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do Carmo GC, de Assis Mota G, da Silva Castro Perdoná G, de Oliveira RB. Integrated Relaxation Pressure and Its Diagnostic Ability May Vary According to the Conditions Used for HREM Recording. Dysphagia 2024:10.1007/s00455-023-10655-1. [PMID: 38182941 DOI: 10.1007/s00455-023-10655-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 12/04/2023] [Indexed: 01/07/2024]
Abstract
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.
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Affiliation(s)
- Gardenia Costa do Carmo
- Department of Medicine, Medical School of Ribeirão Preto, University of São Paulo, 3900, Bandeirantes Avenue, Monte Alegre, Ribeirão Preto, São Paulo, 14049-900, Brazil
| | - Gustavo de Assis Mota
- Department of Medicine, Medical School of Ribeirão Preto, University of São Paulo, 3900, Bandeirantes Avenue, Monte Alegre, Ribeirão Preto, São Paulo, 14049-900, Brazil
| | - Gleici da Silva Castro Perdoná
- Department of Medicine, Medical School of Ribeirão Preto, University of São Paulo, 3900, Bandeirantes Avenue, Monte Alegre, Ribeirão Preto, São Paulo, 14049-900, Brazil
| | - Ricardo Brandt de Oliveira
- Department of Medicine, Medical School of Ribeirão Preto, University of São Paulo, 3900, Bandeirantes Avenue, Monte Alegre, Ribeirão Preto, São Paulo, 14049-900, Brazil.
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Leopold AR, Jalalian A, Thaker P, Wellington J, Papademetriou M, Xie G. Major mixed motility disorders: An important subset of esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2023; 35:e14555. [PMID: 37309619 DOI: 10.1111/nmo.14555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/07/2023] [Accepted: 02/13/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by a lack of relaxation of the esophagogastric junction (EGJ), with preserved esophageal body peristalsis. We propose new terminology for the coexistence of EGJOO with hypercontractile esophagus and distal esophageal spasm as a major mixed motility disorder (MMMD), and normal peristalsis or a minor disorder of peristalsis such as ineffective esophageal motility with EGJOO as isolated or ineffective EGJOO (IEGJOO). METHODS We reviewed prior diagnoses of EGJOO, stratified diagnoses as IEGJOO or MMMD, and compared their symptomatic presentations, high-resolution manometry (HRM) and endoluminal functional lumen imaging probe (EndoFLIP) metrics, and treatment responses at 2-6 months of follow-up. RESULTS Out of a total of 821 patients, 142 met CCv3 criteria for EGJOO. Twenty-two were confirmed by CCv4 and EndoFLIP as having EGJOO and were clinically managed. Thirteen had MMMD, and nine had IEGJOO. Groups had no difference in demographic data or presenting symptoms by Eckardt score (ES). HRM showed MMMD had greater distal contractile integral, frequency of hypercontractile swallows, and frequency of spastic swallows, and greater DI by EndoFLIP. Patients with MMMD showed greater reduction in symptoms after LES-directed intervention when measured by ES compared with IEGJOO (7.2 vs. 4.0). CONCLUSION Patients with MMMD and IEGJOO present similarly. Detectable differences in HRM portend different responses to endoscopic therapy. Because patients with MMMD have greater short-term prognosis, they should be considered a different diagnostic classification to guide therapy.
