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The relationship between gastroesophageal junction pressure and gastroesophageal pressure gradients
1410
ABSTRACTS
OF PAPERS
TEE RmAzIQMsHIP BSTWEN QASTROSSOPIuoIuL JUlWTION PARSSURF:AND QAsl?IoEsoPEM~ PRBSlI.ln 0uAD1BnTs . . tt& and A. Farace. crm ttm bpt. Of I&. Med., Univ. of Virginia, Gharlotte~ville, VA 22909 The intraluminal preeauro at the gastroesophageal junction ('X3.7)is a parameter of the atrenpth of the antireflux barrier and the preswre difference between stomach and esophagus (pdi) in the driving force for gaetroesophageal reflux. The GEJ preosure im contributed by the smooth muscle of the lower esophageal sphincter and the akeletal muscles of the crural diaphragm. We determined GE.7 preaaure in 6 normal health eubjecte during various physiologic maneuvera that increase: 1) negative intraesophageal pressure primarily, 2) poeitive intragastric prewure mainly, and 3) a combination of both. Stomach and esophageal pressures were measured using side hole manometry and GEJ pressure wing a reverse perfused sleeve. In addition, crural diaphragm EMG wao measured using bipolar intraesophageal electrodes placed on the non-pressure sensing surface of the sleeve device. Subjects were trained to perform: 1. Standardized muller maneuver [MM] (inapiratory effort against closed airway] using vieual feedback from inapirometer, 2. Contraction of abdominal wall wing feedback from abdominal wall muscle EMG [AWC], 3. Muller maneuver and abdominal wall contraction simultaneously [MM t AWC], 4. Abdominal compression using an abdominal binder [AC], and 5. Muller maneuver during abdominal compression [MM S AC]. Data are mean t SEM.
GEJ preaeure increases various physiologic maneuvers. during various physiologic maneuvers ate largely related to contraction of the crural diaphragm as evidenced by increases in its EMG activity.
MODIFIED BARIUM SWALLOW: CLINICAL INDICATIONS AND RADIOGRAPHIC RESULTS IN DETHRMINING FEEDING RECOMMENDATIONS. R.G. Hedge, L.A. Pikna, D.J., M.Y.M. Chen, D.W. Gelfand. Depar@nts of Radiology and Otolaryngology, Bowman Gray School of Medicine, Winston-Salem, N. C.
We reviewed the medical and radiological records in 148 patients (73 women; 75 men; mean age, 62 years) evaluated clinically for swallowing difficulty to determine indications for radiographic exam&bon and ilnal feeding recommendations. Clinical bedside evaluation (CE) was done in all patients with oral and phayngeal assessment. Radiographic examination (RE) was performed in 93 (63%) patients using variable viscosity materials and videotape recording of the oral cavity and pharynx. Feeding recommendations were divided into patients receiving oral dietary manipulation and those requiring intestinal intubation. Of the 55 patients having CE only, 24 were judged normal at both oral and pharyngeal levels, and 45 (82%) were managed with oral feedings. Of the 93 patients having both evaluations, RR was performed in 61(66%) because the presence or severity of pharyngeal dysfunction could not be determined on CE, and 25 (27%) were managed by intestinal intubation. Only 4 (12%) of 34 patients with normal pharyngeal function clinically had RF. The severity of pharyngeal dysfunction was the most important dekrmbmnt for recommending tube feeding. In conclusion, feeding tecommendations in patients with swallowing difficulty or related problems, such as aspiration, are based most importantly on the status of pharyngeal Rmction. Although CE may assess pharyngeal function, RE is often indicated for more precise evaluation and will aid in determining feeding recommendations.
