Acute transcutaneous electrical stimulation (TES) augments esophageal contractility in patients with weak peristalsis.

BACKGROUND: Lung transplantation (LTx) remains controversial in patients with absent peristalsis (AP) given the increased risk for gastroesophageal reflux (GER), and chronic lung allograft dysfunction. Furthermore, specific treatments to facilitate LTx in those with AP have not been widely described. Transcutaneous Electrical Stimulation (TES) has been reported to improve foregut contractility in LTx patients and therefore we hypothesize that TES may augment the esophageal motility of patients with ineffective esophageal motility (IEM). METHODS: We included 49 patients, 14 with IEM, 5 with AP, and 30 with normal motility. All subjects underwent standard high-resolution manometry and intraluminal impedance (HRIM) with additional swallows as TES was delivered. RESULTS: TES induced a universal impedance change observable in real-time by a characteristic spike activity. TES significantly augmented the contractile vigor of the esophagus measured by the distal contractile integral (DCI) in patients with IEM [median DCI (IQR) 0 (238) mmHg-cm-s off TES vs. 333 (858) mmHg-cm-s on TES; p = .01] and normal peristalsis [median DCI (IQR) 1545 (1840) mmHg-cm-s off TES vs. 2109 (2082) mmHg-cm-s on TES; p = .01]. Interestingly, TES induced measurable contractile activity (DCI > 100 mmHg-cm-s) in three out of five patients with AP [median DCI (IQR) 0 (0) mmHg-cm-s off TES vs. 0 (182) mmHg-cm-s on TES; p < .001]. CONCLUSION: TES acutely augmented contractile vigor in patients with normal and weak/ AP. The use of TES may positively impact LTx candidacy, and outcomes for patients with IEM/AP. Nevertheless, further studies are needed to determine the long-term effects of TES in this patient population.

Upright Integrated Relaxation Pressure Facilitates Characterization of Esophagogastric Junction Outflow Obstruction.

BACKGROUND & AIMS: Under the Chicago Classification of esophageal motility disorders, esophagogastric junction outflow obstruction (EGJOO) includes a varied clinical spectrum that results in diagnostic and management difficulties. We aimed to demonstrate that including upright swallows during high-resolution manometry (HRM) helps identify patients with clinically significant EGJOO. METHODS: We performed a retrospective study of consecutive patients diagnosed with EGJOO on HRM from January 2015 through July 2017. HRM studies included 10 supine and 5 upright 5-ml liquid swallows. HRM values, esophagrams, and patient-reported outcomes were evaluated to identify factors associated with objective EGJOO (defined by esophagram) and symptomatic dysphagia (brief esophageal dysphagia questionnaire scores, >10). RESULTS: Of the 1911 patients who had HRM during the study period, 16.2% (310) were diagnosed with EGJOO; 155 patients completed an esophagram and 227 completed the brief esophageal dysphagia questionnaire. Of these patients, 30.3% (47/155) had radiographic evidence of EGJOO and 52.4% (119/227) had symptomatic dysphagia. The median upright integrated relaxation pressure for patients with radiographic evidence of EGJOO or symptomatic dysphagia was higher than for patients without. An upright integrated relaxation pressure >12 mmHg identified patients with radiographic evidence of EGJOO with 97.9% sensitivity and 15.7% specificity; for symptomatic dysphagia these values were 88.2% and 23.1%, respectively. CONCLUSION: An upright integrated relaxation pressure of >12 mmHg identifies patients with clinically significant esophageal outflow obstruction or dysphagia with a high level of sensitivity. This simple manometric maneuver (upright swallows) should be added to the standard manometric protocol.

The impact of surgery on quality of life, esophageal motility, and tracheal anatomy and airflow in patients with benign nodular goiter.

