Guillain-Barré Syndrome in a Patient Receiving Anti-Tumor Necrosis Factor for Crohn Disease: Coincidence or Consequence?

BACKGROUND Antibodies against tumor necrosis factor alpha (anti-TNF-alpha) are currently widely used in the treatment of inflammatory bowel diseases (IBD), despite a number of reported adverse effects. Diverse neurologic syndromes, including the Guillain-Barre syndrome (GBS), an immune-mediated disease characterized by evolving ascending limb weakness, sensory loss, and areflexia, have been described in association with anti-TNF-alpha therapy. CASE REPORT A 45-year-old White woman was in follow-up with fistulizing ileocolonic Crohn disease using combination therapy (infliximab plus azathioprine) as CD maintenance therapy. After 3 years of this immunosuppressive therapy, she presented with symmetrical and ascending paresis in the lower limbs, and later in the upper limbs, in addition to reduced reflexes in the knees, 1 day after an infliximab infusion. The patient was hospitalized and treatment for CD was suspended. Neurophysiology studies demonstrated a pattern compatible with acute inflammatory demyelinating polyradiculopathy, with predominantly motor involvement, consistent with Guillain-Barre syndrome (GBS). Clinical, laboratory, and imaging exams were unremarkable. She was treated with intravenous immunoglobulins, with a progressive and complete resolution of neurological symptoms. After 1-year follow-up, she presented with active Crohn disease, and we opted for treating her with vedolizumab, with which she achieved clinical and endoscopic remission. CONCLUSIONS Patients receiving biological therapy with anti-TNF-alpha agents should be monitored for central or peripheral neurological signs and symptoms. The development of GBS can be secondary to anti-TNF-alpha treatment. The positive temporal relationship with TNF-alpha therapy and onset of neurological symptoms reinforces this possibility.

Factors associated with surgical resection in patients with Crohn's disease: long-term evaluation.

PURPOSE: To evaluate patient characteristics and factors associated with surgical resection in patients with Crohn's disease (CD). METHODS: An analysis was performed on data from 295 patients with CD in follow-up from 2001 to 2018. Medical record data comprised age, gender, location, behavior and duration of the CD, smoking, and extraintestinal manifestation. Patients were divided into two groups according to the presence or absence of surgical resection. RESULTS: Out of the 295 patients with CD, 155 underwent surgical resection (53.2% male, mean age: 43.88 ± 14.35 years). The main indications for surgery were stenosis (44.5%), clinical intractability (15.5%), and intra-abdominal fistulas (15.5%). Smoking (p < 0.001), longer CD duration (p < 0.0001), ileo-colonic location (p = 0.003), stenosing behavior (p < 0.0001), and fistulizing behavior (p < 0.0001) were significantly associated with surgical resection. Initial use of biological was significantly more frequent in the group of patients without surgical resection (p < 0.001). CONCLUSIONS: Patients with CD still frequently need surgical treatment. Smoking (current or past), longer disease time, stenosing and fistulizing behavior, and ileo-colonic localization in CD patients were associated with a higher risk of surgery. Awareness about factors associated with unfavorable outcome allows such patients to be treated more appropriately.

Intra-Esophageal pH Monitoring on Two Consecutive Days in Patients With Gastroesophageal Reflux Symptoms.

BACKGROUND: The best method to measure the frequency and duration of gastroesophageal reflux is 24-h pH or 24-h pH/impedance monitoring. However, the detection of reflux can vary when measured on different days. Our aim was to evaluate the possibility that the severity of gastroesophageal reflux is different even under similar conditions on two consecutive days. METHODS: We performed a 48-h pH monitoring in 12 subjects, aged 25 - 63 years, who complaint of heartburn and regurgitation, ten with esophagitis and two with non-erosive disease. The pH measurement was conducted at 5 cm from the lower esophageal sphincter. The patients stayed at the Clinical Investigation Ward of the hospital for 48 h. On each day, they consumed a 2,000 calorie diet. The results obtained on the first day were compared with those on the second day. RESULTS: Mean reflux index in the upright position was different between the two days. Results of the pH-monitoring within the 2 h after the meal revealed differences in the number of acidic reflux and reflux index episodes. Three patients had abnormal DeMeester score on one day and normal score on the other day. Considering the upper limit of 6.0% of the test duration with esophageal pH < 4 as indicative of gastroesophageal reflux disease, two patients showed abnormal results on one day and normal results on the other day. CONCLUSIONS: The 24-h pH monitoring, performed on two consecutive days under similar conditions, can lead to different diagnosis of gastroesophageal reflux disease in symptomatic patients.

EFFECT OF GUM CHEWING ON AIR SWALLOWING, SALIVA SWALLOWING AND BELCHING.

