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Simultaneous Cineradiographic-Manometric Study of the Distal Esophagus: Small Hiatal Hernias and Rings
Vol. 50, No.6 Prlnled 1'n U,S,A.
GASTRO ENTEROLOGY
Copyright
© 1966 by The Williams
& Wilkins Co.
SIMULTANEOUS CINERADIOGRAPHIC·MANOMETRIC STUDY OF THE DISTAL ESOPHAGUS: SMALL HIATAL HERNIAS AND RINGS PETER HEITMANN, M.D., BERNARD S. WOLF, M .D., E . MARVIN SOKOL, M.D., AND BERNARD R. COHEN , M.D. Division of Gast1'oenterology, Department of Medicine and DepaTtment of Radiology, The Mount Sinai Hospital, New York, New York
The roentgen configuration of the normal esophagogastric region on swallowing fluid barium shows three different portions (fig. 1). The long tubular portion which ends a short distance above the diaphragmatic indentation and which empties with a rapid stripping peristaltic wave represents the body of the esophagus. At its lower end, it communicates with a more distensible supradiaphragmatic segment designated the phrenic ampull a. The phrenic ampulla empties more slowly than the body of the esophagus and is exaggerated by increased intraabdominal pressure or deep inspiration. Below the ampulla, there is a relatively narrow, short tubular segment called the submerged segment since it is intraabdominal in location. The submerged segment joins the fundu s of the stomach at an acute angle. 1 - 3 The manometric findings of the normal esophagogastric region (EGR) indicate the presence of a physiological sphincter. It is characterized by an approximately 3-cmlong zone of resting pressure higher than fundic pressure which falls to fundic levels at the onset of swallowing. This high pressure zone extends above and below the physiological hiatus denoted by the pressure inversion point.4-6 On simultaneous Received November 6, 1965. Accepted February 8, 1966. Address requests for reprints to: Dr. Bernard S. Wolf, Department of Radiology, The Mount Sinai Hospital, 11 East 100th Street, New York, New York 10029. This work was supported by Grant AM 06505 from the National Institutes of Health, United States Public Health Service. Dr. H eitmann is a Research Fellow (Lederle International Fellowship) , University of Chile.
radiographic-manometric study, the physiological hiatus corresponds to the diaphragmatic narrowing. 7 - 9 Characteristic resting pressures and swallowing pressure responses are found in the different radiological portions of the normal esophagus.10, 11 In the presence of a small sliding hiatal hernia, a pouch is visible radiologica lly between the tubular esophagus and the diaphragmatic narrowing (fig. 2). As the pouch empties, only its proximal portion is seen to flatten and empty sequentially from above downward. The upper dynamic segment of the pouch has been previously called the "vestibule." 1 In this report, this term is used specifically for this roentgen appearance and is not applied to any normal configuration . Moreover, it is not assumed that the vestibule and high pressure zone are synonymous terms. In the region where the tubular esophagus joins the top of the pouch (tubular esophagus-pouch, or TP region), a localized constriction or ring may be seen during the course of a barium swallow. 1 , 12-14 This ring is 3 to 5 mm in length, is located at the proximal margin of the vestibule, is often seen best during the early phases of filling, changes in caliber, and may disappear with further filling, and presents as a flat-b ased intramural type of circumferential defect. This ring has been called a contractile A-ring and equated with "the inferior esophageal sphincter of Lerche." It differs from the more distally located Schatzki or B-ring which is located within the pouch at the distal margin of the vestibule, distends passively to a constant caliber, and presents as a thin web or diaphragm-like intrusion into the lumen. The portion of the pouch distal to the Schatzki rmg rep-
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FIG. 1. Roentgen configurations of the normal esophagogastric region on swallowing fluid barium. a, During flow and maximal distention, a supradiaphragmatic pouch (phrenic ampulla) (Am) joins the tubular esophagus (T) over a short area designated the tubular esophagus-pouch region (TP). The lower margin of the phrenic ampulla corresponds to the diaphragmatic narrowing (DN). The submerged segment below the ampulla extends through the hiatus to enter the stomach. The location of the gastroesophageal mucosal junction is not indicated by any roentgen landmark. b, After emptying of the tubular esophagus by a rapid stripping wave, the phrenic ampulla shows a peaked apex which represents the TP region as the peristaltic wave enters the ampulla. c, The ampulla during emptying becomes progressively smaller and flat-topped. d, The esophagus is completely stripped of barium. In the area where the flat-topped phrenic ampulla and submerged segment were seen, the manometrically evident resting high pressure zone is reconstituted (dashed line).
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FIG. 2. Roentgen configurations of a small sliding hiatal hernia with a contractile and Schatzki ring. a, During maximal barium distention, a pouch larger than the normal phrenic ampulla is present between the tubular esophagus (T) and the diaphragmatic narrowing (DN). The contractile ring (CR) is located in the tubular esophagus-pouch region (TP). The Schatzki ring (SR), indicating the esophagogastric mucosal junction, divides the pouch into an upper portion (vestibule) (V) and a lower portion (hernial sac) (H). b, The tubular esophagus has been stripped down to the TP region. c, The vestibule becomes flat-topped and appears to shorten from above downward as it empties. d, The vestibule is completely empty. The residual pouch is the hernial sac. The contractile ring may be effaced during maximal filling. The Schatzki ring is seen best during maximal distention. One or the other or both rings may be absent or represented by inconspicuous notches.
resents the true hernial sac. 1, 12, 14 Sequential or peristaltic contractile activity occurs down to but not beyond the level of the Schatzki ring or notches. 15 - 17 As emp-
tying occurs, the vestibule appears to shorten from above downward. As B, result, the distinction between the TP region or contractile A ring and the vestibule be-
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comes obscured in the empty or contracted state. Various manometric findings have been reported in hiatal hernias. The resting high pressure zone may be dislocated from the pressure inversion point or it may be completely absent. 18 -2o Other features detectable on a pull-through study, particularly with a balloon-covered transducer, include an elongation of the zone of high pressure, a plateau of constant pressure, two pressure inversion points, two peaks of pressure elevations, wide swings of pressure, and sudden short rises in pressure ("popups") .21 Altered motor behavior such as very high or low resting sphincteric pressures, poor sphincteric relaxation, and exaggerated contractions have also been noted. 20 -22 These changes occur in various combinations and not all are seen in every case. Several authors have also performed simultaneous cine-manometry in subjects with small hiatal hernias 20 , 23, 24 and distal esophageal rings,25, 26 and their results will be noted later. In this study, patients with small sliding hiatal hernias with and without rings were investigated by simultaneous cineradiography and intraluminal pressure measurements in an effort to correlate manometric aspects with roentgen appearances of the EGR. A ring was designated as contractile from the manometric point of view only if it could be demonstrated that it produced a persistent localized zone of elevated pressure in the resting phase. Other rings or localized contractions evident during the course of a swallow or during reflux which could not be related to persistent elevated pressure in the resting phase were not designated as contractile rings but considered to be part of the swallowing motor mechanism. The pressure changes related to the two portions of the supradiaphragmatic pouch during filling and emptying as well as during retrograde barium flow were analyzed. An attempt was made to ascertain the roentgen correlates of the swallowing complexes, the pressure inversion point, and the pressures observed during retrograde flow.
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Methods and Materials Pressure determinations were made utilizing an assembly of four or occasionally six polyethylene catheters (PE 200, I.D. 0.055 inches) taped parallel to each other. A 3-mm-Iong opening was made in each catheter and the catheters were assembled in such a fashion that the openings were located 1 cm from each other. A 5-mm-Iong radiopaque clip was fixed to the distal end of each catheter opening. The pressure recording points were taken as being at the proximal end of each opening, that is, 3 mm proximal to each clip. A small bag filled with mercury attached to the end of the assembly served to minimize motion. Subjects were intubated in the sitting position and then placed in a prone oblique position with left side elevated on the X-ray table. A large radiolucent bolster was placed under the abdomen in order to increase intraabdominal pressure and facilitate identification of small hernias. 27 Catheter openings were positioned in the EGR by slowly withdrawing the assembly from the fundus under manometric and image intensifier fluoroscopic control. The catheter assembly was taped to the subject's lips when the desired location was achieved. Pressures were measured by attaching the catheters to Sanborn model 267B physiological transducers. Respirations were monitored with a pneumographic belt in such a fashion that inspiration produced a downward deflection. Pressure and respiratory responses were recorded by a four-channel direct writer Sanborn model 964 oscillograph. During pressure recordings, water from separate intravenous bottles was slowly perfused through each catheter by a side connection at approximately 2 ml per min per catheter. The height of the intravenous bottles above the strain gauges or level of the esophagus was 80 em. Constant catheter perfusion provided more consistent recording of elevated resting pressures as well as of phasic respiratory activity (fig. 3). Pressures measured by this technique in the normal esophagogastric sphincteric region were higher than those recorded by utilizing intermittent flush.28. 29 These pressures resemble "yield pressures" and may be a more appropriate indication of "intraluminal pressure" since resistance to opening under the influence of a constant hydrostatic head of pressure plays a role. 28 • 30 Zero reference pressure was set at atmospheric pressure by opening the system to the atmosphere. With the use of the abdominal bolster, all resting pressures were higher than those
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FIG. 3. An example of the influence of continuous catheter perfusion on pressure recording. Four pressure curves obtained from 1-cm-spaced cathet er openings in the esophagogastric region of a patient with a small hernia a re shown. After initial continuous catheter perfusion and stabilization of pressures, perfusion was stopped as indicated. The elevated resting pressures of the middle two tracings fell and respiratory deflections became damped. No significant change was noted in the two tracings that had low resting pressures during perfusion. A "flush" of one catheter produced only a brief return of pressure elevation and respiratory deflections. .