Surgery - is it any good for goiter? In patients with goiter the benefits of thyroid surgery have previously rarely been investigated, as only few alternatives existed. However, the increasing evidence of the advantages with non-surgical substitutes with lower costs and preferable risk profiles prompted us to investi-gate the evidence base for thyroid surgery thoroughly. This thesis consists of three published studies investigating the impact of thyroidectomy on: 1) changes in disease-specific quality of life, 2) swallowing symptoms and esophageal motility, and 3) tracheal anatomy and airflow, in a cohort of patients with benign nodular goiter.

Increased inspiratory esophagogastric junction pressure in systemic sclerosis: an add-on to antireflux barrier.

AIM: To investigate crural diaphragm (CD) function in systemic sclerosis (SSc) using high-resolution manometry and standardized inspiratory maneuvers. METHODS: Eight SSc volunteers (average age, 40.1 years; one male) and 13 controls (average age, 32.2 years; six males) participated in the study. A high-resolution manometry/impedance system measured the esophagus and esophagogastric junction (EGJ) pressure profile during swallows and two respiratory maneuvers: sinus arrhythmia maneuver (SAM; the average of six EGJ peak pressures during 5-s deep inhalations) and threshold maneuver (TM; the EGJ peak pressures during forced inhalation under 12 and 24 cmH2O loads). Inspiratory diaphragm lowering (IDL) was taken as the displacement of the EGJ high-pressure zone during the SAM. RESULTS: SSc patients had lower mean lower esophageal sphincter pressure than controls during normal breathing (19.7±2.8 mmHg vs 32.2±2.7 mmHg, P=0.007). Sinus arrhythmia maneuver pressure was higher in SSc patients than in controls (142.6±9.4 mmHg vs 104.6±13.8 mmHg, P=0.019). Sinus arrhythmia maneuver pressure normalized to IDL was also higher in SSc patients than in controls (83.8±13.4 mmHg vs 37.5±6.9 mmHg, P=0.005). Threshold maneuver pressures normalized to IDL were also greater in SSc patients than in controls (TM 12 cmH2O: 85.1±16.4 mmHg vs 43.9±6.3 mmHg, P=0.039; TM 24 cmH2O: 85.2±16.4 mmHg vs 46.2±6.6 mmHg, P=0.065). Inspiratory diaphragm lowering in SSc patients was less than in controls (2.1±0.3 cm vs 3±0.2 cm, P=0.011). CONCLUSION: SSc patients had increased inspiratory EGJ pressure. This is an add-on to EGJ pressure and indicates that the antireflux barrier can be trained.

Diabetic gastrointestinal autonomic neuropathy: current status and new achievements for everyday clinical practice.

Gastrointestinal symptoms occur frequently among patients with diabetes mellitus and are associated with considerable morbidity. Diabetic gastrointestinal autonomic neuropathy represents a complex disorder with multifactorial pathogenesis, which is still not well understood. It appears to involve a spectrum of metabolic and cellular changes that affect gastrointestinal motor and sensory control. It may affect any organ in the digestive system. Clinical manifestations are often underestimated, and therefore autonomic neuropathy should be suspected in all diabetic patients with unexplained gastrointestinal symptoms. Advances in technology have now enabled assessment of gastrointestinal motor function. Moreover, novel pharmacological approaches, along with endoscopic and surgical treatment options, contribute to improved outcomes. This review summarises the progress achieved in diabetic gastrointestinal autonomic neuropathy during the last years, focusing on clinical issues of practical importance to the everyday clinician.

Tolerance to enteral nutrition therapy in traumatic brain injury patients.

