Normal values for esophageal high-resolution manometry

Normative high resolution esophageal manometry values in asymptomatic patients with obesity

BACKGROUND

Surgical bariatric interventions, while highly effective, can be associated with post-operative esophageal symptoms, gastroesophageal reflux disease and esophageal dysmotility. Whether pre-operative physiology impacts this risk is unknown, in part because expected values on esophageal manometry in patients with obesity are not well understood. This study seeks to establish normative values on esophageal high resolution manometry (HRM) and the prevalence of esophageal dysmotility in the asymptomatic patient with obesity.

METHODS

This retrospective study included adult patients with body mass index (BMI) ≥35 kg m-2 without esophageal symptoms undergoing preoperative bariatric surgical evaluation, including HRM, at a single tertiary care center between February, 2019 and February, 2020.

RESULTS

Of 104 asymptomatic patients with obesity, HRM identified normal esophageal motility in 94 (90.4%) with the remaining 10 having ineffective esophageal motility (3.8%), manometric esophagogastric junction outflow obstruction (3.8%), distal esophageal spasm (1.0%), and hypercontractile esophagus (1.0%). Mean of median lower esophageal sphincter integrated relaxation pressure (LES IRP) was 10.6 mmHg supine (95th percentile 21.5 mmHg) and 8.5 mmHg upright (95th percentile 21.3 mmHg). 86% of patients had intragastric pressure above 8 mmHg. Mean of mean distal contractile integral (DCI) was 2261.6 mmHg cm s-1 (95th percentile 5889.5 mmHg cm s-1).

CONCLUSION

The vast majority of asymptomatic patients with obesity had normal manometry. LES IRP and DCI were higher than that observed in non-obese cohorts. Additionally, BMI correlated to increased intragastric pressure. These data suggest that normative values in patients with obesity should be adjusted to prevent overdiagnosis of EGJOO or hypercontractile esophagus.

Toll-Like Receptor 7-Expressed Macrophages Are Involved in the Pathogenesis of Esophageal Achalasia and Esophagogastric Junction Outflow Obstruction

INTRODUCTION

Esophageal achalasia is a typical esophageal motility disorder (EMD). Although viral infections have been hypothesized to play a role in the pathogenesis of esophageal achalasia, its etiology remains unclear. This study used esophageal muscle layer specimens collected during per-oral endoscopic myotomy (POEM) procedures to investigate the association between esophageal achalasia and esophagogastric junction outflow obstruction (EGJOO) and pattern recognition receptors.

METHODS

Patients with esophageal achalasia and EGJOO who underwent POEM were allocated to the EMD group. Biopsies of the inner circular muscle were conducted during the POEM procedure. The control group comprised individuals diagnosed with esophageal squamous cell carcinoma who underwent surgical resection. Expression of pattern recognition receptors, including Toll-like receptor (TLR) 7, was examined by polymerase chain reaction. Immunohistochemical staining was performed to determine TLR7 expression sites in the esophageal muscle layer, and the relationship between TLR7 mRNA expression and clinical score was investigated.

RESULTS

Our analysis revealed a notable upregulation of TLR7 mRNA levels within the muscle layer of esophageal achalasia and EGJOO, in contrast to those of control specimens. In contrast, the correlation between TLR7 and clinical score was not significant. Immunohistochemical staining revealed increased numbers of TLR7-expressing macrophages between the muscle layers.

CONCLUSIONS

TLR7-expressing macrophages are involved in the innate immune response underlying esophageal achalasia and EGJOO. This result will lead to the elucidation of new pathogenetic mechanisms and the development of novel therapeutic targets.

Integrated Relaxation Pressure and Its Diagnostic Ability May Vary According to the Conditions Used for HREM Recording

Integrated Residual Pressure (IRP) measured under conditions alternative to supine single swallows may provide clinically useful information regarding EGJ relaxation. This study aimed to compare IRP values obtained under different situations and explore their potential clinical utility. We analyzed and compared the values of IRP obtained from healthy volunteers and patients with suspected achalasia during supine single swallows (Ssup-IRP), sitting single swallows (Ssit-IRP), supine multiple rapid swallows (Msup-IRP), and sitting multiple rapid swallows (Msit-IRP). We analyzed the HREM recordings of 40 healthy volunteers and 53 patients with suspected achalasia. The four metrics were significantly different from each other in healthy volunteers (Ssup-IRP > Msup-IRP > Ssit-IRP > Msit-IRP) and their corresponding 95th percentiles were substantially distinct (Ssup-IRP: 25.3 mmHg, Ssit-IRP: 20.9 mmHg, Msup-IRP: 15.9 mmHg, and Msit-IRP: 11.9 mm Hg, respectively). Complete agreement among the four metrics in predicting abnormal IRP was found in 39 of the 47 patients with suspected achalasia who completed the protocol. Optimal cutoffs derived from ROC curve analysis demonstrated ≥ 0.95 specificities for detection of impaired EGJ relaxation among patients with suspected achalasia. Among the eight patients with suspected achalasia with normal Ssup-IRP, five demonstrated abnormal Msit-IRP and four abnormal Ssit-IRP. Significant differences of IRP exist depending on the measurement situation, indicating that correct interpretation of IRP values requires specific cutoffs for each situation.The sensitivities of Ssit-IRP and Msit-IRP in detecting defective EGJ relaxation appear to be slightly higher than that of Ssup-IRP.

The Manometric Representation of the Upper Esophageal Sphincter During the Resting State: A Descriptive Study

The upper esophageal sphincter (UES) is the high-pressure zone marking the transition between the hypopharynx and esophagus. There is limited research surrounding the resting UES using pharyngeal high-resolution manometry (HRM) and existing normative data varies widely. This study describes the manometric representation of the resting UES using a clinically accessible method of measurement. Data were obtained from 87 subjects in a normative database of pharyngeal HRM with simultaneous videofluoroscopy. The resting UES manometric region was identified and ten measurement segments of this region were taken throughout the duration of the study using the Smart Mouse function within the manometry software. Intraclass correlation coefficients (ICC) were used to analyze within-subject reliability across measurements. Linear mixed-effects regression models were used to analyze how subject characteristics and manometric conditions influence resting UES pressure. There was excellent within-subject reliability between resting UES mean pressures (ICC = 0.96). In bivariate analysis, there were significant effects of age, number of sensors contained within the resting UES, and preceding swallow volume on mean resting UES pressure. For every 1 unit increase in age, there was a 0.19 unit decrease in resting UES pressure (p = 0.008). For every 1 unit increase in number of sensors contained within the resting UES, there was a 3.71 unit increase in resting UES pressure (p < 0.001). This study presents normative data for the resting UES, using a comprehensive and clinically accessible protocol that can provide standard comparison for the study of populations with swallowing disorders, particularly UES dysfunction, and provides support for UES-directed interventions.

High-resolution impedance manometry for comparing bolus transit between patients with non-obstructive dysphagia and asymptomatic controls

BACKGROUND

Currently, there are no high-resolution impedance manometry (HRIM)-based diagnostic criteria for non-obstructive dysphagia (NOD). New impedance parameters, such as the esophageal impedance integral (EII) and volume of inverted impedance (VII) ratios, have shown strong correlations with bolus transit. This study compared the EII and VII ratios as diagnostic tools for NOD.

METHODS

We analyzed 36 participants (12 patients with achalasia, 12 patients with NOD [7 with normal motility and 5 with ineffective esophageal motility], and 12 asymptomatic controls) who underwent HRIM with a maximum of 5 swallows per participant. The EII and VII ratios were calculated as Z2 (post-swallow)/Z1 (pre-swallow). Bolus transit was retrospectively evaluated using transluminal impedance analysis.

KEY RESULTS

Both EII and VII ratios could effectively distinguish the achalasia group from the non-achalasia groups (area under the receiver operating characteristic curve [AUROC]: 0.83 for VII vs. 0.80 for EII; p = 0.73). However, the VII ratio was significantly better in discriminating asymptomatic controls from patients with dysphagia (NOD + achalasia) (AUROC: 0.81 vs. 0.68; p = 0.01). Moreover, the VII ratio was better in discriminating asymptomatic controls from patients with NOD (AUROC: 0.68 vs. 0.51; p = 0.06). In repeated swallows, the VII ratio was consistently the lowest in controls and the highest in patients with achalasia, whereas the EII ratio did not show a consistent pattern.

CONCLUSIONS & INFERENCES

The VII ratio was more reliable than the EII ratio for describing bolus transit and distinguishing patients with NOD from asymptomatic controls, even during repeated measures of subsequent swallows.

Subtype of Achalasia and Integrated Relaxation Pressure Measured Using the Starlet High-resolution Manometry System: A Multicenter Study in Japan

Background/Aims

ManoScan and Sandhill high-resolution manometry (HRM) systems are used worldwide; however, the diagnosis of achalasia on the Starlet HRM system is not fully characterized. Furthermore, the impact of calcium channel blockers and nitrites in treating achalasia has not been investigated using HRM. Management of recurrent cases is a priority issue, although few studies have examined patient characteristics.

Methods

We conducted a multicenter, large-scale database analysis. First, the diagnosis of treatment-naive achalasia in each HRM system was investigated. Next, patient characteristics were compared between type I-III achalasia, and the impact of patient characteristics, including calcium channel blocker and nitrite use for integrated relaxation pressure (IRP) values, were analyzed. Finally, patient characteristics with recurrent achalasia were elucidated.

