Ineffective esophageal motility is associated with acute rejection after lung transplantation independent of gastroesophageal reflux

BACKGROUND Gastroesophageal reflux is associated with poorer outcomes after lung transplant,likely through recurrent aspiration and allograft injury.Although prior studies have demonstrated a relationship between impedance-pH results and transplant outcomes,the role of esophageal manometry in the assessment of lung transplant patients remains debated,and the impact of esophageal dysmotility on transplant outcomes is unclear.Of particular interest is ineffective esophageal motility(IEM)and its associated impact on esophageal clearance.AIM To assess the relationship between pre-transplant IEM diagnosis and acute rejection after lung transplantation.METHODS This was a retrospective cohort study of lung transplant recipients at a tertiary care center between 2007 and 2018.Patients with pre-transplant anti-reflux surgery were excluded.Manometric and reflux diagnoses were recorded from pre-transplant esophageal function testing.Time-to-event analysis using Cox proportional hazards model was applied to evaluate outcome of first episode of acute cellular rejection,defined histologically per International Society of Heart and Lung Transplantation guidelines.Subjects not meeting this endpoint were censored at time of post-transplant anti-reflux surgery,last clinic visit,or death.Fisher’s exact test for binary variables and student’s t-test for continuous variables were performed to assess for differences between groups.RESULTS Of 184 subjects(54%men,mean age:58,follow-up:443 person-years)met criteria for inclusion.Interstitial pulmonary fibrosis represented the predominant pulmonary diagnosis(41%).During the follow-up period,60 subjects(33.5%)developed acute rejection.The all-cause mortality was 16.3%.Time-to-event univariate analyses demonstrated significant association between IEM and acute rejection[hazard ratio(HR):1.984,95%CI:1.03-3.30,P=0.04],confirmed on Kaplan-Meier curve.On multivariable analysis,IEM remained independently associated with acute rejection,even after controlling for potential confounders such as the presence of acid and nonacid reflux(HR:2.20,95%CI:1.18-4.11,P=0.01).Nonacid reflux was also independently associated with acute rejection on both univariate(HR:2.16,95%CI:1.26-3.72,P=0.005)and multivariable analyses(HR:2.10,95%CI:1.21-3.64,P=0.009),adjusting for the presence of IEM.CONCLUSION Pre-transplant IEM was associated with acute rejection after transplantation,even after controlling for acid and nonacid reflux.Esophageal motility testing may be considered in lung transplant to predict outcomes.

Is ineffective esophageal motility associated with gastropharyngeal reflux disease?

AIM： TO evaluate the association between IEM and gastropharyngeal reflux disease （GPRD） in patients who underwent ambulatory 24-h dual-probe pH monitoring for the evaluation of supraesophageal symptoms. METHODS： A total of 632 patients who underwent endoscopy, esophageal manometry and ambulatory 24-h dual-pH monitoring due to supraesophageal symptoms （e.g. globus, hoarseness, or cough） were enrolled. Of them, we selected the patients who had normal esophageal motility and IEM. The endoscopy and ambulatory pH monitoring findings were compared between the two groups. RESULTS;： A total of 264 patients with normal esophageal motility and 195 patients with the diagnosis of IEM were included in this study. There was no difference in the frequency of reflux esophagitis and hiatal hernia between the two groups. All the variables showing gastroesophageal reflux and gastropharyngeal reflux were not different between the two groups. The frequency of GERD and GPRD, as defined by ambulatory pH monitoring, was not different between the two groups. CONCLUSION： There was no association between IEM and GPRD as well as between IEM and GERD. IEM alone cannot be considered as a definitive marker for reflux disease.

Exercise-provoked esophageal motility disorder in patients with recurrent chest pain

