Are there any studies of DES by 24-hour pH measurement ?
J. Janssens, G. Vantrappen (Leuven)
Symptomatic diffuse esophageal spasm is still an ill-defined condition : intermittent peristalsis, simultaneous contractions, repetitive waves, spontaneous activity, high amplitude contractions, prolonged contractions and abnormal esophageal sphincter function have been accepted by various authors, but in various degrees, in an attempt to refine the manometric criteria for symptomatic diffuse esophageal spasm [1-15]. One of the problems in the past was that many studies have used suboptimal
manometric instrumentation and dry swallows, both of which underestimate the peristaltic performance of the esophagus. If one accepts relatively strict criteria, symptomatic diffuse esophageal spasm appears to be a rare condition.
A systematic study with 24-hour pH measurements has not been performed thus far in this patient group. Some patients with apparently functional dysphagia have on conventional manometry only non-specific esophageal motor disorders (NEMD) and, in this patient group, 24-hour pH metry has not been performed systematically. Although it is well known that patients with gastroesophageal reflux may have ah increased incidence of manometrically recorded esophageal motility disturbances, the manometric performance of the esophageal body in reflux patients has not been studied extensively. Older studies that did not yet use perfused catheters demonstrated an increase in repetitive simultaneous contractions in up to 75 p. cent of patients with esophagitis, and suggested that the severity of the esophagitis paralleled the degree of abnormal motility [16, 17]. Subsequent studies, however, using a perfused catheter system, demonstrated that only some 20 p. cent of esophagitis patients exhibited abnormal esophageal body contractility; they were unable to confirm the relation between the severity of the esophagitis and the degree of motor abnormalities [18, 20].
In a recent study of Knuff and co-workers, the main finding in reflux patients, especially in those with Barrett's esophagus, was a decrease in amplitude of the contractions in the distal esophagus as compared to controls . Animal studies have shown that only severe acute esophagitis with transmural inflammation is accompanied by important esophageal motor abnormalities, and that these abnormalities disappear upon healing of the lesions [22, 23]. It remains unknown whether the abnormal motility in patients with severe reflux and esophagitis is the cause or the consequence of the reflux problems.
Whatever the mechanism involved, some patients with severe reflux have on conventional manometric examination in their distal esophagus a motility pattern of non-specific esophageal motor disorders (NEMD), or even diffuse spasm; in these instances, the resting pressure in the lower esophageal sphincter is usually normal or decreased, whereas it is normal or increased in typical primary diffuse spasm. Conversely, when conventional manometry shows a tracing of NEMD or diffuse spasm in the esophageal body and a low resting pressure in the sphincter, reflux must be suspected.
Interesting data on the relation between esophageal motor abnormalities and pH proven reflux have come from studies in patients with angina-like chest pain of noncardiac origin who were examined by 24-hour intraesophageal pH and pressure recordings : in the study by Janssens et al. , 18 of 60 patients with non-cardiac chest pain had a manometric picture of multiple non-peristaltic contractions; four of them had proven reflux. Prolonged 24-hour pH and pressure recordings showed a definite esophageal origin of the chest pain in 21 of the 60 patients: reflux was involved in the pain production in 13 patients, 10 of whom had also evidence of abnormal motility.
21. Knuff TE, Benjamin SB, Worsham F, Hancock JE, Castell DO (1984) Histologic evaluation of chronic gastroesophageal reflux : An evaluation of biopsy methods and diagnostic criteria. Dig Dis Sci 29: 194-201.