Enteric nervous control of propulsive motility. a A “hardwired” polysynaptic peristaltic that underlie all forms of esophageal and intestinal propulsive motility. .. I routinely quote anecdotal comments from gastroenterologic colleagues . The relationship between inflammation-induced neuronal excitability. The beneficial effect of dietary fiber on esophageal motility in GERD .. There was a dose-response relationship between GERD symptoms and total quote reduction (to esophageal acid. Esophageal motility testing in addition to h pH-monitoring is .. with quotations from leading physicians treating esophageal diseases.
Whereas a defective gastroesophageal barrier accounts for an increased number of gastroesophageal reflux episodes, abnormal esophageal peristalsis results in impaired esophageal acid clearance. Experimental evidence suggests that gastroesophageal reflux disease GERD is associated with impaired cholinergic excitatory neural modulation of esophageal motility.
Prokinetic drugs that stimulate the cholinergic esophageal neuromuscular function were proposed for treatment of GERD because they could increase the lower esophageal sphincter LES pressure and improve esophageal acid clearance. In this article, we reviewed the current understanding of the esophageal motor dysfunction present in GERD, and the mechanisms by which cholinergic stimulation may improve esophageal motility in patients with GERD.
Lower esophageal sphincter function in GERD As a group, patients with GERD have a lower mean value of basal LES pressure than that in normal subjects, although most patients with reflux disease have basal LES pressure in the normal range and only a small subgroup, usually with severe peptic esophagitis, have pressures less than 10 mmHg [ 1 ]. While the traditional view was that reflux occurs because of a chronically weak LES, it has been shown that most reflux episodes in normal subjects and patients with mild reflux esophagitis occur during transient relaxations of LES TLESRsi.
In more severe reflux esophagitis, although TLESRs are very important and account for two-thirds of reflux episodes, a greater proportion of reflux occurs during absent basal LES pressure [ 2 ]. Esophageal body motor function in GERD Primary peristalsis Effective peristalsis is a critical determinant for esophageal clearance of refluxed gastric contents [ 1 ]. Evaluation of the normal esophageal peristaltic function using concurrent videofluoroscopy and manometry showed that a single normal peristaltic wave completely clears the entire barium bolus from the esophagus.
If a peristaltic wave fails, i.
[Full text] Ineffective esophageal motility and the vagus: current challenges and | CEG
The minimum effective contraction strength for clearance in the distal esophagus is approximately 30 mmHg [ 2 ]. Above a threshold pressure of 30 mmHg, liquid transport was not affected by amplitude 33 to mmHg or duration 3 to 15 seconds of esophageal contractions [ 3 ].
The relationship between esophageal peristalsis and gastroesophageal reflux GER has been extensively studied in patients with GERD using both stationary esophageal manometry and more recently, ambulatory prolonged esophageal manometry. Stationary manometry There is a trend toward a greater percentage of failed primary peristalsis with increasing severity of reflux disease [ 4 - 6 ]. The amplitude of peristaltic contractions in the distal esophagus is significantly lower in the esophagitis patients group than in controls [ 4 - 7 ].
The amplitude of peristaltic contractions is inversely related to the severity of esophagitis [ 48 ]. The duration of contractions was described either shorter [ 4 ] or longer [ 5 ] but the propagation velocity is unequivocally slower in patients with esophagitis than in controls [ 459 ].
Prolonged esophageal manometry During prolonged overnight stationary manometry, Dodds et al. However, there was an increased number of non-transmitted contractions. When contractions were normally transmitted they had normal amplitude but shorter duration and slower propagation velocity [ 11 ]. In patients with esophagitis grade III and IV, the amplitude of contractions observed during hour ambulatory recording was not significantly reduced but like in patients with less severe esophagitis, contractions had shorter duration and slower propagation velocity [ 12 ].