AIM:To investigate the relationship between exerciseprovoked esophageal motility disorders and the prognosis for patients with chest pain.METHODS:The study involved 63 subjects with recurrent angina-like chest pain non-responsive to empirical therapy with proton pump inhibitor(PPI).In all,a coronary artery angiography,panendoscopy,24-h esophageal pH-metry and manometry,as well as a treadmill stress test with simultaneous esophageal pH-metry and manometry monitoring,were performed.Thirtyfive subjects had no significant coronary artery lesions,and 28 had more than 50% coronary artery narrowing.In patients with hypertensive esophageal motility disorders,a calcium antagonist was recommended.The average follow-up period was 977 ± 249 d.RESULTS:The prevalence of esophageal disorders,such as gastroesophageal reflux or diffuse esophageal spasm,was similar in patients both with and without significant coronary artery narrowing.Exercise prompted esophageal motility disorders,such as a decrease in the percentage of peristaltic and effective contractions and their amplitude,as well as an increase in the percentage of simultaneous and non-effective contractions.In 14(22%) patients the percentage of simultaneous contractions during the treadmill stress test exceeded the value of 55%.Using Kaplan-Meier analysis and the proportional hazard Cox regression model,it was shown that the administration of a calcium channel antagonist in patients with such an esophageal motility disorder significantly decreased the risk of hospitalization as a result of a suspicion of acute coronary syndrome after the 2.7-year follow-up period.CONCLUSION:In patients with chest pain non-responsive to PPIs,a diagnosis of exercise-provoked esophageal spasm may have the effect of lowering the risk of the next hospitalization.

Correlation of acid reflux and esophageal motility in patients with gastroesophageal reflux disease

Objective:To explore the relationship between acid reflux and esophageal motility in patients with gastroesophageal reflux disease.Methods:From January 2018 to December 2019,80 patients with typical gastroesophageal reflux symptoms such as reflux and heartburn were randomly selected from the Department of Gastroenterology,First Affiliated Hospital of guangxi university of chinese medicine.The patients were divided into pathological group,sensitive group and physiological group based on the percentage of acid exposure time and reflux-symptom correlation.The GerdQ score,quality of life score,esophageal acid test and esophageal manometry related parameters of the three groups of patients were compared.Results:Compared with the sensitive group and the physiological group,the GerdQ score,DeMeester score,orthostatic acid reflux time,orthostatic acid reflux time,longest acid reflux time and acid reflux times in the pathological group were significantly higher.Sf-36 score,lower esophageal sphincter pressure and effective rate of deglutition were all significantly reduced,with statistically significant differences(P<0.05).Compared with the physiological group,the GerdQ score of the sensitive group was higher.The sf-36 score was low,and the differences were statistically significant(P<0.05).The acid indexes in the sensitive group were higher than those in the physiological group,but the differences were not statistically significant(P>0.05).Compared with the physiological group,the distal contraction integral and the amplitude of the lower esophageal sphincter 3cm above the pathological group and the sensitive group decreased significantly(P<0.05).There were no statistically significant differences in the length of the lower esophageal sphincter,the length of the lower esophageal sphincter in the abdominal segment,the amplitude of the upper esophageal sphincter at 7cm and 11cm and the peristaltic wave velocity of the esophageal body in the three groups(P>0.05).Conclusion:the decrease of lower esophageal sphincter pressure is the key factor leading to pathological acid reflux,and acid reflux is closely related to distal contraction integral and peristaltic amplitude of 3cm on lower esophageal sphincter in patients with gastroesophageal reflux disease.

Gender,medication use and other factors associated with esophageal motility disorders in non-obstructive dysphagia

Background:High-resolution esophageal manometry(HREM)is the diagnostic test of choice for evaluation of nonobstructive dysphagia.Studies regarding the predictors of esophageal dysmotility are limited.Therefore,our aim was to study the prevalence of and factors associated with esophageal motility disorders in patients with non-obstructive dysphagia.Methods:We performed a retrospective review of all patients with non-obstructive dysphagia who underwent HREM in a tertiary center between 1 January 2014 and 31 December 2015.After obtaining IRB approval(16–051),clinical records were scrutinized for demographic data,symptoms,medication use,upper endoscopic findings and esophageal pH findings.HREM plots were classified per Chicago Classification version 3.0.Primary outcome was prevalence of esophageal motility disorders;secondary outcomes assessed predictive factors.Results:In total,155 patients with non-obstructive dysphagia(55616 years old,72%female)were identified.HREM diagnosis was normal in 49%followed by ineffective esophageal motility in 20%,absent contractility in 7.1%,achalasia type II in 5.8%,outflow obstruction in 5.2%,jackhammer esophagus in 4.5%,distal esophageal spasm in 3.9%,fragment peristalsis in 1.9%,achalasia type I in 1.9%,and achalasia type III in 0.6%.Men were five times more likely to have achalasia than women[odds ratio(OR)5.3,95%confidence interval(CI):2.0–14.2;P=0.001].Patients with erosive esophagitis(OR 2.9,95%CI:1.1–7.7;P=0.027)or using calcium channel blockers(OR 3.0,95%CI:1.2–7.4;P=0.015)were three times more likely to have hypomotility disorders.Conclusion:From this study,we concluded that HREM diagnosis per Chicago Classification version 3.0 was normal in 49%of patients with non-obstructive dysphagia.Male gender,erosive esophagitis and use of calcium channel blockers were predictive of esophageal motility disorders.

