Dysphagia pp 339-357 | Cite as

Radiologic Evaluation of Esophageal Function

  • Wolfgang Schima
  • Edith Eisenhuber
  • Christiane Kulinna-Cosentini
Part of the Medical Radiology book series (MEDRAD)


In patients with dysphagia, radiographic studies evaluate both esophageal morphology and esophageal function. Videofluoroscopy accurately diagnoses achalasia, diffuse esophageal spasm, and PSS (scleroderma). Videofluoroscopy is less sensitive for the study of nonspecific motor disorders and gastroesophageal reflux. When accuracy, costs, availability, and patient acceptance are considered (Parkman et al. Dig Dis Sci 41:1355–1368, 1996), videofluoroscopy should be the initial diagnostic test for patients with esophageal dysphagia.


Lower Esophageal Sphincter Eosinophilic Esophagitis Progressive Systemic Sclerosis Esophageal Peristalsis Esophageal Function 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Aksglaede K, Funch-Jensen P, Vestergaard H, Thommesen P (1992) Diagnosis of esophageal motor disorders: a prospective study comparing barium swallow, food barium mixture, and continuous swallows with manometry. Gastrointest Radiol 17:1–4PubMedGoogle Scholar
  2. Anvari M, Richards D, Dent J, Waterfall WE, Stevenson GW (1989) The effect of glucagon on esophageal peristalsis and clearance. Gastrointest Radiol 14:100–102PubMedGoogle Scholar
  3. Auringer ST, Sumner E (1994) Pediatric upper gastrointestinal tract. Radiol Clin North Am 32:1051–1066PubMedGoogle Scholar
  4. Bassotti G, Fiorella S, Germani U, Roselli P, Bataglia E, Morelli A (1998) The nutcracker esophagus: a late diagnostic yield notwithstanding chest pain and dysphagia. Dysphagia 13:213–217PubMedGoogle Scholar
  5. Benjamin SB, Gerhardt DC, Castell DO (1979) High amplitude, peristaltic esophageal contractions associated with chest pain and/or dysphagia. Gastroenterology 77:478–483PubMedGoogle Scholar
  6. Borgström PS, Olsson R, Sundkvist G, Ekberg O (1988) Pharyngeal and esophageal function in patients with diabetes mellitus and swallowing complaints. Br J Radiol 61:817–821PubMedGoogle Scholar
  7. Borrie J, Wilson RLK (1980) Esophageal diverticula: principles of management and appraisal of classification. Thorax 35:759–767PubMedGoogle Scholar
  8. Brombart MM (1980) Radiologie des Verdauungstraktes. Thieme, Stuttgart, pp 244–245Google Scholar
  9. Bruggeman LL, Seaman WB (1973) Epiphrenic diverticula: an analysis of 80 cases. Am J Roentgenol 119:266–276Google Scholar
  10. Burakoff R, Rubinow A, Cohen AS (1985) Esophageal manometry in familial amyloid polyneuropathy. Am J Med 79:85–89PubMedGoogle Scholar
  11. Bytzer P, Talley NJ, Leemon M, Young LJ, Jones MP, Horowitz M (2001) Prevalence of gastrointestinal symptoms associated with diabetes mellitus. Arch Intern Med 161:1989–1996PubMedGoogle Scholar
  12. Campbell WL, Schultz JC (1986) Specificity and sensitivity of esophageal motor abnormality in systemic sclerosis (scleroderma) and related diseases: a cineradiographic study. Gastrointest Radiol 11:218–222PubMedGoogle Scholar
  13. Carter M, Deckmann RC, Smith RC, Burrell MI, Traube M (1997) Differentiation of achalasia from pseudoachalasia by computed tomography. Am J Gastoenterol 92:624–628Google Scholar
  14. Chen YM, Ott DJ, Hewson EG et al (1989) Diffuse esophageal spasm: radiographic and manometric correlation. Radiology 170:807–810PubMedGoogle Scholar
  15. Chen MYM, Ott DJ, Sinclair JW, Wu WC, Gelfand DW (1992) Gastroesophageal reflux disease: correlation of esophageal pH testing and radiographic findings. Radiology 185:483–486PubMedGoogle Scholar
