ESOPHAGEALCATHETERIZATION STUDIES. I. THE MECHA-NISM OF SWALLOWINGIN NORMALSUBJECTSWITH

PARTICULAR REFERENCETO THE VESTIBULE(ESOPHAGO-GASTRICSPHINCTER) *

By JAMES H. PERT, MURRAYDAVIDSON, THOMASP. ALMYANDMARVIN H. SLEISENGER

(From the Departments of Medicine and Pediatrics, The New York Hospital-Cornfell MedicalCenter, New York, N. Y.)

(Submitted for publication October 29, 1957; accepted October 2, 1958)

Although studies of motility by means of anindwelling balloon have furthered understandingof the physiology of the esophagus, this methoddoes not readily lend itself to the simultaneousmeasurements from multiple sites that are neces-sary for understanding the coordinate activitiesof deglutition (1-3). Several investigators werebetter able to study peristalsis in this organ byutilizing tandem systems with open-tipped cathe-ters or transducers (4-10). Sanchez, Kramerand Ingelfinger first pointed out that the motoractivity of the vestibule, or distal 2 to 5 cm. ofesophagus, is different from that of the body (5).Since then there has been considerable discussionregarding the different motility patterns recordedfrom this area and how to interpret them (6,9-11). A good method for the study of thevestibule should allow for sensitive, simultaneousrecordings from closely approximated sites, besufficiently comfortable to the subject to permitprolonged observations, and of course, yield repro-ducible results.

The purpose of this paper is to describe atechnique which fulfills these criteria and to re-port on the results obtained in 15 observations ofesophageal motility in 10 healthy adult subjects.The normal patterns described here will be com-pared (in subsequent communication) with thoseobtained in disease states and during drug ad-ministration.

METHODSAND AMATERIALS

Equipmenitt. The catheterization set consisted of sixpolyethylene tubes (Intramedicg, I.D. 0.055, O.D. 0.075,

* This study was supported by a grant-in-aid of theG. D. Searle and Company, Chicago. Ill., the Ida andWilliam Rosenthal Foundation, and Research Grant RG4460 from the National Institutes of Health. United StatesPublic Health Service.

P.E. 2000)1 cut in three foot lengths and mounted sideby side. The catheters were sealed at their distal endsto a metal gastric bucket so that in effect they repre-sented a single tube with six separate lumina. Lateralopenings, 2 mm. in diameter, were made at fixed intervalsfrom the gastric tip and marked with radiopaque thread(Figure 1).

The catheters were filled with water and pressurechanges were transmitted through these columns to threeSanborn electromanometers and a four-channel Sanbornpolyviso recorder. Details of the operation of the de-

DISTANCEBETWEENOPENINGS

IN CM.

1F

Fi1 Obtained

TIP TUBESNO

4I* :.

I..*..:

it

t- 3- Hi/~B~~~~~I

- 1

2 ...

METAL LGASTRICBUCKET

[G. 1. ESOPHAGEALCATHETERSET

from Clay-Adams, Inc., New York, N. Y.

397

II

J. H. PERT, M. DAVIDSON, T. P. ALMY AND AI. H. SLEISENGER

A UPPERESOPHAGUS

20 .

''' ' 'I A.LOE.;.j,

LOWERESOPHAG~ VESTIBULE

UPPERESOPHAGUS

SI I

-I 1.1

IE :! :. .

LOWERESOPHAGUS

STOMACH iLiz'w.!.. .. -I - 'I'STOMACH VESTIBULE -

-..............

CESOPHAGEALBODY

20 ciHo.~

VESTIBULE 4ORFIG. 2. EFFECT OF RESTING PRESSUREIN THE VESTIBULE

ON MOTILITY DURING SWALLOWING

A. The initial portion of Record A shows a simultane-ous recording from the upper and lower esophageal body.

tecting and recording apparatus and of the connectionsbetween catheters and these instruments were previouslydescribed (12). The records were standardized at 20cm. H2O full scale with a paper speed of 1 mm. per sec-ond, or for higher pressures, at 40 cm. H.O and 0.5 mm.per second.