Water-jet vs traditional triangular tip knife in peroral endoscopic myotomy for esophageal dysmotility:A systemic review and metaanalysis

BACKGROUND Peroral endoscopic myotomy is an increasingly used less invasive modality to treat esophageal dysmotility.Recently,triangular tip knife with integrated water jet function has been introduced to mitigate multiple instrument exchanges.AIM To compare traditional triangular tip knife and water jet knife in terms of procedural success,duration,instrument exchanges,coagulation forceps use,and adverse events.METHODS We conducted a systemic review and meta-analysis with two authors independently in electronic databases(PubMed,Embase,and Cochrane Library)from inception through May 2021.In addition,we conducted a relevant search by Reference Citation Analysis(RCA)(https://www.referencecitationanalysis.com).A fixed-effects model was used to calculate weighted mean,odds ratio(OR),and confidence intervals(CI).RESULTS We included 7 studies involving 558 patients.Triangular knife and water jet knife were similar in odds of procedural success with ratio of 4.78(95%CI=0.22-102.47)and odds of clinical success with ratio of 0.93(95%CI=0.29-2.97),respectively.Water jet knife had fewer instrument exchanges compared to triangular knife(2.21,95%CI=1.98-2.45 vs 11.9,95%CI=11.15-12.70)and usage of coagulation forceps(1.75,95%CI=1.52-1.97 vs 2.63,95%CI=2.37-2.89).Adverse events were higher in triangular knife group(OR:2.30,95%CI=1.35-3.95).CONCLUSION Peroral endoscopic myotomy using water jet knife is comparable in terms of pro cedural success to triangular tip knife.Water jet knife also required shorter procedural duration,less instrument exchanges,coagulation devices,and overall adverse events.

Comparison of clinical features and high-resolution esophageal motility characteristics between esophagogastric junction outflow obstruction and type Ⅱ achalasia patients

Objective To compare the clinical features and high-resolution esophageal motility-impedance characteristics among esophagogastric junction outflow obstruction(Eoo)patients,typeⅡachalasia(Ach)patients and healthy controls(Con),in order to explore the values of esophageal high-resolution manometry(HRM)in diagnosis and treatment of Eoo patients.Methods Patients

Huoxue Tongjiang decoction-resisted reflux esophagitis by activation stem cell factor/c-kit/interstitial cell of cajal pathway and regulating the T-helper 17/regulatory T-cells balance in rats

Background:Huoxue Tongjiang decoction(HXTJD)is an effective prescription for treating reflux esophagitis(RE).We investigated the effects of HXTJD on esophageal motility and mucosal inflammation in a rat RE model.Methods:Chemical composition of HXTJD was analyzed by ultrahigh-performance liquid chromatography Q-Orbitrap mass spectrometry(MS).The change rates of mean contraction tension forces,mean amplitudes,and mean frequencies for the lower esophageal sphincter(LES)were recorded using the isolated tissue bath system,mechanical tension transducer,and PowerLab physiological recorder.After weighing the stomach,the phenol red labeling method was used to measure the gastric emptying rate.The LES ultrastructure was observed through transmission electron microscopy.Immunofluorescence and western blotting were used to detect the number of interstitial cells of Cajal(ICC)and the expression levels of c-kit protein,connexin43(Cx43),and stem cell factor(SCF).Flow cytometric analysis and enzyme-linked immunosorbent assay were conducted to detect the percentages of T helper 17(Th17)cells and regulatory T(Treg)cells and the serum concentrations of interleukin 6(IL-6),interleukin 17(IL-17),and interleukin 10(IL-10)in the rats.Results:We identified 28 chemical constituents in HXTJD.Regarding esophageal motility,we revealed that HXTJD increased the mean contraction tension forces,mean amplitudes,and mean frequency change rate of LES and the gastric emptying rate;decreased stomach weight;and improved the LES ultrastructure.Additionally,HXTJD increased the number of ICC-positive cells,and c-kit,Cx43,and SCF expression levels.Regarding esophageal inflammation,HXTJD significantly decreased the percentage of Th17 cells,and IL-6 and IL-17 concentrations,and increased the percentage of Treg cells and IL-10 concentration.Conclusion:HXTJD was found to be efficacious in the rat RE model.It may promote esophageal motility and alleviate the inflammatory response by activating the SCF/c-kit/ICC pathway and regulating the Th17/Treg cell balance.

