Three-dimensional pressure image and muscular structure of the human lower esophageal sphincter

Stein, Hubert J.; Liebermann-Meffert, D.; DeMeester, Tom R.; Siewert, J. R.

doi:10.1016/s0039-6060(95)80014-x

Cited by 113 publications

(98 citation statements)

References 15 publications

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“…Ulerich et al measured a gradual thickening of the muscularis propria from 1.77 mm at the proximal margin of the GES to 2.55 mm at the distal margin of the abdominal esophagus. Cadaver measurements by other investigators (31,45,52) have reported a similar thickening of the muscle wall in the distal esophagus. The lengths of the abdominal and sphincteric segments were estimated from a number of studies, in addition to those already mentioned, most notably Kahrilas et al (25).…”

Section: The Anatomical Modelsupporting

confidence: 57%

“…2), 2) a 1.5-cm segment of abdominal esophagus, 3) a 3-cm segment of sphincteric muscle, and 4) a substantial length of intrathoracic esophagus. We also felt it important to include in the model the axial thickening of the muscularis from the upper margin to the esophagocardiac junction, as measured in several cadaver and in vivo human studies (31,45,52). A manometric catheter (4.4-mm diameter) was included to make the model relevant to the in vivo motility studies from which the data were obtained.…”

Section: The Anatomical Modelmentioning

confidence: 99%

See 1 more Smart Citation

Liquid in the gastroesophageal segment promotes reflux, but compliance does not: a mathematical modeling study

Ghosh¹,

Kahrilas

Brasseur³

2008

American Journal of Physiology-Gastrointestinal and Liver Physi

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Ghosh SK, Kahrilas PJ, Brasseur JG. Liquid in the gastroesophageal segment promotes reflux, but compliance does not: a mathematical modeling study. Am J Physiol Gastrointest Liver Physiol 295: G920 -G933, 2008. First published August 21, 2008 doi:10.1152/ajpgi.90310.2008.-The mechanical force relationships that distinguish normal from chronic reflux at sphincter opening are poorly understood and difficult to measure in vivo. Our aim was to apply physics-based computer simulations to determine mechanical pathogenesis of gastroesophageal reflux. A mathematical model of the gastroesophageal segment (GES) was developed, incorporating the primary anatomical and physiomechanical elements that drive GES opening and reflux. In vivo data were used to quantify muscle stiffness, sphincter tone, and gastric pressure. The liquid lining the mucosa was modeled as an "effective liquid film" between the mucosa and a manometric catheter. Newton's second law was solved mathematically, and the space-time details of opening and reflux were predicted for systematic variations in gastric pressure increase, film thickness, muscle stiffness, and tone. "Reflux" was defined as "2 ml of refluxate entering the esophagus within 1 s." GES opening and reflux were different events. Both were sensitive to changes in gastric pressure and sphincter tone. Reflux initiation was extremely sensitive to the liquid film thickness; the protective function of the sphincter was destroyed with only 0.4 mm of liquid in the GES. Compliance had no effect on reflux initiation, but affected reflux volume. The presence of abnormal levels of liquid within the collapsed GES can greatly increase the probability for reflux, suggesting a mechanical mechanism that may differentiate normal reflux from gastroesophageal reflux disease. Compliance does not affect the probability for reflux, but affects reflux volume once it occurs. Opening without reflux suggests the existence of "gastroesophageal pooling" in the distal esophagus, with clinical implications. gastroesophageal reflux disease; lower esophageal sphincter; compliance; stiffness MUCH IS UNDERSTOOD ABOUT THE biomechanics underlying gastroesophageal reflux once refluxate flow into the esophagus has occurred, such as sphincter relaxation pressures (21), transsphincteric pressure gradient (46), hiatal distension (25), and the proximal extent of reflux (11). However, the mechanical differences that distinguish normal from chronic reflux are those that manifest at the time of opening and the initiation of reflux; these are less well understood. This lack of understanding of the initiation process is primarily because the initial opening process involves a level of mechanical subtlety in the balances among multiple forces and muscle deformations that are difficult to measure accurately in vivo due to rapid changes occurring over very short times with small changes in radial distention.The opening of the gastroesophageal segment (GES) and reflux result from dynamic adjustments in the subtle force balance that are initi...

