1
|
Scharitzer M, Pokieser P, Ekberg O. Oesophageal fluoroscopy in adults-when and why? Br J Radiol 2024; 97:1222-1233. [PMID: 38547408 PMCID: PMC11186568 DOI: 10.1093/bjr/tqae062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/15/2024] [Accepted: 03/18/2024] [Indexed: 06/21/2024] Open
Abstract
Oesophageal fluoroscopy is a radiological procedure that uses dynamic recording of the swallowing process to evaluate morphology and function simultaneously, a characteristic not found in other clinical tests. It enables a comprehensive evaluation of the entire upper gastrointestinal tract, from the oropharynx to oesophagogastric bolus transport. The number of fluoroscopies of the oesophagus and the oropharynx has increased in recent decades, while the overall use of gastrointestinal fluoroscopic examinations has declined. Radiologists performing fluoroscopies need a good understanding of the appropriate clinical questions and the methodological advantages and limitations to adjust the examination to the patient's symptoms and clinical situation. This review provides an overview of the indications for oesophageal fluoroscopy and the various pathologies it can identify, ranging from motility disorders to structural abnormalities and assessment in the pre- and postoperative care. The strengths and weaknesses of this modality and its future role within different clinical scenarios in the adult population are discussed. We conclude that oesophageal fluoroscopy remains a valuable tool in diagnostic radiology for the evaluation of oesophageal disorders.
Collapse
Affiliation(s)
- Martina Scharitzer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Peter Pokieser
- Teaching Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Olle Ekberg
- Department of Translational Medicine, Diagnostic Radiology, Lund University, Skåne University Hospital, Inga Marie Nilssons gata 49, 205 02 Malmö, Sweden
| |
Collapse
|
2
|
Dysphagia Worsens With Increasing Ineffective Swallows Among Patients With Ineffective Esophageal Motility. J Clin Gastroenterol 2022:00004836-990000000-00045. [PMID: 35960530 DOI: 10.1097/mcg.0000000000001738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 06/15/2022] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Ineffective esophageal motility (IEM) is the most common motility disorder identified on esophageal high-resolution manometry (HRM), but patients with this finding may be asymptomatic. Therefore, we aimed to identify specific HRM findings predictive of symptoms in IEM. METHODS Adult patients (≥18 y) who underwent HRM between March 2016 and July 2019 were retrospectively evaluated and reclassified according to Chicago Classification 4.0 (CC4.0). Demographic information, HRM parameters, and gastroesophageal reflux disease Health-Related Quality of Life Questionnaire responses were captured among those with normal manometry or IEM. We evaluated the association between heartburn, regurgitation, and dysphagia, with respect to HRM findings including ineffective swallows. RESULTS Of 379 patients, 243 (64.1%) had a normal manometry, 136 (35.9%) were on IEM spectrum, and 73 (19.3%) had conclusive IEM by CC4.0. Mean dysphagia scores were significantly higher in those with conclusive IEM compared with those with normal HRM (2.00 vs. 1.36, P=0.002), as was the percentage of individuals reporting dysphagia affecting daily activities (21.9% vs. 11.4%, P=0.02). Heartburn and regurgitation symptoms did not differ between groups. In a multivariable model of IEM patients, the percentage of ineffective swallows independently predicted a higher dysphagia burden (β regression coefficient: 0.032, P=0.04). CONCLUSIONS Applying the CC4.0 definition for conclusive IEM identifies a group of patients with worse dysphagia symptoms. Within this group, the percentage of ineffective swallows was an independent predictor of dysphagia severity. These findings may help practitioners and patients contextualize the heterogeneous diagnosis of IEM.