The scale on the figures indicates magnitude of pressurechange without reference to a zero pressure. This per-mits full use of the scale and depicts accurately the pres-sure gradients between segments, which are the determin-ing factors in the movement of the bolus. The methodalso eliminates the additional error introduced by com-paring measurements to atmospheric pressure. This issometimes inaccurately referred to as "absolute pres-sure," but is in fact another method of expressing rela-tive pressure but in reference to an extraneous variable-atmospheric pressure.

An important feature of the apparatus was the inter-position of three 3-way stopcocks between the six cathe-ters and the connections to the electromanometers (Fig-ure 3). To each of these, two catheters were attached.By switching the stopcock connections, it was possible toselect the desired sites without moving the catheters.Such switching introduced no significant difference in theaccuracy of interpretation of pressure changes when thismaneuver was confined to tips Nos. 3, 4 and 5, whichwere positioned 1 to 2 cm. apart. In this manner, pres-sure in the vestibule relative to that in the stomach orin the body of the esophagus could be determined at anytime by changing from the recording tip in the vestibuleto one in the body above or one in the stomach below.Also, switching aided in locating the terminal segment.Vestibular pressure relative to gastric or body pressurewas frequently ascertained before the effect of swallow-ing was studied (Figure 2).

To record the pressure exerted by the closed organ, amodification of the pump described by Lorber and Shay

By switching the stopcock from the lower esophageal tipto a catheter located 2 cm. below, a vestibular pattern isrecorded with a resting pressure about 20 cm. over thepressure in the esophageal body. Note that with this ele-vated resting pressure the entire response of this segmentto swallowing is a sustained fall in pressure lasting 8 to10 seconds.

S 4, swallow; t, switching of recording catheter tovestibule.

B. In Record B, the bottom tracing shows gastric mo-tility. By switching the stopcock to a tip 2 cm. higher,a vestibular pattern is recorded. In this instance there isvirtually no difference in resting pressure between thestomach and the vestibule. Note that during swallowingthe major component of the vestibular response consistsof a positive pressure wave.

C. In Record C, the initial portion of the vestibularrecord shows an elevated resting pressure and relaxationduring swallowing. There is a spontaneous relaxation ofresting pressure indicated by R, and at this lower restingpressure the response to swallowing consists of a positivepressure wave.

B

20 cm

im

VI I.- V-7-JIP

Al

398

1l-:::.-_ - r

ESOPHAGEALCATHETERIZATION STUDIES

(13) and Davidson, Sleisenger, Almy and Levine (12)was employed. This pump maintained a flow of waterthrough the catheters at the rate of 3 ml. per hour (Fig-ure 3). The effect of this flow upon the form of thepressure tracing recorded from the vestibule was testedin five experiments with four subj ects, with two cathe-ters placed at the same level. No significant differenceswere observed on comparison of records obtained withand without the pump except for more frequent loss ofthe usual phasic activity associated with respiration whenthe pump was not employed. This indicates that thereplacement by the pump of the small amounts of fluidbeing lost at the dependent tip of the catheter diminishesthe possibility of damping in the pressure transmission, be-cause of air bubbles.

The relationship of the pump to the responsiveness ofthe pressure detecting system under conditions when therecording tip is occluded, as wvould exist when a sphinc-ter is closed around the catheter, is seen in Figure 4.The figure illustrates the effect on the pressure recordwhen the tip of a single catheter of the type used in thestudies was manually occluded with the pump turned onand off, while the catheter was connected to the pumpand electromanometer. During simultaneous recordingat the same level, no change in the form of the recordwas produced in the second catheter when the pump wasturned on or off in the first catheter. This indicates thatthese pressure fluctuations are probably not the result ofpumping water into the small closed space of the ves-tibular lumen.

When the diameter of our recording catheter was in-creased and it was made more rigid by fastening thetubes together with an elastic band, pressure changeswere diminished and fluctuations in the resting pressureof the sphincter were minimized.

