Chen Ji-Hong
Department of Gastroenterology, Renmin Hospital, Wuhan University, Wuhan, People's Republic of China; Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada.
Clin Exp Gastroenterol. 2016 Sep 20;9:291-299. doi: 10.2147/CEG.S111820. eCollection 2016.
Ineffective esophageal motility (IEM) is characterized by low to very low amplitude propulsive contractions in the distal esophagus, hence primarily affecting the smooth muscle part of the esophagus. IEM is often found in patients with dysphagia or heartburn and is commonly associated with gastroesophageal reflux disease. IEM is assumed to be associated with ineffective bolus transport; however, this can be verified using impedance measurements or evaluation of a barium coated marshmallow swallow. Furthermore, water swallows may not assess accurately the motor capabilities of the esophagus, since contraction amplitude is strongly determined by the size and consistency of the bolus. The "peristaltic reserve" of the esophagus can be evaluated by multiple rapid swallows that, after a period of diglutative inhibition, normally give a powerful peristaltic contraction suggestive of the integrity of neural orchestration and smooth muscle action. The amplitude of contraction is determined by a balance between intrinsic excitatory cholinergic, inhibitory nitrergic, as well as postinhibition rebound excitatory output to the musculature. This is strongly influenced by vagal efferent motor neurons and this in turn is influenced by vagal afferent neurons that send bolus information to the solitary nucleus where programmed activation of the vagal motor neurons to the smooth muscle esophagus is initiated. Solitary nucleus activity is influenced by sensory activity from a large number of organs and various areas of the brain, including the hypothalamus and the cerebral cortex. This allows interaction between swallowing activities and respiratory and cardiac activities and allows the influence of acute and chronic emotional states on swallowing behavior. Interstitial cells of Cajal are part of the sensory units of vagal afferents, the intramuscular arrays, and they provide pacemaker activity to the musculature that can generate peristalsis in the absence of innervation. This indicates that a low-amplitude esophageal contraction, observed as IEM, can be caused by a multitude of factors, and therefore many pathways can be potentially explored to restore normal esophageal peristalsis.
无效食管动力（IEM）的特征是食管远端推进性收缩幅度低至极低，因此主要影响食管的平滑肌部分。IEM常见于吞咽困难或烧心患者，通常与胃食管反流病相关。IEM被认为与食团运输无效有关；然而，这可以通过阻抗测量或对吞服涂有钡剂的棉花糖进行评估来证实。此外，吞咽水可能无法准确评估食管的运动能力，因为收缩幅度很大程度上取决于食团的大小和稠度。食管的“蠕动储备”可以通过多次快速吞咽来评估，在一段吞咽抑制期后，正常情况下会产生强烈的蠕动收缩，提示神经协调和平滑肌作用的完整性。收缩幅度由内在兴奋性胆碱能、抑制性一氧化氮能以及对肌肉组织的抑制后反弹兴奋性输出之间的平衡决定。这受到迷走神经传出运动神经元的强烈影响，而迷走神经传出运动神经元又受到迷走神经传入神经元的影响，后者将食团信息发送到孤束核，在此启动对食管平滑肌的迷走运动神经元的程序性激活。孤束核活动受到来自大量器官和大脑各个区域（包括下丘脑和大脑皮层）的感觉活动的影响。这使得吞咽活动与呼吸和心脏活动之间能够相互作用，并使得急性和慢性情绪状态能够影响吞咽行为。 Cajal间质细胞是迷走神经传入的感觉单位、肌内排列的一部分，它们为肌肉组织提供起搏活动，在没有神经支配的情况下也能产生蠕动。这表明，作为IEM观察到的低幅度食管收缩可能由多种因素引起，因此可以潜在地探索许多途径来恢复正常的食管蠕动。
