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Presbyesophagus

Presbyesophagus is the change in the structure of the esophagus which causes an alteration in the esophageal motility. It is characterized by reduced contractions, inability of upper esophageal sphincter (UES), lower esophageal sphincter (LES) and esophageal muscles to relax smoothly as well as esophageal dilatation.


Presentation

Most patients with presbyesophagus are asymptomatic. The probable reason behind this is the lack of sensory pain sensations that occurs with ageing and in diseases that accompany with age (e.g. diabetes mellitus). However, some patients do present with clinical symptoms in the long run. The most common complain occurring from esophageal motility dysfunction is chest pain, typically followed by intermittent, non-progressive dysphagia [9]. In the presence of GERD, patients also complain of heartburn and regurgitation resulting from compromised esophageal clearance of gastric acid [10]. Cases of presbyesophagus accompanied by significant achalasia may lead to weight loss [11].

Intravenous Administration
  • Esophageal function was studied basally and after intravenous administration of 80 µg/kg body weight of edrophonium chloride.[annals.org]
Abdominal Mass
  • Characterize abdominal masses and adenopathy with the aid of diffusion-weighted MR imaging.[books.google.com]
Delayed Gastric Emptying
  • Adapted from IFFGD Publication: Gastroparesis (Delayed Gastric Emptying) by J. Patrick Waring, MD, Digestive Healthcare of Georgia, Atlanta, GA; and William F.[aboutgastroparesis.org]
Skin Lesion
  • Lesions 867 Orthopedic Injuries 885 Joint Replacement in the Elderly Patient 900 Nervous System 921 Invited Commentary 923 Effects of Aging on the Human Nervous System 926 Benign and Malignant Tumors of the Brain 949 Spinal Disorders and Nerve Compression[books.google.de]
Freckles
  • There are also scattered freckles and _____. phonically s/l vun-tinge-a-knees or it could start with a b or f. I have no idea.[mtstars.com]
Erythema
  • Radiotx, fundoplication) Due to increase of portal pressure above normal (i.e. 10 mm Hg) Gastrooesophageal varices: Left gastric (coronary) vein and short gastric veins (via splenic hilum) Paraoesophageal varices: outside oesophageal wall Grades: I - erythema[brainscape.com]
Incontinence
  • Bile Ducts 711 Benign and Malignant Tumors of the Liver 729 Pancreatitis in the Elderly 740 Pancreatic Tumors Pathophysiology and Treatment 748 Urogenital System 761 Invited Commentary 763 Renal Function and Fluid and Electrolyte Balance 767 Urinary Incontinence[books.google.de]
  • His interests are in incontinence in the elderly, the effects of medication and co-morbidity on continence status and the epidemiology and aetiology of incontinence in the elderly.[books.google.de]
  • Is not a normal outcome of aging, some stress incontinence may occur because of a weakening of the pelvic diaphragm, particularly in multiparous women.[quizlet.com]

Workup

Diagnostic tests that are useful in confirming presbyesophagus include fluoroscopy, manometry, endoscopy and tissue biopsy. Endoscopy plays an important role in ruling out other etiologies behind esophageal dysmotility.

Esophageal fluoroscopy is performed after administration of barium solution to the patient. In the presence of presbyesophagus, fluoroscopic examination of esophageal muscles during deglutition reveals marked esophageal dilatation, dysfunction in relaxation of LES, several abnormal tertiary non-peristaltic contractions and less frequent episodes of primary and secondary peristalsis [12] [13]. Functional pattern of the LES and esophageal muscles is assessed by observing the LES pressure and relaxation and degree of contraction of esophageal muscle through manometry [14]. The presence of long-term, complicated presbyesophagus can be diagnosed by endoscopic examination. Endoscopy in case of severe dysfunction demonstrates atonic and dilated esophagus. The histological examination of tissue biopsy shows reduced ganglion cells and increased inflammatory mediators. Microscopic examination of muscle cells reveals normal muscle size although there will be considerable thickening in the LES muscle.