Results

The frequency of type I achalasia with Starlet was significantly higher than that with ManoScan and Sandhill HRM systems. In achalasia, multivariate analysis identified male sex, advanced age, long disease duration, obesity, type I achalasia, and sigmoid type as risk factors related to normal IRP values (< 26 mmHg). Calcium channel blockers and nitrites use had no significant impact on the IRP values, although achalasia symptoms were indicated to be alleviated. In recurrent cases, the IRP value was significantly lower, and advanced age, long disease duration, and sigmoid type were more common than in treatment-naive patients.

Conclusions

We should cautiously interpret the type of achalasia and IRP values in the Starlet HRM system. Symptoms of recurrent cases are related to disease progression rather than IRP values, which should be considered in decision making.

Chronic constipation that resulted in fecal impaction and colon perforation: A case report

RATIONALE

Gastrointestinal (GI) motility disorders represent a set of variable presentations caused by an abnormal functioning enteric neuromusculature. Any part of the GI tract can be affected, and depending on the organ involved, the patient presentation will differ.

PATIENT CONCERNS

A 26-years old female who had a history of laparoscopic Heller myotomy 15 years ago for progressive dysphagia. She presented with peritonitis and sigmoid colon perforation secondary to severe chronic constipation. Later after undergoing Hartman procedure, she continued to have significant constipation. In addition, she reported progressive dysphagia and regurgitation to both solids and liquids.

DIAGNOSIS

An esophageal manometry revealed Achalasia type 3, and stomach motility nuclear study showed mild delay in gastric emptying.

INTERVENTIONS

Initially, Hartmann procedure was performed. Afterward, we performed a reversal of Hartman, robotic redo of Heller myotomy, and Dor fundoplication was performed.

OUTCOMES

The patient had an uneventful postoperative course and was discharged in good condition.

LESSONS

Our case highlights an unusual presentation of GI motility disorder resulting in peritonitis from sigmoid colon perforation. Early recognition and prompt treatment of GI motility disorders are essential to avoid severe complications.

High-Resolution Manometry Thresholds and Motor Patterns Among Asymptomatic Individuals

OBJECTIVE

High-resolution manometry (HRM) is the current standard for characterization of esophageal body and esophagogastric junction (EGJ) function. We aimed to examine the prevalence of abnormal esophageal motor patterns in health, and to determine optimal thresholds for software metrics across HRM systems.

DESIGN

Manometry studies from asymptomatic adults were solicited from motility centers worldwide, and were manually analyzed using integrated relaxation pressure (IRP), distal latency (DL), and distal contractile integral (DCI) in standardized fashion. Normative thresholds were assessed using fifth and/or 95th percentile values. Chicago Classification v3.0 criteria were applied to determine motor patterns across HRM systems, study positions (upright vs supine), ages, and genders.

RESULTS

Of 469 unique HRM studies (median age 28.0, range 18-79 years). 74.6% had a normal HRM pattern; none had achalasia. Ineffective esophageal motility (IEM) was the most frequent motor pattern identified (15.1% overall), followed by EGJ outflow obstruction (5.3%). Proportions with IEM were lower using stringent criteria (10.0%), especially in supine studies (7.1%-8.5%). Other motor patterns were rare (0.2%-4.1% overall) and did not vary by age or gender. DL thresholds were close to current norms across HRM systems, while IRP thresholds varied by HRM system and study position. Both fifth and 95th percentile DCI values were lower than current thresholds, both in upright and supine positions.

CONCLUSIONS

Motor abnormalities are infrequent in healthy individuals and consist mainly of IEM, proportions of which are lower when using stringent criteria in the supine position. Thresholds for HRM metrics vary by HRM system and study position.

Characteristics of high-resolution esophageal manometry in children without dysphagia

BACKGROUND

The absence of high-resolution esophageal manometry (HREM) norms in pediatrics limits the assessment of children with dysphagia. This study aimed to describe HREM parameters in a cohort of children without dysphagia.

METHODS

Children ages 9-16 years with a negative Mayo Dysphagia Questionnaire screen and normal histologic findings underwent HREM after completion of esophagogastroduodenoscopy. Ten swallows of 5 ml 0.45% saline boluses per subject were captured in supine position. Analyzed data included resting and integrated relaxation pressures (IRP) of lower (LES) and upper (UES) esophageal sphincters, peristaltic contractile integrals, transition zone (TZ) breaks, velocities, and lengths associated with proximal and distal esophagus.

KEY RESULTS

33 subjects (15 female) with mean (range) age 12.9 (9-16) years completed the study. Two of 330 analyzed swallows failed. The UES mean resting pressure, and its 0.2 s and 0.8 s IRPs were 48.3 (95% CI 12.9) mmHg, 2.9 (95% CI 1.9) mmHg, and 12.1 (95% CI 2.5) mmHg, respectively. The LES mean resting pressure and its 4 s IRP were 29.0 (95% CI 4.0) mmHg and 9.2 (95% CI 1.3) mmHg. The mean proximal (PCI) and distal (DCI) esophageal contractile integrals were 231 (95% CI 54.8) mmHg-s-cm and 1789.3 (95% CI 323.5) mmHg-s-cm, with mean TZ break 0.5 (95% CI 0.3) cm.

CONCLUSIONS & INFERENCES

This is the first study to describe HREM parameters in children without dysphagia. Most of the reported measurements were significantly different and less variable from reported adult norms. This emphasizes the need for child-specific catheters, norms, and protocols to define pediatric esophageal motility disorders.

Powering Implantable and Ingestible Electronics

Implantable and ingestible biomedical electronic devices can be useful tools for detecting physiological and pathophysiological signals, and providing treatments that cannot be done externally. However, one major challenge in the development of these devices is the limited lifetime of their power sources. The state-of-the-art of powering technologies for implantable and ingestible electronics is reviewed here. The structure and power requirements of implantable and ingestible biomedical electronics are described to guide the development of powering technologies. These powering technologies include novel batteries that can be used as both power sources and for energy storage, devices that can harvest energy from the human body, and devices that can receive and operate with energy transferred from exogenous sources. Furthermore, potential sources of mechanical, chemical, and electromagnetic energy present around common target locations of implantable and ingestible electronics are thoroughly analyzed; energy harvesting and transfer methods befitting each energy source are also discussed. Developing power sources that are safe, compact, and have high volumetric energy densities is essential for realizing long-term in-body biomedical electronics and for enabling a new era of personalized healthcare.

Effects of Age on Esophageal Motility: A High-Resolution Manometry Study

Background

Studies have found possible physiologic changes to esophageal motility with aging currently not taken into account in routine high-resolution manometry (HRM) interpretation. We aimed to quantify the relationship between these physiologic changes and aging to improve HRM interpretation.

Methods

We conducted a retrospective analysis of patients who underwent HRM at a tertiary hospital center between 2015 and 2019. Inclusion criteria were patients aged ≥18 years with normal HRM. Exclusion criteria were abnormal HRM, abnormal upper digestive endoscopy or imagery. Outcomes were median integrated relaxation pressure (IRP), lower esophageal sphincter (LES) pressure, distal contractal integral (DCI), distal latency (DL), and peristaltic break (PB) according to the v4.0 Chicago classification criteria. Effect of age was examined through univariate and multivariate linear regression analysis.

Results

We identified 1,917 patients with HRM and included 722 patients with normal exams (median age 56 years (interquartile range (IQR) 46 - 66), 63.8% female). Indications for HRM included dysphagia (39.6%), gastroesophageal reflux disease (29.5%), and chest pain (11.5%). There was statistically significant relationship between age and IRP (r = 0.20, P < 0.0001) as well as DCI (r = 0.12, P = 0.001) and DL (r = -0.09, P = 0.02). No statistically significant relationship was found between age and LES pressure or PB.

Conclusion

We found that IRP, DCI, and to a lesser extent, DL, are significantly correlated with the normal aging process in symptomatic patients. These findings should be taken into consideration when interpreting esophageal HRM.

Esophagogastric junction outflow obstruction

In the Chicago Classification version 4.0 (CCv4), esophagogastric junction outflow obstruction (EGJOO) is manometrically defined as an elevated median integrated relaxation pressure (IRP) and elevated intrabolus pressure (IBP) during supine wet swallows, and persistently elevated median IRP in the upright position. A clinically relevant conclusive diagnosis of EGJOO requires a manometric diagnosis of EGJOO and associated symptoms such as dysphagia and/or chest pain with at least one of the following supportive investigations (pharmacologic provocation, timed barium esophagogram, and/or endoflip). The Chicago Classification is intended for diagnosis of primary esophageal motor disorders, and thus history and endoscopic evaluation are important to exclude conditions (eg, previous surgery, strictures, or masses) that can secondarily generate the EGJOO pattern on HRM. While a manometric finding of EGJOO is often made and can be an early sign of achalasia, more often it is a manometric finding without clinical implications. The proposed changes in CC4.0 have attempted to make the diagnosis more specific, in order to reduce the number of clinically irrelevant diagnoses and avoid confusion by patients and physicians alike.

The upper esophageal sphincter in the high-resolution manometry era

BACKGROUND

The evaluation of the upper esophageal sphincter (UES) has been neglected during routine manometric tests for decades, mostly due to the limitations of the conventional manometry which were eventually overcome by high-resolution manometry (HRM).

METHODS

This study reviewed the current knowledge of the manometric evaluation of the UES in health and disease in the HRM era.

