Pharmacological dissection of the human gastro-oesophageal segment into three sphincteric components
Pharmacological dissection of the human gastro-oesophageal segment into three sphincteric components
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DOI：
10.1113/jphysiol.2006.124032
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发表时间：
2007-05-01
影响因子：
5.5
通讯作者：
Miller, Larry S.
中科院分区：
文献类型：
--
作者：
Brasseur, James G.;Ulerich, Rhys;Miller, Larry S.
对尸体胃食管解剖结构的定量研究使一些人将下食管括约肌（LOS）与食管贲门交界处（OCJ）的解剖胃吊索-钩状纤维识别出来。然而，在体内的研究导致其他人认为两个重叠的组件近端从OCJ位移：一个外在的小腿括约肌的骨骼肌和内在的生理括约肌的圆形平滑肌纤维内的腹部食管。我们的目的是分离和量化在体内的骨骼肌和平滑肌括约肌的组成部分，并澄清LOS的描述。在两个方案中，通过人体胃食管段绘制腔内超声测压组件，以将括约肌压力与解剖学压力相关联。在方案1中，15名正常受试者在牵拉过程中通过完全吸气/呼气（FI/FE）将肋膈保持在下/上级位置。在给予阿托品抑制胆碱能平滑肌括约肌后重复这些。胆碱能成分的重建是通过从全压力中减去抗阿托品的压力，参考解剖结构。为了评估胆碱能贡献接近完整的平滑肌括约肌的程度，在协议II中，7例接受全身麻醉的非食管病理学患者给予顺利库铵麻痹食管。平滑肌括约肌的压力进行测量后，肺膨胀，以近似Fl。胆碱能平滑肌的压力曲线在协议I（FI）密切匹配的后ciscaturium平滑肌的压力曲线在协议II，和阿托品耐压力曲线空间相关的腿吊带在crummatic位移。因此，阿托品抵抗和胆碱能压力的贡献，在协议I近似的骨骼肌和平滑肌括约肌组件。平滑肌压力有明确的上峰和下峰。上峰与小腿吊带重叠并刚性移位，而远端峰在FI和FE之间与小腿/上峰分离1.1 cm。这些结果表明，存在单独的上部和下部的内在平滑肌成分。“上LOS”与小腿吊带重叠和移位，符合生理LOS。远端平滑肌压力峰值定义了一个“较低的LOS”，可能反映了OCJ处的胃吊带/钩肌纤维。这三种成分的不同生理学可能是正常括约肌功能和括约肌功能障碍复杂性的基础。
Quantifications of gastro-oesophageal anatomy in cadavers have led some to identify the lower oesophageal sphincter (LOS) with the anatomical gastric sling-clasp fibres at the oesophago-cardiac junction (OCJ). However, in vivo studies have led others to argue for two overlapping components proximally displaced from the OCJ: an extrinsic crural sphincter of skeletal muscle and an intrinsic physiological sphincter of circular smooth-muscle fibres within the abdominal oesophagus. Our aims were to separate and quantify in vivo the skeletal and smooth muscle sphincteric components pharmacologically and clarify the description of the LOS. In two protocols an endoluminal ultrasound-manometry assembly was drawn through the human gastro-oesophageal segment to correlate sphincteric pressure with the anatomic crus. In protocol 1, fifteen normal subjects maintained the costal diaphragm at inferior/superior positions by full inspiration/expiration (FI/FE) during pull-throughs. These were repeated after administering atropine to suppress the cholinergic smooth-muscle sphincter. The cholinergic component was reconstructed by subtracting the atropine-resistant pressures from the full pressures, referenced to the anatomic crus. To evaluate the extent to which the cholinergic contribution approximated the full smooth-muscle sphincter, in protocol II seven patients undergoing general anaesthesia for non-oesophageal pathology were administered cisatracurium to paralyse the crus. The smooth-muscle sphincter pressures were measured after lung inflation to approximate Fl. The cholinergic smooth-muscle pressure profile in protocol I (FI) matched closely the post-cisatracurium smooth-muscle pressure profile in protocol II, and the atropine-resistant pressure profiles correlated spatially with the crural sling during diaphragmatic displacement. Thus, the atropine-resistant and cholinergic pressure contributions in protocol I approximated the skeletal and smooth muscle sphincteric components. The smooth-muscle pressures had well-defined upper and lower peaks. The upper peak overlapped and displaced rigidly with the crural sling, while the distal peak separated from the crus/upper-peak by 1.1 cm between FI and FE. These results suggest the existence of separate upper and lower intrinsic smooth-muscle components. The `upper LOS' overlaps and displaces with the crural sling consistent with a physiological LOS. The distal smooth-muscle pressure peak defines a `lower LOS' that likely reflects the gastric sling/clasp muscle fibres at the OCJ. The distinct physiology of these three components may underlie aspects of normal sphincteric function, and complexity of sphincter dysfunction.