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TABLE 6-1 -- Esophageal Motility Disorders

Primary

Achalasia, "vigorous" achalasia Diffuse and segmental esophageal spasm Nutcracker esophagus Hypertensive lower esophageal sphincter Nonspecific esophageal motility disorders Secondary Esophageal Motility Disorders

Collagen vascular diseases: progressive systemic sclerosis, polymyositis and dermatomyositis, mixed connective tissue disease, systemic lupus erythematosus Chronic idiopathic intestinal pseudo-obstruction Neuromuscular diseases Endocrine and metastatic disorders

TABLE 6-2 -- Manometric Characteristics of the Primary Esophageal Motility Disorders

Achalasia

Incomplete LES relaxation Aperistalsis in the esophageal body Elevated LES pressure

Increased intraesophageal baseline pressures relative to gastric baseline Diffuse Esophageal Spasm

Simultaneous (nonperistaltic contractions) (>20% of wet swallows) Repetitive and multipeaked contractions Spontaneous contractions Intermittent normal peristalsis

Contractions may be of increased amplitude and duration Nutcracker Esophagus

Increased peristaltic amplitude in the distal esophagus (>180 mmHg) Increased mean duration of contractions (>7.0 seconds) Normal peristaltic sequence Hypertensive Lower Esophageal Sphincter

Elevated LES pressure

Normal LES relaxation

Normal peristalsis in the esophageal body

Nonspecific Esophageal Motility Disorders

Decreased or absent amplitude of esophageal peristalsis Increased number of nonperistaltic or dropped contractions Abnormal waveforms Normal LES pressure and relaxation LES = lower esophageal sphincter.

in a variety of physiological situations. This increases the accuracy and dependability of the measurement.[ ] The application of ambulatory 24-hour esophageal motility monitoring has shown that there are marked differences in the classification of esophageal motor disorders between standard manometry and ambulatory motility monitoring ( Fig. 6-6 ).[ ] The degree of reclassification that occurs when analysis of esophageal motor function is conducted on the basis of ambulatory manometry indicates that the classic categories of esophageal motor disorders are inappropriate. This appears to be due to

Figure 6-6 Classification of esophageal motor disorders in 108 patients with dysphagia or noncardiac chest pain according to the findings on standard or ambulatory 24-hour manometry. (DES, diffuse esophageal spasm; NCE, nutcracker esophagus; NEMD, nonspecific esophageal motor disorder.) (From Stein, H.J., DeMeester, T.R., Eypasch, E.P., and Klingman, R.P.: Ambulatory 24-hour esophageal manometry in the evaluation of esophageal motor disorders and noncardiac chest pain. Surgery, 110:753, 1991, with permission.)

Figure 6-7 Prevalence of "effective contractions" during meal periods in normal volunteers, patients with nonobstructive dysphagia, and patients without dysphagia. Having less than 50% effective contractions during meals Is associated with a high prevalence of nonobstructive dysphagia. Pat = patients.

Figure 6-8 Ambulatory motility record of a patient with frequent episodes of noncardiac chest pain. Esophageal motor activity was recorded 10 cm (top tracing) and 5 cm (bottom tracing) above the lower esophageal sphincter. The patient experienced a spontaneous episode of severe chest pain associated with a high frequency of repetitive and simultaneous contractions in the distal esophagus. (From Stein, H.J., DeMeester, T.R. Eypasch E.P., and Klingman, R.P.: Ambulatory 24-hour esophageal manometry in the evaluation of esophageal motor disorders and noncardiac chest pain. Surgery, 110:753,1991, with permission.)

Figure 6-9 Mechanical model of the esophagus as a propulsive pump, the lower esophageal sphincter as a valve, and the stomach as a reservoir. Esophageal clearance of refluxed gastric juice is determined by the esophageal motor activity, salivation, gravity, and the presence of an anatomic alteration such as a hiatal hernia. The competency of the lower esophageal sphincter depends on its pressure, overall length, and length exposed to abdominal pressure. Gastric function abnormalities causing gastroesophageal reflux include increased intragastric pressure, gastric dilatation, decreased emptying rate, and increased gastric acid secretion. (From DeMeester, T.R., and Attwood, S.E.: Gastroesophageal reflux disease, hiatus hernia, achalasia of the esophagus and spontaneous rupture. In Schwartz, S.I., and Ellis, H. [eds.]: Maingot's Abdominal Operations, 9th ed. Norwalk, CT, Appleton & Lange, 1989, with permission.)

Figure 6-9 Mechanical model of the esophagus as a propulsive pump, the lower esophageal sphincter as a valve, and the stomach as a reservoir. Esophageal clearance of refluxed gastric juice is determined by the esophageal motor activity, salivation, gravity, and the presence of an anatomic alteration such as a hiatal hernia. The competency of the lower esophageal sphincter depends on its pressure, overall length, and length exposed to abdominal pressure. Gastric function abnormalities causing gastroesophageal reflux include increased intragastric pressure, gastric dilatation, decreased emptying rate, and increased gastric acid secretion. (From DeMeester, T.R., and Attwood, S.E.: Gastroesophageal reflux disease, hiatus hernia, achalasia of the esophagus and spontaneous rupture. In Schwartz, S.I., and Ellis, H. [eds.]: Maingot's Abdominal Operations, 9th ed. Norwalk, CT, Appleton & Lange, 1989, with permission.)

Figure 6-10 The three-dimensional lower esophageal sphincter pressure profile in a normal volunteer (A), a patient with a mechanically defective sphincter (B), and the same patient 1 year after Nissen fundoplication (C). (From Stein, H.J., DeMeester, T.R., Naspetti, R., et al.: The three-dimensional lower esophageal sphincter pressure profile in gastroesophageal reflux disease. Ann. Surg., 214:374, 1991, with permission.)

Figure 6-11 Prevalence of a mechanically defective sphincter in patients with increased esophageal exposure to gastric juice and no mucosal injury, esophagitis, stricture, and Barrett's esophagus using standard manometric techniques or analysis of the three-dimensional sphincter image (SPVV analysis). P<.05 versus standard technique. (From Stein, H.J., DeMeester, T.R., Naspetti, R., et al.: The three-dimensional lower esophageal sphincter pressure profile in gastroesophageal reflux disease. Ann. Surg., 214:374, 1991, with permission.)

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