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Affiliation(s)
- Andrew R Leopold
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aria Jalalian
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Parth Thaker
- Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jennifer Wellington
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Atrium Health Gastroenterology and Hepatology, Charlotte, North Carolina, USA
| | - Marianna Papademetriou
- Division of Gastroenterology and Hepatology, Veterans Affairs Washington DC Medical Center, Washington, D.C., USA
| | - Guofeng Xie
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Division of Gastroenterology and Hepatology, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland, USA
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Hata Y, Sato H, Shimamura Y, Abe H, Shiwaku A, Shiota J, Sato C, Ominami M, Fukuda H, Ogawa R, Nakamura J, Tatsuta T, Ikebuchi Y, Yokomichi H, Ihara E, Inoue H. Impact of peroral endoscopic myotomy on high-resolution manometry findings and their association with the procedure's outcomes. Gastrointest Endosc 2023; 97:673-683.e2. [PMID: 36328208 DOI: 10.1016/j.gie.2022.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/15/2022] [Accepted: 10/20/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is conducted for patients with esophageal motility disorders based on high-resolution manometry (HRM) findings. However, the impact of POEM on HRM findings and the associations between post-POEM HRM and outcomes have not been clarified. METHODS In a multicenter, observational, cohort study, patients with achalasia treated by POEM received follow-up HRM. Associations between patient characteristics, POEM procedures, and post-POEM HRM findings, including integrated relaxation pressure (IRP) and distal contractile integral (DCI), were investigated. Furthermore, POEM procedure outcomes were compared with post-POEM HRM findings. RESULTS Of 2171 patients, 151 (7.0%) showed residual high post-POEM IRP (≥26 mm Hg; Starlet [Starmedical Ltd, Tokyo, Japan]). In a multivariate analysis, high pre-POEM IRPs (odds ratio [OR], 24.3) and gastric myotomy >2 cm (OR, .22) were found to be positive and negative predictive factors of high post-POEM IRPs, respectively. Peristalsis recovery (DCI ≥500 mm Hg/cm/s, at least 1 swallow; Starlet) was visible in 121 of 618 patients (19.6%) who had type II to III achalasia. High pre-POEM IRP (OR, 2.65) and DCI ≥500 (OR, 2.98) predicted peristalsis recovery, whereas esophageal dilation (OR, .42) predicted a risk of no recovery. Extended myotomy did not reveal a significant impact on peristalsis recovery. High or low post-POEM IRP and DCI did not increase the incidence of clinical failure, reflux esophagitis, or symptomatic GERD. CONCLUSIONS Extended gastric myotomy decreased IRP values, whereas peristalsis recovery depended on the characteristics of achalasia. A residual high post-POEM IRP does not necessarily mean clinical failure. Routine HRM follow-up is not recommended after POEM.
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Affiliation(s)
- Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroki Sato
- Division of Gastroenterology & Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hirofumi Abe
- Department of Gastroenterology, Kobe University Hospital, Kobe, Japan
| | - Akio Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Junya Shiota
- Department of Gastroenterology & Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Chiaki Sato
- Division of Advanced Surgical Science and Technology, Tohoku University School of Medicine, Sendai, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hisashi Fukuda
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yuichiro Ikebuchi
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Gastroenterology and Metabolism, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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Nakamura J, Sato H, Onimaru M, Abe H, Shiwaku H, Shiota J, Sato C, Sakae H, Ominami M, Hata Y, Fukuda H, Ogawa R, Tatsuta T, Ikebuchi Y, Yokomichi H, Takuto H, Inoue H. Efficacy of peroral endoscopic myotomy for esophageal motility disorders after gastric surgery: Japan Achalasia Multicenter Study. Dig Endosc 2022; 34:1394-1402. [PMID: 35656635 DOI: 10.1111/den.14369] [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: 04/01/2022] [Accepted: 05/31/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Patients with esophageal motility disorders (EMDs) including achalasia after gastric surgery have not been thoroughly characterized. Furthermore, the efficacy of peroral endoscopic myotomy (POEM) in this population should be clarified. METHODS In this retrospective multicenter study of 3707 patients with EMDs, 31 patients (0.8%) had a history of gastric surgery. Patient characteristics and POEM efficacy were compared between patients with and without previous gastric surgery. RESULTS In patients with EMD after gastric surgery, age at EMD diagnosis was higher (72.0 years), male sex was predominant (90.3%), and the American Society of Anesthesiologists physical status score was higher (≥II, 48.4%). High-resolution manometry (HRM) findings did not reveal significant differences. In patients who underwent gastric surgery, atrophic gastritis was common (80.6%), and gastric cancer was the primary surgical indication (32.3%). Distal gastrectomy was performed in 28 patients (90.3%). POEM was effective (3.3% adverse events; 100% treatment success). The incidence rates of reflux esophagitis (RE) and symptomatic gastroesophageal reflux disease (GERD) were 60.0% and 16.7%, respectively, without significant intergroup differences, and severe RE was not observed in the long-term follow-up. Extended gastric myotomy was a risk factor for RE. CONCLUSION Patients with gastric surgery often present severe disease manifestations; the surgical indication is mainly gastric cancer. HRM findings can be similarly used for diagnosis in patients with and without gastric surgery. POEM maintains safety and efficacy with acceptable RE and symptomatic GERD rates. To prevent RE, extended myotomy should be avoided.
