Dysphagia 7:3-7 (1992)

Dysphagia 9 Springer-Verlag New York Inc. 1992

Esophageal Motor Disorders in Patients Evaluated for Dysphagia and/or Noncardiac Chest Pain Gabrio Bassotti, Maria A n t o n i e t t a Pelli, and A n t o n i o Morelli Laboratorio di Motilith Intestinale, Istituto di Gastroenterologia ed Endoseopia Digestiva, Universit~ di Perugia, Italy

Abstract. During the period January, 1983--October, 1990, 429 subjects were referred for functional evaluation o f dysphagia a n d / o r n o n c a r d i a c chest pain. O f these, 304 (70.8%) were shown to have some kind o f esophageal m o t o r abnormality. The most frequent m o t o r a b n o r m a l i t y o f the esophagus was represented by nonspecific m o t o r disorders (31%), followed by achalasia (13%), whereas the other dysfunctions a c c o u n t e d for a smaller percentage. In particular, diffuse esophageal spasm was shown to be quite rare. It is concluded that esophageal r n a n o m e t r y m a y p r o v i d e a high diagnostic yield in patients presenting with dysphagia a n d / o r noncardiac chest pain. Key words: Chest pain -- Esophagus, m a n o m e t r y Deglutition -- Deglutition disorders.

In recent years, esophageal m a n o m e t r y has b e c o m e a widely used diagnostic tool for the evaluation o f esophageal functional abnormalities [1, 2]. In particular, due to suspected m o t o r disorders, patients with dysphagia a n d n o n c a r d i a c chest pain are frequently referred for esophageal m a n o m e t r i c investigations [3, 4]. The availability o f low-compliance infusion sys-

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Motilith Intestinale, Istituto di Gastroenterologia, ed Endoscopia I)igestiva, 06100 Perugia, Italy

tems [5], better standardization o f m a n o m e t r i c techniques [ 6 - I 0 ] , and the evaluation o f large groups o f controls to establish the n o r m a l range for esophageal m o t o r parameters [1 1-13] have led to m o r e hom o g e n e o u s results in this field. We have recently shown [ 13] that by using the same e q u i p m e n t and techniques as those used by other esophageal m o tility laboratories, very similar and c o m p a r a b l e resuits can be obtained. This paper reports our 7 year experience with m a n o m e t r y in patients w h o c o m p l a i n e d o f dysphagia, chest pain, or both. Methods

Between January, 1983, and October, 1990, 429 subjects were referred to our Gastrointestinal Motility Laboratory for evaluation of dysphagia and/or noncardiac chest pain. Most patients complained of dysphagia, and a minority of pure chest pain, which, when present, was often associated. Radiologic esophageal evaluations and upper panendoseopy were performed before manometry in all cases, in order to exclude an organic cause for symptoms. In a few cases manometry led to a re-evaluation of the clinical situation and the discovery plan organic abnormality (see below). In addition, patients who complained of chest pain underwent preliminary cardiologic investigation (physical examination, basal and postexercise electrocardiographic recordings, echocardiographic scans, and, when indicated, coronary arteriography) to exclude, as completely as possible, pain of cardiac origin. Esophageal manometrics were carried out with standard techniques and equipment [13-17]. A commercially available eight-lumen round polyvinyl chloride (PVC) manometric catheter with the distal four side holes arranged radially at the same level at 90 degree angles, and the proximal holes each 5 cm apart (Arndorfer Medical Specialities, type ESM 3R), was used. Each channel was connected to external physiological pressure transducers (Bell & Howell, type 4-327-1)and constantly perfused with

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A. Bassotti et al.: Manometry in Dysphagia and Chest Pain

Table 1. Manometric diagnosis formulated in a group of 429 consecutive subjects evaluated for dysphagia and/or chest pain Diagnosis

Number

%

NEMD Achalasia NE Systemic sclerosis DES Hypertensive LES Motor abnormalities resembling achalasia or DES associated with cancer Dermatopolymyositis

133 56 42 35 20 8

31 13 10 8 4.6 1.8

6 4

1.3 1

bubble-free distilled water at 0.5 ml/min by a low-compliance pneumohydraulic system [5]. lntraluminal pressures were registered on a multichannel Beckman R-611 Dynograph Recorder, with a paper speed of 1 mm/s for the lower esophageal sphincter (LES) and 2.5 mm/s for the esophageal body. At this perfusion rate, the system yields a pressure rise of more than 300 mmHg/s to distal occlusion of catheter tip [ 13-16]. Manometry was performed with the patient in the supine position. The probe was introduced nasally to within the stomach, and then slowly withdrawn in 1 cm increments by station pull-through, to measure LES resting pressure and relaxations with the four radially oriented side holes. Thereafter, the catheter was positioned with its distal recording site 3 cm above the LES, and 10 or more wet swallows (with 5 ml water boli) were administered every 30 s to assess peristaltic activity, with the proximal four recording ports at 3, 8, 13, and 18 cm above the LES.

