A Unique Esophageal Motor Pattern That Involves Longitudinal Muscles Is Responsible for Emptying in Achalasia Esophagus

Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, South Korea.
Gastroenterology (Impact Factor: 16.72). 04/2010; 139(1):102-11. DOI: 10.1053/j.gastro.2010.03.058
Source: PubMed


Achalasia esophagus is characterized by loss of peristalsis and incomplete esophagogastric junction (EGJ) relaxation. We studied mechanisms of esophageal emptying in patients with achalasia using simultaneous high-resolution manometry, multiple intraluminal impedance, and high-frequency intraluminal ultrasonography image recordings.
Achalasia was categorized into 3 subtypes, based on the esophageal response to swallows: types 1 and 2 were defined by simultaneous pressure waves of <30 mm Hg and >30 mm Hg, respectively, and type 3 was defined by spastic simultaneous esophageal contractions.
Based on high-resolution manometry, the predominant achalasia pattern of type 2 was characterized by a unique motor pattern that consisted of upper esophageal sphincter contraction, simultaneous esophageal pressure (pan-esophageal pressurization), and EGJ contraction following swallows. High-frequency intraluminal ultrasonography identified longitudinal muscle contraction of the distal esophagus as the cause of pan-esophageal pressurization in type 2 achalasia. Multiple intraluminal impedance revealed that esophageal emptying occurred intermittently (36% swallows) during periods of pan-esophageal pressurization. Patients with achalasia of types 1 and 3 had no emptying or relatively normal emptying during most swallows, respectively.
In achalasia, esophageal emptying results from swallow-induced longitudinal muscle contraction of the distal esophagus, which increases esophageal pressure and allows flow across the nonrelaxed EGJ.

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Available from: Valmik Bhargava, Feb 21, 2014
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    • "First of all it could be argued that panesophageal pressurization in response to water swallowing, present in the majority of our patients, represents a cavity pressure wave rather than a true contraction as detected in patients with peristalsis. Although this is true, previous convincing findings with the use of high-frequency intraluminal ultrasonography have shown that panesophageal pressurization is the result of longitudinal muscle contraction.29 Nevertheless we have added measurement of a simple index related to esophageal wall contraction, i.e. maximal distal intraesophageal pressurization, which has confirmed no effect of cooling in these achalasia patients. "
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    ABSTRACT: Swallowing of cold liquids decreases amplitude and velocity of peristalsis in healthy subjects, using standard manometry. Patients with achalasia and non obstructive dysphagia may have degeneration of sensory neural pathways, affecting motor response to cooling. To elucidate this point, we used high-resolution manometry. Fifteen healthy subjects, 15 non-obstructive dysphagia and 15 achalasia patients, after pneumatic dilation, were studied. The 3 groups underwent eight 5 mL single swallows, two 20 mL multiple rapid swallows and 50 mL intraesophageal water infusion (1 mL/sec), using both water at room temperature and cold water, in a randomized order. In healthy subjects, cold water reduced distal contractile integral in comparison with water at room temperature during single swallows, multiple rapid swallows and intraesophageal infusion (ratio cold/room temperature being 0.67 [95% CI, 0.48-0.85], 0.56 [95% CI, 0.19-0.92] and 0.24 [95% CI, 0.12-0.37], respectively). A similar effect was seen in non-obstructive dysphagia patients (0.68 [95% CI, 0.51-0.84], 0.69 [95% CI, 0.40-0.97] and 0.48 [95% CI, 0.20-0.76], respectively), whereas no changes occurred in achalasia patients (1.06 [95% CI, 0.83-1.29], 1.05 [95% CI, 0.77-1.33] and 1.41 [95% CI, 0.84-2.00], respectively). Our data suggest impairment of esophageal reflexes induced by cold water in patients with achalasia, but not in those with non obstructive dysphagia.
    Full-text · Article · Jan 2014 · Journal of neurogastroenterology and motility
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    • "Among the 3 subtypes of achalasia, longitudinal muscle contraction and sufficient circular muscle excitation are preserved in type II achalasia, sustaining some degree of esophageal body compression.22 Therefore, type II achalasia shows good treatment response by LES pressure reduction. "
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    ABSTRACT: Achalasia is classified into 3 types according to the Chicago classification. The aim of this study was to investigate characteristics and treatment outcomes of 3 achalasia subtypes in Korean patients. Fifty-five patients diagnosed with achalasia based on conventional or high-resolution esophageal manometry were consecutively enrolled. Their clinical characteristics, manometric, endoscopic and esophagographic findings and treatment responses were analyzed among the 3 subtypes of achalasia. Of 55 patients, 21 (38.2%) patients had type I, 28 (50.9%) patients had type II and 6 (10.9%) patients had type III. The median follow-up period was 22.4 (interquartile range, 3.6-67.4) months. Type III patients were older than type I and II patients (70.0 vs. 46.2 and 47.6 years, P = 0.023). The width of the esophagus in type I patients was wider with more frequent bird's beak appearance on esophagogram than the other 2 types (P = 0.010 and 0.006, respectively). Of the 50 patients who received the evaluation for treatment response at 3 months, 7 patients (36.8% vs. 26.9%) were treated with pneumatic dilatation and 4 patients (21.1% vs. 15.4%) with laparoscopic Heller's myotomy in type I and II groups, respectively. The treatment responses of pneumatic dilatation and Heller's myotomy in type I group were 71.4 and 50.0% and in type II were 85.7 and 75.0%, respectively, and all 5 patients in type III group showed good response to medical therapy. Clinical characteristics of 3 achalasia subtypes in Korean patients are consistent with other studies. Treatment outcomes are variable among 3 subtypes.
    Full-text · Article · Oct 2013 · Journal of neurogastroenterology and motility
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    • "Increase in muscle CSA suggests contraction of the longitudinal muscle of the esophagus. Horizontal dashed line represents 2 kΩ value in panel D. Adapted from Hong et al.36 "
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    ABSTRACT: Muscularis propria of the esophagus is organized into circular and longitudinal muscle layers. Goal of this review is to summarize the role of longitudinal muscle in physiology and pathophysiology of esophageal sensory and motor function. Simultaneous manometry and ultrasound imaging that measure circular and longitudinal muscle contraction respectively reveal that during peristalsis 2 layers of the esophagus contract in perfect synchrony. On the other hand, during transient relaxation of the lower esophageal sphincter (LES), longitudinal muscle contracts independently of circular muscle. Recent studies provide novel insights, i.e., longitudinal muscle contraction of the esophagus induces LES relaxation and possibly descending relaxation of the esophagus. In achalasia esophagus and other motility disorders there is discoordination between the 2 muscle layers. Longitudinal muscle contraction patterns are different in the recently described three types of achalasia identified by high-resolution manometry. Robust contraction of the longitudinal muscle in type II achalasia causes pan-esophageal pressurization and is the mechanism of whatever little esophageal emptying that take place in the absence of peristalsis and impaired LES relaxation. It may be that preserved longitudinal muscle contraction is also the reason for superior outcome to medical/surgical therapy in type II achalasia esophagus. Prolonged contractions of longitudinal muscles of the esophagus is a possible mechanism of heartburn and "angina like" pain seen in esophageal motility disorders and possibly achalasia esophagus. Novel techniques to record longitudinal muscle contraction are on the horizon. Neuro-pharmacologic control of circular and longitudinal muscles is different, which provides an important opportunity for the development of novel pharmacological therapies to treat sensory and motor disorders of the esophagus.
    Full-text · Article · Apr 2013 · Journal of neurogastroenterology and motility
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