  16. Chobanian SJ, Curtis DJ, Benjamin SB, Cattau EL (1986) Radiology of the nutcracker esophagus. J Clin Gastroenterol 8:230–232PubMedGoogle Scholar
  17. Cohen S (1979) Motor disorders of the esophagus. N Engl J Med 301:184–192PubMedGoogle Scholar
  18. Curcic J, Fox M, Kaufman E et al (2010) Gastroesophageal junction: structure and function as assessed by using MR imaging. Radiology 257:115–124PubMedGoogle Scholar
  19. Dantas RO, Deghaide NHS, Donadi EA (1999) Esophageal manometic and radiologic findings in asymptomatic subjects with Chagas disease. J Clin Gastroenterol 28:245–248PubMedGoogle Scholar
  20. Dantas RO, Deghaide NHS, Donadi EA (2001) Esophageal motility of patients with Chagas disease and idiopathic achalasia. Dig Dis Sci 46:1200–1206PubMedGoogle Scholar
  21. Daum R, Keuerleber M (1969) Spätfunktion der intrathorakalen Speiseröhre nach operierter Ösophagusatresie. Kinderchir 7:49–60Google Scholar
  22. Debas HT, Payne WS, Cameron AJ, Carlson HC (1980) Physiopathology of lower esophageal diverticulum and its implication for treatment. Surg Gynecol Obstet 151:593–600PubMedGoogle Scholar
  23. Dodds WJ (1977) Current concepts of esophageal motor function: clinical implications for radiology. Am J Roentgenol 128:549–561Google Scholar
  24. Dodds WJ (1988) The pathogenesis of gastroesophageal reflux disease. Am J Roentgenol 151:49–56Google Scholar
  25. Dodds WJ, Hogan WJ, Helm JF, Dent J (1981) Pathogenesis of reflux esophagitis. Gastroenterology 81:376–394PubMedGoogle Scholar
  26. Dodds WJ, Stewart ET, Kishk SM, Kahrilas PJ, Hogan WJ (1986) Radiologic amyl nitrite test for distinguishing pseudoachalasia from idiopathic achalasia. Am J Roentgenol 146:21–23Google Scholar
  27. Dooley CP, Schlossmacher B, Valenzuela JE (1988) Effects of alterations in bolus viscosity of esophageal peristalsis in humans. Am J Physiol 254:G8–G11PubMedGoogle Scholar
  28. Ekberg O, Feinberg MJ (1991) Altered swallowing function in elderly patients without dysphagia: radiologic findings in 56 patients. Am J Roentgenol 156:1181–1184Google Scholar
  29. Evander A, Little AG, Ferguson MK, Skinner DB (1986) Diverticula of the mid- and lower esophagus: pathogenesis and surgical management. World J Surg 10:820–828PubMedGoogle Scholar
  30. Fibbe C, Layer P, Keller J, Strate U, Emmermann A, Zornig C (2001) Esophageal motility in reflux disease before and after fundoplication: a prospective, randomized, clinical and manometric study. Gastroenterology 121:5–14PubMedGoogle Scholar
  31. Francis DL, Katzka DA (2010) Achalasia: update on the disease and its treatment. Gastroenterology 139:369–374PubMedGoogle Scholar
  32. Fransson S-G, Sökjer H, Johansson K-E, Tibbling L (1989) Radiologic diagnosis of gastro-esophageal reflux. Acta Radiol 30:187–192PubMedGoogle Scholar
  33. Gelfand MD, Botoman AV (1987) Esophageal motility disorders: a clinical overview. Am J Gastroenterol 82:181–187Google Scholar
  34. Goldenberg SP, Burrell M, Fette GG, Vos C, Traube M (1991) Classic and vigorous achalasia: a comparison of manometric, radiographic, and clinical findings. Gastroenterology 101:743–748PubMedGoogle Scholar
  35. Goldberg MF, Levine MS, Torigian DA (2008) Diffuse esophageal spasm: CT findings in seven patients. Am J Roentgenol 191:758–763Google Scholar
  36. Grande L, Monforte R, Ros E et al (1996) High amplitude contractions in the middle third of the esophagus: a manometric marker of chronic alcoholism? Gut 38:655–662PubMedGoogle Scholar
