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Water Swallows Versus Food Ingestion as Manometric Tests for Esophageal Dysfunction
GASTROENTEROLOGY 1988;95:831-3
Water Swallows Versus Food Ingestion as Manometric Tests for Esophageal Dysfunction MELVIN 1. ALLEN, WILLIAM C. ORR, MARK H. MELLOW, and MALCOLM G. ROBINSON HCA Presbyterian Hospital and Oklahoma City Clinic, Oklahoma City, Oklahoma
Data from 100 consecutive patients with chest pain or dysphagia, or both, who underwent esophageal testing with standard water swallows and upright food ingestion were retrospectively evaluated. In addition to having manometric patterns monitored, patients were asked to relate symptoms during testing. Of 77 patients with a history of dysphagia, significantly more had abnormal manometry during the test meal than with water swallows (79 vs. 43%, p < 0.005). Additionally, dysphagia, although reported in only 8% of these patients during standard testing, occurred in 47% during the test meal (p < 0.001). Of 60 patients with chest pain, symptoms were rarely reported (5%) with water or with food ingestion. We conclude that manometry with food ingestion should be used as a provocative test in anatomically normal patients with dysphagia.
F
requ entl y, patients presenting to the motility laboratory with chest pain or dysphagia, or both, have normal motility patterns associated with swallowing standard volumes of water (1). Pharmacologic provocation can stimulate motor abnormalities in some patients. However, even when such provocative studies reveal an abnormality, the correlation of these events with the clinical complaint of chest pain or dysphagia is not impressive (2-10). We previously observed, in a small group of patients, that food ingestion provided a provocative physiologic stimulus for dysphagia and, in some instances, chest pain (1). We now incorporate motility testing during food ingestion as a routine part of most clinical and research esophageal motility tests conducted in our laboratory. To more formally evaluate food ingestion as a provocative stimulus, data from 100 additional patients were evaluated.
both, who underwent testing with both water swallows and food ingestion were included in this analysis. There were 78 women and 22 men, aged 20-79 yr (mean 49 yr for both sexes). Resting pressures and relaxation of the lower and upper esophageal sphincters were measured, although we focus on information obtained from the distal body of the esophagus in this report. Data were collected with pressure transducers (Konigsburg Instruments, Pasadena, Calif.) placed at 3, 8, and 13 em above the proximal margin of the lower esophageal sphincter and recorded on a paper chart recorder (Sandhill Scientific). All patients received ten 5-ml water swallows in the supine position, spaced 30 s apart, followed by testing with upright food ingestion ad libitum. The meal consisted of beef tips, bread, jello, and water. Patients were asked to relate symptoms of chest pain or dysphagia during testing. We considered the presence of an esophageal motor abnormality occurring within 10 s of the patient's relating the complaint of dysphagia or chest pain as a "concurrent" motor abnormality. (It was clear that patients often did not relate symptoms immediately.) Normal data on food ingestion motility parameters were obtained in 20 asymptomatic subjects. Mean (± SD) distal esophageal contractile amplitude was 77 ± 25 mmHg and mean duration was 4.8 ± 0.8 s. Nonperistaltic esophageal contractions were seen in a mean of 8.5% ± 7.0% of swallows in our normal subjects. Abnormal values for amplitude, duration, and nonperistaltic esophageal contractions were defined as greater than two standard deviations above the established mean. Final manometric diagnoses, based on our normals' data and established criteria (11) for abnormalities in the body of the esophagus, were as follows: nonspecific esophageal motility disorder (65), nutcracker esophagus (12), achalasia (8), diffuse esophageal spasm (2), scleroderma (1), and normal (12).
Results Seventy-seven of the 100 patients had a history of dysphagia. Of these, 5 (6%) patients had an
Materials and Methods One hundred consecutive patients presenting to our laboratory for evaluation of dysphagia or chest pain, or
© 1988 by the American Gastroenterological Association
0016-5085/88/$3.50
832
GASTROENTEROLOGY Vol. 95, No.3
ALLEN ET AL.
