THE CHARACTERISTICS AND SIMILARITY OF PRIMARY AND SECONDARY PERISTALSIS IN THE ESOPHAGUS Bertram Fleshler, … , Philip Kramer, Franz J. Ingelfinger J Clin Invest. 1959;38(1):110-116. https://doi.org/10.1172/JCI103780. Research Article Find the latest version: https://jci.me/103780/pdf THE CHARACTERISTICS AND SIMILARITY OF PRIMARY AND SECONDARY PERISTALSIS IN THE ESOPHAGUS * By BERTRAM FLESHLER,t THOMAS R. HENDRIX, PHILIP KRAMER, AND FRANZ J. INGELFINGER (From the Evans Memorial, Massachusetts Memorial Hospitals and Department of Medicine, Boston University School of Medicine, Boston, Mass.) (Submitted for publication August 5, 1958; accepted September 11, 1958) Primary and secondary peristalsis in the esophagus were no bolus present. With modern esophagus are believed to differ in their modes of manometric devices this question can now be initiation and propagation. Since primary peri- solved, for the propagation of secondary peri- stalsis is, by definition, initiated by a swallow and stalsis can be analyzed without using liquid, semi- secondary peristalsis set off by esophageal disten- solid or solid boluses that might stimulate local tion, their difference with respect to initiation is reflexes. We have therefore initiated secondary an a priori matter. Recent studies (1, 2), how- peristalsis in the human esophagus by local disten- ever, challenge the concept that a clear distinction tion, have studied the resultant inhibitory and exists as far as propagation is concerned. motor phenomena by the technique of intra- Classically, primary peristalsis is said to be luminal manometry, and have compared the ef- centrally integrated-that is, the afferent impulse fects produced with those obtained when pri- released by swallowing stimulates a medullary mary peristalsis is induced by swallowing. center which thereupon, without further afferent stimulation, activates in succession oral, pharyn- METHODS geal and esophageal musculature (3). Sec- A tube assembly, as used in previous studies (5) and ondary peristalsis was contrasted by Meltzer and consisting of three open-tipped and water-filled polyvinyl Auer (4) as follows: "This peristaltic move- tubes, was passed via the nose into the esophagus of ment, however, differs from the normal peri- healthy volunteers. The tips were spaced 3 cm. apart. stalsis after deglutition in the essential point that Pressure changes at the tips were transmitted through the water columns to Sanborn electromanometers and it does not progress in the lower section of the recorded. An external pneumograph identified respira- oesophagus if the latter be divided transversely tory excursions on one channel. All recordings of intra- at some place. That shows that this form of luminal esophageal pressure were made with the subject peristalsis depends upon consecutive stimulations supine and the manometers leveled at the posterior axil- of the mucous membrane of the oesophagus and lary line. The high pressure zone which is found in the distal esophagus and ascribed to the lower esophageal consists of a chain of local reflexes." sphincter (6) was located by first placing the distal re- The nature of secondary peristalsis has gener- cording tip in the stomach and then withdrawing it ally been investigated by inserting a bolus into centimeter by centimeter. the esophagus and analyzing the transport phe- A balloon of 40 ml. capacity was attached to a Levin nomena elicited. This technique, however, has tube, passed into the esophagus, and the proximal end the of a bolus of the tube firmly fixed. Radiologic localization of the obvious limitations since presense balloon and of the radiopaque pressure recording tips could elicit local stimuli and reflexes on moving was carried out in all cases. The balloon was inflated downstream. Under these circumstances, it is by several techniques. Momentary or prolonged inflation impossible to tell whether secondary peristalsis, was carried out by injecting an absolute amount of air once elicited, would similarly pass down the rapidly with a syringe, holding the air in the balloon for the desired period of time, and then aspirating the air * Presented in part at the meeting of the Gastroenter- quickly. To achieve a more physiologic distention stimu- ology Research Group, Colorado Springs, Colo., May 23, lus which would not move but would yield to esophageal 1957. contraction isobaric inflation of the balloon was used. t Work performed during period as Public Health In this system, which has been used extensively to re- Service Research Fellow of the National Cancer Institute. cord motility (7,8), the balloon is inflated under moderate, Present address: Department of Medicine, Cleveland approximately constant pressure (6 to 12 cm. water) Metropolitan General Hospital, Cleveland 9, Ohio. produced by the difference between water levels of two 110 PRIMARY AND SECONDARY ESOPHAGEAL PERISTALSIS lit chambers in a damped kymographic system (9). The sure change appearing in only one tip, called a amount of air allowed in the