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Affiliation(s)
- Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, USA
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Hirofumi Abe
- Department of Gastroenterology, Kobe University Hospital, Hyogo, Japan
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Junya Shiota
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Chiaki Sato
- Department of Surgery, Tohoku University School of Medicine, Miyagi, Japan
| | - Hiroyuki Sakae
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hisashi Fukuda
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yuichiro Ikebuchi
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
| | - Hikichi Takuto
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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Risks of refractory chest pain after peroral endoscopic myotomy in achalasia-related esophageal motility disorders: short-term results from a multicenter study in Japan. Gastrointest Endosc 2022; 96:620-629.e4. [PMID: 35568241 DOI: 10.1016/j.gie.2022.04.1347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/30/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The etiology of chest pain in achalasia-related esophageal motility disorders and the frequency and risk factors of persistent chest pain after peroral endoscopic myotomy (POEM) remain unclear. METHODS A multicenter cohort study including 14 hospitals was conducted to elucidate the characteristics of patients with chest pain and the efficacy of POEM. RESULTS Consecutive cases of achalasia-related esophageal motility disorders included 2294 (64.2%) and 1280 (35.8%) patients with and without chest pain, respectively. Among the 2107 patients with chest pain who underwent POEM, we observed complete remission in 1464 patients (69.5%) and nonremission in 643 patients (30.5%), including a partial response in 619 patients (29.4%) and resistance in 24 patients (1.1%). Multivariate analysis revealed that advanced age (odds ratio [OR], .28), male sex (OR, .70), prior treatment (OR, 1.39), and sigmoid type (OR, .65) were related to the prevalence of chest pain. Long disease duration (OR, .69) and esophageal dilation (OR, .79) were related to decreased severity. POEM improved patients' quality of life that was hindered by chest pain. Early onset (OR, 1.45), advanced age (OR, .58), male sex (OR, .79), prior treatment (OR, 1.37), and posterior myotomy (OR, 1.42) were associated with nonremission after POEM; high-resolution manometry (HRM) findings and myotomy length showed no statistical significance on pain etiology and persistence after POEM. CONCLUSIONS The prevalence and severity of chest pain were dependent on age, sex, disease duration, prior treatment, and esophageal morphology rather than HRM findings. The efficacy of POEM is satisfactory; however, residual pain was often observed. Excessively long myotomy can be avoided, and anterior myotomy may be recommended.
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Shiwaku H, Sato H, Shimamura Y, Abe H, Shiota J, Sato C, Ominami M, Sakae H, Hata Y, Fukuda H, Ogawa R, Nakamura J, Tatsuta T, Ikebuchi Y, Yokomichi H, Hasegawa S, Inoue H. Risk factors and long-term course of gastroesophageal reflux disease after peroral endoscopic myotomy: A large-scale multicenter cohort study in Japan. Endoscopy 2022; 54:839-847. [PMID: 35172368 DOI: 10.1055/a-1753-9801] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND : Gastroesophageal reflux disease (GERD) and reflux esophagitis remain problems after peroral endoscopic myotomy (POEM). This study aimed to elucidate the risk factors and long-term course of reflux esophagitis and symptomatic GERD after POEM. METHODS : This multicenter cohort study involved 14 high volume centers. Overall, 2905 patients with achalasia-related esophageal motility disorders treated with POEM were analyzed for reflux esophagitis, severe reflux esophagitis (Los Angeles classification C or D), and symptomatic GERD. RESULTS : Reflux esophagitis was diagnosed in 1886 patients (64.9 %). Age ≥ 65 years (risk ratio [RR] 0.85), male sex (RR 1.11), posterior myotomy (RR 1.12), esophageal myotomy > 10 cm (RR 1.12), and gastric myotomy > 2 cm (RR 1.17) were independently associated with reflux esophagitis. Severe reflux esophagitis was diagnosed in 219 patients (7.5 %). Age ≥ 65 years (RR 1.72), previous treatments (RR 2.21), Eckardt score ≥ 7 (RR 0.68), sigmoid-type achalasia (RR 1.40), and esophageal myotomy > 10 cm (RR 1.59) were factors associated with severe reflux esophagitis. Proton pump inhibitors (PPIs) were more effective for reflux esophagitis at 5-year follow-up (P = 0.03) than after 1 year (P = 0.08). Symptomatic GERD was present in 458 patients (15.9 %). Symptom duration ≥ 10 years (RR 1.28), achalasia diagnosis (RR 0.68), integrated relaxation pressure ≥ 26 (RR 0.60), and posterior myotomy (RR 0.80) were associated with symptomatic GERD. The incidence of symptomatic GERD was lower at 5-year follow-up compared with that after 1 year (P = 0.04), particularly in PPI users (P < 0.001). CONCLUSIONS : The incidence of severe reflux esophagitis was low after POEM, but excessive myotomy for older patients with previous treatments should be avoided. Early phase symptomatic GERD is non-acid reflux dependent and the natural course is favorable, basically supporting conservative treatment.