  37. Grishaw EK, Ott DJ, Frederick MG, Gelfand DW, Chen MYM (1996) Functional abnormalities of the esophagus: a prospective analysis of radiographic findings relative to age and symptoms. Am J Roentgenol 167:719–723Google Scholar
  38. Grübel C, Borovicka J, Schwizer W, Fox M, Hebbard G (2008) Diffuse esophageal spasm. Am J Gastroenterol 103:450–457PubMedGoogle Scholar
  39. Hannig C, Wuttge-Hannig A (1987) Röntgendiagnostik von Motilitätsstörungen des Pharynx und Ösophagus. Leber Magen Darm 1:7–17Google Scholar
  40. Hannig C, Wuttge-Hannig A, Daschner H, Baum S, Güntner G (1990) Bariumsulfat–Gelatinekugeln zur Diagnostik spezieller pharyngoösophagealer Fragestellungen. Rontgenpraxis 43:15–19PubMedGoogle Scholar
  41. Hasse W (1968) Ösophagusatresie. Thoraxchir 16:432–438Google Scholar
  42. Hejazi RA, Reddymasu SC, Sostarich S, McCallum RW (2010) Disturbances of esophageal motility in eosinophilic esophagitis: a case series. Dysphagia 25:231–237PubMedGoogle Scholar
  43. Hewson EG, Ott DJ, Dalton CB, Chen YM, Wu WC, Richter JE (1990) Manometry and radiology: complementary studies in the assessment of esophageal motility disorders. Gastroenterology 98:626–632PubMedGoogle Scholar
  44. Hollis JB, Castell DO (1974) Esophageal function in elderly men: a new look at “presbyesophagus”. Ann Intern Med 80:371–374PubMedGoogle Scholar
  45. Hollis JB, Castell DO, Braddom RL (1977) Esophageal function in diabetes mellitus and its relationship to peripheral neuropathy. Gastroenterology 73:1098–1102PubMedGoogle Scholar
  46. Holloway RH, Tippett MD, Horowitz M, Maddox AF, Moten J, Russo A (1999) Relationship between esophageal motility and transit in patients with type I diabetes mellitus. Am J Gastroenterol 94:3150–3157PubMedGoogle Scholar
  47. Horowitz M, McNeil JD, Maddern GJ, Collins PJ, Shearman DJC (1986) Abnormalities of gastric and esophageal emptying in polymyostitis and dermatomyositis. Gastroenterology 90:434–439PubMedGoogle Scholar
  48. Howard PJ, Maher L, Pryde A, Cameron EWJ, Heading RC (1992) Five years prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh. Gut 33:1011–1015PubMedGoogle Scholar
  49. Howard JM, Reynolds RPE, Frei JV et al (1994) Macrosopic healing of esophagitis does not improve esophageal motility. Dig Dis Sci 39:648–654PubMedGoogle Scholar
  50. Hurst AF, Rake GW (1930) Achalasia of the cardia. Q J Med 23:491–509Google Scholar
  51. Johnston BT, Troshinsky MB, Castell JA, Castell DO (1996) Comparison of barium radiology with esophageal pH monitoring in the diagnosis of gastroesophageal reflux disease. Am J Gastroenterol 91:1181–1185PubMedGoogle Scholar
  52. Kahrilas PJ, Kishk SM, Helm JF, Dodds WJ, Harig JM, Hogan WJ (1987) Comparison of achalasia and pseudoachalasia. Am J Med 82:439–446PubMedGoogle Scholar
  53. Kahrilas PJ, Lin S, Chen J, Manka M (1999) The effect of hiatus hernia on gastro-esophageal junction pressure. Gut 44:476–482PubMedGoogle Scholar
  54. Kaul B, Petersen H, Myrvold HE, Grette K, Røysland P, Halvorsen T (1986) Hiatus hernia in gastroesophageal reflux disease. Scand J Gastroenterol 21:31–34PubMedGoogle Scholar
  55. Kaye MD (1974) Esophageal motor dysfunction in patients with diverticula of the mid-thoracic esophagus. Thorax 29:666–672PubMedGoogle Scholar
  56. Kjellén G, Fransson SG, Lindström F, Sökjer H, Tibbling L (1986) Esophageal function, radiography, and dysphagia in Sjögren′s syndrome. Dig Dis Sci 31:225–229PubMedGoogle Scholar