BACKGROUND: Eructation is a physiologic event which allows gastric venting of swallowed air and most of the time is not perceived as a symptom. This is called gastric belching. Supragastric belching occurs when swallowed air does not reach the stomach and returns by mouth a short time after swallowing. This situation may cause discomfort, life limitations and problems in daily life. OBJECTIVE: Our objective in this investigation was to evaluate if gum chewing increases the frequency of gastric and/or supragastric belches. METHODS: Esophageal transit of liquid and gas was evaluated by impedance measurement in 16 patients with complaint of troublesome belching and in 15 controls. The Rome III criteria were used in the diagnosis of troublesome belching. The esophageal transit of liquid and gas was measured at 5 cm, 10 cm, 15 cm and 20 cm from the lower esophageal sphincter. The subjects were evaluated for 1 hour which was divided into three 20-minute periods: (1) while sitting for a 20-minute base period; (2) after the ingestion of yogurt (200 mL, 190 kcal), in which the subjects were evaluated while chewing or not chewing gum; (3) final 20-minute period in which the subjects then inverted the task of chewing or not chewing gum. In gastric belch, the air flowed from the stomach through the esophagus in oral direction and in supragastric belch the air entered the esophagus rapidly from proximal and was expulsed almost immediately in oral direction. Air swallows were characterized by an increase of at least 50% of basal impedance and saliva swallow by a decrease of at least 50% of basal impedance, that progress from proximal to distal esophagus. RESULTS: In base period, air swallowing was more frequent in patients than in controls and saliva swallowing was more frequent in controls than in patients. There was no difference between the medians of controls and patients in the number of gastric belches and supragastric belches. In six patients, supragastric belches were seen at least once during the 20-minute base period. None of the controls had supragastric belches. In the control group, the ingestion of yogurt caused no significant alteration in the number of air swallows, saliva swallows, gastric belches and supragastric belches. In the patient group, there was an increase in the number of air swallows. If the subjects were chewing gum during this 20-minute period, there was an increase in the number of saliva swallows in both groups, without alterations of the number of air swallow, gastric belches and supragastric belches. There was no alteration in the number of the saliva swallows, air swallows, gastric belches and supragastric belches in both groups for subjects who did not chew gum in the 20-40 minute period after yogurt ingestion. When the subjects were chewing the gum, there was an increase in saliva swallows in the control and patients groups and in air swallows in the patients group. CONCLUSION: Gum chewing causes an increase in saliva swallowing in both patients with excessive belching and in controls, and an increase in air swallowing in patients with excessive belching 20 minutes after yogurt ingestion. Gum chewing did not increase or decrease the frequency of gastric or supragastric belches.

EFFECT OF GUM CHEWING ON AIR SWALLOWING, SALIVA SWALLOWING AND BELCHING / Efeito da goma de mascar na deglutição de ar, deglutição de saliva e na eructação

BackgroundEructation is a physiologic event which allows gastric venting of swallowed air and most of the time is not perceived as a symptom. This is called gastric belching. Supragastric belching occurs when swallowed air does not reach the stomach and returns by mouth a short time after swallowing. This situation may cause discomfort, life limitations and problems in daily life.ObjectiveOur objective in this investigation was to evaluate if gum chewing increases the frequency of gastric and/or supragastric belches.MethodsEsophageal transit of liquid and gas was evaluated by impedance measurement in 16 patients with complaint of troublesome belching and in 15 controls. The Rome III criteria were used in the diagnosis of troublesome belching. The esophageal transit of liquid and gas was measured at 5 cm, 10 cm, 15 cm and 20 cm from the lower esophageal sphincter. The subjects were evaluated for 1 hour which was divided into three 20-minute periods: (1) while sitting for a 20-minute base period; (2) after the ingestion of yogurt (200 mL, 190 kcal), in which the subjects were evaluated while chewing or not chewing gum; (3) final 20-minute period in which the subjects then inverted the task of chewing or not chewing gum. In gastric belch, the air flowed from the stomach through the esophagus in oral direction and in supragastric belch the air entered the esophagus rapidly from proximal and was expulsed almost immediately in oral direction. Air swallows were characterized by an increase of at least 50% of basal impedance and saliva swallow by a decrease of at least 50% of basal impedance, that progress from proximal to distal esophagus.ResultsIn base period, air swallowing was more frequent in patients than in controls and saliva swallowing was more frequent in controls than in patients. There was no difference between the medians of controls and patients in the number of gastric belches and supragastric belches. In six patients, supragastric belches were seen at least once during the 20-minute base period. None of the controls had supragastric belches. In the control group, the ingestion of yogurt caused no significant alteration in the number of air swallows, saliva swallows, gastric belches and supragastric belches. In the patient group, there was an increase in the number of air swallows. If the subjects were chewing gum during this 20-minute period, there was an increase in the number of saliva swallows in both groups, without alterations of the number of air swallow, gastric belches and supragastric belches. There was no alteration in the number of the saliva swallows, air swallows, gastric belches and supragastric belches in both groups for subjects who did not chew gum in the 20-40 minute period after yogurt ingestion. When the subjects were chewing the gum, there was an increase in saliva swallows in the control and patients groups and in air swallows in the patients group.ConclusionGum chewing causes an increase in saliva swallowing in both patients with excessive belching and in controls, and an increase in air swallowing in patients with excessive belching 20 minutes after yogurt ingestion. Gum chewing did not increase or decrease the frequency of gastric or supragastric belches.

ContextoEructação é um evento fisiológico que permite a eliminação de gás presente no estômago, geralmente não percebida como sintoma, situação identificada como eructação gástrica. Eructação supragástrica ocorre quando o ar deglutido não vai ao estômago, mas retorna do esôfago imediatamente após ser deglutido; situação que causa desconforto e limitações ao paciente.ObjetivoO objetivo desta investigação foi avaliar se goma de mascar aumenta a frequência de eructação gástrica e/ou supragástrica.MétodosO trânsito de líquido e gás foi avaliado por impedância in 16 pacientes com queixas de eructação excessiva e 15 controles. O diagnóstico de eructação excessiva foi feito tendo em consideração os critérios descritos no Roma III. O trânsito pelo esôfago foi medido por sensores de impedância localizados a 5 cm, 10 cm, 15 cm e 20 cm do esfíncter inferior do esôfago. Os indivíduos foram avaliados sentados em uma cadeira durante um período basal de 20 minutos, outro período de 20 minutos após a ingestão de iogurte (200 mL, 190 kcal), mastigando ou não goma de mascar, e em outro período por mais 20 minutos no qual invertiam o fato de mastigarem ou não goma de mascar. Na eructação gástrica o ar vinha do estômago em direção proximal, e na eructação supragástrica o ar entrou no esôfago e foi imediatamente eliminado em direção proximal. A deglutição de ar foi caracterizada pelo aumento em pelo menos 50% do valor da impedância e a deglutição de saliva pela diminuição em pelo menos 50% do valor da impedância, que progredia da parte proximal do esôfago para a parte distal.ResultadosNo período basal a deglutição de ar foi mais frequente nos pacientes do que nos controles, e a deglutição de saliva mais frequente nos controles do que nos pacientes. Não houve diferenças na mediana entre os resultados de controles e pacientes no número de eructações gástricas e supragástricas. Em seis pacientes ocorreram eructações supragástricas, o que não aconteceu em nenhum controle. Entre os controles a ingestão de iogurte não alterou a frequência de deglutição de ar, deglutição de saliva, eructações gástricas e eructações supragástricas. No grupo de pacientes houve aumento da deglutição de ar. Mastigar a goma durante este período causou aumento da deglutição de saliva, nos dois grupos, sem alterações na frequência de deglutição de ar, eructação gástrica e eructação supragástrica. No período entre 20 e 40 minutos após a ingestão do iogurte, se a pessoa não mascava a goma, não havia mudança na frequência de deglutição de saliva, deglutição de ar, eructações gástricas e eructações supragástricas. Quando a pessoa mascava a goma, houve aumento da deglutição de saliva nos dois grupos e de deglutição de ar no grupo de pacientes.ConclusãoGoma de mascar causa aumento da deglutição de saliva em pacientes com eructações excessivas e controles, e aumento da deglutição de ar em pacientes 20 minutos após a ingestão de iogurte. Goma de mascar não aumenta ou diminui a frequência de eructação gástrica ou eructação supragástrica.

