Table Of ContentGastrointestinal Motility
Tests and Problem-Oriented Approach
Gastrointestinal Motility
Tests and Problem-Oriented Approach
Edited by
Satish S. C. Rao
University of Iowa College of Medicine
Iowa City, Iowa
Associate Editors
Jeffrey L. Conklin
University of Iowa College of Medicine
Iowa City, Iowa
Frederick C. Johlin
University of Iowa College of Medicine
Iowa City, Iowa
Joseph A. Murray
Mayo Clinic
Rochester, Minnesota
Konrad S. Schulze-Delrieu
The University of Iowa College of Medicine
Iowa City, Iowa
and
Robert W. Summers
The University of Iowa College of Medicine
Iowa City, Iowa
Springer Science+Business Media, LLC
Library of Congress Cataloging-in-Publ ication Data
Gastrointestinal motility tests and problem-oriented approach /
:
edited by Satish S.C. Rao ... [et al.l.
p . cm .
"Proceedings of the Sixth Symposium on Gastrointestinal Motility,
held March 13-15, 1998 in Dana Point, Ca 1ifornia"—T.p. verso.
Includes bibliographical references and index.
ISBN 978-1-4613-7176-2 ISBN 978-1-4615-4803-4 (eBook)
DOI 10.1007/978-1-4615-4803-4
1. Gastrointestinal system—Motility—Disorders Congresses.
I. Rao, Satish S. C. II. Symposium on Gastrointestinal Motility
(6th : 1998 : Dana Point, Calif.)
[DNLM: 1. Gastrointestinal Motility Congresses. 2. Diagnostic
Techniques, Digestive System Congresses. 3. Digestive System
Diseases — physiopatho 1 ogy Congresses. 4. Hypera1gesia .Congresses.
WI 140 G25885 1999]
RC811.G376 1999
616.3'3—dc21
DNLM/DLC
for Library of Congress 99-16121
CIP
Including proceedings of the Sixth and Seventh Symposia on Gastrointestinal Motility, held March 13-15,1998, in
Dana Point, California, and March 19-21, 1999, in Cancün, Mexico, respectively
ISBN 978-1-4613-7176-2
©1999 Springer Science+Business Media New York
Originally published by Kluwer Academic / Plenum Publishers in 1999
Softcover reprint of the hardcover 1st edition 1999
10 9 8 7 6 5 4 32
A CLP. record for this book is available from the Library of Congress.
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, Or transmitted in any form or by any means,
electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the
Publisher
PREFACE
Gastrointestinal motility has evolved from an esoteric laboratory tool into a sophisti
cated diagnostic technique that is now widely used clinically to guide in management of
complex gastrointestinal problems. Today, it is the most rapidly growing subspecialty
within gastroenterology. Previously, many of the gastrointestinal motility problems were
either ignored or attributed to a disturbance of "psyche." But with the growing knowledge
and understanding of how a dysfunction of the gastrointestinal muscle and nerves can
cause disease, we are at the threshold of a revolution in our approach to the diagnosis and
treatment of gastrointestinal motility disorders.
The purpose of this book is to serve as a useful, up-to-date reference manual and
guide for the diagnostic and therapeutic approach towards common adult and pediatric
gastrointestinal motility problems. In order to enhance the understanding of these disor
ders, a problem-oriented approach has been chosen, and wherever possible the authors
have provided clinical case scenarios to illustrate their message. The emphasis has been on
how to diagnose and treat motility disorders rather than to provide an encyclopedic infor
mation. The reference list at the end of each chapter should enable the enthusiast to seek
further information. Some of the material presented in this book has been derived from the
proceedings of the annual University ofIowa College of Medicine GI Motility Symposia.
Motility largely refers to the movement of muscles that line the gastrointestinal con
duit. But the regulation of this movement involves many other components, principally the
nerves, reflexes, visceral sensations, and neurohormones. Hence, this subspecialty is now
more aptly described as neurogastroenterology and gastrointestinal motility. In the follow
ing chapters, we present some new information regarding the genesis, evaluation, and
management of visceral hyperalgesia- the key problem which causes pain and discomfort
related to several gastrointestinal organs. Because motility is a visual science, generous il
lustrations and tables have been provided throughout the text in order to enhance the un
derstandingof common problems.
