Objective: Dynamic barium radiology with cine-or video recording has been the most frequently use... more Objective: Dynamic barium radiology with cine-or video recording has been the most frequently used technique for assessing patients with pharyngeal dysphagia. Although the diagnostic yield of the barium swallow has been high, many patients with pharyngeal dysphagia have normal dynamic barium radiology and remain a diagnostic dilemma. Could manometry add important diagnostic information in these patients? Material and methods: We examined 19 patients (12 men and 7 women, mean age 47 years, range 19-69 years) with pharyngeal dysphagia but a normal barium swallow with simultaneous videoradiography and pharyngeal manometry and compared their manometry to that found in 24 normal volunteers (11 men and 13 women, mean age 37 years, range 23-59 years). Results: Comparing mean values, the patient group showed statistically significant differences from the control group for eight of 10 manometric parameters. Fourteen of 19 patients showed at least one (five patients) and in most cases multiple (nine patients) manometric abnormalities (values exceeding normal mean by 22SD) which might have contributed to their dysphagia: five patients with high upper esophageal sphincter (UES) resting pressures, five with high UES residual pressures, three with weak pharyngeal contractions, three with pharyngeal "spasms," seven with prolonged contraction/relaxation times, five with reduced compliance, and seven with UES/P incoordination. Conclusions: Solid-state computerized manometry is a useful adjunct to videoradiography and can provide potentially important additional information in the diagnosis of dysphagia patients.
American Journal of Physiology Gastrointestinal and Liver Physiology, Feb 1, 1998
The human esophagus is composed of striated muscle proximally and of smooth muscle distally with ... more The human esophagus is composed of striated muscle proximally and of smooth muscle distally with a transition zone between the two. Striated muscle contracts much faster than smooth muscle. The change in pressure over time (dP/dt) of the contraction amplitude should therefore be higher in proximal than in distal esophagus, reflecting the presence of striated muscle proximally. There were 34 normal esophageal manometries of patients analyzed for swallow amplitude and dP/dt in the pharynx and esophagus. An additional 11 healthy controls were similarly studied. Amplitudes in pharynx and proximal and distal esophagus were not different. The mid-esophagus had a pressure trough (P < 0.001). The dP/dt in the pharynx was much higher than that in the esophagus (P < 0.001). The dP/dt of proximal and distal esophagus were of the same order of magnitude. The manometric behavior of the striated muscle portion of the proximal esophagus differs from that seen in the pharynx and shows similar characteristics to distal esophageal smooth muscle.
Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were publish... more Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were published by the American College of Gastroenterology in 1995 (1). These and other guidelines undergo periodic review. Significant advances have been made in the area of GERD over the past several years, leading us to review and revise our previous guidelines statements. These advances have included an increase in our comfort with the chronic use of proton pump inhibitors and an increased acceptance of laparoscopic antireflux surgery, among other factors. These and the original guidelines are intended to apply to all physicians who address GERD and are intended to indicate the preferable, but not only acceptable, approach. Physicians must always choose the course best suited to the individual patient and the variables that exist at the moment of the decision. These guidelines are intended to apply to adult patients with the symptoms, tissue damage, or both that result from the reflux of gastric contents into the esophagus. For the purpose of these guidelines GERD is defined as chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus.
Thirty-four consecutive patients referred to a gastroenterology clinic with suspected esophageal ... more Thirty-four consecutive patients referred to a gastroenterology clinic with suspected esophageal motility abnormality as a cause of their chest pain or dysphagia, or both, were prospectively studied in an 18-mo period. Peristaltic response to 10 wet (5 ml H2O) swallows was recorded in all studies with a low-compliance infusion system. To provoke symptoms and motility abnormalities after baseline evaluation, all patients had acid infusions (0.1 N HCl) and administration of edrophonium (80 micrograms/kg i.v.), pentagastrin (6 micrograms/kg s.c.), and bethanechol (40 micrograms/kg s.c.). Tracings were coded, read, and interpreted blindly. Baseline tracings were abnormal in 23 of 34 patients (68%), including increased amplitude peristaltic contractions ("nutcracker esophagus") in 10 and nonspecific esophageal motor disorders in 13. Acid infusion produced substernal burning in 3 of 33 patients, in motility change in 1 patient. Edrophonium produced chest pain with manometric changes in 6 of 34 (18%) patients. Pentagastrin produced chest pain with manometric change in 1 patient. Bethanechol produced chest pain with manometric change in 2 patients. One patient with low amplitude had elevation of esophageal baseline and multiple simultaneous contractions but no chest pain (subsequently developed achalasia). It was concluded that (a) abnormal motility is a common finding in a symptomatic group of patients with presumed esophageal motility disorder, (b) the "nutcracker" esophagus is the most frequent defect, and (c) attempted provocation of symptoms with acid or drugs is not generally effective; however, edrophonium is the best tolerated and most effective of currently available drugs.