Esophageal Motility Disorder
  • Esophageal motility disorders discussed in this article include the following: Achalasia Spastic esophageal motility disorders, including diffuse esophageal spasm (DES), nutcracker esophagus, and hypertensive LES Nonspecific esophageal motility disorder[tapatalk.com]
  • "Esophageal Motility Disorders - UW Medicine". www.uwmedicine.org. External links [ edit ][en.wikipedia.org]
  • Esophageal motility disorders Esophageal motility disorders are not uncommon in gastroenterology.[emedicine.medscape.com]
  • Definition • Esophageal motility disorder characterized by hypo-peristalsis & incomplete relaxation of the lower esophageal sphincter. 14.[slideshare.net]
  • Barium swallow study showing a case of Presbyesophagus Classification of esophageal motility disorder – Primary Motility Disorder - 2) Diffuse esophageal spasm 4) Nonspecific esophageal motility disorder. 6) Hypertensive lower esophageal sphincter.[radioloksabha.com]
Tertiary Contractions of the Esophagus
  • I was diagnosed as having tertiary contractions of the esophagus and slight gastritis. I have substernal chest pain that doesn't go away after eating. My doctor feels it is not cardiovascular.[articles.chicagotribune.com]
  • In DES there is occasional absence of primary peristalsis and multiple simultaneous non-peristaltic tertiary contractions of the esophagus occur, causing segmentation of the barium column and resulting in a "rosary bead" or "corkscrew" appearance.[mycourses.med.harvard.edu]

Treatment

Treatment of presbyesophagus is targeted at promoting normal smooth contraction and relaxation within the esophagus. Common treatment options include pharmacological agents (smooth muscle relaxants, pain modulators and antireflux therapy), endoscopic balloon disruption, botulinum toxin and esophagogastroduodenoscopy (EGD) with pneumatic dilation.

Smooth muscle relaxants are helpful in correcting esophageal motility dysfunction. Nitrates (isosorbide dinitrate) and calcium channel blockers (nifedipine) are most commonly used muscle relaxants for presbyesophagus. Less common drugs include anticholinergics, xanthines (theophylline), beta-2 adrenergic agonists and phospdiesterase inhibitors. Chest pain resulting from impaired esophageal motility responds well to antireflux treatment. Other drugs that may be used to relieve symptoms associated with presbyesophagus comprise tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin receptor antagonists and reuptake inhibitors (SARIs - trazodone). Chest pain refractory to most analgesics is well managed with TCAs.

A highly effective therapy that controls dysmotility associated with presbyesophagus and is proposed to be a good surgical alternative is administration of botulinum toxin. It helps to relax the LES muscles by inhibiting the release of acetylcholine from nerve terminals [15]. Suggested doses include 80-100 units injected into 4 quadrants of the LES. Botulinum toxin provides relief from symptoms of pain, dysphagia and regurgitation by relaxing the LES.

Another treatment method for correction of the LES and UES dysfunction in presbyesophagus which is still under investigation is EGD with pneumatic dilation. However, sufficient clinical data is needed to support the use of EGD.

Prognosis

Presbyesophagus is not related to mortality or significant morbidity. No significant weight loss occurs in the patients. 

Etiology

The phenomenon of ageing is accompanied by several physiological changes in the body. Sphincter muscles in the alimentary tract undergo age-related modifications with time. In certain cases, prolonged acid reflux occurring from gastroesophageal reflux disease (GERD) causes considerable damage to the esophagus. Consequently, esophageal peristalsis is altered [3].

Epidemiology

Presbyesophagus is particularly a disease of elderly as it occurs due to normal ageing. Therefore, individuals above 80 years of age are more likely to develop the disease [4].

Sex distribution
Age distribution

Pathophysiology

Through numerous case studies it has been postulated that decline in esophageal function manifested by decreased primary and secondary peristalsis, inadequate relaxation of the esophageal sphincters and prolonged esophageal lengthening and dilatation occurs due to ageing and secondary to other frequently age-related disease conditions such as diabetes mellitus, cognitive impairment and use of different drugs. Although, these changes occurring in esophageal physiology are minimal. Age-related degeneration of myenteric neurons has also been studied which ultimately results in compromised esophageal physiology.

