What is the prevalence of presenting symptoms in relation to individual manometric abnormalities ?
R.E. Clouse (Washington)
Little data are available to answer this question. Reports of these comparisons are few, and those written prior to the widespread use of manometric equipment with adequate fidelity to accurately study the distal esophagus may have been, in part, incorrect. The distal esophageal body and the lower esophageal sphincter (LES) are evaluated in the analytical manometric evaluation of the smooth muscle esophagus , and abnormalities are found in both areas in DES.
Peristaltic performance (i.e., a quantitative comparison of peristaltic and simultaneous contraction sequences) and contraction wave characteristics are both evaluable in the distal esophageal body . The prevalence of presenting symptoms in relation to the degree of impaired peristalsis has not been reported. The prevalence of presenting complaints has been examined in relation to each abnormal contraction wave component (e.g., increased wave amplitudes, prolonged wave durations, double-and triple-peaked waves) found in patients with DES and with other similar, but less severe, disorders . Symptoms do not distinguish this cluster of manometric findings, suggesting that none has special meaning from the symptom standpoint. When these contraction abnormalities are grouped together, however, dysphagia is more likely present .
LES characteristics, including basal pressure and post-relaxation residual pressure, are frequently abnormal in patients with DES [3-6]. Elevated LES basal pressure is found in as many as 1/3 of patients with other characteristics of esophageal spasm [4, 5]. It is possible that the increased prevalence of dysphagia found in patients with severe contraction wave abnormalities typical of DES is actually related to LES factors: we found that motility abnormalities in the two areas were correlated (figure 1) . Most likely, the greater severity of detected manometric abnormality in the distal esophageal body and LES, the greater likelihood of dysphagia as a presenting complaint.
Figure 1. Prevalence of hypertensive lower esophageal sphincter (LES) in relation to manometric pattern in the esophageal body. Hypertensive LES is more commonly seen in symptomatic patients with normal motility in the esophageal body (pattern IA) than in asymptomatic controls. The rate of hypertensive LES further increases with the severity of contraction abnormalities in the esophageal body. Data adapted from Reference 3. (Also see Reference 3 for further description of this motility classification scheme.)
Dysfunction of LES relaxation is also noted more frequently in DES and related disorders than would be expected by chance [4, 6]. In a recent review of 500 manometric tracings, it appeared that, once achalasia patients were excluded, impaired LES relaxation correlated both with impaired peristaltic performance (presence of simultaneous contraction sequences) and with contraction wave abnormalities — abnormalities that are all seen in DES . Unfortunately, the presence or absence of this relatively rare manometric finding has not been directly associated or correlated with presenting symptoms.
1. Vantrappen G, Clouse R, Corazziari E, Janssen J, Wienbeck M (1989) Standardisation of esophageal manometry : an outline of required measurements and technical standards. Gastroenterol International 2 : 150-154.