American Journal of Physiology Gastrointestinal and Liver Physiology, 1990
Recent studies have shown that cerebral evoked potentials (EPs) can be recorded after balloon dis... more Recent studies have shown that cerebral evoked potentials (EPs) can be recorded after balloon distension of the human esophagus. The aim of this study was to evaluate the characteristics of these viscerosensory EPs and to investigate the relations between these EPs and perception of esophageal distension. Nineteen healthy volunteers (22-60 yr old) were studied. A balloon positioned 5 cm above the lower esophageal sphincter was inflated 10 times each minute. EPs recorded from four midline scalp electrodes were averaged for 50 and 100 inflation cycles. A clearly defined triphasic (negative-positive-negative) EP was recorded in all subjects and from all four recording sites when a volume leading to definite sensation and rapid balloon inflation (170 ml/s) was used. The latencies of the peaks were 231 +/- 7 (N1), 303 +/- 7 (P1), and 379 +/- 8 ms (N2). No significant correlation between stimulus perception and latency was found. The amplitude and quality of the EPs (scored by 3 blinded observers) increased significantly (P less than 0.01, ANOVA) with increasing sensation. Slow balloon inflation (30 ml/s) was significantly less effective in evoking EPs than rapid inflation (P less than 0.01). The EPs evoked by 100 inflations were not significantly clearer than those evoked by 50 inflations. It is concluded that the ability to record cerebral potentials evoked by esophageal balloon distension is related to the rate of balloon inflation and to the level of awareness of the stimulus.
Background: Toward more understanding esophageal motility disorders it is important to have data ... more Background: Toward more understanding esophageal motility disorders it is important to have data about bolus movement together with associated peristalsis. In previous studies we have shown, that impedancometry is a reliable technique for recording intestinal chyme transport (1, 2), as well as for studying the dynamics of esophageal bolus transport (3). Now, we performed synchronous manometry and impedancometry in healthy subjects and patients with achalasia using a single catheter in order to test the applicability of this combination for the study of esophageal motility. Materials and Methods: Studies were performed in 8 healthy volunteers and 8 patients with achalasia. A custom-made combine catheter consisting of II impedance segments (each 2cm long) and 4 semiconductor pressure transducers was used. The pressure transducers were located between the impedance channels 1-2, 4-5, 7-8 and 10-11 (intertransducer distance 6 ern). The catheter was passed through the nose into the esophagus as previously described . Studies were performed using liquid (10 ml Osmolite) and semisolid boluses (10 ml Yogurt) at supine and upright position. Data were visually analyzed. Results: (a) In healthy subjects bolus transport and associated primary peristalsis with lower sphincter relaxation could be recorded reliably. The patterns were highly unique independent of bolus viscosity and body position. A detailed analysis of the correlation between peristalsis and bolus transit is possible. The propagation of the bolus is significantly faster than the propagation of the associated peristaltic contraction wave. (b) Patients with achalasia featured unique manometry tracings but quite variable impedance tracings, showing that different phenomena can be recorded by the 2 techniques. The spatial and temporal analysis the manometry and impedance tracings indicates that esophageal aperistalsis with simultaneous pressure elevation in achalasia seems to result from a common cavity phenomen. Summary: Simultaneous manometry and impedancometry to study esophageal motility are feasible. Bolus transport and associated peristalsis can be well studied. Both techniques provide different but complementary data on esophageal motility. The combination of both techniques opens new horizons for studying esophageal motility disorders.
