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Esophageal longitudinal muscle contraction: Another component of transient lower esophageal sphincter relaxation (tLESR)?
3204
3206
Esophageal Longitudinal Muscle Contraction: Another Component nf Transient Lower Esophageal Sphincter Relaxation (tLESR)?
Esophageal Function In Normal Volunteers And Patients With Ineffective Esophageal Motility (IEM) Assessed Through Combined Molliehannel Intraluminal Impedance And Manometry (MII/EM).
Guoxiang Shi, John E. Pandolfino, Raymond J. Joehl, Northwestern Univ Medical Sch, Chicago, IL; James G. Brassuer, Penn State Univ, University Park, PA; Peter J. Kahdlas, Northwestern Univ Medical Sch, Chicago, IL Background. Longitudinal muscle contraction is an integral part of primary peristalsis (PP). This study aimed to characterize longitudinal muscle contraction during tLESR. Method. 8 healthy subjects (4 males, 26_+1 yrs) had metal clips endoscopically affixed at O, +3, and + 8 cm relative to the squamocolumnar junction (SCJ), defining two distal esophageal segments. Axial clip movement was assessed by concurrent manometry and fluoroscopy during LES relaxation with PP, secondary peristalsis (SP) induced by esophageal air injection, and tLESR induced by gastric distension with 800ml of air through the manometric catheter. Segment lengths were measuredat 0.5 s intervals during relaxation and the percentagechange relative to the initial length was calculated. If a tLESR ended with PP or SP, only the earlier period was used. Maximal SCJ upward movement was measured at end expiration. Results (Table). Although significant shortening was evident in both segments with all three types of LES relaxation, the magnitude of distal segment shortening was least with tLESR and greatest with PP. On the other hand, the maximal degree of overall esophageal shortening durin0 tLESR, evident by the SCJ excursion, was similar to that during PP suggesting a global effect on the esophagus. In three instances,the moment of LES opening and gas reflux was optimally imaged and SCJ excursion was 0.3-+0.1 cm prior to LES opening and 1.4-+0.7 cm immediately after the occurrence of an esophageal common cavity. Conclusions. Although the segmental pattern appears to be distinct from that seen during PP or SP, esophageal shortening (likely attributable to longitudinal muscle contraction) occurs during tLESR. However, elevation of the LES did not precede LES opening during tLESR suggesting that this is nut part of the opening mechanism, but rather a consequence of the esophageal distension induced by gas reflux.
LE5 Pressure PP $P tLESR
(rnmHg) 18.9!-_2.4 21.3+2.5 21,8:1:1.5
Relaxation
._ % of Shortening
SCJ Rise
Duration(s) 5.5-+0.2 5.6+-0.7 20.4-+2,7'#
Proximal 27.4_+4.0 18.4+_3.3" 22.9-J:2.8
(cm) 2.2__+0.1 1.5-+0.2" 2.4-+0.4#
Distal 41.7_+2.5~ 32.6~2.911" 17.~4.9"#
Marcelo F. Vela, Radu I. Tutuian, Leonard Baidoo, Matthew Gideon, Philip O. Katz, Donald O. Castell, Graduate Hosp, Philadelphia, PA INTRODUCTION:Manometric features of ineffective swallows are low amplitude (<30 mmHg) or absent peristaltic waves. We have previously shown that MII allows accurate measurement of bolus transport time (BTT) and that subjects with IEM on manometry have prolonged Bl-fs. We compared MII with EM in the assessment of ineffective swallows in healthy volunteers (NL) and patients with IEM through measurement of B'I-I and contraction wave amplitude using combined MII/EM (Sandhill Sci, Inc). Assembly included six 2-cm impedance recording segments located 3, 5, 7, 9, 15, and 17 cm above the LES and two solid state pressure transducers located 3 and 8 cm above the LES. Each subject given 20 swallows: 10 x 5ml liquid, 10 x 5ml semisolid (applesauce consistency). Each swallow analyzed separately and blindly with MII and EM. MII analyzed for BTT: time interval (sec) between bolus arrival at the proximal measuring segment and bolus clearance at the distal segment. EM assessed for amplitude of contraction in distal and mid esophagus. Analysis: 1) Correlation of Bl-r and distal esophagealamplitude (DEA); 2) Comparison of BTT in effective vs ineffective (<30mmHg in distal and/or mid esophagus) swallows. RESULTS: There was good curvilinear correlation between B]-r and DEA using liquid bolus (r =0.65), solid bolus (r =0.91) or liquid and solid bolus combined (r=0.77). Comparison of BI-F in effective vs ineffective swallows shown in the table. SUMMARY: Ineffective swallows have longer BI-Fthan effective swallows. CONCLUSIONS: Prolonged BTI predicts ineffective contraction. Combined MII/EM supports the concept that contraction waves below 30mmHg are not propulsive. This technique enables refined characterization of intraluminal events and is a useful tool in evaluation of esophagealfunction. Brr' (mean -+ SEM) liquid 7.31 _+0.19 15.43 _+2.6 <00001
elledive swallows Ineffective maBows
pvahe
semisolid 8.15_+ 0.15 31.69 _+4.35 <0.0001
liquid + semisolid 7.74+_0.12 21.66 +_2.67 <0.0001
"B'£F = BolUSTransportTime *p<0.05vs PP.#p<0.05vs SP.¶p< 0.05vs Proximal.
