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ORIGINAL ARTICLE Table of Contents   
Year : 2006  |  Volume : 12  |  Issue : 2  |  Page : 77-82
Hypertensive lower esophageal sphincter (HLES): Prevalence,symptoms genesis and effect of pneumatic balloon dilatation


1 Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt
2 Al-Azhar University, Cairo, Egypt

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Date of Submission20-Jan-2006
Date of Acceptance22-Apr-2006
 

   Abstract 

Background: Summary and background data: The Hypertensive lower esophageal sphincter (HLES) is an unusual primary motor disorder of the esophagus. The significance of this motility disorder is still questionable. Objective: The objectives were: (a) identification of the prevalence of HLES in these patients, (b) identification of the common presenting symptoms of HLES, (c) study of the correlation of the symptoms with LESP and (d) study of the effectiveness of pneumatic balloon dilation in cases that fail to respond to medical treatment. Methods: A retrospective study that includes four thousand one hundred and seventy patients, who were subjected to esophageal manometry in the period from January 1994 to December 2003, among whom sixty-six patients with HLES (LESP >40 mmHg) were found. In addition to manometry, upper endoscopy was done to forty-nine patients, upper GI barium studies to thirtyeight patients and esophageal pH- metry to sixteen patients. Results: showed that most of our patients were females (45 females and 21 males), with a mean age of 36.6 北14 years. Patients with dysphagia (57.5%) had the highest LESP (52.1 北21, mmHg) while patients with chest pain (47%) had the highest distal esophageal contraction amplitude (153.9 北 93.2 mmHg). Endoscopy showed varying degrees of esophagitis in 17 patients (34%). Barium studies showed corkscrew esophagus in seven patients (18.4%) and dilated esophagus in nine patients (23.7%). LESP was highest in patients with dilated esophagus (57.5 北 33.4 mmHg). All our patients were subjected to medical treatment, of which twelve patients underwent pneumatic dilation with successfully reduced LESP and symptoms relief in 91% of patients. Conclusions: It was concluded that the prevalence of HLES is around 1.6, in which dysphagia and chest pain are the usual presenting symptom, and that pneumatic balloon dilatation is very effective when properly applied. It will probably occupy the same position it has in achalasia.

Keywords: Hypertensive lower esophageal sphincter, chest pain, dysphagia

How to cite this article:
Gad El-Hak NA, Mostafa M, AbdelHamid H, Haleem M. Hypertensive lower esophageal sphincter (HLES): Prevalence,symptoms genesis and effect of pneumatic balloon dilatation. Saudi J Gastroenterol 2006;12:77-82

How to cite this URL:
Gad El-Hak NA, Mostafa M, AbdelHamid H, Haleem M. Hypertensive lower esophageal sphincter (HLES): Prevalence,symptoms genesis and effect of pneumatic balloon dilatation. Saudi J Gastroenterol [serial online] 2006 [cited 2020 Nov 26];12:77-82. Available from: https://www.saudijgastro.com/text.asp?2006/12/2/77/27850


The esophagus is an active muscular organ with a complexneuromuscular structure with specialized sphincter at eachend. The upper esophageal sphincter (UES) contracts duringinspiration, preventing air from entering into the gastrointestinaltract while Lower Esophageal Sphincter (LES) maintains asteady baseline tone to prevent gastric juice from refluxinginto the esophagus[1]. Although gastrointestinal motor activityhas been studied for more than century, the identification ofmotor disorders in clinical practice still represent problems.

Reynolds et al defined HLES as a distinct clinical entity[2],while Wingate defined it as a primary motor disorder of theesophagus with questionable entities[3].

HLES is an uncommon manometric abnormality found inpatients with dysphagia, chest pain, gastroesophageal refluxand/or hiatal hernia[4]. HLES incidence has been reported asbeing between (0.8%-12%) of patient referred for manometricinvestigation of esophageal symptoms[5]. It is characterizedby increase LES pressure of greater than 40 mmHg[6],normal LES relaxation and normal esophageal peristalsis[2],[3].Patients with HLES often have other motility disorders, nonspecificmotility disorder, nutcracker esophagus and diffuseesophageal spasm[2].