Jama the Journal of the American Medical Association, Jul 20, 1984
A wide variety of therapies have been suggested for patients with painful esophageal motility dis... more A wide variety of therapies have been suggested for patients with painful esophageal motility disorders. In a prospective, double-blind, cross-over clinical trial, we evaluated the effectiveness of mercury bougienage ("placebo," 24 F; "therapeutic," 54 F) in eight symptomatic patients with the nutcracker esophagus (NE). There were no significant differences between the placebo or therapeutic dilators in relation to chest pain, dysphagia, lower esophageal sphincter pressure, or amplitude. Chest pain scores after completion of this trial were significantly lower than baseline scores, irrespective of the sequence of dilators used. No subjective or objective improvement could be demonstrated when "therapeutic bougienage" was compared with "placebo bougienage" in patients with the NE. The improvement in symptoms at the completion of the study may result from the close physician-patient interaction, suggesting that this may be more important than the actual size of the bougie.
American Journal of Physiology Gastrointestinal and Liver Physiology, Feb 1, 1990
Manometric studies of pharyngeal-upper esophageal sphincter (UES) coordination during swallowing ... more Manometric studies of pharyngeal-upper esophageal sphincter (UES) coordination during swallowing have proven difficult. Asymmetry of the UES makes pressure measurements with a single, unoriented transducer suspect. Perfused systems lack the necessary response rate for measuring peak pharyngeal contraction pressures. Precise quantification of the coordination of pharyngeal contractions and UES relaxations during swallowing is difficult because of rapid pressure changes. We tested a modified solid-state transducer that measures pressures over 360 degrees. This transducer was placed in the proximal UES with a second, single transducer 5 cm proximal. Data were collected and analyzed with an Apple IIe microcomputer. A computer program was developed to measure nine timing sequences, UES resting pressure, nadir of UES relaxation, and pharyngeal contraction pressures. We studied 21 volunteers with six swallows each for dry, 5, 10, and 20 ml of water. Dry swallows differed significantly (P less than 0.05) from wet (5 ml). All timing sequences became progressively longer with increasing bolus size. Residual pressures were unchanged. Timing sequences were also measured for wet (5 ml) and dry swallows in seven volunteers using a Dent sleeve and single perfused orifice in the UES; no differences were seen.
Women's Medical College Objective: Endoscopic examination and 13C-UBT were performed in 145 patie... more Women's Medical College Objective: Endoscopic examination and 13C-UBT were performed in 145 patients 1 month, 6 months, and 12 months after Helicobacter pylori (Hp) eradication therapy. One month after eradication therapy, about 40% of patients were negative for tissue examinations (TE: culture and Giemsa stain), but positive on UBT. To more clearly evaluate the presence of lip in such patients, Hp was identified by PCR and anti-Hp-IgG was measured at the time of follow up examinations. Subjects: The study group comprised 30 patients who were Hp-negative on TE and positive on UBT 1 month after eradication therapy; all patients underwent follow-up examinations 6 and 12 monnths after therapy. Methods: UBT was performed before endoscopy. Biopsy specimens were taken from the gastric body and antrum for TE, and PCR. The subjects were divided into three groups on basis of the examination results 6 months after eradication therapy: group A (6 patients), TE and UBT were positive; group B (19 patients), TE were negative and UBT was positive; group C ((5 patients), TE and UBT were negative.
We studied the effects of three smooth muscle relaxants on lower esophageal sphincter (LES) press... more We studied the effects of three smooth muscle relaxants on lower esophageal sphincter (LES) pressure and radionuclide esophageal emptying in 15 untreated patients with achalasia. LES pressures were determined before and after the administration of normal saline subcutaneously, terbutaline sulfate subcutaneously, nitroglycerin sublingually, and aminophylline intravenously. All smooth muscle relaxants significantly decreased LES pressures when compared with normal saline controls and pretreatment baseline pressures (p less than 0.01). However, in normal saline controls, LES pressure actually increased over time (p less than 0.01). Control radionuclide esophageal emptying studies were performed in all patients. Subsequent esophageal emptying studies were carried out only in patients responding to smooth muscle relaxants by decreasing LES pressures by greater than or equal to 25% (terbutaline sulfate, n = 8; nitroglycerin, n = 7; and aminophylline, n = 4). Significant improvement in esophageal emptying was observed after nitroglycerin and terbutaline sulfate (p less than 0.05) but not after aminophylline. We conclude that in patients with achalasia (a) terbutaline sulfate, nitroglycerin, and aminophylline can significantly decrease LES pressure; (b) resting LES pressures vary over time; and (c) terbutaline sulfate and nitroglycerin significantly improve esophageal emptying in some subjects.