50
40
ztw
30
U
a: ~ 20 10
DYSPHAGIA (77l
CHEST PAIN {GOl
Figure 1. Percentage of patients with a motor abnormality in the body of the esophagus during water swallows or food ingestion accompanied by symptoms during testing.
abnormal manometric pattern seen only during water swallows and 33 (43%) patients had an abnormal manometric pattern seen only during the test meal (p < 0.005). Twenty-eight (36%) of these patients exhibited abnormalities with both water swallows and food ingestion. Sixty patients had a history of chest pain. Eight (13%) exhibited abnormalities with water swallows alone. Twenty-six (43%) exhibited abnormalities during the test meal alone (p < 0.05). Eighteen (30%) of these patients had both abnormal water swallows and food ingestion. Of the 77 patients with a history of dysphagia, only 6 (8%) patients experienced their dysphagia during water swallows, whereas 36 patients (47%) reported dysphagia during the test meal (p < 0.001) (Figure 1). Of the 60 patients with a history of chest pain, 3 (5%) patients experienced chest pain during water swallows and 3 (5%) patients reported chest pain during the test meal. In those reporting symptoms during the test meal, a motor abnormality occurred in close proximity (within 10 s) to the subject's complaint in 85% of the cases. Motor abnormalities included single-peaked, double-peaked, and repetitive (triple-peaked) nonperistaltic esophageal contractions, and abnormally high-pressure peristaltic contractions. Figure 2 shows a patient with normal water swallows who experienced dysphagia with concurrent dysmotility during the test meal.
Discussion Standard testing with water swallows often fails to produce an esophageal motor abnormality in patients with a history of dysphagia. Additionally, even when motility abnormalities are demonstrable, the link to the patient's symptomatology is less than concrete, as patients rarely experience dysphagia or chest pain during standard motility testing. For this reason, other provocative tests utilizing cholinergic
agonists, cholinesterase inhibitors, and vasoconstrictive agents have all been incorporated into the diagnostic armamentarium. Although each pharmacologic agent has increased the yield of "positive" motility studies, the tests cannot really be considered physiologic. As the most physiologic esophageal "stress test" should be measurement of esophageal motility during food ingestion, we originally examined motility during upright food ingestion in normal subjects and a small number of patients (1). The current report confirms and extends our original observations that esophageal motor abnormalities were seen significantly more frequently in patients during the test meal than they were with water swallows. Without testing during food ingestion, no motor abnormality would have been recognized in a substantial number (43%) of our patients who reported a history of dysphagia. More importantly, although patients were rarely symptomatic during standard water swallows, nearly half reported dysphagia during the test meal. The close temporal relationship between the report of dysphagia and the presence of a motor abnormality in 85% of these patients strongly supports the reliability of these data. Although more patients with chest pain demonstrated abnormal motility during food ingestion than with standard testing, neither technique led to chest pain in more than a few instances. Whether this means that neither water swallows nor food ingestion are sensitive provocative tests in patients with presumed esophageal chest pain, or that the origin of Water Swallows swallow t
Food Ingestion
swallow t
swallow t
c:»:»: swallow
swallow
~
40 mmHflL
Dysphagia
5.
Figure 2. Example of a manometric tracing from a patient with normal functioning in the body of the esophagus during water swallows. but a motor abnormality associated with dysphagia during food ingestion.
FOOD INGESTION FOR ESOPHAGEAL TESTING
September 1988
the patients' chest pain is not esophageal dysmotility, cannot yet be answered. In conclusion, measurement of esophageal motility during upright food ingestion is of benefit in the evaluation of patients with dysphagia and will often demonstrate dysmotility in patients with presumed esophageal chest pain in whom water swallows are normal.
6. 7. 8. 9.
