Investigating the oesophagus.

Editorial Investigating the oesophagus For many years barium swallow and oesophagos-copy were the only specific techniques available for the investigation of oesophageal disease. Since the 1950s, however, developments in oesophageal laboratories have yielded a number of tests which explore the physiology of the organ, rather than its anatomy. Despite this, clinical acceptance of the tests has been slow. While cardiac catheter and respiratory function laboratories multiply the oesophageal laboratory remains a rarity and a curiosity, and there is considerable confusion over its role. Is it a research toy, a clinical luxury, or a clinical necessity, and which cases, if any, require laboratory studies for their proper clinical management? In order to explore these questions it is necessary first to examine the merits and deficiencies of the two traditional methods of oesophageal study. The liquid barium swallow is concerned primarily with demonstrating oesophago-gastric anatomy and its pathological variations, and for this purpose is certainly the most satisfactory technique currently available. Herniations, obstructions , and distortions can all be identified and their pathological nature often deduced. It is seriously inadequate, however, when it is used to assess oesophageal function. Gross disorders can be recognised but subtler disturbances of motility may be missed altogether. In certain types of dysphagia the transit of liquid barium may be completely normal even when a serious disorder exists. Such patients may be labelled as "neurotic" or suffering from globus hystericus unless they are screened while swallowing a solid bolus-for example, bread or marshmallow impregnated with barium. As regards the lower sphincter, its function can only be guessed at. Gastro-oesophageal reflux may or may not be observed but its assessment will be wholly subjective and varies with the vigour, experience, and even the mood of the radiologist. Moreover the examination is conducted over a very short period and the findings may bear no relation to what is happening during normal everyday life. The other main investigation, oesophagoscopy, yields information principally about the lumen and the state of the mucosa. Ulcers, varices, tumours, and strictures can be seen and biopsies taken when appropriate, but again, it gives little information concerning function. We learn nothing about oesophageal peristalsis and cannot even determine whether it is present or absent, weak, normal, or excessive. Certainly we can observe directly the lower oesophageal sphincter and its movements, but what do they mean? The conditions under which oesophagoscopy is performed , whether with the …