3205
E s o l d ~ l Motor Responses To Abrupt Distention Are Fully Developed By 33 Weeks Pesi.CooneptJonalAge In Human Neonates.
Altered and Distinct Cardioautonomic Responses to Esophageal Stimelotion (ES) In Patients with GERD or with Non-Cardiac Chest Pain (NCCP)
Sudershan R, Jadcherla, Hag O. Ouong, Reza Shaker, Medical Coil of Wisconsin, Milwaukee, WI
S Anand, T Hruczkowski, R Spaziani, McMaster Univ, Hamilton Canada;C Dieneteld, Ruhr Univ 8ochum, Bochum Germany; C Pang, M V. Kamath, W Li, D Hung, McMaster Univ, Hamilton Canada; S Hollerbach, Ruhr Univ Bochum, Bochum Germany; A Upton, E L. Fallen, G Tougas, McMaster Univ, Hamilton Canada
O l ~ l l q l ~ : The prevalence of GER in preform (PT) and full term (Ft) neonates is high. There is little information about esophageal motor functions protective against reflux among high risk infants. Aim: To determine the presence or absence of secondary esophageal peristalsis (SP) and upper esophagealsphincter pressure (UESP) responsesto abrupt esophageal distention in PT bum and FT born neonates. Methods: We measured UESP and SP, using a minimally compliant pneumohydraulic pertusion system and a specially designed catheter with a sleeve sensor and 4 side-hole recording sites, after an abrupt mid esophageal distention using air and liquids (water, apple juice) in 6 PT (wt 1.6 -+ 0.3 kg) and 6 FT (wt 3.2 -+ 0.7 kg) infants of 33.6 _+ 1.2 wk and 41.2 + 3 wk post-conceptional age (PCA), respectively. We tested 0.1, 0.5, and 1 mL volumes, three times for each infusion. Results: Mean threshold volumes for air, water and apple juice to elicit SP were 0.50, 0.4, 0.3 mL in PT and 1.0, 0.8, 0.4 mL in FT, respectively. There were 4 types of responses to esophageal disten'oon: SP with UESPincrease ( ) , SP with UESPdecrease ()), SP without UESPchange, and UESP increase ( ) alone. The percent occurrence of these responses are shown in the table below. The response time for SP was 5.9 +- 1.2 vs 3.7 _+1.2sec (PT vs FT all infusions, P < 0.05). Proximal and distal esophageal amplitude and duration, and SP propagating velocity, were similar in both the groups during all infusions. Conclusion: Esophageal and UES motor responses to abrupt mid-esophagealdistention are fully developed prior to normal full term PCA, and as early as 33 wks PCA. These findings may have pathophysiological significance in developing infants.