RESULTS

We found that HRM allowed more precise measurements, in addition to the parameters as compared to conventional manometry, but most of them still need confirmation of the clinical significance. The parameters used to evaluate the UES were extension, basal pressure, residual pressure, relaxation duration, relaxation time to nadir, recovery time, intrabolus pressure, and deglutitive sphincter resistance. UES may be affected by different diseases: achalasia (UES is hypertonic with impaired relaxation), gastroesophageal reflux disease (UES is short and hypotonic), globus (UES ranges from normal to impaired relaxation to hypertonic), neurologic diseases (stroke and Parkinson - UES is hypotonic in early-stage to impaired relaxation in end-stage disease), and Zenker's diverticulum (UES has impaired relaxation).

CONCLUSION

This review shows that UES dysfunction is part of several disease processes and that the study of the UES is possible and valuable with the aid of HRM.

Variations in Clinical Practice of Esophageal High-resolution Manometry: A Nationwide Survey

Background/Aims

Esophageal high-resolution manometry (HRM) enables the comprehensive evaluation of the esophageal motor function. However, protocols are not uniform and clinical practices vary widely among institutions. This study aims to understand the current HRM practice in Korea.

Methods

The survey was sent via email through the Korean Society of Neurogastroenterology and Motility. The questions covered descriptive information, preparation, techniques, analysis, and reporting of esophageal HRM.

Results

The survey was completed in 32 (74.4%) out of 43 centers, including 24 tertiary and 8 secondary referral centers. Of the 32 centers, 25 (78.1%) performed HRM in a sitting position, while 7 centers (21.9%) reported performing HRM in a supine position. All the centers utilized single wet swallows as a standard, but the volume, frequency, and interval between swallows varied widely. Sixteen centers (50.0%) applied adjunctive tests, including multiple rapid swallows (n = 16) and rapid drink challenges (n = 9). Parameters assessed and documented in the report were similar. In addition to the assessment of the esophagogastric junction and esophageal body, 27 centers (84.8%) and 18 centers (56.3%) included measurements for the upper esophageal sphincter and the pharynx, respectively, in the HRM protocol.

Conclusions

We found a variation in the available HRM practice among centers, even though they broadly agreed in the data analysis. Efforts are needed to develop a standardized protocol for HRM measurement.

Chicago Classification Update (v4.0): Technical review on diagnostic criteria for hypercontractile esophagus

Hypercontractile esophagus (HE), defined by the Chicago Classification version 3.0 (CCv3.0) as 20% or more hypercontractile peristalsis (Distal Contractile Integral >8000 mmHg·s·cm) on high-resolution manometry (HRM), is a heterogeneous disorder with variable clinical presentations and natural course, leading to management challenges. An update on the diagnostic criteria for clinically relevant HE was needed. Literature on HE was extensively reviewed by the HE subgroup of the Chicago Classification version 4.0 (CCv4.0) Working Group and statements relating to the diagnosis of HE were ranked according to the RAND UCLA Appropriateness methodology by the Working Group, and the quality of evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. An overall emphasis of the CCv4.0 is on clinically relevant esophageal dysmotility, and thus it is recommended that an HE diagnosis requires both conclusive manometric diagnosis and clinically relevant symptoms of dysphagia and non-cardiac chest pain. The Working Group also recognized the subtypes of HE, including single-peaked, multi-peaked contractions (Jackhammer esophagus), and hypercontractile lower esophageal sphincter. However, there are no compelling data currently for formally subdividing HE to these subgroups in clinical practice.

The effects of different postures and provocative swallow materials on the normative Chicago 3.0 metrics in a healthy Asian population

BACKGROUND AND AIM

Variations in the Chicago 3.0 normative metrics may exist with different postures and with different provocative swallow materials in a healthy Asian population.

METHOD

Eligible healthy Malay volunteers were invited to undergo the high-resolution esophageal manometry (inSIGHT Ultima, Diversatek Healthcare, Milwaukee, WI, USA). In recumbent and standing positions, test swallows were performed using liquid, viscous, and solid materials. Metrics including integrated relaxation pressure 4 s (IRP-4 s, mmHg), distal contractile integral (DCI, mmHg s cm), distal latency (DL, s), and peristaltic break (PB, cm) were reported in median and 95th percentile.

RESULTS

Fifty of 57 screened participants were recruited, and 586 saline, 265 viscous, and 261 solid swallows were analyzed. Per-patient wise, in the recumbent position, 95th percentile for IRP-4 s, DCI, DL, and PB were 16.5 mmHg, 2431 mmHg s cm, 8.5 s, and 7.2 cm, respectively. We observed that with each posture, the use of viscous swallows led to changes in DL, but the use of solid swallows led to more changes in the metrics including DCI and length of PB. Compared with a recumbent posture, anupright posture led to lower IRP-4 s and DCI values. Both per-patient analysis and per-swallow analyses yielded almost similar results when comparing the different postures and types of swallows. No major motility disorders were observed in this cohort of asymptomatic population. However, more motility disorders were reported in the upright position.

CONCLUSIONS

Variations in metrics can be observed in different postures and with different provocative swallow materials in a healthy population. The normative Chicago 3.0 metrics are also determined for the Malay population.

European Society for Neurogastroenterology and Motility (ESNM) recommendations for the use of high-resolution manometry of the esophagus

BACKGROUND

Several patients in gastroenterology practice present with esophageal symptoms, and in case of normal endoscopy with biopsies, high-resolution manometry (HRM) is often the next step. Our aim was to develop a European consensus on the clinical application of esophageal HRM, to offer the clinician guidance in selecting patients for HRM and using its results to optimize clinical outcome.

METHODS

A Delphi consensus was initiated with 38 multidisciplinary experts from 16 European countries who conducted a literature summary and voting process on 71 statements. Quality of evidence was evaluated using grading of recommendations assessment, development, and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 33 statements.

RESULTS

The process generated guidance on when to consider esophageal HRM, how to perform it, and how to generate the report. The Delphi process also identified several areas of uncertainty, such as the choice of catheters, the duration of fasting and the position in which HRM is performed, but recommended to perform at least 10 5-ml swallows in supine position for each study. Postprandial combined HRM impedance is considered useful for diagnosing rumination. There is a large lack of consensus on treatment implications of HRM findings, which is probably the single area requiring future targeted research.

CONCLUSIONS AND INFERENCES

A multinational and multidisciplinary group of European experts summarized the current state of consensus on technical aspects, indications, performance, analysis, diagnosis, and therapeutic implications of esophageal HRM.

Evaluation of the Esophagogastric Junction on High Resolution Manometry

The esophagogastric junction (EGJ) is a complex barrier between the thoracic and abdominal luminal gut compartments, comprised primarily of the lower esophageal sphincter (LES) and crural diaphragm. Although closed at rest, the EGJ relaxes to allow antegrade bolus transit and retrograde venting of air. Abnormal relaxation is the hallmark of achalasia spectrum disorders, while increased frequency of transient lower esophageal sphincter relaxations and/or EGJ disruption are seen in gastroesophageal reflux disease. High resolution manometry (HRM) is the modern day gold standard for assessment of EGJ morphology and function, with better performance characteristics compared with endoscopy and barium esophagography. Conventional LES metrics defining EGJ function include resting LES pressure as well as postswallow residual pressures. Newer HRM-based metrics include EGJ contractile integral, which measures static barrier function at rest, and EGJ morphology, which characterizes the relationship between LES and crural diaphragm. Provocative maneuvers assess dynamic EGJ function during physiological or pharmacologic stress. The most useful of these maneuvers, the rapid drink challenge, assesses for latent obstruction, while multiple rapid swallows evaluate adequacy of deglutitive inhibition. Amyl nitrate and cholecystokinin administration can segregate motor from structural obstruction. Newer provocative tests (straight leg raise maneuver, abdominal compression) and novel diagnostic tools (functional lumen imaging probe) complement HRM evaluation of the EGJ. Although current HRM metrics and maneuvers show promise in identifying clinically relevant EGJ abnormalities, future investigations evaluating management outcomes will improve segregation of normal from abnormal EGJ morphology and function.

Pharyngeal and upper esophageal sphincter motor dynamics during swallow in children

BACKGROUND

Motor abnormalities of pharyngeal contraction or upper esophageal sphincter (UES) relaxation can lead to swallowing problems.

METHODS

We reviewed high-resolution esophageal manometry of children ≤18 years and classified into two groups based on the results of videofluoroscopic study of swallow (VFSS), as normal or abnormal. The UES metrics (integrated relaxation pressure [IRP], resting pressure [URP], and nadir pressure [UNP]), as well as peak pharyngeal pressure (velopharyngeal and meso-hypopharyngeal), were analyzed.

RESULTS

UES metrics: There were 142 and 19 subjects in the normal and abnormal groups, respectively. In the normal group, the median UES-IRP at 0.2, 0.4, 0.6, 0.8 seconds, URP, and UNP were 1.0, 4.0, 11.0, 18.0, 53.5, and -1.0 mm Hg while in the abnormal group were 10.0, 13.0, 21.0, 25.5, 47.0, and 8.0 mm Hg. The UES-IRP at 0.2, 0.4, 0.6 seconds, and UNP was significantly higher in the abnormal group. Pharyngeal metrics: We included 58 subjects in normal and 10 subjects in the abnormal group. The median of peak velopharyngeal and meso-hypopharyngeal pressures were lower in the abnormal group; 188.50 vs 210.50, P = .185 and 110.00 vs 144.75 mm Hg, P = .065.