Altered esophageal motility in presbyesophagus is associated with age-related decline in UES pressure and relaxation following deglutition. Food swallowing is also prolonged owing to rise in sensory threshold for commencement of deglutition [5]. Radiographic and scintigraphic data has revealed significant alteration in the esophageal muscle contractions, specifically in the distal esophagus and UES of elderly individuals [6]. However, the LES does not demonstrate pronounced impairment in contraction and retraction with no considerable changes in the LES pressure during esophageal clearing [7]. Moreover, overweight elderly patients with hiatal hernia are likely to develop GERD. The acid reflux occurring due to the condition is typically cleared through secondary peristalsis, a phenomenon which is significantly altered in GERD. Therefore, presence of GERD is directly related to the incidence of presbyesophagus in old age [8].

Prevention

Reduced esophageal clearing can be facilitated by modifying eating habits and general body postures. Patients with presbyesophagus are advised to split larger meals into smaller meals with reduced portion size along with increased fluid intake. Small food bites that are masticated appropriately are more easily propelled through the esophagus. Additionally, maintaining an upright position by straightening the spine and standing helps facilitate esophageal clearing by increasing intraesophageal pressure and motility. 

Summary

Presbyesophagus is referred to as a decrease in the functional peristalsis occurring due to a gradual decline in the motor function in the esophagus. Several studies have associated the link of deteriorating esophageal function and normal ageing, which may explain why the disease is commonly encountered among elderly patients above 80 years of age.

The esophagus is comprised of variable muscular layers throughout the alimentary canal and contains two specialized muscular rings that promote peristalsis. The upper esophageal sphincter (UES) is a muscle located at the top of the esophagus that is composed of striated muscles. The UES prevents the entrance of air into the gastrointestinal tract (GIT). Another bundle of muscle fibers, the lower esophageal sphincter (LES) is comprised of smooth muscle fibers and plays an important role in preventing acid reflux from the stomach. The muscular layers, more appropriately known as muscularis propria of the esophagus, are arranged in two different layers. An inner circular layer is responsible for the contraction of lumen and an outer longitudinal muscle shortens the length of the esophagus by contraction. The two muscular layers contract concomitantly to facilitate motility within the esophagus. This process is known as peristalsis. During contraction, the synchronous contraction and relaxation of esophageal muscles, UES and LES results in movement and propulsion of the swallowed bolus into the stomach. Therefore, peristaltic contractions are primarily responsible for clearing food and reflux material from the esophagus. The expulsion of the bolus occurs after relaxation of the LES which remains relaxed during peristalsis and retracts once the peristalsis is completed.

Based on triggering factors, peristaltic contractions can be primary, secondary or tertiary. Primary peristalsis results from swallowing and the recorded speed of contraction is 2cm/sec. Presence of gastric contents reflux, swallowed air or retained bolus inside the esophagus results in distension of the esophageal muscles, leading to secondary peristalsis. The tertiary contractions possess no functional value and do not contribute to digestion.

In presbyesophagus, increase in frequency of tertiary non-peristaltic contractions [1] [2] occurs which is accompanied by dilatation of the esophagus and incomplete relaxation of the UES and LES.

Patient Information

Presbyesophagus is condition in which the swallowing tube of digestive tract (esophagus) undergoes abnormal change in its size, shape and function. The muscles that make up the esophagus and promote normal passage of swallowed food are affected due to which the propulsion of food from the esophagus to the stomach is slowed down (dysmotility). Presbyesophagus is more predominant in elderly people since the esophagus changes its structure and function with the passage of time and with the presence of other diseases that occur with age. Presbyesophagus does not lead to secondary diseases but reduces the quality of life.

The most common clinical complains associated with presbyesophagus are difficulty in swallowing foods, heartburn and chest pain. However, many patients do not experience any symptom.

