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Dysphagia is a common problem affecting all ages. It is increasing in frequency particularly among the younger population due to the rising incidence of eosinophilic oesophagitis, a condition which often leads to acute presentation to hospital for the first time with food bolus obstruction requiring endoscopic removal. Careful history taking remains the first and most important step in evaluating dysphagia, and it is especially important to distinguish an oropharyngeal versus oesophageal origin, which helps to guide further investigation and therapy. The three main investigations for dysphagia remain endoscopy, barium study and manometry, with endoscopy also offering therapeutic potential. Management is largely determined by the eventual diagnosis, often in a multi-disciplinary setting.

Achalasia is a motility disorder encountered by surgeons during the investigation and treatment of dysphagia. Recent advances in manometry technology, a widely accepted new classification system and a new treatment rapidly gaining international acceptance, have changed the working knowledge required to successfully manage patients with achalasia. We review the Chicago classification subtypes of achalasia with type II achalasia being a predictor of success and type III achalasia a predictor of treatment failure. We review per-oral endoscopic myotomy as an emerging treatment option and its potential for improving the treatment of type III achalasia.

Background With proton pump inhibitors and current sophisticated endoscopic techniques, the number of patients requiring surgical intervention for upper gastrointestinal bleeding has decreased considerably while trans-arterial embolization is being used more often. There are few direct comparisons between the effectiveness of surgery and embolization. Methods A retrospective study of patients from two Australian teaching hospitals who had surgery or trans-arterial embolization (n = 103) for severe upper gastrointestinal haemorrhage between 2004 and 2012 was carried out. Patient demographics, co-morbidities, disease pathology, length of stay, complications, and overall clinical outcome and mortality were compared. Results There were 65 men and 38 women. The median age was 70 (range 36–95) years. Patients requiring emergency surgical intervention (n = 79) or trans-arterial embolization (n = 24) were compared. The rate of re-bleeding after embolization (42%) was significantly higher compared with the surgery group (19%) (P = 0.02). The requirement for further intervention (either surgery or embolization) was also higher in the embolization group (33%) compared with the surgery group (13%) (P = 0.03). There was no statistical difference in mortality between the embolization group (5/24, 20.8%) and the surgical group (13/79, 16.5%) (P = 0.75). Conclusion Emergency surgery and embolization are required in 2.6% of patients with upper gastrointestinal bleeding. Both techniques have high mortalities reflecting the age, co-morbidities and severity of bleeding in this patient group.

Background and Aim Data on the relationship between epidemiological changes in food bolus impaction (FBI) and its relationship to eosinophilic esophagitis (EoE) are limited. The aim of this study was to evaluate changes in the prevalence and etiology of FBI at the Royal Adelaide Hospital over 15 years. Methods Details of all patients who presented with FBI to Royal Adelaide Hospital (1996–2010) were reviewed from a prospective database. Detailed endoscopic and histological findings were examined for patients admitted under the Gastroenterology team. Results From 1996–2010, 539 patients were admitted. Prevalence of FBI increased overtime, with a male preponderance. The age at presentation was significantly lower in 2006–2010 (56.2 ± 1.6 years) compared with 2001–2005 (61.6 ± 1.9 years, P = 0.03). There was a reduction in the proportion of patients with peptic-related stricture (from 75% [1996–2000] to 41% [2006–2010] [P

Background: Inflammatory bowel disease (IBD) is a chronic disease requiring long-term management. General practitioners (GPs) are often the first point of contact for initial symptoms and flares. Thus we assessed GPs' attitudes to and knowledge of IBD. Methods: A state-wide postal survey of GPs was performed collecting demographic details, practice and attitudes in IBD-specific management and knowledge. Results: Of 1800 GPs surveyed in South Australia, 409 responded; 58% were male, 80% Australian trained and 73% practised in metropolitan areas. Most GPs (92%) reported seeing zero to five IBD patients per month. Overall, 37% of the GPs reported being generally ‘uncomfortable’ with IBD management. Specifically, they were only somewhat comfortable in providing/using maintenance therapy, steroid therapy or unspecified therapy for an acute flare. They were uncomfortable with the use of immunomodulators and biologicals (71 and 91% respectively). No GP reported never referring, referring sometimes (12%), often (34%) or always (55%). Most (87%) GPs rated their communication with private specialists positively; while only 32% were satisfied with support from public hospitals. Of concern, most (70%) monitored patients on immunosuppression on a case-by-case basis rather than by protocol. In multivariable analyses, GPs' IBD-specific knowledge did not influence comfort with overall management, nor did knowledge influence GP comfort with any particular therapy. Conclusion: Individual GPs care for few IBD patients and have variable attitudes in their practice. Whether improvement can realistically be achieved given individual GP's paucity of patients is questionable. These data support the provision of better support and specific action plans for IBD patients.

