophagus, depending on whether a fluid-filled segment existed between the recording sites. A change from isobaric to nonisobaric waves in a given region was associated with segmentation of the fluid continuum into disconnected regions or significant axial movement of the bolus. Though there was overlap in the peak pressure amplitudes seen with isobaric and nonisobaric waves, hypertensive pressure amplitudes were observed only in nonisobaric waves. The resolution of isobaric or nonisobaric waves was associated with the disappearance of the concomitant bolus deformity seen on videofluoroscopy. Isobaric waves were the predominant manometric feature of the fluid-filled esophagus of patients with achalasia (Figure 9). However, nonisobaric waves were frequently recorded when partial emptying of the esophagus resulted in net fluid flow.
Discussion Esophageal manometry and radiography are often used to evaluate patients with suspected major disturbances of esophageal motor function, such as
achalasia or diffuse esophageal spasm. This study shows that manometry and radiography provide information on different but interrelated aspects of esophageal motor function and bolus transport. Manometry records at spatially fixed sites the temporal changes in pressure produced by contractions of the esophageal wall. Radiography records information about both esophageal wall movement and bolus transport within the esophageal lumen. Earlier studies of patients with esophageal motor disorders attempted to correlate the findings of radiographic and manometric studies performed on separate occasions (8-l l), as is the usual clinical practice. However, these studies suffer from the limited number of swallow sequences recorded as well as the intermittent nature of many esophageal motor abnormalities, so that abnormalities present during one study may not be present at the time of another study. When radiography and manometry have been performed concurrently and scored blindly, they have shown 93%-98% agreement between the findings of the two modalities in patients with suspected esophageal motor dysfunction (2,12,13). A given patient may show several different esoph-
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Figure 6. Example of corkscrew and rosary bead appearance as well as transient diverticulum formation. At the start of the sequence barium remains in the esophagus from a previously failed swallow. Following a dry swallow (DS), tertiary waves are seen deforming the barium column at 32.4 seconds. Similar pressure amplitudes and waveforms (i.e., isobaric waves) are recorded at all sites up until 33.9 seconds, consistent with the location of all manometric recording sites within the fluid continuum of an open lumen. However, after 33.9 seconds, the bolus begins to break up. By 33.9 seconds, pressure waves different amplitudes and waveforms (i.e., nonisobaric waves) are recorded at sites 3-5. In this region, the bolus has been deformed into a rosary bead pattern and a transient diverticulum is seen at site 3. At 33.9 seconds, sites 1-2 and 6-7 still show isobaric waves, consistent with the fluid continuum still present in these two regions. Note.that there is partial corkscrew formation at site 2 and that pressures within the region of rosary-beading range from 50 to 175 mm Hg. By 36.4 seconds, the bolus is discontinuous in the region of the distal 5 recording sites, where nonisobaric waves are recorded, and continuous in the region of the proximal 3, where low-amplitude isobaric waves are seen. By 41.3 seconds, the distal esophageal contractions are abating in an aborad sequence. The resultant pressure gradient causes retrograde flow of previously entrapped barium (arrow), as is seen at 43.4 seconds. This example illustrates how the radiographic findings may indicate the occurrence of long-duration esophageal contractions when some barium is retained within the contracting segment.
of
ageal manometric phenomena with deglutition, such as normal peristaltic pressure waves, waves of abnormal amplitude and/or duration, simultaneous or repetitive pressure waves, or absent pressure waves, whereas radiography displays variable patterns of normal bolus transport, proximal bolus escape, absent bolus transport, or varying forms of nonperistaltic contractions. Such findings may suggest poor correlation between these two modalities. However, when recorded concurrently and examined on a swallow-by-swallow basis, the findings from radiographic and manometric recordings show clear patterns of association. When esophageal contractions are peristaltic and the pressure amplitude is sufficiently high to maintain luminal closure, bolus clearance is invariably normal on radiography (3). However, radiography does not record esophageal motor activity occurring in a region after peristalsis has cleared the bolus from that region. Thus, hypertensive
peristaltic,contractions recorded manometrically show peristaltic bolus clearance on radiography. Nonperistaltic contractions result in absent or ineffective bolus clearance from the esophagus. In such instances, some bolus clearance may occur because of gravity if the subject is upright or if a pressure gradient between the esophagus and stomach is created by nonperistaltic esophageal contractions. Radiography may demonstrate different forms of nonperistaltic contractions, such as tertiary indentations, corkscrew deformations, sacculations, rosary beading, or transient diverticula. These nonperistaltic contractions seen on radiography have specific manometric correlates that depend on whether the recording sites are located within the common cavity of a continuous fluid column or within esophageal segments separated by a luminal segment devoid of fluid. As hypothesized by Kaye (14), transmission of pressure throughout a relatively static fluid bolus results
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FLUOROSCOPY OF BARIUM SWALLOW
MANOMETRY Figure 6. Example of a simple isobaric wave in a patient with achalasia. Starting at 30.2 seconds contractions are seen to indent the bolus at different sites along the esophageal wall. Bolus deformation peaks at 33.7 seconds without bolus fluid being expelled from the esophagus. Esophageal contractions and the bolus deformation have resolved by 36.7 seconds. Throughout this sequence pressure waves of similar form and amplitude (i.e., isobaric waves) are recorded from the manometric sites. Although the radiographic record suggests contractions of differing intensity in the esophageal segments adjacent to the different manometric recording sites, none of the contractions occlude the esophageal lumen. Hence, the increased intrabolus pressure caused by these contractions is transmitted throughout the fluid continuum within which the manometric recording sites are located.