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Affiliation(s)
- Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hirofumi Abe
- Department of Gastroenterology, Kobe University Hospital, Hyogo, Japan
| | - Junya Shiota
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Chiaki Sato
- Division of Advanced Surgical Science and Technology, Tohoku University School of Medicine, Miyagi, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroyuki Sakae
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hisashi Fukuda
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yuichiro Ikebuchi
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine Tottori University Faculty of Medicine, Tottori, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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Sato H, Fujiyoshi Y, Abe H, Shiwaku H, Shiota J, Sato C, Sakae H, Ominami M, Hata Y, Fukuda H, Ogawa R, Nakamura J, Tatsuta T, Ikebuchi Y, Yokomichi H, Terai S, Inoue H. Development of Dilated Esophagus, Sigmoid Esophagus, and Esophageal Diverticulum in Patients With Achalasia: Japan Achalasia Multicenter Study. J Neurogastroenterol Motil 2022; 28:222-230. [PMID: 35362448 PMCID: PMC8978127 DOI: 10.5056/jnm21188] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/10/2021] [Accepted: 11/10/2021] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Patients with achalasia-related esophageal motility disorders (AEMDs) frequently present with dilated and sigmoid esophagus, and develop esophageal diverticulum (ED), although the prevalence and patients characteristics require further elucidation. Methods We conducted a multicenter cohort study of 3707 patients with AEMDs from 14 facilities in Japan. Esophagography on 3682 patients were analyzed. Results Straight (n = 2798), sigmoid (n = 684), and advanced sigmoid esophagus (n = 200) were diagnosed. Multivariate analysis revealed that long disease duration, advanced age, obesity, and type I achalasia correlate positively, whereas severe symptoms and integrated relaxation pressure correlate negatively with development of sigmoid esophagus. In contrast, Grade II dilation (3.5-6.0 cm) was the most common (52.9%), while grade III dilation (≥ 6 cm) was rare (5.0%). We found early onset, male, obesity, and type I achalasia correlated positively, while advanced age correlated negatively with esophageal dilation. Dilated and sigmoid esophagus were found mostly in types I and II achalasia, but typically not found in spastic disorders. The prevalence of ED was low (n = 63, 1.7%), and non-dilated esophagus and advanced age correlated with ED development. Patients with right-sided ED (n = 35) had a long disease duration (P = 0.005) with low integrated relaxation pressure values (P = 0.008) compared with patients with left-sided ED (n = 22). Patients with multiple EDs (n = 6) had lower symptom severity than patients with a single ED (P = 0.022). Conclusions The etiologies of dilated esophagus, sigmoid esophagus, and ED are considered multifactorial and different. Early diagnosis and optimal treatment of AEMDs are necessary to prevent these conditions.
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Affiliation(s)
- Hiroki Sato
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Yusuke Fujiyoshi
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hirofumi Abe
- Department of Gastroenterology, Kobe University Hospital, Hyogo, Japan
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Junya Shiota
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Chiaki Sato
- Division of Advanced Surgical Science and Technology, Tohoku University School of Medicine, Miyagi, Japan
| | - Hiroyuki Sakae
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hisashi Fukuda
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yuichiro Ikebuchi
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine Tottori University Faculty of Medicine, Tottori, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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High-Resolution Manometry Thresholds and Motor Patterns Among Asymptomatic Individuals. Clin Gastroenterol Hepatol 2022; 20:e398-e406. [PMID: 33144149 DOI: 10.1016/j.cgh.2020.10.052] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023]
Abstract
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.