FIG. 3B. DIAGRAMMATICREPRESENTATIONOF FIGURE 3A

In an effort to determine if any component of the waveforms was caused by the flow of water past the tipsduring deglutition, a special set of catheters was pre-pared. Three polyethylene catheters were attached to-gether, one with a lateral opening, one with an endopening directed caudad, and one with an end openingcephaled. All openings were at the same level. Motil-ity tracings demonstrated that the flow was too slow tohave any detectable influence on the pressure waves andthat the recording from the lateral opening was identicalto those from the catheters with end openings.

A pneumograph placed around the chest of the sub-ject and connected to the fourth channel served as acheck on the effect of respiration, coughing, talking andso forth upon the recording.

Procedure. In the fasting state and without anesthesiaor premedication, the subj ect swallowed the catheterswhich were positioned fluoroscopically so that the gastrictip (No. 6) was in the body of the stomach and No. 5opening was about 2 cm. below the diaphragm. Be-cause the motility of this segment was found to be dif-ferent from that of the stomach, it was considered to be-- + - -In

7 T_ _ r _n ___ _ _ 1-lxl 1 HW;: __ _ r_ _ __ w . _ I I I I I I 11 _2h 5__ _ _ _ _ r _ rA_FI-W114-H_ F _ _ z _ _ l r w _ _ _ _ _ _ rJBe, E _ i _ '_n 1-., a;E, _ .. _ . _ He

_

0OCM

20

FIG. 3A. PUMPASSEMBLYWITH THREE3-WAY STOP-COCKS FOR ATTACHMENTOF THE ESOPHAGEALCATHETERSET

Pump turned offFIG. 4. EFFECT OF SUDDENOCCLUSIONOF CATHETER

OPENING ON PRESSURERECORD

Periods of catheter occlusion are marked by arrows.Note that when catheter is occluded with pump on, thereis marked rise in pressure and prompt return to baselinewith release of occlusion. During occlusion the pressurefalls slowly when pump is turned off (second complex).Later, with pump still off, occlusion produced only slightrise in pressure; however, when the pump was againturned, on, a sharp rise in pressure is recorded (finalcomplex).

399

0- -r-

J. H. PERT, M. DAVIDSON, T. P. ALMY AND AI. H. SLEISENGER

ESOPHAGEALBODY

FIG. 5A. SPOT FILM ILLUSTRATING LOCALIZATION OF

TIP INFRADIAPHRAGMATICALLY IN STUDIES OF THE

TERMINAL SEGMENTOF ESOPHAGUS

esophagus. Miokon® 2 was injected into the cathetersand their positions demonstrated fluoroscopically and byspot films (Figure 5).

The respiratory tracing also aided in localizing the open-ings. Above the diaphragm, inspiration caused a de-crease in intraesophageal pressure and was registeredas a downward deflection of the recording needle. Con-versely, normal inspiration caused the infradiaphragmaticcatheter to record an upward deflection as did gentlemanual pressure over the stomach. A recording tip atthe level of the diaphragm, however, described a respira-tory record of lower amplitude which was out of phasewith both of these. In the infradiaphragmatic esophagus,a deep breath produced an immediate upward deflectionfollowed by a rapid downward deflection as the di-aphragm passed caudad to the catheter tip (Figure 6).

Although preliminary observations indicated that no

appreciable differences could be observed when patientssat or when they reclined, the studies were performedwith the patient in the sitting position because this is theusual body position during swallowing. Continuous aspi-ration of saliva with a catheter situated beyond the crico-pharyngeus reduced involuntary swallowing, but duringexperimental observations this was not carried out since

2 Miokon® was generously supplied by W. R. Arm-strong. Mallinckrodt Chemical Works, St. Louis, Mo.

the effect of involuntary as well as of voluntary swallow-ing was of interest. The effects of coughing, retching,belching, swallowing saliva and deep inspiration werenoted on the tracings.

To study deglutition, the subject was given 10 ml. ofwater to be held in the mouth and swallowed on com-mand. Continuous pressure measurements were madeover periods of one-half to three hours. In the analysesof all records, the presence or absence of each componentwas noted as were the duration and maximum amplitudeof the complex.