Data Analysis The following variables were taken into account: mean LES pressure and relaxation, mean distal (3 cm above the LES) contraction amplitude, and contraction abnormalities. The LES pressure, recorded in mmHg as an average of four individual pressures, was measured at midexpiration, with mean gastric pressure taken as baseline. Relaxations were considered complete if LES pressure fell at least 80% [ 18]. Wave amplitude (in mmHg) was calculated from the mean intraesophageal baseline pressure to the peak of the wave. A measurable contraction wave was considered at least I0 mmHg in amplitude to differentiate it from potential respiratory artifacts. Contraction abnormalities were defined when a wet swallow was followed by repetitive (three or more peaks with the third peak being at least 10 mmHg in amplitude and at least 1 s apart from the first) [11, 19], nonperistaltic (simultaneous onset of contractions at two or more recording sites) [20-22], spontaneous, and high-amplitude (> 180 mmHg, i.e., >2 SD from our normal upper limit, in the distal recording site) contractions.

Abnormal Esophageal Motility Esophageal motor abnormalities were categorized according to well-established criteria: 1. Achalasia [23-26]: absence of peristalsis in the esophageal body and incomplete or abnormal LES relaxation. Lower esophageal pressure is also often elevated.

2. Diffuse esophageal spasm (DES) [21,24, 27-29]: simultaneous contractions (at least 20% of wet swallows) alternating with intermittent normal peristalsis. These findings are often associated with repetitive, prolonged, spontaneous, and highamplitude contractions. Abnormalities of the LES function may be documented. 3. Nutcracker esophagus (NE) [3, 13, 16, 18, 30]: normal peristaltic progression, but with waves of high amplitude (mean distal contraction amplitude > 180 mmHg) and, sometimes, of prolonged duration (mean distal duration > 6 s). 4. Hypertensive LES [30-33]: resting LES pressure >2 SD from the normal upper range (> 39 mmHg for our laboratory), normal LES relaxations, normal peristalsis of the esophageal body. 5. Scleroderma esophagus [34-38]: low or no LES pressure, weak to absent distal esophageal peristalsis, and normal upper esophageal peristalsis and sphincter pressure. 6. Esophageal involvement in dermato- or polymyositis [39, 40]: weak to absent proximal esophageal peristalsis and UES resting pressure, with normal findings in the distal portions of the esophagus. However, there may also be overlap with other collagen diseases. 7. Nonspecific esophageal motility disorders (NEMD) [30]: any combination of the following: increased nontransmitted contractions (< 30% of wet swallows); repetitive contractions; retrograde contractions; low-amplitude contractions (6 s).

Control Group Sixty-one healthy volunteers were recruited to establish normal parameters. None complained of esophageal symptoms and none had undergone esophageal or abdominal surgery. A detailed history was obtained to ensure that no volunteer was taking, or had taken, drugs known to influence esophageal motility in the weeks before the manometric examinations.

Results T a b l e 1 lists t h e m a n o m e t r i c d i a g n o s i s f o r t h e g r o u p of subjects evaluated for dysphagia and/or chest pain. O v e r a l l , 3 0 4 o f 4 2 9 p a t i e n t s (70.8o/0) w e r e s h o w n to have some kind of esophageal abnormality. NEMD was the most common finding (31%), foll o w e d b y a c h a l a s i a ( 1 3 % ) . S i n c e six s u b j e c t s ( 1 . 3 % ) whose motor abnormalities simulated either achalasia or DES had a history and clinical features that suggested this diagnosis (recent onset of symptoms, a d v a n c e d age, d i s c r e t e w e i g h t l o s s ) [41, 42], t h e r e ferring physician was asked to re-evaluate the patient. More accurate upper endoscopic examinat i o n s o r C T s c a n s r e v e a l e d t h a t t h e six p a t i e n t s h a d motor abnormalities secondary to cancer that simulated a primary esophageal motor disorder,