Oesophageal surgery

INTRODUCTIONThe origins of oesophageal surgery ,like most surgical treatments ,are based in the treatment of traumatic injury .The Smith Surgical Papyrus describes the examination, diagnosis and treatment of 'a gaping wound of throat, penetrating the gullet' [1].

Manometric findings in patients with isolated distal gastroesophageal reflux

AIM： To analyze manometric abnormalities in patients with isolated distal reflux and compare these findings in patients with erosive and non-erosive disease, METHODS： Five hundred and fifty patients who presented to the outpatient clinic of Turkiye Yuksek Ihtisas Hospital with gastroesophageal reflux disease-like symptoms were enrolled, Each individual was evaluated with esophageal manometry, 24-h ambulatory pH monitoring, and upper gastrointestinal endoscopy, Manometric findings for the patients with isolated distal reflux were compared to findings in controls who were free of reflux disorders or hypersensitive esophagus, Findings for isolated distal reflux patients with and without erosive reflux disease were also compared, RESULTS： Of the 550 subjects enrolled, 97 （17.6%, mean age 48 years） had isolated distal reflux and i00 had no abnormalities on ambulatory pH monitoring （control group, mean age 45 years）. There were no significant differences between the isolated distal reflux group and control group with respect to age, body mass index, and esophageal body contraction amplitude （EBCA）. Mean lower esophageal sphincter pressure was significantly higher in the control group （12.7 ± 10.3 mmHg vs 9.6 ± 7.4 mmHg, P = 0.01）. Fifty-five （56.7%） of the 97 patients with isolated distal reflux had erosive reflux disease. There were no statistical differences between the erosive reflux disease and non-erosive reflux disease subgroups with respect to mean EBCA, lower esophageal sphincter pressure, or DeMeester score.However, 13% of patients with gastroesophageal reflux disease had distal wave amplitudes ≤ 30 mmHg, whereas none of the patients with non-erosive reflux disease had distal wave amplitudes in this low category. CONCLUSION： Patients with erosive and non-erosive disease present with similar manometric abnormalities. The only striking difference is the observation of very low EBCA exclusively in patients with erosive disease.

Influence of capsaicin infusion on secondary peristalsis in patients with gastroesophageal reflux disease

AIM To determine whether capsaicin infusion could influence heartburn perception and secondary peristalsis in patients with gastroesophageal reflux disease(GERD). METHODS Secondary peristalsis was performed with slow and rapid mid-esophageal injections of air in 10 patients with GERD. In a first protocol, saline and capsaicincontaining red pepper sauce infusions were randomly performed, whereas 2 consecutive sessions of capsaicin-containing red pepper sauce infusions were performed in a second protocol. Tested solutions including 5 m L of red pepper sauce diluted with 15 m L of saline and 20 m L of 0.9% saline were infused into the mid-esophagus via the manometric catheter at a rate of 10 mL /min with a randomized and doubleblind fashion. During each study protocol, perception of heartburn, threshold volumes and peristaltic parameters for secondary peristalsis were analyzed and compared between different stimuli.RESULTS Infusion of capsaicin significantly increased heartburn perception in patients with GERD(P < 0.001), whereas repeated capsaicin infusion significantly reduced heartburn perception(P = 0.003). Acute capsaicin infusion decreased threshold volume of secondary peristalsis(P = 0.001) and increased its frequency(P = 0.01) during rapid air injection. The prevalence of GERD patients with successive secondary peristalsis during slow air injection significantly increased after capsaicin infusion(P = 0.001). Repeated capsaicin infusion increased threshold volume of secondary peristalsis(P = 0.002) and reduced the frequency of secondary peristalsis(P = 0.02) during rapid air injection. CONCLUSION Acute esophageal exposure to capsaicin enhances heartburn sensation and promotes secondary peristalsis in gastroesophageal reflux disease, but repetitive capsaicin infusion reverses these effects.