in isobaric pressure tracings of similar amplitude and waveform that are recorded simultaneously at all manometric sites located within this continuum. In the case of weak contractions that deform the bolus only slightly, current manometric recordings are relatively insensitive to the minimal increase in basal pressure. With contractions of greater magnitude, such as those associated with corkscrew formation, isobaric waves are generally recorded. This phenomenon is to be distinguished from nonisobaric waves, wherein different manometric sites record from esophageal segments that are separated from one another by lumen-obliterated regions devoid of bolus fluid, a situation which exists when rosary beading is present. In such instances, recorded pressure waves exhibit dissimilar amplitudes and waveforms. Hence, on occasions when the fluoroscopic sequence shows progression from corkscrew deformation to rosary beading, the manometric recording often shows isobaric waves progressing to nonisobaric waves. Because pressure is distributed uniformly in a static fluid column, isobaric waves are recorded from recording orifices within a fluid-filled, nonperistaltic segment, regardless of what portions of the adjacent esophageal wall are contracting. Hence, the occurrence of isobaric waves at different manometric recording sites does not necessarily mean that “simulta-
neous contractions” of the esophagus are occurring at all of those sites. Similarly, a feeble, non-lumenobliterating contraction that sweeps in peristaltic fashion along the bolus tends to cause only slight fluid motion within the bolus. Consequently, spatial variations in pressure within the bolus are modest and pressure signatures from adjacent manometric ports display similar waveforms. Thus, the manometric tracings can have the appearance of nonperistaltic isobaric waves when, in reality, a non-lumenobliterating peristaltic contraction is progressing along the esophageal wall. Such a manometric record should not be misinterpreted as a “simultaneous contraction” or “spasm.” Reports exist of patients with primary (15-18) or secondary (19-25) achalasia whose manometric findings revert to normal peristalsis when outlet obstruction is relieved and esophageal dilatation resolves. That some of these patients were described on fluoroscopy to have feeble peristalsis when the manometric finding was aperistaltic contractions (22,23) suggests that, in some instances, peristaltic contractile activity in the esophagus can exist without appreciable bolus movement. Under such conditions, isobaric waves would be recorded from adjacent sites within the bolus. Normal peristaltic contractile activity may be identified when relief of outflow obstruction allows
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the contractions to occlude the lumen and affect aboral bolus transport. Isobaric waves resulting from non-lumen-obliterating peristaltic contractions have recently been demonstrated in a feline model of esophageal outflow obstruction (26). We conclude that an understanding of the principles of fluid mechanics involved in esophageal bolus transport allows for a meaningful comparison of esophageal motor function as recorded by radiography and manometry. Good correlation exists between the findings of these two modalities when they are analyzed in terms of the two separate pressure domains of intrabolus pressure and pressure within lumen-obliterated segments. An index for the correlates between manometric and radiographic findings is provided in Tables 1 and 2. Whereas manometry quantifies contractile segment and intrabolus pressures, it is insensitive to bolus transport and peristaltic and nonperistaltic esophageal contractions that do not obliterate the lumen. In contrast, radiography images esophageal bolus transport and esophageal clearance but does not measure the magnitude of contractile pressures or detect motor events when barium has been cleared from a contracting esophageal segment. Hence, the limitations and advantages of these two modalities make them complementary techniques for evaluating esophageal motor function. References Brasseur JG. A fluid mechanical perspective on esophageal bolus transport. Dysphagia 1987;2:32-39. 2. Hogan WJ, Dodds WJ, Stewart ET. Comparison of roentgenology and intraluminal manometry for evaluating esophageal peristalsis (abstr). Rendiconti Gastroenterol1973;5:28. 3. Kahrilas PJ, Dodds WJ, Hogan WJ. Effect of peristaltic dysfunction of esophageal volume clearance. Gastroenterology 1988;94:
10. Chen YM, Ott DJ, Hewson EG, Richter JE, Wu WC, Gelfand DW,
Caste11 DO. Diffuse esophageal spasm: radiographic and manometric correlation. Radiology 1989;170:807-810. 11. Geisman RA, Clouse RE. Correlation of radiographic and manometric patterns in patients with esophageal contraction abnormalities [abstr). Gastroenterology 1988;94:A143. 12. Ott DJ, Chen YM, Hewson EG, Richter JE, Dalton CB, Gelfand DW, Wu WC. Esophageal motility: assessment with synchronous video tape fluoroscopy and manometry. Radiology 1989; 173:419-422. 13. Hewson EG, Ott DJ, Dalton CB, Chen YM, Wu WC, Richter JE. Manometry and radiology: complementary studies in the assessment of esophageal motility disorders. Gastroenterology 1990; 98:626-632. 14. Kaye MD. Anomalies of peristalsis in idiopathic diffuse esophageal spasm. Gut 1981;22:217-222. 15. Mellow MH. Return of esophageal peristalsis in idiopathic achalasia. Gastroenterology 1976;70:1148-1151. 16. Vantrappen G, Janssens J, Hellemans J, Coremans G. Achalasia, diffuse esophageal spasm and related motility disorders. Gastroenterology 1979;76:450-457. 17. Bianco A, Cagossi M, Scrimieri D, Greco AV. Appearance of esophageal peristalsis in treated idiopathic achalasia. Dig Dis Sci 1986;31:40-48. 18. Ponce J, Miralbes M, Garrigues V, Berenguer J. Return of esophageal peristalsis after Heller’s myotomy for idiopathic achalasia. Dig Dis Sci 1986;31:545-547. 19. Davis JA, Kantrowitz PA, Chandler HL, Schatzki SC. Reversible achalasia due to reticulum-cell sarcoma. N Engl J Med 1975;293: 130-132. 20. Kline MM. Successful
treatment of vigorous achalasia associated with gastric lymphoma. Dig Dis Sci 1980;25:311-313. 21. Menin R, Fisher RS. Return of esophageal peristalsis in achalasia secondary to gastric cancer. Dig Dis Sci 1981;26:10381044. 22. Goldin
1.
73-80. 4. Dodds WJ, Hogan WJ, Arndorfer RC, Dent J. Efficient manomet-
5.
6.
7.
8.
ric technique for accurate regional measurement of esophageal body motor activity. Am J Gastroenterol 1978;70:21-24. Arndorfer RC, Steff JJ, Dodds WJ, Linehan JH, Hogan WJ. Improved infusion system for intraluminal esophageal manometry. Gastroenterology 1977;73:23-27. Dodds WJ. Current concepts of esophageal motor function: clinical implications for radiology. Am J Roentgen01 1977;128: 549-561. Dodds WJ, Hogan WJ, Reid DP, Stewart ET, Arndorfer RC. A comparison between primary peristalsis following wet and dry swallows. J Appl Physiol 1973;354:851-857. Willerson JT, Thompson RH, Hookman P, Herdt J, Decker JL. Reserpine in Raynaud’s disease and phenomenon: short-term response to intraarterial injection. Ann Intern Med 1970;72:17-
27. 9. Ott DJ, Richter JE, Chen YM, Wu WC, Gelfand DW, Caste11 DO.
Esophageal radiography and manometry: correlation patients with dysphagia. AJR 1987;149:307-311.
in 172
23.
24.
25.
26.