RESULTS

Both during swallowing and in the resting statethere are characteristic wave forms of the uppereight-ninths (body) and lower one-ninth (vesti-bule) of the esophagus (Figure 7).

Resting state

In the resting state only respiratory move-ments are discernible in the body. The yes-tibular segment may exhibit a relatively highresting pressure (Figures 2A and 8B) or a chang-ing tone (Figures 2C and 8C). Pressure usuallyvaries between 10 and 40 cm. H20 but may reacheven 100 cm. H20 over resting gastric pressure.By noting the distance between the tips recordingthis characteristic pattern, usually Nos. 3, 4 and 5(Figures 1 and 7), the length of this segment wasfound to vary from 2 to 5 cm. with an average infive normal subjects roughly estimated at 2.7 cm.

~ ~ ~~~~~~~~~~... _....... Al.||....... ..~~~~~~~~~~~~~~~~~~~~~~~.........

ESOPH-.AG AL

, <S VESTSUA SPICE

FIG.*SB. DIAGRAMMATICREPRESENTATIONOF ....FIUR.-

-~~~ ~ ~ ~ ~ ~ ~ ~ ~........-~~~~~~~~~~~~~~~~~~~~~~~~~.FIG.5B. DIAGRAMMATIC~~... RSNTTOOF.IGUE.5

400

ESOPHAGEALCATHETERIZATION STUDIES

cm., and may last as long as 18 seconds. Deflec-tion 5 represents the effect of respiration. Thistype of deflection, therefore, may occur in anypart of the complex.

With the onset of deglutition, there is a briefrelaxation of the vestibule, the degree of pressuredrop being in part dependent upon the resting pres-sure (Figures 2 and 8). Thus, in some instancesthe relaxation was not apparent when the dif-ference between resting pressure in the vestibuleand stomach was relatively small even though theposition of the recording tip in the vestibule wasestablished by both manometric and radiologiccriteria (Figures 2B and 8B). Fluoroscopic ex-amination will show that some material may bepassed into the stomach at this time. This prob-ably represents a mechanism for emptying theesophagus before the bolus reaches the segment.As the peristaltic wave travels down the body,

-.

FIG. 6. EFFECT OF A DEEP BREATHThe respiratory record aids in localizing the recording

tips. The vestibule does not register fall in pressureuntil the diaphragm has passed caudad to the recordingtip during deep inspiration.

Swallowing

The usual wave form of the esophageal bodyduring swallowing has five recognizable compon-

ents (Figure 7). Component 1 occurs during thesipping of a mouthful of water; if, however, thesubject retains liquid in his mouth prior to swal-lowing, this wave will not appear. Under theconditions used in these studies, it appears thatthis wave is caused by the involuntary inspirationwhich occurs with sipping. Our interpretation isin agreement with others that Wave 2 is relatedto the contraction of the pharyngeal muscles. Itis transmitted to the esophageal body tracing viathe bolus. It seems probable that Component 3represents a summation of the decline in Wave 2and the increase in pressure of Wave 4 and thusappears as a plateau. The major component,Wave 4, represents peristaltic contraction and usu-

ally has a smooth, bell-shaped contour. It travelsat the average rate of 2.5 cm. per second (1.9 to5.5 cm. per second) and, with the recording sys-

tem used, attains a pressure of 15 to 20 cm. water.Its duration is 8 to 10 seconds. Occasionally itreaches a height of 25 cm. water and, rarely, 40

FIG. 7. PRESSURE CHANGES IN NORMALSWALLOWINGThis is a multiple tip recording demonstrating pressure

changes in the body and vestibule during the swallowingof water. Components 1 through 5 of complex are de-scribed in text.