Patients with abnormal GER but no esophagitis and patients with mild esophagitis grade I and II had normal amplitude of contractions but an increased prevalence of simultaneous contractions [ 1314 ]. Patients with stricture or Barrett's esophagus had a low median amplitude of contractions, an increased frequency of contractions with an amplitude below 30 mmHg and an increased prevalence of failed peristalsis [ 13 ].
In summary, primary esophageal peristalsis is not significantly impaired in patients with abnormal esophageal acid exposure without esophagitis or patients with esophagitis grade I-II. These patients may have a slightly increased number of failed peristalsis. Patients with severe esophagitis, however, can have an increased rate of failed primary peristalsis; reduced amplitude of contractions in the distal esophagus and slow propagation velocities. Propulsive force and secondary peristalsis Williams et al.
The majority of patients with GERD with and without esophagitis had both reduced amplitude of esophageal contractions and reduced traction force induced by wet swallows. Some patients, however, had normal peristaltic contractions yet impaired traction forces.
This finding suggests that other factors than contraction's amplitude not detected by manometry are also determining the traction force generated by a propagated esophageal contraction, i. The authors suggested that esophagitis can be more directly related to impaired esophageal clearance forces than contraction amplitudes. Responses to an intraesophageal balloon distention are also abnormal in patients with esophagitis.
These patients showed a higher threshold for induction of contractile activity and weaker traction forces provoked by graded intraluminal distention [ 1617 ]. Prolonged esophageal manometric studies using an adequate pharyngeal swallowing marker have demonstrated that primary peristalsis is more prevalent than secondary peristalsis as the initial esophageal clearance event both in healthy subjects [ 1819 ] and in patients with GERD [ 2021 ].
In healthy subjects, however, the majority of reflux episodes with supine are followed by secondary peristalsis [ 19 ]. Secondary peristalsis is likely to be important during sleep when the rate of primary peristalsis is reduced.
Secondary peristalsis in response to esophageal distention with air or water is impaired in patients with GERD with and without esophagitis [ 9 ]. Patients may have normal primary peristalsis but abnormal secondary peristalsis. In patients, the response rate to air or water injection was significantly low.
In summary, in patients with GERD with or without esophagitis there is an impaired response to esophageal distention. The traction force generated either by primary or secondary peristalsis balloon distention is reduced and the distention threshold needed to trigger secondary peristalsis is higher than in normal subjects.
Esophageal motor response to reflux events Response to endogenous intraluminal acidification In patients with GERD without esophagitis, intraesophageal acidification caused an increase in deglutition frequency, amplitude and duration of primary peristaltic contractions mainly in the proximal esophagus but a decrease in propagation velocities.
This effect is independent from volume distention of the esophagus suggesting a reaction of acid sensitive receptors in the esophageal mucosa [ 22 ]. Peristaltic response to gastroesophageal reflux Two recent studies assessed the esophageal peristaltic response immediately after a reflux episode in patients with GERD and esophagitis. Esophageal neural and myogenic abnormalities in experimental esophagitis The pathogenic correlation between the esophageal mucosal inflammation and motility disturbances was studied in cats and opossums after repeated intraesophageal acid perfusion.
Most of the studies focussed on the LES and little information is available from the esophageal body. Repeated intraesophageal acid perfusion provokes a decrease in amplitude of esophageal body circular contractions [ 2526 ].
In the opossum there was in addition an increased rate of failed primary peristalsis; the appearance of repetitive spontaneous contractions and esophageal shortening [ 2627 ]. The acid perfusion-induced motility abnormalities can be due to changes in contractile function of the muscle, in the neural modulation of contractions or in both.
Another possibility is that release of inflammatory mediators, i. In vitro experiments using muscle strips from acid perfusion induced-esophagitis were performed to elucidate this problem.
Myogenic integrity was studied, either with direct pharmacologic stimulation of muscle receptors or with electrical field stimulation using parameters for muscle stimulation. In cats, stimulation of esophageal body muscle strips with bethanechol showed a reduced but not abolished response of circular, longitudinal and muscularis mucosae smooth muscle [ 25 ].
