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Biomedical subjects

J A Castell

Publications and source records attributed to J A Castell.

At least 19 recordsLinked to original sources
PubMed1998

Globus sensation is associated with hypertensive upper esophageal sphincter but not with gastroesophageal reflux.

Globus sensation (globus) is best described as a constant feeling of a lump or fullness in the throat. Although the etiology of globus remains unclear, it has been attributed to a hypertensive upper esophageal sphincter (UES) resting pressure and to gastroesophageal reflux (GER). The aim of this study was, therefore, to determine if significant associations existed among globus, UES resting pressure, and GER. We reviewed the records of all patients who had stationary esophageal manometry over a 21/2-year interval with specific attention to symptoms of globus, UES pressures, and ambulatory pH studies. Patients with hypotensive UES (<30 mm Hg) were excluded. Chi square (chi2) test was used to determine significant associations. Six hundred fifty patients had normal UES resting pressures and 101 patients had hypertensive UES (>118 mm Hg). Seventeen of the 650 (3%) (16 women/1 man; mean age: 48, range 32-81 years) with normal UES described globus. Conversely, 28 of the 101 (28%) (15 women/13 men; mean age: 43, range 23-61 years) patients with hypertensive UES described globus. There was a significant association between hypertonicity of the UES and globus (chi2=93.42, P < 0.0001). In patients with normal UES, globus occurred predominantly in females (chi2=6.33, P < 0.01). Twenty-three (16 women/7 men; mean age: 43, range 23-60 years) of the 45 patients with globus had prior ambulatory pH studies. Six of 23 (26%) had GER. Compared to an age-, sex-, and UES-pressure-matched group of 23 patients (16 women/7 men; mean age: 44, range 22-75 years) without globus, nine (39%) had GER, thus showing no significant association of globus with GER (P=0.35). There also was no significant association of GER with normal UES or with hypertensive UES in these patients. In conclusion, there is a significant association between hypertensive UES and globus. The data suggest two possible etiologies: female patients with normal UES pressure potentially having increased afferent sensation and a group with equal sex distribution but abnormally elevated UES resting pressure. This study does not support GER as an etiology of globus.

Adult↗
PubMed1998

Proximal and distal esophageal contractions have similar manometric features.

The human esophagus is composed of striated muscle proximally and of smooth muscle distally with a transition zone between the two. Striated muscle contracts much faster than smooth muscle. The change in pressure over time (dP/dt) of the contraction amplitude should therefore be higher in proximal than in distal esophagus, reflecting the presence of striated muscle proximally. There were 34 normal esophageal manometries of patients analyzed for swallow amplitude and dP/dt in the pharynx and esophagus. An additional 11 healthy controls were similarly studied. Amplitudes in pharynx and proximal and distal esophagus were not different. The mid-esophagus had a pressure trough (P < 0.001). The dP/dt in the pharynx was much higher than that in the esophagus (P < 0.001). The dP/dt of proximal and distal esophagus were of the same order of magnitude. The manometric behavior of the striated muscle portion of the proximal esophagus differs from that seen in the pharynx and shows similar characteristics to distal esophageal smooth muscle.

Adult↗
PubMed1997

Comparison of swallowing function in Parkinson's disease and progressive supranuclear palsy.

Dysphagia is common in both Parkinson's disease (PD) and progressive supranuclear palsy (PSP). Although it is believed to be more common in PSP, there are no controlled data and no comparison of swallowing function between these two disorders. Our aim was to assess dysphagia and swallow function in patients with PSP and PD. Seven patients with PSP were matched to seven patients with PD on the basis of disease duration. Self-rated dysphagia, movement disorder disability, modified barium swallow results, and abnormalities noted on manometry of the lower esophageal sphincter, esophageal body, upper esophageal sphincter, and pharynx were compared between the two groups. Neither severity nor duration of dysphagia differed between the two groups. Patients with PSP had a significantly greater degree of disability [median (range) Hoehn & Yahr score, 4 (3-5) vs. 2 (1-2); P < 0.002]. Manometric abnormalities were similar for the two groups. Oral-phase abnormalities on modified barium swallow were significantly more frequent in PSP (four patients with PSP vs. no patients with PD; p < 0.005). Pharyngeal abnormalities did not differ. Modified barium-swallow scores correlated well with self-reported dysphagia severity for patients with PSP (r = 0.93; p < 0.05) but not for those with PD (r = 0.42; p = NS). The frequency of abnormalities noted during the oral phase was significantly increased in PSP. It is hypothesized that the sensory information conveyed due to this may account for the better correlation between symptoms and swallowing abnormalities and the belief that swallowing problems are more common in PSP.

