Shigeo Takeo

Takebayashi, Nozawa, RT

Cervical with US

MD Eiichi

a

Kengo Matsui, Fujioka, RT

a

Esophageal in Progressive

High-resolution ultrasound (US) showed that initial penistalsis propelled ingested soda smoothly and rapidly in 20 volunteers without symptoms who met both manometnc and radionuclide esophageal scintigraphic (RES) criteria for norma! motility. Twenty-eight patients with progressive systemic sclerosis were classified according to results of RES as follows: group 1, normal esophageal motility (three patients [11%]); group 2, hypomotility of the esophagus, excluding the cervical esophagus (18 patients [64%]); and group 3, hypomotility of the cervical esophagus (seven patients [25%]). In the seven patients of group 3, US demonstrated that an incomplete peristalsis sequence or a feeble penstalsis propelled the soda in a slow and/or to-and-fro motion with low velocities. In the other 21 patients (75%), the soda passed through the esophagus smoothly and rapidly. Retention of soda in the cervical ecophagus was not limited to patients with hypomotility of the cervical esophagus. It is concluded that US is useful in evaluation of cervical esophageal motility. Index

terms:

Esophagus,

Esophagus, tility,

function,

71.613,

studies, ies,

71.91

71.1233,

71.1233, studies,

71.613

#{149} Ultrasound

71.12981,

Radiology

71.613

71.1299 a

Radionuclide 71.613

(US),

mo-

a

US

stud-

imaging, Scleroderma,

comparative

studies,

71.613

1991;

179:389-393

Ozawa,

Motility: Systemic

P

MD

ROGRESSIVE

portant

factor

in the

care

of such

pa-

tients. PSS primarily affects the smooth muscle of the esophagus and is usually thought to be limited to the distal two-thirds of the organ. The cervical esophagus of patients with PSS has not attracted considerable attention, although there have been reports that the smooth muscle appears

in the

cervical

esophagus

(2)

and that the striated-muscle portion of the esophagus may be involved in later stages of the disease (3). Ultrasound (US) has largely contributed to diagnoses of various diseases, but almost all US examinations have been used to detect structural abnormality. Recent technologic advances in high-resolution US have provided us with neal-time images of the cervical esophagus. Both esophageal peristalsis and transit of ingested material are easily demonstrated with US. However, to our know!edge, there have been no reports of being

used

to evaluate

esophageal

motility. To investigate this new and potentially effective use of high-resolution US, we performed both US of the cervical esophagus and radionuclide esophageal scintigraphy (RES) in patients with PSS and in volunteens

without

a

Evaluation Sclerosis’

systemic sclerosis (PSS) is characterized by an excessive deposition of collagen and other connective tissue components in skin and multiple internal organs. Esophageal involvement is very cornmon in P55, occurring in up to 90% of patients with this disease (1). Treatment of the esophagus is an im-

US

radionuclide

#{149} Esophagus,

71.1299,

a

Esophagus,

a

Esophagus,

a

71.12981

transit

diseases,

71.1233

#{149} Yukihiko

MD

symptoms.

years).

All patients

had

but

nine

nomenon,

tion.

However,

criteria which

were

mixed

From the Department hama City University

of School

Urafune-cho, Received

1990;

December accepted

to ST. (

RSNA,

Minami-ku, October 22, 5; revision January 1991

received 16. Address

Radiology, of Medicine,

Yokohama, revision

January reprint

Yoko3-46

Japan. requested

7, 1991; requests

The study

population

comprised

28 pa-

fulfilled

connective

with

dys-

the cniteAssocia-

syndromes,

in one

er 21 patients

phehad

patients

tissue

in six patients

dermatomyositis

dis-

and sclero-

patient.

classic

The

oth-

PSS were

subdivided according to the Bamnett classification (4) as follows: Five had sclerodactyly with the Raynaud phenomenon

1), eight had acrosclerotic sclemodemma (type 2), and eight had generalized or (type

diffuse unteers

scleroderma (type were 19 men and

aged

24-50

They

had

years

3). The 20 volone woman

(mean

neither

toms nor underwent

age, 31.2 years).

gastrointestinal

symp-

known esophageal disease and manometmy to confirm normal

esophageal motility. formed as described

Manometmy by Benjamin

was peret al (5).