The American Journal of Gastroenterology, Jun 1, 1988
Although the nutcracker esophagus, characterized by high amplitude peristaltic contractions with ... more Although the nutcracker esophagus, characterized by high amplitude peristaltic contractions with mean distal amplitude greater than 180 mm Hg, is the most common esophageal motility disorder associated with noncardiac chest pain, little is known about its natural history. Therefore, we reviewed the manometric tracings of 23 patients with the nutcracker esophagus who had an average of 4.6 studies during a mean period of 32 months. Ten age-matched volunteers with normal baseline manometry who had undergone multiple studies (mean 5.8) over a mean time span of 32 months served as controls. In the 17 nutcracker patients with three or more motility studies, the variability of mean distal amplitudes between studies was 41.9% +/- 4.1 (+/- SE) compared to 27.0% +/- 3.3 for the control subjects (p less than 0.01). Highest distal pressures were noted during the first study in 11 of 17 patients (65%) compared to two of 10 controls (20%). The consistency of the diagnosis of nutcracker esophagus varied considerably: four patients always had high amplitude pressures, three patients only had the nutcracker diagnosis on the initial study, and 10 patients intermittently had pressures in the nutcracker range. Overall, these 17 patients had the diagnosis of the nutcracker esophagus confirmed on only 54% of subsequent studies. Changes in motility patterns were intermittently seen in six of 23 patients: one diffuse spasm and five nonspecific motility disorders. None of the control subjects developed high amplitude contractions or changed their motility pattern on serial testing. The possible pathophysiological implications of the changing faces of the nutcracker esophagus are discussed.
Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, Jan 20, 2015
Esophageal manometry (EM) is the standard for the diagnosis of esophageal motility disorders. Var... more Esophageal manometry (EM) is the standard for the diagnosis of esophageal motility disorders. Variations in the performance and interpretation from EM result in discrepant diagnoses and unnecessary repeated procedures, and could have negative effects on patient outcomes. We need a method to benchmark the procedural quality of EM; as such our objective was to formally develop quality measures for the performance and interpretation of data from EM. We used the RAND University of California Los Angeles Appropriateness Methodology (RAM) to develop validated quality measures for performing and interpreting esophageal manometry. The research team identified potential quality measures through a literature search and interviews with experts. Fourteen experts in esophageal manometry ranked the proposed quality measures for appropriateness via a 2-round process on the basis of RAM. The experts considered a total of 29 measures; 17 were ranked as appropriate and were related to competency (2),...
Dysphagia is a fascinating symptom. It is ostensibly simple when defined by trouble swallowing ye... more Dysphagia is a fascinating symptom. It is ostensibly simple when defined by trouble swallowing yet its subtleties in deciphering and its variations in pathophysiology almost mandate a thorough knowledge of medicine itself. With patience and careful questioning, a multitude of various disorders may be suggested before an objective test is performed. Indeed, the ability to diligently and comprehensively explore the symptom of dysphagia is not only rewarding but a real test for a physician who prides him or herself on good history taking.
Purpose: Although balloon distension test has been used for identifying esophageal visceral hyper... more Purpose: Although balloon distension test has been used for identifying esophageal visceral hypersensitivity, there is limited data and in small number of patients and its clinical utility is not fully known. Our aim was to prospectively assess symptoms, biomechanical and sensory properties in patients with unexplained chest pain and the yield of this test. Methods: Graded balloon distensions were performed using impedance planimetry in 139 (m/fϭ41/98, x ageϭ46 yr) patients with noncardiac, nonreflux chest pain and 23 (m/fϭ 10/13, x ageϭ43 yr) healthy controls. The frequency, intensity and duration of chest pain was scored on a scale of 1-3. The thresholds for first perception (mean Ϯ CI; 14 Ϯ 2 vs 30 Ϯ 5, pϽ0.01), discomfort (34 Ϯ 2.4 vs 54 Ϯ 4, pϽ0.01) and pain (41 Ϯ 3 vs 62 Ϯ 2, pϽ0.01) were lower in patients than controls. Typical chest pain was reproduced in 105/139 (76%) patients. The cross sectional area was larger (pϽ0.02) and the wall strain was lower (pϽ0.02) in patients, but the reactivity of the esophageal wall was similar to controls (table). Chest pain frequency was scored as 2.5 Ϯ0.3, intensity as 2.2Ϯ0.2 and duration as 2.2Ϯ0.2.