Barium↗
PubMed1997

Ineffective esophageal motility (IEM): the primary finding in patients with nonspecific esophageal motility disorder.

Nonspecific esophageal motility disorder (NEMD) is a vague category used to include patients with poorly defined esophageal contraction abnormalities. The criteria include "ineffective" contraction waves, ie, peristaltic waves that are either of low amplitude or are not transmitted. The aim of this study was to identify the prevalence of ineffective esophageal motility (IEM) found during manometry testing and to evaluate esophageal acid exposure and esophageal acid clearance (EAC) in patients with IEM compared to those with other motility findings. We analyzed esophageal manometric tracings from 600 consecutive patients undergoing manometry in our laboratory following a specific protocol from April 1992 through October 1994 to identify the frequency of ineffective contractions and the percentages of other motility abnormalities present in patients meeting criteria for NEMD. Comparison of acid exposure and EAC was made with 150 patients who also had both esophageal manometry and pH-metry over the same time period. Sixty-one of 600 patients (10%) met the diagnostic criteria for NEMD. Sixty of 61 (98%) of these patients had IEM, defined by at least 30% ineffective contractions out of 10 wet swallows. Thirty-five of these patients also underwent ambulatory esophageal pH monitoring. Patients with IEM demonstrated significant increases in both recumbent median percentage of time of pH <4 (4.5%) and median distal EAC (4.2 min/episode) compared to those with normal motility (0.2%, 1 min/episode), diffuse esophageal spasm (0%, 0.6 min/episode), hypertensive LES (0%, 1.8 min/episode), and nutcracker esophagus (0.4% 1.6 min/episode). Recumbent acid exposure in IEM did not differ significantly from that in patients with systemic scleroderma (SSc) for either variable (5.4%, 4.2 min/episode). We propose that IEM is a more appropriate term and should replace NEMD, giving it a more specific manometric identity. IEM patients demonstrate a distinctive recumbent reflux pattern, similar to that seen in patients with SSc. This finding indicates that there is an association between IEM and recumbent GER. Whether IEM is the cause or the effect of increased esophageal acid exposure remains to be determined.

Adult↗
PubMed1997

Effective gastric acid suppression after oral administration of enteric-coated omeprazole granules.

Omeprazole is inactivated by exposure to gastric acid and is formulated as a gelatin capsule containing enteric-coated granules that release the drug in alkaline medium. In clinical situations where patients are unable to take the capsule orally, the optimum means of administration is uncertain. Eleven normal volunteers were given omeprazole 20 mg every day for one week before breakfast in random order as either a 20-mg capsule with water or free enteric-coated granules with either 8 oz of orange juice, 8 oz of water with 2 Alka-Seltzer antacid tablets (aspirin free), or 1 teaspoon of apple sauce. On day 7 of each regimen, an 8-hr intragastric pH study was performed following omeprazole 20 mg and standard breakfast. The median percentage of time of gastric acid pH > 4 after an omeprazole capsule was 68.5 (25-100); after granules with orange juice 59 (43-100); after granules in Alka-Seltzer solution 63 (31-100), and after granules in apple sauce 65 (30-99), with no significant differences (ANOVA). The time for the gastric pH to reach <4' after having been above was also similar for all four regimens (ANOVA). Omeprazole granules administered orally in a variety of ways achieve gastric acid suppression as effectively as the intact capsule.

Administration, Oral↗
PubMed1997

Evidence for diminished visceral pain with aging: studies using graded intraesophageal balloon distension.

