Physiology of the oesophageal transition zone in the presence of chronic bolus retention: studies using concurrent high resolution manometry and digital fluoroscopy

Abstract

Distinct contraction waves (CWs) exist above and below the transition zone (TZ) between the striated and smooth muscle oesophagus. We hypothesize that bolus transport is impaired in patients with abnormal spatio-temporal coordination and/or contractile pressure in the TZ. Concurrent high resolution manometry and digital fluoroscopy were performed in healthy subjects and patients with reflux oesophagitis; a condition associated with ineffective oesophageal contractility and clearance. A detailed analysis of space-time variations in bolus movement, intra-bolus and intra-luminal pressure was performed on 17 normal studies and nine studies in oesophagitis patients with impaired bolus transit using an interactive computer based system. Compared with normal controls, oesophagitis patients had greater spatial separation between the upper and lower CW tails [median 5.2 cm (range 4.4-5.6) vs 3.1 cm (2.2-3.7)], the average relative pressure within the TZ region (TZ strength) was lower [30.8 mmHg (28.3-36.5) vs 45.8 mmHg (36.1-55.7), P < 0.001], and the risk of bolus retention was higher (90%vs 12%; P < 0.01). The presence of bolus retention was associated with a wider spatial separation of the upper and lower CWs (>3 cm, the upper limit of normal; P < 0.002), independent of the presence of oesophagitis. We conclude that bolus retention in the TZ is associated with excessively wide spatial separation between the upper and lower CWs and lower TZ muscle squeeze. These findings provide a physio-mechanical basis for the occurrence of bolus retention at the level of the aortic arch, and may underlie impaired clearance with reflux oesophagitis.

Combined pH-impedance monitoring and high-resolution manometry of Japanese patients treated with proton-pump inhibitors for persistent symptoms of non-erosive reflux disease

“…The transition between them is identified as the transition zone where the proximal contraction wave originating in the striated esophagus terminates and below which a distal contraction wave simultaneously forms and propagates into the distal smooth muscle esophagus (Ghosh et al, 2006). Ghosh et al (2008) reported that weak mid esophageal contractions at the proximal smooth-muscle segment appear to be the cause of impaired clearance function. Martinek et al (2008) reported no difference between NERD and mild to moderate erosive esophagitis in terms of motor abnormalities.…”

High-resolution Esophageal Manometry: Using Technical Advances for Clinical Advantages

“…However, HRM has been used to characterize this region, and parameters such as the proximal contractile integral (PCI, by analogy with the DCI) can now quantify the profile of this area. 26 Although an isolated defect in this region is a rare cause of dysphagia, it may represent a distinct motility disorder.…”

Dysphagie

“…[4,5]. Die hochauflösende Manometrie ermöglicht in einer kontinuierlichen Darstellung der Druckmesswerte ("spatiotemporal plot") eine objektive Darstellung der physikalischen Druckgradienten für einen Bolustransport vom Pharynx in den Magen (.…”