RESUMEN
BACKGROUND: Previous studies have not been able to correlate manometry findings with bolus perception. The aim of this study was to evaluate correlation of different variables, including traditional manometric variables (at diagnostic and extreme thresholds), esophageal shortening, bolus transit, automated impedance manometry (AIM) metrics and mood with bolus passage perception in a large cohort of asymptomatic individuals. METHODS: High resolution manometry (HRM) was performed in healthy individuals from nine centers. Perception was evaluated using a 5-point Likert scale. Anxiety was evaluated using Hospitalized Anxiety and Depression scale (HAD). Subgroup analysis was also performed classifying studies into normal, hypotensive, vigorous, and obstructive patterns. KEY RESULTS: One hundred fifteen studies were analyzed (69 using HRM and 46 using high resolution impedance manometry (HRIM); 3.5% swallows in 9.6% of volunteers were perceived. There was no correlation of any of the traditional HRM variables, esophageal shortening, AIM metrics nor bolus transit with perception scores. There was no HRM variable showing difference in perception when comparing normal vs extreme values (percentile 1 or 99). Anxiety but not depression was correlated with perception. Among hypotensive pattern, anxiety was a strong predictor of variance in perception (R2 up to .70). CONCLUSION AND INFERENCES: Bolus perception is less common than abnormal motility among healthy individuals. Neither esophageal motor function nor bolus dynamics evaluated with several techniques seems to explain differences in bolus perception. Different mechanisms seem to be relevant in different manometric patterns. Anxiety is a significant predictor of bolus perception in the context of hypotensive motility.
Asunto(s)
Ansiedad/psicología , Trastornos de la Motilidad Esofágica/diagnóstico , Manometría/métodos , Percepción , Adolescente , Adulto , Anciano , Esófago , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto JovenRESUMEN
OBJECTIVES: High-resolution manometry (HRM) is the preferred method for the evaluation of motility disorders. Recently, an update of the diagnostic criteria (Chicago 3.0) has been published. The aim of this study was to compare the performance criteria of Chicago version 2.0 (CC2.0) vs. 3.0 (CC3.0) in a cohort of healthy volunteers and symptomatic patients. METHODS: HRM studies of asymptomatic and symptomatic individuals from several centers of Spain and Latin America were analyzed using both CC2.0 and CC3.0. The final diagnosis was grouped into hierarchical categories: obstruction (achalasia and gastro-esophageal junction obstruction), major disorders (distal esophageal spasm, absent peristalsis, and jackhammer), minor disorders (failed frequent peristalsis, weak peristalsis with small or large defects, ineffective esophageal motility, fragmented peristalsis, rapid contractile with normal latency and hypertensive peristalsis) and normal. The results were compared using McNemar's and Kappa tests. RESULTS: HRM was analyzed in 107 healthy volunteers (53.3% female; 18-69 years) and 400 symptomatic patients (58.5% female; 18-90 years). In healthy volunteers, using CC2.0 and CC3.0, obstructive disorders were diagnosed in 7.5% and 5.6%, respectively, major disorders in 1% and 2.8%, respectively, minor disorders in 25.2% and 15%, respectively, and normal in 66.4% and 76.6%, respectively. In symptomatic individuals, using CC2.0 and CC3.0, obstructive disorders were diagnosed in 11% and 11.3%, respectively, major disorders in 14% and 14%, respectively, minor disorders in 33.3% and 24.5%, respectively, and normal in 41.8% and 50.3%, respectively. In both groups of individuals, only an increase in normal and a decrease in minor findings using CC3.0 were statistically significant using McNemar's test. DISCUSSIONS: CC3.0 increases the number of normal studies when compared with CC2.0, essentially at the expense of fewer minor disorders, with no significant differences in major or obstructive disorders. As the relevance of minor disorders is questionable, our data suggest that CC3.0 increases the relevance of abnormal results.