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Section: The Anatomical Modelsupporting

confidence: 57%

Section: The Anatomical Modelmentioning

confidence: 99%

Liquid in the gastroesophageal segment promotes reflux, but compliance does not: a mathematical modeling study

Ghosh¹,

Kahrilas

Brasseur³

2008

American Journal of Physiology-Gastrointestinal and Liver Physi

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“…The crural diaphragm, positioned between and overlapping these two anatomically distinct smooth muscle structures, constitutes the external skeletal muscle mechanism. The sling/clasp muscle complex has been described as a thickened wall of smooth muscle at the gastroesophageal junction (GEJ) in cadaver studies (Liebermann-Meffert et al, 1979;Stein et al, 1991Stein et al, , 1995. Sling muscle fibers surround the junction of the esophagus on the greater curvature side of the gastric cardia.…”

Section: Introductionmentioning

confidence: 99%

“…Clasp muscle fibers, found on the lesser curvature junction of the stomach, attach to the sling muscle. It has been proposed that the perfect match between the manometric pressure and the gastric sling/clasp complex indicates that the gastric sling/clasp muscle fiber group is actually the anatomic correlate of the manometric lower esophageal sphincter (Stein et al, 1995). However, because these muscles are anatomically part of the stomach and not the esophagus, a more appropriate name for the sling/clasp smooth muscle fiber complex is the "upper gastric sphincter."…”

Section: Introductionmentioning

confidence: 99%

Pharmacologic Specificity of Nicotinic Receptor-Mediated Relaxation of Muscarinic Receptor Precontracted Human Gastric Clasp and Sling Muscle Fibers within the Gastroesophageal Junction

Braverman

Vegesna²,

Miller³

et al. 2011

J Pharmacol Exp Ther

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Relaxation of gastric clasp and sling muscle fibers is involved the transient lower esophageal sphincter relaxations underlying the pathophysiology of gastroesophageal reflux disease (GERD). These fibers do not contribute tone to the high-pressure zone in GERD patients, indicating their role in pathophysiology. This study identifies some mediators of the nicotine-induced relaxation of muscarinic receptor precontracted gastric clasp and sling fibers. Muscle strips from organ donors precontracted with bethanechol were relaxed with nicotine and then rechallenged after washing and adding inhibitors tetrodotoxin (TTX), the nitric-oxide synthase inhibitor L-nitro-arginine methyl ester (L-NAME), the ␤-adrenoceptor antagonist propranolol, the glycine receptor antagonist strychnine or ginkgolide B, and the GABA A receptor antagonist bicuculline or 2-(3-carboxypropyl)-3-amino-6-(4 methoxyphenyl)pyridazinium bromide [(gabazine) SR95531]. TTX only inhibited clasp fiber relaxations. L-NAME and propranolol inhibited, and ginkgolide B was ineffective in both. SR95531 was ineffective in clasp fibers and partially effective in sling fibers. Strychnine and bicuculline prevented relaxations with low potency, indicating actions not on glycine or GABA A receptors but more consistent with nicotinic receptor blockade. Bethanechol-precontracted fibers were relaxed by the nitric oxide donor S-nitroso-N-acetyl-DL-penicillamine and by the ␤-adrenergic agonist isoproterenol (clasp fibers only) but not by the glycine receptor agonist taurine or glycine or the GABA A agonist muscimol. These data indicate that nicotinic receptor activation mediates relaxation via release of nitric oxide in clasp and sling fibers, norepinephrine acting on ␤-adrenoceptors in clasp fibers, and GABA acting on GABA A receptors in sling fibers. Agents that selectively prevent these relaxations may be useful in the treatment of GERD.

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“…Grup 2'de yer alan hastaların vektör volüm değerinin diğer iki gruba göre yüksek olduğu ve en düşük radial asimetri değerinin Grup 3'te olduğu görülmüştür. Gruplar arasında istatiksel olarak anlamlı bir fark saptanmamış-tır (p>0,05 Alt özofagus sfinkteri vektör volüm analizinin defektif bir sfinkteri göstermede üst GİS kontrastlı incelemelerine, 24 saat pH monitörizasyonuna ve konvansiyonel manometrik yöntemlere göre daha üstün olduğu bildirilmiştir (23,24,26) . Ancak, kliniğe uyarlanması açı-sından bakıldığında çocuk yaş grubuna uygulanabilirliği tartışmalıdır.…”

Section: Discussionunclassified

To compare efficiency of diagnositc modalities in gastroesophageal reflux disease

Aydın¹,

Özcan²,

Adaletli³

et al. 2015

Tccd

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Three-dimensional pressure image and muscular structure of the human lower esophageal sphincter

Cited by 113 publications

References 15 publications

Liquid in the gastroesophageal segment promotes reflux, but compliance does not: a mathematical modeling study

Liquid in the gastroesophageal segment promotes reflux, but compliance does not: a mathematical modeling study

Pharmacologic Specificity of Nicotinic Receptor-Mediated Relaxation of Muscarinic Receptor Precontracted Human Gastric Clasp and Sling Muscle Fibers within the Gastroesophageal Junction

To compare efficiency of diagnositc modalities in gastroesophageal reflux disease

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