UPPERBODY

LOWERBODY,

VESTIBULE -

RESPI F

401

J. H. PERT, M. DAVIDSON, T. P. ALMY AND M. H. SLEISENGER

A

1TRANSENTF

ELEVAI

B

STION DRING S:STING VESTIBU

,it- *-i

:|. 20 CM

AX ~H20

1 --tlZWALLOWINGWITH ANLAR PRESSURE

_71Wi-71 20 CM

H20iJa._ +. ,s

SLOWAND RAPID TYPE OF VESTIBULAR RELAXATIONDURING SWALLOWING

C

_±_20CM

__

1-.. I . 1. I I-CHANGINGOF VETIfBULAR PRESSUREWITH AND

WITHOUTSWALLOWING

FIG. 8. DIFFERENT TYPES OF ACTIVITY OF THE VESTIBU-LAR SPHINCTER

These tracings were recorded from three differentnormal individuals, and illustrate the types of patternwhich may be observed in any normaW subject. Assess-ment of vestibular pressure before swallows as "high" or

"low" is in reference to either pressure in the gastricfundus or esophageal body (Figure 2). Scale indicatesmagnitude of pressure change. Swallowing, occurs at ar-

rows only.A. With a high resting vestibular pressure, swallowing

frequently produces a single relaxation with a return to

the elevated baseline.B. Note that there is no initial relaxation with the

onset of each of two swallows. This is observed whenthe resting pressure at the time is only slightly more

than gastric pressure. The ensuing pressure rise may beterminated slowly (first swallow) or rapidly (secondswallow).

C. Spontaneous changes in the resting vestibular pres-sure are illustrated. The relaxation which occurred withswallowing is indicated by the arrow.

the pressure in the vestibule gradually rises to

5 to 20 cm. water and lasts from 5 to 30 seconds.This rise is terminated with a sudden drop in

pressure in 80 per cent of studies. In the remain-ing 20 per cent, especially when the vestibulartonus at the time of swallowing is high, the initialdecline is of long duration and constitutes theentire complex (Figures 2A and 8A).

A comparison of the slopes of contraction and

subsequent relaxation in the vestibule followinga swallow showed that the rate of relaxation was

5 to 10 times as fast as that of contraction, a

pressure drop of 20 cm. water often occurringin one second. No relationship between the twoslopes in any given complex is seen when the twoslopes are plotted against each other and thegradient sum test applied.

Moreover, the rates of fall in pressure in thevestibule which followed periods of contractionvaried among individuals and were different atvarious times in the same normal subject (Fig-ure 8B). The rapid decline in pressure may bedue not to sudden relaxation of the vestibularmusculature, but to the rapidity of equilibration ofpressures in the distal portion of vestibule and thestomach at the time the lumina of these organs arein continuity.

DISCUSSION

These studies confirm the previous work ofothers that there are two separate functional seg-ments of the normal human esophagus: the body(upper eight-ninths) and the vestibule (lowerone-ninth) (5, 6, 8, 10). Also, our observationsand interpretations of the motility characteristicsof the body associated with deglutition are for themost part in agreement with those of others (4,5). While changes in vestibular pressure, par-ticularly with swallowing, have been shown previ-ously, our measurements demonstrate greaterfluctuation of pressure in this segment, particu-larly during rest, than previously noted. Fluctu-ations in resting pressure do not appear to becaused by shifting of the recording tip out of thevestibule, because such pressure changes may beseen to occur simultaneously when recording withclosely placed tips in this segment. Similarlywhen recording within 1 cm. above or below thissegment, the baseline continues to show the rest-ing pressure of the esophageal body or stomachwhile the vestibular tracing shows these changes.Further clarification of such problems will re-quire simultaneous catheterization and cineradio-graphic investigations. Another difference hasbeen our finding that the motility of the vestibuleduring deglutition is in part dependent upon itspressure relative to that in the stomach or loweresophagus at the time of the swallow. This gradi-ent, readily noted in the same recording channelby switching from vestibule to these adjacentsegments, varied greatly, but pressure was al-

402

ESOPHAGEAL CATHETERIZATION STUDIES

wvays equal or higher in the vestibule. This char-acteristic fluctuation in resting pressure and itsinfluence upon pressure changes during degluti-tion certainly are consistent with sphinctericactivity.