Asunto(s)
Acalasia del Esófago/diagnóstico , Espasmo Esofágico Difuso/diagnóstico , Manometría , Adolescente , Adulto , Anciano , Estudios de Casos y Controles , Acalasia del Esófago/clasificación , Acalasia del Esófago/fisiopatología , Enfermedades del Esófago/clasificación , Enfermedades del Esófago/diagnóstico , Enfermedades del Esófago/fisiopatología , Trastornos de la Motilidad Esofágica/clasificación , Trastornos de la Motilidad Esofágica/diagnóstico , Trastornos de la Motilidad Esofágica/fisiopatología , Espasmo Esofágico Difuso/clasificación , Espasmo Esofágico Difuso/fisiopatología , Unión Esofagogástrica/fisiopatología , Femenino , Voluntarios Sanos , Humanos , América Latina , Masculino , Persona de Mediana Edad , Peristaltismo/fisiología , España , Adulto JovenRESUMEN
BACKGROUND: Multiple water swallow is increasingly used as a complementary challenge test in patients undergoing high-resolution manometry (HRM). Our aim was to establish the range of normal pressure responses during the rapid drink challenge test in a large population of healthy subjects. METHODS: Pressure responses to a rapid drink challenge test (100 or 200 mL of water) were prospectively analyzed in 105 healthy subjects studied in nine different hospitals from different countries. Esophageal motility was assessed in all subjects by solid-state HRM. In 18 subjects, bolus transit was analyzed using concomitant intraluminal impedance monitoring. KEY RESULTS: A virtually complete inhibition of pressure activity was observed during multiple swallow: Esophageal body pressure was above 20 mm Hg during 1 (0-8) % and above 30 mm Hg during 1 (0-5) % of the swallow period, and the pressure gradient across the esophagogastric junction was low (-1 (-7 to 4) mm Hg). At the end of multiple swallow, a postswallow contraction was evidenced in only 50% of subjects, whereas the remaining 50% had non-transmitted contractions. Bolus clearance was completed after 7 (1-30) s after the last swallow, as evidenced by multichannel intraluminal impedance. CONCLUSIONS & INFERENCES: The range of normal pressure responses to a rapid drink challenge test in health has been established in a large multicenter study. Main responses are a virtually complete inhibition of esophageal pressures with a low-pressure gradient across esophagogastric junction. This data would allow the correct differentiation between normal and disease when using this test.
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Deglución , Esófago/fisiología , Motilidad Gastrointestinal , Adolescente , Adulto , Anciano , Ingestión de Líquidos , Impedancia Eléctrica , Femenino , Humanos , Masculino , Manometría , Persona de Mediana Edad , Estudios Prospectivos , Adulto JovenRESUMEN
High-resolution esophageal manometry (HRM) is a recent development used in the evaluation of esophageal function. Our aim was to assess the inter-observer agreement for diagnosis of esophageal motility disorders using this technology. Practitioners registered on the HRM Working Group website were invited to review and classify (i) 147 individual water swallows and (ii) 40 diagnostic studies comprising 10 swallows using a drop-down menu that followed the Chicago Classification system. Data were presented using a standardized format with pressure contours without a summary of HRM metrics. The sequence of swallows was fixed for each user but randomized between users to avoid sequence bias. Participants were blinded to other entries. (i) Individual swallows were assessed by 18 practitioners (13 institutions). Consensus agreement (≤ 2/18 dissenters) was present for most cases of normal peristalsis and achalasia but not for cases of peristaltic dysmotility. (ii) Diagnostic studies were assessed by 36 practitioners (28 institutions). Overall inter-observer agreement was 'moderate' (kappa 0.51) being 'substantial' (kappa > 0.7) for achalasia type I/II and no lower than 'fair-moderate' (kappa >0.34) for any diagnosis. Overall agreement was somewhat higher among those that had performed >400 studies (n = 9; kappa 0.55) and 'substantial' among experts involved in development of the Chicago Classification system (n = 4; kappa 0.66). This prospective, randomized, and blinded study reports an acceptable level of inter-observer agreement for HRM diagnoses across the full spectrum of esophageal motility disorders for a large group of clinicians working in a range of medical institutions. Suboptimal agreement for diagnosis of peristaltic motility disorders highlights contribution of objective HRM metrics.