Graded intraesophageal balloon distension (IEBD) has been utilized in the past to evaluate esophageal pain thresholds. With use of a technique that we have found to provide reproducible results for pain thresholds, two groups of normal individuals without esophageal symptoms or diabetes were studied. Group 1 included 10 "young" (age < 65 yr) individuals (mean age 27 yr, range 18-57 yr). Group 2 included 17 individuals age 65 yr or greater (mean age 72.5 yr, range 65-87 yr). Catheters with latex balloons (Wilson-Cook) were used in all 27 subjects with the balloon located 10 cm above the lower esophageal sphincter. Sequential inflations of 2-ml increments were performed until a total volume of 2 ml above the point of pain or to a maximum of 30 ml was reached. A series of two sequential inflations were performed on each subject on the day of the testing, and the mean value was taken to indicate pain threshold volumes for all 27 subjects. In the group of elderly volunteers, 5 subjects felt no pain even at the maximum inflatable volume of the balloon (30 ml) and were assigned a maximum threshold value of 30 ml. Mean pain threshold volumes for the young subjects was 17 +/- 0.8 ml of air (+/- SE) and for the elderly subjects was 27 +/- 1.4 ml (P < 0.01 and 95% confidence interval = 7.1-13.3). Our conclusion is that IEBD results in the esophagus indicate an age-related decrease in human visceral pain threshold.

Adolescent↗
PubMed1997

Recent developments in the manometric assessment of upper esophageal sphincter function and dysfunction.

Coordinated application of videoradiography and solid-state manometry provides insight into the pathophysiology of oropharyngeal dysphagia and helps direct appropriate therapies for a variety of conditions causing this symptom. Controlled evaluations of various treatment modalities, however, are lacking and therapy often remains primarily empiric. Despite this limitation, important strides have been made in the overall management of these patients during the past decade.

Deglutition Disorders↗
PubMed1996

Upper esophageal sphincter and pharyngeal function and oropharyngeal (transfer) dysphagia.

Through the application of videoradiography and solid-state manometry, much insight has been gained into the pathophysiology of oropharyngeal dysphagia, and considerable guidance has been provided toward appropriate therapies for the multitude of conditions causing this symptom. As noted earlier, a multidisciplinary approach to these patients often provides the most effective diagnosis and treatment regimen. In the diagnostic evaluation, barium videoradiography and solid-state intraluminal manometry should be considered as complementary procedures, with each providing important aspects of the overall assessment of the swallowing mechanism. It is important to note that controlled evaluations of the various treatment modalities are lacking and that therapy, although directed by information provided by the radiographic and manometric assessment, is primarily empiric. Despite this limitation, great strides have been made in the overall management of these patients during the past decade.

Aged↗
PubMed1996

Comparison of barium radiology with esophageal pH monitoring in the diagnosis of gastroesophageal reflux disease.

OBJECTIVE: Barium radiology has recently been recommended as a screening procedure for gastroesophageal reflux disease. The aim of this study was to assess the accuracy of barium screening as a predictor of abnormal esophageal acid exposure on pH monitoring. PATIENTS AND METHODS: One hundred and twenty-five patients underwent both barium radiology and esophageal pH monitoring at the Thomas Jefferson Hospital, Philadelphia, from October 1989 through July 1991. The presence or absence of spontaneous reflux, reflux during the water-siphon test, and a hiatus hernia was recorded and assessed retrospectively. RESULTS: The proportion of patients with a positive pH test did not differ among those with spontaneous reflux (21/31, 68%) and those with no reflux, on barium study (61/94, 65%). The proportion of patients with a positive pH test did not differ among those with a hiatus hernia (35/50, 70%) and those without (47/75, 63%). This was despite significantly higher median percent total times pH < 4 among those with spontaneous reflux or a hiatus hernia (p < 0.05). The additional application of a water-siphon test induced reflux in 91% of those tested. The sensitivities of spontaneous reflux and hiatus hernia were low (26% and 43%), and specificities were only modest (77% and 65%). The addition of the water-siphon test gave a sensitivity of 92%, but the specificity was zero. CONCLUSION: A significantly greater degree of abnormal esophageal acid exposure occurs in patients who have either a hiatus hernia or spontaneous reflux, demonstrated during fluoroscopy. However, the sensitivity and specificity of barium radiology for abnormal degrees of acid reflux are insufficient for it to be worthwhile as a screening procedure.

Adolescent↗
PubMed1996

Pulmonary symptoms associated with gastroesophageal reflux: use of ambulatory pH monitoring to diagnose and to direct therapy.

