T1233
Non-Acid Reflux As Well As Acid Reflux Plays a Major Role in Eliciting
Noncardiac Chest Pain
Beom Jin Kim,Poong-Lyul Rhee,Jeong Hwan Kim,Hee Jung Son,Jae J.Kim,Jong Chul
Rhee
Background:Combined esophageal impedance-pH monitoring allows detection of acid as
well as non-acid reflux.However,the role of non-acid reflux in the pathogenesis of noncardiac
chest pain(NCCP)is poorly known.We aimed to detect and characterize NCCP using combined impedance-pH monitoring.Methods:Seventy-five concutive patients with NCCP
were prospectively enrolled and underwent upper endoscopy,esophageal manometry,and
24hour Multichannel Intraluminal Impedance(MII)-pH metry from January2006to October 2008.Results:Forty ven(62.6%)patients complained typical esophageal symptoms(hear-
burn,acid regurgitation).Sixteen patients(21.3%)had reflux esophagitis.Thirty ven patients had esophageal dysmotility:The patients were classified into two groups according
to gastroesophageal reflux dia(GERD):GERD-related NCCP group and non GERD-related NCCP group.Nineteen patients(25.3%)proved to have GERD-related NCCP on
pH metry.On the contrary,thirty patients(40%)had GERD-related NCCP on impedance
test.Especially,non-acid reflux was responsible for NCCP in eight of them(10.7%).There
was no difference in age,x,typical esophageal symptoms,respon to proton pump inhibitor,and esophageal dysmotility between two groups.When the patients with GERD-related NCCP were subdivided into two groups according to acid reflux,22patients were included in acid reflux-related NCCP group and8in non-acid reflux-related NCCP group.
There was no difference in age,x,typical esophageal symptoms,respon to proton
pump inhibitor,and esophageal dysmotility between two groups.On the bolus exposure
in impedance test,non-acid percent time and all reflux percent time of non-acid reflux-related NCCP group were significantly higher than tho of acid reflux-related NCCP group.
When the patients were classified into two groups according to the typical esophageal symptoms,41patients were included in NCCP with typical esophageal symptom and34
in NCCP without typical esophageal symptom.There was no difference in age,x,typical esophageal symptoms,respon to proton pump inhibitor,and esophageal dysmotility between two groups.On the postprandial bolus exposure in impedance test,non-acid percent
柠檬下火吗
time and all reflux percent time of patients with NCCP without typical esophageal symptom
were significantly higher than tho of patients with NCCP with typical esophageal symptom. Conclusion:Combining impedance and pH monitoring improves the detection and character-
深深深几许ization of NCCP.This study suggests that non-acid reflux as well as acid reflux plays a
major role in eliciting NCCP.
T1234
High Resolution Manometry with Large Volume Multiple Rapid Swallows
AIDS the Detection of Esophageal Pathology
Rami Sweis,Terry Wong,Angela Anggiansah,Mark R.Fox
Introduction:Conventional manometry does not provide a diagnosis in many patients becau,in part,it fails to predict effective bolus transport.High resolution manometry (HRM)measures contractile activity,intra-bolus pressure(IBP)and IBP gradient that drives
bolus transport.In the pharynx,the position of maximum IBP gradient following10ml swallows identifies pathology causing resistance to flow.The same principle can be applied
to identify pathology of the esophagus and lower esophageal sphincter(LES),although larger volumes are required Aims:This study assd whether HRM measurements during200ml multiple rapid swallows(MRS)can localize and quantify pathology causing resistance to
flow through the esophageal body and LES.Method:151concutive patients undergoing
HRM for investigation of esophageal symptoms were studied.Measurements for10x10ml
water and5x1cc bread swallows as well as200ml MRS were obtained.Peristaltic contractile pressure,baline and nadir LES pressure,IBP and IBP gradient were recorded.Symptom events were recorded.Results were compared in patients with different symptoms and diagnos(reflux conf
irmed on pH studies).Results:125provided complete data for analysis.
