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Departments of 1 Radiology and 2 Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
Correspondence: Dr Marc S Levine
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Introduction |
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Materials and methods |
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Our institutional review board approved all aspects of the retrospective study and did not require informed consent for patients whose radiographic images or medical records were included in our study.
Examination technique
Six (37%) of the 16 patients had biphasic oesophagrams and 10 (63%) had biphasic upper gastrointestinal tract examinations that included upright, left posterior oblique (LPO) double-contrast views using an effervescent agent (Baros; Lafayette Pharmaceuticals, Lafayette, IN) and a 250% w/v high-density barium suspension (E-Z-HD; E-Z-EM Company, Westbury, NY), and prone, right anterior oblique (RAO) single-contrast views using a 50% w/v barium suspension (Entrobar; Lafayette Pharmaceuticals). The 10 patients who underwent biphasic upper gastrointestinal tract studies all received a standard dose of 0.1 mg of intravenous glucagon to optimize the double-contrast phase of the examination by producing gastric hypotonia [6]. Ideally, we would have preferred that all of the patients in our study received no pharmacological agents for their radiographic examinations. However, it has been shown that glucagon has no effect on oesophageal peristalsis [7]. Although glucagon can have a relaxant effect on the LOS [7], our patients all had incomplete opening of the LOS when swallowing high-density barium in the upright position. Because glucagon has the opposite effect on LOS relaxation, we do not believe this agent was in any way responsible for the findings in our study. As part of the examination, patients routinely were asked to take multiple discrete swallows in the prone, RAO position to evaluate oesophageal motility. All of the studies were performed by residents or fellows or one of three attending gastrointestinal radiologists, and all were interpreted by the attending radiologists.
Image and report review
The original radiographic reports and images from these 16 barium studies were reviewed jointly by two gastrointestinal radiologists without knowledge of the clinical or manometric findings. Although videotapes of swallowing are not stored by our department on a long-term basis, the radiographic reports provided a detailed assessment of oesophageal motility in these patients. In all cases, double-contrast views of the oesophagus were reviewed to determine the morphologic appearance of the distal oesophagus when the patient swallowed high-density barium in the upright, LPO position and whether or not LOS dysfunction persisted on all of the upright images. We also noted whether there was proximal oesophageal dilatation or delayed oesophageal emptying. Single-contrast views of the oesophagus were also reviewed to determine the appearance of the distal oesophagus when the patient swallowed low-density barium in the prone, RAO position and whether or not LOS dysfunction was present on prone images. The radiographic reports were also reviewed by one author to determine whether oesophageal peristalsis was normal or abnormal in the prone, RAO position. If abnormal, the nature of this dysmotility was noted.
The prevalence of transient failure of opening of the LOS in the upright position on barium studies was determined by identifying the total number of patients who had biphasic oesophagrams or upper gastrointestinal tract studies at our hospital during the same 5.5-year period. For the purposes of this study, we excluded from the denominator all patients who were known to have had surgery (e.g. Nissen fundoplication or surgical myotomy) or other procedures (e.g. oesophageal balloon dilatation) on the gastroesophageal junction.
Manometry and report review
Three (19%) of the 16 patients had manometric examinations. In all three cases, oesophageal manometry was performed using a solid-state intraluminal transducer assembly (Konigsberg Instruments, Pasadena, CA). The Konigsberg catheter was placed in the stomach via a transnasal approach. Gastric (i.e. intra-abdominal) positioning of the pressure transducers was confirmed by showing a rise in pressure during the inspiratory phase of respiration. The patient was then placed in a sitting position, and the LOS was identified on the distal circumferential transducer tracing, using the station pull-through technique. Catheter withdrawal was continued until the pressure inversion point was identified. LOS pressure measurements were obtained distal to the inversion point. Oesophageal body motility was then assessed after positioning the distal transducer 3 cm above the proximal border of the LOS. A series of 10 wet swallows was completed while recording pressures at 3 cm, 8 cm and 13 cm above the LOS. Measurement of LOS resting pressure and length was also performed by standard techniques, using the same transducer assembly.
One of the authors reviewed the manometry reports of these three patients to determine LOS resting pressures and LOS residual pressures on manometry. LOS resting pressure was considered high if it exceeded 45 mm Hg and LOS relaxation was considered incomplete if LOS residual pressure exceeded 8 mm Hg after swallowing. The manometry reports were also reviewed to determine whether oesophageal peristalsis was normal.
Medical records review
Medical records were subsequently reviewed by one author to determine the indications for the barium study, the nature and duration of symptoms, treatment, and patient course.