Dysphagia is common in the general population, and is generally due to either mechanical obstruction or dysmotility. Patient demographics and symptom evaluation are often useful in determining the likely cause, and guide subsequent investigation and management. Oropharyngeal dysphagia is usually caused by neurological conditions where treatment options are limited. Conversely, many of the esophageal causes of dysphagia are amenable to therapy. Gastroscopy is often the first test of choice, given its diagnostic and therapeutic potential, especially when mechanical causes are concerned. Esophageal motor function can be assessed by a variety of techniques, ranging from radiology such as barium swallow, to dedicated motility tests such as manometry and impedance monitoring. The choice of test relies on the clinical indication and the results should be interpreted in conjunction with the patients' symptoms. High-resolution manometry with topography is now the new benchmark for motility studies. Several new techniques for motility testing have also become available, such as esophageal ultrasound and functional lumen imaging probe, but are currently limited to the research setting.

Background The advent of drugs that inhibit transient lower esophageal sphincter relaxation (TLESR) necessitates accurate identification and scoring. We assessed the intra- and inter-assessor variability of the existing objective criteria for TLESR, improving them where necessary. Methods Two 3-h postprandial esophageal manometric and pH recordings were performed in 20 healthy volunteers. Each recording was duplicated. The recordings were analyzed by five experienced observers for TLESRs based on their expert opinion. TLESRs were also analyzed for the presence of the original four criteria as well as inhibition of the crural diaphragm (ID), a prominent after-contraction (AC), acid reflux and an esophageal common cavity. Key Results The overall inter- and intra-observer agreements for TLESRs scored, according to observer’s expert opinion, were 59% (range 56–67%) and 74% (60–89%), respectively. When TLESRs were restricted to those fulfilling the original criteria, these agreements fell to 46% (40–53%) and 60% (44–67%), respectively. Cleaning the recordings by removal of technically flawed sections improved agreements by 5%. Inclusion of additional criteria (ID and AC) resulted in inter- and intra-observer agreements of 62% (52–70%) and 69% (53–79%), respectively. A consensus analysis performed collectively by three observers and based on the new criteria (original ± ID and AC) resulted in 84% agreement between the paired recordings. Conclusions & Inferences The original criteria for the definition of TLESRs allows for substantial inter- and intra-observer variability, which can be reduced by incorporation of additional objective criteria. However, the highest level of intra-observer agreement can be achieved by consensus analysis.

Aliment Pharmacol Ther 2010; 32: 1023–1030 Summary Background Acid reflux is often difficult to control medically. Aim To assess the effect of 40 mg twice daily esomeprazole (high-dose) on gastric and oesophageal pH and symptoms, and biomarkers relevant to adenocarcinoma, in patients with Barrett’s oesophagus (BO). Methods Eighteen patients, treated with proton pump inhibitors as prescribed by their treating doctor, had their therapy increased to high-dose esomeprazole for 6 months. Results At entry into the study, 9/18 patients had excessive 24-h oesophageal acid exposure, and gastric pH remained 16 h in 8/18. With high-dose esomeprazole, excessive acid exposure occurred in 2/18 patients, and gastric pH

Background and Aims: Peptic ulcer disease (PUD) usually manifests as either dyspepsia or less commonly with complications such as bleeding. Patients with bleeding ulcers are often asymptomatic until the bleeding occurs. A lack of dyspeptic symptoms might be explained by impaired visceral sensory function. The aim of this study was to assess symptom profiles and compare visceral sensory thresholds in patients with bleeding peptic ulcer (BPU) and uncomplicated PUD. Methods: A total of 30 patients with BPU, 25 with uncomplicated PUD and 32 healthy controls (HC) without dyspeptic symptoms were recruited. In ulcer patients after at least 8 weeks of ulcer treatment and an 8-hr fast, visceral sensitivity was tested using a standardized nutrient challenge with an enteral feeding solution. Five key symptoms (fullness, abdominal pain, retrosternal/abdominal burning, nausea, and regurgitation) were assessed using visual analog scales (0–100). Results: Twenty-five of the 30 (83%, 95% confidence interval 65–94%) patients with BPU had no dyspeptic symptoms compared with none of the 25 uncomplicated PUD patients. Patients with BPU and HC had significantly lower symptom responses (BPU 127.6 ± 24.6, HC 89.8 ± 13.9) to the nutrient challenge than uncomplicated PUD patients (338.4 ± 56.2, P