Objective: Dynamic barium radiology with cine-or video recording has been the most frequently use... more Objective: Dynamic barium radiology with cine-or video recording has been the most frequently used technique for assessing patients with pharyngeal dysphagia. Although the diagnostic yield of the barium swallow has been high, many patients with pharyngeal dysphagia have normal dynamic barium radiology and remain a diagnostic dilemma. Could manometry add important diagnostic information in these patients? Material and methods: We examined 19 patients (12 men and 7 women, mean age 47 years, range 19-69 years) with pharyngeal dysphagia but a normal barium swallow with simultaneous videoradiography and pharyngeal manometry and compared their manometry to that found in 24 normal volunteers (11 men and 13 women, mean age 37 years, range 23-59 years). Results: Comparing mean values, the patient group showed statistically significant differences from the control group for eight of 10 manometric parameters. Fourteen of 19 patients showed at least one (five patients) and in most cases multiple (nine patients) manometric abnormalities (values exceeding normal mean by 22SD) which might have contributed to their dysphagia: five patients with high upper esophageal sphincter (UES) resting pressures, five with high UES residual pressures, three with weak pharyngeal contractions, three with pharyngeal "spasms," seven with prolonged contraction/relaxation times, five with reduced compliance, and seven with UES/P incoordination. Conclusions: Solid-state computerized manometry is a useful adjunct to videoradiography and can provide potentially important additional information in the diagnosis of dysphagia patients.
American Journal of Physiology Gastrointestinal and Liver Physiology, Feb 1, 1998
The human esophagus is composed of striated muscle proximally and of smooth muscle distally with ... more The human esophagus is composed of striated muscle proximally and of smooth muscle distally with a transition zone between the two. Striated muscle contracts much faster than smooth muscle. The change in pressure over time (dP/dt) of the contraction amplitude should therefore be higher in proximal than in distal esophagus, reflecting the presence of striated muscle proximally. There were 34 normal esophageal manometries of patients analyzed for swallow amplitude and dP/dt in the pharynx and esophagus. An additional 11 healthy controls were similarly studied. Amplitudes in pharynx and proximal and distal esophagus were not different. The mid-esophagus had a pressure trough (P < 0.001). The dP/dt in the pharynx was much higher than that in the esophagus (P < 0.001). The dP/dt of proximal and distal esophagus were of the same order of magnitude. The manometric behavior of the striated muscle portion of the proximal esophagus differs from that seen in the pharynx and shows similar characteristics to distal esophageal smooth muscle.
Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were publish... more Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were published by the American College of Gastroenterology in 1995 (1). These and other guidelines undergo periodic review. Significant advances have been made in the area of GERD over the past several years, leading us to review and revise our previous guidelines statements. These advances have included an increase in our comfort with the chronic use of proton pump inhibitors and an increased acceptance of laparoscopic antireflux surgery, among other factors. These and the original guidelines are intended to apply to all physicians who address GERD and are intended to indicate the preferable, but not only acceptable, approach. Physicians must always choose the course best suited to the individual patient and the variables that exist at the moment of the decision. These guidelines are intended to apply to adult patients with the symptoms, tissue damage, or both that result from the reflux of gastric contents into the esophagus. For the purpose of these guidelines GERD is defined as chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus.
Thirty-four consecutive patients referred to a gastroenterology clinic with suspected esophageal ... more Thirty-four consecutive patients referred to a gastroenterology clinic with suspected esophageal motility abnormality as a cause of their chest pain or dysphagia, or both, were prospectively studied in an 18-mo period. Peristaltic response to 10 wet (5 ml H2O) swallows was recorded in all studies with a low-compliance infusion system. To provoke symptoms and motility abnormalities after baseline evaluation, all patients had acid infusions (0.1 N HCl) and administration of edrophonium (80 micrograms/kg i.v.), pentagastrin (6 micrograms/kg s.c.), and bethanechol (40 micrograms/kg s.c.). Tracings were coded, read, and interpreted blindly. Baseline tracings were abnormal in 23 of 34 patients (68%), including increased amplitude peristaltic contractions ("nutcracker esophagus") in 10 and nonspecific esophageal motor disorders in 13. Acid infusion produced substernal burning in 3 of 33 patients, in motility change in 1 patient. Edrophonium produced chest pain with manometric changes in 6 of 34 (18%) patients. Pentagastrin produced chest pain with manometric change in 1 patient. Bethanechol produced chest pain with manometric change in 2 patients. One patient with low amplitude had elevation of esophageal baseline and multiple simultaneous contractions but no chest pain (subsequently developed achalasia). It was concluded that (a) abnormal motility is a common finding in a symptomatic group of patients with presumed esophageal motility disorder, (b) the "nutcracker" esophagus is the most frequent defect, and (c) attempted provocation of symptoms with acid or drugs is not generally effective; however, edrophonium is the best tolerated and most effective of currently available drugs.