CONCLUSIONS AND INFERENCES

The UES-IRP was lower than adults, URP was higher than preterm but less than adults, and UNP was lower than neonates but similar to adults. The pharyngeal pressures were higher than those reported for neonates and adults. Our data indicate that motor dynamics of swallowing may change from neonates to adulthood and reflect a maturational process. The subjects with abnormal VFSS had significantly higher UES-IRP and UNP compared to normal VFSS.

High Resolution Manometry Guidance During Laparoscopic Fundoplication in Pediatric Surgically "Fragile" Patients: Preliminary Report

Background: High resolution manometry (HRM), has been recently introduced in clinical practice to detect esophageal intraluminal pressure and esophageal motor function. We evaluated the feasibility and usefulness of intraoperative esophageal HRM during antireflux laparoscopic procedures in pediatric cases with neurological impairment (NI) or esophageal atresia (EA). Methods: From January to November 2019, seven children (5 NI, 2 EA) with gastroesophageal reflux (GER) were enrolled. Data on intraoperative pressure changes of the esophagogastric junction (EGJ) and postoperative follow-up data were collected. Results: Average preoperative LES pressures were not significantly different from postoperative pressures. A sliding hernia was detected in all patients as evidenced by EGJ double peak pressures. Hernia correction after esophageal traction was complete in 71.4% of the patients, and residual hernia (<2 cm) was detected in 28.6%. Postoperative EGJ pressures were higher compared to preoperative sphincteric pressures (p < 0.001); in NI patients, higher postoperative values were noted compared to EA (p = 0.05). No sliding hernia and/or GER relapses were recorded. Two patients reported dysphagia postoperatively. Conclusions: Intraoperative HRM may optimize esophageal pressure changes during laparoscopic fundoplication. Further studies are needed to confirm the usefulness of a tailored surgical approach to reduce postoperative complications.

Jackhammer esophagus: Clinical presentation, manometric diagnosis, and therapeutic results-Results from a multicenter French cohort

BACKGROUND/AIMS

Jackhammer esophagus (JE) is a hypercontractile esophageal motor disorder defined by at least two swallows with a distal contractile integral (DCI) >8000 mm Hg.s.cm during high-resolution manometry (HRM). The relationship between symptoms and hypercontractility and the response to therapies have been poorly evaluated. The aim of this study was to determine the clinical presentation, manometric diagnosis, and therapeutic results in a large cohort of JE patients.

METHODS

Patients with JE diagnosed among the HRM tests performed in nine academic French centers from 01/01/2010 to 08/31/2016 were included. Patient charts were reviewed to collect clinical and therapeutic data.

RESULTS

Among the 16 264 HRM tests performed during this period, 227 patients (60.8 ± 13.8 years, 151 male) had JE (1.7%). Dysphagia was the most frequent symptom (74.6%), followed by regurgitation (37.1%) and chest pain (36.6%); 4.7% of the patients were asymptomatic. The diagnostic workup was heterogeneous, and only a minority of patients had esophageal biopsies. None of the individual symptoms were significantly associated with any of the manometric parameters defined, except for dysphagia, which was significantly associated with the mean of all DCIs >8000 mm Hg.s.cm (P = .04). Additionally, the number of symptoms was not associated with any manometric parameter. Medical treatment and endoscopic treatments had poor efficacy and a high relapse rate.

CONCLUSION

Jackhammer esophagus is a rare motility disorder. Diagnostic workup is heterogeneous and should be standardized. Symptoms are poorly associated with manometric parameters. The medical treatments and endoscopic therapies currently used are inefficient.

Esophageal Baseline Impedance From High-resolution Impedance Manometry Correlates With Mean Nocturnal Baseline Impedance From pH-impedance Monitoring

Background/Aims

Esophageal baseline impedance (BI) can be extracted from pH-impedance tracings as mean nocturnal baseline impedance (MNBI), and from high-resolution impedance manometry (HRIM), but it is unknown if values are similar between acquisition methods across HRIM manufacturers. We aim to assess correlations between MNBI and BI from HRIM (BI-HRIM) from 2 HRIM manufacturers in the setting of physiologic acid exposure time (AET).

Methods

HRIM and pH-impedance monitoring demonstrating physiologic AET (< 4%) off proton pump inhibitors were required. BI-HRIM was extracted as the average from 5 cm and 10 cm above the lower esophageal sphincter. Distal BI-HRIM (DBI-HRIM) was also extracted from the most distal channel (Medtronic studies). MNBI was extracted from 6 channels. Concordance between BI-HRIM across manufacturers with MNBI was analyzed.

Results

Thirty-six patients met the inclusion criteria (59.6 ± 1.7 years; 22% female; body mass index 30.5 ± 0.7; AET 1.6 ± 0.2%). Although MNBI was similar at all channels (P ≥ 0.18), Diversatek BI-HRIM was lower than Medtronic BI-HRIM (P = 0.003). Overall, BI-HRIM correlated with MNBI at corresponding recording sites, 7 cm and 9 cm (P < 0.05), but not at other sites (P ≥ 0.19). Pearson’s correlations > 0.5 were seen at MNBI at 7 cm for both systems, and at 9 cm for Medtronic. DBI-HRIM correlated with MNBI at 3 cm and 5 cm (P < 0.03), but not at other locations (P > 0.1).

Conclusions

While numeric differences exist between manufacturers, BI-HRIM correlates with MNBI from corresponding channels in patients with physiologic AET. Comparison with AET elevation is needed to determine correlations between pathologic MNBI with BI-HRIM across manufacturers. The optimal HRIM channels from which BI values should be extracted also warrants further study.

NORMAL VALUES OF ESOPHAGEAL HIGH-RESOLUTION MANOMETRY: A BRAZILIAN MULTICENTER STUDY

ABSTRACT BACKGROUND: The high-resolution manometry has been a significant advance in esophageal diagnostics. There are different types of catheter and systems devices to capture esophageal pressures that generate variable data related to Chicago Classification (CC) and consequently influence normal values results. There are not normative data for the 24-channel water-perfused high-resolution manometry system most used in Brazil with healthy volunteers in supine posture. OBJECTIVE: To determine manometric esophageal normative values for a 24-channel water-perfused high-resolution manometry catheter in supine posture using healthy volunteers according to CC 3.0 parameters. METHODS: A total of 92 volunteers with no gastrointestinal symptoms or medications affecting GI motility underwent esophageal high-resolution manometry by standard protocol. Age, gender and manometry parameters analyzed using Alacer software were collected. The median, range, and 5th and 95th percentiles (where applicable) were obtained for all high-resolution manometry metrics. Normal value percentiles were defined as 95th integrated relaxation pressure, 5th-100th distal contractile integral, and 5th distal latency. RESULTS: The mean age was 40.5±13.2 years. Our normative metrics were integrated relaxation pressure <16 mmHg and distal contractile integral (708-4111 mmHg.cm.s) distal latency was <6 s and peristaltic break size (>4 cm). For EGJ-CI the range 5th-95th was 21.7-86.9 mmHg.cm.s. CONCLUSION: This is the first report of normative data for the 24-channel water-perfused system in supine posture. It revealed higher integrated relaxation pressure and distal latency duration which suggest the need to change CC 3.0 cutoffs for this system. It is observed that there is a tendency that DCI >7000 mmHg.cm.s may represent the lower limit of hypercontractility, and when <700 mmHg.cm.s (<5% percentile) interpreted as ineffective esophageal motility or failcontraction. Also compared to Chicago 3.0, higher integrated relaxation pressure and duration of distal latency were found. We emphasize that these data must be confirmed by future studies.

Correlation between reflux burden, peristaltic function, and mucosal integrity in GERD patients

BACKGROUND

Mean nocturnal baseline impedance (MNBI) augments the diagnostic yield of multichannel intraluminal impedance-pH (MII-pH) monitoring. While acid exposure time (AET) correlates with MNBI, it remains unclear whether esophageal motility affects MNBI values. The present study was aimed at evaluating the respective roles of esophageal motor function and AET on MNBI.

METHODS

High-resolution manometry (HRM) studies and ambulatory 24-hour MII-pH monitoring tracings were retrospectively analyzed from consecutive endoscopy-negative GERD patients with typical symptoms responsive to previous acid-suppressive therapy from three tertiary care centers. Univariate and multivariate analyses were performed to determine predictors of pathologic MNBI values at 3 cm and 5 cm above the lower esophageal sphincter (LES).

KEY RESULTS

Patients with pathological AET displayed lower MNBI values at 3 cm and 5 cm (P < .01) compared to patients with non-pathological AET. Similarly, significantly lower MNBI values were also noted at both sites with type 3 EGJ compared to type 1 EGJ (P ≤ .02 for each comparison), and with absent contractility compared to normal peristalsis (P ≤ .02 for each comparison). On multivariate analysis, the presence of type 2 or 3 EGJ and absent contractility were associated with a significantly higher probability of pathological MNBI values at 3 cm and 5 cm above the LES.

CONCLUSIONS AND INFERENCES

Disruption of the EGJ and absent contractility on HRM are both associated with lower MNBI values. HRM findings complement reflux testing using MII-pH monitoring.