  57. Konturek T, Lembo A (2008) Spasm, nutcracker, and IEM: real or manometry findings? J Clin Gastroenterol 42:647–651PubMedGoogle Scholar
  58. Krieger-Grübel C, Hiscock R, Nandurkar S, Heddle R, Hebbard G (2010) Physiology of diffuse esophageal spasm (DES)–when normal swallows are not normal. Neurogastroenterol Motil 22:1056–e279Google Scholar
  59. Kulinna-Cosentini C, Schima W, Cosentini EP (2007) Dynamic MR imaging of the gastroesophageal junction in healthy volunteers during bolus passage. J Magn Reson Imaging 25:749–754PubMedGoogle Scholar
  60. Lefkowitz JR, Brand DL, Schuffler MD, Brugge WR (1989) Amyloidosis mimics achalasia’s effect on lower esophageal sphincter. Dig Dis Sci 34:630–635PubMedGoogle Scholar
  61. Leopold NA, Kagel MC (1997) Pharyngo-esophageal dysphagia in Parkinson’s disease. Dysphagia 12:11–18PubMedGoogle Scholar
  62. Li Q, Castell JA, Castell DO (1994) Manometric determination of esophageal length. Am J Gastroenterol 89:722–725PubMedGoogle Scholar
  63. Manabe T, Kawamitsu H, Higashino T, Shirasaka D, Aoyama N, Sugimura K (2009) Observation of gastro-esophageal reflux by MRI: a feasibility study. Abdom Imaging 34:419–423PubMedGoogle Scholar
  64. Mandelstam P, Siegel CI, Lieber A, Siegel M (1969) The swallowing disorder in patients with diabetic neuropathy-gastroenteropathy. Gastroenterology 56:1–12PubMedGoogle Scholar
  65. Marshall JB, Kretschmar DC, Winship DC, Winn D, Treadwell EL, Sharp GC (1990) Gastrointestinal manifestations of mixed connective tissue disease. Gastroenterology 98:1232–1238PubMedGoogle Scholar
  66. Meijssen MAC, Tilanus HW, van Blankenstein M, Hop WCJ, Ong GL (1992) Achalasia complicated by esophageal squamous cell carcinoma: a prospective study in 195 patients. Gut 33:155–158PubMedGoogle Scholar
  67. Meshkinpour H, Kaye L, Elias A, Glick ME (1992) Manometric and radiologic correlations in achalasia. Am J Gastroenterol 87:1567–1570PubMedGoogle Scholar
  68. Meyer GW, Gerhardt DC, Castell DO (1981) Human esophageal response to rapid swallowing: muscle refractory period or neural inhibition? Am J Physiol 241:G129–G136PubMedGoogle Scholar
  69. Montesi A, Pesaresi A, Cavalli ML, Ripa G, Candela M, Gabrielli A (1991) Oropharyngeal and eophageal function in scleroderma. Dysphagia 6:219–223PubMedGoogle Scholar
  70. Ott DJ (1994) Gastroesophageal reflux disease. Radiol Clin North Am 32:1147–1166PubMedGoogle Scholar
  71. Ott DJ, Gelfand DW, Chen YM, Wu WC, Munitz HA (1985) Predictive relationship of hiatal hernia to reflux esophagitis. Gastrointest Radiol 10:317–320PubMedGoogle Scholar
  72. Ott DJ, Richter JE, Chen MY, Wu WC, Gelfand DW, Castell DO (1987) Esophageal radiography and manometry: correlation in 172 patients with dysphagia. Am J Roentgenol 149:307–311Google Scholar
  73. Ott DJ, Abernethy WB, Chen MYM, Wu WC, Gelfand DW (1990) Radiologic evaluation of esophageal motility: results in 170 patients with chest pain. Am J Roentgenol 155:983–985Google Scholar
  74. Ott DJ, Kelley TF, Chen MYM et al (1991) Evaluation of the esophagus with a marshmallow bolus: clarifying the cause of dysphagia. Gastrointest Radiol 16:1–4PubMedGoogle Scholar
  75. Ott DJ, Glauser SJ, Ledbetter MS, Chen MYM, Koufman JA, Gelfand DW (1995) Association of hiatal hernia and gastroesophageal reflux: correlation between presence and size of hiatal hernia and 24-h pH monitoring of the esophagus. Am J Roentgenol 165:557–559Google Scholar