Background and Aim: The pathophysiology of non-erosive reflux disease is poorly understood. Triggering of secondary peristalsis is impaired in patients with erosive esophagitis but data in patients with non-erosive reflux disease are lacking. The aim of this study was to evaluate the difference in esophageal motility between patients with non-erosive reflux disease and healthy subjects. Methods: Twenty patients with non-erosive reflux disease, with reflux symptoms occurring more than twice per week, and 20 healthy subjects of comparable age and sex underwent esophageal manometry. Primary peristalsis was tested with 10 swallows of a 5-mL water bolus. Secondary peristalsis was triggered by esophageal distention using a 20-mL air bolus, which was injected rapidly into the mid-esophagus. After 20 s, each stimulus was followed by a dry swallow to clear any residual air and then each stimulus was repeated five times. Results: Basal lower esophageal sphincter pressure, pressure wave amplitude in the upper, middle and lower esophagus, wave velocity and the rates of successful primary peristalsis were similar in non-erosive reflux disease patients and controls. The rate of triggering of secondary peristalsis in patients with non-erosive reflux disease (median 20%, interquartile range 0–40%) was significantly lower (P

A functional integration exists between proximal and distal gastric motor activity in dogs but has not been demonstrated in humans. To determine the relationship between proximal and distal gastric motor activity in humans. Concurrent proximal (barostat) and distal (antro-pyloro-duodenal (APD) manometry) gastric motility were recorded in 10 healthy volunteers (28 +/- 3 years) during (i) fasting and (ii) two 60-min duodenal infusions of Ensure((R)) (1 and 2 kcal min(-1)) in random order. Proximal and APD motor activity and the association between fundic and propagated antral waves (PAWs) were determined. During fasting, 32% of fundic waves (FWs) were followed by a PAW. In a dose-dependent fashion, duodenal nutrients (i) increased proximal gastric volume, (ii) reduced fundic and antral wave (total and propagated) activity, and (iii) increased pyloric contractions. The proportion of FWs followed by a distal PAW was similar between both infusions and did not differ from fasting. During nutrient infusion, nearly all PAWs were antegrade, propagated over a shorter distance and less likely to traverse the pylorus, compared with fasting. In humans, a functional association exists between proximal and distal gastric motility during fasting and duodenal nutrient stimulation. This may have a role in optimizing intra-gastric meal distribution.