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Clinical presentation and therapeutic outcome of patients with jackhammer esophagus-a multicenter cohort study in Japan. Esophagus 2022; 19:393-400. [PMID: 35249162 PMCID: PMC9166863 DOI: 10.1007/s10388-022-00916-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 02/21/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Jackhammer esophagus (JE) is a hypercontractile esophageal motility disorder diagnosed using high-resolution manometry (HRM). We sought to determine the clinical presentation and therapeutic data of patients with JE in Japan. METHODS The study included patients with JE, diagnosed through HRM performed for suspicious esophageal motility disorders. Demographics, esophagogastroduodenoscopy, radiology, and therapy data were collected from patient charts. RESULTS Among the 4,412 HRM tests performed, 89 patients (61.6 ± 13.4 years; 64 males, 25 females) were diagnosed with JE (2.0%). Dysphagia was the most frequent symptom (80%), followed by chest pain (40%) and heartburn (25%). Esophagogastroduodenoscopy showed abnormal findings in 32% of patients: corkscrew/rosary beads appearance in 26%, narrowing in 11%. Eosinophilic infiltration (> 15 eosinophils/high power field) was diagnosed in 21%. Esophagography showed abnormal findings in 9% of the patients. For the initial therapy, 47 patients received medical treatment followed by peroral endoscopic myotomy (21 patients) and laparoscopic myotomy (two patients). Thirteen patients did not receive any treatment and 10 of those (77%) reported spontaneous resolution of symptoms. Patients who required invasive treatment experienced severe disability in their quality of life and greater maximal distal contractile integral than those who did not. CONCLUSIONS HRM showed that the prevalence of JE was very low (2%). Esophagogastroduodenoscopy revealed some characteristic features of JE in patients. Some patients showed improvement of symptoms without invasive treatments. Follow-up with/without medical treatment should be considered before performing invasive treatment in patients whose distal contractile integral is relatively low and the quality of life is not impaired.
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Bredenoord AJ, Babaei A, Carlson D, Omari T, Akiyama J, Yadlapati R, Pandolfino JE, Richter J, Fass R. Esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2021; 33:e14193. [PMID: 34120375 DOI: 10.1111/nmo.14193] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Arash Babaei
- Division of Gastroenterology, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Dustin Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Taher Omari
- College or Medicine & Public Health, Flinders University, Adelaide, SA, Australia
| | - Jun Akiyama
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Rena Yadlapati
- Division of Gastroenterology & Hepatology, Center for Esophageal Diseases, University of California San Diego, La Jolla, CA, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joel Richter
- Joy McCann Culverhouse Center for Esophageal Diseases, University of South Florida College of Medicine, Tampa, FL, USA
| | - Ronnie Fass
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Metrohealth Medical System, Case Western Reserve University, Cleveland, OH, USA
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Wellington J, Kim J, Castell DO, Xie G. Dysphagia lusoria: utility of high-resolution impedance manometry to identify true disease. Neurogastroenterol Motil 2021; 33:e14176. [PMID: 34061427 DOI: 10.1111/nmo.14176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/21/2021] [Accepted: 04/28/2021] [Indexed: 02/08/2023]
Abstract
Dysphagia lusoria is a rare cause of dysphagia due to impingement of the esophagus by an aberrant right subclavian artery. Although most remain asymptomatic, this aberrant vessel can lead to progressive dysphagia in childhood or even later in life as a result of arteriosclerotic burden and attenuation of esophageal compliance that led to esophageal compression. We present a 56-year-old man with a 3-year history of progressively worsening dysphagia to solids and liquids and globus sensation. Videofluoroscopic swallowing study (modified barium esophagram) and barium esophagram showed delayed barium tablet transit in the upper esophagus and focal smooth narrowing of the upper esophagus caused by external compression, respectively. Computed tomography imaging demonstrated external compression of proximal esophagus from an aberrant right subclavian artery with high atherosclerotic burden. In addition, high-resolution impedance manometry (HRiM) revealed a striking high-pressure pulsatile vascular band in the proximal esophagus (108 mmHg) associated with poor bolus transit, demonstrating the utility of HRiM in strengthening the diagnoses of true dysphagia lusoria.
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Affiliation(s)
- Jennifer Wellington
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joseph Kim
- Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Donald O Castell
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Guofeng Xie
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Division of Gastroenterology & Hepatology, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland, USA
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12
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The upper esophageal sphincter in the high-resolution manometry era. Langenbecks Arch Surg 2021; 406:2611-2619. [PMID: 34462811 DOI: 10.1007/s00423-021-02319-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 08/26/2021] [Indexed: 12/13/2022]
Abstract
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.
