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LETTER TO THE EDITOR
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 80-82

Impact of age on esophageal motility in patients with gastroesophageal reflux


Arihant Hospital and Research Centre, Indore, Madhya Pradesh, India

Date of Submission11-Mar-2021
Date of Decision01-Feb-2022
Date of Acceptance02-Feb-2022
Date of Web Publication23-Mar-2022

Correspondence Address:
Mayank Jain
Department of Gastroenterology, Arihant Hospital and Research Centre, Indore - 452 009, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ghep.ghep_44_21

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How to cite this article:
Jain M. Impact of age on esophageal motility in patients with gastroesophageal reflux. Gastroenterol Hepatol Endosc Pract 2022;2:80-2

How to cite this URL:
Jain M. Impact of age on esophageal motility in patients with gastroesophageal reflux. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 May 23];2:80-2. Available from: http://www.ghepjournal.com/text.asp?2022/2/2/80/340392



Sir

The impact on aging on esophageal motility has been a subject of debate and discussion. Studies have highlighted that esophageal function deteriorates beyond the age of 40 years.[1] Whether this esophageal dysfunction is related to age-related dysmotility or is the effect of underlying pathology such as gastroesophageal reflux disease (GERD)[2] remains controversial. With this background, we hypothesized that esophageal dysmotility would be more frequent in elderly patients with GERD. We reviewed our experience with patients of different ages who underwent esophageal function testing for GERD at our center.

A retrospective analysis was conducted and included all patients referred for high-resolution esophageal manometry (HREM) and 24-h pH metry between July 2011 and July 2021. For this study, GERD was diagnosed based on the presence of typical symptoms of reflux (heartburn, regurgitation, and/or chest pain) for more than 6 months and a positive 24 h pH test (Johnson-DeMeester score >14.7 and percentage of total time with pH below 4 exceeding >4.2% of the study duration of ambulatory pH monitoring). Associated atypical features such as dysphagia, throat clearing, throat irritation, voice change, and chronic cough were also noted. Proton pump inhibitors, anticholinergics, and prokinetics were stopped for 7 days before the procedures. We excluded patients with achalasia cardia, jackhammer esophagus, esophagogastric junction outflow obstruction, negative 24 h pH test, and those with history of foregut endoscopic or surgical intervention.

Initially, the study group was divided into eight age groups decade-wise and proportion of patients having dysmotility and normal motility was analyzed. In the second step, the study cohort was classified into three groups – Group 1 (age up to 40 years, young age), Group 2 (age 41–64 years, middle age), and Group 3 (age ≥65 years, elderly) to study the impact of age on esophageal dysmotility in GERD cases. This age classification was based on previous studies and the World Health Organization definitions.[1],[3],[4],[5],[6] The patient details recorded included age, sex, symptoms with duration, and upper gastrointestinal endoscopy reports. Endoscopic hiatus hernia was determined by apparent separation >1 cm of the lower margin of the esophageal palisade vessels and the diaphragm hiatus on endoscopy under deep inspiration. We reviewed the static endoscopic images or videos if available and in case they were not available, we noted the findings mentioned by the endoscopist.

HREM was done using 16-channel water perfusion HREM system (GS Hebbard system, Melbourne, Australia) in supine position, and reporting was done as per Trace 1.3.3 (GS Hebbard, Melbourne, Australia) as per the Chicago Classification 3.0. Provocative maneuvers such as multiple rapid swallows and rapid drink challenges were not done in all patients, and hence not included for the study analysis. For tests done before the introduction of Chicago Classification 3.0, reanalysis and classification of tracings were done. Manometry reports were classified into two categories – normal motility and dysmotility including minor motility disorders such as ineffective esophageal motility or fragmented peristalsis and major motility disorder such as absent contractility, as per Chicago Classification 3.0. Twenty-four hour pH testing was done using a single-sensor probe (Sandhill Scientific, Highlands Ranch, USA) and reported using computerized software (Sandhill Scientific, Highlands Ranch, USA).

Data were analyzed using the Chi-square test and Kruskal–Wallis test. P < 0.05 was considered statistically significant.