  76. Palma R, Freire A, Freitas J et al (1994) Esophageal motility disorders in patients with Sjögren′s syndrome. Dig Dis Sci 39:758–761PubMedGoogle Scholar
  77. Parkman HP, Cohen S (1993) Malignancy-induced secondary achalasia. Dysphagia 8:292–296PubMedGoogle Scholar
  78. Parkman HP, Maurer AH, Caroline DF, Miller DL, Krevsky B, Fisher RS (1996) Optimal evaluation of patients with nonobstructive dysphagia. Manometry, scintigraphy, or videesophagography? Dig Dis Sci 41:1355–1368PubMedGoogle Scholar
  79. Park JH, Park DI, Kim HJ et al (2010) An unusual case of submucosal invasion of esophageal squamous cell carcinoma mistaken as primary achalasia. J Neurogastroenterol Motil 16:194–198PubMedGoogle Scholar
  80. Paulsen JM, Aragon GC, Ali MA, Brody FJ, Borum ML (2010) Pseudoachalasia secondary to metastatic breast carcinoma. Dig Dis Sci 55:1179–1181PubMedGoogle Scholar
  81. Pouderoux P, Shi G, Tatum RP, Kahrilas PJ (1999) Esophageal solid bolus transit: studies using concurrent videofluoroscopy and manometry. Am J Gastroenterol 94:1458–1463Google Scholar
  82. Price S, Castell DO (1978) Esophageal mythology. J Am Med Assoc 240:44–46Google Scholar
  83. Reynolds JC, Parkman HP (1989) Achalasia. Gastroenterol Clin North Am 18:223–255PubMedGoogle Scholar
  84. Richter JE (2001) Esophageal motility disorders. Lancet 358:823–828PubMedGoogle Scholar
  85. Richter JE (2010) Achalasia—an update. J Neurogastroenterol Motil 16:232–242PubMedGoogle Scholar
  86. Richter JE, Castell DO (1984) Diffuse esophageal spasm. Ann Intern Med 100:242–245PubMedGoogle Scholar
  87. Richter JE, Wu WC, Johns DN et al (1987) Esophageal manometry in 95 healthy adult volunteers: variability of pressures with age and frequency of “abnormal” contractions. Dig Dis Sci 32:583–592PubMedGoogle Scholar
  88. Rivkin L, Bremner CG, Bremner CH (1984) Pathophysiology of mid-esophageal and epiphrenic diverticula of the esophagus. S Afr Med J 66:127–129PubMedGoogle Scholar
  89. Rubinow A, Burakoff R, Cohen AS, Harris LD (1983) Esophageal manometry in systemic amyloidosis. Am J Med 75:951–956PubMedGoogle Scholar
  90. Schima W, Stacher P, Pokieser P et al (1992) Esophageal motor disorders: videofluoroscopic and manometric evaluation–prospective study in 88 symptomatic patients. Radiology 185:487–491PubMedGoogle Scholar
  91. Schima W, Sterz F, Pokieser P (1993) Syncope after eating. N Engl J Med 328:1572PubMedGoogle Scholar
  92. Schima W, Pokieser P, Forstinger C et al (1994) Videofluoroscopy of the pharynx and esophagus in chronic graft-versus-host disease. Abdom Imaging 19:191–194PubMedGoogle Scholar
  93. Schima W, Pokieser P, Schober E (1995) Funktionsstörungen des Ösophagus: Radiologische Funktionsdiagnostik. Radiologe 35:693–702PubMedGoogle Scholar
  94. Schima W, Schober E, Stacher G et al (1997) Association of midesophageal diverticula with esophageal motor disorders: videofluoroscopy and manometry. Acta Radiol 38:108–114PubMedGoogle Scholar
  95. Schima W, Ryan JM, Harisinghani M et al (1998) Radiographic detection of achalasia: diagnostic accuracy of videofluoroscopy. Clin Radiol 53:372–375PubMedGoogle Scholar
  96. Schmidt R, Weidemann H, Bücherl ES (1991) Ösophagusdivertikel. Klinik und Therapie. Zentralbl Chir 116:89–93PubMedGoogle Scholar
  97. Schober E, Schima W, Stacher G, Pokieser P, Uranitsch K, Tscholakoff D (1993) Yield of a sustained barium “support level” upon video-fluoroscopy in the diagnosis of esophageal motor disorders (abstract). In: 8th European Congress of Radiology, scientific programme and abstracts, p 112Google Scholar