Asunto(s)
Trastornos de la Motilidad Esofágica/diagnóstico , Interpretación de Imagen Asistida por Computador/normas , Manometría/normas , Adulto , Consenso , Deglución/fisiología , Acalasia del Esófago/clasificación , Acalasia del Esófago/diagnóstico , Trastornos de la Motilidad Esofágica/clasificación , Esófago/fisiopatología , Humanos , Interpretación de Imagen Asistida por Computador/métodos , Manometría/métodos , Variaciones Dependientes del Observador , Peristaltismo/fisiología , Estudios Prospectivos , Método Simple CiegoRESUMEN
AIM: Upper oesophageal pH monitoring may play a significant role in the study of extra-oesophageal GERD, but limited normal data are available to date. Our aim was to develop a large series of normal values of proximal oesophageal acidification. METHODS: 155 healthy volunteers (74 male) participated in a multi-centre national study including oesophageal manometry and 24 hours oesophageal pH monitoring using two electrodes individually located 5 cm above the LOS and 3 cm below the UOS. RESULTS: 130 participants with normal manometry completed all the study. Twelve of them were excluded for inadequate pH tests. Twenty-seven subjects had abnormal conventional pH. The remaining 91 subjects (37 M; 18-72 yrs age range) formed the reference group for normality. At the level of the upper oesophagus, the 95th percentile of the total number of reflux events was 30, after eliminating the meal periods 22, and after eliminating also the pseudo-reflux events 18. Duration of the longest episodes was 5, 4 and 4 min, respectively (3.5 min in upright and 0.5 min in supine). The upper limit for the percentage of acid exposure time was 1.35, 1.05 and 0.95%, respectively. No reflux events were recorded in the upper oesophagus in 8 cases. CONCLUSION: This is the largest series of normal values of proximal oesophageal reflux that confirm the existence of acid reflux at that level in healthy subjects, in small quantity and unrelated to age or gender. Our data support the convenience of excluding pseudo-reflux events and meal periods from analysis.
Asunto(s)
Atención Ambulatoria , Monitorización del pH Esofágico , Adolescente , Adulto , Anciano , Femenino , Reflujo Gastroesofágico/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Valores de Referencia , España , Adulto JovenAsunto(s)
Humanos , Reflujo Gastroesofágico/diagnóstico , Enfermedades del Esófago/diagnóstico , Esófago/citología , Esófago/fisiología , Esófago/ultraestructura , Manometría/métodos , Manometría , Enfermedades Respiratorias/complicaciones , Enfermedades Respiratorias/diagnóstico , Manometría/tendenciasRESUMEN
AIM: A Spanish Consensus Conference had been arranged by the Spanish Club for the Study of Helicobacter pylori to encourage the use of eradication regimens in appropriate indications. The aim of our study was to assess whether the publication of these recommendations in November 1999 induced a change on the indications of eradication in the referring primary care district. METHOD: Patients who had undergone Helicobacter pylori eradication therapy indicated by a gastroenterologist and referred to perform the 13C-labelled marked urea breath test were evaluated. Indications of eradication therapy were analysed and divided in: a) use of Conference recommended procedures (duodenal or gastric ulcer, erosive duodenitis, gastric MALT lymphoma and after resection of gastric adenocarcinoma); and b) other procedures not included in the recommendations (the rest). Indications established during former and latter years of publication of the Club's recommendations were compared. RESULTS: A total of 659 established eradications in 1999 against 537 in 2000, were studied. Regarding established eradications in 1999, 418 out of 659 (63%) followed the recommendations made by the Spanish Club, while 241 (37%) did not. In 2000, the proportion of eradication therapy administered using the recommendations made by the Spanish Club was similar to previous year: 338 (63%) followed the recommendations, against 199 (37%) that did not (p = not significant). In both years, considering those indications not recommended, patients either with superficial chronic gastritis with or without dyspepsia or with gastrooesophageal reflux disease were the main disorders to indicate eradication therapy. CONCLUSIONS: The recommendations of the Spanish Helicobacter pylori Study Club have not triggered a significant change after their publication on the indications for Helicobacter pylori eradication therapy in the setting studied.