References 1. Mellow MH. Esophageal motility during food ingestion: a physiologic test of esophageal motor function. Gastroenterology 1983;85:570-7. 2. Nebel OT, Fornes MD. Castell DO. Symptomatic gastroesophageal reflux: incidence and precipitating factors. Dig Dis 1976; 21:953-6. 3. Mellow MH. Symptomatic diffuse esophageal spasm: manometric follow-up and response to cholinergic stimulation and cholinesterase inhibition. Gastroenterology 1977;73:237-40. 4. Orlando RB, Bozymski EM. The effects of pentagastrin in achalasia and diffuse esophageal spasm. Gastroenterology 1979;77:472-7. 5. London RL, Ouyang A, Snape WJ, Goldberg S, Hirshfeld JW.
10.
11.
833
Provocation of esophageal pain by ergonovine or edrophonium. Gastroenterology 1981;81:10-4. Eastwood GL, Weiner BH, Dickerson WJ, et al. Use of ergonovine to identify esophageal spasm in patients with chest pain. Ann Intern Med 1981;94:768-71. Gravino FN, Perl off JK, Yeatman LA, Ippolitti AF. Coronary arterial versus esophageal spasm response to ergonovine. Am J Med 1981;70:1293-6. Mellow MH. A gastroenterologist's view of chest pain. Curr Probl CardioI1983;1-36. Peter LJ, Maas LC, Dalton CB, et al. 24 hour ambulatory combined esophageal motility/pH monitoring in evaluation of non-cardiac chest pain (abstr). Gastroenterology 1986;90: 1584. Katz PO, Dalton CB, Richter JE, Wu WC, Castell DO. Esophageal testing of patients with noncardiac chest pain or dysphagia. Ann Intern Med 1987;106:593-7. Katz PO, Castell DO. Review: esophageal motility disorders. Am J Med Sci 1985;290:81-9.
Received September 30, 1987. Accepted April 19, 1988. Address requests for reprints to: Mark H. Mellow, M.D., Division of Gastroenterology, Oklahoma City Clinic, 701 Northeast Tenth Street, Oklahoma City, Oklahoma 73104.
Water Swallows Versus Food Ingestion as Manometric Tests for Esophageal Dysfunction MELVIN 1. ALLEN, WILLIAM C. ORR, MARK H. MELLOW, and MALCOLM G. ROBINSON HCA Presbyterian Hospital and Oklahoma City Clinic, Oklahoma City, Oklahoma
Data from 100 consecutive patients with chest pain or dysphagia, or both, who underwent esophageal testing with standard water swallows and upright food ingestion were retrospectively evaluated. In addition to having manometric patterns monitored, patients were asked to relate symptoms during testing. Of 77 patients with a history of dysphagia, significantly more had abnormal manometry during the test meal than with water swallows (79 vs. 43%, p < 0.005). Additionally, dysphagia, although reported in only 8% of these patients during standard testing, occurred in 47% during the test meal (p < 0.001). Of 60 patients with chest pain, symptoms were rarely reported (5%) with water or with food ingestion. We conclude that manometry with food ingestion should be used as a provocative test in anatomically normal patients with dysphagia.
F
requ entl y, patients presenting to the motility laboratory with chest pain or dysphagia, or both, have normal motility patterns associated with swallowing standard volumes of water (1). Pharmacologic provocation can stimulate motor abnormalities in some patients. However, even when such provocative studies reveal an abnormality, the correlation of these events with the clinical complaint of chest pain or dysphagia is not impressive (2-10). We previously observed, in a small group of patients, that food ingestion provided a provocative physiologic stimulus for dysphagia and, in some instances, chest pain (1). We now incorporate motility testing during food ingestion as a routine part of most clinical and research esophageal motility tests conducted in our laboratory. To more formally evaluate food ingestion as a provocative stimulus, data from 100 additional patients were evaluated.