recorded without a bolster but relative pressures remained essentially unchanged.31 Fluid barium suspension (25 ml) was instilled into the subject's mouth. On command, a single swallow was performed as continuous pressures and cineradiographs were recorded. Five to 14 swallows were recorded per subject as the three catheter openings were repositioned at different levels of the EGR. Cine exposures were made at 10 frames/sec using a 9-inch image intensifier and a 35-mm camera. The exact beginning and end of each cine run was automatically recorded on the oscillograph paper so that each cine frame could be located on the pressure tracings. Subsequent viewing of the cine films was done with a Tage Arno viewer editor. Analysis of the records consisted of correlation of instantaneous changes in pressures and
roentgen configurations. For example, the onset of the peristaltic contraction wave corresponded to the disappearance of barium as the stripping wave progressed. It is not appropriate, however, to attribute all pressure changes at at a given point to local activity at t hat site. This can be done only if the measurement is being taken from a closed sac or from a collapsed area. While free continuous flow is occurring through t he esophagus and into the stomach, with or without a hernial sac, pressures throughout the column of barium are equal to each other and equal to fundic pressure. An isobaric period corresponding to the plateau phase of the swallowing is then present."· 32 As noted above, identification of the nature of the ring, that is, whether contractile or not, depends on the presence or absence of a persistent localized zone of elevated
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pressure at the site of the ring during the resting or empty phase. To accomplish this, the location of the ring in the resting state must be determined. This can occasionally be done when residual barium continues to outline the ring satisfactorily after emptying. In most instances, however, sequential frame by frame study of the earliest filling and of the final emptying stages must be utilized to determine the position of the ring at the onset and at the end of the swallow. As such stages are studied, motion of the opaque clips must be carefully noted to determine the relationship of measuring sites to the position of the ring in the resting state. The relative positions of clips and rings during filled or free flowing phases are not pertinent to the resting state. In 18 patients, 138 swallows were recorded and analyzed. On prior routine radiography these patients were shown to have small sliding hiatal hernias, some with distal esophageal rings.
Results The patients in this study can be divided into five types based on the cine-mano-
FIG. 4A. Case 1: Hiatal hernia with absent resting high pressure zone. Conventional film shows a nonstenotic ring (arrows) a short distance above the hiatus. The vestibule above the ring is wider in caliber than the hernial sac distal to it.
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metric criteria. A representative case of each type will be described. As will be noted, the major difference among the patients studied was the presence or absence of a zone of resting high pressure. Individual cases differed in details but their main features were consistent enough to permit this type of grouping for purposes of presentation. Case 1: Hiatal hernia with absent resting high pressure zone (figs. 4- and 5). This 54year-old man had a history of heartburn of many years' duration. Conventional roentgen examination showed a moderate-sized pouch with a wide hiatus with free reflux. A Schatzki ring of large caliber was present in the middle of the pouch. No contractile ring was evident. Cine-pressure study showed no evidence of a resting high pressure zone. Resting pressures from tubular esophagus to fundus were equal and showed abdominal type of respiratory excursions. The upper or vestibular portion of the supradiaphragmatic pouch emptied sequentially with the body of the esophagus. The lower portion or hernial sac retained barium and remained inactive by pressure criteria. In the group studied, five other cases demonstrated findings similar to this patient. Two of these five patients showed obstructive or stenotic Schatzki rings. Case 2: Hiatal hernia with transient high pressure zone after swallowing (figs. 6 and 7). This patient was a girl of 15 with severe heartburn since childhood. Conventional roentgen examination demonstrated a supradiaphragmatic pouch and a wide hiatus. No distinct rings were demonstrated. Reflux was seen occasionally when intraabdominal pressure was increased. Cine-pressure study showed no zone of resting high pressure. The point of respiratory reversal was above the diaphragmatic narrowing. In contrast to the previous case, elevated pressure was sustained in the vestibular region for many seconds after each swallow. This was the only patient in the series who showed this phenomenon. Case 3: Hiatal hernia with resting high pressure zone and contractile ring (figs. 8 and 9). This was a middle-aged obese woman with intermittent retrosternal pain and dysphagia for several years. Conventional roentgen examination showed a sliding hiatal hernia and numerous tertiary contractions in the body of the esophagus. At the junction of tubular esophagus and pouch, there was a contractile ring approximately 5 mm in length. Small
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FIG. 4B. Case 1: R epresentative barium swallow during simultaneous cineradiographymanometry. On the cine frames, the recording catheter openings are located approximately midway between the retouched clips. The three pressure tracings obtained are labeled upper, middle, and lower, respectively. The vertical lines on the tracings indicate the moments at which individual cine frames designated 1 to 6 ~vere exposed. Onset of a swallow is indicated by SW. Pressures prior to the swallow indicate resting pressures. Resting pressures and respiratory deflections from all openings were the same as those recorded from the stomach below the diaphragm . There was no identifiable resting high pressure zone. During filling, no pressure change was recorded from any of the three openings. In frame 1, the stripping wave is seen in the tubular esophagus. In frame 2, a supradiaphragmatic pouch with pointed top is formed. A faint circumferential Schatzki or B-ring (arrow) is seen in the middle of the pouch. Between frames 2 and 3, the upper portion of the pouch (vestibule) flattens and diminishes in size as a peristaltic wave traverses it. Between frames 3 and 4, the pouch empties down to the Schatzki ring level as the peristaltic wave is recorded from the proximal two openings. The peristaltic wave does not enter the hernial sac. Frame 5 shows retrograde flow of barium into the esophagus (arrow) through a short constriction above the sac. Retrograde flow starts when the peristaltic wave disappears. Continued retrograde flow (arrow) is seen in frame 6. For a short period during retrograde flow, pressure in the sac exceeds pressure in the esophagus. After this, all pressures return to original resting levels.
notches were seen in the middle of the pouch when it was maximally distended. Cine-pressure study showed a short zone of high resting pressure corresponding to the contractile ring.
There was an abrupt fall in resting pressure in the tubular esophagus immediately above the ring. The hernial sac showed minimal elevation of resting pressure with diminution to
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FIG. 5. Case 1: Schematic presentation of cineradiographic-manometric events. In this and in similar subsequent idealized diagrams, pressure curves obtained from four sites and selected cine frames represent a summary of findings observed on multiple swallows with the catheter assembly at different levels. Recording sites are indicated by solid circles on the cine sketches. Tracing T is obtained from the tubular esophagus; tracing P from the hernial sac immediately above the hiatus; tracing TP from a point between T and P; and tracing IP from a point below the pouch at the diaphragmatic narrowing. PIP refers to the point of inversion of pressure or point of respiratory reversal. Vertical lines, indicating the moments at which cine images 1 to .4 are seen, permit correlation of roentgen configurations with instantaneous pressures.
fundic level during a swallow. No reflux into the esophagus was noted at any time. Five other patients demonstrated a resting high pressure zone. Two had a contractile ring associated with the high pressure zone while three showed only a transient narrowing at the onset of filling of the high pressure zone. Case 4: Hiatal hernia with resting high pressure zone, contractile ring and stenotic Schatzki ring (figs. 10 to 12). This 44-year-old man complained of intermittent, severe dysphagia for solid food. Routine radiographic examination demonstrated a stenotic Schatzki ring appearing as a constant weblike indentation above the diaphragmatic narrowing during complete distention of the EGR. In addition, a short distance above the Schatzki ring, there was a contractile A-ring appearing as a circumferential narrowing seen during early phases of filling which widened with maximal distention. On esophagoscopy, a weblike or Schatzki ring was identified, and biopsy of the ring revealed both squamous and columnar epithelium. On thoracotomy and gastrotomy, a typical Schatzki ring intruding into the lumen was exposed at the mucosal junction. The ring was excised and the mucosa coapted with sutures. No other ring was evident. A small sliding hiatal
hernia was repaired. Microscopic examination of excised segments of the ring again showed squamous and columnar epithelium. Cinepressure study showed a short zone of resting high pressure at the level of the contractile ring. Pressures at and distal to the Schatzki ring were equal to fundic pressure and did not change during the course of a swallow. Two other stenotic Schatzki ring cases with zones of resting high pressure above the Schatzki ring were observed in this series. An additional contractile ring, however, above the level of the Schatzki ring was not evident in these patients. Case 5: Hiatal hernia with resting hypertensive zone and an incompletely distensible contractile A-ring (figs. i3 and i.n. This patient was a 47-year-old man with intermittent dysphagia for solid food. His esophagogram demonstrated a persistent thick ring between the tubular esophagus and a supradiaphragmatic pouch. The pouch showed faint notches in its midportion when distended. The ring did not distend completely during any phase of swallowing and obstructed passage of a compressed Y2-inch barium tablet. It was assumed that the persistent narrowing of this ring was the result of local "spasm," a mild degree of peptic stricture, or both. Cine-pressure stud~'
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FIG. 6. Case 2: Hiatal hernia with temporary high pressure zone after a swallow. Resting pressures from the middle and lower openings were equal to infra diaphragmatic fundic pressure while t hat at the upper opening was equal to intrathoracic pressure. There was no identifiable resting high pressure zone. The pressure tracings from the three openings are superimposed in the lowermost box. In fram e 1, free flow of barium occurs as the pressure at the upper opening reaches fundi c level. Toward the end of the swallow, frame 2, a prolonged elevation of pressure is recorded from the vestibular region (upper opening) while a sac persists below it. During frame 3, a spontaneous swallow results in a fall of this elevated pressure as retrograde flow occurs through the short, incompletely distended vestibule (arrow). During reflux, simultaneous sharp short waves ("pop-ups") are recorded from all openings. Frame 4 shows widening and elongation of the vestibule as swallowed barium refills the tubular esophagus. This is followed by anot her stripping peristaltic wave and another elevation of pressure in the vestibular area (upper tracing, after fram e 4). Spontaneous fall of pressure at this site subsequently occurs relatively slowly. Note that pressures are equal during free flow, both anterograde and retrograde (superimposed tracings, between fram es 1 and 2 and between f rames 3 and 4).
