Radiographic evaluation of esophageal function

Assessment of Esophageal Shifts during Catheter Ablation of Atrial Fibrillation Using Intracardiac Ultrasound Integrated with 3-Dimensional Electroanatomical Mapping System

Purpose: Atrioesophageal fistula is one of the most feared complications of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) as it is associated with high mortality. Determining the esophagus location during RFCA might reduce the risk of esophageal injury. The present study aims to evaluate the feasibility of using intracardiac echocardiography integrated into a 3-dimensional electroanatomical mapping system (ICE/3D EAM) for the assessment of esophageal position and shifts in response to ablation. Methods: We prospectively enrolled 20 patients that underwent RFCA of AF under conscious analgosedation. The virtual anatomy of the left atrium, the pulmonary vein (PV) ostia, and the esophagus was created with ICE/3D EAM. The esophageal positions were obtained at the beginning of the procedure and then after left and right PV isolation (PVI). Esophageal shifts were measured offline after the procedure using the tools available in the 3D EAM system. Results: Most esophagi moved away from the ablated PV ostia. After the left PVI, the median of the shifts was 2.8 mm (IQR 1.0-6.3). In 25% of patients, the esophagus shifted by >5.0 mm (max. 13.4 mm). After right PVI, the median of shifts was 2.0 mm (IQR 0.7-4.9). In 10% of patients, the esophageal shift was >5.0 mm (max. 7.8 mm). Conclusions: ICE/3D EAM enables the intraprocedural visualization of baseline esophageal position and its shifts after PVI. The shifts are variable, but they tend to be small and directed away from the ablation site. Repeated intraprocedural visualization of the esophagus may be needed to reduce the risk of esophageal injury.

Esophageal Radiography Interpretation: a Primer for the Gastroenterologist

PURPOSE OF REVIEW

Radiological studies can be helpful when evaluating patients with suspect esophageal disorders. From benign strictures to malignancy and motility disorders such as achalasia, imaging modalities play a significant role in diagnosis. This review explores the role of different imaging modalities in the most frequently encountered esophageal pathologies.

RECENT FINDINGS

Conventional barium esophagram has long been considered the primary imaging modality of the esophagus. In the same fashion, a timed barium esophagram is a valuable tool in the evaluation of achalasia and esophagogastric junction outlet obstruction. Over the last few decades there has been an increase in CT and MRI studies, which also play a role in the evaluation of esophageal pathologies. However, not infrequently, these newer imaging techniques can result in incidental esophageal findings. It is important that gastroenterologists appreciate the value of different modalities and recognize key imaging features. The diagnosis and management of esophageal disorders is evolving. A basic understanding of esophageal radiology is essential to any gastroenterologist caring for patients with esophageal complaints.

Association of Bolus Transit Time on Barium Esophagram With Esophageal Peristalsis on High-resolution Manometry and Nonobstructive Dysphagia

GOAL

The goal of this study was to correlate upright and prone bolus transit time (BTT) on barium esophagography (BE) with esophageal peristalsis on high-resolution manometry (HRM) and self-reported dysphagia in patients with normal lower esophageal sphincter parameters on HRM.

BACKGROUND

BTT on BE could be the gold standard for assessing the effectiveness of esophageal peristalsis if it can be quantified.

MATERIALS AND METHODS

Patients with normal lower esophageal sphincter parameters and standard-protocol BE from 2017 to 2020 were included. Patients were divided, based on the number of normal swallows (distal contractile integral >450 mm Hg-s-cm), into 11 groups (10 normal swallows to 0 normal swallows). Liquid barium swallows in prone position were objectively evaluated for prone BTT. Patients reported difficulty in swallowing on a scale from 0 (none) to 4 (very severe). Fractional polynomial and logistic regression analysis were used to study the association (along with the rate of change) between BTT, peristalsis, and dysphagia.

RESULTS

A total of 146 patients were included. Prone BTT increased as the number of normal swallows decreased ( P <0.001). Two deflection points were noted on the association between peristalsis and prone BTT at 50% normal swallows, 40 seconds and 30% normal swallows, 80 seconds, after which peristaltic function declined independently of prone BTT. Patients with prone BTT>40 seconds had nearly 6-fold higher odds of 0% normal swallows on HRM than patients with prone BTT<40 seconds ( P =0.002). Increasing prone BTT was associated with increasing dysphagia grades 1 and 2 ( P ≤0.036).

CONCLUSIONS

Esophageal motility can be quantified by BE. Prone BTT correlates with the proportion of normal esophageal swallows and dysphagia.

The Mexican consensus on non-cardiac chest pain

INTRODUCTION

Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases.

AIM

To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients.

METHODS

Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system.

RESULTS AND CONCLUSIONS

The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.

Esophageal positions relative to the left atrium; data from 293 patients before catheter ablation of atrial fibrillation

Aims

Three-dimensional rotational angiography (3DRA) of the left atrium (LA) and the esophagus is a simple and safe method for analyzing the relationship between the esophagus and the LA during catheter ablation of atrial fibrillation. The purpose of this study is to describe the location of the esophagus relative to the LA and mobility of the esophagus during ablation procedure.