Discussion E s o p h a g e a l m a n o m e t r y is a f i r s t - l i n e d i a g n o s t i c a i d for the investigation of patients who complain of

A. Bassotti et al.: Manometry in Dysphagia and Chest Pain dysphagia a n d / o r chest pain [ 1, 2, 43, 44]. T h i s study reports o u r m a n o m e t r i c experience in a large g r o u p o f subjects referred for e v a l u a t i o n o f these s y m p t o m s a n d reveals certain points that m e r i t discussion. First, there are n o reports f r o m Italy on the m a n o m e t r i c investigation o f consistent groups o f patients complaining o f d y s p h a g i a a n d / o r chest pain. Although m a n o m e t r i c techniques are finding e v e r wider application in Italy, they are m o s t frequently directed to the investigation o f patients with reflux esophagitis, which is surprising considering their marginal role, a p a r t f r o m research purposes, in the clinical e v a l u a t i o n o f these patients [44--47]. Second, the high percentage (70.8%) o f esophageal m o t o r a b n o r m a l i t i e s we detected b y m a n o m etry contrasts drastically with the 35% K a t z et al. [48] reported in their i m p r e s s i v e study on m o r e t h a n 1000 subjects. A n u m b e r o f factors could h a v e contributed to the m a r k e d discrepancy: different selection o f the patients referred for m a n o m e t r y (a sizable n u m b e r o f o u r patients were investigated for suspected achalasia, whereas such referrals were m u c h less c o m m o n in K a t z et al.'s series), m o r e or less accurate p r e m a n o m e t r i c evaluation, differences in the p o p u l a t i o n s a m p l e s (for instance, we are often required to evaluate patients with suspected collagen disease, w h o not infrequently h a v e esophageal dysmotility), different diagnostic criteria, particularly in the case o f N E M D . Third, as others h a v e [48], we f o u n d specific esophageal m o t o r disorders to be c o m p a r a t i v e l y rare. In fact, the m a j o r i t y o f esophageal m o t o r a b n o r malities were N E M D , as they were in K a t z et al.'s [48] series. Despite the fact that we and others [16, 19, 48-52] h a v e r e p o r t e d N E as the m o s t frequent p r i m a r y esophageal m o t o r disturbance, the incidence o f N E was c o m p a r a t i v e l y low (10%) in the Present series; this m a y be due to the lower n u m b e r o f specific referrals for chest pain. Furthermore, since m o r e accurate diagnostic criteria h a v e allowed the incidence o f DES, once r e p u t e d to be very frequent, to be reduced to m o r e realistic proportions, it n o w accounts for only 5 - 1 0 % o f esophageal m o t o r abnormalities [48, 53, present study]. T h e r e q u i r e m e n t that at least 20% s i m u l t a n e o u s contractions m u s t be d o c u m e n t e d before a diagnosis o f DES can be established s e e m s to us a good c o m p r o m i s e between the overrestrictive and t o o loose criteria cited in the literature [53]. We m u s t also a d d a w o r d a b o u t esophageal m o tor a b n o r m a l i t i e s associated with cancer. Because the m a n o m e t r i c findings in these cases are indistinguishable f r o m those o f p r i m a r y dysmotilities [41,

5 42], it is essential that e v e r y subject w h o undergoes m a n o m e t r y be accurately q u e s t i o n e d a b o u t his or her s y m p t o m s a n d that a detailed history be obtained. O n l y by carrying out t h o r o u g h p r e - e x a m i nation screening can errors that w o u l d delay form u l a t i o n o f a correct diagnosis be a v o i d e d . T h e present study on the m a n o m e t r i c e v a l u a tion o f patients w h o c o m p l a i n o f d y s p h a g i a a n d / o r n o n c a r d i a c chest p a i n d e m o n s t r a t e s that esophageal m a n o m e t r y yields high diagnostic accuracy p r o v i d ed that the patients referred are carefully studied before functional studies are begun, the indications for m a n o m e t r y are p r o p e r l y established, the m a n o m e t r i c e x a m i n a t i o n s are c a r d e d out by d e p e n d a b l e techniques with reliable i n s t r u m e n t s , a n d an adeq u a t e control group is available for c o m p a r i s o n . Acknowledgments. We are indebted to Judy Dale-Etherington for expert revision of the English form of the manuscript. This study is part of Dr Bassotti's second year research program in experimental surgery.

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