Background:The pathogenesis of GERD and NCCP remain elusive. Vagal and sympathetic abnormalities have been described but autonomic activity and responsivenessto ES have not been systematically examined. We compared autonomic activity and responsivenessto ES in healthy controls (HC), NCCP and GERD patients. Methods: HC (n=12; 24-51 yrs), NCCP patients (n=8; 26-58 yrs), and GERD patients (n=7; 30-50 yrs) were studied. Heart rate was recorded using standard ECG. Electrical ES (15 mA, 200/~sec, 0.16 Hz, 25 stimuli) was delivered to the distal esophagus using a 5 mm ring electrode. Power spectral analysis of heart rate variability (PS/HRV) was computed at rest and during ES through analysis of beatto-beat HRV using autoregressive modeling to identify and measure the area of the vaoal (HF; 0.15-0.5Hz) and sympathetic (LF; 0.025-0.15Hz)frequency peaks.Sympathovagalbalance was estimated using LF;HF ratio. Results: (Table) Conclusions: Cardioautonomic responses to ES differ in GERD and NCCP. NCCP patients have normal resting sympethovagal balance but higher resting vagal and sympathetic activity than HC. GERD patients exhibit increased resting vagal activity than HC, and lower resting LF:HF ratio. During ES, NCCP patients and HC exhibit a decreasedsympathovagal balancethat is greater in NCCPthan HC. GERDpatients have high resting vagat tone but during ES show no change in LF:HF ratio and a blunted pseudoaffective autonomic response. The increased resting sympathetic and vagal activity as well as the magnified pseudcaffective cardioautonomic response to ES in NCCPare likely due to central processing rather than peripheral neural factors. Group
Condition
LF(SympathetJc HF(Vagat) )
LF:HF Ratio
NCCP
Baseline(rest) ES (15mA) Baseline(rest) ES (15mA) Baseline(rest) ES (15mA)
6119+-224" 4661+_227"," 5678+-681 4913+-42"P* 4259-+266 3308d:266"
1.4_+0.11 0.78+-0.07*," 1.14+-0.21"* 1.13~D.19 1.63+-0.22 1.15+-0.09"
GERD Conb'ol
4819+-249"* 6363-+329", ~ 5410~407'* 4757+519"* 2912-+237 3224_+130"
Charecteri~cs
SP+UESPt
SP+ UESP ~
SP+UESPno change
UESP'~, *
Airin PT,% Uquid In PT, % Air in Fr, % Uquid in FT, %
79 68 91 55
7 5 9 9
3 12 0 0
11 15 0 36
# responsesfor: Air=28(PT), 11 (FT); bquids=40(PT), 11(FT) Incroase:l",Decrease:~,; * P< 0.001, Fisherexact test PT vs FT
3208 * p
Coordination of Deglotition and Phases of Respiration in Preterm and Term Babies. Sudarshan R. Jadcheda, Hag Q. Duong, Medical Coil of Wisconsin, Milwaukee, Wl; Tim Waither, Children's Hosp of Wisconsin, Milwaukee, WI; Reza Shaker, Medical Coil of Wisconsin, Milwaukee, Wl
Background: Previous studies showed significant alteration of this coordination in elderly, however data on deglutition-respiration coordination in early stages of life are scarce. Available data which addresses the coordination of respiration with pharyngeal pressure events do not always represent propagated swallowS in babies. Aim: To determine the temporal relationship of spontaneous propagated swallowing with phases of respiration in preterm (PT) and full
A-632
3206
Esophageal Longitudinal Muscle Contraction: Another Component nf Transient Lower Esophageal Sphincter Relaxation (tLESR)?
Esophageal Function In Normal Volunteers And Patients With Ineffective Esophageal Motility (IEM) Assessed Through Combined Molliehannel Intraluminal Impedance And Manometry (MII/EM).
Guoxiang Shi, John E. Pandolfino, Raymond J. Joehl, Northwestern Univ Medical Sch, Chicago, IL; James G. Brassuer, Penn State Univ, University Park, PA; Peter J. Kahdlas, Northwestern Univ Medical Sch, Chicago, IL Background. Longitudinal muscle contraction is an integral part of primary peristalsis (PP). This study aimed to characterize longitudinal muscle contraction during tLESR. Method. 8 healthy subjects (4 males, 26_+1 yrs) had metal clips endoscopically affixed at O, +3, and + 8 cm relative to the squamocolumnar junction (SCJ), defining two distal esophageal segments. Axial clip movement was assessed by concurrent manometry and fluoroscopy during LES relaxation with PP, secondary peristalsis (SP) induced by esophageal air injection, and tLESR induced by gastric distension with 800ml of air through the manometric catheter. Segment lengths were measuredat 0.5 s intervals during relaxation and the percentagechange relative to the initial length was calculated. If a tLESR ended with PP or SP, only the earlier period was used. Maximal SCJ upward movement was measured at end expiration. Results (Table). Although significant shortening was evident in both segments with all three types of LES relaxation, the magnitude of distal segment shortening was least with tLESR and greatest with PP. On the other hand, the maximal degree of overall esophageal shortening durin0 tLESR, evident by the SCJ excursion, was similar to that during PP suggesting a global effect on the esophagus. In three instances,the moment of LES opening and gas reflux was optimally imaged and SCJ excursion was 0.3-+0.1 cm prior to LES opening and 1.4-+0.7 cm immediately after the occurrence of an esophageal common cavity. Conclusions. Although the segmental pattern appears to be distinct from that seen during PP or SP, esophageal shortening (likely attributable to longitudinal muscle contraction) occurs during tLESR. However, elevation of the LES did not precede LES opening during tLESR suggesting that this is nut part of the opening mechanism, but rather a consequence of the esophageal distension induced by gas reflux.