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Results |
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). The narrowing was severe enough that it caused delayed emptying of barium into the stomach in seven cases (44%) and proximal oesophageal dilatation in six (38%) (see Figure 1a). Although the appearance of the distal oesophagus could be mistaken for that of achalasia on individual images, the LOS intermittently opened to varying degrees in the upright position at fluoroscopy in all patients.
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). In all 16 cases, there was evidence of primary peristalsis in the body of the oesophagus at fluoroscopy, with normal peristalsis in 10 cases (63%), occasional non-peristaltic contractions in three (19%), and intermittently weakened peristalsis with non-peristaltic contractions in three (19%). A total of about 4000 biphasic oesophagrams and upper gastrointestinal tract examinations were performed on patients who were not known to have had surgery or other procedures on the gastroesophageal junction during the 5.5-year time period of our study. In 19 of these 4000 radiographic examinations (including the three cases in which medical records were not available), transient failure of opening of the LOS was reported in the upright, LPO position on barium studies (excluding the 10 cases in which spot images failed to confirm this finding), a prevalence of 0.5%.
Clinical findings
Nine patients (56%) were women and seven (44%) were men. The average age of the 16 patients was 57.5 years (range 27–82 years). Two of the patients had a history of diabetes, one had polymyositis, one had myasthenia gravis, and one tested positive for HIV. Six patients had received calcium channel blockers, one had received nitrates, and one had received botulinum toxin injections at the LOS in the past. 14 patients (88%) had symptoms at the time of the barium study, including dysphagia in seven (44%), chest pain in six (38%), heartburn in six (38%), weight loss in five (31%), regurgitation in three (19%), cough in two (13%), vomiting in two (13%), and belching in two (13%). Four of the seven patients with dysphagia had dysphagia for solids only, two had dysphagia for solids and liquids, and one had unspecified dysphagia. The mean duration of dysphagia was 26.1 months (range 0.5–60 months).
Five (71%) of the seven patients with dysphagia had follow-up clinical data (mean duration of follow-up 19.8 months; range 7–36 months). Four (80%) of these five patients had improvement or resolution of their dysphagia without specific treatment for LOS dysfunction (i.e. oesophageal balloon dilatation, botulinum toxin injection, or surgical myotomy). The remaining patient had persistent dysphagia, but this individual had underlying polymyositis as the likely cause for his dysphagia.
Manometric findings
Manometry revealed LOS dysfunction in two of three patients, manifested by incomplete LOS relaxation with high LOS residual pressures (12 mm Hg and 13 mm Hg, respectively) in both patients and by a hypertensive sphincter with a high LOS resting pressure (102 mm Hg) in one. The remaining patient had normal LOS function. All three patients had normal oesophageal peristalsis.
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Discussion |
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Other patients may have isolated LOS dysfunction with a hypertensive LOS at rest or incomplete relaxation of the LOS during swallowing but no abnormalities of peristalsis in the body of the oesophagus. In a study by Vantrappen et al [3], three (2%) of 156 patients presenting for endoscopic dilatation of the LOS for impaired LOS relaxation had intact primary peristalsis on manometry. In another study by Aliperti and Clouse [5], 17 (28%) of 60 patients with incomplete LOS relaxation had normal peristalsis on manometry, and none of these cases progressed to the classic form of achalasia. In still another study by Freidin et al [4], four (25%) of 16 patients with a hypertensive LOS and normal peristalsis on manometry underwent endoscopic dilatation of the LOS for dysphagia, and all had symptomatic relief of their dysphagia. Thus, isolated LOS dysfunction has been implicated in the gastroenterology literature as a treatable cause of dysphagia with characteristic manometric features.
In contrast, we report 16 patients who had incomplete opening of the LOS manifested by tapered, beaklike narrowing of the distal oesophagus as a transient finding on upright double-contrast views of the oesophagus using a high-density barium, with a normal-appearing distal oesophagus, normal opening of the LOS, and intact primary peristalsis in the body of the oesophagus on prone single-contrast views using a low-density barium (Figure 1). The prevalence of this phenomenon on biphasic oesophagrams or upper gastrointestinal tract examinations at our hospital was 0.5%. However, this figure probably underestimates the true frequency of transient failure of opening of the LOS in the upright position on barium studies, as the three attending gastrointestinal radiologists did not always mention this finding in the radiographic reports because of uncertainty about its clinical implications.
Manometry was performed on three patients with transient LOS dysfunction in the upright position on barium studies, and impaired relaxation of the LOS was documented in two. It should be recognized that manometry routinely is performed with the patient in the sitting position at our institution. Two of our patients therefore had evidence of LOS dysfunction in the upright position both on barium studies and manometry. In the remaining patient, manometry revealed normal relaxation of the LOS despite transient LOS dysfunction in the upright position on the barium study. However, it would be unreasonable to expect perfect correlation between barium studies and manometry for evaluation of LOS function. In fact, previous studies of achalasia have shown that as many as 20–30% of patients with findings of achalasia and incomplete opening of the LOS on barium studies have normal LOS function on manometry [11, 12].
