24‐hour monitoring of transient lower esophageal sphincter relaxation events by long‐term high‐resolution impedance manometry in normal volunteers: The “mirror phenomenon”

Abstract

Background The aim of this study was to investigate the frequency and circadian changes in transient lower esophageal sphincter relaxations (TLESRs) in normal volunteers using 24‐hour high‐resolution impedance manometry (HRIM). Methods Fifteen volunteers underwent HRIM. TLESRs were recorded during the mealtime, 2‐hour postprandial, daytime, and supine periods. The catheter was firmly secured to the nose, and subjects went home, ate normal meals, and continued routine daily activities. Key Results Successful recordings were obtained in 11 volunteers. Overall, 1083 TLESRs were documented; the average occurrence was 4.2/h, and the duration was 21.0 ± 5.2 seconds. The majority of the TLESRs occurred during the 2‐hour postprandial (42.7%) and daytime (31.5%) periods, while 10.2% and 15.6% occurred during the mealtime and supine periods, respectively. Eight hundred and eighty‐six (81.8%) TLESRs were associated with reflux. Overall, 25.5% of TLESRs were preceded by partial secondary peristalsis (PSP), while 74.5% were preceded by nothing. Terminating events included primary peristalsis (PP; 40.3%), PSP (42.8%), full secondary peristalsis (FSP; 8.2%), or nothing (8.7%). Both preceding and terminating events periodically changed throughout the four periods. One hundred and twelve (10.3%) TLESRs with both preceding and terminating events of PSP, presenting as a “mirror phenomenon,” were documented. The majority of these TLESRs occurred during the supine (70.5%). Conclusions & Inferences Transient lower esophageal sphincter relaxations are common physiological motor events in normal volunteers; these events have certain circadian rhythms, as do the events that precede and terminate TLESR events. A special “mirror phenomenon” is observed when both the preceding and terminating events are PSP.

The mechanisms associated with reflux episodes in ambulant subjects with gastro‐esophageal reflux disease

“…Two previous ambulatory studies in GERD subjects 7,8 utilized outdated perfused sleeve manometry. The current prolonged ambulant study of the mechanisms associated with GER in GERD subjects took advantage of the new HRM technology combined with pH impedance that has been utilized in healthy volunteers to study TLESR over a 24‐h period 27 . The present study confirmed that TLESR is unequivocally the dominant mechanism associated with GER.…”

“…TLESR with GER [group A 18.0 (9-42) and group B 24.0(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31), p = 0.06]. However, post-prandial TLESR with GER were more common in group B [17.0 (9-24)] than group A[13.5 (7-34), p = 0.014].During post-prandial exercise, group B had significantly more TLESRs with GER [8.0 (4-14)] than group A [6.0 (3-19), p = 0.007].…”

Characterization of esophageal motor activity, gastroesophageal reflux, and evaluation of prokinetic effectiveness in mechanically ventilated critically ill patients: a high-resolution impedance manometry study

“…However, our data suggest that maintaining rest LES tone may not be essential for preventing reflux, as almost 70% of the reflux episodes we observed occurred due to TLESR. Although TLESR may be a normal physiological motor event in healthy subjects [12], previous studies have proven that TLESR plays a crucial role in the occurrence of gastroesophageal reflux disease [13]. It appears that the major mechanisms of reflux in our cohort of patients recovering from critical illness and receiving minimal sedation are similar to non-ventilated patients.…”

“…It appears that the major mechanisms of reflux in our cohort of patients recovering from critical illness and receiving minimal sedation are similar to non-ventilated patients. By contrast, a notable feature of esophageal activity that often preceded TLESR was panesophageal secondary peristalsis, an abnormality never seen in healthy subjects [12]. It remains unclear, whether this secondary peristalsis is itself a trigger of TLESR.…”

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“…Meanwhile, the role of HRM in human medicine is expanding. Emerging applications in humans include the implementation of three-dimensional (3-D) HRM, in which there is a 9-cm segment lined with 12 pressure sensing loci and 8 radially dispersed pressure sensors at each locus, to evaluate pressure distributions at the pharynx, UES, and EGJ (249) or combination HRM-impedance technology to evaluate post-prandial TLESRs (250) or belching disorders (247). HRMimpedance technology is also being trialed in humans to assess bolus transit and post-residue swallows in patients with oropharyngeal (251) and esophageal dysmotility (252,253).…”