NR, Burns TW, Ferrante WA. Secondary achalasia: association with adenocarcinoma of the lung and reversal with radiation therapy. Am J Gastrenterol 1983;78:203-205. Costigan DJ, Clouse RE. Achalasia-like esophagus from amyloidosis: successful treatment with pneumatic bag dilatation. Dig Dis Sci 1983;28:763-765. Kahrilas PJ, Kishk SM, Helm JF, Dodds WJ, Harig JM, Hogan WJ. Comparison of pseudoachalasia and achalasia. Am J Med 1987;82:439-446. Woods CA, Foutch PG, Waring JP, Sanowski RA. Pancreatic pseudocyst as a cause for secondary achalasia. Gastroenterology 1989;96:235-239. Mittal RK, Ren J, McCallum RW, Shaffer HA, Sluss J. Modulation of feline esophageal contractions by bolus volume and outflow obstruction. Am J Physiol1990;258:G208-G215.
Received March 1,199O. Accepted December 13.1990. Address requests for reprints to: Benson T. Massey, M.D., Division of Gastroenterology, Froedtert Memorial Lutheran Hospital, 9200 West Wisconsin Avenue, Milwaukee, Wisconsin 53226. This study was supported in part by National Institutes of Health grant DK 25731 and training grant AM07267 (Dr. Massey]. This work was presented at the biennial meeting of the American Motility Society in Asilomar, California, on October 2, 1988, and was published in abstract form (Gastroenterology 1988;95:A878).
Abnormal Esophageal Motility An Analysis of Concurrent Mariometric Findings BENSON T. MASSEY, JAMES G. BRASSEUR,
Radiographic
WYLIE J. DODDS, WALTER and JAMES F. HELM
and
J. HOGAN,
Departments of Medicine and Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin; and Department of Mechanical Engineering, School of Engineering, Pennsylvania State University, University Park, Pennsylvania _
The findings of concurrent esophageal videofluoroscopy and manometry in 15 patients with major disturbances of esophageal motor function were evaluated and the data were analyzed from a fluid mechanical perspective. Each of 153 fluoroscopic barium swallow sequences was analyzed on a swallow-by-swallow basis. Two distinct pressure domains were identified: intrabolus pressure and pressure within a bolus-free contracting esophageal segment. Analyses in terms of these pressure domains showed specific and consistent correlations between the radiographic and manometric findings. Radiography was insensitive to contractions occurring in esophageal segments devoid of bolus fluid, whereas manometry was insensitive to contractions that did not occlude the lumen. It is concluded that using fluid mechanical principles of bolus transport allows meaningful comparison of esophageal motility as recorded by radiography and intraluminal manometry. However, the inherent limitations in the range of physical phenomena recorded by each modality make these techniques complementary for evaluating esophageal motor function. adiography and manometry are the two diagnostic modalities used most commonly for the evaluation of patients with suspected esophageal motor disturbances. These two modalities record different parameters of esophageal motor function, thereby raising the possibility that they may not be equally useful in detecting all facets of disturbances in esophageal motor function. However, recent analysis of fluid mechanical models of esophageal bolus transport suggests that some parameters measured by manometry and radiography may have a predictable correspondence (1).Previously, we evaluated the relationship between concurrent manometric and radiographic findings in subjects with normal or only
R
mildly abnormal esophageal motor function (2,s). Our aims in this study were to (a) obtain concurrent manometric and radiographic recordings in patients with substantial abnormalities of esophageal motor function and (b) analyze the data from a fluid mechanical perspective to determine if correlates exist between the two recording modalities when such abnormalities are present. Methods We performed concurrent esophageal videofluoroscopy and manometry in 15 patients (seven men and eight women, aged 39-83 years) with diverse esophageal motor disorders. The patients were referred to our manometry laboratory for evaluation of dysphagia and/or chest pain. The final diagnoses in the 15 patients included hypertensive peristalsis (Z patients), achalasia (4 patients], diffuse esophageal spasm (3 patients), myotonic dystrophy (1 patient), and unclassified esophageal motor disorders (5 patients). The study was approved by the Medical College of Wisconsin Institutional Review Board. For i&alumina1 manometry we used an eight-lumen recording catheter, described previously (3,~). Eight orifices, cut at 3-cm intervals, beginning 1 cm from the assembly tip, gave a span of 21 cm. A metal marker immediately distal to each recording orifice enabled radiographic localization of each recording site. After the subjects fasted 6-12 hours, the manometric assembly was passed transnasally and positioned with the distal recording orifice [site 1) 1-2 cm proximal to the lower esophageal sphincter (LES). During recordings each manometric recording orifice was perfused with water (0.5 mL/min) by a minimally compliant perfusion system (5). Each recording lumen was connected to an external transducer (model 23Db; Gould Inc., Oxnard, CA). Pressures were recorded with an eight-channel polygraph recorder (SensorMedics
o 1991bytheAmericanGastroenterologicalAssociation 0016-5005/91/$3.00
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CONCURRENT ESOPHAGEAL RADIOGRAPHYAND h4ANOMETRY 345
Corp., Anaheim, CA), at a paper speed of 10 mm/s. Pressures were recorded only from the distal seven sideholes of the manometric catheter while the eighth polygraph channel was used to record a timing signal. After placement of the manometric assembly, the subject lay in a supine position, rotated 15” left side down, so that the esophagus projected slightly to the left of the spine. The output from the videofluoroscopic image intensifier was transmitted to a Betamax videorecorder (Sony model SLHF 900) with a 0.5-in tape recording at 30 frames per second. The video and manometric recordings were synchronized using a modified timer (model VC-436; Thalner Electronics Laboratories Inc., Ann Arbor, MI) that encoded digital time on each videoframe and sent a signal each second to the eighth channel of the polygraph (3). For each patient, a median of 10 fluoroscopic sequences were recorded, each initiated by a single 5-mL or 10&L barium swallow (40% wt/vol, SG 1.6). For most sequences, the fluoroscope was swept over the entire esophagus, whereas on other sequences the fluoroscope was fixed over the proximal or distal half of the esophagus. Spontaneous or requested dry swallows were recorded during some of the fluoroscopic sequences. Some sequences were recorded after the patient was given IV edrophonium (80 pg/kg) or atropine (3 or 6 l&g). Data analysis was performed by slow motion and freezeframe playback of the videorecordings with reference to the concurrent manometric tracings. Each sequence and swallow was analyzed individually. The analysis was conducted to identify (a) what manometric correlates existed for a given radiographic phenomenan and, conversely, (b) what radiographic appearances existed for a given manometric phenomenon. For example, the manometric correlates were determined for the radiographic appearances of tertiary contractions (shallow, sawtooth indentations along the barium bolus), corkscrew (curling) configurations, and rosary beading (barium saculation separated by segmental luminal occlusions). Conversely, the radiographic appearances were established for hypertensive peristaltic pressure waves, simultaneous spastic esophageal contractions, and retrograde waves.
imparted an inverted-V configuration to the tail of the barium bolus and traversed the entire esophagus (6). With manometry this peristaltic action was identified as a peristaltic pressure wave that passed each recording site successively in an aboral direction, traversing the entire esophagus at an average speed of 2-4 cm/s (7). As described previously (3,6) the tail peristaltic stripping wave seen radiologically close temporal relationship with the onset upstroke of the pressure wave (Figure 1). Two Domains of Intraluminal
of the had a of the
Pressure
Initial review confirmed, as suggested previously (l), that when a lumen-obliterating contraction is present after a wet swallow, intraluminal pressure is segregated into two distinct domains: that of intrabolus pressure and that within the contracted esophageal segment which is devoid of bolus fluid. As illustrated in Figure 1, these two pressure domains are separated spatially and temporally from one another.