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CINERADIOGRAPHY-MANOMETRY OF ESOPHAGUS 3
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showed a zone of markedly elevated resting pressure associated with the ring. Although pressure fell to fundic level on swallowing and no flow pressure gradient was present, the ring remained evident during all phases of filling. Another patient in the series showed a similar thick contractile ring. In this patient, a high pressure zone was located at and for a short distance below the ring.
Discussion The results of this study confirm the roentgen observation that the pouch formed above the hiatus during maximal filling in patients with small sliding hiatal hernias consists of two parts-an upper esophageal or vestibular segment and a lower gastric portion or hernial sac per se. The upper portion is emptied by a continuation of the stripping peristaltic wave in a slower broader form. It is not possible to predict whether the elevated pressure in the vestibular segment during emptying will persist into the resting phase. If a contractile A-ring is evident, a localized zone of elevated resting pressure can be anticipated. A resting high pressure zone in the vestibular region may, however, be present without a demonstrable contractile ring. Since the vestibule shortens during emptying, the relative contributions of A-ring, when present, and vestibule to a resting high pressure zone proximal to the hernial sac are difficult to determine. When the ring is prominent, it appears to form the
major component and creates a peak pressure at the junction of tubular esophagus and pouch. The zone of resting high pressure in such cases is short with abrupt transition to adjacent lower pressures. In contrast, the normally located physiological sphincter is longer, has a peak at its center and is less sharply demarcated. 4 - 6 Whether a contractile A-ring is derived from the normal physiological sphincter or appears de novo is a question that requires further study. The behavior of the ring, however, does indicate that it plays a role in preventing retrograde flow from hernial sac into the esophagus. Relaxation and opening of the ring are frequently delayed until the filling pressure proximal to it attains fundic pressure level. With emptying of the tubular esophagus, pressure at the ring promptly rises and remains elevated. Occasionally, the resting pressure associated with a contractile ring may be higher than pressures within the normal sphincter resembling the "hypertensive sphincter" described by Code et al. 33 In its most typical form, with the current technique, the lower portion of the combined pouch, i.e., the hernial sac, shows no pressure change' during the course of a swallow. No pressure change is required to permit flow since resting pressure within the sac equals fundic pressure. At the end of a swallow, a peristaltic contraction wave is not recorded from the hernial sac.
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FIG . 8. Case 3 : Hiatal herni a with a resting high pressure zone and contractile A-ring. In t he resting s tate, a persistent high pressure zone was obtained from t he upper catheter opening shown at the onset of filling to be within the contractile ring (frame 2, arrow). Resting pressures from th e middle and lower openings were approximately 20 mm Hg less but exceeded fundi c p ressure. In frame 1, barium fills the tubular esophagus but is held up at the TP level by a delayed fall of the resting high pressure. Frame 2 shows the beginning of flow through the ring (arrow) at th e TP level as pressure at this site falls rapi dly. A fall to fundic pressure level also occurs in the two lowercatheter openings with fi lling of the pouch and free flow (frame 3). During flow, all pressures are essentially equal ( superimposed curves). Frame .4 shows tertiary contractions in t he tubular esophagus during emptying. Notches (arrows) are evident in the midpQrtion of the pouch between vestibule and hernial sac. Frame 5 shows an early phase of emptying of the vestibule. Pressure at t he upper opening has returned to high resting level. Between f rames 5 and 6, the vestibule empties completely and appears to shorten . Pressures within the hernial sac (middle and lower tracings ) r et urn to resting levels. No retrograde flow occurred at any time.
Resting pressure within a hernial sac may, however, exceed fundic pressure and produce a plateau of elevated pressure on pullthrough studies. 21 In such cases, pressure within the sac decreases during a swallow and returns to resting pressure at the end of a swallow. There is nevertheless no evi-
dence of a peristaltic wave in the hernial sac, i.e., return to resting pressure is not accompanied by an increase in pressure above base line or resting pressure. The manometric features of a hernial sac therefore differ from those of the vestibule, which shows a sequential peristaltic wave
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CINERADIOGRAPHY-MANOMETRY OF ESOPHAGUS
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FIG. 10. Case 4: Hiatal hernia with resting high pressure zone, contractile ring, and stenotic Schatzki ring. Four spot films taken with the patient upon a bolster. View A shows a Schatzki ring (lower arrow) and a contractile ring (upper arrow). In view B, the tubular esophagus has been stripped of barium and a supradiaphragmatic pouch with the Schatzki ring in its midportion is seen. View C shows the portion of the pouch located between the two rings (vestibule) contracted circumferentially. View D shows the Schatzki ring obstructing the passage of a half-inch compressed barium tablet. The contractile ring is seen immediately above the tablet.
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FIG. 11. Case 4: Hiatal hernia with resting high pressure zone, contractile ring, and stenotic Schatzki ring. Barium swallow during cineradiography-manometry. In the resting state, a high pressure zone was recorded from the middle opening shown at the onset of filling to be located within the contractile ring (arrow in frame 2, upper arrow in frame 3). The upper catheter opening is in the tubular esophagus and the lower at the level of the Schatzki ring. Frame 1 shows barium filling the tubular esophagus and held up above the contractile ring while high pressure is maintained at the middle opening. Frame 2 illustrates the beginning of flow through the contractile ring (arrow) as pressure within the ring abruptly decreases to a v alue equal to the filling pressure above it. Continuous flow of barium is seen in frame 3 with both rings (arrows) evident. In frame 4, a supradiaphragmatic pouch divided by the Schatzki ring (arrow) is evident. The tubular esophagus is stripped of barium as a tall peristaltic wave is inscribed in the upper tracing. Frame 5 shows shortening and flattening of that portion of the pouch (vestibule) above the Schatzki ring as a peristaltic wave is recorded from it. The arrow indicates the Schatzki ring. In frame 6, the vestibule is almost completely empty. The Schatzki ring (arrow) approaches the hiatus as the hernial sac distal to it shortens during emptying. The tubular esophagus lengthens to a similar degree during emptying. In the resting state, on quiet breathing, the pressure inversion point is at the level of the contractile ring. On a deep inspiration (latter part of tracings), it is located distally below the level of the pouch. Note that, during continuous flow (frame 3), obstruction at the level of the Schatzki ring is indicated by a pressure gradient between the upper two openings and the lowermost opening (superimposed tracings).
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CIN ERA DIOGRA PHY-MA NOMETRY OF ESOPHAGUS
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during which pressures greater than resting pressures are recorded.lO· 11 The "active" character of the vestibule is indicated radiologically by rapid progressive emptying from above downward, while a hernial sac fails to show a typical stripping wave. In patients with sliding hernias and no resting high pressure zone, retrograde flow or reflux from the hernial sac into the esophagus was frequently seen at the end of a swallow when the peristaltic wave di sappeared from the vestibular segment. During reflux, pressure in the sac slightly exceeded or equaled pressure in the esophagus. A transient narrowing of variable length proximal to the sac seen at the onset of retrograde flow appeared to represent residual activity of the peristaltic cont raction and was not associated with elevated resting pressure. This narrowing promptly disappeared when reflux was marked. Retrograde flow from hernial sac into esophagus must be di stinguished from retrograde flow from the infradiaphragmati c portion of the stomach into the hernial sac. This latter type of reflux through the hiatus depends on multiple factors. Some of these m ay not be detectable by intraluminal pressure changes. 34 • 35 Either type of retrograde flow may occur independently or they may occur simult aneously as free or complete gastroesophageal reflux. If resting pressures and respiratory excursions a re identical in
stomach and esophagus (case 1), free reflux can be anticipated. In the " complete" radiological configuration of a s mall sliding hiatal hernia, a contractile A-ring is present at the proximal margin of the vestibule and a Schatzki or B-ring at its distal margin. When only one ring is evident, it may not always be possible to distinguish between an A- and a Bring. When both rings are absent, the roentgen recognition of a small herni a may be difficult. It must be based on the demonstration of a s tatic pouch, a wide hi atus, and reflux . The absence of perista ltic activity within a questionable supradiaphragmatic pouch and the absence of a high pressure zone are best demonstrated by pressure studies. Conclusions from pressure studies, however, should not be based on the assumption that the point of respiratory reversal always indicat es the level of the hi atus. This is true in normal individuals but, in patients with a sliding hernia, this point is frequently above the diaphragmatic narrowing seen on roent gen examination. 24 In fact, it is usually located at t he level of the displaced high pressure zone when such a zone is present. In such cases, if it is assumed without reservation that the point of respiratory r eversal represents the hiatus, the record may be interpreted as indicating that the high pressure zone and hiatus are at t he same level and that no hernia is present. As noted
FIG . 13. Case 5: Hiatal hernia with resting hypertensive zone and an incompletely distensible contractile ring. In the resting stat.e, elevated pressure 25 mm Hg greater than fundic pressure was recorded from the middle opening which was within the contractile ring early in the swallow (fram e 1). R esting pressure from th e lower opening, shown to be within the pouch, was the same as fundic pressure. The upper opening within the tubular esophagus had a resting pressure less than fundic but slightly greater than the pressure more proximally in the esophagus. Frame 1 shows beginning flow through a broad ring in the TP region after pressure has risen at the upper opening and fallen at the middle opening. During continuous flow, frame 2, the ring achieves its maximal diameter. During t he period of flow, pressures from all openings are equal ( superimposed tracings). F rame 3 shows stripping of the tubular esophagus. In frame 4, the proximal portion of the pouch above faint notches contracts as a broad peristaltic wave is recorded from it . The lower portion of the pouch or hernial sac shows no pressure change. No reflux was observed.