LE5 Pressure PP $P tLESR
(rnmHg) 18.9!-_2.4 21.3+2.5 21,8:1:1.5
Relaxation
._ % of Shortening
SCJ Rise
Duration(s) 5.5-+0.2 5.6+-0.7 20.4-+2,7'#
Proximal 27.4_+4.0 18.4+_3.3" 22.9-J:2.8
(cm) 2.2__+0.1 1.5-+0.2" 2.4-+0.4#
Distal 41.7_+2.5~ 32.6~2.911" 17.~4.9"#
Marcelo F. Vela, Radu I. Tutuian, Leonard Baidoo, Matthew Gideon, Philip O. Katz, Donald O. Castell, Graduate Hosp, Philadelphia, PA INTRODUCTION:Manometric features of ineffective swallows are low amplitude (<30 mmHg) or absent peristaltic waves. We have previously shown that MII allows accurate measurement of bolus transport time (BTT) and that subjects with IEM on manometry have prolonged Bl-fs. We compared MII with EM in the assessment of ineffective swallows in healthy volunteers (NL) and patients with IEM through measurement of B'I-I and contraction wave amplitude using combined MII/EM (Sandhill Sci, Inc). Assembly included six 2-cm impedance recording segments located 3, 5, 7, 9, 15, and 17 cm above the LES and two solid state pressure transducers located 3 and 8 cm above the LES. Each subject given 20 swallows: 10 x 5ml liquid, 10 x 5ml semisolid (applesauce consistency). Each swallow analyzed separately and blindly with MII and EM. MII analyzed for BTT: time interval (sec) between bolus arrival at the proximal measuring segment and bolus clearance at the distal segment. EM assessed for amplitude of contraction in distal and mid esophagus. Analysis: 1) Correlation of Bl-r and distal esophagealamplitude (DEA); 2) Comparison of BTT in effective vs ineffective (<30mmHg in distal and/or mid esophagus) swallows. RESULTS: There was good curvilinear correlation between B]-r and DEA using liquid bolus (r =0.65), solid bolus (r =0.91) or liquid and solid bolus combined (r=0.77). Comparison of BI-F in effective vs ineffective swallows shown in the table. SUMMARY: Ineffective swallows have longer BI-Fthan effective swallows. CONCLUSIONS: Prolonged BTI predicts ineffective contraction. Combined MII/EM supports the concept that contraction waves below 30mmHg are not propulsive. This technique enables refined characterization of intraluminal events and is a useful tool in evaluation of esophagealfunction. Brr' (mean -+ SEM) liquid 7.31 _+0.19 15.43 _+2.6 <00001
elledive swallows Ineffective maBows
pvahe
semisolid 8.15_+ 0.15 31.69 _+4.35 <0.0001
liquid + semisolid 7.74+_0.12 21.66 +_2.67 <0.0001
"B'£F = BolUSTransportTime *p<0.05vs PP.#p<0.05vs SP.¶p< 0.05vs Proximal.
3205
E s o l d ~ l Motor Responses To Abrupt Distention Are Fully Developed By 33 Weeks Pesi.CooneptJonalAge In Human Neonates.
Altered and Distinct Cardioautonomic Responses to Esophageal Stimelotion (ES) In Patients with GERD or with Non-Cardiac Chest Pain (NCCP)
Sudershan R, Jadcherla, Hag O. Ouong, Reza Shaker, Medical Coil of Wisconsin, Milwaukee, WI
S Anand, T Hruczkowski, R Spaziani, McMaster Univ, Hamilton Canada;C Dieneteld, Ruhr Univ 8ochum, Bochum Germany; C Pang, M V. Kamath, W Li, D Hung, McMaster Univ, Hamilton Canada; S Hollerbach, Ruhr Univ Bochum, Bochum Germany; A Upton, E L. Fallen, G Tougas, McMaster Univ, Hamilton Canada
O l ~ l l q l ~ : The prevalence of GER in preform (PT) and full term (Ft) neonates is high. There is little information about esophageal motor functions protective against reflux among high risk infants. Aim: To determine the presence or absence of secondary esophageal peristalsis (SP) and upper esophagealsphincter pressure (UESP) responsesto abrupt esophageal distention in PT bum and FT born neonates. Methods: We measured UESP and SP, using a minimally compliant pneumohydraulic pertusion system and a specially designed catheter with a sleeve sensor and 4 side-hole recording sites, after an abrupt mid esophageal distention using air and liquids (water, apple juice) in 6 PT (wt 1.6 -+ 0.3 kg) and 6 FT (wt 3.2 -+ 0.7 kg) infants of 33.6 _+ 1.2 wk and 41.2 + 3 wk post-conceptional age (PCA), respectively. We tested 0.1, 0.5, and 1 mL volumes, three times for each infusion. Results: Mean threshold volumes for air, water and apple juice to elicit SP were 0.50, 0.4, 0.3 mL in PT and 1.0, 0.8, 0.4 mL in FT, respectively. There were 4 types of responses to esophageal disten'oon: SP with UESPincrease ( ) , SP with UESPdecrease ()), SP without UESPchange, and UESP increase ( ) alone. The percent occurrence of these responses are shown in the table below. The response time for SP was 5.9 +- 1.2 vs 3.7 _+1.2sec (PT vs FT all infusions, P < 0.05). Proximal and distal esophageal amplitude and duration, and SP propagating velocity, were similar in both the groups during all infusions. Conclusion: Esophageal and UES motor responses to abrupt mid-esophagealdistention are fully developed prior to normal full term PCA, and as early as 33 wks PCA. These findings may have pathophysiological significance in developing infants.