Slow gastric emptying and intolerance to nasogastric feeds occurs in up to 40–50% of critically ill patients [1, 2]. Not only does this result in inadequate nutritional support, but it is also a major risk factor for gastro-oesophageal reflux and aspiration, with potential adverse affects on both morbidity and mortality [2, 3]. The currently available therapeutic options for managing delayed gastric emptying and feed intolerance in critically ill patients are: total parenteral nutrient therapy, prokinetic therapy and postpyloric feeding [4, 5]. Of these, treatment with prokinetic agents is efficacious and frequently used as the first-line therapy to avoid the septic complications associated with total parenteral nutrient therapy and the technical demand of postpyloric feeding [4, 5]. Low-dose erythromycin (1–3 mg kg−1), a motilin agonist, is a widely used prokinetic agent in critically ill patients. However, erythromycin has recently been reported to effect human haemodynamics adversely, with a fall in systolic blood pressure (SBP) of 10 ± 9 mmHg 1.5–2.5 h after an oral dose of 300 mg [6]. The mechanism responsible for the hypotension following erythromycin remains unclear. In animals, infusion of motilin was found to induce endothelial-dependent vasodilation and a transient reduction in blood pressure (BP) [7]. As erythromycin leads to an increase in plasma motilin concentrations in humans, it is conceivable that the hypotension associated the drug is related to the endothelium-mediated vasodilation exerted by motilin [8]. Although erythromycin is frequently used in critically ill patients, its haemodynamic effects in this group are unknown. A reduction of 10 mmHg in SBP after erythromycin may not be important in healthy subjects but may be clinically relevant in patients with potential cardiovascular compromise such as the critically ill [6]. This study therefore aimed to examine the acute effects of a single intravenous prokinetic dose of erythromycin on BP) and heart rate (HR) in critically ill patients, who were intolerant to nasogastric feeds and were not on inotropic supportive therapy. Nineteen mechanically ventilated, critically ill patients (age 52 ± 18 years, M:F 10 : 9, Acute Physiology and Chronic Health Evaluation II score 21 ± 6, length of Intensive Care Unit stay 10 ± 9 days) were randomized to either erythromycin (i.v. 200 mg) or placebo (i.v. normal saline) in a cross-over study, 12 h apart. Intolerance to intragastric feeding was defined as vomiting or regurgitation during feeding, or a 6-hourly gastric aspirate > 250 ml [9]. The cut-off gastric aspirate > 250 ml used in this study is a previously published clinical marker of feed intolerance [9, 10]. The majority of patients were sedated with morphine and midazolam and only two patients received propofol alone. Five patients received nasogastric antihypertensive medications (ACE inhibitors n = 3, β-blockers n = 1 and calcium channel blockers n = 1). Continuous lying BP (systolic, diastolic and mean) and HR were measured via an arterial line at 15-min intervals for 60 min before and 180 min after the administration of prokinetic therapy by using an automatic device (TRAM-RAC 4A; General Electric, Milwaukee, WI, USA). A reduction in SBP of >10% from baseline was defined as a clinically significant change. The study was approved by the Local Research Ethics Committee. Each subject gave written informed consent prior to the study. The effects of erythromycin on BP and HR were analysed using a linear mixed effects model fitted to the data. In this model, group status (erythromycin or placebo) and time were treated as fixed effects, while subject was treated as a random effect. Data are expressed as mean ± SD, except in Figure 1, where the error bars represent 95% confidence intervals. A P-value

BACKGROUND/AIMS A marked elevation in the blood glucose concentration (approximately 15 mmol L-1) slows oesophageal peristalsis. Recent studies indicate that changes in blood glucose within the normal postprandial range affect gastric motility and emptying. The aim of this study was to investigate whether such alterations in blood glucose also affect oesophageal motility. METHODS In eight healthy subjects oesophageal motility and sensation to balloon distension were measured on two separate days while blood glucose concentrations were stabilized with an insulin-glucose clamp at 4 mmol L-1 and 8 mmol L-1. RESULTS Peristaltic velocity in the proximal oesophagus and over the oesophagus as a whole was faster at a plasma glucose concentration of 8 mmol L-1 compared with those at 4 mmol L-1 (proximal 3.3 +/- 0.3 cm s-1 vs 2.6 +/- 0.2 cm s-1, P < 0.05, total 3.1 +/- 0.2 cm s-1 vs 2.7 +/- 0.2 cm s-1, P < 0.005) but there were no differences in wave amplitude or duration, or basal lower oesophageal sphincter pressure (LOSP). The threshold for initial perception of oesophageal distension was lower at a plasma glucose of 8 mmol L-1 (2.9 +/- 0.5 mL vs 4.9 +/- 1.0 mL, P < 0.05). CONCLUSIONS physiological variations in plasma glucose concentration influence oesophageal motility and sensation. These observations suggest that in order to minimize effects of varying plasma glucose levels on oesophageal motility, manometry should be performed under the same fasting or fed conditions when oesophageal motor function is evaluated.

Background Whilst oesophageal manometry outcomes following fundoplication performed by open techniques have been described, detailed reports of changes in manometric parameters following large series of laparoscopic Nissen fundoplication have yet to be described. Methods An analysis of oesophageal manometry studies performed on patients undergoing laparoscopic Nissen fundoplication at the Royal Adelaide Hospital was performed to quantitate the effect of surgery and to determine whether manometric indicators of adverse surgical outcome could be identified. The original manometric recordings from a subset of 103 patients were reviewed. Only patients who had undergone preoperative and postoperative examinations in this department, and assessment by an independent investigator using a standardized clinical questionnaire, were included in the study. Results Mean resting lower oesophageal sphincter (LOS) pressure increased from 8.5 to 21.5 mmHg (P

