Background A number of commercial and research systems are available for making high‐resolution manometry recordings.
Purpose In this document, we review the standard equipment, patient preparation ...and routine protocol for high‐resolution manometry. The major differences between HRM systems lie in the method of signal transduction, with solid‐state catheter systems recording form intraluminal transducers and water perfusion systems recording pressures from external transducers via a perfused silicone catheter. The variations in recording systems result in different mechanical and electrical characteristics which dictate different techniques for setting up and using equipment. These issues are relevant in terms of costs and day to day management, but have little clinical significance. After the equipment is prepared for a manometric study, the esophagus is intubated transnasally with the manometric catheter and the catheter is positioned so that the UES and LES/diaphragm are visualized on the recording screen. The subject then undergoes 10 5ml water swallows in the supine position. Manometric data may be integrated with other data streams such as multichannel impedance or images from fluoroscopy to increase the power of the technique in difficult cases.
Summary
Background
The mechanism of reflux protection may involve a ‘flap valve’ at the oesophago‐gastric junction (OGJ).
Aim
To assess the effects of baclofen, a gamma‐aminobutyric acid receptor ...type‐B (GABA‐B) agonist known to suppress reflux events, on the ‘functional anatomy’ of the OGJ and proximal stomach after a large test meal.
Methods
Twelve healthy volunteers (HVs) and 12 patients with gastro‐oesophageal reflux disease (GERD); with erosive oesophagitis or pathological oesophageal acid exposure completed a randomised, double‐blind, cross‐over study. On 2 test days participants received 40‐mg baclofen or placebo before ingestion of a large test meal. OGJ structure and function were assessed by high‐resolution manometry (HRM) and magnetic resonance imaging (MRI) using validated methods. Measurements of the oesophago‐gastric angle were derived from three‐dimensional models reconstructed from anatomic MRI images. Cine‐MRI and HRM identified postprandial reflux events. Mixed model analysis and Wilcoxon rank signed tests assessed differences between participant groups and treatment conditions.
Results
In both HVs and GERD patients, baclofen reduced the frequency of postprandial reflux events. The oesophago‐gastric insertion angle in GERD patients was reduced (−4.1 ± 1.8, P = 0.025), but was unchanged in healthy controls. In both study groups, baclofen augmented lower oesophageal sphincter (LES) pressure (HVs: +7.3 ± 1.8 mmHg, P < 0.0001, GERD: +4.50 ± 1.49 mmHg, P < 0.003) and increased LES length (HVs: +0.48 ± 0.11 cm, P < 0.0003, GERD: +0.35 ± 0.06 cm, P < 0.0001).
Conclusions
Baclofen inhibits transient LES relaxations and augments LES pressure and length. Additionally, baclofen has effects on the ‘functional anatomy’ of the OGJ and proximal stomach in GERD patients, which may suppress reflux by means of a ‘flap valve’ mechanism.
Background and aims: High‐resolution manometry (HRM) is a recent development in oesophageal measurement; its value in the clinical setting remains a matter of controversy. (i) We compared the ...accuracy with which bolus transport could be predicted from conventional manometry and HRM. (ii) The clinical value of HRM was assessed in a series of patients with endoscopy‐negative dysphagia in whom conventional investigations had been non‐diagnostic.
Method: (i) Control subjects and patients with endoscopy‐negative dysphagia underwent concurrent HRM and video‐fluoroscopy. Ninety‐five records were reviewed using HRM with spatiotemporal plot and conventional line plots of the pressure data derived from the same recording. (ii) The HRM and notes of patients with endoscopy‐negative dysphagia and abnormal bolus transport were analysed to identify additional information provided by the new technique.
Results: (i) Receiver operating characteristic analysis demonstrated that HRM predicts the presence of abnormal bolus transport more accurately than conventional manometry. (ii) HRM identified clinically important motor dysfunction not detected by manometry and radiography. These included localized disturbances of peristalsis and abnormal movement of the lower oesophageal sphincter during oesophageal spasm.