However, the LES muscle strips responsiveness to bethanechol was not reduced by esophagitis [ 2930 ]. This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers.
They were examined with the use of symptom questionnaire GERD-Qhigh-resolution esophageal manometry, h esophageal pH-impedance examinations, and food frequency questionnaire before and after 10 d of usual diet supplemented by psyllium 5.
Complete data of 30 patients were available to the final analysis.
Peristalsis - Wikipedia
The obtained results were analyzed with the use of non-parametric statistics Wilcoxon matched pairs test. Minimal resting lower esophageal sphincter LES pressure increased from 5.
Total number of gastroesophageal refluxes GER decreased from Maximal reflux time decreased from Gastroesophageal reflux disease, Psyllium, Gastroesophageal reflux, Lower esophageal sphincter relaxation, Esophageal motility, Dietary fiber, Heartburn, Non-erosive gastroesophageal reflux disease Core tip: Low dietary fiber intake is associated with decreased stomach and gut motility and delayed gastric emptying, which may contribute to the risk of gastroesophageal reflux and gastroesophageal reflux disease GERD symptom frequency.
The ability of dietary fibers to bind nitric oxide contained in food may diminish its negative effect on lower esophageal sphincter pressure. Our study is the first prospective trial demonstrating that increasing dietary fiber intake results in an increase of minimal esophageal resting pressure, a decrease in the number of gastroesophageal refluxes, and a decrease in heartburn episodes per week in patients with non-erosive GERD.
Impaired gastroesophageal motility with an increased number of transient lower esophageal sphincter relaxations TLESRacidification of the esophagus, and low esophageal clearance are considered to be the most important factors in the pathogenesis of GERD[ 15 - 7 ].
Current treatment of GERD includes lifestyle modification, antisecretory drug use, and anti-reflux surgery[ 6 - 9 ]. While healing of reflux esophagitis requires profound suppression of gastric acid secretion and long-term use of maintenance treatment with proton pump inhibitors PPIspatients with non-erosive GERD NERD may also benefit from other treatment options, like lifestyle or diet modification[ 10 ].
Dietary fiber supplementation may be one of the nutrients used for usual diet modification in GERD patients. It was shown that decreased stomach and gut motility, prolonged period of gastric content evacuation, and gastric over-distension associated with low dietary fiber intake and low fiber consumption may play a crucial role in formation of hiatal hernia, which negatively interferes with anti-reflux barrier[ 11 - 13 ].
Increased intragastric pressure and decreased motility are also established risk factors of gastroesophageal reflux[ 14 - 22 ].
Ineffective esophageal motility and the vagus: current challenges and future prospects
The beneficial effect of dietary fiber on esophageal motility in GERD patients is also assumed to be mediated through its ability to bind nitric oxide contained in food and diminish its negative influence on lower esophageal sphincter LES pressure[ 2324 ].
It was demonstrated that some of the dietary fibers may affect not only the rate of gastric emptying but also decrease gastric acidity, making the number of gastroesophageal refluxes lower and reducing their damaging capacity[ 25 ]. There is no direct evidence to date on the positive influence of dietary fiber on GERD.
Therefore, the aim of the present study was to evaluate the effect of dietary fiber on the presence of gastroesophageal reflux, esophageal acidity, lower esophageal sphincter pressure, and clinical manifestations of non-erosive gastroesophageal reflux disease in patients with low dietary fiber intake. This study was registered on the ClinicalTrials. Enrollment criteria Enrollment criteria were: Exclusion criteria were as follows: The presence of GERD symptoms, their severity and frequency were evaluated by certified gastroenterologists.
The primary selection criteria for GERD patients was the presence of heartburn and acid regurgitation for at least 2 times a week. These symptoms were verified with a language-specific version of the international GERD-Q questionnaire[ 26 ].