Final diagnos were reflux dia(10),normal(23),hypertensive peristalsis(10),diffu esophageal spasm(DES,20),achalasia(25)and structural pathology(pharynx3and lower esophageal8).Failed swallows(p<0.001)and spasm(p<0.01)were more frequent for solids. Contractile pressure,IBP,IBP gradient and LES residual pressure were higher for solids(all
p<0.01).During200ml MRS contractile activity was suppresd and on completion a power-
ful peristaltic contraction(or spasm in DES)was often obrved.LES residual pressure was
lower for MRS than10ml swallows(p<0.01),greater relaxation was obrved also in achalasia. Although IBP and IBP gradient decread more during MRS than10ml swallows(p<0.001),
both incread in achalasia(p<0.001)and tho with structural LES pathology.Average IBP gradient during MRS incread from reflux,normal,hypertensive peristalsis,DES and achala-
sia(1,4,10,18,35mmHg respectively).Dysphagia and belching were more likely during
MRS(p<0.01),especially when IBP>25mmHg(p<0.01).Conclusion:MRS highlights func-
tional and structural pathology that impair bolus transport by increasing IBP above and IBP gradient across the lesion.The association of IBP gradient with diagnosis indicates that MRS
can quantify the verity of esophageal dia.By reflecting normal drinking behavior,MRS
may provide insights into manometric findings and relevant information concerning the
cau of symptoms
T1235
Factors Associated with Esophageal Involvement in Systemic Sclerosis
Sabine Roman,Arnaud Hot,Jacques Ninet,Francois Mion
Background and aims:Esophageal involvement occurs in about80%of patients with systemic sclerosis,with a marked diminution of peristaltic pressures in the distal two-thirds of the esophagus and hypotension of the lower esophageal sphincter(LES).Our aims were to determine if esophageal involvement in systemic sclerosis was associated with other organ involvement and with a particular autoantibody profile.Patients and Methods:Forty patients
张奕轩
(35females,mean age52years,range21-76)with systemic sclerosis were included in this prospective study.Esophageal motility was characterized using high resolution manometry
A-528 AGA Abstracts (HRM)(Sierra Scientific Instruments Inc.,Los Angeles,CA).Esophageal aperistaltis was defined as an abnce of esophageal waves in the2distal thirds of the esophagus and hypoperistaltism as30%or more of distal esophageal waves with a≥2-cm defect in the 30-mmHg isobaric contour.The demographic data,duration of the dia,prence of other organ involvement and autoantibody profile(Antinuclear antibodies(ANA),anti-Scl70 antibody(Scl70),anticentromere antibodies(ACA))were recorded for all patients.Chi square test was ud to compare the association between the criteria and esophageal involvement. Results:Thirty two patients(80%)had a decread eso-gastric junction(EGJ)pressure(<10 mmHg).Esophageal body dysmotility was prent in31patients(77.5%)(aperistaltis in 17,hypoperistaltism in14).Only2patients had normal EGJ pressure and esophageal body motility.Esophageal body dysmotility was more frequent in patients older than50years (22/24patients(92%)vs9/16patients younger than50years(56%),p<0.01).Esophageal body dysmotility was prent in all13patients with a diffu skin involvement(all with positive Scl70)and in66%of the27others(all with negative Scl70)(p=0.02).No significant association was obrved between esophageal body dysmotility and other organ involvement (lung,heart).ACA were
positive in52%of patients with esophageal body dysmotility and in88%of patients without esophageal involvement(p=0.03).The ANA were positive in 92.5%of patients without significant association with esophageal body dysmotility.No predictive factors of hypotensive EGJ occurrence alone or associated with esophageal body dysmotility were obrved in this ries.Conclusion:This HRM ries confirms the high prevalence of EGJ hypotension and esophageal body dysmotility in systemic sclerosis.Eso-phageal body dysmotility is associated with age and diffu skin involvement,and with positive Scl70and negative ACA antibodies.