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CINERADIOGRAPHY-MANOMETRY OF ESOPHAGUS 1
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by Code et al.,21 two points of respiratory reversal may be found. The more distal one may be demonstrated or exaggerated by deep inspiration or by the use of a balloon rather than an open end catheter. This distal point corresponds to the hiatal level. The peristaltic wave which empties the vestibular segment extends down to but does not include the level of the Schatzki ring. This static behavior is in agreement with histological observations that the muscularis propria is not hypertrophic nor does it form an intrinsic component of a Schatzki ring. 36 -38 In patients with a stenotic Schatzki ring, the additional presence of a contractile A-ring is the exception rather than the rule, and a high pressure zone proximal to the Schatzki ring is likely to be absent. Pressure within the hernial sac distal to the Schatzki ring may be elevated and may fall during the course of a swallow. This type of change may be interpreted as indicating that the physiological sphincter is located distal to the ring whereas, in fact, a sphincteric area in the course of the esophagus is absent. An incorrect impression may also be gained if resting pressures are compared with the filled rather than the collapsed appearance of the EGR. This arises from the fact that during filling, the hernia distal to the ring elongates and the ring is therefore located
more proximally in the filled than in the empty state. It is, however, not clear why the findings reported in this study in regard to the motor behavior in the region of the Schatzki ring differ from those reported by Harris et al. 39 and by Cauthorne et aP6 Some variation may be expected on the basis of different techniques of measurement. The current observations agree with those reported by Rinaldo et al. 25 and appear more consistent with the surgical observations 37 , 38 that this ring is at the mucosal junction. There is no convincing evidence that peristaltic activity has been recorded distal to a Schatzki ring. The nature and origin of a contractile A-ring are not clear. It appears to be a functional phenomenon related to activity of the muscularis propria at this site. A discrete circumferential muscular ring in the distal esophagus located a short distance above the mucosal junction was originally described by Lerche 40 as normally present and designated the "inferior esophageal sphincter." Used in this fashion, the term "inferior esophageal sphincter" does not apply to the normal physiological sphincter or zone of high pressure recorded manometrically. Other anatomical studies 41 have failed to confirm Lerche's findings. Ingelfinger and Kramer 42 described an operative case with localized muscular
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HEITMANN ET AI.,.
narrowing in the distal esophagus and used the term "contractile ring." These authors suggested that the ringlike constriction might represent an overactive mechanism of the inferior esophageal sphincter. In our experience, a contractile ring has not been evident at operation although clearly seen radiologically (for example, case 4). Specimens of the area in such cases are not, however, available for study.
stant in its location in hiatal hernia subjects. It was often located at the site of the upwardly displaced high pressure zone, although a second pressure inversion point could be identified at the hiatal level on deep inspiration. REFERENCES 1. Wolf, B. S., R. H. Marshak, M. L. Som, S. A. Brahms, and E. 1. Greenberg. 1958. The
Summary
Manometric features were correlated with roentgen configurations of the esophagogastric region in subjects with hiatal hernias and with rings by simultaneous cineradiographic and manometric study. The supradiaphragmatic pouch in small hiatal hernias was shown to have two functionally distinct components. Its upper portion (vestibule) had sequential contractile motor activity in response to swallowing. The lower portion was inactive and represented the true hernial sac. A weblike ring (Schatzki) or notches were often identified at the junction of these two segments. There was no peristaltic activity at or below this type of ring. A broad ring with contractile radiological behavior at the upper margin of the vestibule showed resting high pressure which fell on swallowing. This differed from the resting high pressure zone of normals in being shorter in length and showing an abrupt rather than gradual transition to contiguous pressures. Retrograde barium flow from hernial sac into the tubular esophagus was not seen when such a contractile A-ring was evident. Retrograde barium flow into the esophagus from the hernial sac occurred in those subjects not having a resting high pressure zone. Such reflux was delayed as long as the peristaltic wave persisted in the vestibular segment above the hernial sac. A constriction above the hernial sac during retrograde flow presumably represents a residual manifestation of the peristaltic wave, is transient, and is not associated with elevated resting pressure. The pressure inversion point was incon-
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6.
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8.
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gastroesophageal vestibule on roentgen examination; differentiation from the phrenic ampulla and minimal hiatal herniation. J. Mount Sinai Hosp. N. Y. 25: 167-200. Wolf, B. S. 1960. Roentgen features of the normal and herniated esophagogastric region; problems in terminology. Amer. J. Dig. Dis. 5: 751-769. Botha, G. S. 1962. The gastro-oesophageal junction. J. and A. Churchill, Ltd., London. Fyke, F. E., Jr., C. F. Code, and J. F. Schlegel. 1956. The gastroesophageal sphincter in healthy human beings. Gastroenterologia (Basel), 86: 135--150. Hightower, N. C. 1958. The physiology of symptoms. 1. Swallowing and esophageal motility. Amer. J. Dig. Dis. 3: 562-583. Kelley, M. L. Jr., D. L. Wilbur, III, J. F. Schlegel, and C. F. Code. 1960. Deglutitive responses in gastroesophageal sphincter of healthy human beings. J. Appl. Physiol. 15: 483-488. Creamer, B., G. K. Harrison, and J. W. Pierce. 1959. Further observations on the gastroesophageal junction. Thorax 14: 132137. Cohen, B. R., and B. S. Wolf. 1962. Roentgen localization of the physiologically determined esophageal hiatus. Gastroenterology 43: 43-50. Wolf, B. S., and B. R. Cohen. 1961. Radiologic localization of the esophageal hiatus as determined by intraluminal pressure measurements. Radiology 76: 903-910. Cohen, B. R., and B. S. Wolf. 1961. The gastroesophageal junction in man; a combined manometric and radiologic analysis. Clin. Res. 9: 151. Cohen, B. R., E. M. Aronow, and B. S. Wolf. 1964. Simultaneous pressure and radiologic study of the distal esophagus. Physiologist 7: 105. Johnson, C., D. E. Paterson, and 1. B. Scudder. 1961. Hiatus hernia and hiatal disorder; eighteen radiological signs. Brit. J. Radiol. 24: 499-505. Johnstone, A. S. 1959. Observations on the
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radiologic anatomy of the esophagogastric junction. Radiology 73 : 501-510. Berridge, F. R. 1961. The mechanism of the cardia; radiological aspects. Brit. J. Radiol. 24: 487-498. Wolf, B. S. 1960. The definition of a sliding hiatal hernia. A radiologist's point of view. Amer. J. Dig. Dis. 5: 168-173. Potsaid, M. S., 1. Goro, and N. T. Griscom. 1961. Motility changes revealing esophagogastric junction. Radiology 76: 262--263. Vandervelde, G. M., and H . C. Carlson. 1964. Esophageal reflux. Am . J . Roentgen. 92:
989-993. 18. Atkinson, M., D. A. W. Edwards, A. J. Honour, and E. N. Rowlands. 1957. The oe-
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sophagogastric sphincter in hiatus hernia. Lancet 2: 1138-1142. Vantrappen, G., M. D. Liemer, J. Ikeya, E. C. Texter, and C. J . Barborka. 1958. Simult aneous fluorocinematography and intraluminal pressure measurements in the study of esophageal motility. Gastroenterology 35 : 592-002. T exter, E. C., Jr., G. VanDerstappen, G. Chejfec, V. E. Chvojka, M . Vidinli, C. J. Barborka, and W. E. Bundesen. 1962. Crit eria for the diagnosis of hiatal hernia. Arch. Intern. Med. (Chicago) 110: 827-836. Code, C. F., M. L. K elley, J. F. Schlegel, and A. M. Olsen. 1962. Detection of hiatal hernia during esophageal motility tests. Gastroenterology 43: 520-531. K elley, M. L. 1965. Deglutitive pressure responses in the gastroesophageal sphincters of symptomatic hiatal h ernia patients. Amer. J. Dig. Dis. 10: 582-595. Fleshier, B., and H. P. Roth. 1962. Concomitant manometric and radiologic observations in apparent hiatal hernias. J . Lab. Clin. Med. 60: 320-330. Rinaldo, J. A., and M. D. Clark. 1964. Simultaneous cineradiographic and manometric analysis of the gastroesophageal junctional zone. Gastroenterology 46: 757. Rinaldo, J. A., M . D. Clark, and T. Gahagan. 1963. The dynamics of the distal esophagus. Gastroenterology 44: 848-849. Cauthorne, R. T., J. J. Vanhoutte, M. W. D onner, and T. R. H endrix. 1964. Study of patients with distal esophageal ring (Schatzki) by simultaneous manometry and cineradiography. Gastroenterology 46: 736. Wolf, B. S., and J. Guglielmo. 1956. A method for the roentgen demonstration of minimal hiatal herniation. J. Mount Sinai Hosp. N. Y. 23 : 738-741. P ert, J. D., M. Davidson, T. P . Almy, and
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M. H. Sleisenger. 1959. Esophageal catheterization studies. 1. The mechanism of swallowing in normal subjects with particular reference to the vestibule (esophagogastric sphincter). J. Clin. Invest. 38: 397406. 29. Cohen, B. R. 1965. Cardiospasm in achalasia ;
demonstration of an abnormally elevated esophagogastric sphincter pressure with partial relaxation on swallowing. Gastroenterology 48: 864. 30. Harris, L. D., and C. E. Pope. 1964. "Squeeze" VB. resistance; an evaluation of the mechanism of sphincter competence. J . Clin. Invest. 43: 2272-2278. 31. VanDerstappen, G. V., and E. C. T exter. 1964. Response of the physiologic gastroesophageal sphincter to increased intra-abdominal pressure. J. Clin. Invest. 43: 1856-1868. 32. Ingelfinger, F. J. 1958. Esophageal motility. Physiol. Rev. 38: 533-584. 33. Code, C. F., J. F . Schlegel, M. C. K elley, A. M. Olsen, and F. H. Ellis. 1960. Hypertensive gastroesophageal sphincter. Proc. Mayo Clin. 35: 391-399. 34. Edwards, D. A. W. 1961. The anti-reflux mechanism; manometric and radiologic studies. Brit. J. Radiol. 34: 474-487. 35. Sandmark, S. 1963. Intraluminal pressures and pH in hiatus hernia and gastro-oesophageal reflux . Act a Otolaryng. (Stockholm) 56: 116. 36. McMahon, H. E., R. Schatzki, and J . E . Gary. 1958. Pathology of a lower esophageal ring;
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report of a case, with autopsy, observed for nine years. New Eng. J. Med. 259 : 1-8. Wilkins, E. W., and M. K. Bartlett. 1963. Surgical treatment of the lower esophageal ring. New Eng. J. Med. 268: 461-464. Postlethwait, R. W., and A. W. Musser. 1965. Pathology of lower esophageal web. Surg. Gynec. Obstet. 120: 571-575. Harris, L. D., J. E. Kelly, Jr., and P . Kramer. 1960. Relation of the lower esophageal ring to the esophagogastric junction. New Eng. J. Med. 263 : 1232-1235. Lerche, W. 1950. The esophagus and pharynx in action. Charles C Thomas, Springfield, Ill. Zaino, C., M. H . Poppel, H. G. J acobson, and H. Lepow. 1963. The lower esophageal vestibular complex. Charles C Thomas, Springfield, Ill. Ingelfinger, F. J., and P. Kramer. 1953. Dysphagia produced by a contractile ring in the lower esophagus. Gastroenterology 23 : 419430.