Collapse
|
3
|
Rogers BD, Cisternas D, Rengarajan A, Marin I, Abrahao L, Hani A, Lequizamo AM, Remes-Troche JM, Perez de la Serna J, Ruiz de Leon A, Zerbib F, Serra J, Gyawali CP. Breaks in peristaltic integrity predict abnormal esophageal bolus clearance better than contraction vigor or residual pressure at the esophagogastric junction. Neurogastroenterol Motil 2022; 34:e14141. [PMID: 33772977 DOI: 10.1111/nmo.14141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/09/2021] [Accepted: 03/09/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND High-resolution impedance manometry (HRIM) evaluates esophageal peristalsis and bolus transit. We used esophageal impedance integral (EII), the ratio between bolus presence before and after an expected peristaltic wave, to evaluate predictors of bolus transit. METHODS From HRIM studies performed on 61 healthy volunteers (median age 27 years, 48%F), standard metrics were extracted from each of 10 supine water swallows: distal contractile integral (DCI, mmHg cm s), integrated relaxation pressure (IRP, mmHg), and breaks in peristaltic integrity (cm, using 20 mmHg isobaric contour). Pressure and impedance coordinates for each swallow were exported into a dedicated, python-based program for EII calculation (EII ratio ≥ 0.3 = abnormal bolus clearance). Univariate and multivariate analyses were performed to assess predictors of abnormal bolus clearance. KEY RESULTS Of 591 swallows, 80.9% were intact, 10.5% were weak, and 8.6% failed. Visual analysis overestimated abnormal bolus clearance compared to EII ratio (p ≤ 0.01). Bolus clearance was complete (median EII ratio 0.0, IQR 0-0.12) in 82.0% of intact swallows in contrast to 53.3% of weak swallows (EII ratio 0.29, IQR 0.0-0.57), and 19.6% of failed swallows (EII ratio 0.5, IQR 0.34-0.73, p < 0.001). EII correlated best with break length (ρ = 0.52, p < 0.001), compared to IRP (ρ: -0.17) or DCI (ρ: -0.42). On ROC analysis, breaks predicted abnormal bolus transit better than DCI or IRP (AUC 0.79 vs. 0.25 vs. 0.44, p ≤ 0.03 for each). On logistic regression, breaks remained independently predictive of abnormal bolus transit (p < 0.001). CONCLUSIONS & INFERENCES Breaks in peristaltic integrity predict abnormal bolus clearance better than DCI or IRP in healthy asymptomatic subjects.
Collapse
Affiliation(s)
- Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA.,Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, KY, USA
| | - Daniel Cisternas
- Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago de Chile, Chile
| | - Arvind Rengarajan
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - Ingrid Marin
- Enfermedades Hepáticas y Digestivas (CIBERehd), University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Luiz Abrahao
- University Hospital Clementino Fraga Filho, Rio de Janeiro, Brazil
| | - Albis Hani
- Departamento de Gastroenterologíay Laboratorio de Motilidad, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Ana M Lequizamo
- Departamento de Gastroenterologíay Laboratorio de Motilidad, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - José M Remes-Troche
- Digestive Physiology and Motility Lab, Medical Biological Research Institute, Universidad Veracruzana, Veracruz, Mexico
| | - Julio Perez de la Serna
- Unidad de Motilidad, Servicio de Aparto Digestivo, Hospital Clinico San Carlos, Madrid, Spain
| | - Antonio Ruiz de Leon
- Unidad de Motilidad, Servicio de Aparto Digestivo, Hospital Clinico San Carlos, Madrid, Spain
| | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, Bordeaux, France
| | - Jordi Serra
- Digestive System Research Unit, Centro de Investigación Biomedical en Red enfermedades hepáticas y digestivas (CIBERehd), University Hospital Vall d'Hebron, Barcelona, Spain
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| |
Collapse
|
4
|
Cock C, Leibbrandt RE, Dinning PG, Costa MC, Wiklendt L, Omari TI. Changes in specific esophageal neuromechanical wall states are associated with conscious awareness of a solid swallowed bolus in healthy subjects. Am J Physiol Gastrointest Liver Physiol 2020; 318:G946-G954. [PMID: 32281396 DOI: 10.1152/ajpgi.00235.2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Esophageal neuromechanical wall states are the physical manifestations of circular muscle inhibition and contraction resulting from neural inputs and leading to bolus propulsion. A novel method infers esophageal neuromechanical wall states through simultaneous determination of pressure and diameter in vivo using impedance manometry. We hypothesized that changes in esophageal neuromechanical wall states relate to conscious awareness of esophageal bolus passage ("bolus perception"). Seven healthy participants were selected for perception of solid bolus passage and were compared with seven healthy participants with no conscious awareness of solid bolus passage. Participants were studied using impedance manometry (MMS Solar, Unisensor, 20 Hz). Subjects swallowed ten 5-ml liquid and ten 2-cm square saline-soaked bread boluses and rated bolus perception using a visual analog scale. Esophageal neuromechanical wall states were calculated and analyzed. Proportions of time spent in states with and without luminal distension were compared using a two-proportions Z-test. Bolus perception was associated with neuromechanical wall states corresponding to luminal distension more frequently than matching states without distension in the proximal esophagus (P < 0.001) and transition zone (P < 0.001), whereas there were no differences for the distal esophagus. In healthy volunteers, perceived swallows relate to changes in esophageal neuromechanical wall states in the proximal esophagus. We postulate that these changes relate to bolus retention and summation of active and passive wall tension activating intramural tension receptors.NEW & NOTEWORTHY This study explores esophageal neuromechanical wall states derived from changes in pressure and impedance-derived distension in relation to conscious awareness of esophageal solid bolus transit in healthy volunteers. There are increases in neuromechanical wall states indicative of esophageal distension in healthy volunteers with conscious awareness of bolus transit as compared with unaware individuals. Bolus-based esophageal distension is postulated as a mechanism for esophageal symptoms such as dysphagia.