Fyke, Code and Schlegel, using a single trans-ducer, demonstrated slightly higher resting pres-sure in the vestibular segment than in the stomach.Wdith composite tracings recorded by withdrawingthis catheter, and also from recordings made withopen-tipped catheters in tandem, these authorsdemonstrated not only that relaxation occurred inthis area with deglutition, but also that there wasa rise in pressure above baseline for about 13 sec-onds thereafter. Analysis of their tandem recordshows a fluctuation of 40 cm. H20 in the vesti-bule during deglutition. They concluded thatthis behavior warranted designation of this seg-ment as the "esophago-gastric sphincter" (10).Creamer, Fyke, Code and Olsen have reportedsimilar findings with an electromagnetic trans-ducer or an open-tipped catheter connected to amanometer (9). As further evidence, Fyke andco-workers cited the fact that pressure in thisarea relative to fundic pressure became greater inthe head-down position (10).

Sanchez and associates, using open-tipped,water-filled catheter and electromanometers, havereported that the vestibule demonstrated motorbehavior different from the body of the organ.Later, Ingelfinger mentioned "receptive relaxationof the vestibule with swallowing" (14). Morerecently, Fleshler, Hendrix, Kramer and Ingel-finger working in the same laboratory, have re-ported that there is an elevated resting pressurewhich disappears with or immediately after onsetof body peristalsis (15). In addition, this seg-ment resisted hydrostatic force. From these find-ings the authors concluded that the vestibule be-haves as a sphincter. Our studies also indicatethat the vestibule operates as a sphincter capable ofrapid, vigorous contraction and relaxation andwarrants designation as the "esophago-gastricsphincter."

Rapid changes in pressure in any short segmentof gut pose two problems in recording, particu-larly when the walls are in apposition to eachother and the lumen is completely obliterated.One is maintenance of the recording tip in the

area for prolonged periods, and the other is thereliability of the recording, even if one is certainthat the recording tip has not been dislodged.The first problem is largely solved by the cathetersystem employed in these studies which permitsrapid localization of the sphincter without movingthe catheter.

Since the vestibule may often be only 2 cm. inlength, the generation of high pressures will tendto displace any catheter whose terminus is in thearea, especially if there is a bulky tip at its end.As previously noted, bulkiness of catheters affectsaccuracy of pressure recording. It is also prob-able that a sudden increase in tone will dislodgeany contents of the lumen, including a cathetertip, into the body of the esophagus above or intothe stomach below. Frequent movement of thecatheters by the observer to assure proper posi-tioning may also cause retching or coughing whichmay displace the tips.

These difficulties are largely obviated by the six-tube system with closely approximated lateralopenings, which makes possible a set of cathetersof uniform diameter free of bulky recording tips,the terminus of the system residing in the stomach.Discomfort and retching are thus minimized. Inaddition, by means of switching the stopcock set-tings between the closely approximated lateralopenings, small shifts in position can be adjustedfor, and continuous recording for several hoursis possible without moving the tubes. In this wayone is better able to characterize and record con-tinuously the motor behavior of the distal 2 to5 cm. of the esophagus.

The sustained obliteration of the lumen whichoccurs at a sphincter interferes with reliable re-cording and is not easily obviated by changingthe catheter design. Even assuming that one isrecording constantly from the sphincteric region,the deficiencies of the measuring system have tobe taken into account. In other hollow viscera theopen-tipped catheters attached to the electromano-meters always reside in a fluid-filled loop. Changesin pressure exerted on the fluid in the lumenare, therefore, transmitted through the catheters.In a sphincter, however, if all the gas or liquid issqueezed out when the lumen is obliterated, thereis no medium on which pressure can be exerted.Instead, the opening of the catheter becomes

403

J. H. PERT, M. DAVIDSON, T. P. ALMY AND M. H. SLEISENGER

STOMACH

DIAPHRAGM I DIAPHRAGM if

FIG. 9. A BARIUM FILLED SLIDING HIATUS HERNIA, ILLUSTRATING THAT THE SPHINCTERIC ACTION IS INDEPENDENTOF THE DIAPHRAGM

plugged at its distal end as the mucosa of thesphincter occludes it, or even protrudes into it.