Effect of swallowed bolus viscosity and body position on esophageal transit, contraction and perception of transit.

BACKGROUND: The esophagus has a different response in relation to the characteristics of a swallowed bolus. Bolus viscosity and body position may affect esophageal contraction and transit. Objectives To investigate the effect of bolus viscosity and body position on esophageal contraction, transit and perception. METHODS: Esophageal contraction, transit and perception of transit were evaluated in 26 asymptomatic volunteers, 13 men and 13 women aged 18-60 years, mean: 33.6 (12.2) years. Esophageal contraction (manometry) and transit (impedance) were measured with a solid state catheter with sensors located 5, 10, 15, and 20 cm from the lower esophageal sphincter. Each volunteer swallowed in duplicate and in random sequence a 5 mL low viscous (LV) liquid bolus of an isotonic drink with pH 3.3, and a 5 mL high viscous (HV) paste bolus, which was prepared with 7.5 g of instant food thickener diluted in 50 mL of water (pH: 6.4). RESULTS: Total bolus transit time, in the sitting position, was longer with the HV bolus than with the LV bolus. Esophageal transit was longer in the supine position than in the sitting position. Bolus head advance time was longer with the HV bolus than with the LV bolus in both positions. Contraction esophageal amplitude was higher in the supine position than in the sitting position. The perception of bolus transit was more frequent with the HV bolus than with the LV bolus, without differences related to position. CONCLUSIONS: The viscosity of the swallowed bolus and body position during swallows has an influence on esophageal contractions, transit and perception of transit.

Effect of swallwwed bolus viscosity and body poition on esophageal transit, coontraction and perception of transit / Efeito da viscosidade do bolo e da posição corporal no trânsito, contrações do esôfago e na percepção do trânsito

Background The esophagus has a different response in relation to the characteristics of a swallowed bolus. Bolus viscosity and body position may affect esophageal contraction and transit. Objectives To investigate the effect of bolus viscosity and body position on esophageal contraction, transit and perception. Methods Esophageal contraction, transit and perception of transit were evaluated in 26 asymptomatic volunteers, 13 men and 13 women aged 18-60 years, mean: 33.6 (12.2) years. Esophageal contraction (manometry) and transit (impedance) were measured with a solid state catheter with sensors located 5, 10, 15, and 20 cm from the lower esophageal sphincter. Each volunteer swallowed in duplicate and in random sequence a 5 mL low viscous (LV) liquid bolus of an isotonic drink with pH 3.3, and a 5 mL high viscous (HV) paste bolus, which was prepared with 7.5 g of instant food thickener diluted in 50 mL of water (pH: 6.4). Results Total bolus transit time, in the sitting position, was longer with the HV bolus than with the LV bolus. Esophageal transit was longer in the supine position than in the sitting position. Bolus head advance time was longer with the HV bolus than with the LV bolus in both positions. Contraction esophageal amplitude was higher in the supine position than in the sitting position. The perception of bolus transit was more frequent with the HV bolus than with the LV bolus, without differences related to position. Conclusions The viscosity of the swallowed bolus and body position during swallows has an influence on esophageal contractions, transit and perception of transit. .

Contexto O esôfago tem resposta diferente relacionada às características do bolo deglutido. A viscosidade do bolo e a posição corporal podem afetar a contração do esôfago e o trânsito. Objetivos Investigar o efeito da viscosidade do bolo e da posição corporal sobre a contração do esôfago e no trânsito. Métodos A contração do esôfago, o trânsito e a percepção do trânsito foram avaliadas em 26 voluntários assintomáticos, 13 homens e 13 mulheres com idade entre 18 e 60 anos, média: 33,6 (12,2) anos. A contração do esôfago (manometria) e trânsito (impedância) foram medidas com um cateter de estado sólido com sensores localizados a 5, 10, 15 e 20 cm do esfíncter esofágico inferior. Cada voluntário deglutiu, em duplicata, 5 mL de bolo líquido (baixa viscosidade - BV, pH: 3,3) e 5 mL de bolo pastoso (alta viscosidade - AV, pH: 6,4). Resultados O tempo de trânsito total do bolo, na posição sentada, foi mais longo com o bolo AV do que com bolo BV. O trânsito pelo esôfago foi mais longo na posição supina do que na posição sentada. O tempo de avanço da cabeça do bolo foi mais longo com bolo AV do que com bolo BV, em ambas as posições. A amplitude da contração do esôfago foi maior na posição supina do que na posição sentada. A percepção do trânsito do bolo foi mais frequente com o bolo AV do que com o bolo BV, sem diferença relacionada com a posição. Conclusões A viscosidade do bolo deglutido e a posição do corpo durante a deglutição têm influência sobre as contrações esofágicas e no trânsito pelo esôfago. .