Only seven (44%) of the 16 patients with transient LOS dysfunction on barium studies were found to have dysphagia. Furthermore, the dysphagia improved or resolved without specific treatment for LOS dysfunction (i.e. oesophageal balloon dilatation, botulinum toxin injection, or surgical myotomy) in all but one case with clinical follow-up. If the dysphagia had been caused by the underlying LOS dysfunction, however, it would be unlikely for this symptom to improve or resolve without some form of intervention on the sphincter. Our findings therefore suggest that LOS dysfunction may be observed on upright double-contrast views of the oesophagus as a transient phenomenon of little clinical importance.
It is important for radiologists to be aware of this phenomenon on upright double-contrast oesophagrams, so that it is not mistaken for achalasia or other morphological abnormalities of the distal oesophagus. Although oesophageal motility normally is evaluated with the patient in the prone, RAO position, the fluoroscopist may fail to obtain prone views in patients with severe spasm of the LOS on upright views because of the dramatic nature of the findings or because this spasm is associated with delayed emptying of barium and proximal dilatation (as occurred in 44% and 38% of our patients, respectively), raising concern about the patient's ability to ingest barium in the prone position. In all of our cases, however, prone single-contrast views of the oesophagus using a low-density barium revealed a normal-appearing distal oesophagus with normal opening of the LOS and intact primary peristalsis in the body of the oesophagus. It therefore is important to obtain prone single-contrast views with a low-density barium when incomplete opening of the LOS is observed on upright double-contrast views with a high-density barium in order to differentiate this finding from true achalasia or isolated LOS dysfunction that persists on the prone examination.
The cause of this transient LOS dysfunction in the upright position on barium studies is uncertain. One possible explanation could be related to the temporal relationship between the pharyngeal and oesophageal phases of deglutition. Normally, a pharyngeal contractile wave precedes the onset of LOS relaxation by up to 3.2 s in order to give the swallowed bolus adequate time to reach the LOS, thereby facilitating passage of the bolus into the stomach [13]. Because of the effect of gravity, however, it is possible that swallowed barium in the upright position traverses the oesophagus ahead of the peristaltic wave, reaching the distal oesophagus before the LOS relaxes. This could result in transient failure of opening of the LOS (manifested by beaklike narrowing of the distal oesophagus) with proximal oesophageal dilatation and delayed emptying of barium into the stomach. On prone views from the same examination, however, barium might be expected to pass more slowly through the oesophagus, allowing the LOS to open as the normal contractile wave reaches the gastroesophageal junction, so the distal oesophagus appears normal on these views.
Another possible explanation could be related to the response of the LOS to increased gastric pressures. Under normal conditions, even a small increase in intragastric pressure causes LOS resting pressure to increase [14]. It is possible that administration of an effervescent agent (which is given routinely to distend the stomach before upright double-contrast views of the oesophagus are obtained) sometimes causes a brief increase in intragastric pressure with a concomitant increase in LOS resting pressure, manifested by the transient, beaklike narrowing that was observed in our patients.
It is important to recognize the inherent limitations of our retrospective study, including selection bias and possible inaccurate reporting of symptoms in medical records. We also had to rely on the original radiographic reports for characterization of the motility findings, as the videotapes from these examinations were not stored on a long-term basis. Only three (19%) of the 16 patients in our study underwent manometry, presumably because we often suggested in the radiographic reports that incomplete opening of the LOS only in the upright position was of doubtful clinical importance. Nevertheless, two of the three patients who did undergo manometry also had manometric evidence of LOS dysfunction in the upright position. Finally, no patients had follow-up barium studies, so we were unable to ascertain whether this finding persisted on serial examinations. Because of these limitations, a prospective study of a large series of patients with transient LOS dysfunction on barium studies and manometric correlation is needed to further elucidate the clinical, radiographic, and manometric features of this phenomenon.
In conclusion, our experience suggests that failure of opening of the LOS may be observed as a transient finding on upright double-contrast views of the oesophagus using high-density barium, with normal opening of the LOS on prone single-contrast views using low-density barium. Although some patients had dysphagia, their dysphagia improved or resolved without specific treatment for LOS dysfunction in all but one patient with clinical follow-up. Our experience suggests that transient LOS dysfunction on upright double-contrast views of the oesophagus is of little clinical importance in the absence of LOS dysfunction or oesophageal dysmotility on prone single-contrast views. It is important to be aware of this finding, so that it is not mistaken for achalasia or other abnormalities of the distal oesophagus.
Received for publication August 5, 2004. Revision received October 27, 2004. Accepted for publication December 6, 2004.
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