Endoscopy has the advantage of direct visualization ofstructural lesions and biopsies can be obtained. However, itdoes not play a role in the diagnosis of motility disorders[7].Barium studies assess the emptying of the esophagus as wellas structural abnormality. Esophageal motility is best assessedby the full column technique and fluoroscopic observation[8].Although radiological investigation, such as contrast studies,may have a role in the diagnosis of achalasia, the correlationbetween isolated HLES and radiological findings is unclearand the diagnosis is made by manometry [2].

The pathophysiology of HLES is complex and poorlyunderstood. There is experimental evidence that loweresophageal hypertension occurs following stimulation of thecut ends of splanchnic nerves[9]. Histological studies haveshown degeneration of myenteric ganglion cells, with sparingof post-ganglionic cholinergic nerves[10].

Regarding the treatment of HLES, no established methodsare available at present, but oral administration of nitrate,anti-depressant, anti-cholinargic, smooth muscle relaxantsas calcium channel blockers (nifiedipine, etc.) and antiscertoryhave been tested, with improvement of subjectivesymptoms[6]. Passage of a 50 F Bougie dilator or pneumaticballoon dilatation reserved for patient with severe dysphagiaand chest pain with clinical relief in some patients[11],[12].Esophagomyotomy restores LES pressure to physiologicallynormal levels and is the treatment of choice for isolated HLESthat fails medical treatment[2]. In addition, gastro-esophagealreflux has been shown to occur in some patients with HLESand anti-reflux treatment achieves symptom relief[13].


   Objectives Top


We aim to study the following:

(1) Prevalence of HLES in patients subjected to esophageal manometry.

(2) The common symptoms and clinical presentations of HLES.

(3) Correlation of the symptoms with LESP.

(4) Effectiveness of pneumatic dilatation in patients refractory to medical treatment.


   Patients and methods Top


In the period between January 1994 December 2003more than four thousand one hundred and seventy patientswere referred to the esophageal function laboratory for theinvestigation of upper gastrointestinal symptoms by esophagealmanometry. Sixty-six patients (21 males, 45 females) withmean age of (36.6+14) years met the manometric criteria forHLES. These are a mean resting pressure of >40 mmHg abovegastric pressure, normal lower esophageal sphincter relaxation(LESR) and normal esophageal peristalsis[6]. Patients withachalasia were excluded from our study.

Details of clinical assessment and symptoms analysis fordysphagia, chest pain, reflux and/or mixed symptoms werecorrelated with different manometric findings.

Esophageal manometry was carried out for all patients.Patients were studied in the fasting state; oral administrationof nitrate, anti-cholinargic, smooth muscle relaxant as calciumchannel blockers (nifiedipine, etc.), anti-scertory, proton pumpinhibitors and prokinetics were all stopped seven days, beforethe test.

The pressure characteristics of the gastro-esophagealjunction were measured by a water perfused eight lumenpressure catheter side holes with an outside diameter of4.5mm at 5, 5, 5, 2, 1, 1 and 1 cm apart from each other,from the proximal and they are radially oriented by 360鞍 andwere constantly perfused with distilled water from the "Muiscintific"perfusion pump at a rate of 0.5ml/min. Each channelwas connected to pressure transducers which transmit datainto a personal computer via an elecronic micro-laboratory(SmartLab. Motility System; Sandhill, USA). A station pullthroughtechnique was used and the probe was withdrawn 0.5cm each time and kept at each level for at least 30s or until therecording became stable.

The high pressure zone was defined as the mean of thehighest pressure plateau recorded by each of the eight portsminus the mean pressure in the gastric fundus measured atthe mid of respiration and the patients were asked to take 5mlwater to obtain % (the percentage) relaxation and its residualpressure.

Thoracic esophageal motility evaluated by positioning threeholes at 5,10 and 15 cm proximal to the upper border of theLES, ten wet swallows were assessed at each level and themean values of these swallows were analyzed in each patientto evaluate peristaltic contractions.

Esophageal body amplitude was considered as hypertensivewhen distal body amplitude was >180mmHg[14] andhypotensive when distal body amplitude <35 mmHg[15],[16],[17].

Ambulatory 24-h pH monitoring was done for sixteenpatients whom had reflux symptoms or endoscopic evidence ofreflux. A disposable antimony, or glass ingold pH electrodes,was passed and secured to the nose with an electrode placed5cm above the high pressure zone as located by manometricexamination and connected to a portable Digtrapper MKIII(Synectics Medical, Sweden). The patients were ambulatorythroughout all recordings and were instructed to follow theirusual pattern of living. Reflux symptoms, meals and restingperiods were recorded in a diary by the patients. The pHdata and information given in the diary were evaluated bycomputer software.