Asunto(s)
Infecciones por Helicobacter/prevención & control , Helicobacter pylori , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Presentamos una paciente con disfagia en la que se realizó un seguimiento clínico y manométrico. Inicialmente se observó un trastorno motor sugerente de espasmo difuso; en controles manométricos posteriores se observó progresión a achalasia vigorosa. La paciente fue tratada con dilatación neumática, obteniéndose una buena respuesta. En manometrías realizadas después del tratamiento se objetivo una recuperación de la peristalsis en cuerpo esofágico distal. El tratamiento precoz y la corta evolución de la enfermedad pueden facilitar la recuperación de la peristalsis en estos casos. Dicha recuperación plantea nuevas dudas acerca de la etiología de la achalasia (AU)
Asunto(s)
Adulto , Femenino , Humanos , Resultado del Tratamiento , Peristaltismo , Trastornos de Deglución , Dilatación , Manometría , Esófago , Acalasia del Esófago , Trastornos de DegluciónRESUMEN
Objetivo: el Club Español para el Estudio del Helicobacter pylori (CEHP) decidió organizar una Conferencia Española de Consenso que, entre otros objetivos fomentara el empleo de tratamientos erradicadores en indicaciones adecuadas. El objetivo de nuestro estudio fue valorar si la publicación de dichas recomendaciones en noviembre de 1999 induce un cambio en las indicaciones de erradicación en el área 7 de salud de Madrid. Método: se valoran los pacientes que han seguido un tratamiento erradicador del Helicobacter pylori, indicado por un especialista en Aparato Digestivo, y remitidos para realizar un test de aliento. Se analizan las indicaciones del tratamiento erradicador y se dividen en: a) recomendadas por la Conferencia (úlcera duodenal o gástrica, duodenitis erosiva, linfoma MALT gástrico y adenocarcinoma gástrico tratado con resección); y b) no recomendadas (el resto). Se comparan las indicaciones formuladas en el año anterior con las del año posterior a la publicación de las recomendaciones del Club. Resultados: se han comparado un total de 659 erradicaciones establecidas en 1999, frente a 537 en el año 2000. De las indicaciones establecidas en 1999, 418 (63 por ciento) seguían las recomendaciones del CEHP mientras que 241 (37 por ciento) no las seguían. En el 2000 la proporción de indicaciones de erradicación que seguían las recomendaciones del CEHP fue similar a la del año anterior: 338 (63 por ciento) se adherían a las recomendaciones del CEHP, mientras que 199 (37 por ciento) no las seguían (p= no significativo). En ambos años, y siempre dentro de las indicaciones no recomendadas, la mayoría de erradicaciones se formulan por gastritis crónica superficial con o sin dispepsia o por enfermedad por reflujo gastroesofágico. Conclusión: las recomendaciones del CEHP no han inducido en el año subsiguiente a su publicación un cambio significativo en las indicaciones de erradicación del Helicobacter pylori en nuestro medio (AU)
Asunto(s)
Persona de Mediana Edad , Niño , Adolescente , Adulto , Anciano de 80 o más Años , Anciano , Masculino , Femenino , Humanos , Helicobacter pylori , Infecciones por Helicobacter , Infecciones por HelicobacterRESUMEN
We report the case of a patient with dysphagia in whom a clinical and manometric follow-up was carried out. We initially observed a motor disorder of the esophageal spasm type. During manometric follow-up a progression to vigorous achalasia was observed. The patient was treated with pneumatic dilation, which obtained a good response to treatment. In manometries performed after treatment we observed a return of peristalsis in the distal esophageal body. Early treatment and short evolution of disease may allow peristalsis to recover in these cases. Peristalsis recovery casts new doubts on achalasia etiology.