Validity of the Cutoff Value for Integrated Relaxation Pressure Used in the Starlet High-Resolution Manometry System

BACKGROUND

In a previous study that used the Starlet high-resolution manometry system to assess integrated relaxation pressure (IRP) in healthy adults, the predicted cutoff value was about 26 mm Hg. However, some patients with achalasia have an IRP value of <26 mm Hg. This study examined the validity of the Starlet IRP cutoff value in patients with achalasia.

METHODS

Among 37 patients with achalasia, the percentage of patients with a Starlet IRP value ≥26 mm Hg was calculated. Patients were then classified as IRP-high (IRP ≥26 mm Hg) and IRP-low (IRP <26 mm Hg), and the groups were compared in relation to basal lower esophageal sphincter (LES) pressure, Chicago classification achalasia subtype, and esophagography subtype.

RESULTS

Twenty (54%) of the 37 patients had an IRP of ≥26 mm Hg. Basal LES pressure was significantly higher in the IRP-high group than in the IRP-low group. Chicago classification Type II achalasia was most common in the IRP-high group, whereas Type I was most common in the IRP-low group. No significant difference was noted in the distribution of esophagography subtypes between groups.

CONCLUSIONS

It is difficult to determine an IRP cutoff value with Starlet. When diagnosing achalasia with Starlet, comprehensive assessment must consider findings other than IRP values. In addition, IRP was associated with Chicago classification type.

High-resolution esophageal manometry in pediatrics: Effect of esophageal length on diagnostic measures

BACKGROUND

High-resolution esophageal manometry (HREM), derived esophageal pressure topography metrics (EPT), integrated relaxation pressure (IRP), and distal latency (DL) are influenced by age and size. Combined pressure and intraluminal impedance also allow derivation of metrics that define distension pressure and bolus flow timing. We prospectively investigated the effects of esophageal length on these metrics to determine whether adjustment strategies are required for children.

METHODS

Fifty-five children (12.3 ± 4.5 years) referred for HREM, and 30 healthy adult volunteers (46.9 ± 3.8 years) were included. Studies were performed using the MMS system and a standardized protocol including 10 × 5 mL thin liquid bolus swallows (SBM kit, Trisco Foods) and analyzed via Swallow Gateway (www.swallowgateway.com). Esophageal distension pressures and swallow latencies were determined in addition to EGJ resting pressure and standard EPT metrics. Effects of esophageal length were examined using partial correlation, correcting for age. Adult-derived upper limits were adjusted for length using the slopes of the identified linear equations.

KEY RESULTS

Mean esophageal length in children was 16.8 ± 2.8 cm and correlated significantly with age (r = 0.787, P = .000). Shorter length correlated with higher EGJ resting pressure and 4-s integrated relaxation pressures (IRP), distension pressures, and shorter contraction latencies. Ten patients had an IRP above the adult upper limit. Adjustment for esophageal length reduced the number of patients with elevated IRP to three.

CONCLUSIONS & INFERENCES

We prospectively confirmed that certain EPT metrics, as well as potential useful adjunct pressure-impedance measures such as distension pressure, are substantially influenced by esophageal length and require adjusted diagnostic thresholds specifically for children.

Clinical impact of different cut-off values in high-resolution manometry systems on diagnosing esophageal motility disorders

BACKGROUND

The values of the parameters in the Chicago classification measured by a high-resolution manometry (HRM) system with the Unisensor catheter (Starlet) are significantly different from those measured by the ManoScan. The contraction vigor is categorized by values of the distal contractile integral (DCI) in the Chicago classification v3.0; however, reference values of the DCI in the Starlet and the clinical impact of the different reference values in the Starlet and ManoScan on diagnosing esophageal motility disorders are not known.

METHODS

We evaluated data from a previous report in which ManoScan and Starlet were compared in the same subjects. The DCI values in each system were compared and reference DCI values were calculated. Moreover, diagnoses assessed by Starlet using reference values in ManoScan were compared with those using calculated reference values and those assessed by ManoScan.

RESULTS

There was a significant positive correlation between the DCI values measured by ManoScan and those measured by Starlet (r = 0.80, p < 0.01). Based on a linear functional relationship considering measurement errors, the reference DCI values for diagnosing failed, weak and hypercontractile contraction vigor were calculated as 590.6, 1011.3 and 10,085.8 mmHg-s-cm, respectively, in the Starlet. Therefore, the proposed reference values in the Starlet were 500, 1000 and 10,000 mmHg-s-cm, respectively. When the reference values in the ManoScan were used in the Starlet data, approximately 30% of subjects were diagnosed inappropriately. This issue was resolved using the proposed reference values in the Starlet.

CONCLUSION

Recognizing systemic differences in HRM systems is important.

British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring

These guidelines on oesophageal manometry and gastro-oesophageal reflux monitoring supersede those produced in 2006. Since 2006 there have been significant technological advances, in particular, the development of high resolution manometry (HRM) and oesophageal impedance monitoring. The guidelines were developed by a guideline development group of patients and representatives of all the relevant professional groups using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. A systematic literature search was performed and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool was used to evaluate the quality of evidence and decide on the strength of the recommendations made. Key strong recommendations are made regarding the benefit of: (i) HRM over standard manometry in the investigation of dysphagia and, in particular, in characterising achalasia, (ii) adjunctive testing with larger volumes of water or solids during HRM, (iii) oesophageal manometry prior to antireflux surgery, (iv) pH/impedance monitoring in patients with reflux symptoms not responding to high dose proton pump inhibitors and (v) pH monitoring in all patients with reflux symptoms responsive to proton pump inhibitors in whom surgery is planned, but combined pH/impedance monitoring in those not responsive to proton pump inhibitors in whom surgery is planned. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG.

Achalasia: Insights into Diagnostic and Therapeutic Advances for an Ancient Disease

Achalasia is a chronic idiopathic disease characterized by the absence of esophageal body peristalsis and by defective lower esophageal sphincter (LES) relaxation. The incidence rate ranges from 1.07 to up to 2.8 new cases per year per 100,000 population. Presenting symptoms include dysphagia, regurgitation, vomiting, and weight loss. The diagnosis of achalasia has undergone a revolution in the last decade due to the advent of high-resolution manometry (HRM) and the consequent development of the Chicago Classification. Recent progress has allowed achalasia to be more precisely diagnosed and to be categorized into three subtypes, based on the prevalent manometric features of the esophageal peristalsis. Treatment options are pharmacotherapy, endoscopic management (Botox injection or pneumatic dilation), and surgery, e.g. laparoscopic Heller myotomy (LHM). More recently, a new endoscopic technique, per oral endoscopic myotomy (POEM), has developed as a less invasive approach alternative to the traditional LHM. Since the first POEM procedure was performed in 2008, increasing evidence is accumulating regarding its efficacy and safety profiles. Currently, POEM is being introduced as a reasonable therapeutic option, though randomized controlled trails are still lacking. The current review sheds light onto the diagnosis and management of achalasia, with special focus on the recent advances of HRM and POEM.

The critical importance of pharyngeal contractile forces on the validity of intrabolus pressure as a predictor of impaired pharyngo-esophageal junction compliance

INTRODUCTION

Restrictive defects of the pharyngo-esophageal junction (PEJ) are common in both structural and neurological disorders and are amenable to therapies aiming to reduce outflow resistance. Intrabolus pressure (IBP) acquired with high-resolution manometry and impedance (HRMI) is an indicator of resistance and a marker of reduced PEJ compliance. Constraints and limitations of IBP as well as the optimal IBP parameter remain undefined.

AIMS

To determine: (i) the impact of peak pharyngeal pressure (PeakP) on the diagnostic accuracy of IBP for the detection of a restrictive defect at the PEJ and (ii) the optimal IBP parameter for this purpose.

METHODS

In 52 dysphagic patients previously treated for head and neck cancer. Five candidate IBP measures and PeakP were obtained with HRMI, as well as a presence of a stricture determined by a mucosal tear after endoscopic dilatation. Predictive values of IBP measures were evaluated by receiver operating characteristic (ROC) analysis for all patients and reiterated as patients with lowest PeakP were progressively removed from the cohort.

RESULTS

All IBP parameters had fair to good accuracy at predicting strictures. Intrabolus pressure measured at a discrete point of maximum admittance 1 cm above the maximal excursion of the upper esophageal sphincter had highest sensitivity (0.76) and specificity (0.78). When PeakP was at least 57 mm Hg both sensitivity and specificity improved to 0.9.

CONCLUSIONS

Pharyngeal propulsive force has substantial impact on the accuracy of IBP as a predictor of a PEJ stricture. When PeakP is ≥57 mm Hg, an elevated IBP is highly predictive of a restrictive defect at the PEJ.

The Esophageal Manometry with Gas-perfused Catheters

Background

The well-established methods for esophageal manometry have some disadvantages: the-water-perfused catheters needs calibration by gravity and measuring in supine position, and the solid-state catheters are very expensive. Manometry using gas-perfused catheters is a suitable alternative. There have been only a few publications about this.

Objectives and methods

The results for esophageal manometry in 1700 patients were retrospectively analyzed based on the clinical reports and the manometry data. The gas-perfusion manometry was critically assessed.