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13
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Recovery of lower oesophageal barrier function: a pilot study comparing a mixture of atropine and neostigmine and sugammadex: A randomised controlled pilot study. Eur J Anaesthesiol 2021; 38:856-864. [PMID: 34226418 DOI: 10.1097/eja.0000000000001464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The lower oesophageal sphincter (LOS) barrier serves to prevent regurgitation of gastric contents. Although general anaesthesia depresses its function, its recovery process during emergence from anaesthesia has not been systematically examined. OBJECTIVE To explore whether recovery of lower oesophageal barrier function differed between patients receiving a mixture of 1 mg atropine and 2 mg neostigmine and those receiving 2 mg kg-1 sugammadex during emergence from anaesthesia. DESIGN An unblinded randomised controlled pilot study. SETTING A single university hospital from January 2016 to December 2018. PATIENTS A total of 20 non-obese adult females undergoing minor surgery. INTERVENTION The patients were randomly assigned to a group either receiving atropine and neostigmine or sugammadex for reversal of rocuronium. MAIN OUTCOME MEASURES Through use of the high-resolution manometry technique, the lower oesophageal barrier pressure (PBAR: primary variable) defined as a pressure difference between pressures at the LOS and the stomach was measured at five distinguishable time points during emergence from total intravenous anaesthesia. A mixed effects model for repeated measures was used to test the hypothesis. RESULTS In all patients baseline PBAR values were positive even under muscle paralysis and general anaesthesia before administration of reversal agents, and did not differ between the groups (P = 0.299). During recovery from muscle paralysis and general anaesthesia, PBAR (mean ± SD) significantly increased (P = 0.004) from 17.0 ± 2.9 to 21.0 ± 5.0 mmHg in the atropine and neostigmine group (n = 8) and from 19.1 ± 9.0 to 24.5 ± 12.7 mmHg in the sugammadex group (n = 11). PBAR significantly increased immediately after return of consciousness in both groups, whereas return of muscle tone, lightening of anaesthesia and tracheal extubation did not change it. CONCLUSION Recovery of the lower oesophageal barrier function does not differ between patients receiving either atropine and neostigmine or sugammadex and is completed after recovery of consciousness from general anaesthesia. TRIAL REGISTRATION UMIN Clinical Trials Registry: UMIN000020500: https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&recptno=R000023594&type=summary&language=E.
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Gong EJ, Choi SI, Lee BE, Min YW, Cho YK, Jung KW, Kim JH, Park MI. Variations in Clinical Practice of Esophageal High-resolution Manometry: A Nationwide Survey. J Neurogastroenterol Motil 2021; 27:347-353. [PMID: 34210899 PMCID: PMC8266491 DOI: 10.5056/jnm20217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon-do, Korea
| | - Soo In Choi
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Bong Eun Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Yang Won Min
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yu Kyung Cho
- Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Good Gangan Hospital, Busan, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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Matsubara M, Manabe N, Ayaki M, Nakamura J, Murao T, Fujita M, Kuinose M, Yamatsuji T, Naomoto Y, Haruma K. Clinical significance of esophagogastroduodenoscopy in patients with esophageal motility disorders. Dig Endosc 2021; 33:753-760. [PMID: 32892432 DOI: 10.1111/den.13836] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/26/2020] [Accepted: 08/31/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVES The first aim of this study was to elucidate the detection rate of esophagogastroduodenoscopy (EGD) in patients complaining of dysphagia with esophageal motility disorders; the second was to clarify the useful parameters of EGD associated with esophageal motility disorders. METHODS Participants included 380 patients who underwent EGD before high-resolution manometry (HRM) for dysphagia. EGD findings were investigated according to the following five parameters: resistance when passing through the esophagogastric junction (EGJ), residue in the esophageal lumen, esophageal dilation, and spastic and nonocclusive contractions. HRM diagnoses were based on the Chicago classification (v3.0). RESULTS The percentage of abnormal EGD findings was 64.4% among patients with esophageal motility disorders, and the results differed for each esophageal motility disorder. The rate of abnormal EGD for both EGJ outflow obstruction and major disorders of peristalsis was significantly higher than that for manometrically normal subjects. On multivariate analysis, resistance when passing through EGJ, residue in the esophageal lumen, spastic and nonocclusive contraction were significantly associated with esophageal motility disorders. The sensitivity, specificity, positive predictive value, and negative predictive value of these parameters for detection of esophageal motility disorders were 75.1%, 86.6%, 84.8% and 77.8%, respectively. CONCLUSION Esophagogastric junction outflow obstruction and major disorders of peristalsis can be screened with EGD. Among several endoscopic parameters, resistance when passing through EGJ, residue in the esophageal lumen, spastic and nonocclusive contraction are considered significantly useful indicators.