Normal mean pressure in the proximal or distal esophagus was defined as values greater than 50 mm Hg, and normal midexpiratory sphincter pressure in the low-

em esophageal

sphincter

was defined

as

values greater than 10 mm Hg (3,5). All subjects underwent US of the cervical esophagus after RES on the same day they underwent RES.

RES was performed supine

position.

i0

with

The

mL of water

subjects

subjects

containing

in the

received

0.30

10

X l0-0.37

tin colloid.

MCi) of technetium-99m Imaging was performed

riomly

a large-field-of-view

X

Bq (80-100 with

camera

with

Continuous performed

second

a parallel-hole

collimator.

computer acquisition with an acquisition

per frame.

ante-

gamma

was mate of 1

The images

were

ac-

quired for a total of 1 10-130 seconds. ing a cumulative image of esophageal tivity, we generated regions of interest for the whole esophagus, the proximal

sit I

seven

ease (MCTD)

of the

sternal

METHODS

Raynaud

patients

for overlapping

third

AND

the

phagia. PSS was diagnosed with na of the American Rheumatism

esophagus,

esophagus

PATIENTS

only

above notch.

time

The

(RTT),

tial entrance

and

the which

level

90%

the

of the

cervical

supra-

radionuclide is the

time

of radionuclide

Usac-

tran-

mi-

from

activity

into

connective systemic

scle-

tients with PSS and 20 volunteers without symptoms. The 28 patients were 25 fe-

male

and three male subjects aged 12-74 (mean age, 51.6 years). The duration of PSS since onset of symptoms had ranged from 1 to 37 years (mean, 11.1 years

Abbreviations: tissue rosis,

phy,

disease, RES =

RTT

=

MCTD mixed progressive

P55 = radionuclide radionuclide

esophageal transit

scintigratime.

389

b.

a. Figure

c.

1. Images of a 59-year-old man who had had MCTD for 2 years and who had no gastrointestinal symptoms. tivity curves for the whole esophagus (a) and the cervical esophagus (b) are normal. (c) A 7.5-MHz sonogmam of the (short arrows) demonstrates a normal undulation of a peristaltic wave (long arrows), which propels soda represented acoustic shadow. The transit was smooth and rapid, with a velocity of 4 cm/sec. No fluid was retained in the cervical stalsis ceased. T = thyroid.

(a, b) The time-radioaccervical esophagus by a strong echo and esophagus after pen-

the esophagus until it returns to 10% of peak activity, was calculated for each megion of interest. The upper limit of normal RTT is 12 seconds for a whole esophagus

(3) and

for

the

approximately

proximal

(6). The normal geal

RTT

sults

of the

portion, the

from

volunteers

was

test

Hypomotility the cervical

whenever

RU

the

was prolonged but RTT was within

esophageal which

meRTT

normal

esophagus. excluding

limits,

esopha-

the

with

diagnosed

cervical

seconds

esophagus

of cervical

derived

esophageal

normal

of the

values

were

of the proximal of the esophagus, whole

2-3

third

were

defined

from

the data in the volunteers, in whom esophageal motility was normal at manometry. Gray-scale US of the cervical esophagus

a.

b.

was performed with subjects in the supine position by use of high-resolution real-time linear electric scanners (10 MHz: Sonic Scanner, Terumo, Tokyo; and 7.5 MHz:

SSD

270,

Aloka,

rate of the real-time frames per second. the

wall

and

the

diameter

were measured the esophagus. agus scan, tients

drate

given

water)

low were

it all

and

pattern

of the

were

cervical

in the

ceased. the

as the

velocity

to swal-

examinations

The factors

motility

soda

included as well

US

soda

tern

The pa(carbohy-

instructed

These

of ingested

penistalsis

The transit

lobe. of soda

on videotape.

after sis

were

in evaluating

tion

a longitudinal from an acoustic

10 mL

at once.

recorded

used

of

lumen

with a transverse scan of The motility of the esoph-

of the left thyroid were

The

of the

was evaluated with whenever possible,

window

sit

Tokyo).

imaging was 30 Both the thickness

the

and

the

esophagus

The transit

appearance motion

tranreten-

pat-

of pemistalof ingested

by

dividing the length of the cervical esophagus at US by the transit time of the soda. The transit time was defined as the time from the entrance of the soda as a linear strong echo with an acoustic shadow until

the

time

390

disappearance

was

a

measured

Radiology

of this

with

echo;

a stopwatch.

d.