T1236
Apple Sauce Improves the Detection of Abnormal Esophageal Motor Function During High Resolution Manometry Evaluation of Dysphagia
Benjamin Basri,Omid Shaye,Mark Pimentel,Edy E.Soffer,Jeffrey L.Conklin Traditional esophageal manometry utilizes water swallows to evaluate esophageal motor abnormalities in patients with dysphagia,chest pain,or reflux symptoms.Although eso-phageal manometry is the gold standard for the evaluation of the symptoms,patients with dysphagia often have relatively normal manometry studies.The advent of high-resolution esophageal manometry(HRM)allows a more detailed spacio-te
老师的眼睛
mporal evaluation of eso-phageal motor function.Aim:To test the hypothesis that challenging the esophagus with viscous bolus uncovers motor abnormalities in patients with dysphagia.Methods:36 channel solid-state HRM was performed using10traditional water swallows followed by 10viscous apple sauce swallows in concutive subjects prenting with dysphagia.Subjects with grossly abnormal water swallow evaluations were excluded.Each swallow was categor-ized as normal,hypotensive,or simultaneous.Swallows generating distal isobaric contour plots of<30mmHg over>5cm were considered hypotensive,and simultaneous swallows had a distal esophageal velocity exceeding8.0cm/s.Overall,ineffective esophageal motility (IEM)was defined as30%or more hypotensive swallows and diffu esophageal spasm (DES)was defined as20%or more simultaneous pressure waves.An abnormal study was defined as IEM and/or DES.Results:42studies were included in the analysis.Overall,95.2% of the total number of water swallows were normal,4.1%failed,and0.7%simultaneous, compared to70.1%,17.2%,and15.5%of viscous swallows,respectively(p<0.05).None of the subjects had IEM or DES with water swallows while7subjects had IEM(p<0.05) and10subjects demonstrated DES with viscous swallows(p<0.005).Overall,15subjects had abnormal viscous swallow studies(p<0.005).In comparison to water swallows,viscous swallows were associated with incread velocity(5.6±6.8vs2.9±0.8cm/s;p<0.05), intrabolus pressure(20.4±3.7vs15.0±1.1mmHg;p<0.05),and
number of patients with repetitive swallows(10vs3;p<0.05).With water and viscous swallows,respectively, there was no difference in amplitude(92.2±41.4vs84.2±38.7mmHg;p>0.05),upper (5.1±3.9vs4.3±3.3mmHg;p>0.05)and lower(7.6±4.5vs8.0±4.3mmHg;p> 0.05)esophageal sphincter relaxation pressures,or transition zone(4.3±2.0vs4.6±2.6 cm;p>0.05).Conclusions:Apple sauce as a viscous challenge incread the identification of classifiable motor disorders in patients prenting with dysphagia.Apple sauce may be preferred over alternative bolus bread,which normally may not traver the entire esophagus with1swallow.
T1237
纽曼行车记录仪Measurement of Intrabolus Pressure(IBP)Using High-Resolution Manometry: Normative Ranges in the Upright and Supine Position
Brittany M.Mitchell,John E.Pandolfino,Eric Leslie,Thomas R.Parks,Monika A. Kwiatek,Peter J.Kahrilas
Background:Intrabolus pressure(IBP)during peristalsis is a potential determinant of dys-phagia and/or chest pain,as this is the primary force determining esophageal wall strain and flow.IBP is also
火属性the most reasonable physiologic correlate to the stimulus of esophageal balloon distention in experimental conditions.However,there are no standardized techniques to quantify IBP and normative values of IBP are unknown.Aim:To quantify normal vales of IBP during peristalsis using two novel high-resolution manometric metrics.Methods:68 asymptomatic subjects(33male,ages19to57)underwent10supine and10upright water swallows(5ml)using a solid-state high-resolution manometry asmbly with36nsors spaced at1cm intervals(Manoscan™,Sierra Scientific Instruments Inc.,Los Angeles,CA). IBP was measured1cm proximal to the esophagogastric junction(EGJ)using two new ManoView™tools.IBP-IRP provides an average measurement of the IBP during the4s period after a swallow EGJ pressure is minimal;IBP-max quantifies the maximal IBP for a 3s period between swallowing and the completion of peristalsis.All IBP measurements were referenced to atmospheric pressure.Results:All subjects had an intact EGJ with less than1cm parating the LES and crural diaphragm.Mean EGJ pressure was19.4mmHg (SD,10.6)in the supine position and16.0mmHg(SD,11.4)in the sitting position.Mean IBP-IRP and IBP-max values are prented in the Table.The mean IRP,IBP-IRP and IBP-max were all greater in the supine compared to sitting position.Furthermore,the esophago-gastric pressure gradient driving flow was greater in the supine compared to sitting position (supine,6.2mmHg,SD4.4;sitting0.9mmHg,SD3.5;P<0.001).Conclusion:Normative