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Results For the 15 patients, 153 fluoroscopic sequences containing 165 barium swallows and 125 dry swallows as well as intervals of nondeglutitive motor activity were analyzed. Initial review showed several important principles concerning the relationship between manometrically recorded pressure phenomena and intraluminal bolus transport recorded by radiography. These principles were then used to correlate specific radiographic and manometric patterns. General Observations Relationship Between Bolus Tail and Peristaltic Pressure Wave
On fluoroscopy, esophageal peristaltic bolus transport was seen as a stripping wave that generally
T3
Figure 1. Schematic illustration of the two domains of intrabolus pressure and pressure within a lumen-occluded esophageal segment. The left side of the illustration shows the position of the bolus relative to three manometry recording sites (PI-P,) at three different times (T,-T,) corresponding to the passage of the bolus tail past these manometric sites. The right side of the illustration shows the pressure tracings from the three manometric sites. The shaded areas under the pressure curves represent the interval during which pressure is recorded from within the fluid-filled esophageal lumen (i.e., intrabolus pressure). The upstroke of the pressure wave at each site is closely associated with passage of the bolus tail past that site. Between times T, and T,, recording sites P, and P, are within the fluid continuum of the bolus and are segregated from site P, by a contracted esophageal segment. Hence, during this time interval the elevated contractile pressure at P, is not transmitted to either sites P, or P,, both of which record similar low-amplitude intrabolus pressures.
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This distinction is essential because contractile pressures within the bolus-free segment are not transmitted directly to the bolus itself, because fluid must be present for pressure to be transmitted axially along the length of the esophageal lumen. Hence, for a peristaltic stripping wave, when the contractile pressure wave is recorded from a lumen-occluded esophageal segment, the peak wave pressure is never observed concurrently at manometric recording sites located distally within the bolus-filled esophagus.
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Isobaric Versus Nonisobaric
IA
Waves
An essential distinction exists on manometry between what we call isobaric waves and nonisobaric waves. Previously, isobaric waves have been termed simultaneous waves and nonisobaric waves had been referred to as simultaneous contractions. However, we believe that this new terminology of isobaric and nonisobaric waves avoids misconceptions about the underlying fluid mechanics of the observed manometric phenomena. We define isobaric waves as pressure waves of similar amplitude and waveform that are recorded concurrently from two or more adjacent recording sites. Isobaric, or simultaneous waves, were recorded only when two or more manometric sites were located within a fluid-filled, open-lumened esophageal segment in which there was negligible fluid flow. This observation is illustrated schematically in Figure 2A, in which intraluminal pressure waves resulting from contraction of any portion of the esophageal wall bounding the trapped bolus are transmitted uniformly to all recording sites located within the bolus, so long as the esophageal lumen is not occluded between the two recording sites. This phenomenon of isobaric waves which erroneously has been referred to as simultaneous contractions as well as simultaneous waves is in contrast tothe phenomenon of nonisobaric waues, which we define as the simultaneous occurrence of pressure waves of adifferent amplitude and configuration recorded from adjacent recording sites. When nonisobaric waves are present (Figure 2B), the recording sites are located within (a) bolus-depletea, contracted esophageal segments, (b) two or more regions of bolus fluid that are segregated by a lumen-occluded segment of esophagus, or (c) fluid-filled esophageal segments experiencing appreciable fluid 40~.
Correlation of Videofluoroscopic and Manometric Findings Analysis of the. tideofluoroscopic and manometric recordings showed that some patients (e.g., those with achalasia) showed similar radiographic
Figure 2. Schematic illustration of the difference baric waves and nonisobaric waves.
t
:
between
iso-
A. Isobaric waves. The left part of the diagram represents the radiographic appearance at time A corresponding to the manometric tracings recorded from sites P,-P, located within the esophageal lumen, At time A (verkal dotted line), P, and P, are located within a fluid continuum (shaded area) that is bounded by segments of the esophagus where the lumen is occluded. When the bolus is not in motion, pressures transmitted from the esophageal wall to the fluid are transmitted uniformly throughout the fluid [i.e., P, = PJ. Thus, isobaric or simultaneous waves of similar form and amplitude are recorded at P, and P,. Such waves do not require the simultaneous contraction of the esophagus at P, and P,; therefore, these waves should not be called simultaneous contractions. B. Nonisobaric waves. At time B, sites P, and P, are both within portions of the bolus separated by a lumen-occluded segment of esophagus devoid of bolus fluid. Pressures generated at P,, therefore, cannot be transmitted to P,, so that nonisobaric waves having different forms and amplitudes exist at these two sites, indeed, at all 4 sites. Nonisobaric waves generally result from contractions occurring simultaneously at several sites along an esophageal segment, although they may also be seen if a nonperistaltic contraction at one site only causes appreciable fluid flow.