We hope that this book will serve as useful reading material for practitioners and
trainees in gastroenterology, as well as for radiologists, internists, family practitioners, and
general surgeons, each of whom encounter patients with motility problems on a daily ba
sis. The "tests" section can be particularly useful for nurses and technical personnel that
are involved in gastrointestinal motility. These diagnostic tests are evolving and there is
no standardized approach. But the authors-who are experts in their field- have provided
a succinct, practical, and balanced approach that can be used in any laboratory. We believe
v
vi Preface
that users will gain information that will enable them to provide better care for their pa
tients.
Given the increasing impositions of clinical work, and constraints on academic time,
editing this book has not been easy. But this task was accomplished, because of the dedi
cated and uncompromising support of my wife Sheila, my children Priyanka, Anita and
Nikilesh, and my secretary, Ms. Susie McConnell. I would like to especially thank the as
sociate editors for helping me see the light when I was blindfolded, and each of the
authors who have expended their valuable time in the service of humanity. Plenum Pub
lishers, in particular Ms. Mary Ann McCarra and Jonathan Harmon, deserve special credit
for their painstaking and meticulous efforts to produce this book in a timely fashion.
Clearly, you the reader can only judge the quality of this work, and I hope you like it.
Salish S. C. Rao
CONTENTS
Section 1. Tests of Gastrointestinal Motility,
Associate Editor: Satish S. C. Rao
I. Videofluoroscopic Assessment of Swallowing
Bruce P. Brown
2. Esophageal Manometry .................... ...... ................... 9
Jeffrey L. Conklin and Joseph A. Murray
3. 24 Hour Ambulatory pH Test 23
Joseph A. Murray
4. Scintigraphic and Ultrasound Evaluation of Gastric Motility 31
Bruce P. Brown
5. Electrogastrography .... .............. ..... .... .......... ....... .... 39
Mark Pimentel and Henry C. Lin
6. Antroduodenojejunal Manometry .......... ....... ......... .. ........ . 51
Robert W. Summers and Satish S. C. Rao
7. Sphincter of Oddi Manometry 61
Glen A. Lehman
8. Colonic Transit and Anorectal Manometry 71
Satish S. C. Rao
9. Defecography and Anal Endosonography 83
Retta E. Pelsang
Section 2. Clinical Approach to Disorders of Oropharyngeal and Esophageal Motility,
Associate Editor: Konrad S. Schulze-Delrieu
10. Oropharyngeal Dysphagia ................ ..... ... .. ........... ... .. . 93
Konrad S. Schulze-Delrieu and Bruce Brown
vii
viii Contents
11. Esophageal Dysphagia 107
Jeffrey L. Conklin
12. Typical and Atypical Manifestations of Gastroesophageal Reflux Disease 121
Donald O. Castell
Section 3. Clinical Approach to Disorders of Gastric and Small Intestinal Motility,
Associate Editor: Robert W. Summers
13. Disorders of Gastric Motility and Emptying 131
Konrad S. Schulze-Delrieu
14. Disorders of Small Intestinal Motility 143
Robert W. Summers
15. Post Surgical Gastric Dysmotility Syndromes 153
John H. Pemberton
16. Dyspepsia and Upper Gastrointestinal Motility in Children 159
Carlo Di Lorenzo
17. Prokinetics.... .... ..... .... .. ......... ..... ........... .. .. ... ... .. 169
Joseph A. Murray
Section 4. Clinical Approach to Disorders of Pancreas and Biliary Motility,
Associate Editor: Frederick C. Johlin
18. Gallbladder Dysmotility 179
Glen A. Lehman
19. Sphincter ofOddi and Pancreatic Sphincter Dysmotility 183
Frederick C. Johlin
Section 5. Clinical Approach to Disorders of Colon and Anorectal Motility,
Associate Editor: Jeffrey L. Conklin
20. Constipation ... .............. .............. ....... ..... ........... 197
Satish S. C. Rao
21. Fecal Incontinence ... ............ ..... ... ....... ... .. .. .. .... .. .. .. 213
John H. Pemberton
22. Biofeedback Therapy for Constipation and Fecal Incontinence 223
Satish S. C. Rao
23. Pediatric Colorectal Disorders 237
Carlo Di Lorenzo
24. Bloating and Gas ....... .... ... ....... ....... .. .......... ....... ... . 249
William J. Snape, Jr.