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Affiliation(s)
- Masaki Matsubara
- Department of General Surgery, Kawasaki Medical School, Okayama, Japan
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Maki Ayaki
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Jun Nakamura
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Takahisa Murao
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Okayama, Japan
| | - Minoru Fujita
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Masahiko Kuinose
- Department of General Surgery, Kawasaki Medical School, Okayama, Japan
| | - Tomoki Yamatsuji
- Department of General Surgery, Kawasaki Medical School, Okayama, Japan
| | - Yoshio Naomoto
- Department of General Surgery, Kawasaki Medical School, Okayama, Japan
| | - Ken Haruma
- Division of Gastroenterology, Department of Internal Medicine 2, Kawasaki Medical School, Okayama, Japan
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Chen JW, Savarino E, Smout A, Xiao Y, de Bortoli N, Yadlapati R, Cock C. Chicago Classification Update (v4.0): Technical review on diagnostic criteria for hypercontractile esophagus. Neurogastroenterol Motil 2021; 33:e14115. [PMID: 33729642 DOI: 10.1111/nmo.14115] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/06/2021] [Accepted: 02/14/2021] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Joan W Chen
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - André Smout
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Yinglian Xiao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Nicola de Bortoli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Rena Yadlapati
- Division of Gastroenterology & Hepatology, Center for Esophageal Diseases, University of California San Diego, La Jolla, CA, USA
| | - Charles Cock
- Department of Gastroenterology & Hepatology, Flinders University, Adelaide, SA, Australia
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17
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Mohd Said MR, Wong Z, Abdul Rani R, Ngiu CS, Raja Ali RA, Lee YY. The effects of different postures and provocative swallow materials on the normative Chicago 3.0 metrics in a healthy Asian population. J Gastroenterol Hepatol 2021; 36:1244-1252. [PMID: 33002243 PMCID: PMC8246748 DOI: 10.1111/jgh.15284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/30/2020] [Accepted: 09/22/2020] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
| | - Zhiqin Wong
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of MedicineUniversiti Kebangsaan MalaysiaKuala LumpurMalaysia,Gut Research Group, Faculty of MedicineUniversiti Kebangsaan MalaysiaKuala LumpurMalaysia
| | - Rafiz Abdul Rani
- Gastroenterology UnitMARA University of TechnologyShah AlamMalaysia
| | - Chai Soon Ngiu
- Digestive and Endoscopy CenterCardiac Vascular Sentral Kuala LumpurKuala LumpurMalaysia
| | - Raja Affendi Raja Ali
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of MedicineUniversiti Kebangsaan MalaysiaKuala LumpurMalaysia,Gut Research Group, Faculty of MedicineUniversiti Kebangsaan MalaysiaKuala LumpurMalaysia
| | - Yeong Yeh Lee
- Gut Research Group, Faculty of MedicineUniversiti Kebangsaan MalaysiaKuala LumpurMalaysia,School of Medical SciencesUniversity of Science MalaysiaKota BharuMalaysia
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Abstract
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.
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Hypercontractile Esophagus From Pathophysiology to Management: Proceedings of the Pisa Symposium. Am J Gastroenterol 2021; 116:263-273. [PMID: 33273259 DOI: 10.14309/ajg.0000000000001061] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022]
Abstract
Hypercontractile esophagus (HE) is a heterogeneous major motility disorder diagnosed when ≥20% hypercontractile peristaltic sequences (distal contractile integral >8,000 mm Hg*s*cm) are present within the context of normal lower esophageal sphincter (LES) relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). HE can manifest with dysphagia and chest pain, with unclear mechanisms of symptom generation. The pathophysiology of HE may entail an excessive cholinergic drive with temporal asynchrony of circular and longitudinal muscle contractions; provocative testing during HRM has also demonstrated abnormal inhibition. Hypercontractility can be limited to the esophageal body or can include the LES; rarely, the process is limited to the LES. Hypercontractility can sometimes be associated with esophagogastric junction (EGJ) outflow obstruction and increased muscle thickness. Provocative tests during HRM can increase detection of HE, reproduce symptoms, and predict delayed esophageal emptying. Regarding therapy, an empiric trial of a proton pump inhibitor, should be first considered, given the overlap with gastroesophageal reflux disease. Calcium channel blockers, nitrates, and phosphodiesterase inhibitors have been used to reduce contraction vigor but with suboptimal symptomatic response. Endoscopic treatment with botulinum toxin injection or pneumatic dilation is associated with variable response. Per-oral endoscopic myotomy may be superior to laparoscopic Heller myotomy in relieving dysphagia, but available data are scant. The presence of EGJ outflow obstruction in HE discriminates a subset of patients who may benefit from endoscopic treatment targeting the EGJ.