Transmitted cardiovascular pulsations on high resolution esophageal impedance manometry, and their significance in dysphagia

AIM To investigate the behavior of pulsatile pressure zones(PPZ's) as noted on high resolution esophageal impedance manometry(HREIM), and determine their association with dysphagia.METHODS Retrospective, single center case control design scr-eening HREIM studies for cases(dysphagia) and controls(no dysphagia). Thoracic radiology studies were reviewed further in cases for(thoracic cardiovascular) thoracic cardiovascular(TCV) structures in esophageal proximity to compare with HREIM findings. Manometric data was collected for number, location, axial length, PPZ pressure and esophageal clearance function(impedance). RESULTS Among 317 screened patients, 56% cases and 64% controls had PPZ's. Fifty cases had an available thoracic radiology comparison. The distribution of PPZ's in these 50 cases and 59 controls was similar(average 1.4 PPZ/patient). Controls(mean 31.2 ± SD 12 years) were a significantly younger population than cases(mean 67.3 ± SD 14.9 years) with P < 0.0001. The upright posture PPZ pressure was higher in controls(15.7 ± 10.0 mm Hg) than cases(10.8 ± 9.7 mm Hg). Although statistically significant(P = 0.005), it was a weak predictor using logistic regression and ROC model(AUC = 0.65). Three dysphagia patients had partial compression from external TCV on radiology(1 aberrant subclavian artery, 2 dilated left atrium). The posture(supine vs upright) with more prominent PPZ's impaired bolus clearance in 9 additional cases by > 20%. CONCLUSION Transmitted TCV pulsations observed in HREIM bear no significant impact on swallowing. However, in older adults with dysphagia, evidence of impaired bolus clearance on impedance should be evaluated for external TCV compression. These associations have never been explored previously in literature, and are novel.

Lower esophageal sphincter relaxation is impaired in older patients with dysphagia

AIM: To characterize the effects of age on the mechanisms underlying the common condition of esophageal dysphagia in older patients, using detailed manometric analysis. METHODS: A retrospective case-control audit was performed on 19 patients aged ≥ 80 years (mean age 85 ± 0.7 year) who underwent a manometric study for dysphagia (2004-2009). Data were compared with 19 younger dysphagic patients (32 ± 1.7 years). Detailed manometric analysis performed prospectively included basal lower esophageal sphincter pressure (BLESP), pre-swallow and nadir LESP, esophageal body pressures and peristaltic duration, during water swallows (5 mL) in right lateral (RL) and upright (UR) postures and with solids. Data are mean ± SE; a P-value < 0.05 was considered significant. RESULTS: Elderly dysphagic patients had higher BLESP than younger patients (23.4 ± 3.8 vs 14.9 ± 1.2 mmHg; P < 0.05). Pre-swallow LESP was elevated in the elderly in both postures (RL: 1 and 4 s P = 0.019 and P = 0.05; UR: P < 0.05 and P = 0.05) and solids (P < 0.01). In older patients, LES nadir pressure was higher with liquids (RL: 2.3 ± 0.6 mmHg vs 0.7 ± 0.6 mmHg, P < 0.05; UR: 3.5 ± 0.9 mmHg vs 1.6 ± 0.5 mmHg, P = 0.01) with shorter relaxation after solids (7.9 ± 1.5 s vs 9.7 ± 0.4 s, P = 0.05). No age-related differences were seen in esophageal body pressures or peristalsis duration. CONCLUSION: Basal LES pressure is elevated and swallow-induced relaxation impaired in elderly dysphagic patients. Its contribution to dysphagia and the effects of healthy ageing require further investigation.

World Federation of Acupuncture-Moxibustion Societies(WFAS)Clinical Practice Guideline on Acupuncture and Moxibustion:Gastroesophageal Reflux Disease(GERD)recommendation summaries

The Clinical Practice Guideline on Acupuncture and Moxibustion:Gastroesophageal Reflux Disease(GERD)(WFAS 007.9-2023),officially released by the World Federation of Acupuncture-Moxibustion Societies(WFAS)on October 9,2023,represents the inaugural acupuncture and moxibustion clinical practice guideline dedicated to GERD globally.This guideline outlines its purpose,scope,target audience,and relevant environments,along with detailing the acupuncture and moxibustion treatment methodology for GERD,as well as the guideline development process and recommendations.This article specifically emphasizes the recommendations of the guideline,highlighting the crucial importance of both the dissemination and adherence to this guideline to standardize acupuncture and moxibustion treatments for GERD.Such standardization plays a pivotal role in the advancement and widespread utilization of acupuncture and moxibustion in the management of GERD.