and manometric patterns during most swallows. However, the majority (e.g., patients with nonspecific esophageal motor disorders) showed considerable variation in manometric and radiographic patterns from swallow to swallow. Because of this variation, the recorded sequences were more appropriately analyzed on a swallow-by-swallow basis, rather than by averaging results within diagnostic categories. Analysis of the recorded sequences showed that a limited range of manometric findings was associated with a specific motor pattern observed fluoroscopically and vice versa. These relationships are outlined in Tables 1 and2. Peristaltic Contractions
From the 15 patients we recorded 69 sequences with hypertensive peristalsis (e.g., distal esophageal pressures waves > 200 mm Hg in amplitude), 22 sequences with hypotensive peristalsis (esophageal
CONCURRENT ESOPHAGEAL RADIOGRAPHY AND MANOMETRY
August 1991
Table 2. Esophageal Manometric Patterns and Their Radiographic Correlates
Table 1. Esophageal Radiographic Patterns and Their Manometric Correlates Radiographic
Peristaltic contractions Normal peristalsis
Normal peristaltic wave, hypertensive peristalsis, nonisobaric waves following a leading peristaltic front Hypotensive peristalsis Elevated basal pressure, isobaric, and/or nonisobaric waves Retrograde peristalsis
Proximal escape Non-lumen-obliterating peristaltic contraction Retrograde peristalsis Nonperistaltic contractions Tertiary contractions
Elevated basal pressure, lowamplitude isobaric waves Isobaric waves, nonisobaric waves (with appreciable fluid flow) Nonisobaric waves
Curling (corkscrew) contractions Rosary bead (lumenoccluding) contractions Sacculations Transient diverticulum
Nonperistaltic movement
Nonisobaric waves Nonisobaric waves, no pressure wave if orifice facing diverticulum neck Antegrade successive relaxation of nonisobaric waves Regional pressure gradient
bolus
Radiographic findings
Manometric findings
Manometric findings
findings
347
Peristaltic waves Normal peristalsis or hypertensive peristalsis
Hypotensive
peristalsis
Retrograde peristalsis Nonperistaltic waves Isobaric waves or elevated basal pressure
Nonisobaric waves
Initial isobaric or nonisobaric waves with subsequent sequential, nonsimultaneous relaxation
FLUOROBCOPY 41k
Normal stripping wave, possible tertiary contractions along bolus ahead of bolus tail, occasional residual barium in sacculations or diverticula Regional bolus escape, occasional normal stripping wave Retrograde stripping wave
Continuous fluid column within open lumen; possible tertiary contractions, curling, or nonlumen-obliterating peristalsis Bolus absent or bolus portions segregated by lumen-occluded segments [rosary beading, sacculations, transient diverticula), fluid continuum present but appreciable fluid flow occurs Nonperistaltic bolus flow (generally retrograde] along pressure gradient
OF BAIUM
BWALLOW
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Figure 3. Example of hypertensive peristalsis. As with peristaltic waves of normal amplitude, the tail of the barium bolus passes each mauometric recording site coincident with the onset of the peristaltic pressure wave at that site. The prolonged high-pressure contractions are not evident radiographically because barium has been cleared from each site before the maximal pressure waves are recorded.
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GASTROENTEROLOGY
pressures waves <3O mm Hg) and proximal bolus escape, 22 sequences with non-lumen-obliterating peristaltic contractions, and 20 sequences with retrograde peristalsis. Manometric
correlates of radiographic
findings.
When the fluoroscopic image showed an intact stripping wave, the leading edge of the manometrically recorded contraction wave always showed peristaltic progression and its initial upstroke was closely associated temporally with passage of the bolus tail (Table 1). Because intact stripping waves did not generally leave any residual barium in the esophagus, videofluoroscopy did not show motor events occurring in the esophagus after the stripping wave had passed that region of the esophagus. In our patients with hypertensive peristaltic contractions, an effective stripping wave was seen radiographically (Figure 3). Because the bolus is propelled ahead of the peristaltic contraction wave, there is no radiographic image from within the region of elevated pressures that follows the bolus. In episodes of retrograde peristalsis, the pressure
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Vol. 101, No. 2
wave upstroke was associated with the retrograde passage of the bolus tail at that site (Figure 4). Contractions following the leading edge of a peristaltic contraction wave were evident radiographically only when residual barium was left in the esophageal body, because of retention in sacculations or transient diverticula or because of proximal bolus escape caused by hypotensive peristalsis. In the case of barium becoming trapped within sacculations or transient diverticula, termination of the contraction wave at that site corresponded fluoroscopically to escape of the trapped barium, thus allowing fluoroscopic determination of contraction duration at that site. When videofluoroscopy recorded proximal escape of a portion of the bolus (usually in the region of the aortic arch), manometry recorded hypotensive peristaltic pressure waves in the region of escape, as described previously (3). In several sequences, videofluoroscopy recorded a non-lumen-obliterating peristaltic contraction that traversed part of the esophagus without occluding its
SECONOSOr'
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MANOMETRY Figure 4. Example of retrograde peristalsis in a patient with an unclassified esophageal motility disorder. At the beginning of this sequence, barium remains in the esophagus after a failed swallow. Starting at 25.8 seconds, tertiary contractions, seen along the contour of the barium bolus, correspond to the onset of low-amplitude isobaric waves recorded manometrically throughout the esophagus’(note differences in scale on different channels). These waves peak at 28.8 seconds. Starting at 27’.9 seconds, a retrograde peristaltic stripping wave is seen. The aborad passage of the barium bolus tail past the three distal recording sites (vertical arrows) corresfionds closely With the onset of the contraction wave at each site. The retrograde peristaltic pressure wave is not seen at the fourth manometric site, corresponding to the failure of the retrograde stripping wave to carry the bolus tail past that site.
CONCURRENT ESOPHAGEAL RADIOGRAPHY
August 1991
SECOIIOS, , ,I , , , , ,, ,
FLUOROSCOPY
OF BARIUM
AND MANOMETRY
349
SWALLOW
14.2s 6.18 6.9s 7.5s 9.1s 94s 9.4s ~~~~_~~~~~~_____~~_~~~______~~~~~~~~~~~~~~~~~~_~___~~~~~~~~~~~~~~~
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3cm _____/_3cm -_L_. 1 m & /; Figure 5. Example of a non-lumen-obliterating peristaltic contraction. In this patient, hypertensive contractions were diminished by 6 pgkg atropine. Bolus transport proceeds normally in the proximal, striated muscle portion of the esophagus, but retrograde bolus escape and a slight delay in the peristaltic wave are observed at the aortic arch, in the region of the junction between the striated and smooth muscle parts of the esophagus. By the time the peristaltic wave reaches site 4, as determined by fluoroscopy (7.5 seconds), it is no longer lumen obliterating. Note that starting at about 6.8 seconds isobaric waves are initially seen in channels 1-4. The passage of the non-lumen-obliterating peristaltic wave (horizontal arrows) is marked only by a slight indentation of the barium bolus that moves distally. In effect, the non-lumen-obliterating peristaltic contraction is seen as a ripple along the barium-filled esophagus. Its arrival at recording sites Z-4 has no distinct manometric correlates, because pressures are recorded within an open lumen of a relatively motionless fluid continuum, Because of extensive retrograde escape of the bolus, minimal barium enters the stomach. The relaxation phase of the pressure wave has slightly different amplitades and waveforms at the different distal recording sites (i.e., they have changed to nonisobaric waves), corresponding to net retrograde axial flow in the esophagus as it relaxes.