GASTRO ENTEROLOGY
Copyright
© 1966 by The Williams
& Wilkins Co.
SIMULTANEOUS CINERADIOGRAPHIC·MANOMETRIC STUDY OF THE DISTAL ESOPHAGUS: SMALL HIATAL HERNIAS AND RINGS PETER HEITMANN, M.D., BERNARD S. WOLF, M .D., E . MARVIN SOKOL, M.D., AND BERNARD R. COHEN , M.D. Division of Gast1'oenterology, Department of Medicine and DepaTtment of Radiology, The Mount Sinai Hospital, New York, New York
The roentgen configuration of the normal esophagogastric region on swallowing fluid barium shows three different portions (fig. 1). The long tubular portion which ends a short distance above the diaphragmatic indentation and which empties with a rapid stripping peristaltic wave represents the body of the esophagus. At its lower end, it communicates with a more distensible supradiaphragmatic segment designated the phrenic ampull a. The phrenic ampulla empties more slowly than the body of the esophagus and is exaggerated by increased intraabdominal pressure or deep inspiration. Below the ampulla, there is a relatively narrow, short tubular segment called the submerged segment since it is intraabdominal in location. The submerged segment joins the fundu s of the stomach at an acute angle. 1 - 3 The manometric findings of the normal esophagogastric region (EGR) indicate the presence of a physiological sphincter. It is characterized by an approximately 3-cmlong zone of resting pressure higher than fundic pressure which falls to fundic levels at the onset of swallowing. This high pressure zone extends above and below the physiological hiatus denoted by the pressure inversion point.4-6 On simultaneous Received November 6, 1965. Accepted February 8, 1966. Address requests for reprints to: Dr. Bernard S. Wolf, Department of Radiology, The Mount Sinai Hospital, 11 East 100th Street, New York, New York 10029. This work was supported by Grant AM 06505 from the National Institutes of Health, United States Public Health Service. Dr. H eitmann is a Research Fellow (Lederle International Fellowship) , University of Chile.
radiographic-manometric study, the physiological hiatus corresponds to the diaphragmatic narrowing. 7 - 9 Characteristic resting pressures and swallowing pressure responses are found in the different radiological portions of the normal esophagus.10, 11 In the presence of a small sliding hiatal hernia, a pouch is visible radiologica lly between the tubular esophagus and the diaphragmatic narrowing (fig. 2). As the pouch empties, only its proximal portion is seen to flatten and empty sequentially from above downward. The upper dynamic segment of the pouch has been previously called the "vestibule." 1 In this report, this term is used specifically for this roentgen appearance and is not applied to any normal configuration . Moreover, it is not assumed that the vestibule and high pressure zone are synonymous terms. In the region where the tubular esophagus joins the top of the pouch (tubular esophagus-pouch, or TP region), a localized constriction or ring may be seen during the course of a barium swallow. 1 , 12-14 This ring is 3 to 5 mm in length, is located at the proximal margin of the vestibule, is often seen best during the early phases of filling, changes in caliber, and may disappear with further filling, and presents as a flat-b ased intramural type of circumferential defect. This ring has been called a contractile A-ring and equated with "the inferior esophageal sphincter of Lerche." It differs from the more distally located Schatzki or B-ring which is located within the pouch at the distal margin of the vestibule, distends passively to a constant caliber, and presents as a thin web or diaphragm-like intrusion into the lumen. The portion of the pouch distal to the Schatzki rmg rep-
737
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HEITMANN ET AL.
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Vol. 50, No.6
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FIG. 1. Roentgen configurations of the normal esophagogastric region on swallowing fluid barium. a, During flow and maximal distention, a supradiaphragmatic pouch (phrenic ampulla) (Am) joins the tubular esophagus (T) over a short area designated the tubular esophagus-pouch region (TP). The lower margin of the phrenic ampulla corresponds to the diaphragmatic narrowing (DN). The submerged segment below the ampulla extends through the hiatus to enter the stomach. The location of the gastroesophageal mucosal junction is not indicated by any roentgen landmark. b, After emptying of the tubular esophagus by a rapid stripping wave, the phrenic ampulla shows a peaked apex which represents the TP region as the peristaltic wave enters the ampulla. c, The ampulla during emptying becomes progressively smaller and flat-topped. d, The esophagus is completely stripped of barium. In the area where the flat-topped phrenic ampulla and submerged segment were seen, the manometrically evident resting high pressure zone is reconstituted (dashed line).
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FIG. 2. Roentgen configurations of a small sliding hiatal hernia with a contractile and Schatzki ring. a, During maximal barium distention, a pouch larger than the normal phrenic ampulla is present between the tubular esophagus (T) and the diaphragmatic narrowing (DN). The contractile ring (CR) is located in the tubular esophagus-pouch region (TP). The Schatzki ring (SR), indicating the esophagogastric mucosal junction, divides the pouch into an upper portion (vestibule) (V) and a lower portion (hernial sac) (H). b, The tubular esophagus has been stripped down to the TP region. c, The vestibule becomes flat-topped and appears to shorten from above downward as it empties. d, The vestibule is completely empty. The residual pouch is the hernial sac. The contractile ring may be effaced during maximal filling. The Schatzki ring is seen best during maximal distention. One or the other or both rings may be absent or represented by inconspicuous notches.
resents the true hernial sac. 1, 12, 14 Sequential or peristaltic contractile activity occurs down to but not beyond the level of the Schatzki ring or notches. 15 - 17 As emp-
tying occurs, the vestibule appears to shorten from above downward. As B, result, the distinction between the TP region or contractile A ring and the vestibule be-
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CINERADIOGRAPHY-MANOMETRY OF ESOPHAGUS
comes obscured in the empty or contracted state. Various manometric findings have been reported in hiatal hernias. The resting high pressure zone may be dislocated from the pressure inversion point or it may be completely absent. 18 -2o Other features detectable on a pull-through study, particularly with a balloon-covered transducer, include an elongation of the zone of high pressure, a plateau of constant pressure, two pressure inversion points, two peaks of pressure elevations, wide swings of pressure, and sudden short rises in pressure ("popups") .21 Altered motor behavior such as very high or low resting sphincteric pressures, poor sphincteric relaxation, and exaggerated contractions have also been noted. 20 -22 These changes occur in various combinations and not all are seen in every case. Several authors have also performed simultaneous cine-manometry in subjects with small hiatal hernias 20 , 23, 24 and distal esophageal rings,25, 26 and their results will be noted later. In this study, patients with small sliding hiatal hernias with and without rings were investigated by simultaneous cineradiography and intraluminal pressure measurements in an effort to correlate manometric aspects with roentgen appearances of the EGR. A ring was designated as contractile from the manometric point of view only if it could be demonstrated that it produced a persistent localized zone of elevated pressure in the resting phase. Other rings or localized contractions evident during the course of a swallow or during reflux which could not be related to persistent elevated pressure in the resting phase were not designated as contractile rings but considered to be part of the swallowing motor mechanism. The pressure changes related to the two portions of the supradiaphragmatic pouch during filling and emptying as well as during retrograde barium flow were analyzed. An attempt was made to ascertain the roentgen correlates of the swallowing complexes, the pressure inversion point, and the pressures observed during retrograde flow.