Esophageal acid exposure was then scored accordingto DeMeester's system[18]. This score is a composite ofphysiological parameters including frequency and duration ofacid exposure and position during reflux events, with a scoreof 14.7 as the upper limit of normal. Patients were studiedin the fasting state. Proton pump inhibitors were stoppedseven days, and antacids and prokinetics three days, beforethe test[2].

Upper GIT endoscopy were done for 49 patients usingOlympus video endoscopy for examination of esophagusstomach duodenum to exclude patients who had any organiclesions and to evaluate the presence of esophageal erosions,spastic cardia, dilated esophagus and/or gastrodudenallesions[3],[8]. The classification of the different degrees ofesophagitis was taken according to a modification of SavaryM. et al criteria[19] and Csendes A. et al[20].

Barium swallow and meal were done for 38 patients. Theywere evaluated by standard liquid barium with water siphontest for evaluation of abnormal esophageal motility, dilatedesophagus and evidence of reflux esophagitis. Reassurance andmedical treatment in the form of anaxolytic, antidepressant,smooth muscle relaxant, calcium channel blockers, nitrateand anti-scertory was given according to the results of ourinvestigation.

Pneumatic balloon dilatation was done for twelve patientsafter failure of medical treatment. A rigiflex balloon (35 mmouter diameter) was passed over a guide wire with length 10cm, and inflation pressure of 15:18 PSI was applied for 1minute. Eleven patients had one session only while one patientneeded two sessions for clinical improvement. Esophagealmanometry and clinical assessment were evaluated forthem after a period of (5.83北0.92) months after balloondilatation.


   Statistical analysis Top


Data were analyzed using SPSS, Version 10. Qualitativedata was presented in the form of number and percentage.Quantitative data were presented as mean and +SD. Theparametric data followed normal distribution[4]. Unpairedstudent T-test was used for comparison between variables.p<0.05 was considered to be statistically significant.


   Results Top


HLES prevalence in our group of symptomatic patients isapproximately 1.6%. HLES was detected in a wide spectrumof ages ranging from six to seventy-one years and the majority(76%) had an age range of 21:50 years [Figure - 1]. The female/male ratio was more than 2/1. Females constituted 68.2%while males only 31.8%. Correlation of sex and age showedthat females presented more than ten years earlier than males(34.18 北 14.2 years Vs. 45.14 北 13 years). LESP wasparticularly high in the extremes of the age in both males andfemales [Figure - 2]. Amplitude of distal body contractions wasmore in males than females (141.57 北 87 and 100.44 北 63mmHg respectively, p<0.05).

Dysphagia was the chief presenting symptom, either alonein twenty-three patients (34.8%), or associated with othersymptoms, such as chest pain or heartburn, in thirty-eightpatients (57.5%). Chest pain, alone or with other symptomscomes next with 31 patients (64.4%). Symptoms related toreflux was noticed in twelve patients (18%) who constitutedthe main bulk of patients subjected to ambulatory pH-metry.LESP was highest in patients with dysphagia with a meanof 52.1 北 21.1 mmHg while the amplitude of the distalesophageal contractions was highest in cases with chest painwith a mean of 153.8 北 93.2 mmHg versus 89.3 北 57.1mmHg in patients with dysphagia, p<0.05 [Table - 1].

The majority of the dysphagia group (87%) had anormotensive body, while the majority of the chest paingroup (53%) had a hypertensive body. Patients with refluxsymptoms had more often a normotensive body (66.7%) butmay be hypertensive in 33.3%, [Figure - 3].

Endoscopically: Seventeen patients (34%) showed varyingdegrees of esophagitis, six (12.2%) had mild dilated esophagusand four (8.2%) had spastic cardia. Meanwhile thirteen(26.5%) had normal endoscopic examination [Table2].

LESP was higher in patients with mild dilated esophagus(50.5+16.7 mmHg), but the lowest LESP was in spasticcardia patients (45.2+2.6 mmHg), p>0.05. On the other handthe distal body amplitude was higher in patients with varyingdegrees of esophagitis (153.5+65.5 mmHg) versus others, andthe lowest distal body amplitude was in patients with milddilated esophagus (59.5+18.5 mmHg), p< 0.05.