lumen. Such contractions did not effectively transport the bolus distally. In such instances, the manometric tracings from within the bolus transiently showed isobaric waveforms that appeared nonperistaltic. The example shown in Figure 5 shows a nonlumen-obliterating peristaltic contraction in a patient with hypertensive peristalsis who had received atropine. Atropine decreased peristaltic pressure wave amplitude in the distal esophagus, and the recorded pressures initially displayed the pattern of isobaric waves. The upstrokes of these waves do not correspond temporally to the passage of the nonlumenoccluding peristaltic contraction wave past the respective recording sites. Radiographic correlates of manometric findings. When manometry recorded a peristaltic pressure wave, several other videofluoroscopic appearances were observed in addition to the normal stripping wave pattern (Table 2). Figure 6 shows a hypotensive pressure wave proximally, which is associated with partial escape of the barium bolus. Manometry was insensitive to the feeble non-lumen-obliterat-
ing contractions occurring in the bolus-filled esophageal segment distal to the peristaltic stripping wave located at the bolus tail. This phenomenon is shown in Figure 7, in which tertiary contraction waves occur along the edge of the barium bolus. The only manometric finding is an increase in basal intrabolus pressure. Nonperistaltic
Contractions
We recorded 98 fluoroscopic sequences with nonperistaltic tertiary contractions, 33 sequences with corkscrew (curling) contractions, 72 with sacculations or rosary beading, and 27 with transient diverticulum formation. Of these nonperistaltic contractions, 69 sequences were associated with concurrent isobaric waves and 62 with concurrent nonisobaric waves. Manometric correlates of radiographic findings. Because barium was generally completely stripped from the esophagus when a normal peristaltic sequence occurred, many abnormal fluoroscopic appear-
350
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GASTROmTEROLOGYVol.101,No.Z
FLUOROSCOPY
Of BARIUM SWALLOW
4.8a --UY---------6.687.7s a.38ui lo.ls
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MAlOHETRY Figure 6. Example of hypertensive peristalsis with proximal bolus escape. Although hypertensive peristaltic pressure waves are recorded distally, retrograde escape of the barium bolus from the stripping wave is seen at the region of the aortic arch, where a low-amplitude pressure wave is recorded. After clearance of the bolus from the distal esophagus, long-duration repetitive contractions are recorded manometrically from this region, and the pressure complexes at each recording site have different amplitudes and waveforms (i.e., they are nonisobaric waves). In this case, the nonisobaric waves represent “simultaneous” contractions of the esophageal wall that are not acting on a continuous fluid column.
antes were seen between swallows when residual barium was left in the esophagus after failure of peristalsis (Table 1).Contraction abnormalities were then commonly observed spontaneously or in response to a subsequent dry swallow. The fluoroscopic abnormalities observed were tertiary waves, corkscrew deformities, rosary beading, sacculations, and transient diverticula (Figures 4,7,and 8). Again, there was a limited range of manometric correlates for specific fluoroscopic appearances. When abnormal radiographic features were present and effective peristaltic bolus transport was absent, the manometric recordings never showed a normal peristaltic sequence. In general, the peak pressures recorded were progressively higher during tertiary wave (lo-95 mm Hg), corkscrew (25-l50 mm Hg), and rosary bead (40-630mm Hg) formation. However, considerable overlap existed in the range of peak pressures recorded during these different phenomena, depending on the recording site, recording sequence, and subject. An important finding was that hypertensive and/or prolonged pressure waves were not necessary for corkscrew or rosary bead deformities to occur. Conversely, hypertensive pressure waves were never recorded from sites located with regions of corkscrew or tertiary wave bolus deformation.
When tertiary waves were seen on radiography, the manometric tracing usually showed a slight increase in basal pressure or low-amplitude isobaric waves. When a corkscrew deformity was present and negligible axial flow was present, the manometric finding was generally that of isobaric waves. This finding was in contrast to corkscrew deformities with appreciable fluid flow or rosary beading, in which the manometric pattern was one of nonisobaric waves. Frequently, the corkscrew deformity progressed into rosary beading. This occurrence was heralded by a change in the manometric pattern from isobaric waves to nonisobaric waves, as is seen at 32.9 seconds in Figure 8. Isolated transient diverticula or sacculations iYere seen in the setting of nonperistaltic contractions. In such instances, nonisobaric waves were recorded manometrically. During some epigdes of nonperistaltic esophageal contractions, barium bolus transport was observed. When this phenomenon occurred, bolus flow was along a gradient of spatially decreasing pressure as seen in Figure 8 during the interval from 41.3 to 42.4 seconds. Radiographic correlates of manometric findings. The two broad categories of manometric waveforms present when peristalsis was absent were isobaric and nonisobaric waves. These two different
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MANOMETRY Figure 7. Example of a failed swallow with subsequent tertiary contractions. The initial barium swallow (SW) resulted in a failed peristaltic sequence, marked by the failure of the bolus tail to progress past site 6, at the level of the aortic arch. After a subsequent spontaneous dry swallow (DS), the peristaltic sequence is observed radiugraphically only when it reaches the tail of the bolus. Starting at 12.0 seconds, sawtooth tertiary contractions are seen deforming the holus column ahead of the leading edge of the peristaltic wave. The only manometric activity recorded fi-om this region during the tertiary contractions is a slight elevation in baseline pressure. Note that at 16.1 seconds a small amount of barium is trapped in a sacculation (orrow) in the vicinity of site 2 following the passage of the leading edge of the peristaltic wave. Subsequent escape of barium from this sacculation (not shown) occurred at the termination of contractile activity in this region.
pressure phenomena, in some instances, occurred concurrently in different regions of the esophagus, depending on whether a fluid-filled segment existed between the recording sites. A change from isobaric to nonisobaric waves in a given region was associated with segmentation of the fluid continuum into disconnected regions or significant axial movement of the bolus. Though there was overlap in the peak pressure amplitudes seen with isobaric and nonisobaric waves, hypertensive pressure amplitudes were observed only in nonisobaric waves. The resolution of isobaric or nonisobaric waves was associated with the disappearance of the concomitant bolus deformity seen on videofluoroscopy. Isobaric waves were the predominant manometric feature of the fluid-filled esophagus of patients with achalasia (Figure 9). However, nonisobaric waves were frequently recorded when partial emptying of the esophagus resulted in net fluid flow.
