BACKGROUND The esophagus can be affected by a variety of disorders that may be primary or secondary to another pathologic process, but the resulting symptoms are usually not pathognomonic for a specific problem, making diagnosis and further management somewhat challenging. High resolution impedance manometry (HRiM) has established itself as a valuable tool in evaluating esophageal motility disorder. HRiM is superior in comparison with conventional water perfused manometric recordings in delineating and tracking the movement of functionally defined contractile elements of the esophagus and its sphincters, and in distinguishing the luminal pressurization of spastic esophageal contraction from a trapped bolus. Making these distinctions can help to identify achalasia, distal esophageal spasm, functional obstruction, and subtypes according to the latest Chicago Classification of Esophageal Motility Disorders version 3.0. CASE REPORT We report a case series of 4 patients that presented with dysphagia; and with the ancillary help of the HRiM, we are able to diagnose esophageal motility disorder and evaluate its pathogenetic mechanism. This approach aids in tailoring each management individually and avoiding disastrous mismanagement. CONCLUSIONS From the series of case reports, we believe that HRiM has an important role to play in deciding appropriate management for patients presenting with esophageal motility disorders, and HRiM should be performed before deciding on management.
We report 2 cases where treatment of achalasia type symptoms due to severe non-specific oesophageal dysmotility have shown symptom resolution and manometric improvement to intrasphincteric botulinum injections either by itself or in combination with oesophageal dilatation.
Ten patients presenting with central chest pain and/or dysphagia were diagnosed to have oesophageal motility disorders (OMD) with an incoordinate motor function using computerised radionuclide oesophageal transit study (RT). The criteria for diagnosis of OMD with incoordination using RT were: an 'incoordinate' or 'to and fro' pattern characterised by multiple peaks of activity, prolonged total transit time or radionuclide bolus through entire length of oesophagus and a significant portion of bolus entering the stomach. These features are characteristic but not pathognomonic of diffuse oesophageal spasm (DES) as they are also seen in non-specific motility disorders (NSMD) and occasionally in order oesophageal motility disorders. Mechanical obstruction in the oesophagus and coronary artery disease were excluded appropriately in these patients. When manometry is not available, RT is a sensitive, safe, simple, rapid and non-invasive alternative modality in confirming certain oesophageal motility disorders.
Development of infantile hypertrophic pyloric stenosis during postoperative period in EA with TEF is rare. Postoperative vomiting or feeding intolerance in EA is more common which is due to esophageal stricture, gastroesophageal reflux and esophageal dysmotility. A typical case of IHPS also presents with non-bilious projectile vomiting at around 3-4 weeks of life. The diagnosis of infantile hypertrophic pyloric stenosis in this subset is usually delayed because of its rarity. We report a case of IHPS in postoperative EA and emphasize on high index of suspicion to avoid any delay in diagnosis with its metabolic consequences.
OBJECTIVES: To evaluate the associations between objectively measured gastroesophageal involvement using high-resolution manometry and 24- hour impedance-pH study, and clinical presentations in systemic sclerosis (SSc) patients.
METHODS: This cross-sectional study was conducted in University of Malaya Medical Centre (UMMC) with 31 consecutive SSc patients recruited into this study. Clinical symptoms of gastroesophageal involvement, high-resolution impedance-manometry and 24-hour impedance-pH monitoring were assessed. Their associations with serological features and other organ involvement were evaluated.
RESULTS: Twenty-five (80.6%) patients had gastroesophageal reflux disease (GORD) symptoms, mainly heartburn (45.1%), regurgitation (32.2%) and dysphagia (29%). Using manometry, oesophageal dysmotility was detected in 24 (88.9%) patients, while hypotensive lower oesophageal sphincter (LOS) was observed in 17 (63%) patients. 21 (84%) patients had GORD based on pH study. Hypotensive LOS was significantly associated with presence of digital ulcers. The main gastroesophageal symptoms were absent in majority of the SSc patients including in those with severe gastroesophageal manifestations demonstrating failed peristalsis >75%, hypotensive LOS, Demeester score >200 and acid reflux >200 per day. Demeester score >200 is associated with severity of GORD symptoms. Demeester score >200 was also associated with restrictive lung pattern (p=0.001). Significant association between GORD severity (daily number of acid reflux episodes >200) and pulmonary fibrosis was seen (p=0.030).
CONCLUSIONS: The presence and severity of gastroesophageal symptoms may not accurately reflect the seriousness of oesophageal involvement. GORD severity is associated with presence of restrictive lung pattern and pulmonary fibrosis. Oesophageal manometry and 24-hour pH study should be considered more frequently in the assessment of SSc patients.