Volume 130, Issue 1, Pages 89-95 (January 2006) Transient Lower Esophageal Sphincter Relaxations Do Not Result From Passive Opening of the Cardia by Gastric Distention  Benson T. Massey, Chelsey Simuncak, Nicole J. LeCapitaine–Dana, Sudhindra Pudur  Gastroenterology  Volume 130, Issue 1, Pages 89-95 (January 2006) DOI: 10.1053/j.gastro.2005.11.003 Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 1 Endoscopic images of the cardia during different phases of a TLESR. The endoscope shaft is readily seen and, in this example, obscures the view of the manometry catheter. (A) Image taken at the start of the TLESR. A thin mucosal cuff is observed adjacent to the endoscope shaft. (B) Image taken at time that the LESP first reaches IGP during TLESR. Over the time interval between images A and B, no obvious change in the mucosal cuff is observed. (C) Image during the period of maximal GEJ opening. A wide circular opening between esophagus and stomach is established. The mucosal cuff is no longer present, and the GEJ has moved proximally. (D) Image taken from the time of GEJ closure. Propulsion of fluid and foam through the GEJ has finished, and this material partially obscures the view of the cardia. The cardia has returned to a more distal position. Gastroenterology 2006 130, 89-95DOI: (10.1053/j.gastro.2005.11.003) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 2 Manometric tracings during the TLESR shown in Figure 1. The distal-most channel displays intragastric pressure, the second channel displays the recording from the sleeve device, and the next 3 channels record at 0, 3, and 6 cm from the top of the sleeve. Times of endoscopic events are shown for comparison, with letters corresponding to those of the images in Figure 1. The TLESR begins and first reaches IGP before the GEJ is first seen to open, which is temporally closely associated with the onset of a common cavity pressure that is seen on the manometric channels in the esophageal body. Transient low-amplitude pressure impulses superimposed on the common cavity and intragastric pressures are due to straining during audible belches. The termination of the TLESR by the peristaltic wave is temporally associated with the closure of the GEJ. Gastroenterology 2006 130, 89-95DOI: (10.1053/j.gastro.2005.11.003) Copyright © 2006 American Gastroenterological Association Terms and Conditions

Figure 3 Time differentials between endoscopic and manometric events. Boxes depict the 25th–75th percentiles, and whiskers depict the 10th–90th percentiles. The line in the box depicts the median value for the net time difference. Times of TLESR onset and nadir occur significantly (*P < .001) before the opening of the GEJ. Times of common cavity (CC) onset and GEJ opening do not differ significantly (#P > .1), nor do those for TLESR end and GEJ closure. Gastroenterology 2006 130, 89-95DOI: (10.1053/j.gastro.2005.11.003) Copyright © 2006 American Gastroenterological Association Terms and Conditions