Contents Ix
Section 6. Gastrointestinal Visceral Pain,
Associate Editor: Joseph A. Murray
25. Neurophysiology of Visceral Pain 257
G. F. Gebhart
26. Clinical Evaluation of Visceral Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Satish S. C. Rao
27. Clinical Approach to Non-Cardiac Chest Pain. . . . . . . . . . . . . . . . . . . . . 2. 77. . . . . .
Donald O. Castell
28. Clinical Approach to Non-Ulcer Dyspepsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Mark Pimentel and Henry C. Lin
29. Clinical Approach to Colorectal Pain 295
William J. Snape, Jr.
Contributors 303
Index. . . . . . . . .. . . . ... ... . . . . . . . . . . . . .. .. .. ... . . . . . . . . . . . . . .• . .. .. .. ... 305
1
VIDEOF LUOROSCOPIC ASSESSMENT OF
SWALLOWING
Bruce P. Brown'
Department of Radiology
University of Iowa Hospitals and Clinics
Iowa City, Iowa
INTRODUCTION
Because radiographic techniques of evaluating the upper, striated-muscle portion of
the esophagus differ significantly from those of evaluating the lower, smooth-muscle por
tion of the esophagus, a radiographic assessment of swallowing should be directed by the
patient's history. The history enables the examiner to focus on the anatomical segment that
is most likely involved and to tailor the study accordingly. If the history suggestsp roblems
related to the upper esophagus, the patient will require rapid-sequence, cine-fluoroscopy
of the oropharynx and hypopharynx with only a few spot films. In contrast, if the history
suggests problems of the lower esophagus, then the patient will require cine-radiographic
evaluation of swallows in the prone positio!1. to assess motility, and double-contrast spot
films to detect anatomic abnormalities.
NORMAL PHARYNGEAL ANATOMY (FIGURE 1)
The Cervical Esophagus
The pharynx is arbitrarily divided into the nasopharynx, oropharynx, and hypo
pharynx. The nasopharynx extends from the base of the skull to the soft palate, the oro
pharynx from the soft palate to the level of the vallecula, and the hypopharynx from the
vallecula to the lower extent of the cricopharyngeus. The pharyngeal constrictors (supe
rior, middle, and inferior) form the muscular posterior and lateral walls of the pharynx. On
Phone: 319/356-4374, E-Mail: [email protected]
Gastrointestinal Motility, edited by Rao et al.
Kluwer Academic 1 Plenum Publishers, New York, 1999.
2 B. P. Brown
~T:~;~~~~wtl~~_-=~:NASOPHARYNX
HARD PALATE
SOFT PALATE
TONGUE
LARYNGEAL VENTRICLE
CRICOPHARYNGEUS
TRACHEA
ESOPHAGUS
Figure l. Normal anatomy of the pharynx.
either side and extending posteriorly around the laryngeal apparatus, there is space be
tween the larynx and constrictors, the pyriform sinuses.
The Esophagus from the Cricopharyngeus Distally
The cricopharyngeus forms the major portion of the upper esophageal sphincter and
is continuous with the caudal aspect of the inferior constrictor. It originates from the lat
eral aspect of the cricoid cartilages where it encircles the pharynx at approximately the
level of C5-6. The cricopharyngeus is tonically contracted and relaxes as the constrictors
above it force the food bolus into the upper esophagus.
Four to eight centimeters distal to the cricopharyngeus, the circular and longitudinal
muscle layers of the esophagus change from striated to smooth muscle. The outer longitu
dinal layer crosses the gastroesophageal junction and merges with the outer layer of the
gastric musculature. The inner circular layer thickens as it passes through the diaphrag
matic hiatus and becomes part of the lower esophageal sphincter complex.
Normally, there is a thickening of the circular muscle at or slightly below the dia
phragmatic hiatus, and this segment is referred to as the lower esophageal sphincter
(LES). This sphincteric ring is tonically contracted but opens immediately after initiation
of a swallow.