739
Methods and Materials Pressure determinations were made utilizing an assembly of four or occasionally six polyethylene catheters (PE 200, I.D. 0.055 inches) taped parallel to each other. A 3-mm-Iong opening was made in each catheter and the catheters were assembled in such a fashion that the openings were located 1 cm from each other. A 5-mm-Iong radiopaque clip was fixed to the distal end of each catheter opening. The pressure recording points were taken as being at the proximal end of each opening, that is, 3 mm proximal to each clip. A small bag filled with mercury attached to the end of the assembly served to minimize motion. Subjects were intubated in the sitting position and then placed in a prone oblique position with left side elevated on the X-ray table. A large radiolucent bolster was placed under the abdomen in order to increase intraabdominal pressure and facilitate identification of small hernias. 27 Catheter openings were positioned in the EGR by slowly withdrawing the assembly from the fundus under manometric and image intensifier fluoroscopic control. The catheter assembly was taped to the subject's lips when the desired location was achieved. Pressures were measured by attaching the catheters to Sanborn model 267B physiological transducers. Respirations were monitored with a pneumographic belt in such a fashion that inspiration produced a downward deflection. Pressure and respiratory responses were recorded by a four-channel direct writer Sanborn model 964 oscillograph. During pressure recordings, water from separate intravenous bottles was slowly perfused through each catheter by a side connection at approximately 2 ml per min per catheter. The height of the intravenous bottles above the strain gauges or level of the esophagus was 80 em. Constant catheter perfusion provided more consistent recording of elevated resting pressures as well as of phasic respiratory activity (fig. 3). Pressures measured by this technique in the normal esophagogastric sphincteric region were higher than those recorded by utilizing intermittent flush.28. 29 These pressures resemble "yield pressures" and may be a more appropriate indication of "intraluminal pressure" since resistance to opening under the influence of a constant hydrostatic head of pressure plays a role. 28 • 30 Zero reference pressure was set at atmospheric pressure by opening the system to the atmosphere. With the use of the abdominal bolster, all resting pressures were higher than those
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PERFUSION ON
PERFUSION OFF
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FIG. 3. An example of the influence of continuous catheter perfusion on pressure recording. Four pressure curves obtained from 1-cm-spaced cathet er openings in the esophagogastric region of a patient with a small hernia a re shown. After initial continuous catheter perfusion and stabilization of pressures, perfusion was stopped as indicated. The elevated resting pressures of the middle two tracings fell and respiratory deflections became damped. No significant change was noted in the two tracings that had low resting pressures during perfusion. A "flush" of one catheter produced only a brief return of pressure elevation and respiratory deflections. .
recorded without a bolster but relative pressures remained essentially unchanged.31 Fluid barium suspension (25 ml) was instilled into the subject's mouth. On command, a single swallow was performed as continuous pressures and cineradiographs were recorded. Five to 14 swallows were recorded per subject as the three catheter openings were repositioned at different levels of the EGR. Cine exposures were made at 10 frames/sec using a 9-inch image intensifier and a 35-mm camera. The exact beginning and end of each cine run was automatically recorded on the oscillograph paper so that each cine frame could be located on the pressure tracings. Subsequent viewing of the cine films was done with a Tage Arno viewer editor. Analysis of the records consisted of correlation of instantaneous changes in pressures and
roentgen configurations. For example, the onset of the peristaltic contraction wave corresponded to the disappearance of barium as the stripping wave progressed. It is not appropriate, however, to attribute all pressure changes at at a given point to local activity at t hat site. This can be done only if the measurement is being taken from a closed sac or from a collapsed area. While free continuous flow is occurring through t he esophagus and into the stomach, with or without a hernial sac, pressures throughout the column of barium are equal to each other and equal to fundic pressure. An isobaric period corresponding to the plateau phase of the swallowing is then present."· 32 As noted above, identification of the nature of the ring, that is, whether contractile or not, depends on the presence or absence of a persistent localized zone of elevated
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CINERADIOGRAPHY-MANOMETRY OF ESOPHAGUS
pressure at the site of the ring during the resting or empty phase. To accomplish this, the location of the ring in the resting state must be determined. This can occasionally be done when residual barium continues to outline the ring satisfactorily after emptying. In most instances, however, sequential frame by frame study of the earliest filling and of the final emptying stages must be utilized to determine the position of the ring at the onset and at the end of the swallow. As such stages are studied, motion of the opaque clips must be carefully noted to determine the relationship of measuring sites to the position of the ring in the resting state. The relative positions of clips and rings during filled or free flowing phases are not pertinent to the resting state. In 18 patients, 138 swallows were recorded and analyzed. On prior routine radiography these patients were shown to have small sliding hiatal hernias, some with distal esophageal rings.
Results The patients in this study can be divided into five types based on the cine-mano-
FIG. 4A. Case 1: Hiatal hernia with absent resting high pressure zone. Conventional film shows a nonstenotic ring (arrows) a short distance above the hiatus. The vestibule above the ring is wider in caliber than the hernial sac distal to it.
741
metric criteria. A representative case of each type will be described. As will be noted, the major difference among the patients studied was the presence or absence of a zone of resting high pressure. Individual cases differed in details but their main features were consistent enough to permit this type of grouping for purposes of presentation. Case 1: Hiatal hernia with absent resting high pressure zone (figs. 4- and 5). This 54year-old man had a history of heartburn of many years' duration. Conventional roentgen examination showed a moderate-sized pouch with a wide hiatus with free reflux. A Schatzki ring of large caliber was present in the middle of the pouch. No contractile ring was evident. Cine-pressure study showed no evidence of a resting high pressure zone. Resting pressures from tubular esophagus to fundus were equal and showed abdominal type of respiratory excursions. The upper or vestibular portion of the supradiaphragmatic pouch emptied sequentially with the body of the esophagus. The lower portion or hernial sac retained barium and remained inactive by pressure criteria. In the group studied, five other cases demonstrated findings similar to this patient. Two of these five patients showed obstructive or stenotic Schatzki rings. Case 2: Hiatal hernia with transient high pressure zone after swallowing (figs. 6 and 7). This patient was a girl of 15 with severe heartburn since childhood. Conventional roentgen examination demonstrated a supradiaphragmatic pouch and a wide hiatus. No distinct rings were demonstrated. Reflux was seen occasionally when intraabdominal pressure was increased. Cine-pressure study showed no zone of resting high pressure. The point of respiratory reversal was above the diaphragmatic narrowing. In contrast to the previous case, elevated pressure was sustained in the vestibular region for many seconds after each swallow. This was the only patient in the series who showed this phenomenon. Case 3: Hiatal hernia with resting high pressure zone and contractile ring (figs. 8 and 9). This was a middle-aged obese woman with intermittent retrosternal pain and dysphagia for several years. Conventional roentgen examination showed a sliding hiatal hernia and numerous tertiary contractions in the body of the esophagus. At the junction of tubular esophagus and pouch, there was a contractile ring approximately 5 mm in length. Small
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FIG. 4B. Case 1: R epresentative barium swallow during simultaneous cineradiographymanometry. On the cine frames, the recording catheter openings are located approximately midway between the retouched clips. The three pressure tracings obtained are labeled upper, middle, and lower, respectively. The vertical lines on the tracings indicate the moments at which individual cine frames designated 1 to 6 ~vere exposed. Onset of a swallow is indicated by SW. Pressures prior to the swallow indicate resting pressures. Resting pressures and respiratory deflections from all openings were the same as those recorded from the stomach below the diaphragm . There was no identifiable resting high pressure zone. During filling, no pressure change was recorded from any of the three openings. In frame 1, the stripping wave is seen in the tubular esophagus. In frame 2, a supradiaphragmatic pouch with pointed top is formed. A faint circumferential Schatzki or B-ring (arrow) is seen in the middle of the pouch. Between frames 2 and 3, the upper portion of the pouch (vestibule) flattens and diminishes in size as a peristaltic wave traverses it. Between frames 3 and 4, the pouch empties down to the Schatzki ring level as the peristaltic wave is recorded from the proximal two openings. The peristaltic wave does not enter the hernial sac. Frame 5 shows retrograde flow of barium into the esophagus (arrow) through a short constriction above the sac. Retrograde flow starts when the peristaltic wave disappears. Continued retrograde flow (arrow) is seen in frame 6. For a short period during retrograde flow, pressure in the sac exceeds pressure in the esophagus. After this, all pressures return to original resting levels.
notches were seen in the middle of the pouch when it was maximally distended. Cine-pressure study showed a short zone of high resting pressure corresponding to the contractile ring.
There was an abrupt fall in resting pressure in the tubular esophagus immediately above the ring. The hernial sac showed minimal elevation of resting pressure with diminution to
June 1966
743
CINERADICGRAPHY-MANOMETRY OF ESOPHAGUS
"
50_
2
IfIPl T
3
4
SW
O:----------~r-_+--+-~----------
50_
- TP
0:-----------1---+--~-1---------
50_
- P
0:-----------r--4--+--4---------
50_
2
3
4
0:~~~------r-_+--4---~--------
FIG. 5. Case 1: Schematic presentation of cineradiographic-manometric events. In this and in similar subsequent idealized diagrams, pressure curves obtained from four sites and selected cine frames represent a summary of findings observed on multiple swallows with the catheter assembly at different levels. Recording sites are indicated by solid circles on the cine sketches. Tracing T is obtained from the tubular esophagus; tracing P from the hernial sac immediately above the hiatus; tracing TP from a point between T and P; and tracing IP from a point below the pouch at the diaphragmatic narrowing. PIP refers to the point of inversion of pressure or point of respiratory reversal. Vertical lines, indicating the moments at which cine images 1 to .4 are seen, permit correlation of roentgen configurations with instantaneous pressures.
fundic level during a swallow. No reflux into the esophagus was noted at any time. Five other patients demonstrated a resting high pressure zone. Two had a contractile ring associated with the high pressure zone while three showed only a transient narrowing at the onset of filling of the high pressure zone. Case 4: Hiatal hernia with resting high pressure zone, contractile ring and stenotic Schatzki ring (figs. 10 to 12). This 44-year-old man complained of intermittent, severe dysphagia for solid food. Routine radiographic examination demonstrated a stenotic Schatzki ring appearing as a constant weblike indentation above the diaphragmatic narrowing during complete distention of the EGR. In addition, a short distance above the Schatzki ring, there was a contractile A-ring appearing as a circumferential narrowing seen during early phases of filling which widened with maximal distention. On esophagoscopy, a weblike or Schatzki ring was identified, and biopsy of the ring revealed both squamous and columnar epithelium. On thoracotomy and gastrotomy, a typical Schatzki ring intruding into the lumen was exposed at the mucosal junction. The ring was excised and the mucosa coapted with sutures. No other ring was evident. A small sliding hiatal
hernia was repaired. Microscopic examination of excised segments of the ring again showed squamous and columnar epithelium. Cinepressure study showed a short zone of resting high pressure at the level of the contractile ring. Pressures at and distal to the Schatzki ring were equal to fundic pressure and did not change during the course of a swallow. Two other stenotic Schatzki ring cases with zones of resting high pressure above the Schatzki ring were observed in this series. An additional contractile ring, however, above the level of the Schatzki ring was not evident in these patients. Case 5: Hiatal hernia with resting hypertensive zone and an incompletely distensible contractile A-ring (figs. i3 and i.n. This patient was a 47-year-old man with intermittent dysphagia for solid food. His esophagogram demonstrated a persistent thick ring between the tubular esophagus and a supradiaphragmatic pouch. The pouch showed faint notches in its midportion when distended. The ring did not distend completely during any phase of swallowing and obstructed passage of a compressed Y2-inch barium tablet. It was assumed that the persistent narrowing of this ring was the result of local "spasm," a mild degree of peptic stricture, or both. Cine-pressure stud~'
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HEITMANN ET AL.
