A Questionnaire Study to Assess Long-Term Outcome in Patients with Abnormal Esophageal Manometry

Abstract

Patients with unexplained chest pain or dysphagia are often referred for esophageal manometric studies to further investigate their symptoms. Four main manometric abnormalities have been described: achalasia, diffuse esophageal spasm, “nutcracker” (hypercontracting) esophagus, and hypocontracting esophagus. With the exception of achalasia, treatments are of limited benefit and the natural history of these conditions is largely unknown. We sent questionnaires to patients who were investigated at least three years before our study began. They repeated a DeMeester symptom questionnaire that they had completed at the time of their initial study. Questionnaires were sent to 137 patients with diffuse esophageal spasm, “nutcracker” (hypercontracting) esophagus, or hypocontracting esophagus. We also sent questionnaires to 57 patients with dysphagia or chest pain who had had normal esophageal manometry and pH studies. These patients acted as symptomatic controls. Responses were compared using the Wilcoxon signed ranks test. Seventy-two (53%) patients with diffuse esophageal spasm, “nutcracker” esophagus, or hypocontracting esophagus replied. An additional 8 (6%) patients died. Symptom scores in all three conditions had improved significantly over time (p ≤ 0.01 for each condition, Wilcoxon signed ranks test). Patients with dysphagia or chest pain but normal esophageal studies had not improved. The significance of diffuse esophageal spasm, “nutcracker” esophagus, and hypocontracting esophagus found at esophageal manometry remains uncertain. Although treatment is often ineffective, these conditions typically run a benign course. Patients can be reassured that their symptoms are likely to improve with time.

Appendices

Appendix 1. Classification of Primary Esophageal Motility Disorders [4,5]

• Achalasia

• Absent distal peristalsis

• Abnormal lower esophageal sphincter (LES) relaxation

• Can have raised LES pressure (>45 mmHg)

• Diffuse Esophageal Spasm

• Simultaneous contractions 20% or more of wet swallows

• Intermittent peristalsis

• Can have repetitive or multipeak contractions (3 or more peaks)

• Can have spontaneous contractions not associated with swallows

• Contraction amplitude > 30 mmHg but usually not high amplitude

• Hypercontracting Esophagus

• Hypertensive esophagus—“nutcracker”

• Increased mean distal amplitude (>180 mmHg)

• Normal peristalsis

• Can be of increased distal duration (>6 seconds)

• Hypertensive LES

• Resting LES pressure > 45 mmHg

• May be incomplete LES relaxation

• Hypocontracting Esophagus

• Ineffective esophageal motility

• 30% or more, low distal amplitude (<30 mmHg) or failed nontransmitted contractions

• Hypotensive LES

• Resting LES pressure <10 mmHg

Appendix 2. Modified DeMeester Questionnaire

• Heartburn?

• 0 - None

• 1 - Minimal

• 2 - Moderate

• 3 - Severe

• Regurgitation ?

• 0 - None

• 1 - Minimal

• 2 - Moderate

• 3 - Severe

• Vomiting?

• 0 - None

• 1 - Rarely

• 2 - Moderately severe

• 3 - Severe

• Difficulty swallowing (things getting stuck)?

• 0 - None

• 1 - Coarse foods only (e.g., chunks of bread)

• 2 - Solid foods

• 3 - Either: - liquids, or lasting for more than 5 minutes, or with associated pain

• Indigestion?

• 0 - None

• 1 - Mild abdominal pain or flatulence (wind)

• 2 - Troublesome abdominal pain or excess flatulence or excess salivation

• 3 - Very severe

• Night-time symptoms?

• 0 - None

• 2 - Any symptom that wakes you up

• Minimum score = 0; Maximum score = 17

Appendix 3. Supplementary Questions Asked in Mailed Questionnaire

• 1. Compared with how you were when you were investigated at Northern General Hospital with the esophageal manometry study, would you say that the symptoms you were investigated for are: -

  • Better □ The same □ Worse □

• 2. How often do these symptoms occur compared with when you were investigated?

  • More □ About as often □ Less □

• 3. How do these symptoms affect your quality of life?

  • A little □ A lot □ Not at all □

• 4. Did you find the explanation of the results of your manometry study affected how you coped with your symptoms?

  • Helpful □ Not helpful □

• 5. What medicine (if any) have you found most helpful over the years at controlling these symptoms?

• 6. What single thing (medicine or otherwise) do you think has been the most useful over the years in helping to control these symptoms?

• 7. Do you currently suffer with chest pain?

  • □ -None □ - Minimal □ - Moderate □ - Severe

• Please list all your current medication, stating doses if possible ........................................................................... ..........................................................................

• Do you drink alcohol?................. If so, how much per week?

• Do you smoke?.................. If so, how many per day?

• Do you drink tea or coffee?.................. How many mugs/cups per day?