Collapse
Affiliation(s)
- Charles Cock
- Department of Gastroenterology and Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Richard E Leibbrandt
- Department of Gastroenterology and Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Department of Human Physiology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Phil G Dinning
- Department of Gastroenterology and Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Department of Human Physiology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Marcello C Costa
- Department of Human Physiology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Lukasz Wiklendt
- Department of Human Physiology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Taher I Omari
- Department of Gastroenterology and Hepatology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Department of Human Physiology, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| |
Collapse
|
5
|
Sato H, Takahashi K, Mizuno KI, Hashimoto S, Kawata Y, Mizusawa T, Tominaga K, Yokoyama J, Terai S. Overlap in disease concept of functional esophageal disorders and minor esophageal motility disorders. J Gastroenterol Hepatol 2019; 34:1940-1945. [PMID: 31034660 DOI: 10.1111/jgh.14691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/05/2019] [Accepted: 04/23/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Functional gastrointestinal disorders are the most common disorders in gastroenterology and are currently considered as gut-brain interaction disorders with multiple related factors including motility disturbance. However, high-resolution manometry (HRM) had revealed a new disease concept known as minor esophageal motility disorders. This study aimed to investigate the correlation between functional esophageal disorders (FEDs) and minor esophageal motility disorders. METHODS Functional esophageal disorders were diagnosed using upper endoscopy, pH monitoring, and HRM, to exclude achalasia, esophago-gastric junction outflow obstruction, and other major esophageal motility disorders. FEDs with or without minor esophageal motility disorders were compared using the Chicago classification. RESULTS Twelve healthy volunteers also subjected to HRM showed no minor esophageal motility disorders. Of the 40 patients with FEDs, 15 (37.5%) were diagnosed with minor esophageal motility disorders. Characteristics were not different between patients with and without minor esophageal motility disorders (sex: P = 0.609, age: P = 0.054, body mass index: P = 0.137, and presence of psychiatric disorders: P = 0.404). The type and location of symptoms were not related to the comorbidity rate of minor esophageal motility disorders (P = 0.744 and 0.094). No patients with FEDs developed major esophageal motility disorders. CONCLUSIONS Minor esophageal motility disorders were frequently observed in FEDs, but the causal relationship between esophageal symptoms remains unclear. The disease concepts of FEDs and minor esophageal motility disorders are considered to overlap and are both independent of major esophageal motility disorders.
Collapse
Affiliation(s)
- Hiroki Sato
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kazuya Takahashi
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Ken-Ichi Mizuno
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Satoru Hashimoto
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Yuzo Kawata
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Takeshi Mizusawa
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kentaro Tominaga
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Junji Yokoyama
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Shuji Terai
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
| |
Collapse
|
6
|
Abstract
BACKGROUND High-resolution manometry (HRM) is used to assess esophageal motility diseases. Abnormalities in a number of HRM parameters have been reported in patients with dysphagia. However, it is unclear whether some of abnormal HRM parameters are predictive of dysphagia. The aim of this retrospective study was to investigate the roles of HRM parameters in predicting incomplete bolus clearance (IBC) in patients with dysphagia using high-resolution impedance manometry. METHODS A total of 644 wet swallows were reviewed and analyzed in 63 patients with symptoms of dysphagia or reflux who underwent a clinical high-resolution impedance manometry test. IBC was defined based on impedance measurement. The relationship of each of abnormal HRM parameters with IBC was analyzed and their roles in predicting IBC were determined. RESULTS Patients with symptoms of both dysphagia and reflux showed the highest IBC rate, and patients with symptoms of reflux had the lowest IBC rate. The IBC was more prevalent in the distal esophagus. Premature contractions and peristalsis with large breaks were associated with a higher IBC rate in the proximal esophagus (P<0.05); large breaks, ineffective peristalsis, and abnormalities of the esophageal gastric junction functions were associate with higher IBC rates in the distal esophagus (P<0.05). Abnormalities in a number of motility parameters were able to predict IBC with high specificities and/or high sensitivity, such as pan esophageal pressurization, ineffective peristalsis, and large breaks. Abnormal integrative relaxation pressure of the lower esophageal sphincter with concurrent pan esophageal pressurization, ineffective peristalsis, or large breaks is predictive of IBC with nearly 100% of specificity. CONCLUSIONS Abnormalities in a number of HRM parameters are not only useful in diagnosing esophageal motility diseases, but also valuable in predicting IBC during swallowing.