Conclusion: The HRM predicts bolus movement more accurately than conventional manometry and identifies clinically relevant oesophageal dysfunction not detected by other investigations including conventional manometry.
Background Poor feeding is a common cause of prolonged hospitalization of preterm infants. Pharyngeal and upper esophageal sphincter (UES) function of preterm infants has been technically difficult ...to assess and is therefore poorly characterized. The aim of this study was to assess the development of pharyngeal motility, UES function, and their coordination during nutritive swallowing in preterm infants.
Methods Development of swallowing was assessed in 18 preterm infants. High resolution manometry was performed at first oral feeding attempt (31–32 week) and then weekly for 4 weeks. Pharyngeal and UES pressure changes were characterized in 980 swallows.
Key Results During swallowing, we observed an age‐related increase in peak pharyngeal pressure at the laryngeal inlet (1 cm above UES) but an age‐related decrease in the time required for the UES to fully relax to nadir. Analysis of the timing of proximal pharyngeal contractile peak and UES nadir showed that the UES was not fully relaxed when bolus propulsive forces were at their peak in the youngest infants.
Conclusions & Inferences Results show developmental changes in infant swallow physiology that can be clearly linked to the effectiveness of nutritive swallowing. Most preterm infants demonstrated poor pharyngeal pressures at the laryngeal inlet coupled with poor coordination of pharyngeal propulsion with UES relaxation. These pressure patterns were less efficient than those demonstrated by older infants who were more adept at feeding. These observations may explain why infants under 34 weeks are physiologically unable to feed effectively and experience frequent choking and fatigue during feeding.
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.
In Australia, correspondence is routinely sent to general practitioners following a specialist consultation. Written communication is an important way to enhance patient experiences and ...understanding, yet most patients do not receive copies of their medical correspondence.
To determine whether providing clinic correspondence and endoscopy reports to patients leads to improved understanding, satisfaction or anxiety.
This is a prospective, randomised controlled study conducted at an Australian tertiary hospital from October 2013 to February 2015. New adult referrals to the general gastroenterology clinic requiring an urgent endoscopic procedure were eligible for the study. The intervention group received a copy of their clinic correspondence and endoscopy report, while the control group received neither. Participants completed questionnaires, including visual analogue scales and the Hospital Anxiety and Depression Scale, at three time points. Primary outcomes were patient understanding, anxiety and satisfaction.
A total of 70 participants was included in the study. There was no reduction in anxiety levels (P = 0.52), no increase in understanding (P = 0.73) or any increase in satisfaction (P = 0.33) in participants receiving correspondence. However, 97% of participants indicated that they wished to receive correspondence in the future, and 94% of participants in the correspondence group reported that receiving correspondence had helped them to understand their medical condition.
Patients wish to receive copies of their correspondence and feel it improves their understanding of their medical condition. Although we were unable to demonstrate a measurable reduction in anxiety, increase in understanding or satisfaction, we recommend that patients be offered the choice of receiving copies of their clinic correspondence and endoscopy reports.
BACKGROUND AND AIMS Distension of the proximal stomach is a major stimulus for triggering transient lower oesophageal sphincter (LOS) relaxations. We have shown recently that atropine inhibits ...triggering of transient LOS relaxations in both normal subjects and patients with gastro-oesophageal reflux disease. Atropine could potentially act centrally by inhibiting the central integrating mechanism in the brain stem, or act peripherally by altering the response of the stomach to distension. The aim of this study was to investigate the effect of atropine on fasting gastric compliance and postprandial gastric tone using an electronic barostat. METHODS Fasting and postprandial proximal gastric motor and sensory functions were assessed in 10 normal healthy volunteers. Oesophageal manometry and pH were simultaneously measured. On separate days, atropine (15 μg/kg bolus, 4 μg/kg/h intravenous infusion) or saline was given and maintained for the duration of the recording period. RESULTS In the fasting period, atropine significantly reduced minimum distending pressure (5.5 (0.4) v 4.4 (0.4) mm Hg; p<0.005) and increased proximal gastric compliance (81.3 (5.3)v 102.1 (8.7) ml/ mm Hg; p<0.05). In response to a meal, maximal gastric relaxation was similar on both study days. However, during atropine infusion, there was no recovery of proximal gastric tone in the two hour postprandial observation period. Postprandial fullness scores were higher during atropine infusion and correlated with changes in intrabag volume. Atropine significantly reduced the rate of postprandial transient LOS relaxations: first hour, 7.0 (5.3–10.0) v 3.0 (1.0–4.0) (p<0.02); second hour, 5.0 (3.3–5.8) per hour v 1.0 (0–3.0) per hour (p<0.05). CONCLUSIONS In humans, fasting and postprandial proximal gastric motor function is under cholinergic control. Atropine induced inhibition of transient LOS relaxations is unlikely to be caused by its effect on the proximal stomach, but rather by a central action on the integrating mechanisms in the brain stem.