Esophageal Transit, Contraction and Perception of Transit After Swallows of Two Viscous Boluses.

BACKGROUND: There have been results showing the influence of bolus viscosities and consistency on esophageal motility and transit. However, there is no description about the influence of two different viscous boluses on esophageal contractions, bolus transit and perception of transit. Our objective in this investigation was to evaluate the esophageal transit and contraction after swallows of two viscous boluses. METHODS: By impedance and manometric methods, we measured the esophageal transit and contraction after swallows of two viscous boluses of 5 mL volume, 100% barium sulfate and yogurt, swallowed in duplicate in the supine and upright positions. The bolus transit, esophageal contractions and the perception of bolus transit through the esophagus were evaluated in both positions. Impedance and contraction were measured at 5, 10, 15 and 20 cm from the lower esophageal sphincter. After each swallow, the volunteers were asked about the sensation of bolus transit through the esophagus. RESULTS: In supine position, the yogurt had a less frequent complete bolus transit than barium. Also in the supine position, the esophageal transit was longer with yogurt than with barium. Esophageal contractions after swallows were similar between barium and yogurt boluses. There was no difference in perception of transit between the two boluses. CONCLUSION: Although both 100% barium sulfate and yogurt are viscous boluses and have similar viscosities, the transit through the esophagus is slower with yogurt bolus than with barium bolus, which suggests that viscosity may be not the sole factor to determine transit.

Esophageal motility in troublesome belching.

CONTEXT: Supragastric belches are the main determinants of troublesome belching symptoms. In supragastric belches, air is rapidly brought into the esophagus and is immediately followed by a rapid expulsion before it has reached the stomach. OBJECTIVE: To evaluate the esophageal contraction and transit after wet swallows in patients with troublesome belching. METHODS: Esophageal contraction and transit were evaluated in 16 patients with troublesome belching and 15 controls. They were measured at 5, 10, 15, and 20 cm from the lower esophageal sphincter (LES) by a solid state manometric and impedance catheter. Each subject swallowed five 5 mL boluses of saline. RESULTS: The amplitude, duration and area under the curve of contractions were similar in patients with troublesome belching and control subjects. The total esophageal bolus transit time was 6.2 (1.8) s in patients with troublesome belching and 6.1 (2.3) s in controls (P=0.55). The bolus presence time was longer in controls than in patients at 5 cm from the LES [controls: 6.0 (1.1) s, patients: 4.9 (1.2) s, P=0.04], without differences at 10, 15 and 20 cm from the LES. The bolus head advanced time was longer in patients than controls from 20 cm to 15 cm [controls: 0.1 (0.1) s, patients: 0.7(0.8)s, P=0.01] and from 15 cm to 10 cm [controls: 0.3 (0.1) s, patients: 1.6 (2.6) s, P=0.01] of the LES, without difference from 10 cm to 5 cm [controls: 0.7 (0.3) s, patients: 1.0 (1.1) s, P=0.37]. There was no difference in segment transit time. CONCLUSION: There was no difference in esophageal contractions between patients with troublesome belching and controls. The swallowed bolus went slower into the proximal and middle esophageal body in patients than in control, but cross the distal esophageal body faster in patients than in controls.

Esophageal motliity in troublesome bllching / Motilidade do esofago de pacientes com eructacao supragastrica

Context Supragastric belches are the main determinants of troublesome belching symptoms. In supragastric belches, air is rapidly brought into the esophagus and is immediately followed by a rapid expulsion before it has reached the stomach. Objective To evaluate the esophageal contraction and transit after wet swallows in patients with troublesome belching. Methods Esophageal contraction and transit were evaluated in 16 patients with troublesome belching and 15 controls. They were measured at 5, 10, 15, and 20 cm from the lower esophageal sphincter (LES) by a solid state manometric and impedance catheter. Each subject swallowed five 5 mL boluses of saline. Results The amplitude, duration and area under the curve of contractions were similar in patients with troublesome belching and control subjects. The total esophageal bolus transit time was 6.2 (1.8) s in patients with troublesome belching and 6.1 (2.3) s in controls (P = 0.55). The bolus presence time was longer in controls than in patients at 5 cm from the LES [controls: 6.0 (1.1) s, patients: 4.9 (1.2) s, P = 0.04], without differences at 10, 15 and 20 cm from the LES. The bolus head advanced time was longer in patients than controls from 20 cm to 15 cm [controls: 0.1 (0.1) s, patients: 0.7(0.8)s, P = 0.01] and from 15 cm to 10 cm [controls: 0.3 (0.1) s, patients: 1.6 (2.6) s, P = 0.01] of the LES, without difference from 10 cm to 5 cm [controls: 0.7 (0.3) s, patients: 1.0 (1.1) s, P = 0.37]. There was no difference in segment transit time. Conclusion There was no difference in esophageal contractions between patients with troublesome belching and controls. The swallowed bolus went slower into the proximal and middle esophageal body in patients than in control, but cross the distal esophageal body faster in patients than in controls. .