Methods

From 3/2011 to 9/2015, 3DRA of the LA and esophagus was performed in 326 patients before catheter ablation of atrial fibrillation. 3DRAwas performed with visualization of the esophagus via peroral administration of a contrast agent. The positions of the esophagus were determined at the beginning of the procedure, for part of patients also at the end of procedure with contrast esophagography.

Results

The most frequent position is behind the center of the LA (91 pts., 31.9%) The least frequent position is behind the right pulmonary veins (27 pts., 9.4%). The average shift of the esophagus position was 3.36 ± 2.15 mm, 3.59 ± 2.37 mm and 3.67 ± 3.23 mm for superior, middle and inferior segment resp.

Conclusions

The position of the esophagus to the LA is highly variable. The most common position of the esophagus relative to the LA is behind the middle and left part of the posterior wall of the LA. The least frequently observed position is behind the right pulmonary veins. No significant position change of esophagus motion from before to after the ablation procedure in the majority (≥95%) of the patients was observed.

Intestinal dysbiosis is common in systemic sclerosis and associated with gastrointestinal and extraintestinal features of disease

BACKGROUND

Recent evidence suggests a link between autoimmunity and the intestinal microbial composition in several rheumatic diseases including systemic sclerosis (SSc). The objective of this study was to investigate the prevalence of intestinal dysbiosis in SSc and to characterise patients suffering from this potentially immunomodulatory deviation.

METHODS

This study consisted of 98 consecutive patients subject to in-hospital care. Stool samples were analysed for intestinal microbiota composition using a validated genome-based microbiota test (GA-map™ Dysbiosis Test, Genetic Analysis, Oslo, Norway). Gut microbiota dysbiosis was found present as per this standardised test. Patients were examined regarding gastrointestinal and extraintestinal manifestations of SSc by clinical, laboratory, and radiological measures including esophageal cineradiography, the Malnutrition Universal Screening Tool (MUST), levels of plasma transthyretin (a marker of malnutrition) and faecal (F-) calprotectin (a marker of intestinal inflammation).

RESULTS

A majority (75.5%) of the patients exhibited dysbiosis. Dysbiosis was more severe (rs = 0.31, p = 0.001) and more common (p = 0.013) in patients with esophageal dysmotility. Dysbiosis was also more pronounced in patients with abnormal plasma levels of transthyretin (p = 0.045) or micronutrient deficiency (p = 0.009). In 19 patients at risk for malnutrition according to the MUST, 18 exhibited dysbiosis. Conversely, of the 24 patients with a negative dysbiosis test, only one was at risk for malnutrition. The mean ± SEM levels of F-calprotectin were 112 ± 14 and 45 ± 8 μg/g in patients with a positive and negative dysbiosis test, respectively. Dysbiosis was more severe in patients with skin telangiectasias (p = 0.020), pitting scars (p = 0.023), pulmonary fibrosis (p = 0.009), and elevated serum markers of inflammation (p < 0.001). However, dysbiosis did not correlate with age, disease duration, disease subtype, or extent of skin fibrosis.

CONCLUSIONS

In this cross-sectional study, intestinal dysbiosis was common in patients with SSc and was associated with gastrointestinal dysfunction, malnutrition and with some inflammatory, fibrotic and vascular extraintestinal features of SSc. Further studies are needed to elucidate the potential causal relationship of intestinal microbe-host interaction in this autoimmune disease.

Long-term mobility of the esophagus in patients undergoing catheter ablation of atrial fibrillation: data from computer tomography and 3D rotational angiography of the left atrium

PURPOSE

Computed tomography (CT) and 3D rotational angiography (3DRA) of the left atrium (LA) are used to evaluate the esophagus prior to radiofrequency ablation for atrial fibrillation. The aim of this study was to compare preprocedural and periprocedural views of the esophagus and the left atrium.

METHODS

From September 2011 to August 2012, 3DRA and CT of the LA were performed on 56 patients before they underwent catheter ablation of atrial fibrillation. The 3DRA was performed periprocedurally, and the CT was performed an average of 20 days prior to the procedure. 3D models of the LA and the esophagus were then segmented on the EP Navigator V 3.1 workstation. Five positions of the esophagus, A-E, in order from left to right, were evaluated.

RESULTS

The most common position of the esophagus was behind the left part of the LA (CT, position B (n = 26)) and behind the central part of the LA (3DRA, position C (n = 21)). The maximum shift of the esophagus was three positions, and the average shift was 0.857 ± 0.766 of a position. There was a shift of one position in 44.6 % of the patients, two positions in 17.9 %, and three positions in 1.8 %. A statistically significant difference was found between the positions of the esophagus when the 3DRA and CT evaluations were compared.

CONCLUSIONS

The most common position of the esophagus was behind the middle and left part of the LA. The outpatient views of the esophagus obtained before ablation did not reflect the position of the esophagus at the beginning of the procedure.