Collapse
|
7
|
Oesophageal dysphagia: a stepwise approach to diagnosis and management. Lancet Gastroenterol Hepatol 2018; 2:604-609. [PMID: 28691686 DOI: 10.1016/s2468-1253(17)30001-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/20/2016] [Accepted: 01/03/2017] [Indexed: 12/19/2022]
Abstract
Dysphagia is a common symptom in the general population. Incidence varies depending on the specific definition used. A good medical history is vital for distinguishing true oesophageal dysphagia from oropharyngeal dysphagia or other causes. Oesophageal dysphagia is a so-called red flag alarm symptom requiring oesophagogastroduodenoscopy. However, even after investigations including oesophagogastroduodenoscopy (with biopsy), barium swallow, and oesophageal manometry, no obstructive cause may be found. This Review suggests an algorithm of history-taking and investigation to allow the causes of non-obstructive dysphagia to be identified, including functional dysphagia. The Review then discusses management strategies and outcomes for functional dysphagia.
Collapse
|
8
|
Rangan V, George NS, Khan F, Geng Z, Gabbard S, Kichler A, Gittleman H, Fass R. Severity of ineffective esophageal motility is associated with utilization of skeletal muscle relaxant medications. Neurogastroenterol Motil 2018; 30:e13235. [PMID: 29027725 DOI: 10.1111/nmo.13235] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 09/19/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Ineffective esophageal motility (IEM) is the most common finding on high-resolution esophageal manometry (HREM). The underlying mechanisms for IEM remain to be fully elucidated. The aim of this study was to determine if utilization of skeletal muscle relaxants is associated with IEM, and with more severe subtypes of the disorder. METHODS Patients with diagnosis of IEM were gender and age matched to patients with normal HREM. Demographic information, symptoms, endoscopic findings, medication usage and medical comorbidities were recorded. Patients with a diagnosis of IEM were divided into subgroups based on mean distal contractile integral (DCI) and percentage of ineffective swallows, and assessed for clinically significant differences among patients with varying severity of underlying IEM. KEY RESULTS A total of 118 patients were included in each group. There were no significant clinical differences between the group of patients with IEM and the group of patients with normal manometry. Within the group of IEM patients, those with mean DCI < 250 mm Hg/s/cm were more likely to be prescribed skeletal muscle relaxants (27.8% vs 11.0%, P = .044), and those using skeletal muscle relaxants had a larger mean percentage of ineffective swallows (81.1% vs 71.5%, P = .029). There were no significant differences across mean DCI subgroups in usage of any other medication, or in any of the demographic variables or disease comorbidities examined in this study. CONCLUSIONS & INFERENCES Use of skeletal muscle relaxants is associated with more severe IEM, which may suggest a causal association between this class of medications and weaker esophageal peristalsis.
Collapse
Affiliation(s)
- V Rangan
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - N S George
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - F Khan
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Z Geng
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - S Gabbard
- The Esophageal Center, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A Kichler
- The Esophageal Center, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - H Gittleman
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - R Fass
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| |
Collapse
|
9
|
Cisternas D, Scheerens C, Omari T, Monrroy H, Hani A, Leguizamo A, Bilder C, Ditaranto A, Ruiz de León A, Pérez de la Serna J, Valdovinos MA, Coello R, Abrahao L, Remes-Troche J, Meixueiro A, Zavala MA, Marin I, Serra J. Anxiety can significantly explain bolus perception in the context of hypotensive esophageal motility: Results of a large multicenter study in asymptomatic individuals. Neurogastroenterol Motil 2017; 29. [PMID: 28480513 DOI: 10.1111/nmo.13088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/14/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous studies have not been able to correlate manometry findings with bolus perception. The aim of this study was to evaluate correlation of different variables, including traditional manometric variables (at diagnostic and extreme thresholds), esophageal shortening, bolus transit, automated impedance manometry (AIM) metrics and mood with bolus passage perception in a large cohort of asymptomatic individuals. METHODS High resolution manometry (HRM) was performed in healthy individuals from nine centers. Perception was evaluated using a 5-point Likert scale. Anxiety was evaluated using Hospitalized Anxiety and Depression scale (HAD). Subgroup analysis was also performed classifying studies into normal, hypotensive, vigorous, and obstructive patterns. KEY RESULTS One hundred fifteen studies were analyzed (69 using HRM and 46 using high resolution impedance manometry (HRIM); 3.5% swallows in 9.6% of volunteers were perceived. There was no correlation of any of the traditional HRM variables, esophageal shortening, AIM metrics nor bolus transit with perception scores. There was no HRM variable showing difference in perception when comparing normal vs extreme values (percentile 1 or 99). Anxiety but not depression was correlated with perception. Among hypotensive pattern, anxiety was a strong predictor of variance in perception (R2 up to .70). CONCLUSION AND INFERENCES Bolus perception is less common than abnormal motility among healthy individuals. Neither esophageal motor function nor bolus dynamics evaluated with several techniques seems to explain differences in bolus perception. Different mechanisms seem to be relevant in different manometric patterns. Anxiety is a significant predictor of bolus perception in the context of hypotensive motility.
