Olfactory stimuli provoke diffuse esophageal spasm: reversal by ipratropium bromide.

Diffuse esophageal spasm (DES) is a motor disorder of the esophageal smooth muscle characterized by multiple spontaneous contractions and by swallow-induced contractions that are of simultaneous onset, large amplitude, long duration, and repetitive occurrence. Although the pathogenesis of DES is unknown, provocative studies with cholinergic stimulation, esophageal balloon distention, or acid instillation have suggested involvement of both sensory and motor mechanisms. This report describes a patient with DES who would predictably become symptomatic with dysphagia and chest pain upon inhalation of perfume or other strong odors. Using esophageal scintigraphy to quantitate and analyze esophageal transit in this patient, we report for the first time that olfactory stimulation triggers episodes of DES and that such phenomena are mediated through the vagus nerve, because they can be ameliorated by the administration of ipratropium bromide. These observations suggest a new (sensory) pathway for the induction of DES and raise the intriguing possibility that inhaled anticholinergics may have a therapeutic role in the management of spastic esophageal motility disorders.

Hot water swallows improve symptoms and accelerate esophageal clearance in esophageal motility disorders.

Cold liquid ingestion may precipitate episodes of dysphagia and chest pain in patients with spastic esophageal motility disorders. The effect of hot liquids on esophageal symptoms, esophageal peristalsis, and clearance and any potential therapeutic benefit in such patients has not been examined. Using esophageal scintigraphy and manometry, we have investigated the effects of hot water swallows on dysphagia, chest pain, and esophageal motility and clearance in patients with esophageal motility disorders. We studied 48 men and women with intermittent dysphagia to both solids and liquids, chest pain, and/or regurgitation. All patients underwent upper endoscopy, barium swallow, and esophageal manometry using standard techniques. Esophageal scintigraphy assessed esophageal transit time (ETT) and retrograde intraesophageal movement of bolus at baseline (22 degrees C) and after hot (60 degrees C) water swallows. Esophageal manometry assessed the amplitude and duration of esophageal contractions in response to baseline and hot water swallows. Patients were followed clinically for as long as 6 months to assess symptomatic response. We found that baseline esophageal scintigraphy revealed a mean ETT of 48.5 seconds; after hot water swallow, mean ETT was 27.8 seconds (p < 0.001). The number of secondary peaks at baseline was 3.5; after hot water swallow, it was 2.1 (p < 0.001). Baseline esophageal manometry showed a mean esophageal body contraction amplitude of 188 mm Hg (mean duration, 11.8 seconds) in response to wet swallows and 125 mm Hg (mean duration, 5.7 seconds) with hot water swallows (p < 0.001). Clinically, 28 (58%) of 48 patients noted significant (>50%) improvement of their symptoms and have been ingesting hot water or other hot liquids regularly with their meals. We conclude that hot water accelerates esophageal clearance, decreases the amplitude and duration of esophageal body contractions, and improves symptoms in patients with esophageal motility disorders. Because of its safety and simplicity, it may have an important role in the management of these chronic conditions.

Feasibility of simultaneous dual-isotope myocardial perfusion acquisition using a lower dose of sestamibi.

The feasibility of simultaneous dual-isotope myocardial perfusion imaging was assessed using a ca. 12 mCi dose of technetium-99m sestamibi (MIBI) and ca. 3 mCi thallium-201. Planar and single-photon emission tomographic (SPET) data from 40 patients (41 studies) imaged with both a single- and a dual-isotope protocol were analyzed. Rest injected 201T1 (pure-T1) images were acquired using 20% windows at 70 and 166 keV about 15 min after the 201T1 injection. Patients were then stressed, and at peak stress 99mTc-sestamibi was injected. About 30 min later 99mTc data were recorded with a 20% window center at 140 keV, and simultaneous 201T1 (dual-T1) data were recorded with a single 20% window centered at 80 keV. Total myocardial counts based on SPET data in the dual-T1 images were increased by 18.61% +/- 2.91% (SEM) (range: -12.8% to 84.1%) compared to pure-T1 images. Region of interest analysis revealed the greater increase in counts in the apical region and the least in the lateral wall. Pure T1 and dual-T1 images were visually evaluated for image quality (IQ) on a five-point scale (0 = unacceptable to 4 = excellent). Dual-T1 IQ was lower than that of pure-T1 in 61% of cases, and similar in 37% (12% of the pure-T1 and 41% of the dual-T1 images fell into the 0 and 1 categories). Thallium perfusion abnormalities were of similar extent in 70% of segments, less severe in 18%, and more severe in 12%. There was an inverse correlation with patient weight, such that patients weighing more than 180 lbs had substantially worse images than those below this cutoff value. While dual-tracer images are of lower quality, they are interpretable if the patient is not severely overweight.