ranges for IBP during peristalsis in the sitting and supine posture reveal values slightly greater than IGP consistent with there being a flow-permissive pressure gradient.In addition,IBP is greater during supine swallows and this may be due to greater outflow resistance in the abnce of hydrostatic forces.Normative Ranges for
IBP
*P<0.001vs.supine,†referenced to gastric pressure T1238
Comparison of Muscarinic Receptor Subtypes Mediating Contraction of Human and Pig Gastric Clasp and Sling Fibers
Anil K.Vegesna,Alan S.Braverman,Larry S.Miller,Mansoor I.Tiwana,Ronald J.Tallarida,Michael R.Ruggieri
This study determined how cloly the contractile physiology of the pig gastroesophageal junction follows the human.We obtained human tissue from organ transplant donors and pig tissue from a slaughterhou.Total,M-2and M-3receptor density was determined by subtype specific immunoprecipitation.Total and M-2are higher in pig than human.M-3receptors are 2fold higher in human than pig sling and over 2fold lower in human than pig clasp fibers.The methoctramine and darifenacin potency to inhibit bethanechol contractions,calculated by classic Schild analysis,indicates that both M-2and M-3receptors cau contraction which violates the assumption of one receptor causing the effect.An analysis method relating dual occupation of M-2and M-3receptors to the contractile respon was developed bad on the published Ka values of M-2and M-3receptors for bethanechol of 170μM and 110μM respectively,and mass-action binding which,at equilibrium,gives receptor occupation =[A][R]/([A]+Ka),where [A]denotes the agonist concentration,[R]is the receptor concentration and Ka is the agonist dissociation constant (reciprocal of affinity).Three dimensional plots for M-2and M-3occupation and contractile respon are shown in the figure.Although the M-3receptor subtype density is different between human and pig,the physiology of the contractile respon is similar.This indicates that the pig may be a good model for human gastroesophageal junction physiology.Muscarinic receptor density (fMol/mg solubile
protein)
A-529AGA Abstracts
T1239
Standing Upright Readily Detects Hiatal Hernia and Distinguishes
Diaphragmatic and LES Pressures with High Resolution Esophageal Pressure Topography (HREPT)
Syed Hashmi,Konrad S.Schulze,Robert W .Summers,Satish S.Rao
Introduction:Manometry,although uful has been a nemesis for detection of hiatal hernia.Recently,HREPT has provided clearer delineation of bolus transport and spatiotemporal changes.We hypothesized that standing position more clearly distinguishes crural and LES pressures and enhances detection of hiatal hernia when compared to supine position.AIM:To examine the effects of body position on LES tone and high pressure zone (HPZ)using HREPT.METHOD:A HREPT (Sierra Scientific)probe with 36nsors,1cm apart was positioned from the pharynx to stomach in 23patients (m/f=8/15;mean age 48yr)referred for esophageal manometry.Manometric data including LES basal pressure,length and HPZ length were assd in
the standing and supine positions.Hiatal hernia was identified as two parate bands of HPZ,at least 1cm apart on HREPT.RESULTS (Table,Bold=p<0.05):Two parate HPZs suggesting hiatal hernia were en in the supine position in 4(17%)and in standing position in 14(61%)subjects,p<0.001.LES pressure was higher (p<0.001),length of HPZ was longer (p<0.0004)and LES length was shorter (p<0.03)in the upright than supine position.CONCLUSION:In the standing position,HREPT readily parates two HPZ and has a higher nsitivity for detection of hiatal hernia than supine position.Body position affects LES length and pressure.The ea of identifying hiatal hernia with HREPT may aid management of
GERD.