Collapse
Affiliation(s)
- D Cisternas
- Universidad del Desarrollo, Facultad de Medicina, Clínica Alemana de Santiago, Santiago, Chile
| | - C Scheerens
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - T Omari
- Human Physiology, Medical Science and Technology, School of Medicine, FlindersUniversity, Adelaide, SA, Australia
| | - H Monrroy
- Department of Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - A Hani
- San Ignacio Hospital, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - A Leguizamo
- San Ignacio Hospital, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - C Bilder
- Neurogastroenterology, School of Medicine, Universitary Hospital FundacionFavaloro, Buenos Aires, Argentina
| | - A Ditaranto
- Neurogastroenterology, School of Medicine, Universitary Hospital FundacionFavaloro, Buenos Aires, Argentina
| | - A Ruiz de León
- Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | | | - M A Valdovinos
- Motility Lab, Department of Gastroenterology, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | | | - L Abrahao
- University Hospital Clementino Fraga Filho, Rio de Janeiro, Brazil
| | - J Remes-Troche
- Digestive Physiology and Motility Lab, Medical BiologicalResearchInstitute, Veracruzana University, Veracruz, Mexico
| | - A Meixueiro
- Digestive Physiology and Motility Lab, Medical BiologicalResearchInstitute, Veracruzana University, Veracruz, Mexico
| | - M A Zavala
- Digestive Physiology and Motility Lab, Medical BiologicalResearchInstitute, Veracruzana University, Veracruz, Mexico
| | - I Marin
- Motility and Functional Gut Disorders Unit, Department of Medicine, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Autonomous University of Barcelona, University Hospital Germans TriasiPujol, Badalona, Spain
| | - J Serra
- Motility and Functional Gut Disorders Unit, Department of Medicine, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Autonomous University of Barcelona, University Hospital Germans TriasiPujol, Badalona, Spain
| |
Collapse
|
10
|
Gross RD, Gisser R, Cherpes G, Hartman K, Maheshwary R. Subclinical dysphagia in persons with Prader-Willi syndrome. Am J Med Genet A 2016; 173:384-394. [PMID: 27759943 DOI: 10.1002/ajmg.a.38015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/18/2016] [Indexed: 12/17/2022]
Abstract
Prader-Willi Syndrome (PWS) is caused by a genetic imprinting abnormality resulting from the lack of expression of the paternal genes at 15q11-q13. Intellectual disability, low muscle tone, and life-threatening hyperphagia are hallmarks of the phenotype. The need for the Heimlich maneuver, death from choking, and pulmonary infection occur in a disproportionally high number of persons with PWS. The widely held belief is that eating behaviors are responsible for choking and aspiration; yet, no investigation had sought to determine if swallowing impairments were present in persons with PWS. To address this research and clinical gap, simultaneous videofluoroscopy and nasal respiratory signals were used to record swallowing function and breathing/swallowing coordination in 30 participants with PWS. Subjects consumed thin liquid and barium cookies under two randomized conditions as follows: (i) controlled (cues to swallow and standardized bolus sizes); (ii) spontaneous (no cues or bolus size control). Under videofluoroscopy, the cohort showed disordered pharyngeal and esophageal swallowing in both conditions with disturbances in timing, clearance, and coordination of swallowing with the respiratory cycle. No participant showed a sensory response such as attempting to clear residue or coughing; thereby supporting the lack of overt symptoms. We conclude that the high death rate from choking and pulmonary infection in children and adults with PWS may be related, in part, to underlying, asymptomatic dysphagia. The combination of rapid eating and dysphagia would increase the risk of aspiration-related morbidity and mortality. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Roxann Diez Gross
- Department of Medical Research, The Children's Institute of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ronit Gisser
- Department of Medical Research, The Children's Institute of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gregory Cherpes
- Department of Medical Research, The Children's Institute of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katie Hartman
- Department of Medical Research, The Children's Institute of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rishi Maheshwary
- Department of Radiology, West Penn Allegheny Health System, Pittsburgh, Pennsylvania
| |
Collapse
|
11
|