OBJECTIVE: To evaluate the tolerance to enteral nutrition (EN) and the effects of pro-kinetic drugs in critical traumatic brain injury (TBI) patients. METHODS: Transversal observational study. A total of 32 out of 45 TBI patients of both genders receiving EN were evaluated in a trauma referral hospital intensive care unit (ICU). Data from each patient were collected for a period of 10 consecutive days after initiation of enteral feeding: gastric residue, presence of vomiting, abdominal distension, Glasgow coma scale and the use of pro-kinetic agents. RESULTS: In 20 of the 32 patients high levels of gastric residue were found. Of these 20 patients, half could not tolerate the diet within the first 72 hours following infusion. However, no association was found between disease severity and occurrence of gastrointestinal complications (p > 0.05). Feeding intolerance was observed in 75.0% (n = 24) of patients, even with the systematic use of metaclopramide from the outset of nutritional therapy. All patients with feeding intolerance who used erythromycin by nasogastric tube showed improvement. CONCLUSIONS: The high level of gastric residue was the most common feeding intolerance and the delivery of erythromycin by nasogastric tube seems to control gastrointestinal disorders in TBI patients.

[Obesity and gastrointestinal motility].

Gastrointestinal (GI) motility has a crucial role in the food consumption, digestion and absorption, and also controls the appetite and satiety. In obese patients, various alterations of GI motility have been investigated. The prevalence of GERD and esophageal motor disorders in obese patients are higher than those of general population. Gastric emptying of solid food is generally accelerated and fasting gastric volume especially in distal stomach is larger in obese patients without change in accommodation. Contractile activity of small intestine in fasting period is more prominent, but orocecal transit is delayed. Autonomic dysfunction is frequently demonstrated in obese patients. These findings correspond with increased appetite and delayed satiety in obese patients, but causes or results have not been confirmed. Therapeutic interventions of these altered GI motility have been developed using botulinum toxin, gastric electrical stimulation in obese patients. Novel agents targeted for GI hormone modulation (such as ghrelin and leptin) need to be developed in the near future.

Obesity and Gastrointestinal Motility / 대한소화기학회지

Gastrointestinal (GI) motility has a crucial role in the food consumption, digestion and absorption, and also controls the appetite and satiety. In obese patients, various alterations of GI motility have been investigated. The prevalence of GERD and esophageal motor disorders in obese patients are higher than those of general population. Gastric emptying of solid food is generally accelerated and fasting gastric volume especially in distal stomach is larger in obese patients without change in accommodation. Contractile activity of small intestine in fasting period is more prominent, but orocecal transit is delayed. Autonomic dysfunction is frequently demonstrated in obese patients. These findings correspond with increased appetite and delayed satiety in obese patients, but causes or results have not been confirmed. Therapeutic interventions of these altered GI motility have been developed using botulinum toxin, gastric electrical stimulation in obese patients. Novel agents targeted for GI hormone modulation (such as ghrelin and leptin) need to be developed in the near future.

[Effects of Yunqitang on both esophageal mucosal morphology and esophageal motility in reflux esophagitis patients].

OBJECTIVE: To observe the effects of Yunqitang (YQT) on both esophageal mucosal morphology and esophageal motility in patients with reflux esophagitis (RE). METHODS: According to Syndrome Differentiation of TCM, 42 RE patients were divided into three groups: Disharmony of Liver and Stomach (D) group, Deficiency-Cold of Spleen and Stomach (DC) group, Heat Syndrome caused by depression of Liver Qi (H) group. No. I, II, III of YQT were taken respectively for 4 weeks. Before and after treatment scores of typical symptoms were collected, gastroscope and esophageal motility were measured. RESULTS: (1) The symptom remission rate was 81.1%, there were significant differences between the group DC with group D and Group H (P < 0.01). (2) The esophageal mucosal healing rate was 61.9%, the effective rate was 90.5%, and the ineffective rate 9.5%. There weren't significant difference of effective rates among the three groups (P < 0.05). (3) The changes of esophageal motility: lower esophageal sphictor pressure (LESP), average peristaltic pressure (APP) of group D were higher (P < 0.05), LESP, gastro-esophageal barrier pressure (GEBP) and peristaltic conduct speed (PCS) of group DC were remarkably higher (P < 0.05), GEBP of group H was improved (P < 0.05). CONCLUSIONS: YQT has a good therapeutical effect, it's not only resolving reflux symptoms, healing esophageal mucosa, but also improving esophageal motile function.