A total of 152 patients (98 males, 64.5%) formed the study cohort. Normal motility was noted in 82 cases (54%). Dysmotility was noted in 70 (46%) of cases with GERD – ineffective esophageal motility in 54, fragmented peristalsis in six cases, and absent contractility in 10 cases, respectively. As noted from [Figure 1], the proportion of patients having dysmotility was higher in the age groups of 51–60 years and 61–70 years. Below the age of 50 years, normal motility was more frequent than dysmotility in patients with GERD.
Figure 1: Decade-wise distribution of normal motility and dysmotility in patients with reflux disease

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The number of patients in the three groups was as follows – Group 1 (72 and 52 males), Group 2 (63 and 33 males), and Group 3 (17 and 13 males). The male: female ratio in the Groups 1, 2, and 3 were 52:20, 33:30, and 13:4, respectively. The number of females in Group 2 was significantly higher (P = 0.03) compared to the other two groups. There was no statistically significant difference in the symptoms (P = 0.18) and endoscopic findings (P = 0.92) in the three groups [Table 1]. The esophagogastric junction morphology, basal inspiratory pressures, basal expiratory pressures, and integrated relaxation pressures were also not statistically significantly different in the three groups. However, dysmotility was more frequently noted in Group 3 (P = 0.024).
Table 1: Comparison of symptoms, endoscopic findings, and manometry parameters in Groups 1, 2, and 3

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The proximal esophagus has both striated and smooth muscle types with predominance of striated muscle, whereas the distal part consists of smooth muscle only. The loss of esophageal myenteric plexus neurons, which lie within the smooth muscle layers, with aging, is likely to lead to reduced esophageal motility.[7],[8]

We noted that the proportion of patients with dysmotility increased beyond 50 years of age. Moreover, atypical symptoms such as dysphagia were more frequent in Group 3 (age >65 years). Moreover, dysmotility was more common in age >65 years highlighting impaired clearance of refluxate. The decrease of the upper esophageal sphincter pressure, distal esophageal motility, and peristaltic velocity with aging has been considered responsible for esophageal symptoms in the aged population.[9],[10],[11]

The present study is limited by retrospective design, use of previously done endoscopic images for interpretation, and small sample size. Comparison with age-matched normal participants would have been more useful. However, this was not logistically possible. Details of comorbid diseases and degenerative neurological conditions were not available in the records.

Despite these limitations, we demonstrated that esophageal dysmotility is more frequent beyond 50 years of age in patients with GERD, more so in those aged >65 years (elderly). This information would be useful for esophageal surgeons, gastroenterologists, and physicians caring for elderly patients in deciding the appropriate management of GERD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gregersen H, Pedersen J, Drewes AM. Deterioration of muscle function in the human esophagus with age. Dig Dis Sci 2008;53:3065-70.  Back to cited text no. 1
    
2.
Achem AC, Achem SR, Stark ME, DeVault KR. Failure of esophageal peristalsis in older patients: Association with esophageal acid exposure. Am J Gastroenterol 2003;98:35-9.  Back to cited text no. 2
    
3.
OECD. Elderly Population (Demography); 2020 Available from: https://data.oecd.org/pop/elderly-population.htm. [Last accessed on 2021 Jan 19].  Back to cited text no. 3
    
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Orimo H, Ito H, Suzuki T, Araki A, Hosoi T, Sawabe M. Reviewing the definition of elderly. Geriatr Gerontol Int 2006;6:149-58.  Back to cited text no. 4
    
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Singh S, Bajorek B. Defining 'elderly' in clinical practice guidelines for pharmacotherapy. Pharm Pract (Granada) 2014;12:489.  Back to cited text no. 5
    
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Geifman N, Cohen R, Rubin E. Redefining meaningful age groups in the context of disease. Age (Dordr) 2013;35:2357-66.  Back to cited text no. 6
    
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Wade PR, Cowen T. Neurodegeneration: A key factor in the ageing gut. Neurogastroenterol Motil 2004;16 Suppl 1:19-23.  Back to cited text no. 7
    
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Meciano Filho J, Carvalho VC, de Souza RR. Nerve cell loss in the myenteric plexus of the human esophagus in relation to age: A preliminary investigation. Gerontology 1995;41:18-21.  Back to cited text no. 8
    
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Shim YK, Kim N, Park YH, Lee JC, Sung J, Choi YJ, et al. Effects of age on esophageal motility: Use of high-resolution esophageal impedance manometry. J Neurogastroenterol Motil 2017;23:481.  Back to cited text no. 9
    
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Gutschow CA, Leers JM, Schröder W, Prenzel KL, Fuchs H, Bollschweiler E, et al. Effect of aging on esophageal motility in patients with and without GERD. Ger Med Sci 2011;9:Doc22.  Back to cited text no. 10
    
11.
Ferriolli E, Oliveira RB, Matsuda NM, Braga FJ, Dantas RO. Aging, esophageal motility, and gastroesophageal reflux. J Am Geriatr Soc 1998;46:1534-7.  Back to cited text no. 11
    


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