Brock C, McCallum RW, Gyawali CP, Farmer AD, Frøkjaer JB, McMahon BP, Drewes AM. Neurophysiology and new techniques to assess esophageal sensory function: an update. Ann N Y Acad Sci 2016; 1380:78-90. [DOI: 10.1111/nyas.13175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/10/2016] [Accepted: 06/15/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital and Clinical Institute; Aalborg University; Aalborg Denmark
| | - Richard W. McCallum
- Department of Internal Medicine; Texas Tech University Health Sciences Center; El Paso Texas
| | - C. Prakash Gyawali
- Division of Gastroenterology; Washington University School of Medicine; St. Louis Missouri
| | - Adam D. Farmer
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital and Clinical Institute; Aalborg University; Aalborg Denmark
- Centre for Digestive Diseases, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London United Kingdom
- Department of Gastroenterology; University Hospitals of North Midlands; Stoke on Trent United Kingdom
| | - Jens Brøndum Frøkjaer
- Mech-Sense, Department of Radiology, Aalborg University Hospital and Clinical Institute; Aalborg University; Aalborg Denmark
| | - Barry P. McMahon
- Department of Medical Physics and Clinical Engineering; Tallaght Hospital and Trinity College; Dublin Ireland
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital and Clinical Institute; Aalborg University; Aalborg Denmark
| |
Collapse
|
12
|
Abstract
Ingestion and digestion of food as well as expulsion of residual material from our gastrointestinal tract requires normal propulsive, i.e. motor, function. Hypomotility refers to inherited or acquired changes that come with decreased contractile forces or slower transit. It not only often causes symptoms but also may compromise nutritional status or lead to other complications. While severe forms, such as pseudo-obstruction or ileus, may have a tremendous functional impact, the less severe forms of hypomotility may well be more relevant, as they contribute to common disorders, such as functional dyspepsia, gastroparesis, chronic constipation, and irritable bowel syndrome (IBS). Clinical testing can identify changes in contractile activity, defined by lower amplitudes or abnormal patterns, and the related effects on transit. However, such biomarkers show a limited correlation with overall symptom severity as experienced by patients. Similarly, targeting hypomotility with pharmacological interventions often alters gut motor function but does not consistently improve symptoms. Novel diagnostic approaches may change this apparent paradox and enable us to obtain more comprehensive information by integrating data on electrical activity, mechanical forces, patterns, wall stiffness, and motions with information of the flow of luminal contents. New drugs with more selective effects or more specific delivery may improve benefits and limit adverse effects. Lastly, the complex regulation of gastrointestinal motility involves the brain-gut axis as a reciprocal pathway for afferent and efferent signaling. Considering the role of visceral input in emotion and the effects of emotion on visceral activity, understanding and managing hypomotility disorders requires an integrative approach based on the mind-body continuum or biopsychosocial model of diseases.
Collapse
Affiliation(s)
- Klaus Bielefeldt
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ashok Tuteja
- Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Salman Nusrat
- Department of Medicine, Oklahoma University Medical Center, Oklahoma City, OK, USA
| |
Collapse
|
13
|
van Hoeij FB, Bredenoord AJ. Clinical Application of Esophageal High-resolution Manometry in the Diagnosis of Esophageal Motility Disorders. J Neurogastroenterol Motil 2015; 22:6-13. [PMID: 26631942 PMCID: PMC4699717 DOI: 10.5056/jnm15177] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 11/19/2015] [Accepted: 11/22/2015] [Indexed: 02/06/2023] Open
Abstract
Esophageal high-resolution manometry (HRM) is replacing conventional manometry in the clinical evaluation of patients with esophageal symptoms, especially dysphagia. The introduction of HRM gave rise to new objective metrics and recognizable patterns of esophageal motor function, requiring a new classification scheme: the Chicago classification. HRM measurements are more detailed and more easily performed compared to conventional manometry. The visual presentation of acquired data improved the analysis and interpretation of esophageal motor function. This led to a more sensitive, accurate, and objective analysis of esophageal motility. In this review we discuss how HRM changed the way we define and categorize esophageal motility disorders. Moreover, we discuss the clinical applications of HRM for each esophageal motility disorder separately.