American Journal of Physiology Gastrointestinal and Liver Physiology, 1990
Recent studies have shown that cerebral evoked potentials (EPs) can be recorded after balloon dis... more Recent studies have shown that cerebral evoked potentials (EPs) can be recorded after balloon distension of the human esophagus. The aim of this study was to evaluate the characteristics of these viscerosensory EPs and to investigate the relations between these EPs and perception of esophageal distension. Nineteen healthy volunteers (22-60 yr old) were studied. A balloon positioned 5 cm above the lower esophageal sphincter was inflated 10 times each minute. EPs recorded from four midline scalp electrodes were averaged for 50 and 100 inflation cycles. A clearly defined triphasic (negative-positive-negative) EP was recorded in all subjects and from all four recording sites when a volume leading to definite sensation and rapid balloon inflation (170 ml/s) was used. The latencies of the peaks were 231 +/- 7 (N1), 303 +/- 7 (P1), and 379 +/- 8 ms (N2). No significant correlation between stimulus perception and latency was found. The amplitude and quality of the EPs (scored by 3 blinded observers) increased significantly (P less than 0.01, ANOVA) with increasing sensation. Slow balloon inflation (30 ml/s) was significantly less effective in evoking EPs than rapid inflation (P less than 0.01). The EPs evoked by 100 inflations were not significantly clearer than those evoked by 50 inflations. It is concluded that the ability to record cerebral potentials evoked by esophageal balloon distension is related to the rate of balloon inflation and to the level of awareness of the stimulus.
Background: Toward more understanding esophageal motility disorders it is important to have data ... more Background: Toward more understanding esophageal motility disorders it is important to have data about bolus movement together with associated peristalsis. In previous studies we have shown, that impedancometry is a reliable technique for recording intestinal chyme transport (1, 2), as well as for studying the dynamics of esophageal bolus transport (3). Now, we performed synchronous manometry and impedancometry in healthy subjects and patients with achalasia using a single catheter in order to test the applicability of this combination for the study of esophageal motility. Materials and Methods: Studies were performed in 8 healthy volunteers and 8 patients with achalasia. A custom-made combine catheter consisting of II impedance segments (each 2cm long) and 4 semiconductor pressure transducers was used. The pressure transducers were located between the impedance channels 1-2, 4-5, 7-8 and 10-11 (intertransducer distance 6 ern). The catheter was passed through the nose into the esophagus as previously described . Studies were performed using liquid (10 ml Osmolite) and semisolid boluses (10 ml Yogurt) at supine and upright position. Data were visually analyzed. Results: (a) In healthy subjects bolus transport and associated primary peristalsis with lower sphincter relaxation could be recorded reliably. The patterns were highly unique independent of bolus viscosity and body position. A detailed analysis of the correlation between peristalsis and bolus transit is possible. The propagation of the bolus is significantly faster than the propagation of the associated peristaltic contraction wave. (b) Patients with achalasia featured unique manometry tracings but quite variable impedance tracings, showing that different phenomena can be recorded by the 2 techniques. The spatial and temporal analysis the manometry and impedance tracings indicates that esophageal aperistalsis with simultaneous pressure elevation in achalasia seems to result from a common cavity phenomen. Summary: Simultaneous manometry and impedancometry to study esophageal motility are feasible. Bolus transport and associated peristalsis can be well studied. Both techniques provide different but complementary data on esophageal motility. The combination of both techniques opens new horizons for studying esophageal motility disorders.