  98. Schoeman MN, Holloway RH (1995) Integrity and characteristics of secondary esophageal peristalsis in patients with gastro-esophageal reflux disease. Gut 36:499–504PubMedGoogle Scholar
  99. Schwickert HC, Schadmand-Fischer S, Klose P, Staritz M, Ueberschaer B, Thelen M (1993) Motilitätsstörungen des Ösophagus–Diagnostik mit dem Reisbreischluck. Fortschr Rontgenstr 159:511–517Google Scholar
  100. Sears V, Castell J, Castell D (1989) “Abnormal” motility during upright and solid swallows in normal volunteers (abstract). Gastroenterology 96:A693Google Scholar
  101. Soergel K, Zboralske FF, Amberg JR (1964) Presbyesophagus: esophageal motility in nonagenarians. J Clin Invest 43:1472–1479PubMedGoogle Scholar
  102. Spechler SJ, Souza RF, Rosenberg SJ, Ruben RA, Goyal RK (1995) Heartburn in patients with achalasia. Gut 37:305–308PubMedGoogle Scholar
  103. Sprung DJ, Gibb SP (1985) Dysplastic Barrett’s esophagus in scleroderma. Am J Gastroenterol 80:518–522PubMedGoogle Scholar
  104. Stacher G, Schmierer G, Landgraf M (1979) Tertiary esophageal contractions evoked by acoustic stimuli. Gastroenterology 77:49–54PubMedGoogle Scholar
  105. Stacher G, Schima W, Bergmann H et al (1994) Sensitivity of radionuclide bolus transport and videofluoroscopic studies compared with manometry in the detection of achalasia. Am J Gastroenterol 89:1484–1488PubMedGoogle Scholar
  106. Stein HJ, Eypasch EP, DeMeester TR, Smyrk TC, Attwood SEA (1990) Circadian esophageal motor function in patients with gastroesophageal reflux disease. Surgery 108:769–778PubMedGoogle Scholar
  107. Stewart ET (1981) Radiographic evaluation of the esophagus and its motor disorders. Med Clin N Am 65:1173–1194PubMedGoogle Scholar
  108. The Royal College of Radiologists (2007) Making the best use of a clinical radiology services: referral guidelines, 6th edn. Royal College of Radiologists, London, p 85Google Scholar
  109. Thompson JK, Koehler RE, Richter JE (1994) Detection of gastroesophageal reflux: value of barium studies compared with 24-h pH monitoring. Am J Roentgenol 162:621–626Google Scholar
  110. Timmer R, Breumelhof R, Nadorp JHSM, Smout AJPM (1994) Esophageal motility and gastro-esophageal reflux before and after healing of reflux esophagitis. A study using 24-h ambulatory pH and pressure monitoring. Gut 35:1519–1522PubMedGoogle Scholar
  111. Tremble GE (1959) The clinical significance of a lump in the throat. Arch Otolaryngol 70:157–165Google Scholar
  112. Tscholakoff D, Frühwald F, Kainberger F, Wicke K (2011) Orientierungshilfe radiologie: anleitung zum optimalen klinischen einsatz der radiologie, 4th edn. Verlagshaus der Ärzte, Vienna, p 79Google Scholar
  113. Woodfield CA, Levine MS, Rubesin SE, Langlotz CP, Laufer I (2000) Diagnosis of primary versus secondary achalasia: reassessment of clinical and radiographic criteria. Am J Roentgenol 175:727–731Google Scholar
  114. Wright RA, Penner DB (1981) Myxedema and upper esophageal dysmotility. Dig Dis Sci 26:376–377PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg  2011

Authors and Affiliations

  • Wolfgang Schima
    • 1
  • Edith Eisenhuber
    • 2
  • Christiane Kulinna-Cosentini
    • 3
  1. 1.Department of RadiologyKrankenhaus Goettlicher HeilandViennaAustria
  2. 2.Krankenhaus Goettlicher HeilandViennaAustria
  3. 3.Department of RadiologyMedical University of ViennaViennaAustria

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