Collapse
Affiliation(s)
- Froukje B van Hoeij
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
14
|
Bogte A, Bredenoord AJ, Oors J, Siersema PD, Smout AJPM. Assessment of bolus transit with intraluminal impedance measurement in patients with esophageal motility disorders. Neurogastroenterol Motil 2015; 27:1446-52. [PMID: 26284688 DOI: 10.1111/nmo.12642] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 06/23/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND The clinical management of patients with non-obstructive dysphagia is notoriously difficult. Esophageal impedance measurement can be used to measure esophageal bolus transit without the use of radiation exposure to patients. However, validation of measurement of bolus transit with impedance monitoring has only been performed in healthy subjects with normal motility and not in patients with dysphagia and esophageal motility disorders. The aim was, therefore, to investigate the relationship between transit of swallowed liquid boluses in healthy controls and in patients with dysphagia. METHODS Twenty healthy volunteers and 20 patients with dysphagia underwent concurrent impedance measurement and videofluoroscopy. Each subject swallowed five liquid barium boluses. The ability of detecting complete or incomplete bolus transit by means of impedance measurement was assessed, using radiographic bolus transit as the gold standard. KEY RESULTS Impedance monitoring recognized stasis and transit in 80.5% of the events correctly, with 83.9% of bolus transit being recognized and 77.2% of stasis being recognized correctly. In controls 79.8% of all swallows were scored correctly, whereas in patients 81.3% of all swallows were scored correctly. Depending on the contractility pattern, between 77.0% and 94.3% of the swallows were scored correctly. CONCLUSIONS & INFERENCES Impedance measurement can be used to assess bolus clearance patterns in healthy subjects, but can also be used to reliably assess bolus transit in patients with dysphagia and motility disorders.
Collapse
Affiliation(s)
- A Bogte
- Department of Gastroenterology and Hepatology, University Medical Center, Utrecht, The Netherlands
| | - A J Bredenoord
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - J Oors
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - P D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center, Utrecht, The Netherlands
| | - A J P M Smout
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
15
|
Ravi K, Friesen L, Issaka R, Kahrilas PJ, Pandolfino JE. Long-term Outcomes of Patients With Normal or Minor Motor Function Abnormalities Detected by High-resolution Esophageal Manometry. Clin Gastroenterol Hepatol 2015; 13:1416-23. [PMID: 25771245 PMCID: PMC4510014 DOI: 10.1016/j.cgh.2015.02.046] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 02/19/2015] [Accepted: 02/25/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS High-resolution manometry (HRM) expands recognition of minor esophageal motor abnormalities, but the clinical significance of these is unclear. We aimed to determine the outcomes of minor esophageal motor abnormalities. METHODS We reviewed HRM tracings from patients who underwent esophageal manometry at Northwestern Memorial Hospital from July 2004 through October 2005 by using the Chicago classification (version 2.0). We identified 301 patients with normal findings or minor manometric abnormalities (weak peristalsis, hypertensive peristalsis, frequent failed peristalsis, or rapid contractions with normal latency). Ninety-eight patients participated in a phone survey in which they were asked questions from the impact dysphagia questionnaire (mean follow-up period, 6 years 5 months). RESULTS Of 301 patients assessed, 166 had normal findings from HRM, 82 had weak peristalsis, 34 had hypertensive peristalsis, 17 had frequent failed peristalsis, and 2 had rapid contractions with normal latency. The primary indications for HRM of dysphagia (44%) and gastroesophageal reflux disease (63%) were unrelated to manometric findings. There were no endoscopic or videofluoroscopic differences between patients with minor manometric abnormalities. Of 98 patients with follow-up, findings from HRM were normal in 63, weak peristalsis was observed in 23, hypertensive peristalsis was observed in 10, and frequent failed peristalsis was observed in 2. No patients underwent surgical myotomy, pneumatic dilation, or botulinum toxin injection. Use of proton pump inhibitors and rates of fundoplication were similar, regardless of manometric findings. Sixteen patients (16%) had significant dysphagia at follow-up; hypertensive peristalsis was the most likely to be symptomatic. CONCLUSIONS Patients with normal and minor esophageal motor abnormalities report minimal symptoms and have few medical interventions related to esophageal dysfunction during long-term follow-up. Therefore, identification of normal and minor motor function is likely a good prognostic indicator.
