Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University , Chicago, Illinois.
Am J Physiol Gastrointest Liver Physiol. 2018 Mar 1;314(3):G334-G340. doi: 10.1152/ajpgi.00368.2017. Epub 2017 Dec 21.
Repetitive retrograde contractions (RRCs) in response to sustained esophageal distension are a distinct contractility pattern observed with functional luminal imaging probe (FLIP) panometry that are common in type III (spastic) achalasia. RRCs are hypothesized to be indicative of either impaired inhibitory innervation or esophageal outflow obstruction. We aimed to apply FLIP panometry to patients with postfundoplication dysphagia (a model of esophageal obstruction) to explore mechanisms behind RRCs. Adult patients with dysphagia after Nissen fundoplication ( n = 32) or type III achalasia ( n = 25) were evaluated with high-resolution manometry (HRM) and upper endoscopy with FLIP. HRM studies were assessed for outflow obstruction and spastic features: premature contractility, hypercontractility, and impaired deglutitive inhibition during multiple-rapid swallows. FLIP studies were analyzed to determine the esophagogastric junction (EGJ)-distensibility index and contractility pattern, including RRCs. Barium esophagram was evaluated when available. RRCs were present in 8/32 (25%) fundoplication and 19/25 (76%) achalasia patients ( P < 0.001). EGJ outflow obstruction was detected in 21 (67%) fundoplication patients by HRM, FLIP, or esophagram [6 (29%) had RRCs]. On HRM, none of the fundoplication patients had premature contractility, whereas 3/4 with defective inhibition on multiple-rapid swallows and 2/4 with hypercontractility had RRCs. Regression analysis demonstrated HRM with spastic features, but not esophageal outflow obstruction, as a predictor for RRCs. RRCs in response to sustained esophageal distension appear to be a manifestation of spastic esophageal motility. Although future study to further clarify the significance of RRCs is needed, RRCs on FLIP panometry should prompt evaluation for a major motor disorder. NEW & NOTEWORTHY Repetitive retrograde contractions (RRCs) are a common response to sustained esophageal distension among spastic achalasia patients when evaluated with the functional luminal imaging probe. We evaluated patients with postfundoplication dysphagia, i.e., patients with suspected mechanical obstruction, and found that RRCs occasionally occurred among postfundoplication patients, but often in association with manometric features of esophageal neuromuscular imbalance. Thus, RRCs appear to be a manifestation of spastic esophageal dysmotility, likely from neural imbalance resulting in excess excitation.
重复的逆行收缩（RRC）是对功能性腔内成像探头（FLIP）测压食管扩张的一种独特收缩模式，在 III 型（痉挛性）贲门失弛缓症中很常见。RRC 被认为是抑制神经支配受损或食管流出道梗阻的指标。我们旨在将 FLIP 测压应用于胃食管反流病后吞咽困难（食管梗阻模型）的患者，以探讨 RRC 背后的机制。对 32 例 Nissen 胃底折叠术后吞咽困难（n = 32）和 25 例 III 型贲门失弛缓症（n = 25）患者进行高分辨率测压和上消化道内镜检查。对 HRM 进行评估，以确定流出道梗阻和痉挛特征：过早收缩、过度收缩和多次快速吞咽时吞咽抑制受损。分析 FLIP 研究以确定食管胃交界（EGJ）扩张指数和收缩模式，包括 RRC。当有钡餐食管造影时进行评估。32 例胃底折叠术患者中有 8 例（25%）和 25 例贲门失弛缓症患者中有 19 例（76%）存在 RRC（P < 0.001）。通过 HRM、FLIP 或食管造影在 21 例（67%）胃底折叠术患者中检测到 EGJ 流出道梗阻[6 例（29%）存在 RRC]。在 HRM 上，胃底折叠术患者均无过早收缩，但在多次快速吞咽时抑制不全的 3/4 例和过度收缩的 2/4 例存在 RRC。回归分析表明，具有痉挛特征的 HRM 而非食管流出道梗阻是 RRC 的预测因素。对持续食管扩张的 RRC 似乎是一种痉挛性食管动力障碍的表现。尽管需要进一步研究来进一步阐明 RRC 的意义，但 FLIP 测压上的 RRC 应该提示对主要运动障碍进行评估。新的和值得注意的是，在使用功能性腔内成像探头评估时，痉挛性贲门失弛缓症患者对持续食管扩张的常见反应是重复逆行收缩。我们评估了胃食管反流病后吞咽困难的患者，即疑似机械性梗阻的患者，发现胃底折叠术后患者偶尔会出现 RRC，但通常与食管神经肌肉失衡的测压特征相关。因此，RRC 似乎是一种痉挛性食管动力障碍的表现，可能是由于神经失衡导致过度兴奋。