Results

The mean age was 54 years. The indications for esophageal manometry were GER symptoms in 58.5% (pathological DeMeester score in 41.8%), dysphagia in 12.4%, and already known achalasia in 8.9%. Motility disorders could be found in 40% of the patients with GER symptoms (51% of the patients with pathological DeMeester score), and in 88% of achalasia patients. The resting LES pressure was 8.9±5.94 mmHg with GER symptoms, 16.4±12.79 mmHg without GER symptoms, and 26.8±14.03 mmHg with achalasia. The relaxation LES pressure was 20.0±10.93 mmHg in achalasia patients, and 8.3±5.77 mmHg in the others.The gas-perfusion manometry was well tolerated by all patients without any serious complications.

Discussion

Manometry using gas-perfused catheters is an easy to handle and inexpensive method to investigate the esophageal motility. The suitability of gas perfusion with helium for esophageal manometry depends on physical and technical requirements, such as a constant gas flow, a dead space in the transducer, and the catheter being as small as possible. In consideration of this, the detection of the pressure changing in swallowing acts is excellent. The measured LES pressures are generally lower than with other methods like with water-perfused or solid-state catheters, possibly because of the higher compliance in a gas-filled surrounding. The normal values in gas-perfusion manometry are comparable but not identical with the values of other manometric methods.

Variation in esophageal physiology testing in clinical practice: Results from an international survey

BACKGROUND

Advances in clinical measurement of esophageal motility and function have improved the assessment of swallowing disorders and reflux symptoms. Variation in data acquisition, analysis, and reporting exists and impacts on diagnosis and management.

AIMS AND METHODS

This study examined variation in esophageal manometry methodology between institutions to establish the status in current practice. A structured survey was distributed through international NGM societies using an Internet-based platform. Questions explored infrastructure, technology, analysis, and reporting.

KEY RESULTS

Responses were received from 91 centers from 29 countries. Eighteen (20%) centers used "conventional" manometry, 75 (82%) high-resolution manometry, and 53 (58%) HR impedance manometry. All centers documented motility for single water swallows. The Chicago Classification was applied by 65 (71.4%) centers. In contrast, analysis of EGJ morphology varied widely. Adjunctive testing was often applied: multiple rapid swallows (77%), rapid drink challenge (77%), single solid swallows (63%), and a standard test meal (18%). Of 86 (94.5%) units that offered pH impedance (pH-Z) studies, approximately half (53.5%) performed tests on acid-suppressant medication in patients with a high pretest probability (eg, erosive esophagitis). Most (75.6%) centers manually reviewed every reflux event. Others examined pH-Z data only prior to symptoms. To assess symptom association with reflux events, 73.6% centers analyzed each symptom separately, whereas 29.7% centers pooled symptoms.

CONCLUSIONS AND INFERENCES

There is marked variation in the data acquisition, analysis, and reporting of esophageal manometry studies. Further efforts to improve quality and uniformity in testing and reporting are required. This survey provides information upon which best-practice guidelines can be developed.

Clinicomanometric factors associated with clinically relevant esophagogastric junction outflow obstruction from the Sandhill high-resolution manometry system

BACKGROUND

Integrated relaxation pressure (IRP) is a key metric for diagnosing esophagogastric junction outflow obstruction (EGJOO). However, its normal value might be different according to the manufacturer of high-resolution manometry (HRM). This study aimed to investigate optimal value of IRP for diagnosing EGJOO in Sandhill HRM and to find clinicomanometric variables to segregate clinically relevant EGJOO.

METHODS

We analyzed 262 consecutive subjects who underwent HRM between June 2011 and December 2016 showing elevated median IRP (> 15 mm Hg) but did not satisfy criteria for achalasia. Clinically relevant subjects were defined as follows: (i) subsequent HRM met achalasia criteria during follow-up (early achalasia); (ii) Eckardt score was decreased at least two points without exceeding a score of 3 after pneumatic dilatation (variant achalasia); and (iii) significant passage disturbance on esophagogram without structural abnormality (possible achalasia).

KEY RESULTS

Seven subjects were clinically relevant, including two subjects with early achalasia, four subjects with variant achalasia, and one subject with possible achalasia. All clinically relevant subjects had IRP 20 mm Hg or above. Among subjects (n = 122) with IRP 20 mm Hg or more, clinically relevant group (n = 7) had significantly higher rate of dysphagia (100% vs 24.3%, P < .001) and compartmentalized pressurization (85.7% vs 21.7%, P = .001) compared to clinically non-relevant group (n = 115).

CONCLUSIONS & INFERENCES

Our results suggest that IRP of 20 mm Hg or higher could segregate clinically relevant subjects showing EGJOO in Sandhill HRM. Additionally, if subjects have both dysphagia and compartmentalized pressurization, careful follow-up is essential.

Esophageal high-resolution impedance manometry alterations in asymptomatic patients with systemic sclerosis: prevalence, associations with disease features, and prognostic value

This study aims to investigate pre-clinical esophageal involvement in systemic sclerosis (SSc) by high-resolution impedance manometry (HRiM), its associations with disease features including lung involvement, and its predictivity of esophageal symptoms overtime. Charts of 45 asymptomatic (no heartburn/regurgitation/dysphagia) SSc patients (96% females; mean age 46 years) with at least one follow-up (FU) visit and complete clinical, serological, functional, and radiological assessment, including high-resolution computed tomography (HRCT) of the chest and lung function tests, that had undergone esophageal HRiM were retrospectively evaluated. Esophagogastric junction-contractile integral (EGJ-CI) and esophageal body motility, as evaluated by mean distal contractile integral (DCI), were assessed. SSc patients had a normal esophageal motility in 7/45 cases, a defective EGJ-CI in 28, an ineffective esophageal motility (IEM) in 17, and aperistalsis in 12. Defective EGJ-CI was associated with IEM/aperistalsis in 20 cases, while 9 patients had isolated IEM. Defective EGJ-CI and/or IEM/aperistalsis were associated with a diffusing lung capacity for CO < 80% of predicted value (all p < 0.05), while defective EGJ-CI was also associated with interstitial lung disease on HRCT (p = 0.03). Prevalence of any HRiM abnormality was higher in anti-centromere antibody negative patients (all p < 0.05). IEM/aperistalsis independently increased the risk of esophageal symptoms by 2.3-fold (95% CI 1.1-5.7) and was associated with their higher cumulative incidence with respect to patients with other HRiM patterns at FU (χ² = 4.63; p = 0.03). SSc patients asymptomatic for esophageal involvement can have HRiM abnormalities in up to 84% of cases. A baseline-impaired motility is a risk factor for symptomatic esophageal disease.

Oesophageal motor function in chronic intestinal idiopathic pseudo-obstruction: A study with high-resolution manometry

BACKGROUND

Chronic intestinal idiopathic pseudo-obstruction (idiopathic CIPO) is a rare heterogeneous condition for which the different phenotypes are difficult to be established. Oesophageal motility has shown to be impaired in patients with idiopathic CIPO at traditional manometry, whereas no studies have assessed it by high resolution manometry (HRM).

AIMS

To evaluate oesophageal motility by HRM in patients with idiopathic CIPO.

METHODS

14 patients with idiopathic CIPO underwent oesophageal HRM. Multiple rapid swallows (MRS) were performed in order to evaluate contraction reserve. The Chicago Classification 3.0 was used to classify the oesophageal motility disorders.

RESULTS

One idiopathic CIPO patient had type-II achalasia, one aperistalsis and 12 had minor disorder of peristalsis (11 ineffective oesophageal motility and one fragmented peristalsis). These minor disorders were not significantly different from those of 50 other consecutive patients who underwent HRM for dysphagia or GERD and received the diagnosis of ineffective oesophageal motility. Three of the 12 idiopathic CIPO patients with minor disorder of peristalsis had no contraction reserve after MRS.

CONCLUSIONS

HRM is able to identify different grades of oesophageal motor impairment in patients with idiopathic CIPO. Presence of major oesophageal dismotility or absent contraction reserve suggest a more severe and widespread motor disorder.

Normal Values of High-Resolution Manometry in Supine and Upright Positions in a Thai Population

BACKGROUND

Although cut-off values used in high-resolution manometry (HRM) to diagnose esophageal motility disorders are based on representative samples of the US population and assume a supine position, differences in population and body positioning can reportedly affect results.

AIMS

To establish normal HRM values for Thai people in both supine and upright positions.

METHODS

Forty-one healthy subjects were recruited, each of whom underwent solid-state HRM with ten 5-mL swallows of water in both the supine and upright positions. Measuring parameters according to the Chicago classification criteria (CC v3.0) were included, for which the mean, median and 5th and 95th percentiles (PCTLs) were calculated.

RESULTS

The results corresponded with the CC v3.0 criteria, except for the mean, and 5th PCTL of the distal contractile integral (DCI), which were lower for this population. In the upright position, the mean and median values for DCI, intrabolus pressure and integrated relaxation pressure were significantly decreased, whereas the length of the transitional zone was significantly increased. The limitations of this study include: (1) the relatively low number of participants, (2) the limited recruitment of participants only at Ramathibodi Hospital and (3) the limited recruitment of only young and middle-aged participants.

CONCLUSIONS

We established normal values for the HRM parameters in a representative sample of the Thai population. Our supine results still prove that the use of the CC v3.0 is preferable. HRM testing in patients measured in the upright position should be analyzed based on the normative values obtained from upright swallow studies.