Contexto Na eructação esofágica o ar é rapidamente trazido para o esôfago, fato imediatamente seguido pela rápida expulsão, antes de ter atingido o estômago. Objetivo Avaliar a contração e o trânsito pelo esôfago após deglutições líquidas em pacientes com eructações excessivas. Métodos Contração do esôfago e o trânsito foram avaliados em 16 pacientes com eructações excessivas e 15 controles. Elas foram medidas a 5, 10, 15 e 20 cm do esfíncter inferior do esôfago (EIE) por um cateter em estado sólido de manometria e impedância. Cada indivíduo deglutiu cinco vezes 5 mL de salina. Resultados A amplitude, duração e área sob a curva das contrações foram similares em pacientes com eructação e controles. O tempo total de trânsito esofágico foi de 6,2 (1,8) s em pacientes com eructação e 6,1 (2,3) s em controles (P = 0,55). O tempo de presença de bolus foi mais longo nos controles do que nos pacientes a 5 cm do EIE [controles: 6.0 (1.1) s, pacientes: 4.9 (1.2) s, P = 0,04], sem diferenças a 10, 15 e 20 cm do EIE. O tempo de avanço da cabeça bolo foi mais longo em pacientes do que nos controles, de 20 cm a 15 cm [controles: 0,1 (0,1) s, pacientes: 0,7 (0,8) s, P = 0,01] e de 15 cm a 10 cm [controles: 0,3 (0,1) s, pacientes: 1.6 (2.6) s, P = 0,01] do corpo esofágico, sem diferença de 10 cm a 5 cm [controles: 0,7 (0,3) s, de pacientes: 1.0 (1.1) s, P = 0,37]. Não houve diferença no tempo de trânsito segmentar. Conclusão Não houve diferença nas contrações do esôfago entre pacientes com eructação excessiva e controles. O bolo líquido deglutido teve propagação ...

Esophageal contractions, bolus transit and perception of transit after swallows of liquid and solid boluses in normal subjects / Contrações esofágicas, trânsito do bolo e percepção do trânsito após deglutições de bolos líquido e sólido em voluntários normais

CONTEXT: Esophageal dysphagia is the sensation that the ingested material has a slow transit or blockage in its normal passage to the stomach. It is not always associated with motility or transit alterations. OBJECTIVES: To evaluate in normal volunteers the possibility of perception of bolus transit through the esophagus after swallows of liquid and solid boluses, the differences in esophageal contraction and transit with these boluses, and the association of transit perception with alteration of esophageal contraction and/or transit. METHODS: The investigation included 11 asymptomatic volunteers, 4 men and 7 women aged 19-58 years. The subjects were evaluated in the sitting position. They performed swallows of the same volume of liquid (isotonic drink) and solid (macaroni) boluses in a random order and in duplicate. After each swallow they were asked about the sensation of bolus passage through the esophagus. Contractions and transit were evaluated simultaneously by solid state manometry and impedance. RESULTS: Perception of bolus transit occurred only with the solid bolus. The amplitude and area under the curve of contractions were higher with swallows of the solid bolus than with swallows of the liquid bolus. The difference was more evident in swallows with no perception of transit (n = 12) than in swallows with perception (n = 10). The total bolus transit time was longer for the solid bolus than for the liquid bolus only with swallows followed by no perception of transit. CONCLUSION: The results suggest that the perception of esophageal transit may be the consequence of inadequate adaptation of esophageal transit and contraction to the characteristics of the swallowed bolus.

CONTEXTO: Disfagia esofágica é a sensação de que o alimento ingerido tem trânsito lento ou é bloqueado em sua passagem para o estômago. Nem sempre o sintoma é associado com alterações em trânsito ou motilidade. OBJETIVOS: Avaliar, em voluntários normais, a possibilidade de percepção do trânsito através do esôfago de bolo sólido e líquido, as diferenças nas contrações esofágicas e no trânsito pelo esôfago com estes bolos, e a associação entre percepção do trânsito com alterações nas contrações e/ou trânsito. MÉTODOS: Foram estudados 11 voluntários assintomáticos, 4 homens e 7 mulheres com idades entre 19 e 58 anos. Os voluntários foram avaliados na posição sentada. Eles deglutiram, em duplicata, o mesmo volume de bolo sólido (macarrão) e líquido (bebida isotônica). Após cada deglutição foi perguntado sobre sensação da passagem do bolo pelo esôfago. Contrações e trânsito foram avaliados simultaneamente por manometria de estado sólido e impedância. RESULTADOS: Percepção do trânsito ocorreu apenas com o bolo sólido. A amplitude e área sob a curva das contrações foram maiores com a deglutição do bolo sólido do que com a deglutição de bolo líquido. A diferença foi mais evidente nas deglutições em que não houve percepção do trânsito (n = 12) do que nas deglutições com percepção (n = 10). O tempo total de trânsito foi mais longo para o bolo sólido do que para o bolo líquido somente com as deglutições seguidas pela não percepção do trânsito. CONCLUSÃO: Os resultados sugerem que a percepção da passagem do bolo pelo esôfago deve estar relacionada à adaptação inadequada das contrações esofágicas e do trânsito às características do bolo deglutido.

Esophageal contractions, bolus transit and perception of transit after swallows of liquid and solid boluses in normal subjects.

CONTEXT: Esophageal dysphagia is the sensation that the ingested material has a slow transit or blockage in its normal passage to the stomach. It is not always associated with motility or transit alterations. OBJECTIVES: To evaluate in normal volunteers the possibility of perception of bolus transit through the esophagus after swallows of liquid and solid boluses, the differences in esophageal contraction and transit with these boluses, and the association of transit perception with alteration of esophageal contraction and/or transit. METHODS: The investigation included 11 asymptomatic volunteers, 4 men and 7 women aged 19-58 years. The subjects were evaluated in the sitting position. They performed swallows of the same volume of liquid (isotonic drink) and solid (macaroni) boluses in a random order and in duplicate. After each swallow they were asked about the sensation of bolus passage through the esophagus. Contractions and transit were evaluated simultaneously by solid state manometry and impedance. RESULTS: Perception of bolus transit occurred only with the solid bolus. The amplitude and area under the curve of contractions were higher with swallows of the solid bolus than with swallows of the liquid bolus. The difference was more evident in swallows with no perception of transit (n = 12) than in swallows with perception (n = 10). The total bolus transit time was longer for the solid bolus than for the liquid bolus only with swallows followed by no perception of transit. CONCLUSION: The results suggest that the perception of esophageal transit may be the consequence of inadequate adaptation of esophageal transit and contraction to the characteristics of the swallowed bolus.

Response of the esophageal body to wet and dry swallows in Chagas' disease.