Asunto(s)
Dilatación/métodos , Acalasia del Esófago/fisiopatología , Esófago/fisiopatología , Adulto , Trastornos de Deglución/etiología , Acalasia del Esófago/terapia , Femenino , Humanos , Manometría , Peristaltismo/fisiología , Resultado del TratamientoRESUMEN
Hemochromatosis is a disorder of parenchymal iron overload. The diagnosis is based upon clinical manifestations, laboratory findings and iron concentration in liver. Magnetic resonance imaging (MRI) shows a decrease in liver signal intensity. Its role has not been already defined. Nonetheless, ratio of liver to muscle proton density (LMPD) shows a significant correlation with hepatic iron. One patient with a long-standing cirrhosis with data of hemochromatosis whose coagulation study did not allow to perform a liver biopsy was diagnosed with this method. Hepatic iron concentration was calculated based upon: microgram/g of hepatic iron = (-5.174* LMPD) + 9.932. MRI can be useful in the evaluation of hemochromatosis among patients who refuse or have contraindication to liver biopsy.
Asunto(s)
Hemocromatosis/diagnóstico , Hepatopatías/diagnóstico , Imagen por Resonancia Magnética , Anciano , Humanos , MasculinoRESUMEN
Achalasia is a motor disorder of the esophagus resulting in functional obstruction. The cause of the lesion is unknown although genetic and immunologic factors have been suggested. An association with serological HLA epitopes has been previously reported. In this study, we have further examined this HLA class II association with susceptibility to achalasia by DNA based methods. Achalasia patients (n=40) and healthy controls (n=275), all Caucasians and unrelated, were included in the analysis. The strongest associations were with HLA-DQA1*0101 and two HLA-DQ alphabeta heterodimers having their alpha chain encoded by this allele. Moreover, relative risk was significantly higher in DQA1*0101 homozygotes as compared to heterozygotes and results suggested that DQB1*02 may have a protective role.
Asunto(s)
Acalasia del Esófago/genética , Genes MHC Clase II/genética , Predisposición Genética a la Enfermedad/genética , Alelos , Dimerización , Acalasia del Esófago/epidemiología , Frecuencia de los Genes , Antígenos HLA-DQ/genética , Cadenas alfa de HLA-DQ , Cadenas beta de HLA-DQ , Antígenos HLA-DR/genética , Haplotipos , Heterocigoto , Homocigoto , Humanos , España/epidemiologíaRESUMEN
OBJECTIVE: To define the relationship between esophageal dysmotility and severity of gastroesophageal reflux (GER) at the distal and proximal levels. METHODS: Two-level, 24-hour ambulatory pH monitoring and manometry of the esophagus were performed in 40 patients with abnormal distal acid exposure and in 20 healthy controls. Twenty patients with normal endoscopy or endoscopic evidence of grade I esophagitis were assigned to group 1 and 20 with grade II-III esophagitis were assigned to group 2. We used a dual-site pH probe with antimony electrodes spaced 15 cm apart. RESULTS: Patients had greater acid exposure than controls at both levels. The percentage of distal reflux episodes reaching proximal esophagus was significantly greater in group 1 than in the control group. The most marked reductions in the percentage of time of the pH remaining under 4 were detected in the patients with the most severe distal acid reflux and esophagitis (group 2). The mean lower esophageal sphincter pressure was significantly lower in group 2 than in group 1. The percentage of tertiary waves or nonperistaltic contractions was significantly higher in group 2 than in group 1 and the control group. Patients with milder distal reflux had significantly lower distal and middle esophageal wave amplitudes than controls. There were no significant differences between controls and patients with severe esophagitis in terms of the esophageal peristaltic wave amplitude in the middle third of the esophagus. CONCLUSIONS: No correlation was observed between episodes of distal reflux and proximal reflux in GER patients. Esophageal motor activity appears to be an important determinant of the severity and extension of GER in the proximal esophagus.