Collapse
Affiliation(s)
- Karthik Ravi
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Laurel Friesen
- Department of Gastroenterology and Hepatology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Rachel Issaka
- Department of Gastroenterology and Hepatology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Peter J Kahrilas
- Department of Gastroenterology and Hepatology, Northwestern Memorial Hospital, Chicago, Illinois
| | - John E Pandolfino
- Department of Gastroenterology and Hepatology, Northwestern Memorial Hospital, Chicago, Illinois
| |
Collapse
|
16
|
Bredenoord AJ. Minor Disorders of Esophageal Peristalsis: Highly Prevalent, Minimally Relevant? Clin Gastroenterol Hepatol 2015; 13:1424-5. [PMID: 25796576 DOI: 10.1016/j.cgh.2015.03.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 03/12/2015] [Accepted: 03/12/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, the Netherlands
| |
Collapse
|
17
|
DALMAZO J, APRILE LRO, DANTAS RO. EFFECT OF SWALLOWED BOLUS VISCOSITY AND BODY POSITION ON ESOPHAGEAL TRANSIT, CONTRACTION AND PERCEPTION OF TRANSIT. ARQUIVOS DE GASTROENTEROLOGIA 2015; 52:27-31. [DOI: 10.1590/s0004-28032015000100007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 05/29/2014] [Indexed: 11/22/2022]
Abstract
Background The esophagus has a different response in relation to the characteristics of a swallowed bolus. Bolus viscosity and body position may affect esophageal contraction and transit. Objectives To investigate the effect of bolus viscosity and body position on esophageal contraction, transit and perception. Methods Esophageal contraction, transit and perception of transit were evaluated in 26 asymptomatic volunteers, 13 men and 13 women aged 18-60 years, mean: 33.6 (12.2) years. Esophageal contraction (manometry) and transit (impedance) were measured with a solid state catheter with sensors located 5, 10, 15, and 20 cm from the lower esophageal sphincter. Each volunteer swallowed in duplicate and in random sequence a 5 mL low viscous (LV) liquid bolus of an isotonic drink with pH 3.3, and a 5 mL high viscous (HV) paste bolus, which was prepared with 7.5 g of instant food thickener diluted in 50 mL of water (pH: 6.4). Results Total bolus transit time, in the sitting position, was longer with the HV bolus than with the LV bolus. Esophageal transit was longer in the supine position than in the sitting position. Bolus head advance time was longer with the HV bolus than with the LV bolus in both positions. Contraction esophageal amplitude was higher in the supine position than in the sitting position. The perception of bolus transit was more frequent with the HV bolus than with the LV bolus, without differences related to position. Conclusions The viscosity of the swallowed bolus and body position during swallows has an influence on esophageal contractions, transit and perception of transit.
Collapse
|
18
|
Herregods TVK, Roman S, Kahrilas PJ, Smout AJPM, Bredenoord AJ. Normative values in esophageal high-resolution manometry. Neurogastroenterol Motil 2015; 27:175-87. [PMID: 25545201 DOI: 10.1111/nmo.12500] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 12/01/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Esophageal high-resolution manometry (HRM) has rapidly gained much popularity worldwide. The Chicago Classification for esophageal motility disorders is based on a set of normative values for key metrics that was obtained using one of the commercially available HRM systems. Thus, it is of great importance to evaluate whether these normative values can be used for other HRM systems as well. PURPOSE In this review, we describe the presently available HRM systems, the currently known normative thresholds and the factors that influence them, and assess the use of these thresholds. Numerous factors including the type of HRM system, demographic factors, catheter diameter, body position during testing, consistency of bolus swallows, and esophageal length have an influence on the normative data. It would thus be ideal to have different sets of normal values for each of these factors, yet at the moment the amount of normative data is limited. We suggest broadening the normal range for parameters, as this would allow abnormal values to be of more significance. In addition, we suggest conducting studies to assess the physiological relevance of abnormal values and stress that for each system different normative thresholds may apply.
Collapse
Affiliation(s)
- T V K Herregods
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | | | | |
Collapse
|
19
|
Park JH. Abnormal sensory perception or peristaltic dysfunction: which one is associated with symptoms? J Neurogastroenterol Motil 2014; 20:412-3. [PMID: 24938309 PMCID: PMC4102154 DOI: 10.5056/jnm14065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 06/11/2014] [Accepted: 06/13/2014] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jung Ho Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University College of Medicine, Seoul, Korea
| |
Collapse
|