Genesis of Esophageal Pressurization and Bolus Flow Patterns in Patients With Achalasia Esophagus

Park, Su Bum; Zifan, Ali; Kumar, Dushyant; Mittal, Ravinder K.

doi:10.1053/j.gastro.2018.04.033

Cited by 26 publications

(35 citation statements)

References 28 publications

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“…In type 3 achalasia, the circular and longitudinal muscle contraction lack co-ordination. Luminal crosssectional area is largest in type 1 and smallest in type 3, which is in accordance with the finding that the esophageal wall is thinnest in type 1 and thickest in type 3 achalasia [76]. Finally, prolonged longitudinal muscle contraction is hypothesized to be responsible for the chest pain and heartburn sensation reported in achalasia patients due to the impact of that contraction on esophageal wall blood perfusion [77] while dysphagia may be related to varying bolus flow patterns [76].…”

Section: Achalasiasupporting

confidence: 81%

Neuronal Control of Esophageal Peristalsis and Its Role in Esophageal Disease

Nikaki¹,

Sawada²,

Ustaoglu³

et al. 2019

Curr Gastroenterol Rep

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Purpose of Review Esophageal peristalsis is a highly sophisticated function that involves the coordinated contraction and relaxation of striated and smooth muscles in a cephalocaudal fashion, under the control of central and peripheral neuronal mechanisms and a number of neurotransmitters. Esophageal peristalsis is determined by the balance of the intrinsic excitatory cholinergic, inhibitory nitrergic and post-inhibitory rebound excitatory output to the esophageal musculature. Recent Findings Dissociation of the longitudinal and circular muscle contractions characterizes different major esophageal disorders and leads to esophageal symptoms. Provocative testing during esophageal high-resolution manometry is commonly employed to assess esophageal body peristaltic reserve and underpin clinical diagnosis. Summary Herein, we summarize the main factors that determine esophageal peristalsis and examine their role in major and minor esophageal motility disorders and eosinophilic esophagitis.

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Section: Achalasiasupporting

confidence: 81%

Neuronal Control of Esophageal Peristalsis and Its Role in Esophageal Disease

Nikaki¹,

Sawada²,

Ustaoglu³

et al. 2019

Curr Gastroenterol Rep

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“…Although absent peristalsis is a defining manometric feature of achalasia, we also previously demonstrated that esophageal contractility can be observed in patients with achalasia during evaluation with FLIP panometry . Presence of non‐occluding esophageal contractions in achalasia was also observed using high‐frequency, intra‐luminal ultrasound and these contractions were associated with the pan‐esophageal pressurization of the type II achalasia subtype . Although antegrade contractions can be seen in achalasia, patients with achalasia tend to have a chaotic pattern consisting of sporadic focal contractions and retrograde propagation.…”

Section: Introductionmentioning

confidence: 68%

The rhythm and rate of distension‐induced esophageal contractility: A physiomarker of esophageal function

Carlson

Kou

Pandolfino

2020

Neurogastroenterology Motil

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Background Distention of the esophagus elicits a unique pattern of repetitive contractions in healthy controls. We aimed to assess the rhythm and rate of distension‐induced contractile patterns between achalasia and controls and identify factors that distinguish the normal contractile response to distension. Methods Twenty asymptomatic controls and 140 adult patients with treatment‐naïve achalasia defined by HRM (29 type I, 81 type II, 30 type III) were prospectively evaluated with functional luminal imaging probe (FLIP) during sedated endoscopy. 16‐cm FLIP balloons were positioned within the distal esophagus during stepwise balloon distension. Functional luminal imaging probe panometry studies were retrospectively analyzed using a customized program. Key results All controls had contractility in a repetitive antegrade contraction (RAC) pattern with a rate of mean (10‐90th) 6 (4‐8) contractions per minute. 19/20 controls had > 6 consecutive antegrade contractions (ACs), that is, duration > 6 ACs, >6 cm in length, at a rate of 6 ± 3 contractions per minute (met the “Rule‐of‐6s”). 50 achalasia patients had repetitive contractions that occurred at a rates of 11 (7 ‐ 15) ACs per minute; P < .001 compared with controls, or 12 (8‐15) repetitive retrograde contractions per minute. Only 1/140 achalasia patients had a contractile response that met the “Rule‐of‐6s.” Conclusion The normal contractile response to sustained distention is associated with > 6 RACs with a consistent rate of 6 ± 3 per minute, which was exceptionally rare in achalasia. These findings support that the RAC pattern is disrupted in achalasia and the faster rate may be a manifestation of abnormal inhibition and/or a reduced refractory period.