both, who underwent testing with both water swallows and food ingestion were included in this analysis. There were 78 women and 22 men, aged 20-79 yr (mean 49 yr for both sexes). Resting pressures and relaxation of the lower and upper esophageal sphincters were measured, although we focus on information obtained from the distal body of the esophagus in this report. Data were collected with pressure transducers (Konigsburg Instruments, Pasadena, Calif.) placed at 3, 8, and 13 em above the proximal margin of the lower esophageal sphincter and recorded on a paper chart recorder (Sandhill Scientific). All patients received ten 5-ml water swallows in the supine position, spaced 30 s apart, followed by testing with upright food ingestion ad libitum. The meal consisted of beef tips, bread, jello, and water. Patients were asked to relate symptoms of chest pain or dysphagia during testing. We considered the presence of an esophageal motor abnormality occurring within 10 s of the patient's relating the complaint of dysphagia or chest pain as a "concurrent" motor abnormality. (It was clear that patients often did not relate symptoms immediately.) Normal data on food ingestion motility parameters were obtained in 20 asymptomatic subjects. Mean (± SD) distal esophageal contractile amplitude was 77 ± 25 mmHg and mean duration was 4.8 ± 0.8 s. Nonperistaltic esophageal contractions were seen in a mean of 8.5% ± 7.0% of swallows in our normal subjects. Abnormal values for amplitude, duration, and nonperistaltic esophageal contractions were defined as greater than two standard deviations above the established mean. Final manometric diagnoses, based on our normals' data and established criteria (11) for abnormalities in the body of the esophagus, were as follows: nonspecific esophageal motility disorder (65), nutcracker esophagus (12), achalasia (8), diffuse esophageal spasm (2), scleroderma (1), and normal (12).
Results Seventy-seven of the 100 patients had a history of dysphagia. Of these, 5 (6%) patients had an
Materials and Methods One hundred consecutive patients presenting to our laboratory for evaluation of dysphagia or chest pain, or
© 1988 by the American Gastroenterological Association
0016-5085/88/$3.50
832
GASTROENTEROLOGY Vol. 95, No.3
ALLEN ET AL.
50
40
ztw
30
U
a: ~ 20 10
DYSPHAGIA (77l
CHEST PAIN {GOl
Figure 1. Percentage of patients with a motor abnormality in the body of the esophagus during water swallows or food ingestion accompanied by symptoms during testing.
abnormal manometric pattern seen only during water swallows and 33 (43%) patients had an abnormal manometric pattern seen only during the test meal (p < 0.005). Twenty-eight (36%) of these patients exhibited abnormalities with both water swallows and food ingestion. Sixty patients had a history of chest pain. Eight (13%) exhibited abnormalities with water swallows alone. Twenty-six (43%) exhibited abnormalities during the test meal alone (p < 0.05). Eighteen (30%) of these patients had both abnormal water swallows and food ingestion. Of the 77 patients with a history of dysphagia, only 6 (8%) patients experienced their dysphagia during water swallows, whereas 36 patients (47%) reported dysphagia during the test meal (p < 0.001) (Figure 1). Of the 60 patients with a history of chest pain, 3 (5%) patients experienced chest pain during water swallows and 3 (5%) patients reported chest pain during the test meal. In those reporting symptoms during the test meal, a motor abnormality occurred in close proximity (within 10 s) to the subject's complaint in 85% of the cases. Motor abnormalities included single-peaked, double-peaked, and repetitive (triple-peaked) nonperistaltic esophageal contractions, and abnormally high-pressure peristaltic contractions. Figure 2 shows a patient with normal water swallows who experienced dysphagia with concurrent dysmotility during the test meal.