Asunto(s)
Trastornos de la Motilidad Esofágica/fisiopatología , Esofagitis/fisiopatología , Esófago/fisiología , Adolescente , Adulto , Anciano , Femenino , Reflujo Gastroesofágico/fisiopatología , Humanos , Concentración de Iones de Hidrógeno , Masculino , Manometría , Persona de Mediana Edad , Monitoreo AmbulatorioRESUMEN
Simultaneous ambulatory esophageal pH monitoring was performed in 10 patients (group 1) with normal distal acid exposure and in 40 patients (group 2) with pathological distal reflux. The probes were placed 5 and 10 cm above the lower esophageal sphincter to quantify variations of pH values that can be due to a displacement of pH sensor. In group 1 the median percent time with pH < 4 for total and upright monitoring periods and composite score were significantly lower at the proximal than the distal level. In group 2 all pH data were significantly lower at the proximal than the distal level. The patients with pathological reflux were subdivided into two subgroups based on endoscopic findings (mild and severe esophagitis). The patients with severe esophagitis showed a proximal acid reduction higher than in patients with mild esophagitis. Nine patients with mild esophagitis showed normal values at 10 cm, but all patients with severe esophagitis had abnormal proximal acid exposure.
Asunto(s)
Esofagitis Péptica/fisiopatología , Esófago/fisiopatología , Monitoreo Fisiológico/métodos , Adolescente , Adulto , Anciano , Electrodos , Unión Esofagogástrica/fisiopatología , Femenino , Humanos , Concentración de Iones de Hidrógeno , Masculino , Persona de Mediana EdadRESUMEN
Two-level pH monitoring was performed for 24 hours in 20 healthy subjects to document the presence of reflux episodes and to obtain reference values for reflux studies. The pH probes were placed 5 and 20 centimetres above the LES by means of a manometric technique. Significant differences were found at these two levels. At the proximal esophageal level 18 of the 20 subjects had reflux episodes. Five centrimetres above the lower esphageal sphincter the total reflux time was 1.35%, 2.05% in the upright and 0.15% in the supine positions. At 20 centimetres level it was significantly lower: 0.5% the total percent time with pH below 4, 0.8% and 0% in the upright and supine positions respectively. The mean reflux time was about 40% of the distal value, but the same pattern of reflux was observed at two levels of the esophagus. This technique is useful in documenting the cephalad extend of GER and allows to identify normal GER patterns at different levels of the esophagus.
Asunto(s)
Esófago/fisiología , Adolescente , Adulto , Anciano , Femenino , Reflujo Gastroesofágico , Humanos , Concentración de Iones de Hidrógeno , Masculino , Persona de Mediana Edad , Valores de Referencia , Factores de TiempoRESUMEN
We present 4 cases of common variable immunodeficiency with main digestive clinical manifestations. In all four cases chronic diarrhea with intestinal malabsorption predominated, as well as the presence lymphoid nodular hyperplasia; in one case Giardia infestation could be identified; one patient also presented chronic pancreatitis, or recurrent aphthous stomatitis and active chronic hepatitis; sideroblastic anemia could be observed in another patient. All patients had favorable evolution during follow-up which lasted at least 14 months in substitutive treatment with immunoglobulins. One of our patients presented an elevated number of suppressor T lymphocytes, with inversion of the T helper/T suppressor ratio which improved with cimetidine treatment.