This study assessed the effect of fundoplication on liquid and solid bolus transit across the esophagogastric junction (EGJ) in relation to EGJ dynamics and dysphagia.
Twelve patients with ...gastro-esophageal reflux disease (GERD) were studied before and after fundoplication. Concurrent high-resolution EGJ manometry and fluoroscopy were performed whilst swallowing liquid barium and a solid bolus. The EGJ transit time, EGJ opening duration, transit efficacy, and EGJ relaxation were measured. During the test symptoms of dysphagia were scored using a visual analog scale.
The minimal opening aperture at fluoroscopy was located at the manometric EGJ in all subjects. Fundoplication markedly reduced the EGJ opening diameter from 1.0 +/- 0.1 to 0.6 +/- 0.1 cm (p < 0.01) and rendered deglutative EGJ relaxation incomplete. After fundoplication, a higher intrabolus pressure was found (p < 0.05) associated with a reduced axial bolus length (p < 0.001). EGJ transit time increased from 6.9 +/- 0.9 to 9.8 +/- 1.0 s for liquids (p < 0.01) and from 2.8 +/- 0.5 to 5.8 +/- 0.8 s (p < 0.01) for solids after fundoplication. No relation between EGJ transit and dysphagia scores was observed before fundoplication. In contrast, EGJ transit time significantly correlated with dysphagia scores both during liquid (r = 0.84; p < 0.01) and solid (r = 0.69; p < 0.05) bolus transit following fundoplication.
Fundoplication patients exhibit a restricted hiatal opening and an incomplete deglutative EGJ relaxation. To facilitate EGJ transit despite these altered EGJ dynamics a higher intrabolus pressure is created by augmented bolus compression. Fundoplication increases EGJ transit time, the degree of which is associated with postoperative dysphagia.
Background
Advanced training in gastroenterology currently consists of 2 years of core training and 1 elective (non‐core) year. We surveyed gastroenterologists 2–7 years following completion of ...training to determine the strengths and weaknesses of their training.
Methods
All gastroenterologists were invited to participate in an anonymous online survey.
Results
There was a 46% response rate (49/110). Eighty‐one per cent were male with most aged 36–45. Respondents felt that the current training programme prepared them well for public practice and endoscopy but less well for private practice, ambulatory care, surgical aspects of gastroenterology and functional gastrointestinal disorders. Most had faced challenges transitioning to consultant practice. The majority (53%) spent more than the standard 3 years to complete training in gastroenterology. The top three subspecialty Fellowships were in endoscopy (45%), inflammatory bowel disease (29%) and hepatology (23%). In their elective year, 42% undertook a predominantly clinical year (registrar‐type position in general or subspecialty gastroenterology), 28% engaged in research while 24% trained in another specialty. Seventy‐eight per cent were in full‐time work, and 36% were supervising trainees. Ninety‐eight per cent felt that it was beneficial for trainees to move between hospitals during the core years of their advanced training.
Conclusions
The current Australian gastroenterology training programme is generally adequate in preparing trainees for consultant practice but could be improved by increased emphasis on areas such as private practice, ambulatory gastroenterology and functional gastrointestinal diseases. Exposure to a variety of experiences by training in several different hospitals during core training was universally viewed as being important.
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