balloon is determined by the "spasm," was elicited in an additional seven tests. esophageal reaction: Once the balloon has reached a certain size, the esophagus contracts and expels air back The amount of air used for inflation of the bal- into the external system. During the various techniques loon varied from 5 to 40 ml. with a mean of 21 ml. of inflation used, the balloon was also connected to an No correlation was found between the amounts of electromanometer and writing channel in order to pro- air used and the incidence of either progressive vide for accurate recording of times of inflation and de- or nonprogressive positive pressure responses. flation, or of esophageal contraction or relaxation in the was area of the balloon. Substernal pain occasionally produced when 35 to 40 ml. was injected but did not appear to RESULTS affect the results. In those tests in which a moving pressure wave was elicited by esophageal 1. Effect of momentary distention on esophageal distention, the interval between beginning of bal- motility loon inflation and the start of the pressure rise Rapid inflation and deflation of the fixed bal- at the tip nearest the balloon was 5.5 seconds; loon was carried out 115 times in 11 subjects. the interval between the beginning of balloon The balloon was held inflated for a mean time deflation and the start of pressure rise at the of 3.7 seconds. In 55 tests (47 per cent), pro- nearest tip, 2.1 seconds. Since the duration of gressive pressure waves were produced and re- inflation averaged 3.7 seconds, it appears that corded as passing sequentially over tips placed in initiation of the moving pressure wave in this the esophagus distal to the ballon (Figure 1A). experimental design was closely related to defla- No swallowing movements preceded the ap- tion. The speed of progression of the wave, pearance of these waves. A nonprogressive pres- once set off, averaged 3 cm. per second. Bodbon iblotd 15c. of ai relea 404 D.S. ;1 MMHo. |20-4 ,:;m.,i.-z. o ; 4 W H. 40-, Mm.2. .:+,+tt ... UM ' ~~~40- :~.,V44i~ Jf Mm.200 ~~~ ~ ~ ~ ~ ~ ~ ~~~~4Io FIG. 1. COMPARISON OF SECONDARY (A) AND PRIMARY (B) ESOPHAGEAL PERISTALSIS CURVES A. Momentary distention with an air-filled balloon fixed in the mid-esophagus produced a drop mn pressure in the sphincteric zone (bottom tracing), followed by a progressive contraction recorded at two esophageal sites distal to the balloon (upper two tracings). These pressure phenomena, elicited without a swallow or moving bolus, are comparable to those characterizing primary esophageal peristalsis initiated by swallowing (Fig. iB). Reprinted with permission from The Journal of Applied Physiology, 1958, 12, 341. B. The drop in pressure in the sphincteric zone (bottom tracing) and the progressive contraction in the esophagus (upper two tracings) released by a dry swallow (one containing only air and a little saliva) are demonstrated. DS indicates dry swallow. 112 B. FLESHLER, T. R. HENDRIX, P. KRAMER, AND F. J. INGELFINGER 20 CC. OF AIR PNEUMOGRAPH 44- PROXIMAL TIP HG T.4 MIDDLE TIP HGria°i '' t a 10 DISTAL TIP' HG 2 0 20 40 so so 100 TIME IN SECONDS SWALLOWS PNEUMOGRAPH * 75 PROXIMAL TIP Hg.He .....::::.::.-.. .. 20 a MIDDLE TIP 100 40 . .. so- .. ..... .......... DISTAL TIP l . go so 3 io io i TIME IN SECONDS FIG. 2. PRESSURE TRACINGS DURING PROLONGED DISTENTION (A) COM- PARED WITH FREQUENT SWALLOWINGS (B) A. Prolonged distention (solid bar at top of record) of a balloon fixed in the mid-esophagus was attended by no changes in the body of the esophagus distal to the balloon (proximal and middle tips), and produced a sustained drop in intrasphincteric pressure (distal tip), maintained until the balloon was deflated. Thereafter a pressure wave passed through the lower esopha- gus and sphincter. The overall effect on esophageal motility is similar to that produced by rapidly repeated swallows (Fig. 2B). B. Liquid swallows taken at approximately seven second intervals pro- duced a sustained drop in pressure in the sphincteric zone (distal tip), and no peristaltic pressure phenomena appeared in the body of the esophagus (proximal and middle tips) during this time. The sustained rise and the occasional spikes of pressure recorded are ascribable to fluid introduced into the esophagus and to transmitted oropharyngeal pressures. After the swal- lowing efforts ceased, a peristaltic contraction travelled down the esophagus. PRIMARY AND SECONDARY ESOPHAGEAL PERISTALSIS 113 2. Effect of momentary distention on the lower decrease in intrasphincteric pressure. In the esophageal sphincter group of 12 tests exhibiting only a drop in intra- The lowermost recording tip was in the sphincteric pressure, this drop was less marked high than in those pressure zone (lower esophageal sphincter) on exhibiting the full sequence, and in no case did 62 of the occasions when the balloon was inflated pressures overshoot the resting momentarily. A drop in pressure occurred 51 levels at the completion of the low pressure times, 39 associated with the interval.