UNEXPLAINED DYSPHAGIA - VISCOUS SWALLOW-INDUCED ESOPHAGEAL DYSMOTILITY

Dysphagia is a manifestation of several clinical conditions of diverse origin. In spite of the variation in these disease entities in terms of their etiology, clinical presentation, natural history, and treatme nt, the mechanism of this clinical complaint is not always clear. We s tudied a group of patients with dysphagia for solids in whom no anatom ic or motor abnormalities were encountered on standard studies. The gr oup consisted of 37 patients, 25 women and 12 men, who were complainin g of dysphagia of 6 months or longer duration and they did not demonst rate structural or motor abnormalities on barium esophagogram, esophag oscopy, and standard esophageal manometry. A group of 24 age-matched p atients, 14 women and 10 men, with noncardiac chest pain served as the patient control. Esophageal contractile activities were studied after 10 wet swallows (5 mi of water) and 10 viscous swallows (5 cubic cm o f marshmallow). Resting lower esophageal sphincter pressure and its re laxation response to swallows, amplitude of peristaltic activities, ra te of dysphagia provoked during the study, and the frequency of abnorm al esophageal contractions were evaluated. Six abnormal esophageal con tractile activities-failed peristalsis, dropout, repetitive, simultane ous, spontaneous contractions, and aperistalsis - were utilized to gen erate an esophageal peristaltic dysfunction index. The mean LESP was 8 .1 +/- 4.7 in the dysphagia group and 16.1 +/- 4.3 in the chest pain g roup. The mean amplitude of peristaltic contractions was 37.1 +/- 16.1 and 89.0 +/- 27.0 mmHg after wet swallows for dysphagia and chest pai n groups, respectively. These values were 58.2 +/- 12.4 and 92.4 +/- 2 2.1 for viscous swallows. Swallowing provoked dysphagia in 89% of the dysphagia group after viscous swallows and 9% after wet swallows. In c ontrast, only 11% and 3% of control group complained of dysphagia duri ng the study. This group of patients probably represent a cohort of pa tients with a nonspecific esophageal motor disorder in whom both clini cal symptom and their esophageal motor counterpart can only be elicite d in response to viscous swallows. We strongly believe in addition of viscous swallows in evaluating dysphagic patients in whom symptoms rem ain unexplained in light of standard studies.