BACKGROUND: Wet swallows cause a greater esophageal contraction amplitude and duration than dry swallows. In Chagas' disease there is a reduction in amplitude of esophageal contraction but we do not know if the difference between wet and dry swallows is seen in the disease. AIM: To compare the esophageal contractions after wet and dry swallows in patients with Chagas' disease. METHODS: We measured the area under the curve (amplitude x duration) of the esophageal contractions in 30 patients with a diagnosis of esophageal involvement by Chagas' disease and 44 controls. We used the manometric method with continuous perfusion. The contractions were measured at 2, 7, 12 and 17 cm below the upper esophageal sphincter, after five swallows of a 5 mL bolus of water alternated with five dry swallows. RESULTS: In the control group wet swallows caused a higher area under the curve than dry swallows. There was no difference between wet and dry swallows in Chagas' disease patients, and there was no difference in wet and dry swallows in Chagas' disease patients compared with dry swallows of controls. At 12 and 17 cm from the upper esophageal sphincter the area under the curve after wet and dry swallows in Chagas' disease patients younger than 60 years (n = 15) was higher than in Chagas' disease patients older than 60 years (n = 15). CONCLUSION: We conclude that in normal subjects there is adaptation to the presence of a liquid bolus inside the esophageal body, which does not happen in patients with Chagas' disease.

Response of the esophageal body to wet and dry swallows in Chagas' disease / Resposta do corpo do esôfago a deglutições de água e secas na doença de Chagas

BACKGROUND: Wet swallows cause a greater esophageal contraction amplitude and duration than dry swallows. In Chagas' disease there is a reduction in amplitude of esophageal contraction but we do not know if the difference between wet and dry swallows is seen in the disease. AIM: To compare the esophageal contractions after wet and dry swallows in patients with Chagas' disease. METHODS: We measured the area under the curve (amplitude x duration) of the esophageal contractions in 30 patients with a diagnosis of esophageal involvement by Chagas' disease and 44 controls. We used the manometric method with continuous perfusion. The contractions were measured at 2, 7, 12 and 17 cm below the upper esophageal sphincter, after five swallows of a 5 mL bolus of water alternated with five dry swallows. RESULTS: In the control group wet swallows caused a higher area under the curve than dry swallows. There was no difference between wet and dry swallows in Chagas' disease patients, and there was no difference in wet and dry swallows in Chagas' disease patients compared with dry swallows of controls. At 12 and 17 cm from the upper esophageal sphincter the area under the curve after wet and dry swallows in Chagas' disease patients younger than 60 years (n = 15) was higher than in Chagas' disease patients older than 60 years (n = 15). CONCLUSION: We conclude that in normal subjects there is adaptation to the presence of a liquid bolus inside the esophageal body, which does not happen in patients with Chagas' disease.

RACIONAL: Deglutições de água causam maior amplitude e duração das contrações esofágicas do que deglutições "secas". Na doença de Chagas as contrações esofágicas são de baixa amplitude e de menor duração, porém não se sabe se há diferença entre deglutições líquidas e secas. OBJETIVO: Comparar as contrações esofágicas após deglutições líquidas e "secas" em pacientes com doença de Chagas. MÉTODOS: Estudou-se a área sob a curva (amplitude x duração) das contrações esofágicas em 30 pacientes com diagnóstico de esofagopatia chagásica, com diâmetro do esôfago no exame radiológico inferior a 4 cm, e 44 controles. Utilizou-se o método manométrico com perfusão contínua. As contrações foram medidas a 2, 7, 12 e 17 cm distais ao esfíncter superior do esôfago, após cinco deglutições de 5 mL de água alternadas com cinco deglutições "secas". RESULTADOS: No grupo controle deglutições de água provocaram maior área sob a curva do que deglutições "secas". Na doença de Chagas não houve diferença entre deglutições de água e "secas", bem como não houve diferença entre deglutições de água e "secas" nos pacientes com doença de Chagas e deglutições "secas" nos controles. A 12 e 17 cm do esfíncter superior do esôfago a área sob a curva após deglutições de água e "seca", em pacientes com doença de Chagas, foi maior em pacientes com idades abaixo de 60 anos (n = 15) do que pacientes com idades acima de 60 anos (n = 15). CONCLUSÃO: Concluiu-se que em pessoas normais há adaptação à presença do bolo líquido dentro do esôfago, o que não acontece em pacientes com doença de Chagas.

Comparison of esophageal motility impairment caused by Chagas' disease in two age groups.

BACKGROUND: Chagas' disease and the aging process cause loss of neurons of the esophageal myenteric plexus. AIM: To evaluate the esophageal motility impairment caused by Chagas' disease in two age groups. Our hypothesis was that the aging process may cause further esophageal motility impairment in patients with Chagas' disease. METHODS: We studied the esophageal motility of 30 patients with Chagas' disease and dysphagia, with esophageal retention of barium sulfate and an esophageal diameter within the normal range. Fifteen were 34 to 59 years old (younger group, median 51 years) and 15 were 61 to 77 years old (older group, median 66 years). As a control group we studied 15 subjects aged 33 to 58 years (median 42 years) and 7 subjects aged 61 to 73 years (median 66 years). The esophageal contractions were measured by the manometric method with continuous perfusion after five swallows of a 5 mL bolus of water at 2, 7, 12 and 17 cm below the upper esophageal sphincter. RESULTS: Patients with Chagas' disease had lower amplitude of contractions and fewer peristaltic, more simultaneous, and more non-conducted contractions than controls. Older patients with Chagas' disease had lower amplitude of contractions in the distal esophagus (mean +/- SE: 30.8 +/- 4.3 mm Hg) than younger patients (51.9 +/- 8.6 mm Hg). From 12 to 17 cm, older patients had more non-conducted (41%) and fewer peristaltic (8%) contractions than younger patients (non-conducted: 16%, peristaltic: 21%). CONCLUSION: Older patients with Chagas' disease with clinical and radiological examinations similar to those of younger patients had motility alterations suggesting that the aging process may cause further deterioration of esophageal motility.