Vol. 50, No.6
FIG. 6. Case 2: Hiatal hernia with temporary high pressure zone after a swallow. Resting pressures from the middle and lower openings were equal to infra diaphragmatic fundic pressure while t hat at the upper opening was equal to intrathoracic pressure. There was no identifiable resting high pressure zone. The pressure tracings from the three openings are superimposed in the lowermost box. In fram e 1, free flow of barium occurs as the pressure at the upper opening reaches fundi c level. Toward the end of the swallow, frame 2, a prolonged elevation of pressure is recorded from the vestibular region (upper opening) while a sac persists below it. During frame 3, a spontaneous swallow results in a fall of this elevated pressure as retrograde flow occurs through the short, incompletely distended vestibule (arrow). During reflux, simultaneous sharp short waves ("pop-ups") are recorded from all openings. Frame 4 shows widening and elongation of the vestibule as swallowed barium refills the tubular esophagus. This is followed by anot her stripping peristaltic wave and another elevation of pressure in the vestibular area (upper tracing, after fram e 4). Spontaneous fall of pressure at this site subsequently occurs relatively slowly. Note that pressures are equal during free flow, both anterograde and retrograde (superimposed tracings, between fram es 1 and 2 and between f rames 3 and 4).
June 1966
745
CINERADIOGRAPHY-MANOMETRY OF ESOPHAGUS 3
" sw o:~~~~-+
4
sw
______~~~~~~~
50_
: TP
O:---------+----------r-----r-~
50_
: IP 2
3
4
FIG. 7. Case 2: Schematic presentation.
showed a zone of markedly elevated resting pressure associated with the ring. Although pressure fell to fundic level on swallowing and no flow pressure gradient was present, the ring remained evident during all phases of filling. Another patient in the series showed a similar thick contractile ring. In this patient, a high pressure zone was located at and for a short distance below the ring.
Discussion The results of this study confirm the roentgen observation that the pouch formed above the hiatus during maximal filling in patients with small sliding hiatal hernias consists of two parts-an upper esophageal or vestibular segment and a lower gastric portion or hernial sac per se. The upper portion is emptied by a continuation of the stripping peristaltic wave in a slower broader form. It is not possible to predict whether the elevated pressure in the vestibular segment during emptying will persist into the resting phase. If a contractile A-ring is evident, a localized zone of elevated resting pressure can be anticipated. A resting high pressure zone in the vestibular region may, however, be present without a demonstrable contractile ring. Since the vestibule shortens during emptying, the relative contributions of A-ring, when present, and vestibule to a resting high pressure zone proximal to the hernial sac are difficult to determine. When the ring is prominent, it appears to form the
major component and creates a peak pressure at the junction of tubular esophagus and pouch. The zone of resting high pressure in such cases is short with abrupt transition to adjacent lower pressures. In contrast, the normally located physiological sphincter is longer, has a peak at its center and is less sharply demarcated. 4 - 6 Whether a contractile A-ring is derived from the normal physiological sphincter or appears de novo is a question that requires further study. The behavior of the ring, however, does indicate that it plays a role in preventing retrograde flow from hernial sac into the esophagus. Relaxation and opening of the ring are frequently delayed until the filling pressure proximal to it attains fundic pressure level. With emptying of the tubular esophagus, pressure at the ring promptly rises and remains elevated. Occasionally, the resting pressure associated with a contractile ring may be higher than pressures within the normal sphincter resembling the "hypertensive sphincter" described by Code et al. 33 In its most typical form, with the current technique, the lower portion of the combined pouch, i.e., the hernial sac, shows no pressure change' during the course of a swallow. No pressure change is required to permit flow since resting pressure within the sac equals fundic pressure. At the end of a swallow, a peristaltic contraction wave is not recorded from the hernial sac.
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HE ITMANN ET AL.
Vol . 50 , No. 6
FIG . 8. Case 3 : Hiatal herni a with a resting high pressure zone and contractile A-ring. In t he resting s tate, a persistent high pressure zone was obtained from t he upper catheter opening shown at the onset of filling to be within the contractile ring (frame 2, arrow). Resting pressures from th e middle and lower openings were approximately 20 mm Hg less but exceeded fundi c p ressure. In frame 1, barium fills the tubular esophagus but is held up at the TP level by a delayed fall of the resting high pressure. Frame 2 shows the beginning of flow through the ring (arrow) at th e TP level as pressure at this site falls rapi dly. A fall to fundic pressure level also occurs in the two lowercatheter openings with fi lling of the pouch and free flow (frame 3). During flow, all pressures are essentially equal ( superimposed curves). Frame .4 shows tertiary contractions in t he tubular esophagus during emptying. Notches (arrows) are evident in the midpQrtion of the pouch between vestibule and hernial sac. Frame 5 shows an early phase of emptying of the vestibule. Pressure at t he upper opening has returned to high resting level. Between f rames 5 and 6, the vestibule empties completely and appears to shorten . Pressures within the hernial sac (middle and lower tracings ) r et urn to resting levels. No retrograde flow occurred at any time.
Resting pressure within a hernial sac may, however, exceed fundic pressure and produce a plateau of elevated pressure on pullthrough studies. 21 In such cases, pressure within the sac decreases during a swallow and returns to resting pressure at the end of a swallow. There is nevertheless no evi-
dence of a peristaltic wave in the hernial sac, i.e., return to resting pressure is not accompanied by an increase in pressure above base line or resting pressure. The manometric features of a hernial sac therefore differ from those of the vestibule, which shows a sequential peristaltic wave
June 1966
•
• ~-', ~.
T
•
TP
/ ,
./
~
~
I
~
1
747
CINERADIOGRAPHY-MANOMETRY OF ESOPHAGUS
2
'l'
3
1
50_
-
:::T 0:::
•
-'
,
4
50_
-
2 3
'w...rV\ ,~
-TP
-
0 50_
! I
:'!-
i
0: 50_mJ
--
:::IP
-
4
0: l, ..
c. J
~. i
/"'
~
----~-
--
~
FIG. 9. Case 3: Schematic representation.
FIG. 10. Case 4: Hiatal hernia with resting high pressure zone, contractile ring, and stenotic Schatzki ring. Four spot films taken with the patient upon a bolster. View A shows a Schatzki ring (lower arrow) and a contractile ring (upper arrow). In view B, the tubular esophagus has been stripped of barium and a supradiaphragmatic pouch with the Schatzki ring in its midportion is seen. View C shows the portion of the pouch located between the two rings (vestibule) contracted circumferentially. View D shows the Schatzki ring obstructing the passage of a half-inch compressed barium tablet. The contractile ring is seen immediately above the tablet.
748
HEITMANN ET AL.
Vol. 50, No.6
FIG. 11. Case 4: Hiatal hernia with resting high pressure zone, contractile ring, and stenotic Schatzki ring. Barium swallow during cineradiography-manometry. In the resting state, a high pressure zone was recorded from the middle opening shown at the onset of filling to be located within the contractile ring (arrow in frame 2, upper arrow in frame 3). The upper catheter opening is in the tubular esophagus and the lower at the level of the Schatzki ring. Frame 1 shows barium filling the tubular esophagus and held up above the contractile ring while high pressure is maintained at the middle opening. Frame 2 illustrates the beginning of flow through the contractile ring (arrow) as pressure within the ring abruptly decreases to a v alue equal to the filling pressure above it. Continuous flow of barium is seen in frame 3 with both rings (arrows) evident. In frame 4, a supradiaphragmatic pouch divided by the Schatzki ring (arrow) is evident. The tubular esophagus is stripped of barium as a tall peristaltic wave is inscribed in the upper tracing. Frame 5 shows shortening and flattening of that portion of the pouch (vestibule) above the Schatzki ring as a peristaltic wave is recorded from it. The arrow indicates the Schatzki ring. In frame 6, the vestibule is almost completely empty. The Schatzki ring (arrow) approaches the hiatus as the hernial sac distal to it shortens during emptying. The tubular esophagus lengthens to a similar degree during emptying. In the resting state, on quiet breathing, the pressure inversion point is at the level of the contractile ring. On a deep inspiration (latter part of tracings), it is located distally below the level of the pouch. Note that, during continuous flow (frame 3), obstruction at the level of the Schatzki ring is indicated by a pressure gradient between the upper two openings and the lowermost opening (superimposed tracings).