Current clinical approach to achalasia

Idiopathic achalasia is a rare primary motility disorder of the esophagus. The classical features are incomplete relaxation of a frequently hypertensive lower esophageal sphincter (LES) and a lack of peristalsis in the tubular esophagus. These motor abnormalities lead to dysphagia, stasis, regurgitation, weight loss, or secondary respiratory complications. Although major strides have been made in understanding the pathogenesis of this rare disorder, including a probable autoimmune mediated destruction of inhibitory neurons in response to an unknown insult in genetically susceptible individuals, a definite trigger has not been identified. The diagnosis of achalasia is suggested by clinical features and conf irmed by further diagnostic tests, such as esophagogastroduodenoscopy (EGD), manometry or barium swallow. These studies are not only used to exclude pseudoachalasia, but also might help to categorize the disease by severity or clinical subtype. Recent advances in diagnostic methods, including high resolution manometry (HRM), might allow prediction of treatment responses. The primary treatments for achieving long-term symptom relief are surgery and endoscopic methods. Although limited high-quality data exist, it appears that laparoscopic Heller myotomy with partial fundoplication is superior to endoscopic methods in achieving long-term relief of symptoms in the majority of patients. However, the current clinical approach to achalasia will depend not only on patients' characteristics and clinical subtypes of the disease, but also on local expertise and patient preferences.

Achalasia and thyroid disease

AIM: To investigate some possible etiologies of achalasia by screening patients with achalasia for some autoimmune diseases such as thyroid disease. METHODS: We examined 30 known cases of achalasia (20 females, 10 males). Their age ranged 15-70 years. All of them were referred to our institute for treatment. Their sera were evaluated to detect some possible associations with rheumatoid disease, thyroid disease, inflammatory process, anemia, etc. RESULTS: Seven out of 30 patients (23%) had thyroid disease including four patients with hypothyroidism (13.3%), two patients with hyperthyroidism (6.6%), and one had only thyroid nodule but was in euthyroid state (3.3%). Two of these hypothyroid patients had no related clinical symptoms (subclinical) and two had clinical manifestations of hypothyroidism. There were no correlations between the intensity of thyroid diseases and the severity of achalasia symptoms. CONCLUSION: The etiology of achalasia is unknown although autoimmunity has been implicated and is supported by several studies. Thyroid disease presents concomitantly with achalasia in about one fourth of our patients who may have a common etiology.

Pseudoachalasia in a patient after truncal vagotomy surgery successfully treated by subsequent pneumatic dilations

Pseudoachalasia is a difficult condition for the clinician to differentiate from idiopathic achalasia even by manometry, radiological studies or endoscopy. Its etiology is usually associated with tumors. In most cases, the diagnosis is made after surgical explorations. The proposed pathogenesis of the disease is considered as mechanical obstruction of the distal esophagus or infiltration of the malignancy that affects the inhibitory neurons of the meyenteric plexus in the majority of cases. Surgery has been reported as a cause of pseudoachalasia. We report a 70-year-old man who suffered from deglutination disorder caused by pseudo-achalasia after truncal vagotomy. The patient was symptom-free after a nine-year follow-up and complete recovery of esophageal motility status from pseudoachalasia after pneumatic dilations. We also reviewed the literature of pseudoachalasia.

Effect of Yunqi Decoction (匀气汤 ) on Esophageal Mucosal Morphology and Esophapeal Motility in Reflux Esophagitis Patients

Objective: To observe the effects of Yunqi decoction (匀气汤, YQD) on both esophageal mucosal morphology and esophageal motility in patients with reflux esophagitis (RE). Methods: According to syndrome differentiation of traditional Chinese medicine (TCM), 42 RE patients were divided into three groups fdisharmony of Liver and Stomach (group D), Deficiency-Cold of Spleen and Stomach (Group DC), Heat Syndrome caused by stagnation of Liver Qi (Group H). No. Ⅰ, Ⅱ, Ⅲ of YQD were taken respectively for 4 weeks.Before and after treatment scores of typical symptoms were collected, gastroscopy was performed and esophagealmotility were measured. Results: (1 ) The symptom remission rate was 81. 1 %, there were significant differences between the group DC with group D and group H (P< 0. 01 ). (2) The esophageal mucosal healing ratewas 61. 9 %, the effective rate was 90. 5 %, and the ineffective rate was 9. 5 %. There were not significant differences of effective rate among the three groups (P > 0. 05). (3) The changes of esophageal motility: Loweresophageal sphincter pressure (LESP) and average peristaltic pressure (APP) of group D were obviously higherthan before treatment (P < 0. 05), LESP, gastro--esophageal barrier pressure (GEBP) and peristaltic conductspeed (PCS) of group DC were remarkably higher (P < 0. 05). GEBP of group H was improved (P < 0. 05 ).Conclusions: YQD has a good therapeutic effect. It's not only resolving reflux esophageal symptoms, healingesophageal mucosa, but also improving esophageal motile function.