Background:The pathogenesis of GERD and NCCP remain elusive. Vagal and sympathetic abnormalities have been described but autonomic activity and responsivenessto ES have not been systematically examined. We compared autonomic activity and responsivenessto ES in healthy controls (HC), NCCP and GERD patients. Methods: HC (n=12; 24-51 yrs), NCCP patients (n=8; 26-58 yrs), and GERD patients (n=7; 30-50 yrs) were studied. Heart rate was recorded using standard ECG. Electrical ES (15 mA, 200/~sec, 0.16 Hz, 25 stimuli) was delivered to the distal esophagus using a 5 mm ring electrode. Power spectral analysis of heart rate variability (PS/HRV) was computed at rest and during ES through analysis of beatto-beat HRV using autoregressive modeling to identify and measure the area of the vaoal (HF; 0.15-0.5Hz) and sympathetic (LF; 0.025-0.15Hz)frequency peaks.Sympathovagalbalance was estimated using LF;HF ratio. Results: (Table) Conclusions: Cardioautonomic responses to ES differ in GERD and NCCP. NCCP patients have normal resting sympethovagal balance but higher resting vagal and sympathetic activity than HC. GERD patients exhibit increased resting vagal activity than HC, and lower resting LF:HF ratio. During ES, NCCP patients and HC exhibit a decreasedsympathovagal balancethat is greater in NCCPthan HC. GERDpatients have high resting vagat tone but during ES show no change in LF:HF ratio and a blunted pseudoaffective autonomic response. The increased resting sympathetic and vagal activity as well as the magnified pseudcaffective cardioautonomic response to ES in NCCPare likely due to central processing rather than peripheral neural factors. Group
Condition
LF(SympathetJc HF(Vagat) )
LF:HF Ratio
NCCP
Baseline(rest) ES (15mA) Baseline(rest) ES (15mA) Baseline(rest) ES (15mA)
6119+-224" 4661+_227"," 5678+-681 4913+-42"P* 4259-+266 3308d:266"
1.4_+0.11 0.78+-0.07*," 1.14+-0.21"* 1.13~D.19 1.63+-0.22 1.15+-0.09"
GERD Conb'ol
4819+-249"* 6363-+329", ~ 5410~407'* 4757+519"* 2912-+237 3224_+130"
Charecteri~cs
SP+UESPt
SP+ UESP ~
SP+UESPno change
UESP'~, *
Airin PT,% Uquid In PT, % Air in Fr, % Uquid in FT, %
79 68 91 55
7 5 9 9
3 12 0 0
11 15 0 36
# responsesfor: Air=28(PT), 11 (FT); bquids=40(PT), 11(FT) Incroase:l",Decrease:~,; * P< 0.001, Fisherexact test PT vs FT
3208 * p
Coordination of Deglotition and Phases of Respiration in Preterm and Term Babies. Sudarshan R. Jadcheda, Hag Q. Duong, Medical Coil of Wisconsin, Milwaukee, Wl; Tim Waither, Children's Hosp of Wisconsin, Milwaukee, WI; Reza Shaker, Medical Coil of Wisconsin, Milwaukee, Wl
Background: Previous studies showed significant alteration of this coordination in elderly, however data on deglutition-respiration coordination in early stages of life are scarce. Available data which addresses the coordination of respiration with pharyngeal pressure events do not always represent propagated swallowS in babies. Aim: To determine the temporal relationship of spontaneous propagated swallowing with phases of respiration in preterm (PT) and full
A-632