Jama the Journal of the American Medical Association, Jul 20, 1984
A wide variety of therapies have been suggested for patients with painful esophageal motility dis... more A wide variety of therapies have been suggested for patients with painful esophageal motility disorders. In a prospective, double-blind, cross-over clinical trial, we evaluated the effectiveness of mercury bougienage ("placebo," 24 F; "therapeutic," 54 F) in eight symptomatic patients with the nutcracker esophagus (NE). There were no significant differences between the placebo or therapeutic dilators in relation to chest pain, dysphagia, lower esophageal sphincter pressure, or amplitude. Chest pain scores after completion of this trial were significantly lower than baseline scores, irrespective of the sequence of dilators used. No subjective or objective improvement could be demonstrated when "therapeutic bougienage" was compared with "placebo bougienage" in patients with the NE. The improvement in symptoms at the completion of the study may result from the close physician-patient interaction, suggesting that this may be more important than the actual size of the bougie.
American Journal of Physiology Gastrointestinal and Liver Physiology, Feb 1, 1990
Manometric studies of pharyngeal-upper esophageal sphincter (UES) coordination during swallowing ... more Manometric studies of pharyngeal-upper esophageal sphincter (UES) coordination during swallowing have proven difficult. Asymmetry of the UES makes pressure measurements with a single, unoriented transducer suspect. Perfused systems lack the necessary response rate for measuring peak pharyngeal contraction pressures. Precise quantification of the coordination of pharyngeal contractions and UES relaxations during swallowing is difficult because of rapid pressure changes. We tested a modified solid-state transducer that measures pressures over 360 degrees. This transducer was placed in the proximal UES with a second, single transducer 5 cm proximal. Data were collected and analyzed with an Apple IIe microcomputer. A computer program was developed to measure nine timing sequences, UES resting pressure, nadir of UES relaxation, and pharyngeal contraction pressures. We studied 21 volunteers with six swallows each for dry, 5, 10, and 20 ml of water. Dry swallows differed significantly (P less than 0.05) from wet (5 ml). All timing sequences became progressively longer with increasing bolus size. Residual pressures were unchanged. Timing sequences were also measured for wet (5 ml) and dry swallows in seven volunteers using a Dent sleeve and single perfused orifice in the UES; no differences were seen.
Women's Medical College Objective: Endoscopic examination and 13C-UBT were performed in 145 patie... more Women's Medical College Objective: Endoscopic examination and 13C-UBT were performed in 145 patients 1 month, 6 months, and 12 months after Helicobacter pylori (Hp) eradication therapy. One month after eradication therapy, about 40% of patients were negative for tissue examinations (TE: culture and Giemsa stain), but positive on UBT. To more clearly evaluate the presence of lip in such patients, Hp was identified by PCR and anti-Hp-IgG was measured at the time of follow up examinations. Subjects: The study group comprised 30 patients who were Hp-negative on TE and positive on UBT 1 month after eradication therapy; all patients underwent follow-up examinations 6 and 12 monnths after therapy. Methods: UBT was performed before endoscopy. Biopsy specimens were taken from the gastric body and antrum for TE, and PCR. The subjects were divided into three groups on basis of the examination results 6 months after eradication therapy: group A (6 patients), TE and UBT were positive; group B (19 patients), TE were negative and UBT was positive; group C ((5 patients), TE and UBT were negative.
We studied the effects of three smooth muscle relaxants on lower esophageal sphincter (LES) press... more We studied the effects of three smooth muscle relaxants on lower esophageal sphincter (LES) pressure and radionuclide esophageal emptying in 15 untreated patients with achalasia. LES pressures were determined before and after the administration of normal saline subcutaneously, terbutaline sulfate subcutaneously, nitroglycerin sublingually, and aminophylline intravenously. All smooth muscle relaxants significantly decreased LES pressures when compared with normal saline controls and pretreatment baseline pressures (p less than 0.01). However, in normal saline controls, LES pressure actually increased over time (p less than 0.01). Control radionuclide esophageal emptying studies were performed in all patients. Subsequent esophageal emptying studies were carried out only in patients responding to smooth muscle relaxants by decreasing LES pressures by greater than or equal to 25% (terbutaline sulfate, n = 8; nitroglycerin, n = 7; and aminophylline, n = 4). Significant improvement in esophageal emptying was observed after nitroglycerin and terbutaline sulfate (p less than 0.05) but not after aminophylline. We conclude that in patients with achalasia (a) terbutaline sulfate, nitroglycerin, and aminophylline can significantly decrease LES pressure; (b) resting LES pressures vary over time; and (c) terbutaline sulfate and nitroglycerin significantly improve esophageal emptying in some subjects.