Radiologically: Seven patients (18.4%) showed corkscrewesophagus, nine (23.7%) had mild dilated esophagus, six ofthem dilated also by endoscopic examination and five (13.2%)had positive evidence of GERD.(1, 4, 6) Meanwhile sixteen(42.1%) had normal barium study [Table - 3].

LESP was highest in patients with mild dilatated esophagus(57.5北33.4 mmHg) and corkscrew esophagus (56.2北13.7mmHg) and lowest, though still higher than normal, in patientswith GERD (42.1北8.1 mmHg), p>0.05. The amplitude ofthe distal esophageal contractions was highest in corkscrewesophagus (151.2北83.2 mmHg) and GERD (159.4北101.2mmHg), and lowest in mild dilatation of the esophagus (72.4北 53.1 mmHg), p>0.05.

Esophageal manometry showed mean LESP of (49.3+14.9mmHg) and the mean distal esophageal amplitude of (115+72.6mmHg). Fifteen (22.7%) patients had high distal amplitude(>180 mmHg), four (6.1%) patients had low amplitude (<35mmHg), and forty-seven (71.2%) patients had normal distalamplitude.

Simultaneous esophageal contractions were consideredabnormal if it exceeds 30% and were detected in fifteen(22.7%) patients with mean simultaneous waves of (39.8 北16.1%) [5]. Eight patients (53.3%) presented with chest painand four patients (26.7%) with dysphagia, so chest pain anddysphagia represent the main symptoms in those patients.

Six out of the sixteen patients were subjected to ambulatorypH-metry, showed evidence of pathological acid reflux with amean LESP of 55.56 北 14.7 mmHg, which was higher thanin the remaining ten patients with physiological reflux of 42.8北 5.49 mmHg, p>0.05[6].. Distal body amplitude was higherin patients with pathological reflux of 196.0 北 42.2 mmHgthan in patients with normal reflux of 138.00 北 101.6 mmHg,p>0.05.

Pneumatic balloon dilatation was successful in the all twelvepatients to whom it was applied, but one patient required twosessions. The remaining eleven patients (91%) were relievedsymptomatically and manometrically in one session. TheLESP improved after six months of balloon dilatation from amean of 46.8北9.9 mmHg to 29.7北12.8 mmHg, p=0.005[7]..


   Discussion Top


The hypertensive lower esophageal sphincter (HLES) is anunusual primary motor disorder of the esophagus. The lackof a precise definition has made it difficult to establish itsprevalence and its clinical and manometric characteristics.

The clinical significance of HLES in previous studies wascontroversial; Reynolds et al defined HLES as a distinctclinical entity [2], while Wingate et al defined it as a primarymotor disorder of the esophagus with questionable assoiatedentities [3]. On the other hand, the results of our study clearlyindicated that HLES is a manometric entity that correlateswell with dysphagia and chest pain and it could be helpful indeciding the treatment plan.

The prevalence of HLES in one previous study rangedfrom 0.8% to 8%(5), while the prevalence in our patients was1.6%, which is comparable to the 1% that found by Cameron-Sanchez R. et al[21], and the 0.9% by Reynolds et al[2].

HLES disorder presented over a very wide age range, withpatients ranging from six to seventy-one years, predominantly(76%) between twenty and fifty years of age. This age rangeextended more than described by Reynolds, et al[2] (25:49years). The LESP was observed in our study to be higher atthe extremities, rather than the middle, of the age range.

HLES disorder was noticed to be more common in femaleswith a female to male ratio of 2:1. This observation was nearlythe same as recorded by Anand P. et al(4), who studied sixteenpatients (11 females and 5 males), and less than Reynolds, etal[2], at 78:22 % (21 females versus 6 males). In our patients,females were affected 11 years earlier than males with astatistically significant difference (p<0.05).

The Chief complaint of our patients were dysphagia (34.8%)or non-cardiac chest pain (28.8%), or combined (18.2%).Similar results were observed by Anand P et al [4], while thechief complaints in the Reynolds, et al study(2) were GERD(33%), dysphagia (18.5%) and chest pain (15%).