T1240
Inter-Obrver Agreement with a High-Resolution Manometry Classification Scheme Bad On Pressure Topography Patterns
运动会策划书Eric Leslie,Peter J.Kahrilas,Mark R.Fox,Albert J.Bredenoord,Monika A.Kwiatek,John E.Pandolfino
Background:High-resolution manometry is a relatively new clinical tool utilized to character-ize esophageal motor dias.Unfortunately,there is currently no connsus regarding a classification scheme and interpretation has not been standardized.The goal of this study was to determine whether a classification of individual swallows bad on pressure topography patterns is associated with acceptable inter-obrver agreement amongst experienced clini-cians.Methods:Fifty single swallows from 25patients (2swallows per patient)were de-identified,randomized and converted into single JPEG images.The images were uploaded to a central website (Adobe Dreamweaver)to easily display the 50swallows.8experienced esophagologists were asked to participate by grading each swallow using a classification scheme provided which focud on pressure topography patterns.There were 7possible swallow types and the inter-obrver agreement between the participants was analyzed using a Kappa analysis of agreement.Results:The overall agreement of the 8experts was excellent (kappa =0.84)and the overall agreement between the experts and the reference key ranged from 85to 100%.The agreement for normal swallows (kappa =0.94),hypotensiv
e swallows (kappa =0.88),abnt peristalsis (kappa =0.95),hypertensive swallows (kappa =0.76),spasm (kappa =0.78)and panesophageal pressurization (kappa =0.87)were excellent where as elevated intrabolus pressure (IBP)was slightly lower but still very good (kappa =0.72).The main disagreement was an inability to differentiate spasm and IBP (12%disagreement)and misclassification of hypertensive swallows as spasm where the propagated peristaltic wave was associated with repetitive spastic contractions (23%disagreement).Conclusions:Classifying esophageal motor function using pressure topography patterns has excellent agreement amongst expert esophagologists.The main area of disagreement focud on the distinction between a compartmentalized IBP and a spastic contraction and thus,a more careful descrip-tion of the swallow types is required.In addition,a parate category for spastic nutcracker may improve overall agreement.T1241
5ht4-Agonist (Mosapride)Improves the Clinical Symptoms in PPI-Resistant NERD Patients via Improvement of Gastric Emptying
Seiji Futagami,Katsuhiko Iwakiri,Tomotaka Shindo,Tetsuro Kawagoe,Akane Horie,Mayumi Shimpuku,Katya Gudis,Kazumasa Miyake,Taku Tsukui,Choitsu Sakamoto Background/Aims:Previous studies have demonstrated that the non-erosive reflux dia (NERD)p
atients are less nsitive to proton pump inhibitor (PPI)treatment than the patients with erosive reflux dia.There is no available data about relationship between gastric motility and NERD patients.Some previous studies have revealed that mosapride decreas the acid reflux to the esophagus in the GERD patients and improves gastric emptying in healthy volunteers and diabetic patients for both solids and liquids.The aim of this study was to investigate whether mosapride treatment in addition to PPI administration could improve the clinical symptoms in the PPI-resistant NERD patients via improvement of gastric emptying and esophageal peristalsis.Methods:One hundred and fifty-two concutive patients prenting with typical symptoms of FD (EPS,n=36;PDS,n=76)or PPl-resistant NERD (n=40),and 20healthy volunteers were enrolled.The gastric motility was evaluated by T-max value using the 13C-acetate breath test.Secondary peristalsis was determined by esophageal manometry.We ud GSRS criteria to evaluate the clinical symptoms.We measured both acylated-and des-acylated plasma ghrelin levels by the ELISA method.Results:Tmax values in the PDS and PPI-resistant NERD patients were significantly higher than that of the healthy volunteers.Mosapride significantly improved clinical symptoms such as reflux,indigestion,and constipation in the PPI-resistant NERD patients.Administration of
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A G A A b s t r a c t s
