Influence of Bolus Consistency and Position on Esophageal High-Resolution Manometry Findings

Background Conventional esophageal manometry evaluating liquid swallows in the recumbent position measures pressure changes at a limited number of sites and does not assess motility during solid swallows in the physiologic upright position. Aim To evaluate esophageal motility abnormalities during water and bread swallows in the upright and recumbent positions using high-resolution manometry (HRM). Methods Thirty-two-channel HRM testing was performed using water (10ml each) and bread swallows in the upright and recumbent positions. The swallows were considered normal if the distal peristaltic segment >30mmHg was >5cm, ineffective if the 30-mmHg pressure band was 8cm/s. Abnormal esophageal manometry was defined as the presence of ≥30% ineffective and/or ≥20% simultaneous contractions. Results The data from 96 patients (48 F; mean age 51years, range 17-79) evaluated for dysphagia (56%), chest pain (22%), and gastroesophageal reflux disease (GERD) symptoms (22%) were reviewed. During recumbent water swallows, patients with dysphagia, chest pain, and GERD had a similar prevalence of motility abnormalities. During upright bread swallows, motility abnormalities were more frequent (p=0.01) in patients with chest pain (71%) and GERD (67%) compared to patients with dysphagia (37%). Conclusions Evaluating bread swallows in the upright position reveals differences in motility abnormalities overlooked by liquid swallows alon

Akuttherapie der aortoösophagealen und aortoenteralen Fistel

Die aortoösophageale und aortoenterale Fistel sind seltene Ursachen der gastrointestinalen Blutung. Die niedrige Inzidenz kann Ursache für verzögerte Diagnosestellung und erhöhte Mortalität sein

How to select patients for anti-reflux surgery? The ICARUS guidelines (International Consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for AntiReflUx Surgery)

Objective: Anti-reflux surgery can be proposed in patients with gastro-esophageal reflux disease, especially when proton pump inhibitor use leads to incomplete symptom improvement. However, to date, international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for anti-reflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for anti-reflux surgery. Design: We included 35 international experts (gastroenterologists, surgeons and physiologists) in a Delphi process and developed 37 statements that were revised by the Consensus Group, to start the Delphi process. Three voting rounds followed where each statement was presented with the evidence summary. The panel indicated the degree of agreement for the statement. When 80% of the Consensus Group agreed (A+/A) with a statement, this was defined as consensus. All votes were mutually anonymous.Results: Patients with heartburn with a satisfactory response to PPIs, patients with a hiatal hernia (HH), patients with esophagitis LA grade B or higher and patients with Barrett’s esophagus are good candidates for anti-reflux surgery. An endoscopy prior to anti-reflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short esophagus. Esophageal manometry is mandatory to rule out major motility disorders. Finally, esophageal pH (+/- impedance) monitoring off PPI is mandatory to select patients for anti-reflux surgery, if endoscopy is negative for unequivocal reflux esophagitis. Conclusion: With the ICARUS guidelines, we generated key recommendations for selection of patients for anti-reflux surgery

Adverse effects of drugs on the esophagus

Given the function of the esophagus to transport orally ingested solids and liquids into the stomach there are several medications with adverse effect on esophageal structures and function. Various pharmacologic agents can induce esophageal injury, promote gastroesophageal reflux by decreasing lower esophageal sphincter tone or affect esophageal perception and motility. The risks of bisphosphonates, doxycycline, ferrous sulfate, ascorbic acid, aspirin/NSAIDs and chemotherapeutic agents to induce esophageal lesions have been documented in case reports and short series. In addition to direct mucosal injury, many commonly used medications including nitroglycerins, anticholinergics, beta-adrenergic agonists, aminophyllines, and benzodiazepines promote/facilitate gastroesophageal reflux by reducing lower esophageal sphincter pressure. Additional evidence accumulates on the adverse effects of various medications on esophageal motility and perception. The treatment of medication-induced esophageal lesions includes (1) identifying and discontinuing the causative medication, (2) promoting healing of esophageal injury by decreasing esophageal acid exposure or coating already existing esophageal lesions, (3) eventual use of protective compounds

Evaluating Esophageal Bolus Transit by Impedance Monitoring

The function of the esophagus is transporting nutrients from the oropharyngeal cavity to the stomach. This is achieved by coordinated contractions and relaxation of the tubular esophagus and the upper and lower esophageal sphincter. Multichannel intraluminal impedance monitoring offers quantification of esophageal bolus transit and/or retention without the use of ionizing radiation. Combined with conventional or high-resolution manometry, impedance measurements complement the quantification of esophageal body contraction and sphincter relaxation, offering a more comprehensive evaluation of esophageal function. Further studies evaluating the utility of quantifying bolus transit will help clarify the role and position of impedance measurements

Obesity and GERD: pathophysiology and effect of bariatric surgery

Epidemiologic, endoscopic, and pathophysiologic studies document the relationship between obesity and gastroesophageal reflux disease (GERD). Increased body mass index and accumulation of visceral fat are associated with a two- to threefold increased risk of developing reflux symptoms and esophageal lesions. Given this association, many studies were designed to evaluate the outcome of reflux symptoms following conventional and surgical treatment of obesity. Among bariatric procedures, gastric sleeve and banded gastroplasty were shown to have no effect or even worsen reflux symptoms in the postoperative setting. Gastric banding improves reflux symptoms and findings (endoscopic and pH-measured distal esophageal acid exposure) in many patients, but is associated with de novo reflux symptoms or lesions in a considerable proportion of patients. To date, Roux-en-Y gastric bypass is the most effective bariatric procedure that consistently leads to weight reduction and improvement of GERD symptoms in patients undergoing direct gastric bypass and among those converted from restrictive bariatric procedures to gastric bypass

Reflux nach bariatrischen Operationen

Obesity and gastro-esophageal reflux disease (GERD) are two of the major health problems of the industrialized world. Both condition have increased prevalence, pathophysiological and endoscopic studies identified obesity a major risk factor in the development of GERD. Conversely, successful weight reduction improves GERD symptoms and diminishes the use of acid suppressive medication. Bariatric interventions are not all equal when it comes to controlling GERD symptoms, lesions and use of medication. Gastric banding has a variable influence on GERD, while most patients report improved reflux symptoms, up to 20% of patient can develop "de novo" reflux symptoms following gastric banding. Gastric sleeve resection increases reflux symptoms, in particular in patients with an ideal, tubular gastroplasty and those with proximal (fundic) pouch. Roux-en-Y gastric bypass has a positive effect of GERD, reducing symptoms and use of acid suppressive medications. From an esophageal perspective, gastric bypass is the preferred bariatric procedure to treat and prevent GERD in morbidly obese patients.Epidemiologische, pathophysiologische und endoskopische Studien belegen die positive Assoziation zwischen GERD und Adipositas. Von den bariatrischen Eingriffen hat das Magenband einen nicht vorhersehbaren Einfluss auf den gastro-ösophagealen Reflux (bei manchen Patienten führt das Magenband zu einer Abnahme des gastro-ösophagealen Refluxes, andere hingegen entwickeln neu Reflux Symptome), die Magenteilresektion führt zu einer Zunahme des gastro-ösophagealen Refluxes und der Roux-en-Y Magenbypass reduziert GERD-Symptome und Bedarf an säurehemmender Therapie. Aus ösophagealer Perspektive ist der Roux-en-Y Magenbypass die bariatrische Operation der Wahl