Lower esophageal sphincter dysfunction in diffuse esophageal spasm

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0002-9270/89/8408-0928 Vol.84.No.fi, 1989 Prinied in LI,S,A,

Tm; AMtiRiCAN JOURNAL or GASTROPNTEROIOGY

Copyrighi to 1989 by Am. Coll. of Gastrocnicrnlogy

Lower Esophageal Sphincter Dysfunction in Diffuse Esophageal Spasm Salvatore Campo, M.D.,* and Morris Traube, M.D., F.A.C.G. Gastroenterology Unit, Yale University School ofMedieine, New Haven. Connecticut, and the Medical Service. Veterans Administration Medical Center. We.st Haven, Connecticut

Although lower esophageal sphincter (KES) dysfunction has been reported in patients with diffuse esophageal spasm, recent changes in manometric criteria for spasm and for LES relaxation suggested a need for reassessment. Moreover, LES relaxation in refluxassociated spasm has not been reported previously. On clinical criteria and independent of manometric findings, 22 patients witb spasm were assigned to eitber idiopatbic (I-DES, N = 9) or reflux-associated spasm (RDES, N = 13) groups. Patients wbo underwent manometry for cbest pain (C-NL, N = 10) or reflux (R-NL, N = IU) and bad normal peristalsis served as control groups. Percent LES relaxation was signiflcantly reduced in botb spasm groups, and R-DES bad significantly lower percent relaxation tban I-DKS. Post-deglutitive nadir spbincter pressure was signiflcantly greater in R-DES tban in I-DES. Duration of relaxation was normal in I-DES, but was signiflcantly decreased in ROES. 1 bis study indicates that /) EES relaxation may be impaired in I-DES patients meeting current criteria for spasm, 2) the impairment in I-DES is primarily in "amplitude" of relaxation, /.e., percent relaxation and nadir pressure, but not duration, 3) LES relaxation may also be impaired in R-DES, and 4) the impairment in R-DES is to a greater degree tban in I-DES patients and may be seen in botb "amplitude" and duration of relaxation. This study sbows tbat there is a spectrum of sphincter dysfunction in patients witb esopbageal spasm. It also suggests tbat there may be separate mecbanisms for EES relaxation in R-DES patients, one with impaired relaxation and ihe other with near complete relaxation, "transient" or otherwise, to allow for reflux. INTRODUCTION Although the manometric criteria for ditTuse esophageal spasm (DES) have varied, the presence of an increased percentage ofsimultaneous contractions, with preservation of some peristalsis, has recently been re* Dr. Campo"s current position is at Divisione Medicina Generale, Ospedaie Fatebenfralelli, Isola Tiberina. Rome, ReceivedJan. Id. 1989: revised April 3. 19S9: accepted April 12, 1989.

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quired before the diagnosis of DES could be made ( 1 3). These criteria allow for identification of a more homogeneous group of patients, eflectively exclude classic achalasia. and stress the critical finding of increased nonperistalsis. The latter emphasis is justified, since nonperistaltic cotitractions. but not repetitive contractions, have impaired volume clearance from the esophagus {4). Impaired relaxation of the LES has been identified in some patients with idiopathic DES (5) and has led to successful treatment of patients with dysphagia by pneumatic dilatation of the sphincter (6). U has also been partly responsible for the hypothesis that LES dysfunction may have a centra! etiologic role in various esophageal motor disorders (7). In addition to idiopathic DES, there exists a group of patients with reflux-associated DES (8-11). Such gastroesophageal reflux patients exhibit evidence of esophageal motor dysfunction, iticluding an increased percentage ofsimultaneous contractions (12, 13), i.e., the criterion used for the manometric diagnosis of DES. Although patients with rcilux may have LES dysfunction with either LES hypotension (12. 13) or "transient relaxation" responsible for episodes of reflux (14). incomplete relaxation has received only little attention, having recently been noted without comment in two patients with esophageal reflux (12). Although an earlier paper described incomplete relaxation in some patients with esophagitis (15), the study population did not involve reflux-associated spasm specifically. In addition to changes in diagnostic criteria for DES, manometric technique has recently changed. Pneumohydraulic infusion pumps have led to the redefining of normal and abnormal manometric findings (16, 17). Greater attention has been given to LES relaxation, including post-deglutitive nadir sphincter pressure (17) and duration of relaxation (18), aspects not included in earlier reports of relaxation in normals, esophagitis (15), or idiopathic DES (5). In light of the foregoing, the priticipal aim of our study was to evaluate patients with DES for the presence of LES dysfunction. More specifically we wished to answer the following: I) Does LES dysfunction occur

August 1989

LES DYSFUNCTION IN DIFFUSE ESOPHAGEAL SPASM

in patients meeting current criteria for DES? 2) Can current techniques of measuring LES relaxation characterize in more detail the nature of LES dysfunction? .^) Is such dysfunction seen in both idiopathic DES and reflux-associated DES? MATERIALS AND METHODS Patient population The manometric records of all patients who underwent esophageal manometry at Yale-New Haven Hospital between August I. 1985 and February 29. 1988 were reviewed, and all patients (N = 35) who had been given a diagnosis of DES were identified. (The manometric criteria are given below.) Thirteen patients were excluded from the study because of incomplete clinical records (N = 4), prior fundoplication (N = 4), presence of esophageal stricture (N = 2). use of a Dent sleeve (N = 2) during a short period when all recordings were performed with such device, and the presence of LES hypotension (