Discussion Esophageal manometry and radiography are often used to evaluate patients with suspected major disturbances of esophageal motor function, such as
achalasia or diffuse esophageal spasm. This study shows that manometry and radiography provide information on different but interrelated aspects of esophageal motor function and bolus transport. Manometry records at spatially fixed sites the temporal changes in pressure produced by contractions of the esophageal wall. Radiography records information about both esophageal wall movement and bolus transport within the esophageal lumen. Earlier studies of patients with esophageal motor disorders attempted to correlate the findings of radiographic and manometric studies performed on separate occasions (8-l l), as is the usual clinical practice. However, these studies suffer from the limited number of swallow sequences recorded as well as the intermittent nature of many esophageal motor abnormalities, so that abnormalities present during one study may not be present at the time of another study. When radiography and manometry have been performed concurrently and scored blindly, they have shown 93%-98% agreement between the findings of the two modalities in patients with suspected esophageal motor dysfunction (2,12,13). A given patient may show several different esoph-
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Figure 6. Example of corkscrew and rosary bead appearance as well as transient diverticulum formation. At the start of the sequence barium remains in the esophagus from a previously failed swallow. Following a dry swallow (DS), tertiary waves are seen deforming the barium column at 32.4 seconds. Similar pressure amplitudes and waveforms (i.e., isobaric waves) are recorded at all sites up until 33.9 seconds, consistent with the location of all manometric recording sites within the fluid continuum of an open lumen. However, after 33.9 seconds, the bolus begins to break up. By 33.9 seconds, pressure waves different amplitudes and waveforms (i.e., nonisobaric waves) are recorded at sites 3-5. In this region, the bolus has been deformed into a rosary bead pattern and a transient diverticulum is seen at site 3. At 33.9 seconds, sites 1-2 and 6-7 still show isobaric waves, consistent with the fluid continuum still present in these two regions. Note.that there is partial corkscrew formation at site 2 and that pressures within the region of rosary-beading range from 50 to 175 mm Hg. By 36.4 seconds, the bolus is discontinuous in the region of the distal 5 recording sites, where nonisobaric waves are recorded, and continuous in the region of the proximal 3, where low-amplitude isobaric waves are seen. By 41.3 seconds, the distal esophageal contractions are abating in an aborad sequence. The resultant pressure gradient causes retrograde flow of previously entrapped barium (arrow), as is seen at 43.4 seconds. This example illustrates how the radiographic findings may indicate the occurrence of long-duration esophageal contractions when some barium is retained within the contracting segment.
of
ageal manometric phenomena with deglutition, such as normal peristaltic pressure waves, waves of abnormal amplitude and/or duration, simultaneous or repetitive pressure waves, or absent pressure waves, whereas radiography displays variable patterns of normal bolus transport, proximal bolus escape, absent bolus transport, or varying forms of nonperistaltic contractions. Such findings may suggest poor correlation between these two modalities. However, when recorded concurrently and examined on a swallow-by-swallow basis, the findings from radiographic and manometric recordings show clear patterns of association. When esophageal contractions are peristaltic and the pressure amplitude is sufficiently high to maintain luminal closure, bolus clearance is invariably normal on radiography (3). However, radiography does not record esophageal motor activity occurring in a region after peristalsis has cleared the bolus from that region. Thus, hypertensive
peristaltic,contractions recorded manometrically show peristaltic bolus clearance on radiography. Nonperistaltic contractions result in absent or ineffective bolus clearance from the esophagus. In such instances, some bolus clearance may occur because of gravity if the subject is upright or if a pressure gradient between the esophagus and stomach is created by nonperistaltic esophageal contractions. Radiography may demonstrate different forms of nonperistaltic contractions, such as tertiary indentations, corkscrew deformations, sacculations, rosary beading, or transient diverticula. These nonperistaltic contractions seen on radiography have specific manometric correlates that depend on whether the recording sites are located within the common cavity of a continuous fluid column or within esophageal segments separated by a luminal segment devoid of fluid. As hypothesized by Kaye (14), transmission of pressure throughout a relatively static fluid bolus results
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MANOMETRY Figure 6. Example of a simple isobaric wave in a patient with achalasia. Starting at 30.2 seconds contractions are seen to indent the bolus at different sites along the esophageal wall. Bolus deformation peaks at 33.7 seconds without bolus fluid being expelled from the esophagus. Esophageal contractions and the bolus deformation have resolved by 36.7 seconds. Throughout this sequence pressure waves of similar form and amplitude (i.e., isobaric waves) are recorded from the manometric sites. Although the radiographic record suggests contractions of differing intensity in the esophageal segments adjacent to the different manometric recording sites, none of the contractions occlude the esophageal lumen. Hence, the increased intrabolus pressure caused by these contractions is transmitted throughout the fluid continuum within which the manometric recording sites are located.
in isobaric pressure tracings of similar amplitude and waveform that are recorded simultaneously at all manometric sites located within this continuum. In the case of weak contractions that deform the bolus only slightly, current manometric recordings are relatively insensitive to the minimal increase in basal pressure. With contractions of greater magnitude, such as those associated with corkscrew formation, isobaric waves are generally recorded. This phenomenon is to be distinguished from nonisobaric waves, wherein different manometric sites record from esophageal segments that are separated from one another by lumen-obliterated regions devoid of bolus fluid, a situation which exists when rosary beading is present. In such instances, recorded pressure waves exhibit dissimilar amplitudes and waveforms. Hence, on occasions when the fluoroscopic sequence shows progression from corkscrew deformation to rosary beading, the manometric recording often shows isobaric waves progressing to nonisobaric waves. Because pressure is distributed uniformly in a static fluid column, isobaric waves are recorded from recording orifices within a fluid-filled, nonperistaltic segment, regardless of what portions of the adjacent esophageal wall are contracting. Hence, the occurrence of isobaric waves at different manometric recording sites does not necessarily mean that “simulta-
