Underlying etiology associated with the diagnosis of absent contractility on high resolution esophageal manometry

Clinical characteristics of absent contractility and ineffective esophageal motility: a multicenter study in Japan

BACKGROUND AND AIM

Absent contractility (AC) and ineffective esophageal motility (IEM) are esophageal hypomotility disorders diagnosed using high-resolution manometry (HRM). Patient characteristics and disease course of these conditions and differential diagnosis between AC and achalasia are yet to be elucidated.

METHODS

A multicenter study involving 10 high-volume hospitals was conducted. Starlet HRM findings were compared between AC and achalasia. Patient characteristics including underlying disorders and disease courses were analyzed in AC and IEM.

RESULTS

Fifty-three patients with AC and 92 with IEM were diagnosed, while achalasia was diagnosed in 1784 patients using the Chicago classification v3.0 (CCv3.0). The cut-off integrated relaxation pressure (IRP) value at 15.7 mmHg showed maximum sensitivity (0.80) and specificity (0.87) for differential diagnosis of AC from type I achalasia. While most ACs were based on systemic disorders such as scleroderma (34%) and neuromuscular diseases (8%), 23% were sporadic cases. The symptom severity of AC was not higher than that of IEM. Regarding the diagnosis of IEM, the more stringent CCv4.0 excluded 14.1% of IEM patients than the CCv3.0, although patient characteristics did not change. In patients with the hypomotile esophagus, concomitance of reflux esophagitis was associated with low distal contractile integral and IRP values. AC and IEM transferred between each other, paralleling with the underlying disease course, although no transition to achalasia was observed.

CONCLUSION

A successful determination of the optimal cut-off IRP value was achieved using the starlet HRM system to differentiate AC and achalasia. Follow-up HRM is also useful for differentiating AC from achalasia. Symptom severity may depend on underlying diseases instead of hypomotility severity.

Integrated Relaxation Pressure (IRP) Distinguishes between Reflux-Predominant and Dysphagia-Predominant Phenotypes of Esophageal "Absent Contractility"

Background: Patients with absent contractility (AC) often suffer from either reflux or dysphagia. It remains unclear what factors determine which phenotype patients present with. We sought to evaluate if high-resolution manometry metrics, especially integrated relaxation pressure (IRP), could explain this. Methods: Cases of AC from three medical centers were reviewed for demographic, clinical, and manometric data. Cases with an IRP between 10−15 mmHg or subsequent diagnosis of achalasia were excluded. Results: 69 subjects were included (mean age 56.1; 71% female). A total of 41 (59.4%) were reflux-predominant. The reflux-predominant group was younger (51.1 vs. 63.5, p = 0.002) and had lower median LES basal pressures (7.5 vs. 12.5 mmHg, p = 0.014) and IRP values (1.5 vs. 5.6 mmHg, p < 0.001) compared to the dysphagia group. When divided into tertiles, the trend in symptoms between LES basal pressure tertiles was not significant. However, the trend for IRP was significant (p < 0.001). For example, in the lowest IRP tertile, 91.3% of subjects were reflux-predominant compared to only 26.1% in the highest tertile, while the dysphagia-predominant group increased from 8.7% to 73.9%. In a regression model controlling for age and using IRP tertile 1 as the reference, having an IRP in tertile 2 increased the likelihood of having dysphagia-predominant disease by 7, while being in tertile 3 increased the likelihood by 22. Conclusions: IRP helps distinguish between the reflux-predominant and dysphagia-predominant phenotypes of AC. This may have therapeutic clinical consequences as procedures such as fundoplication to tighten the LES may benefit patients with reflux and a low IRP, while procedures like peroral endoscopic myotomy (POEM) to disrupt the LES may benefit patients with dysphagia and a relatively high IRP.

The Natural History of Esophageal “Absent Contractility” and Its Relationship with Rheumatologic Diseases: A Multi-Center Case–Control Study

(1) Background: Absent contractility (AC) is an esophageal motility disorder defined as a normal integrated relaxation pressure with 100% failed peristalsis. We sought to clarify the natural history of this disorder and its relationship with rheumatologic diseases, such as systemic sclerosis (scleroderma). (2) Methods: We retrospectively identified patients with AC based on high-resolution manometry findings at three referral institutions and then matched them with controls with esophageal complaints who had normal manometries. (3) Results: Seventy-four patients with AC were included (mean age 56 years; 69% female). Sixteen patients (21.6%) had a rheumatologic disease. Compared to controls, patients with AC were significantly more likely to present with heartburn, dysphagia, vomiting, and weight loss. During follow-up, they were also more likely to be seen by a gastroenterologist, be diagnosed with gastroesophageal reflux disease, take a proton pump inhibitor, and undergo repeat upper endoscopies. No AC patients developed a new rheumatologic disease during follow-up. No significant differences were noted in the clinical presentation or course of AC patients with rheumatologic disease compared to those without. (4) Conclusions: Patients with AC have more esophageal symptoms and require more intense gastrointestinal follow-up than controls. Only a minority of patients with AC have underlying rheumatologic disease. Those without rheumatologic disease at baseline did not subsequently develop one, suggesting that a rheumatologic evaluation is likely unnecessary. The clinical course of AC in patients with rheumatologic disease and those without appears to be similar.