Esophageal Dysmotility in Patients following Total Laryngectomy

Objectives Dysphagia is common in total laryngectomees, with some symptoms suggesting esophageal dysmotility. Tracheoesophageal (TE) phonation requires effective esophagopharyngeal air passage. Hence, esophageal dysmotility may affect deglutition or TE phonation. This study aimed to determine (1) the characteristics of esophageal dysmotility in laryngectomees, (2) whether clinical history is sensitive in detecting esophageal dysmotility, and (3) the relationship between esophageal dysmotility and TE prosthesis dysfunction. Study Design Multidisciplinary cross-sectional study. Setting Tertiary academic hospital. Subjects and Methods For 31 participants undergone total laryngectomy 1 to 12 years prior, clinical histories were taken by a gastroenterologist and a speech pathologist experienced in managing dysphagia. Esophageal high-resolution manometry was performed and analyzed using Chicago Classification v3.0. Results Interpretable manometric studies were obtained in 23 (1 normal manometry). Esophageal dysmotility patterns included achalasia, esophagogastric junction outflow obstruction, diffuse esophageal spasm, and other major (30%) and minor (50%) peristaltic disorders. The sensitivity of predicting any esophageal dysmotility was 28%, but it is noteworthy that patients with achalasia and diffuse esophageal spasm (DES) were predicted. Two of 4 participants with TE puncture leakage had poor esophageal clearance. Of 20 TE speakers, 12 had voice problems, no correlation between poor voice, and any dysmotility pattern. Conclusions Peristaltic and lower esophageal sphincter dysfunction are common in laryngectomees. Clinical history, while not predictive of minor motor abnormalities, predicted correctly cases with treatable spastic motor disorders. Dysmotility was not associated with poor phonation, although TE puncture leakage might be linked to poor esophageal clearance. Esophageal dysmotility should be considered in the laryngectomees with persisting dysphagia or leaking TE puncture.

Classification of esophageal motor findings in gastro-esophageal reflux disease: Conclusions from an international consensus group

BACKGROUND

High-resolution manometry (HRM) has resulted in new revelations regarding the pathophysiology of gastro-esophageal reflux disease (GERD). The impact of new HRM motor paradigms on reflux burden needs further definition, leading to a modern approach to motor testing in GERD.

METHODS

Focused literature searches were conducted, evaluating pathophysiology of GERD with emphasis on HRM. The results were discussed with an international group of experts to develop a consensus on the role of HRM in GERD. A proposed classification system for esophageal motor abnormalities associated with GERD was generated.

KEY RESULTS

Physiologic gastro-esophageal reflux is inherent in all humans, resulting from transient lower esophageal sphincter (LES) relaxations that allow venting of gastric air in the form of a belch. In pathological gastro-esophageal reflux, transient LES relaxations are accompanied by reflux of gastric contents. Structural disruption of the esophagogastric junction (EGJ) barrier, and incomplete clearance of the refluxate can contribute to abnormally high esophageal reflux burden that defines GERD. Esophageal HRM localizes the LES for pH and pH-impedance probe placement, and assesses esophageal body peristaltic performance prior to invasive antireflux therapies and antireflux surgery. Furthermore, HRM can assess EGJ and esophageal body mechanisms contributing to reflux, and exclude conditions that mimic GERD.

CONCLUSIONS & INFERENCES

Structural and motor EGJ and esophageal processes contribute to the pathophysiology of GERD. A classification scheme is proposed incorporating EGJ and esophageal motor findings, and contraction reserve on provocative tests during HRM.

Hiatus Hernia as a Cause of Dysphagia

PURPOSE OF REVIEW

This review aims to discuss the putative relationship between hiatus hernia and dysphagia.

RECENT FINDINGS

Proposed mechanisms of dysphagia in patients with hiatus hernia are usually difficult to identify, but recent advances in technology (high-resolution manometry with or without concomitant impedance, ambulatory pH with impedance, videofluoroscopy, and the endoluminal functional lumen imaging probe (EndoFLIP)) and methodology (inclusion of swallows of various consistencies and volumes or shifting position during the manometry protocol) can help induce symptoms and identify the underlying disorder. Chronic reflux disease is often associated with hiatus hernia and is the most common underlying etiology. Dysmotility because of impaired contractility and vigor can occur as a consequence of repeated acid exposure from the acid pocket within the hernia, and the resultant poor clearance subsequently worsens this insult. As such, dysphagia appears to be more common with increasing hiatus hernia size. Furthermore, mucosal inflammation can lead to fibrotic stricture formation and in turn obstruction. On the other hand, there appears to be a difference in the pathophysiology of smaller sliding hernias, in that those with dysphagia are more likely to have extrinsic compression at the crural diaphragm as compared to those with reflux symptoms only. Sliding hiatus hernia, especially when small, does not commonly lead to dysmotility and dysphagia; however, in those patients with symptoms, the underlying etiology can be sought with new technologies and, in particular, the reproduction of normal eating and drinking during testing.

Upper esophageal sphincter motility in gastroesophageal reflux disease in the light of the high-resolution manometry

This study aims to evaluate the upper esophageal sphincter (UES) motility in patients with gastroesophageal reflux disease (GERD) as compared to healthy volunteers. We retrospectively studied the HRM tests of 44 patients (median age: 61 years, 54% females) under evaluation for GERD. The manometric UES parameters of these patients were compared to 40 healthy volunteers (median age: 27 years, 50% females). Almost half of the patients had a short and hypotonic UES. Patients with extraesophageal symptoms had a higher proportion of hypotonic UES as compared to patients with esophageal symptoms. Reflux pattern did not influence manometric parameters. Proximal reflux (any number of episodes) was present in 37(84%) patients (median number of proximal episodes = 6). Manometric parameters are similar in the presence or absence of proximal reflux. There is not a correlation between the UES length and UES basal pressure. In conclusion, our results show that: (1) the manometric profile of the UES in patients with GERD is characterized by a short and hypotonic UES in half of the patients; (2) this profile is more pronounced in patients with extraesophageal symptoms; and (3) neither the presence of proximal reflux nor reflux pattern bring a different manometric profile.

High-resolution manometric evaluation of the effects of cisapride on the esophagus during administration of solid and liquid boluses in awake healthy dogs

OBJECTIVE To validate the use of high-resolution manometry (HRM) in awake, healthy dogs and compare the effects of bolus type (liquid vs solid) and drug treatment (saline [0.9% NaCl] solution [SS] vs cisapride) on esophageal pressure profiles. ANIMALS 8 healthy dogs. PROCEDURES In a crossover study, each dog received SS (10 mL) IV, and HRM was performed during oral administration of 10 boluses (5 mL each) of water or 10 boluses (5 g each) of canned food. Cisapride (1 mg/kg in 60 mL of SS) was subsequently administered IV to 7 dogs; HRM and bolus administration procedures were repeated. Two to 4 weeks later, HRM was repeated following administration of SS and water and food boluses in 4 dogs. Pressure profile data were obtained for all swallows, and 11 outcome variables were statistically analyzed. RESULTS After SS administration, predicted means for the esophageal contractile integral were 850.4 cm/mm Hg/s for food boluses and 660.3 cm/mm Hg/s for water boluses. Predicted means for esophageal contraction front velocity were 6.2 cm/s for water boluses and 5.6 cm/s for food boluses after SS administration. Predicted means for residual LES pressure were significantly higher following cisapride administration. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that HRM was feasible and repeatable in awake healthy dogs of various breeds and sizes. Stronger esophageal contractions and faster esophageal contraction velocity occurred during solid bolus and liquid bolus swallows, respectively. Lower esophageal sphincter pressure increased significantly following cisapride administration. Esophageal contractions and bolus transit latency should be further evaluated by HRM in clinically dysphagic dogs.

Comparison of two high-resolution manometry software systems in evaluating esophageal motor function

BACKGROUND

High-resolution manometry (HRM) utilizes software tools to diagnose esophageal motor disorders. Performance of these software metrics could be affected by averaging and by software characteristics of different manufacturers.

METHODS

High-resolution manometry studies on 86 patients referred for antireflux surgery (61.6 ± 1.4 year, 70% F) and 20 healthy controls (27.9 ± 0.7 year, 45% F) were first subject to standard analysis (Medtronic, Duluth, GA, USA). Coordinates for each of 10 test swallows were exported and averaged to generate a composite swallow. The swallows and averaged composites were imported as ASCII file format into Manoview (Medtronic) and Medical Measurement Systems database reporter (MMS, Dover, NH, USA), and analyses repeated. Comparisons were made between standard and composite swallow interpretations.

KEY RESULTS

Correlation between the two systems was high for mean distal contractile integral (DCI, r² ≥ 0.9) but lower for integrated relaxation pressure (IRP, r² = 0.7). Excluding achalasia, six patients with outflow obstruction (mean IRP 23.2 ± 2.1 with 10-swallow average) were identified by both systems. An additional nine patients (10.5%) were identified as outflow obstruction (15 mmHg threshold) with MMS 10-swallow and four with MMS composite swallow evaluation; only one was confirmed. Ineffective esophageal motility was diagnosed by 10-swallow evaluation in 19 (22.1%) with Manoview, and 20 (23.3%) with MMS. On Manoview composite, 17 had DCI <450 mmHg/cm/s, and on MMS composite, 21, (p ≥ 0.85 for each comparison) but these did not impact diagnostic conclusions.

CONCLUSIONS & INFERENCES

Comparison of 10 swallow and composite swallows demonstrate variability in software metrics between manometry systems. Our data support use of manufacturer specific software metrics on 10-swallow sequences.

