Gastrointestinal Motility: Tests and Problem-Oriented Approach PDF
Preview Gastrointestinal Motility: Tests and Problem-Oriented Approach
Gastrointestinal 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.
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