Dysphagia,reflux and related sequelae due to altered physiology in scleroderma

Systemic sclerosis is a connective tissue disease that presents with significant gastrointestinal involvement,commonly in the esophagus.Dysphagia is a common clinical manifestation of systemic sclerosis and is strongly related to esophageal dysmotility.However,there are multiple other contributing factors in each step in the physiology of swallowing that may contribute to development of severe dysphagia.The oral phase of swallowing may be disrupted by poor mastication due to microstomia and poor dentition,as well as by xerostomia.In the pharyngeal phase of swallowing,pharyngeal muscle weakness due to concurrent myositis or cricopharyngeal muscle tightening due to acid reflux can cause disturbance.The esophageal phase of swallowing is most commonly disturbed by decreased peristalsis and esophageal dysmotility.However,it can also be affected by obstruction from chronic reflux changes,pill-induced esophagitis,or Candida esophagitis.Other contributing factors to dysphagia include difficulties in food preparation and gastroparesis.Understanding the anatomy and physiology of swallowing and evaluating systemic sclerosis patients presenting with dysphagia for disturbances in each step can allow for development of better treatment plans to improve dysphagia and overall quality of life.

Changes in the esophagogastric junction outflow obstruction manometric feature based on the Chicago Classification updates

BACKGROUND The critical diagnostic criteria for esophagogastric junction outflow obstruction(EGJOO)were published in the latest Chicago Classification version 4.0(CCv4.0).In addition to the previous criterion[elevated integrated relaxation pressure(IRP)in supine position],manometric diagnosis of EGJOO requires meeting the criteria of elevated median-IRP during upright wet swallows and elevated intrabolus pressure.However,with the diagnostic criteria modification,the change in manometric features of EGJOO remained unclear.AIM To evaluate the esophageal motility characteristics of patients with EGJOO and select valuable parameters for confirming the diagnosis of EGJOO.METHODS We performed a retrospective analysis of 370 patients who underwent highresolution manometry with 5 mL water swallows×10 in supine,×5 in upright position and the rapid drink challenge(RDC)with 200 mL water from November 2016 to November 2021 at Peking University First Hospital.Fifty-one patients with elevated integrated supine IRP and evidence of peristalsis were enrolled,with 24 patients meeting the updated manometric EGJOO diagnosis(CCv4.0)as the EGJOO group and 27 patients not meeting the updated EGJOO criteria as the isolated supine IRP elevated group(either normal median IRP in upright position or less than 20%of supine swallows with elevated IBP).Forty-six patients with normal manometric features were collected as the normal high-resolution manometry(HRM)group.Upper esophageal sphincter(UES),esophageal body,and lower esophageal sphincter(LES)parameters were compared between groups.RESULTS Compared with the normal HRM group,patients with EGJOO(CCv4.0)had significantly lower proximal esophageal contractile integral(PECI)and proximal esophageal length(PEL),with elevated IRP on RDC(P<0.05 for each comparison),while isolated supine IRP elevated patients had no such feature.Patients with EGJOO also had more significant abnormalities in the esophagogastric junction than isolated supine IRP elevated patients,including higher LES resting pressure(LESP),intrabolus pressure,median supine IRP,median upright IRP,and IRP on RDC(P<0.05 for each comparison).Patients with dysphagia had significantly lower PECI and PEL than patients without dysphagia among the fifty-one with elevated supine IRP.Further multivariate analysis revealed that PEL,LESP,and IRP on RDC are factors associated with EGJOO.The receiver-operating characteristic analysis showed UES nadir pressure,PEL,PECI,LESP,and IRP on RDC are parameters supportive for confirming the diagnosis of EGJOO.CONCLUSION Based on CCv4.0,patients with EGJOO have more severe esophagogastric junction dysfunction and are implicated in the proximal esophagus.Additionally,several parameters are supportive for confirming the diagnosis of EGJOO.