The American Journal of Gastroenterology, Jun 1, 1988
Although the nutcracker esophagus, characterized by high amplitude peristaltic contractions with ... more Although the nutcracker esophagus, characterized by high amplitude peristaltic contractions with mean distal amplitude greater than 180 mm Hg, is the most common esophageal motility disorder associated with noncardiac chest pain, little is known about its natural history. Therefore, we reviewed the manometric tracings of 23 patients with the nutcracker esophagus who had an average of 4.6 studies during a mean period of 32 months. Ten age-matched volunteers with normal baseline manometry who had undergone multiple studies (mean 5.8) over a mean time span of 32 months served as controls. In the 17 nutcracker patients with three or more motility studies, the variability of mean distal amplitudes between studies was 41.9% +/- 4.1 (+/- SE) compared to 27.0% +/- 3.3 for the control subjects (p less than 0.01). Highest distal pressures were noted during the first study in 11 of 17 patients (65%) compared to two of 10 controls (20%). The consistency of the diagnosis of nutcracker esophagus varied considerably: four patients always had high amplitude pressures, three patients only had the nutcracker diagnosis on the initial study, and 10 patients intermittently had pressures in the nutcracker range. Overall, these 17 patients had the diagnosis of the nutcracker esophagus confirmed on only 54% of subsequent studies. Changes in motility patterns were intermittently seen in six of 23 patients: one diffuse spasm and five nonspecific motility disorders. None of the control subjects developed high amplitude contractions or changed their motility pattern on serial testing. The possible pathophysiological implications of the changing faces of the nutcracker esophagus are discussed.
Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, Jan 20, 2015
Esophageal manometry (EM) is the standard for the diagnosis of esophageal motility disorders. Var... more Esophageal manometry (EM) is the standard for the diagnosis of esophageal motility disorders. Variations in the performance and interpretation from EM result in discrepant diagnoses and unnecessary repeated procedures, and could have negative effects on patient outcomes. We need a method to benchmark the procedural quality of EM; as such our objective was to formally develop quality measures for the performance and interpretation of data from EM. We used the RAND University of California Los Angeles Appropriateness Methodology (RAM) to develop validated quality measures for performing and interpreting esophageal manometry. The research team identified potential quality measures through a literature search and interviews with experts. Fourteen experts in esophageal manometry ranked the proposed quality measures for appropriateness via a 2-round process on the basis of RAM. The experts considered a total of 29 measures; 17 were ranked as appropriate and were related to competency (2),...
Dysphagia is a fascinating symptom. It is ostensibly simple when defined by trouble swallowing ye... more Dysphagia is a fascinating symptom. It is ostensibly simple when defined by trouble swallowing yet its subtleties in deciphering and its variations in pathophysiology almost mandate a thorough knowledge of medicine itself. With patience and careful questioning, a multitude of various disorders may be suggested before an objective test is performed. Indeed, the ability to diligently and comprehensively explore the symptom of dysphagia is not only rewarding but a real test for a physician who prides him or herself on good history taking.
Purpose: Although balloon distension test has been used for identifying esophageal visceral hyper... more Purpose: Although balloon distension test has been used for identifying esophageal visceral hypersensitivity, there is limited data and in small number of patients and its clinical utility is not fully known. Our aim was to prospectively assess symptoms, biomechanical and sensory properties in patients with unexplained chest pain and the yield of this test. Methods: Graded balloon distensions were performed using impedance planimetry in 139 (m/fϭ41/98, x ageϭ46 yr) patients with noncardiac, nonreflux chest pain and 23 (m/fϭ 10/13, x ageϭ43 yr) healthy controls. The frequency, intensity and duration of chest pain was scored on a scale of 1-3. The thresholds for first perception (mean Ϯ CI; 14 Ϯ 2 vs 30 Ϯ 5, pϽ0.01), discomfort (34 Ϯ 2.4 vs 54 Ϯ 4, pϽ0.01) and pain (41 Ϯ 3 vs 62 Ϯ 2, pϽ0.01) were lower in patients than controls. Typical chest pain was reproduced in 105/139 (76%) patients. The cross sectional area was larger (pϽ0.02) and the wall strain was lower (pϽ0.02) in patients, but the reactivity of the esophageal wall was similar to controls (table). Chest pain frequency was scored as 2.5 Ϯ0.3, intensity as 2.2Ϯ0.2 and duration as 2.2Ϯ0.2.
Uploads
Papers by Donald Castell