Impaired bolus clearance in asymptomatic older adults during high-resolution impedance manometry

BACKGROUND

Dysphagia becomes more common in old age. We performed high-resolution impedance manometry (HRIM) in asymptomatic healthy adults (including an older cohort >80 years) to assess HRIM findings in relation to bolus clearance.

METHODS

Esophageal HRIM was performed in a sitting posture in 45 healthy volunteers (n = 30 young control, mean age 37 ± 11 years and n = 15 older subjects aged 85 ± 4 years) using a 3.2-mm solid-state catheter (Solar GI system; MMS, Enschede, The Netherlands) with 25 pressure (1-cm spacing) and 12 impedance segments (2-cm intervals). Five swallows each of 5- and 10-mL liquid and viscous bolus were performed and analyzed using esophageal pressure topography metrics and Chicago classification criteria as well as pressure-flow parameters. Bolus transit was determined using standard impedance criteria. A p-value <0.05 was considered significant.

KEY RESULTS

Impaired bolus clearance occurred more frequently in asymptomatic older subjects compared with young controls (YC) during liquid (40 vs 18%, χ²  = 4.935; p < 0.05) and viscous (60 vs 17%; χ²  = 39.08; p < 0.001) swallowing. Longer peristaltic breaks (p < 0.05) and more rapid peristalsis (L: p < 0.004, V: p = 0.003) occurred in the older cohort, with reduced impedance-based clearance for both bolus consistencies (L: p < 0.05, V: p < 0.001). Decreased peristaltic vigor (distal contractile integral <450 mmHg/s/cm) was associated with reduced liquid clearance in both age groups (p < 0.001) and of viscous swallows in the older group (p < 0.001). Impedance ratio, a marker of bolus retention, was increased in older subjects during liquid (p = 0.002) and viscous (p < 0.001) swallowing.

CONCLUSIONS & INFERENCES

Impaired liquid and viscous bolus clearance, esophageal pressure topography, and pressure-flow changes were seen in asymptomatic older subjects.

Oropharyngeal acid reflux and motility abnormalities of the proximal esophagus

AIM

To investigate the relationship between pathological oropharyngeal (OP) acid exposure and esophageal motility in patients with extra-esophageal syndromes.

METHODS

In this prospective study we enrolled consecutive outpatients with extra-esophageal symptoms suspected to be related to gastroesophageal reflux disease (GERD). We enrolled only patients with a reflux symptom index (RSI) score-higher than 13 and with previous lung, allergy and ear, nose and throat evaluations excluding other specific diagnoses. All patients underwent 24-h OP pH-metry with the Dx probe and esophageal high-resolution manometry (HRM). Patients were divided into two groups on the basis of a normal or pathological pH-metric finding (Ryan Score) and all manometric characteristics of the two groups were compared.

RESULTS

We examined 135 patients with chronic extra-esophageal syndromes. Fifty-one were considered eligible for the study. Of these, 42 decided to participate in the protocol. Patients were divided into two groups on the basis of normal or pathological OP acid exposure. All the HRM parameters were compared for the two groups. Significant differences were found in the median upper esophageal sphincter resting pressure (median 71 mmHg vs 126 mmHg, P = 0.004) and the median proximal contractile integral (median 215.5 cm•mmHg•s vs 313.5 cm•mmHg•s, P = 0.039), both being lower in the group with pathological OP acid exposure, and the number of contractions with small or large breaks, which were more frequent in the same group. This group also had a larger number of peristaltic contractions with breaks in the 20 mmHg isobaric contour (38.7% vs 15.38%, P < 0.0001).

CONCLUSION

In patients with suspected GERD-related extra-esophageal syndromes pathological OP acid exposure was associated with weaker proximal esophageal motility.

Practice guidelines on the use of esophageal manometry - A GISMAD-SIGE-AIGO medical position statement

Patients with esophageal symptoms potentially associated to esophageal motor disorders such as dysphagia, chest pain, heartburn and regurgitation, represent one of the most frequent reasons for referral to gastroenterological evaluation. The utility of esophageal manometry in clinical practice is: (1) to accurately define esophageal motor function, (2) to identify abnormal motor function, and (3) to establish a treatment plan based on motor abnormalities. With this in mind, in the last decade, investigations and technical advances, with the introduction of high-resolution esophageal manometry, have enhanced our understanding and management of esophageal motility disorders. The following recommendations were developed to assist physicians in the appropriate use of esophageal manometry in modern patient care. They were discussed and approved after a comprehensive review of the medical literature pertaining to manometric techniques and their recent application. This position statement created under the auspices of the Gruppo Italiano di Studio per la Motilità dell'Apparato Digerente (GISMAD), Società Italiana di Gastroenterologia ed Endoscopia Digestiva (SIGE) and Associazione Italiana Gastroenterologi ed Endoscopisti Digestivi Ospedalieri (AIGO) is intended to help clinicians in applying manometric studies in the most fruitful manner within the context of their patients with esophageal symptoms.

Novel insights into esophageal diagnostic procedures

The 21st century offers new advances in diagnostic procedures and protocols in the management of esophageal diseases. This review highlights the most recent advances in esophageal diagnostic technologies, including clinical applications of novel endoscopic devices, such as ultrathin endoscopy and confocal laser endomicroscopy for diagnosis and management of Barrett's esophagus; novel parameters and protocols in high-resolution esophageal manometry for the identification and better classification of motility abnormalities; innovative connections between esophageal motility disorder diagnosis and detection of gastroesophageal reflux disease (GERD); impedance-pH testing for detecting the various GERD phenotypes; performance of distensibility testing for better pathophysiological knowledge of the esophagus and other gastrointestinal abnormalities; and a modern view of positron emission tomography scanning in metastatic disease detection in the era of accountability as a model for examining other new technologies. We now have better tools than ever for the detection of esophageal diseases and disorders, and emerging data are helping to define how well these tools change management and provide value to clinicians. This review features novel insights from multidisciplinary perspectives, including both surgical and medical perspectives, into these new tools, and it offers guidance on the use of novel technologies in clinical practice and future directions for research.

Pharyngeal Pressure and Timing During Bolus Transit

Determining intrabolus pressure (IBP) at the upper esophageal sphincter (UES) and in the esophagus has given compelling evidence that IBP can be a predictor for swallowing dysfunction. Studies have looked most superiorly at the low hypopharynx region but there has been no inquiry into what IBP measures throughout the entire pharynx can tell us. We present a study to describe the pressures within and surrounding the moving bolus throughout the pharynx and into the UES. Simultaneous high-resolution manometry (HRM) and videofluoroscopy were performed in ten healthy subjects swallowing ten 10 mL thin-liquid barium boluses. Three events surrounding bolus movement were tracked via videofluoroscopy, and two additional events were found using manometric measures. As the bolus passes through the pharynx, low pressure is created at and below the head of the bolus. A modest pressure increase is seen as the bolus passes through the pharynx, and finally, high pressure is observed at the bolus tail, followed by an even larger pressure generation of a clearance event. HRM allows for greater resolution in data collection in the pharynx and in this study, aided in identifying semi-unique characteristics around the hypopharynx and the UES which are consistent with the complex anatomy of the regions and the transition of the UES from active closure to relaxed opening. In the future, additional studies designed to look at aged and diseased populations may lead to better understanding of disease etiology, and treatment options.

Biomechanics of Pharyngeal Deglutitive Function following Total Laryngectomy

OBJECTIVE

Postlaryngectomy, pharyngeal weakness, and pharyngoesophageal junction (PEJ) restriction are the candidate mechanisms of dysphagia. The aims were, in laryngectomees, whether (1) hypopharyngeal propulsion is reduced and/or PEJ resistance is increased, (2) dilatation improves dysphagia, and (3) whether symptomatic improvement correlates with reduced PEJ resistance.

DESIGN

Multidisciplinary cross-sectional study.

SETTING

Tertiary academic hospital.

SUBJECTS AND METHODS

Swallow biomechanics were assessed in 30 laryngectomees. Patients were stratified into severe dysphagia (Sydney Swallow Questionnaire >500) and mild/nil dysphagia (Sydney Swallow Questionnaire ≤500). Average hypopharyngeal peak (contractile) pressure (hPP) and hypopharyngeal intrabolus pressure (hIBP) were measured from high-resolution manometry with concurrent videofluoroscopy based on barium swallows (2.5 and 10 mL). In consecutive 5 patients, measurements were repeated after dilatation.

RESULTS

Dysphagia was reported by 87%, and 57% had severe and 43% had mild/nil dysphagia. hIBP increased with larger bolus volumes (P < .0001), while hPP stayed stable and PEJ diameter plateaued at 9 mm. Laryngectomees had lower hPP (110 ± 14 vs 170 ± 15 mm Hg; P = .0162) and higher hIBP (29 ± 5 vs 6 ± 5 mm Hg; P = .156) than controls. There were no differences in hPP between patient groups. However, hIBP was higher in severe than in mild/nil dysphagia (41 ± 10 vs 13 ± 3 mm Hg; P = .02). Predilation hIBP (R(2) = 0.97) and its decrement postdilatation (R(2) = 0.98) well predicted symptomatic improvement.

CONCLUSIONS

PEJ resistance correlates better with dysphagia severity than peak pharyngeal pressure and is more sensitive to bolus sizes than PEJ diameter. Both baseline PEJ resistance and its decrement following dilatation are strong predictors of treatment outcome. PEJ resistance is vital to detect, as it is reversible and can predict the response to dilatation regimens.