Videofluoroscopic swallowing study: esophageal alterations in patients with dysphagia

CONTEXT

Videofluoroscopic swallowing study is a dynamic exam and allows the evaluation of the complete swallowing process. However, most published studies have only reported alterations in the oropharynx and pharyngoesophageal transition, leaving the analysis of the esophagus as a secondary goal.

OBJECTIVES

The goal of this study was to investigate the prevalence of alterations in the esophageal phase thorough videofluoroscopic swallowing study in patients with dysphagia.

METHODS

Consecutive patients with dysphagia who underwent videofluoroscopic swallowing study including esophageal analysis between May 2010 and May 2012 had their exams retrospectively reviewed. Patients were classified into two groups: Group I - without a pre-established etiological diagnosis and Group II - with neurological disease. During the exam, the patients ingested three different consistencies of food (liquid, pasty and solid) contrasted with barium sulfate and 19 items were analyzed according to a protocol. The esophageal phase was considered abnormal when one of the evaluated items was compromised.

RESULTS

Three hundred and thirty-three (n = 333) consecutive patients were studied - 213 (64%) in Group I and 120 (36%) in Group II. Esophageal alterations were found in 104 (31%) patients, with a higher prevalence in Group I (36.2%), especially on the items esophageal clearance (16.9%) and tertiary contractions (16.4%). It was observed that 12% of individuals in Group I only presented alterations on the esophageal phase.

CONCLUSION

Evaluation of the esophageal phase of swallowing during videofluoroscopic swallowing study detects abnormalities in patients with cervical dysphagia, especially in the group without pre-established etiological diagnosis.

Achalasia

This article reviews the diagnosis and treatment of achalasia, a rare esophageal motility disorder characterized by absent peristalsis and failure of the lower esophageal sphincter (LES) to relax. Various treatment options including management with sublingual nitrates or calcium channel blockers, injection of the LES with botulism toxin, pneumatic dilation of the LES, and pneumatic dilation are discussed. Laparoscopic Heller myotomy is minimally invasive with incumbent low morbidity and mortality rates, and combined with a partial fundoplication is a durable, safe, and effective treatment option for patients with achalasia.

Esophageal clearance patterns in normal older adults as documented with videofluoroscopic esophagram

Normal esophageal bolus transport in asymptomatic healthy older adults has not been well defined, potentially leading to ambiguity in differentiating esophageal swallowing patterns of dysphagic and healthy individuals. This pilot study of 24 young (45-64 years) and old (65+years) men and women was designed to assess radiographic esophageal bolus movement patterns in healthy adults using videofluoroscopic recording. Healthy, asymptomatic adults underwent videofluoroscopic esophagram to evaluate for the presence of ineffective esophageal clearance, namely, intraesophageal stasis and intraesophageal reflux. Intraesophageal stasis and intraesophageal reflux were visualized radiographically in these normal subjects. Intraesophageal stasis occurred significantly more frequently with semisolid (96%) compared with liquid (16%) barium, suggesting that a variety of barium consistencies, as opposed to only the traditional fluids, would better define the spectrum of esophageal transport. Intraesophageal reflux was observed more frequently in older males than in their younger counterparts. The rates of intraesophageal stasis and intraesophageal reflux were potentially high given that successive bolus presentations were spaced 10 seconds apart. These findings suggest a need for a more comprehensive definition regarding the range of normal esophageal bolus transport to (a) prevent misdiagnosis of dysphagia and (b) to enhance generalization to functional eating, which involves solid foods in addition to liquids.

Gastrointestinal motility testing

Gastrointestinal motility and the effects on luminal contents that are brought about by it can be studied in several ways. In clinical practice, manometry remains one of the most important investigational techniques, in particular for oesophageal and anorectal disorders. Radiographic examination of bolus transit through the gastrointestinal tract also continues to be a valuable tool. Scintigraphy still is the gold standard for assessment of gastric emptying, but (13)(C) breath tests are an alternative. Many other techniques are used mainly in the context of scientific research but some of these may become incorporated in the diagnostic armamentarium.

Diagnosis and treatment of noncardiac chest pain

Chest pain is common: one in four of the population have an episode annually. Of those who present to hospital, nearly two-thirds have noncardiac chest pain. More than half of these cases might have gastroesophageal reflux disease. Opinion differs over what is the most appropriate application of current investigatory methods. Evidence suggests that, once cardiac disease is ruled unlikely, empiric use of a proton pump inhibitor is an option; if acid suppression fails, detailed investigations as clinically indicated can be considered. A range of esophageal investigations is available, including 24-hour or 48-hour esophageal pH testing and esophageal manometry, as well as provocative tests, but there is no consensus as to which methods are the most useful. Psychiatric evaluation is not routine, but psychiatric or psychological disorders are common. Musculoskeletal disorders are also common, but are frequently overlooked. It is possible to subject patients to a comprehensive set of investigations before empiric therapy, but recent studies have failed to demonstrate an improved outcome using this exhaustive approach. A new tactic is required, with less attention spent on absolute diagnostic accuracy and more emphasis on optimizing the long-term clinical outcome in patients with noncardiac chest pain. It is possible that the targeted use of multiple drug trials in a policy of 'therapy as investigation' might be a superior methodology.