October 1992
TEE PRRSSVRE AT TILEESOPRAGOGASTRIC JDNCTION IN ACRALASIA: IS IT DUE To LOWRR EROPRRQRAL SPEINCTRR OR CRDRU DIAPRRAGN? .R.R.Nittal, W.R. Stewart, and Y. Ramahi. Prom the Dept. of Int. Med., Univ. of Virginia, Charlottesville, VA 22909 The end exoiratorv DreBBure at the eeoohaeoaastrie junction (EGJ) ii the r&r"g state in normal sub>ec&*is due to the smooth muscles of the lower esophageal aphincter ILES. HO”*“*r, under certain situations crurai diapi%agm (CR)‘may contribute to thie end expiratory pressure (e.g. during periods of increased intraabdominal pressure). We wanted to determine. whether the end exoiratorv nreeaure in achalaeia (so-called LES pressure] is- contkduted by the crural diaphragm. We tested this hypothesis by measuring reeoonse of the EGJ pressure to atro&e. (Tire press&e would be resistant to atropine if it were due to contraction of the skeletal muscles of the crural diaphragm). Secondly we measured tonic or end expiratory crural diaphragm EMG activity (if crural diaphragm contributed to the end expiratory EGJ pressure, we should be able to record end expiratory EHG activity). Studies were performed in 8 normal eubjects and 7 patients known to have achalaeia of the esophagus. None of the patients had any treatment for achalaeia prior to the study. EGJ pressure was measured manometrically ueing a cleave device. Crural diaphragm ERG was measured with the help of two electrodes placed on the non-pressure seneing surface of the sleeve device and J&J apparatus. Subjects received a lZpg/kg bolus of atropine IV. RB&lJ: with the electrodes in the stomach, no EMG activity was detected in either inspiration or expiration and this was used as the zero reference for meaourement of crural diaphragm EHG. End ewpiratory (tonic) and inapiratory (or phasic)
activity and response to atropine in controls and patients with achalasia. CONCLtJSIONlThe LES, not the crural diaphragm, is the major contributor to the EGJ pressure in achalasia
ESOPHAGEAL DIVERTICULA IN ACHALASIA: PREVALENCE AND POTENTIAL IMPLICATIONS. D,J., R.G. Hodge, M.Y.M. Chen, W.C. Wu, D.W. Gelfand. Departments of Radiology and Medicine, Bowman Gray School of Medicine, Winston-Salem, N. C. Although esophageal diverticula have been rqorted rarely in patients with achalasia, their prevalence and potential implciations are not well known. We reviewed the medical records and manometric and radiographic examinations in 120 patients (60 women; 60 men; mean age, 53 years) with achalasia to determine the prevalence of esophageal diverticula and to evaluate their importance in diagnosing and managing patients with this motility disorder. Esophageal divert&la were found in only 6 (5%) of 120 patients and were all located in the lower half of the esophagus. Sex distribution and the prevalence of dysphagii and regurgitation, which affected all patients with diver&la and 88% of those with achalasia only, were not different significantly. However, patients with eosphageal diverticula were significantly older (72 vs. 52 years) than those without diver&la @=.02). In 5 of 6 patients with dlverticula, mean lower eosphageal sphincter pressme was 44.5 mmHg compared to 39.1 mm Hg @ > .M) in 86 of 114 patients with a&aksia only. Aperistalsis was present in all patients analyzed. Treatment by pneumatic dilatation was done in 4 patients with esophageal diverticula and in Five esophageal pezforations 105 patients without diverticula. ommed but all in patients without esohageal diverticula. In conclusion, esophageal diverticula are rarely present in patients with achalasia. Results of esophageal manometry showed no significant differences in findings between the two groups of patients. The only significant observation was that patients with divertkula were older for masons not known. Finally, the presence of esophageal diverticula in achalasia is not a contraindication to treatment by pneumatic dilatation.
ABSTRACTS
OF PAPERS
TEE RmAzIQMsHIP BSTWEN QASTROSSOPIuoIuL JUlWTION PARSSURF:AND QAsl?IoEsoPEM~ PRBSlI.ln 0uAD1BnTs . . tt& and A. Farace. crm ttm bpt. Of I&. Med., Univ. of Virginia, Gharlotte~ville, VA 22909 The intraluminal preeauro at the gastroesophageal junction ('X3.7)is a parameter of the atrenpth of the antireflux barrier and the preswre difference between stomach and esophagus (pdi) in the driving force for gaetroesophageal reflux. The GEJ preosure im contributed by the smooth muscle of the lower esophageal sphincter and the akeletal muscles of the crural diaphragm. We determined GE.7 preaaure in 6 normal health eubjecte during various physiologic maneuvera that increase: 1) negative intraesophageal pressure primarily, 2) poeitive intragastric prewure mainly, and 3) a combination of both. Stomach and esophageal pressures were measured using side hole manometry and GEJ pressure wing a reverse perfused sleeve. In addition, crural diaphragm EMG wao measured using bipolar intraesophageal electrodes placed on the non-pressure sensing surface of the sleeve device. Subjects were trained to perform: 1. Standardized muller maneuver [MM] (inapiratory effort against closed airway] using vieual feedback from inapirometer, 2. Contraction of abdominal wall wing feedback from abdominal wall muscle EMG [AWC], 3. Muller maneuver and abdominal wall contraction simultaneously [MM t AWC], 4. Abdominal compression using an abdominal binder [AC], and 5. Muller maneuver during abdominal compression [MM S AC]. Data are mean t SEM.
GEJ preaeure increases various physiologic maneuvers. during various physiologic maneuvers ate largely related to contraction of the crural diaphragm as evidenced by increases in its EMG activity.
MODIFIED BARIUM SWALLOW: CLINICAL INDICATIONS AND RADIOGRAPHIC RESULTS IN DETHRMINING FEEDING RECOMMENDATIONS. R.G. Hedge, L.A. Pikna, D.J., M.Y.M. Chen, D.W. Gelfand. Depar@nts of Radiology and Otolaryngology, Bowman Gray School of Medicine, Winston-Salem, N. C.