neous contractions” of the esophagus are occurring at all of those sites. Similarly, a feeble, non-lumenobliterating contraction that sweeps in peristaltic fashion along the bolus tends to cause only slight fluid motion within the bolus. Consequently, spatial variations in pressure within the bolus are modest and pressure signatures from adjacent manometric ports display similar waveforms. Thus, the manometric tracings can have the appearance of nonperistaltic isobaric waves when, in reality, a non-lumenobliterating peristaltic contraction is progressing along the esophageal wall. Such a manometric record should not be misinterpreted as a “simultaneous contraction” or “spasm.” Reports exist of patients with primary (15-18) or secondary (19-25) achalasia whose manometric findings revert to normal peristalsis when outlet obstruction is relieved and esophageal dilatation resolves. That some of these patients were described on fluoroscopy to have feeble peristalsis when the manometric finding was aperistaltic contractions (22,23) suggests that, in some instances, peristaltic contractile activity in the esophagus can exist without appreciable bolus movement. Under such conditions, isobaric waves would be recorded from adjacent sites within the bolus. Normal peristaltic contractile activity may be identified when relief of outflow obstruction allows
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the contractions to occlude the lumen and affect aboral bolus transport. Isobaric waves resulting from non-lumen-obliterating peristaltic contractions have recently been demonstrated in a feline model of esophageal outflow obstruction (26). We conclude that an understanding of the principles of fluid mechanics involved in esophageal bolus transport allows for a meaningful comparison of esophageal motor function as recorded by radiography and manometry. Good correlation exists between the findings of these two modalities when they are analyzed in terms of the two separate pressure domains of intrabolus pressure and pressure within lumen-obliterated segments. An index for the correlates between manometric and radiographic findings is provided in Tables 1 and 2. Whereas manometry quantifies contractile segment and intrabolus pressures, it is insensitive to bolus transport and peristaltic and nonperistaltic esophageal contractions that do not obliterate the lumen. In contrast, radiography images esophageal bolus transport and esophageal clearance but does not measure the magnitude of contractile pressures or detect motor events when barium has been cleared from a contracting esophageal segment. Hence, the limitations and advantages of these two modalities make them complementary techniques for evaluating esophageal motor function. References Brasseur JG. A fluid mechanical perspective on esophageal bolus transport. Dysphagia 1987;2:32-39. 2. Hogan WJ, Dodds WJ, Stewart ET. Comparison of roentgenology and intraluminal manometry for evaluating esophageal peristalsis (abstr). Rendiconti Gastroenterol1973;5:28. 3. Kahrilas PJ, Dodds WJ, Hogan WJ. Effect of peristaltic dysfunction of esophageal volume clearance. Gastroenterology 1988;94:
10. Chen YM, Ott DJ, Hewson EG, Richter JE, Wu WC, Gelfand DW,
Caste11 DO. Diffuse esophageal spasm: radiographic and manometric correlation. Radiology 1989;170:807-810. 11. Geisman RA, Clouse RE. Correlation of radiographic and manometric patterns in patients with esophageal contraction abnormalities [abstr). Gastroenterology 1988;94:A143. 12. Ott DJ, Chen YM, Hewson EG, Richter JE, Dalton CB, Gelfand DW, Wu WC. Esophageal motility: assessment with synchronous video tape fluoroscopy and manometry. Radiology 1989; 173:419-422. 13. Hewson EG, Ott DJ, Dalton CB, Chen YM, Wu WC, Richter JE. Manometry and radiology: complementary studies in the assessment of esophageal motility disorders. Gastroenterology 1990; 98:626-632. 14. Kaye MD. Anomalies of peristalsis in idiopathic diffuse esophageal spasm. Gut 1981;22:217-222. 15. Mellow MH. Return of esophageal peristalsis in idiopathic achalasia. Gastroenterology 1976;70:1148-1151. 16. Vantrappen G, Janssens J, Hellemans J, Coremans G. Achalasia, diffuse esophageal spasm and related motility disorders. Gastroenterology 1979;76:450-457. 17. Bianco A, Cagossi M, Scrimieri D, Greco AV. Appearance of esophageal peristalsis in treated idiopathic achalasia. Dig Dis Sci 1986;31:40-48. 18. Ponce J, Miralbes M, Garrigues V, Berenguer J. Return of esophageal peristalsis after Heller’s myotomy for idiopathic achalasia. Dig Dis Sci 1986;31:545-547. 19. Davis JA, Kantrowitz PA, Chandler HL, Schatzki SC. Reversible achalasia due to reticulum-cell sarcoma. N Engl J Med 1975;293: 130-132. 20. Kline MM. Successful
treatment of vigorous achalasia associated with gastric lymphoma. Dig Dis Sci 1980;25:311-313. 21. Menin R, Fisher RS. Return of esophageal peristalsis in achalasia secondary to gastric cancer. Dig Dis Sci 1981;26:10381044. 22. Goldin
1.
73-80. 4. Dodds WJ, Hogan WJ, Arndorfer RC, Dent J. Efficient manomet-
5.
6.
7.
8.
ric technique for accurate regional measurement of esophageal body motor activity. Am J Gastroenterol 1978;70:21-24. Arndorfer RC, Steff JJ, Dodds WJ, Linehan JH, Hogan WJ. Improved infusion system for intraluminal esophageal manometry. Gastroenterology 1977;73:23-27. Dodds WJ. Current concepts of esophageal motor function: clinical implications for radiology. Am J Roentgen01 1977;128: 549-561. Dodds WJ, Hogan WJ, Reid DP, Stewart ET, Arndorfer RC. A comparison between primary peristalsis following wet and dry swallows. J Appl Physiol 1973;354:851-857. Willerson JT, Thompson RH, Hookman P, Herdt J, Decker JL. Reserpine in Raynaud’s disease and phenomenon: short-term response to intraarterial injection. Ann Intern Med 1970;72:17-
27. 9. Ott DJ, Richter JE, Chen YM, Wu WC, Gelfand DW, Caste11 DO.
Esophageal radiography and manometry: correlation patients with dysphagia. AJR 1987;149:307-311.
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23.
24.
25.
26.
NR, Burns TW, Ferrante WA. Secondary achalasia: association with adenocarcinoma of the lung and reversal with radiation therapy. Am J Gastrenterol 1983;78:203-205. Costigan DJ, Clouse RE. Achalasia-like esophagus from amyloidosis: successful treatment with pneumatic bag dilatation. Dig Dis Sci 1983;28:763-765. Kahrilas PJ, Kishk SM, Helm JF, Dodds WJ, Harig JM, Hogan WJ. Comparison of pseudoachalasia and achalasia. Am J Med 1987;82:439-446. Woods CA, Foutch PG, Waring JP, Sanowski RA. Pancreatic pseudocyst as a cause for secondary achalasia. Gastroenterology 1989;96:235-239. Mittal RK, Ren J, McCallum RW, Shaffer HA, Sluss J. Modulation of feline esophageal contractions by bolus volume and outflow obstruction. Am J Physiol1990;258:G208-G215.
Received March 1,199O. Accepted December 13.1990. Address requests for reprints to: Benson T. Massey, M.D., Division of Gastroenterology, Froedtert Memorial Lutheran Hospital, 9200 West Wisconsin Avenue, Milwaukee, Wisconsin 53226. This study was supported in part by National Institutes of Health grant DK 25731 and training grant AM07267 (Dr. Massey]. This work was presented at the biennial meeting of the American Motility Society in Asilomar, California, on October 2, 1988, and was published in abstract form (Gastroenterology 1988;95:A878).