This study aimed to assess the relationship between nadir lower oesophageal sphincter pressure (LOSP) and wave amplitude (WA) in oesophageal bolus clearance. Concurrent oesophageal manometry and impedance were performed in 146 subjects [41 healthy, 24 non-obstructive dysphagia (NOD) and 81 gastro-oesophageal reflux (GOR)]. Patients with achalasia and diffuse oesophageal spasm were excluded. Swallow responses were categorized by nadir LOSP. For each category of nadir LOSP, WA at the distal 2 recording sites were grouped into bins of 10 mmHg and the proportion of waves in each bin associated with a normal bolus presence time (BPT) was determined. Nadir LOSP, distal BPT, total bolus transit time and the proportion of impaired oesophageal clearance in patients with NOD were greater than those of healthy subjects and patients with GOR. Overall, responses with impaired oesophageal clearance had significantly lower WA (54 +/- 1 vs 81 +/- 1 mmHg; P < 0.0001) and higher nadir LOSP (2.7 +/- 0.4 vs 1.0 +/- 0.1 mmHg, P < 0.001). For each level of nadir LOSP, there was a direct relationship between distal WA and successful bolus clearance of both liquid and viscous boluses from the distal oesophagus. As nadir LOSP increased, the relationship between WA and bolus clearance shifted to the right and higher amplitudes were required to achieve the same effectiveness of clearance. Hypotensive responses with nadir LOSP > or = 3 mmHg were less likely to clear than those with nadir LOSP < 3 mmHg, for both liquid (7/29 vs 162/276; P < 0.001) or viscous boluses (11/46 vs 176/279; P < 0.0001). Nadir LOSP is an important determinant of bolus clearance from the distal oesophagus, particularly in patients with NOD

Background Automated integrated analysis of impedance and pressure signals has been reported to identify patients at risk of developing dysphagia post fundoplication. This study aimed to investigate this analysis in the evaluation of patients with non-obstructive dysphagia (NOD) and normal manometry (NOD/NM). Methods Combined impedance-manometry was performed in 42 patients (27F : 15M; 56.2 ± 5.1 years) and compared with that of 24 healthy subjects (8F : 16M; 48.2 ± 2.9 years). Both liquid and viscous boluses were tested. MATLAB-based algorithms defined the median intrabolus pressure (IBP), IBP slope, peak pressure (PP), and timing of bolus flow relative to peak pressure (TNadImp-PP). An index of pressure and flow (PFI) in the distal esophagus was derived from these variables. Key Results Diagnoses based on conventional manometric assessment: diffuse spasm (n = 5), non-specific motor disorders (n = 19), and normal (n = 11). Patients with achalasia (n = 7) were excluded from automated impedance-manometry (AIM) analysis. Only 2/11 (18%) patients with NOD/NM had evidence of flow abnormality on conventional impedance analysis. Several variables derived by integrated impedance-pressure analysis were significantly different in patients as compared with healthy: higher PNadImp (P

BACKGROUND The prevalence of dyspepsia and the severity of reflux symptoms decreases with advancing age. We postulate that advancing age influences sensory function and this will be associated with a diminished symptom response to a standardized meal stimulus.Our aim was to assess the influence of age on visceral sensory function. METHODS Baseline gastrointestinal symptoms and anxiety and depression were assessed in 53 healthy volunteers using validated questionnaires. After an 8-h fast, subjects received 200 mL of a standardized enteral feeding solution every 5 min up to a cumulative volume of 800 mL. After each 200 mL drink, five key symptoms were assessed (fullness, abdominal pain, retrosternal/abdominal burning, nausea and regurgitation) using a standardized instrument on visual analogue scales (0-100). The cumulative symptom score across all symptoms was calculated. KEY RESULTS Fullness was the most prominent symptom reported (79.8 +/- 9.5) followed by nausea (14.9 +/- 4.9) and pain (9.8 +/- 4.5); these three items accounted for more than 90% of the overall symptom load. The cumulative pain and nausea scores during a standardized nutrient challenge were significantly and inversely correlated with age (r = -0.43, P = 0.002 and r = -0.28, P = 0.045). Subjects >60 years of age reported significantly lower pain and nausea scores (0.9 +/- 0.9, 4.5 +/- 3.9) than did subjects