We reviewed the medical and radiological records in 148 patients (73 women; 75 men; mean age, 62 years) evaluated clinically for swallowing difficulty to determine indications for radiographic exam&bon and ilnal feeding recommendations. Clinical bedside evaluation (CE) was done in all patients with oral and phayngeal assessment. Radiographic examination (RE) was performed in 93 (63%) patients using variable viscosity materials and videotape recording of the oral cavity and pharynx. Feeding recommendations were divided into patients receiving oral dietary manipulation and those requiring intestinal intubation. Of the 55 patients having CE only, 24 were judged normal at both oral and pharyngeal levels, and 45 (82%) were managed with oral feedings. Of the 93 patients having both evaluations, RR was performed in 61(66%) because the presence or severity of pharyngeal dysfunction could not be determined on CE, and 25 (27%) were managed by intestinal intubation. Only 4 (12%) of 34 patients with normal pharyngeal function clinically had RF. The severity of pharyngeal dysfunction was the most important dekrmbmnt for recommending tube feeding. In conclusion, feeding tecommendations in patients with swallowing difficulty or related problems, such as aspiration, are based most importantly on the status of pharyngeal Rmction. Although CE may assess pharyngeal function, RE is often indicated for more precise evaluation and will aid in determining feeding recommendations.
October 1992
TEE PRRSSVRE AT TILEESOPRAGOGASTRIC JDNCTION IN ACRALASIA: IS IT DUE To LOWRR EROPRRQRAL SPEINCTRR OR CRDRU DIAPRRAGN? .R.R.Nittal, W.R. Stewart, and Y. Ramahi. Prom the Dept. of Int. Med., Univ. of Virginia, Charlottesville, VA 22909 The end exoiratorv DreBBure at the eeoohaeoaastrie junction (EGJ) ii the r&r"g state in normal sub>ec&*is due to the smooth muscles of the lower esophageal aphincter ILES. HO”*“*r, under certain situations crurai diapi%agm (CR)‘may contribute to thie end expiratory pressure (e.g. during periods of increased intraabdominal pressure). We wanted to determine. whether the end exoiratorv nreeaure in achalaeia (so-called LES pressure] is- contkduted by the crural diaphragm. We tested this hypothesis by measuring reeoonse of the EGJ pressure to atro&e. (Tire press&e would be resistant to atropine if it were due to contraction of the skeletal muscles of the crural diaphragm). Secondly we measured tonic or end expiratory crural diaphragm EMG activity (if crural diaphragm contributed to the end expiratory EGJ pressure, we should be able to record end expiratory EHG activity). Studies were performed in 8 normal eubjects and 7 patients known to have achalaeia of the esophagus. None of the patients had any treatment for achalaeia prior to the study. EGJ pressure was measured manometrically ueing a cleave device. Crural diaphragm ERG was measured with the help of two electrodes placed on the non-pressure seneing surface of the sleeve device and J&J apparatus. Subjects received a lZpg/kg bolus of atropine IV. RB&lJ: with the electrodes in the stomach, no EMG activity was detected in either inspiration or expiration and this was used as the zero reference for meaourement of crural diaphragm EHG. End ewpiratory (tonic) and inapiratory (or phasic)
activity and response to atropine in controls and patients with achalasia. CONCLtJSIONlThe LES, not the crural diaphragm, is the major contributor to the EGJ pressure in achalasia
ESOPHAGEAL DIVERTICULA IN ACHALASIA: PREVALENCE AND POTENTIAL IMPLICATIONS. D,J., R.G. Hodge, M.Y.M. Chen, W.C. Wu, D.W. Gelfand. Departments of Radiology and Medicine, Bowman Gray School of Medicine, Winston-Salem, N. C. Although esophageal diverticula have been rqorted rarely in patients with achalasia, their prevalence and potential implciations are not well known. We reviewed the medical records and manometric and radiographic examinations in 120 patients (60 women; 60 men; mean age, 53 years) with achalasia to determine the prevalence of esophageal diverticula and to evaluate their importance in diagnosing and managing patients with this motility disorder. Esophageal divert&la were found in only 6 (5%) of 120 patients and were all located in the lower half of the esophagus. Sex distribution and the prevalence of dysphagii and regurgitation, which affected all patients with diver&la and 88% of those with achalasia only, were not different significantly. However, patients with eosphageal diverticula were significantly older (72 vs. 52 years) than those without diver&la @=.02). In 5 of 6 patients with dlverticula, mean lower eosphageal sphincter pressme was 44.5 mmHg compared to 39.1 mm Hg @ > .M) in 86 of 114 patients with a&aksia only. Aperistalsis was present in all patients analyzed. Treatment by pneumatic dilatation was done in 4 patients with esophageal diverticula and in Five esophageal pezforations 105 patients without diverticula. ommed but all in patients without esohageal diverticula. In conclusion, esophageal diverticula are rarely present in patients with achalasia. Results of esophageal manometry showed no significant differences in findings between the two groups of patients. The only significant observation was that patients with divertkula were older for masons not known. Finally, the presence of esophageal diverticula in achalasia is not a contraindication to treatment by pneumatic dilatation.