The association of GERD with HLES is unclear; inour opinion, the acid may stimulate LESP contraction asa protective mechanism, or else a failure of clearance ofphysiologically refluxed acid causing sensation of heart burn,and this need more studies.

The highest LESP was noticed in dysphagia patients(52.1+21.1mmHg) while distal body amplitude was higher inchest pain group (153.9+93.2mmHg), p<0.05. The esophagusand heart have a similar autonomic nerve supply, andesophageal motility has been recognized since the early 1960as a significant cause of non-cardiac chest pain[22].

Upper GIT endoscopy is insensitive in determining primarymotility abnormalities of the esophagus[23]. Endoscopicexaminations of studied patients revealed 34.7% had variantdegrees of reflux even in patients without any evidence ofreflux by barium or pH study, the majority being grade 1(28.6%). Although 20% of patients had endoscopic evidenceof esophageal motility disorders, either mild dilated esophagus(12.2%) or spastic cardia (8.2%), these endoscopic findingsare not specific for HLES and can simulate other motilitydisorders.

The highest LESP and the lowest distal body amplitude werefound in patients with dilated esophagus by endoscopy; thiscan probably be explained as an adaptive effect of esophagusto the highest LESP. The highest distal body amplitude, onthe other hand, was found in patients with GERD; this can beexplained by the stimulant effect of acid on the distal body oras protective mechanism against reflux.

Barium studies assess the emptying of the esophagus as wellas structural abnormality. Esophageal motility is best assessedby full column technique and fluoroscopic observation[24].However, HLES is a manometric diagnosis and radiologicalstudies do not have much of a role in its elucidation. It is oftenparadoxically associated with gastro-esophageal reflux[2].Abnormal radiological findings were encountered in 57.9%of the patients in our study, and the indicator of abnormalmotility was found to be 42.1% (mild dilated esophagus in23.7% and corkscrew in 18.4%). These findings, however, arenot specific for HLES. These results are higher than the studydone by Reynolds et al[2], who found 22% of his patients had aradiological abnormality (11% had corkscrew esophagus and11% had hiatus hernia).

Patients with dilated esophagus, according to barium study,had the highest LESP and lowest distal body amplitude,which goes hand on hand with endoscopic findings. Patientswith GERD had higher distal body amplitude and the lowestLESP, while corkscrew patients had both high LESP and highdistal body amplitude. Neuromuscular discoordination wasreported to be the main explanatory mechanism.

Regarding the association of HLES with pathologicalGERD by pH studies, six out of sixteen patients (37.5 %)complaining of heart burn had pathological reflux, which wascomparable to Rynolds JV[2], who reported (20.7%) of theirpatients with HLES and abnormal pH studies.

This apparently paradoxical association stresses the factthat the magnitude of LESP is not the main, or even animportant, factor in the genesis of most cases of GERD.It was interesting in our series that ten patients, out of thesixteen subjected to pH-metry, showed physiological refluxin spite of their complaints of frequent heartburn. This couldbe explained by assuming a high frequency of hypersensitiveesophagus in HLES, more so than GERD; a point which needsfurther exploration for association, especially if we know thatGockel et al, for example, considers heartburn as common asdysphagia in HLES.

Pneumatic balloon dilation was almost 100% effective whenused (12 cases). It seems that the protocol of therapy for HLES,which is still unclear, will be more or less like the protocolin achalasia. This means that we have to try the followingthree modalities: medical treatment, pneumatic dilatation andmyotomy in this order. Like in achalasia, pneumatic dilatationis effective in most cases for HLES when done properly, andmyotomy seems to be reserved only for refractory or possiblyrecurrent cases.


   Conclusions Top


(1) HLES seems to be a definite motor abnormality with prevalence around 1.6%.

(2) The commonest presenting symptoms are dysphagia and chest pain singly or in combination. Heartburn and reflux related symptoms occur in about 25% in our cases.

(3) Symptoms correlate with LESP in most cases especially dysphagia.

(4) Pneumatic dilatation is an effective method of treatment, probably as good as in achalasia.

In addition to the above, some light was thrown on the pathogenesis of dysphagia and chest pain. We have to admit that it was not initially planned to explore the pathogenesis, a point that emerged as a very important byproduct of our study.

 
   References Top

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Correspondence Address:
Nabil A Gad El-Hak
Gastroenterology Surgical Center, Mansoura University, Mansoura
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.27850

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