[Aging and esophageal motility in patients with gastroesophageal reflux disease]. / Relação entre idade e motilidade do esôfago em pacientes com doença do refluxo gastroesofágico.

BACKGROUND: Alterations of esophageal contractions may worsen the esophageal lesions caused by gastroesophageal reflux. The impairment of the contractions may be localized only in the distal esophagus or in the entire esophageal body, and may be worse with the aging process. AIMS: To evaluate the proximal and distal esophageal contractions in patients with gastroesophageal reflux symptoms with or without esophagitis. PATIENTS AND METHODS: We studied esophageal motility in 104 patients with gastroesophageal reflux symptoms, 42 with normal esophageal endoscopic examination, 47 with mild esophagitis and 15 with severe esophagitis. The esophageal contractions were measured by the manometric method at 2, 7, 12 and 17 cm from the upper esophageal sphincter, after five swallows of a 5 mL bolus of water. RESULTS: The amplitude and area under the curve of contractions were lower in patients with severe esophagitis than in patients without esophagitis or with mild esophagitis in the distal part of the esophageal body (17 cm from the upper esophageal sphincter). In the proximal esophageal body there was no difference in amplitude or area under the curve. In the entire esophageal body there was no difference between the three groups of patients in duration, velocity of peristaltic contractions, or proportion of failed, simultaneous, non-propagated or peristaltic contractions. There was no difference between the patients with less than 50 years or with more than 50 years of age. CONCLUSIONS: Patients with severe esophagitis had lower distal esophageal contraction amplitude than patients without esophagitis or with moderate esophagitis. There was no effect of aging on esophageal contractions.

Comparison of esophageal motility impairment caused by Chagas' disease in two age groups / Comparação em duas faixas etárias das alterações motoras do esôfago conseqüentes à doença de Chagas

BACKGROUND: Chagas' disease and the aging process cause loss of neurons of the esophageal myenteric plexus. AIM: To evaluate the esophageal motility impairment caused by Chagas' disease in two age groups. Our hypothesis was that the aging process may cause further esophageal motility impairment in patients with Chagas' disease. METHODS: We studied the esophageal motility of 30 patients with Chagas' disease and dysphagia, with esophageal retention of barium sulfate and an esophageal diameter within the normal range. Fifteen were 34 to 59 years old (younger group, median 51 years) and 15 were 61 to 77 years old (older group, median 66 years). As a control group we studied 15 subjects aged 33 to 58 years (median 42 years) and 7 subjects aged 61 to 73 years (median 66 years). The esophageal contractions were measured by the manometric method with continuous perfusion after five swallows of a 5 mL bolus of water at 2, 7, 12 and 17 cm below the upper esophageal sphincter. RESULTS: Patients with Chagas' disease had lower amplitude of contractions and fewer peristaltic, more simultaneous, and more non-conducted contractions than controls. Older patients with Chagas' disease had lower amplitude of contractions in the distal esophagus (mean ± SE: 30.8 ± 4.3 mm Hg) than younger patients (51.9 ± 8.6 mm Hg). From 12 to 17 cm, older patients had more non-conducted (41 percent) and fewer peristaltic (8 percent) contractions than younger patients (non-conducted: 16 percent, peristaltic: 21 percent). CONCLUSION: Older patients with Chagas' disease with clinical and radiological examinations similar to those of younger patients had motility alterations suggesting that the aging process may cause further deterioration of esophageal motility.

RACIONAL: Doença de Chagas e o processo do envelhecimento causam perda de neurônios do plexo mientérico do esôfago. OBJETIVO: Avaliar em duas faixas etárias as possíveis alterações da motilidade do esôfago em pacientes com doença de Chagas. A hipótese é de que o envelhecimento pode provocar aumento na intensidade das alterações motoras do esôfago conseqüentes à doença de Chagas. PACIENTES E MÉTODO: Estudou-se a motilidade do esôfago em 30 pacientes com doença de Chagas e disfagia, com retenção do meio de contraste no exame radiológico do esôfago, com diâmetro do órgão dentro dos limites normais. Quinze tinham de 34 a 59 anos (mediana: 51 anos) e 15 tinham de 61 a 77 anos (mediana: 66 anos). Como grupo controle, estudaram-se 15 pessoas com idades entre 33 e 58 anos (mediana: 42 anos) e 7 pessoas com idades entre 61 e 73 anos (mediana: 66 anos). As contrações esofágicas foram medidas pelo método manométrico com perfusão contínua, após cinco deglutições de 5 mL de água, a 2, 7, 12 e 17 cm distal ao esfíncter superior do esôfago. RESULTADOS: Pacientes com doença de Chagas tiveram menor amplitude das contrações, menor proporção de contrações peristálticas, maior proporção de contrações simultâneas e maior proporção de contrações não propagadas do que os controles. Os pacientes com doença de Chagas e mais idade tiveram menor amplitude das contrações em esôfago distal (média ± EP: 30,8 ± 4,3 mm Hg) do que os pacientes com menos idade (51,9 ± 8,6 mm Hg). Entre 12 e 17 cm do esfíncter superior do esôfago os pacientes de mais idade tiveram mais contrações não propagadas (41 por cento) e menos contrações peristálticas (8 por cento) do que os pacientes com menos idade (não propagadas: 16 por cento peristálticas 21 por cento). CONCLUSÃO: Pacientes com doença de Chagas mais idosos, com clínica e exame radiológico do esôfago similar ao de pacientes mais jovens, têm alterações motoras do esôfago que sugerem que o envelhecimento pode provocar comprometimemento...