C.

soda.

was also calculated

transit

The

Figure

2. and

Images of a 43-year-old who had no gastrointestinal

woman who symptoms.

had

suffered from type 2 classic PSS for 28 years (a) The time-radioactivity curve for the whole esophagus demonstrates markedly prolonged 90% RTT (greater than 130 seconds). (b) The curve for the cervical esophagus shows prolonged 90% RTT (14 seconds). (c) A 7.5MHz sonogram of the cervical esophagus (short arrows) demonstrates a feeble penistaltic wave (arrowheads), which propels soda (long arrows) slowly with a velocity of 0.95 cm/sec. T = thyroid (left lobe). (d) A barium examination shows that the distal two-thirds of the esophagus is dilated secondary to hypomotility.

May

1991

was No

a. 3. and

years

1 classic P55 for 18 curve for the esophagus demonstrates markedly prolonged 90% RTT (63 seconds). (b) A 10-MHz of the cervical esophagus (short arrows) demonstrates no undulation of perista!transit of soda (long arrows) was slow, with a velocity of 0.95 cm/sec. T thyroid

cervical

sonogram sis.

The

(left

Images of a 58-year-old who had no gastrointestinal

woman who symptoms.

normal

velocity

was

determined

of the volunteers manometric criteria

from

who met both for normal

the RES motil-

All US authors

RES

scans were reviewed (ST.), who was

results,

another

were

which

(Y.O.).

compared

with

thermore,

patients

the

cervical

one

interpreted The

US

of to the by

results

the RES results. who

had

esophagus

RES underwent the evaluation the

were

author

by blinded

Fur-

hypomotility

at US

and/or

barium examinations of the distal two-thirds

for of

The

ingested

smoothly

soda and

was

rapidly

propelled (within

2 sec-

onds) by initial peristalsis. Its transit velocity was 2.4-6.0 cm/sec (mean, 4.0 cm/sec ± 0.7). The soda was retamed in the cervical esophagus in five volunteers (25%). These esophagi had a widen mean lumen diameter (5.8 mm ± 0.8) than the others (3.3 mm ± 0.9) (P < .001). Patients

with

P55

esophagus.

The 28 patients were three groups according

RESULTS Volunteers

without

suits.

Symptoms

Of the 20 volunteers, all met both manometnic and RES criteria for norma! esophageal motility. Mean midexpiratony

lower

esophageal

sphinc-

ten pressures measured with manometry were greater than 10 mm Hg (mean, 22 mm Hg ± 4 [standard deviation]; range, 18-30 mm Hg). The mean distal esophageal pressure was 85 mm

Hg

± 10 (range,

64-98

mm

Hg). The mean proximal pressure was 70 mm Hg

esophageal ± 7 (mange,

60-82

proximal

mm

Hg).

Neither

cape phenomenon, reflux, nor chaotic served with RES. agea! RTT ranged onds

(mean,

1.3 seconds

es-

± 0.4).

At US of the cervical esophagus, the mean thickness of the wall and diameter of the lumen were 2.1 mm ± 0.2 (mange, 2.0-2.5 mm) and 3.9 mm ± 1.3 (range, 2-7 mm), respectively. The mean length of the cervical esophagus 3.0-4.5

Volume

was cm) on

179

a

4.2 cm ± 0.5 longitudinal

Number

2

(range, scans.

Group

classified into to the RES me-

1 represented

normal

esophageal motility (Fig la, ib), which was observed in three patients (11%) with MCTD. Group 2 represented hypomotility of the esophagus; excluding the cervical esophagus; this was observed in 18 patients (64%). Of these 18 patients, 14 had classic P55 (two with type 1, six with type 2, and six with type 3), three had MCTD, and one had sclerodenmatomyositis.