Presbyesophagus is diagnosed by performance of a physical examination and some tests. Common diagnostic tests include fluoroscopy, endoscopy and manometry. Fluoroscopy and manometry are used to detect abnormal pattern of motility inside esophagus while endoscopy reveals a more detailed image of the the esophagus and is helpful in detecting advanced cases. In the fluoroscopy, the patient is asked to drink a chalky solution of barium salt and then an X-ray beam is passed through the patient's esophageal area to detect dysmotility. In presbyesophagus, increased abnormal contractions along with reduced normal contractions are observed. The esophagus also appears to be abnormally elongated. Manometry is used to study function of the esophageal muscles and force of contraction. In tissue biopsy, a part of affected esophageal tissue is observed under microscope to identify abnormal muscle cells.

Treatment is based on disease severeness and the patient's health condition. In very elderly patients suffering from several diseases, surgery is not recommended. Medications are indicated to relax the muscles of the esophagus, promote smooth passage of food and relief pain and discomfort. In the presence of acid reflux disease in which the stomach acid flows back into the esophagus and worsens pain and discomfort, antireflux treatment is indicated. Patients are also counseled regarding changing their eating habits and improving body posture. Large meals three times a day must be avoided and split into several smaller meals, each with reduced portion size. Moreover, small bites of food with increased chewing is recommended. Liquid and semi-solid diet must be increased as it is easier to pass through the esophagus without significant resistance.

References

Article

  1. Mardini IA, McCarter RJ, Neal GD, et al. Contractile properties of laryngeal muscles in young and old baboons. Am J Otolaryngol. 1987;8:85–90.
  2. Zboralske FF, Amberg JR, Soergel KH. Presbyesophagus: cineradiographic manifestations. Radiology 1964;82:463–467.
  3. Welford AT. Reaction time, speed of performance, and age. Ann NY Acad Sci. 1988;515:1–17.
  4. Kruse-Andersen S, Wallin L, Madsen T. The influence of age on esophageal acid defense mechanisms and spontaneous acid gastroesophageal reflux. Am J Gastroenterol. 1998; 83:637–639.
  5. Shaker R, Ren J, Zamir Z, et al. Effect of aging, position and temperature on the threshold volume triggering pharyngeal swallows. Gastroenterology. 1994;107:396–402.
  6. Grishaw EK, Ott DJ, Frederick MG, et al. Functional abnormalities of the esophagus: a prospective analysis of radiographic findings relative to age and symptoms. AJR Am J Roentgenol. 1996;167:719–723.
  7. Ali Khan T, Shragge BW, Crispin JS, et al Esophageal motility in the elderly. Dig Dis. 1977;22:1049–1054.
  8. Ren J, Shaker R, Kusano M, et al. Effect of aging on the secondary esophageal peristalsis: presbyesophagus revisited. Am J Physiol. 1995;268:G772–G779.
  9. Raiha I, Hietanen E, Sourander L. Symptoms of gastro-oesophageal reflux disease in elderly people. Age Ageing. 1991;20:365–370.
  10. Dodds WJ, Dent J, Hogan WJ, et al. Mechanisms of gastroesophageal reflux in patients with reflux esophagitis. N Engl J Med. 1982;307:1547–1552.
  11. Brown M, Hasser EM. Differential effects of reduced muscle use (hindlimb unweighting) on skeletal muscle with aging. Aging (Milano). 1996; 8:99–105.
  12. Eisenberg RL. Gastrointestinal radiology. Lippincott Williams & Wilkins. 2003; ISBN:0781737060.
  13. Gore RM, Levine MS. Textbook of Gastrointestinal Radiology. Saunders. 2008; ISBN:1416023321.
  14. Salvador R, Dubecz A, Polomsky M, et al. A new era in esophageal diagnostics: the image-based paradigm of high-resolution manometry. J Am Coll Surg. 2009;208(6):1035-1044.
  15. Schneider I, Thumfart WF, Pototschnig C, et al.Treatment of dysfunction of the cricopharyngeal muscle with botulinum A toxin: introduction of a new, noninvasive method. Ann Otol Rhinol Laryngol. 1994;103:31–35

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Last updated: 2018-06-22 09:42