Discussion Standard testing with water swallows often fails to produce an esophageal motor abnormality in patients with a history of dysphagia. Additionally, even when motility abnormalities are demonstrable, the link to the patient's symptomatology is less than concrete, as patients rarely experience dysphagia or chest pain during standard motility testing. For this reason, other provocative tests utilizing cholinergic
agonists, cholinesterase inhibitors, and vasoconstrictive agents have all been incorporated into the diagnostic armamentarium. Although each pharmacologic agent has increased the yield of "positive" motility studies, the tests cannot really be considered physiologic. As the most physiologic esophageal "stress test" should be measurement of esophageal motility during food ingestion, we originally examined motility during upright food ingestion in normal subjects and a small number of patients (1). The current report confirms and extends our original observations that esophageal motor abnormalities were seen significantly more frequently in patients during the test meal than they were with water swallows. Without testing during food ingestion, no motor abnormality would have been recognized in a substantial number (43%) of our patients who reported a history of dysphagia. More importantly, although patients were rarely symptomatic during standard water swallows, nearly half reported dysphagia during the test meal. The close temporal relationship between the report of dysphagia and the presence of a motor abnormality in 85% of these patients strongly supports the reliability of these data. Although more patients with chest pain demonstrated abnormal motility during food ingestion than with standard testing, neither technique led to chest pain in more than a few instances. Whether this means that neither water swallows nor food ingestion are sensitive provocative tests in patients with presumed esophageal chest pain, or that the origin of Water Swallows swallow t
Food Ingestion
swallow t
swallow t
c:»:»: swallow
swallow
~
40 mmHflL
Dysphagia
5.
Figure 2. Example of a manometric tracing from a patient with normal functioning in the body of the esophagus during water swallows. but a motor abnormality associated with dysphagia during food ingestion.
FOOD INGESTION FOR ESOPHAGEAL TESTING
September 1988
the patients' chest pain is not esophageal dysmotility, cannot yet be answered. In conclusion, measurement of esophageal motility during upright food ingestion is of benefit in the evaluation of patients with dysphagia and will often demonstrate dysmotility in patients with presumed esophageal chest pain in whom water swallows are normal.
6. 7. 8. 9.
References 1. Mellow MH. Esophageal motility during food ingestion: a physiologic test of esophageal motor function. Gastroenterology 1983;85:570-7. 2. Nebel OT, Fornes MD. Castell DO. Symptomatic gastroesophageal reflux: incidence and precipitating factors. Dig Dis 1976; 21:953-6. 3. Mellow MH. Symptomatic diffuse esophageal spasm: manometric follow-up and response to cholinergic stimulation and cholinesterase inhibition. Gastroenterology 1977;73:237-40. 4. Orlando RB, Bozymski EM. The effects of pentagastrin in achalasia and diffuse esophageal spasm. Gastroenterology 1979;77:472-7. 5. London RL, Ouyang A, Snape WJ, Goldberg S, Hirshfeld JW.
10.
11.
833
Provocation of esophageal pain by ergonovine or edrophonium. Gastroenterology 1981;81:10-4. Eastwood GL, Weiner BH, Dickerson WJ, et al. Use of ergonovine to identify esophageal spasm in patients with chest pain. Ann Intern Med 1981;94:768-71. Gravino FN, Perl off JK, Yeatman LA, Ippolitti AF. Coronary arterial versus esophageal spasm response to ergonovine. Am J Med 1981;70:1293-6. Mellow MH. A gastroenterologist's view of chest pain. Curr Probl CardioI1983;1-36. Peter LJ, Maas LC, Dalton CB, et al. 24 hour ambulatory combined esophageal motility/pH monitoring in evaluation of non-cardiac chest pain (abstr). Gastroenterology 1986;90: 1584. Katz PO, Dalton CB, Richter JE, Wu WC, Castell DO. Esophageal testing of patients with noncardiac chest pain or dysphagia. Ann Intern Med 1987;106:593-7. Katz PO, Castell DO. Review: esophageal motility disorders. Am J Med Sci 1985;290:81-9.
Received September 30, 1987. Accepted April 19, 1988. Address requests for reprints to: Mark H. Mellow, M.D., Division of Gastroenterology, Oklahoma City Clinic, 701 Northeast Tenth Street, Oklahoma City, Oklahoma 73104.