Relação entre idade e motilidade do esôfago em pacientes com doença do refluxo gastroesofágico / Aging and esophageal motility in patients with gastroesophageal reflux disease

RACIONAL: O comprometimento das contrações esofágicas pode agravar as lesões em esôfago conseqüentes ao refluxo gastroesofágico. A hipótese do presente estudo é de que alterações das contrações são limitadas ao esôfago distal e pioram com o processo de envelhecimento. OBJETIVO: Avaliar as contrações esofágicas em parte proximal e distal do esôfago em pacientes com sintomas de refluxo gastroesofágico, com e sem lesões no esôfago. CASUíSTICA E MÉTODOS: Estudaram-se pelo método manométrico as contrações esofágicas a 2, 7, 12 e 17 cm do esfíncter superior do esôfago, após cinco deglutições de 5 mL de água, em 104 pacientes com pirose e regurgitação ácida, 42 com endoscopia do esôfago normal, 47 com esofagite moderada e 15 com esofagite grave. RESULTADOS: Nas medidas realizadas a 12 e 17 cm do esfíncter superior do esôfago, a amplitude e área sob a curva das contrações esofágicas foram menores nos pacientes com esofagite grave, quando comparadas com os pacientes sem esofagite ou com esofagite moderada. A 2 e 7 cm do esfíncter superior do esôfago não houve diferenças na amplitude e área sob a curva das contrações. Não houve diferenças entre os grupos, em todo o esôfago, em relação à duração das contrações, velocidade de propagação do peristaltismo e nas proporções de contrações falhas, simultâneas, não propagadas e peristálticas. Não houve diferenças entre os pacientes com mais de 50 anos e aqueles com menos de 50 anos. CONCLUSÕES: Esofagite grave esteve associada com diminuição da amplitude das contrações esofágicas, alteração limitada à parte distal do esôfago. Não foi observado efeito do envelhecimento nas contrações.

BACKGROUND: Alterations of esophageal contractions may worsen the esophageal lesions caused by gastroesophageal reflux. The impairment of the contractions may be localized only in the distal esophagus or in the entire esophageal body, and may be worse with the aging process. AIMS: To evaluate the proximal and distal esophageal contractions in patients with gastroesophageal reflux symptoms with or without esophagitis. PATIENTS AND METHODS: We studied esophageal motility in 104 patients with gastroesophageal reflux symptoms, 42 with normal esophageal endoscopic examination, 47 with mild esophagitis and 15 with severe esophagitis. The esophageal contractions were measured by the manometric method at 2, 7, 12 and 17 cm from the upper esophageal sphincter, after five swallows of a 5 mL bolus of water. RESULTS: The amplitude and area under the curve of contractions were lower in patients with severe esophagitis than in patients without esophagitis or with mild esophagitis in the distal part of the esophageal body (17 cm from the upper esophageal sphincter). In the proximal esophageal body there was no difference in amplitude or area under the curve. In the entire esophageal body there was no difference between the three groups of patients in duration, velocity of peristaltic contractions, or proportion of failed, simultaneous, non-propagated or peristaltic contractions. There was no difference between the patients with less than 50 years or with more than 50 years of age. CONCLUSIONS: Patients with severe esophagitis had lower distal esophageal contraction amplitude than patients without esophagitis or with moderate esophagitis. There was no effect of aging on esophageal contractions.

Esophageal contractions in Chagas' disease and in idiopathic achalasia.

GOALS: The aim of this study was to compare the esophageal contractions in Chagas' disease and in idiopathic achalasia. BACKGROUND: It is suggested that the esophageal involvement caused by Chagas' disease and by idiopathic achalasia, although similar, shows some differences. STUDY: We studied the contractions at 2, 7, 12, and 17 cm below the upper esophageal sphincter in 25 patients with idiopathic achalasia (15 with dilatation), 52 with Chagas' disease (22 with dilatation), and 18 controls. Each subject performed 5 swallows of a 5-mL bolus of water alternated with 5 dry swallows. RESULTS: In the distal esophageal body, the amplitude was lower in patients than in controls. Among patients with esophageal dilatation, the proximal amplitude was lower in patients with idiopathic achalasia, and the time interval between the contractions at 2 and 7 cm was longer in patients with Chagas' disease, the number of failed contractions was higher in Chagas' disease, and simultaneous contractions were more frequent in idiopathic achalasia. The simultaneous isobaric pressure in the distal esophagus was associated with an increase in proximal pressure that was higher than distal but lower than proximal swallowing pressure. CONCLUSION: The results suggested that idiopathic achalasia and Chagas' disease cause similar impairment of distal esophageal motility, but in patients with esophageal dilatation the impairment of proximal motility may be not the same.

Proximal and distal esophageal contractions in patients with vigorous or classic esophageal Chagas' disease.

BACKGROUND: Some patients with achalasia have distal esophageal contraction amplitude in the normal range, a condition called vigorous achalasia, and others have low contraction amplitude, a condition named classic achalasia. The difference in distal contraction amplitude may also be associated with a difference in proximal contraction amplitude. AIM: To study the proximal and distal esophageal contractions in patients with Chagas' disease. MATERIAL AND METHODS: We studied 28 patients with Chagas' disease, all with dysphagia and an esophageal radiologic examination with retention without dilation, and 18 controls. The patients with Chagas' disease had vigorous achalasia (distal amplitude over 34 mm Hg, n = 13) or classic achalasia (distal amplitude below 34 mm Hg, n = 15). We measured the contractions by the manometric method with continuous perfusion at 2, 7, 12 and 17 cm below the upper esophageal sphincter after five swallows of a 5 mL bolus of water. RESULTS: There was no difference in proximal amplitude of contractions between classic or vigorous achalasia, and controls. In the proximal esophagus there was also no difference in duration or area under curve of contractions. In the distal esophagus, duration and area under curve were lower in classic than vigorous disease. Failed and simultaneous contractions were more frequent in patients than controls. Simultaneous contractions were seen more frequently in classic disease, and peristaltic contractions were seen more frequently in vigorous disease. CONCLUSION: We did not find differences in proximal esophageal contractions of patients with classical or vigorous esophageal Chagas' disease, except for the higher number of simultaneous contractions seen in classic disease.