BACKGROUND: We studied 54 patients with chronic persistent cough or asthma suspected to be due to reflux using distal and proximal pH monitoring. Therapy for reflux was determined by the referring physician and included H2 blockers (51%), omeprazole (36%), surgery (10%), and lifestyle modifications only (3%). On follow-up evaluation, the effect of anti-reflux therapy on pulmonary symptoms (PS) was scored as excellent, good, fair, no change, or worsening symptoms. RESULTS: Forty-two of the 54 patients (78%) had abnormal reflux. Of these, 28 patients (67%) had abnormal proximal acid exposure. Seventy-one percent of reflux patients achieved good to excellent response in PS from anti-reflux therapy. The response was not significantly different between patients with proximal reflux and those with only distal reflux. None of the patients without documented reflux who nevertheless received anti-reflux therapy had a response, even when fair improvement was included as a response. Seventeen percent of patients whose pulmonary symptoms responded to anti-reflux therapy would not have been recognized as having abnormal reflux if proximal pH monitoring had not been done. CONCLUSIONS: The percentage of patients (78%) with pulmonary symptoms having abnormal reflux is consistent with prior studies. Documenting abnormal gastroesophageal reflux helps direct appropriate therapy, and proximal pH monitoring may identify patients with pulmonary symptoms who respond to anti-reflux therapy.

Anti-Ulcer Agents↗
PubMed1996

Mechanisms of gastroesophageal acid reflux and esophageal acid clearance in heartburn patients.

OBJECTIVES: Gastroesophageal reflux can occur because of low resting pressure, transient relaxation, or normal relaxation of the lower esophageal sphincter. Mechanisms for delayed esophageal clearance include impaired peristalsis, infrequent swallowing, and impaired sphincter relaxation. The purpose of this study was to examine esophageal function in patients with gastroesophageal reflux and to determine esophageal acid clearance. METHODS: Esophageal contractile pressure, duration, velocity, pH, sphincter pressure, and deglutition were monitored in 12 heartburn patients 1 h before and 3 h postprandially twice. RESULTS: Eighty-seven episodes of gastroesophageal reflux occurred during normal sphincter relaxation, and 72 episodes occurred during transient sphincter relaxation; however, the frequency with normal sphincter relaxations was quite low (1%) compared with transient sphincter relaxations (33%). Mean and median esophageal acid exposure was not different during normal sphincter relaxation (71 and 80 s) compared with during transient sphincter relaxation (71 and 81 s). There were 284 instances of primary peristalsis, with 157 resulting in esophageal acid clearance, compared with simultaneous contractions (6 of 66), secondary peristalsis (1 of 7), and tertiary contractions (0 of 45). Contractile pressures were higher and durations were longer with acid clearance, but velocities were not different. CONCLUSIONS: Frequency of gastroesophageal reflux is the same during normal and transient sphincter relaxation in heartburn patients. Primary peristalsis is necessary to accomplish acid clearance. Secondary peristalsis is rare and ineffective.

Adult↗
PubMed1995

Manometric characteristics of the pharynx, upper esophageal sphincter, esophagus, and lower esophageal sphincter in patients with oculopharyngeal muscular dystrophy.

Improved techniques in esophageal manometry have made this test an attractive option for investigating pharyngeal or esophageal disorders in patients with dysphagia. We studied esophageal as well as upper esophageal sphincter/pharyngeal (UES/P) pressure dynamics in 11 patients with an established diagnosis of oculopharyngeal muscular dystrophy with modern solid-state manometric techniques and then compared manometric and clinical findings. Esophageal manometric abnormalities were found in 10/11 patients, with the most common being simultaneous contractions and incomplete lower esophageal relaxation. 9/11 patients showed abnormal UES/P manometrics, with the most common abnormalities found in the pharynx. The presence of manometric abnormalities closely paralleled clinical assessment of degree of disease severity. Modern manometric techniques offer an opportunity for a quantitative assessment of swallow abnormalities.

Aged↗
PubMed1995

Swallowing and esophageal function in Parkinson's disease.

Dysphagia and drooling of saliva are frequent symptoms in Parkinson's disease (PD), occurring in one-half and three-quarters of all patients, respectively. Aspiration related to swallowing is a major cause of morbidity and mortality in PD. Defects in oral, pharyngeal, and esophageal phases of swallowing have been documented in patients with PD, and these defects precede symptoms. This paper reviews the current knowledge concerning swallowing abnormalities in PD. The pathogenesis of dysphagia and drooling of saliva is multifactorial, involving cognitive and psychological changes in addition to abnormalities of the extrapyramidal and autonomic nervous systems. Videofluoroscopic imaging of the upper esophageal sphincter and pharynx during mastication and swallowing has been the basis of our understanding of the mechanical malfunction present in patients with PD. Manometric abnormalities of the esophageal body and lower esophageal sphincter have also been documented. The use of combined manofluoroscopy to examine the upper esophageal sphincter and pharynx in PD offers great promise both in understanding the defects and directing therapy. Voluntary airway protection techniques may reduce aspiration, but they need to be tested in a clinical study. Such maneuvers may reduce the morbidity seen in PD.