The electromanometer is designed to registerpressure changes induced at the end of a catheterto which it is attached by means of small volumedisplacements of the liquid in the system. Oncethe opening of a catheter becomes completely oc-cluded by a "membrane" such as the mucosa ofthe obliterating wall, there may be failure of theelectromanometer to register the exact height ofthe tonus change in the musculature, since therewill be no displacement of liquid after the time ofcomplete occlusion of the tip. However, if thesystem employs a constant infusion pump, a risein pressure will be recorded since fluid is enteringat the proximal end without any distal escape.This rise can only reach the level of that exertedat the distal opening by the sphincteric muscula-ture. If it exceeds this level, it would force themucosa away from the orifice, causing fluid toescape, and the pressure in the catheter could go

no higher. Thus, the pump makes possible amuch closer approximation to the actual pressurebeing exerted by a segment contracting stronglyenough to produce occlusion. Furthermore, evenwhen the tip is not occluded, the pump tends tokeep the system continuously free of the cushion-ing effect of air bubbles.

The ability to record pressures from this shortsegment over long periods makes it possible tostudy the area in greater detail and to observethe coordinate action of the proximal and distalesophagus during the resting state, swallowingand drug administration. It is also possible todifferentiate the sphincter pattern from the effectof the diaphragm by recording above, at and be-low the diaphragm simultaneously.

Aside from its pattern of contraction and re-laxation during deglutition, there is other evidencethat the vestibule constitutes an intrinsic sphincter.A short, contractile segment at the junction of theesophagus and the stomach may be observed

STOMACH

404

ESOPHAGEALCATHETERIZATION STUDIES

fluoroscopically and has been clearly demonstratedlby Wolf and co-workers with cinemaradiography(16). Figure 9 shows respresentative roentgeno-grams to illustrate that the action of this segmentis independent of the diaphragm. In the case il-lustrated, pressure studies of the vestibule showeda normal resting tone and a coordinated responseto deglutition.

This physiologic sphincter cannot be readilyidentified morphologically as a localized muscularring. In his careful study, Lerche (17) suc-ceeded in finding a small band of muscle, but thiswas microscopic in size. The ease of passage ofa bolus through this segment is attributable toreflex relaxation and this behavior is more con-sistent with the behavior of an intrinsic sphincterthan of a valve. The relationship of the slingaction of the right crus of the diaphragm (18) tothe function of the intrinsic sphincter has not beenevaluated by the present method. However, thissling action is probably unnecessary for, and un-related to, normal sphincteric activity. Underphysiological conditions the respirations occurmore frequently than do the openings and closingsof the sphincter. In addition, breath holding haslittle influence on the measurements of sphinctericactivity, which also continues in the presence ofhiatus hernia (Figure 9).

SUMMARY

1. A technique of esophageal catheterization isdescribed for measuring the motility of the es-ophagus. The method employs electromano-meters, a constant infusion pump, and a speciallyprepared set of six catheters connected to three3-way stopcocks. The advantages of this systemfor pressure measurements from a sphincter aredetailed.

2. The pattern of pressure changes obtainedfrom the vestibule is different from that of thebody of the esophagus both at rest and duringdeglutition, indicating that each of these is a sepa-rate functioning segment.

3. At rest, there are changing tonus levels inthe vestibule, often with sudden generation or re-lease of high pressures. These patterns are inde-pendent of those seen in the body of the esophagus

and influence the type of response obtained in thissegment during swallowing.

4. At the onset of swallowing, the vestibulebriefly relaxes and, as peristalsis reaches this seg-ment, a positive pressure wave is developed, fol-lowing which relaxation again occurs. However,if vestibular resting pressure closely approximatesthat in the stomach, this initial relaxation does notoccur. Conversely, when resting pressure is high,the drop in pressure is greater and so prolongedas to comprise the entire vestibular complex.

