A Questionnaire Study to Assess Long-Term Outcome in Patients with Abnormal Esophageal Manometry

Abstract

Patients with unexplained chest pain or dysphagia are often referred for esophageal manometric studies to further investigate their symptoms. Four main manometric abnormalities have been described: achalasia, diffuse esophageal spasm, "nutcracker" (hypercontracting) esophagus, and hypocontracting esophagus. With the exception of achalasia, treatments are of limited benefit and the natural history of these conditions is largely unknown. We sent questionnaires to patients who were investigated at least three years before our study began. They repeated a DeMeester symptom questionnaire that they had completed at the time of their initial study. Questionnaires were sent to 137 patients with diffuse esophageal spasm, "nutcracker" (hypercontracting) esophagus, or hypocontracting esophagus. We also sent questionnaires to 57 patients with dysphagia or chest pain who had had normal esophageal manometry and pH studies. These patients acted as symptomatic controls. Responses were compared using the Wilcoxon signed ranks test. Seventy-two (53%) patients with diffuse esophageal spasm, "nutcracker" esophagus, or hypocontracting esophagus replied. An additional 8 (6%) patients died. Symptom scores in all three conditions had improved significantly over time (p < or = 0.01 for each condition, Wilcoxon signed ranks test). Patients with dysphagia or chest pain but normal esophageal studies had not improved. The significance of diffuse esophageal spasm, "nutcracker" esophagus, and hypocontracting esophagus found at esophageal manometry remains uncertain. Although treatment is often ineffective, these conditions typically run a benign course. Patients can be reassured that their symptoms are likely to improve with time.

Do Jackhammer contractions lead to achalasia? A longitudinal study

“…No demographic predictors were identified in this study; however, dysphagia as the presenting symptom was found to be associated with higher likelihood of developing achalasia . Another study showed symptomatic improvement without intervention in patients with either DES or hypertensive peristalsis . These findings suggest that these motility disorders vary temporally in their presentation, adding to the difficulty of their categorization and characterization.…”

“…A recent review surmises that JE is more likely an excessively excitatory and therefore contractile state, whereas other spastic disorders, namely type III achalasia and DES, appear to be secondary to loss of inhibitory signals . Previous studies on type III achalasia and DES have investigated their natural course and found that DES infrequently evolves into type III achalasia, and more often resolves manometrically and symptomatically . Because of a presumably different underlying etiology, no extrapolation of these previous studies could apply to JE.…”

The favourable effect of Helicobacter pylori eradication therapy in patients with recurrent angina-like chest pain and non-responsive to proton pump inhibitors – a preliminary study

“…Secondly, the recommendation of Hp-eradication therapy might have a psychological effect. The psychological aspect of chest pain recurrence has been underlined in a number of papers, concerning not only individuals with NCCP and a normal coronary angiogram, but also patients with CAD [8, 9, 35, 36]. Among the Polish population in general, Hp infection is recognized as a common cause of a number of symptoms, probably due to the high overall infection rate, which amounts to 73%, and in subjects over 25 years of age to 85-95% [37].…”

Recent developments in esophageal motor disorders

“…Therefore this finding is not specific or sensitive in diagnosing intermittently occurring esophageal spasm. To what extent DES is simply a manometric finding or is indeed clinically relevant is debated, as half of patients with manometric criteria of DES have normal bolus transit [13 ] and symptom scores often improve significantly over time [40]. If symptoms persist, however, and treatment is required, proton pump inhibitors are the treatment of choice, especially as DES may result from gastroesophageal reflux.…”