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“…In the absence of structural processes, motility disorders associated with abnormal inhibition involving the LES manifest esophageal outflow obstruction and are defined on the basis of elevated IRP . We used type 3 achalasia as a control group for this pathophysiologic phenotype, where there is abnormal inhibition involving not just the LES but also the smooth muscle esophageal body resulting in simultaneous or premature contractions . We acknowledge that distal esophageal spasm would have been another useful comparison group; however, this disorder is extremely rare, and adequate patient numbers with distal esophageal spasm could not be identified during the study period.…”

Section: Discussionmentioning

confidence: 99%

“…The primary aim of this study was to compare clinical and motility features in jackhammer esophagus with and without EGJ obstruction, using standard HRM as well as provocative testing with MRS. We hypothesized that a common clinical and pathophysiologic thread could exist between jackhammer esophagus and jackhammer esophagus with EGJ obstruction, similar to that seen in type 3 achalasia. A cohort of type 3 achalasia patients was therefore used as a comparison cohort, where abnormal inhibition results in premature or simultaneous contractility and abnormal LES relaxation . A secondary aim was to correlate pathophysiologic mechanisms with presenting symptoms.…”

Section: Introductionmentioning

confidence: 99%

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Jackhammer esophagus with and without esophagogastric junction outflow obstruction demonstrates altered neural control resembling type 3 achalasia

Quader

Mauro

Savarino

et al. 2019

Neurogastroenterology Motil

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Background Esophageal hypercontractility can manifest with and without esophagogastric junction (EGJ) outflow obstruction. We investigated clinical presentations and motility patterns in patients with esophageal hypercontractile disorders. Methods Esophageal HRM studies fulfilling Chicago Classification 3.0 criteria for jackhammer esophagus (distal contractile integral, DCI >8000 mmHg.cm.s in ≥ 20% swallows) with (n = 30) and without (n = 83) EGJ obstruction (integrated relaxation pressure, IRP > 15 mm Hg) were retrospectively reviewed from five centers (4 in Europe, 1 in US). Single swallows (SS) and multiple rapid swallows (MRS) were analyzed using HRM software tools (IRP, DCI, distal latency, DL); MRS: SS DCI ratio >1 defined contraction reserve. Comparison groups were achalasia type 3 (n = 72, positive control for abnormal inhibition and EGJ obstruction) and healthy controls (n = 18). Symptoms, HRM metrics, and MRS contraction reserve were analyzed within jackhammer subgroups and comparison groups. Key Results The esophageal smooth muscle was excessively stimulated at baseline in jackhammer subgroups, with lack of augmentation following MRS identified more often compared with controls (P = .003) and type 3 achalasia (P = .07). Consistently abnormal inhibition was identified in type 3 achalasia (47%), and to a lower extent in jackhammer with obstruction (37%, P = .33), jackhammer esophagus (28%, P = .01), and controls (11%, P < .01 compared with type 3 achalasia). Perceptive symptoms (heartburn, chest pain) were common in jackhammer esophagus (P < .01 compared with type 3 achalasia), while transit symptoms (dysphagia) were more frequent with presence of EGJ obstruction (P ≤ .01 compared with jackhammer without obstruction). Conclusions and inferences The balance of excessive excitation and abnormal inhibition defines clinical and manometric manifestations in esophageal hypercontractile disorders.

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Genesis of Esophageal Pressurization and Bolus Flow Patterns in Patients With Achalasia Esophagus

Abstract: We observed distinct mechanisms of esophageal pressurization and bolus flow patterns in patients with type 2 or type 3 achalasia esophagus compared with control individuals. These findings will increase our understanding of the mechanisms of dysphagia.

Cited by 26 publications

References 28 publications

Neuronal Control of Esophageal Peristalsis and Its Role in Esophageal Disease

Neuronal Control of Esophageal Peristalsis and Its Role in Esophageal Disease

The rhythm and rate of distension‐induced esophageal contractility: A physiomarker of esophageal function

Jackhammer esophagus with and without esophagogastric junction outflow obstruction demonstrates altered neural control resembling type 3 achalasia

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