5. These motor patterns at rest and duringswallowing indicate that the vestibule behaves asan intrinsic sphincter and should be referred to asthe esophago-gastric sphincter.

REFERENCES

1. Kramer, P., and Ingelfinger, F. J. Motility of thehuman esophagus in control subj ects and in pa-tients with esophageal disorders. Amer. J. Med.1949, 7, 168.

2. Kramer, P., and Ingelfinger, F. J. Esophageal sen-sitivity to mecholyl in cardiospasm. Gastroen-terology 1951, 19, 242.

3. Sleisenger, M. H., Steinberg, H., and Almy, T. P.The disturbance of esophageal motility in cardio-spasm: Studies on autonomic stimulation and auto-nomic blockade of the human esophagus, includingthe cardia. Gastroenterology 1953, 25, 333.

4. Butin, J. W., Olsen, A. M., Moersch, H. J., andCode, C. F. A study of esophageal pressures innormal persons and patients with cardiospasm.Gastroenterology 1953, 23, 278.

5. Sanchez, G. C., Kramer, P., and Ingelfinger, F. J.Motor mechanisms of the esophagus, particularly ofits distal portion. Gastroenterology 1953, 25, 321.

6. Ingelfinger, F. J., Kramer, P., and Sanchez, G. C.The gastroesophageal vestibule, its normal func-tion and its role in cardiospasm and gastroesopha-geal reflux. Amer. J. med. Sci. 1954, 228, 417.

7. Hightower, N. C., Jr., Olsen, A. M., and Moersch,H. J. A comparison of the effects of acetyl-beta-methyl-choline chloride (mecholyl) on esophagealintraluminal pressure in normal persons and patientswith cardiospasms. Gastroenterology 1954, 26, 592.

S. Sleisenger, M. H., Davidson, M., Pert, J. H., andAlmy, T. P. Recent advances in physiology of theesophagus. N. Y. St. J. Med. 1955, 55, 2747.

9. Creamer, B., Fyke, F. E., Jr., Code, C. F., and Olsen,A. M. Intraluminal pressures at the esophago-gastric junction in healthy persons and in patientswith cardiospasm (achalasia of the cardia). Clin.Res. Proc. 1956, 4, 130.

405

J. H. PERT, M. DAVIDSON, T. P. ALMY AND M. H. SLEISENGER

10. Fyke, F. E., Jr., Code, C. F., and Schlegel, J. F. Thegastroesophageal sphincter in healthy human be-ings. Gastroenterologia (Basel) 1956, 86, 135.

11. Proceedings of the meeting of the GastroenterologyResearch Group, May 16, 1957, Colorado Springs,Colo. Amer. J. dig. Dis. 1957, 2, 743.

12. Davidson, M., Sleisenger, M. H., Almy, T. P., andLevine, S. Z. Studies of distal colonic motility inchildren. I. Non-propulsive patterns in normalchildren. Pediatrics 1956, 17, 807.

13. Lorber, S. H., and Shay, H. Technical and physio-logical considerations in measuring gastrointestinalpressures in man. Gastroenterology 1954, 27, 478.

14. Ingelfinger, F. J. Disorders of esophageal motorfunctions. Advanc. intern. Med. 1956, 8, 11.

15. Fleshler, B., Hendrix, T. R., Kramer, P., and Ingel-finger, F. J. Resistance and reflex function of thelower esophageal sphincter. Clin. Res. Proc. 1957,5, 199.

16. Wolf, S. B., Marshak, R. H., Som, M. L., Brahms,S. A., and Greenberg, E. I. The gastroesophagealvestibule on roentgen examination; differentiationfrom phrenic ampulla and minimal hiatal herniation.J. Mt Sinai Hosp. 1958, 25, 167.

17. Lerche, W. The Esophagus and Pharynx in Action.Springfield, Ill., Charles C Thomas, 1950.

18. Allison, P. R. Reflux esophagitis, sliding hiatalhernia, and anatomy of repair. Surg. Gynec.Obstet. 1951, 92, 419.

406