Group

hypomotility

of the

gus (Figs in seven

gastroesophageal activity was obThe cervical esophfrom 0.9 to 2.1 sec-

2b, 3a), patients

3 represented

cervical

which (25%)

was with

esophaobserved classic

P55 (three with type 1, two with type 2, and two with type 3). In each of these seven patients, the cervical esophageal RTT was greater than 3 seconds (mange, 4.4-63 seconds). The groups ranked in decreasing order of mean duration of disease were as follows: group 3, 20.8 years ± 8.9; group 2, 8.7 years ± 5.7, and group 1, 2.6 years ± 1.7 (P < .001). At US of the cervical esophagus, the mean thickness of the wall was 2.2

and

existed

passed smoothly

through and

range, mained

2.6-6.2 cm/sec). in the cervical

patients

ity.

of

suffered from type (a) The time-radioactivity

lobe).

data and

the

had

± 1.4 (range,

2-7 in the

mm). mean

thickness of the wall on the diameter of the lumen between patients with P55 and healthy volunteers. The mean length of the cervical esophagus was 4.0 cm ± 0.5 (range, 3.0-4.5 cm) on longitudinal scans. In seven of the patients (25%), US demonstnated that an incomplete penista!sis sequence on a feeble penistalsis (Fig 2c, 3b) propelled the soda in a slow or to-and-fro motion, with low velocities ranging from 0.4 to 1.3 cm/sec (mean, 0.8 cm/sec ± 0.3). In the memaining 75% of the patients, the soda

b.

Figure

3.7 mm difference

mm

the

± 0.4

mean

(mange,

diameter

2.0-3.0

of the

mm),

lumen

the rapidly

(86%),

esophagus (velocity

The soda esophagi

including

all

meof 24

seven

patients with an abnormal transit pattern. The mean thickness of the esophageal wall in each group was as follows: group 1, 2.3 mm ± 0.5; group 2.2 mm 0.5. The

± 0.4; mean

and group diameter

2,

3, 2.3 mm ± of the esoph-

ageal lumen was 3.0 mm ± 0 in group 1, 3.8 mm ± 1.4 in group 2, and 2.6 mm ± 0.7 in group 3. No diffemence existed in the mean thickness of the wall on the diameter of the !umen among the three groups of patients.

The

RES soda

findings is shown

comparison

of the

US

results coincided with the RES sults in the detection of cervical

esophageal hypomotility when finding that abnormal penistalsis pelled the soda in a slow and/or to-and-fro motion was defined abnormal. Retention

and

in transit of ingested in the Table. The US

of soda

in the

me-

the proas

cervical

esophagus was not limited to those patients with hypomoti!ity of the cervical esophagus. Al! seven patients with cervical esophageal hypomotility sic P55.

at both Of these

RES and US had seven patients,

three had symptoms Barium examinations both dilatation and the distal two-thirds gus

(Fig

normal

2d)

in six

findings

clasonly

of dysphagia. demonstrated hypomotility of of the esophaof the

patients

in one

and

patient.

DISCUSSION In P55, feeble or absent penistalsis in the distal two-thirds or smoothmuscle portion of the esophagus occurs characteristically but may be found in other connective tissue disorders (7). ory is that

to the

A commonly dysfunction

atrophy

believed is secondary

of muscularis Radiology

the-

propnia 391

#{149}

Us and RES in the Evalu ation

of Cervical

Esophageal

Motili

ty in Patients

with

PSS

Patients Group Volunteers

without

Symptoms

and

Normal (n Velocity

20)

1,

Excluding

Motility* (n

Cervical

3)

the

of the

Esophagus (n

18)

3.9

1.0

P

Cervical

Group

Esophagus (n

1

Group

vs

7)

I

Group

vs

Group

2

Group

2

vs 3

Group

3

(cm/sec)

Mean

4.0 ± 0.7

Range

4.5 ± 0.4

2.4-6.0

No. of patients with rapidt, smooth transit No.

Group

Normal

PSS

Group 3, Hypomotilityt

Hypomotilityf

with

Motility*

2,

with

20 (100)

by normal peristalsis of patients with

slow’, to-and-fm transit by abnormal peristalsis No. of patients with retention of soda in the cervical esophagus

0.8 * 0.3

NS