June 1966
749
CIN ERA DIOGRA PHY-MA NOMETRY OF ESOPHAGUS
"
2
50_
:: T
2
3
..__~-+----r=~. .~~
O:: --~~
•
•
3 4
50_
:: TP
4
:: IP
FIG. 12. Case 4: Schematic representation.
during which pressures greater than resting pressures are recorded.lO· 11 The "active" character of the vestibule is indicated radiologically by rapid progressive emptying from above downward, while a hernial sac fails to show a typical stripping wave. In patients with sliding hernias and no resting high pressure zone, retrograde flow or reflux from the hernial sac into the esophagus was frequently seen at the end of a swallow when the peristaltic wave di sappeared from the vestibular segment. During reflux, pressure in the sac slightly exceeded or equaled pressure in the esophagus. A transient narrowing of variable length proximal to the sac seen at the onset of retrograde flow appeared to represent residual activity of the peristaltic cont raction and was not associated with elevated resting pressure. This narrowing promptly disappeared when reflux was marked. Retrograde flow from hernial sac into esophagus must be di stinguished from retrograde flow from the infradiaphragmati c portion of the stomach into the hernial sac. This latter type of reflux through the hiatus depends on multiple factors. Some of these m ay not be detectable by intraluminal pressure changes. 34 • 35 Either type of retrograde flow may occur independently or they may occur simult aneously as free or complete gastroesophageal reflux. If resting pressures and respiratory excursions a re identical in
stomach and esophagus (case 1), free reflux can be anticipated. In the " complete" radiological configuration of a s mall sliding hiatal hernia, a contractile A-ring is present at the proximal margin of the vestibule and a Schatzki or B-ring at its distal margin. When only one ring is evident, it may not always be possible to distinguish between an A- and a Bring. When both rings are absent, the roentgen recognition of a small herni a may be difficult. It must be based on the demonstration of a s tatic pouch, a wide hi atus, and reflux . The absence of perista ltic activity within a questionable supradiaphragmatic pouch and the absence of a high pressure zone are best demonstrated by pressure studies. Conclusions from pressure studies, however, should not be based on the assumption that the point of respiratory reversal always indicat es the level of the hi atus. This is true in normal individuals but, in patients with a sliding hernia, this point is frequently above the diaphragmatic narrowing seen on roent gen examination. 24 In fact, it is usually located at t he level of the displaced high pressure zone when such a zone is present. In such cases, if it is assumed without reservation that the point of respiratory r eversal represents the hiatus, the record may be interpreted as indicating that the high pressure zone and hiatus are at t he same level and that no hernia is present. As noted
FIG . 13. Case 5: Hiatal hernia with resting hypertensive zone and an incompletely distensible contractile ring. In the resting stat.e, elevated pressure 25 mm Hg greater than fundic pressure was recorded from the middle opening which was within the contractile ring early in the swallow (fram e 1). R esting pressure from th e lower opening, shown to be within the pouch, was the same as fundic pressure. The upper opening within the tubular esophagus had a resting pressure less than fundic but slightly greater than the pressure more proximally in the esophagus. Frame 1 shows beginning flow through a broad ring in the TP region after pressure has risen at the upper opening and fallen at the middle opening. During continuous flow, frame 2, the ring achieves its maximal diameter. During t he period of flow, pressures from all openings are equal ( superimposed tracings). F rame 3 shows stripping of the tubular esophagus. In frame 4, the proximal portion of the pouch above faint notches contracts as a broad peristaltic wave is recorded from it . The lower portion of the pouch or hernial sac shows no pressure change. No reflux was observed.
750
June 1966
751
CINERADIOGRAPHY-MANOMETRY OF ESOPHAGUS 1
50: T
2
3
4
sw
O:------------~+_--~--1-----_
•
-~
•
5O~
TP
---~
O:------------~+_---r--~-----
50: 2
3
4
IP L Sltc )
O:~~~~----~+_---r--4------
" FIG. 14. Case 5: Schematic representation.
by Code et al.,21 two points of respiratory reversal may be found. The more distal one may be demonstrated or exaggerated by deep inspiration or by the use of a balloon rather than an open end catheter. This distal point corresponds to the hiatal level. The peristaltic wave which empties the vestibular segment extends down to but does not include the level of the Schatzki ring. This static behavior is in agreement with histological observations that the muscularis propria is not hypertrophic nor does it form an intrinsic component of a Schatzki ring. 36 -38 In patients with a stenotic Schatzki ring, the additional presence of a contractile A-ring is the exception rather than the rule, and a high pressure zone proximal to the Schatzki ring is likely to be absent. Pressure within the hernial sac distal to the Schatzki ring may be elevated and may fall during the course of a swallow. This type of change may be interpreted as indicating that the physiological sphincter is located distal to the ring whereas, in fact, a sphincteric area in the course of the esophagus is absent. An incorrect impression may also be gained if resting pressures are compared with the filled rather than the collapsed appearance of the EGR. This arises from the fact that during filling, the hernia distal to the ring elongates and the ring is therefore located
more proximally in the filled than in the empty state. It is, however, not clear why the findings reported in this study in regard to the motor behavior in the region of the Schatzki ring differ from those reported by Harris et al. 39 and by Cauthorne et aP6 Some variation may be expected on the basis of different techniques of measurement. The current observations agree with those reported by Rinaldo et al. 25 and appear more consistent with the surgical observations 37 , 38 that this ring is at the mucosal junction. There is no convincing evidence that peristaltic activity has been recorded distal to a Schatzki ring. The nature and origin of a contractile A-ring are not clear. It appears to be a functional phenomenon related to activity of the muscularis propria at this site. A discrete circumferential muscular ring in the distal esophagus located a short distance above the mucosal junction was originally described by Lerche 40 as normally present and designated the "inferior esophageal sphincter." Used in this fashion, the term "inferior esophageal sphincter" does not apply to the normal physiological sphincter or zone of high pressure recorded manometrically. Other anatomical studies 41 have failed to confirm Lerche's findings. Ingelfinger and Kramer 42 described an operative case with localized muscular
752
HEITMANN ET AI.,.
narrowing in the distal esophagus and used the term "contractile ring." These authors suggested that the ringlike constriction might represent an overactive mechanism of the inferior esophageal sphincter. In our experience, a contractile ring has not been evident at operation although clearly seen radiologically (for example, case 4). Specimens of the area in such cases are not, however, available for study.
stant in its location in hiatal hernia subjects. It was often located at the site of the upwardly displaced high pressure zone, although a second pressure inversion point could be identified at the hiatal level on deep inspiration. REFERENCES 1. Wolf, B. S., R. H. Marshak, M. L. Som, S. A. Brahms, and E. 1. Greenberg. 1958. The
Summary
Manometric features were correlated with roentgen configurations of the esophagogastric region in subjects with hiatal hernias and with rings by simultaneous cineradiographic and manometric study. The supradiaphragmatic pouch in small hiatal hernias was shown to have two functionally distinct components. Its upper portion (vestibule) had sequential contractile motor activity in response to swallowing. The lower portion was inactive and represented the true hernial sac. A weblike ring (Schatzki) or notches were often identified at the junction of these two segments. There was no peristaltic activity at or below this type of ring. A broad ring with contractile radiological behavior at the upper margin of the vestibule showed resting high pressure which fell on swallowing. This differed from the resting high pressure zone of normals in being shorter in length and showing an abrupt rather than gradual transition to contiguous pressures. Retrograde barium flow from hernial sac into the tubular esophagus was not seen when such a contractile A-ring was evident. Retrograde barium flow into the esophagus from the hernial sac occurred in those subjects not having a resting high pressure zone. Such reflux was delayed as long as the peristaltic wave persisted in the vestibular segment above the hernial sac. A constriction above the hernial sac during retrograde flow presumably represents a residual manifestation of the peristaltic wave, is transient, and is not associated with elevated resting pressure. The pressure inversion point was incon-
Vol. 50, No.6
2.
3.
4.
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6.
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9.
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13.
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M. H. Sleisenger. 1959. Esophageal catheterization studies. 1. The mechanism of swallowing in normal subjects with particular reference to the vestibule (esophagogastric sphincter). J. Clin. Invest. 38: 397406. 29. Cohen, B. R. 1965. Cardiospasm in achalasia ;
demonstration of an abnormally elevated esophagogastric sphincter pressure with partial relaxation on swallowing. Gastroenterology 48: 864. 30. Harris, L. D., and C. E. Pope. 1964. "Squeeze" VB. resistance; an evaluation of the mechanism of sphincter competence. J . Clin. Invest. 43: 2272-2278. 31. VanDerstappen, G. V., and E. C. T exter. 1964. Response of the physiologic gastroesophageal sphincter to increased intra-abdominal pressure. J. Clin. Invest. 43: 1856-1868. 32. Ingelfinger, F. J. 1958. Esophageal motility. Physiol. Rev. 38: 533-584. 33. Code, C. F., J. F . Schlegel, M. C. K elley, A. M. Olsen, and F. H. Ellis. 1960. Hypertensive gastroesophageal sphincter. Proc. Mayo Clin. 35: 391-399. 34. Edwards, D. A. W. 1961. The anti-reflux mechanism; manometric and radiologic studies. Brit. J. Radiol. 34: 474-487. 35. Sandmark, S. 1963. Intraluminal pressures and pH in hiatus hernia and gastro-oesophageal reflux . Act a Otolaryng. (Stockholm) 56: 116. 36. McMahon, H. E., R. Schatzki, and J . E . Gary. 1958. Pathology of a lower esophageal ring;
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report of a case, with autopsy, observed for nine years. New Eng. J. Med. 259 : 1-8. Wilkins, E. W., and M. K. Bartlett. 1963. Surgical treatment of the lower esophageal ring. New Eng. J. Med. 268: 461-464. Postlethwait, R. W., and A. W. Musser. 1965. Pathology of lower esophageal web. Surg. Gynec. Obstet. 120: 571-575. Harris, L. D., J. E. Kelly, Jr., and P . Kramer. 1960. Relation of the lower esophageal ring to the esophagogastric junction. New Eng. J. Med. 263 : 1232-1235. Lerche, W. 1950. The esophagus and pharynx in action. Charles C Thomas, Springfield, Ill. Zaino, C., M. H . Poppel, H. G. J acobson, and H. Lepow. 1963. The lower esophageal vestibular complex. Charles C Thomas, Springfield, Ill. Ingelfinger, F. J., and P. Kramer. 1953. Dysphagia produced by a contractile ring in the lower esophagus. Gastroenterology 23 : 419430.