Deglutition↗
PubMed1994

Frequency and site of gastroesophageal reflux in patients with chest symptoms. Studies using proximal and distal pH monitoring.

Prolonged ambulatory pH monitoring was performed on 89 patients with previous diagnosis of asthma (27 patients), chronic cough (28 patients), noncardiac chest pain (34 patients), and on 27 healthy control subjects. The extent of gastroesophageal reflux (GER) was determined using a catheter containing two antimony pH electrodes positioned 5 cm and 20 cm above the superior border of the manometrically determined lower esophageal sphincter. Reflux was defined as a drop in pH to < 4 in the distal esophagus. We compared both pH < 4 and pH < 5 as the beginning of reflux episodes for the proximal esophagus. Considering the confidence interval of 95% in healthy control subjects as a normality criterion, we found a prevalence of abnormal distal GER in 44% of asthmatics, 50% of patients with cough, and 53.8% of patients with noncardiac chest pain. Abnormal proximal acid exposure was found in 24% of asthmatics, 10.7% of patients with cough and 44.1% of patients with chest pain. Distal acid exposure was significantly longer than proximal esophageal acid exposure in all patient groups (p < 0.05). There were no differences in the evaluation of proximal GER comparing pH < 4 with pH < 5. The data also indicate a tendency toward upright, rather than supine acid exposure. These results support the use of 24-h pH monitoring in patients with chest complaints and indicate that GER may frequently be involved in the pathogenesis. They do not support the theory that proximal GER is a specific etiologic factor in chronic cough or asthma.

Asthma↗
PubMed1994

Approach to patients with oropharyngeal dysphagia.

Oropharyngeal dysphagia is a difficult clinical problem that is commonly found in patients with diffuse neurological or local laryngeal disorders. Gastroenterologists are frequently consulted regarding management of these patients. Diagnosis of specific pathophysiology is best accomplished with a combined approach, including barium video radiography and solid-state manometry. Therapy includes specific modalities where appropriate and mechanical manipulations aimed at prevention of aspiration, in consultation with a speech language pathologist.

Deglutition Disorders↗
PubMed1994

Manometric determination of esophageal length.

OBJECTIVE: Two hundred and fifty-two esophageal manometric studies were reviewed retrospectively to determine the length of esophagus and its relationship to disease, sex, height, and weight. METHODS: For all studies, solid state intraluminal transducers were used, with patients in the supine position. Esophageal length was defined as the difference between the high pressure zone of the upper esophageal sphincter and proximal margin of the lower esophageal sphincter. The mean length of the esophagus was 22.9 +/- 0.2 cm (+/- SEM) in all patients and volunteers (excluding those with achalasia). RESULTS: The 40 patients with achalasia had a significantly (p < 0.05) longer mean esophageal length (24.5 +/- 0.5 cm) than normal volunteers or other patient groups with scleroderma, GERD, chest pain, and dysphagia. Excluding patients with achalasia, 96 males had a significantly (p < 0.05) longer mean esophageal length (23.6 +/- 0.3 cm) than 116 females (22.4 +/- 0.3 cm). A normal distribution of esophageal length was demonstrated in all subjects (excluding those with achalasia). Esophageal length showed poor correlation with either height (r2 = 0.15) or body weight (r2 = 0.003). CONCLUSION: esophageal length showed considerable intersubject variation. Patients with achalasia had a longer esophagus consistent with esophageal dilation. Males had a longer esophagus than females. Esophageal length did not correlate with either height or weight.

Adolescent↗
PubMed1994

Manometric analysis of the pharyngo-esophageal segment.

Manometry of the pharyngo-esophageal segment can be a valuable tool in the investigation of pharyngeal dysphagia. Advances in technology have overcome previous equipment shortcomings and now allow accurate measurements of such factors as the rapid response rate of the striated muscle and asymmetry of the upper esophageal sphincter. Close attention to technique can overcome difficulties with movement artifacts encountered during deglutition. There are an increasing number of reports in the literature of manometric studies of normal swallow function as well as of patients with oropharyngeal dysphagia.

Deglutition Disorders↗