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Damrongmanee A, El-Chammas K, Fei L, Zang H, Santucci N, Kaul A. Pharyngeal and upper esophageal sphincter motor dynamics during swallow in children. Neurogastroenterol Motil 2021; 33:e13962. [PMID: 32789998 DOI: 10.1111/nmo.13962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/27/2020] [Accepted: 07/20/2020] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Alisara Damrongmanee
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Khalil El-Chammas
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lin Fei
- Division of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Huaiyu Zang
- Division of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Neha Santucci
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ajay Kaul
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Alcala Gonzalez LG, Oude Nijhuis RAB, Smout AJPM, Bredenoord AJ. Normative reference values for esophageal high-resolution manometry in healthy adults: A systematic review. Neurogastroenterol Motil 2021; 33:e13954. [PMID: 32715569 DOI: 10.1111/nmo.13954] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/18/2020] [Accepted: 07/06/2020] [Indexed: 12/21/2022]
Abstract
Establishing normative values of high-resolution esophageal manometry is necessary for accurate interpretation and comparison of measurements. In this systematic review, we aimed to summarize normal values for different esophageal high-resolution manometry systems. Moreover, we assessed the effect of body position, bolus consistency, and provocative maneuvers on these normative thresholds. We searched Medline, Embase, and the Cochrane Library from January 1st, 2006, to January 20th, 2020, for studies that reported normative data of high-resolution manometry in healthy volunteers. We assessed methodological quality of the included studies and planned a descriptive analysis. We analyzed data from 54 articles describing normative thresholds in high-resolution manometry using solid-state or water-perfused systems. Forty-six studies performed the manometry study in the supine position with liquid swallows, whereas sixteen studies described normative values in the upright position. Twelve studies assessed normative values for different bolus consistencies, and nine studies evaluated different provocative maneuvers. There is a considerable variety of normative values for esophageal high-resolution manometry depending on the equipment used and the protocols performed to obtain measurements. This should be taken into account when evaluating measurements in clinical practice and when comparing results of published research studies.
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Affiliation(s)
| | - Renske A B Oude Nijhuis
- Department of Gastroenterology and Hepatology, University Medical Centers Amsterdam, Amsterdam, The Netherlands
| | - Andreas J P M Smout
- Department of Gastroenterology and Hepatology, University Medical Centers Amsterdam, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, University Medical Centers Amsterdam, Amsterdam, The Netherlands
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22
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Distal contractile integral measurement and vascular compression in the esophagus: a problem unsolved? Esophagus 2020; 17:502-507. [PMID: 32356213 DOI: 10.1007/s10388-020-00740-x] [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: 10/03/2019] [Accepted: 04/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Distal contractile integral (DCI) is influenced by factors other than esophageal smooth muscle contractility, such as intrabolus pressure and vascular and respiratory movements' artifacts. We aimed to determine the size of the contribution of pressures generated by vascular compression on the esophagus to the DCI measured in HRM recordings in symptomatic patients. METHODS HRM manometry recordings obtained from 383 subjects referred to the GI motility laboratory at a tertiary center (2012-2016) were evaluated by visual inspection for evidence of strong vascular compression (SVC) of the esophagus. Clinical, demographic, manometric, and serologic data for Chagas disease were obtained. Subjects were classified, respectively, as asymptomatics (ASYM) or symptomatics (SYMP). DCI and SVC-DCI were measured, and the SVC-DCI/DCI ratio was expressed as a percentage and the difference between DCI and SVC-DCI (neat-DCI) was calculated. DCI, SVC-DCI, SVC-DCI/DCI % and neat-DCI from SYMP and ASYM were compared. RESULTS SVC was conspicuous in 42 of 383 subjects (11%). In 33 subjects, SVC was detected only in supine position. SVC was localized in middle esophagus in 21 subjects (50%), in distal esophagus in 12 subjects (29%) and in both regions in 9 subjects (21%). In 9 subjects, SVC vanished from the swallowing window analysis (21%). CONCLUSIONS SVC is a common finding in esophageal HRM study, particularly in the supine position. Occasionally, its contribution to DCI value is sufficiently great to masquerade esophageal hypocontractility. Different manometric protocols may be required in patients with SVC.
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Aoyama K, Kunieda K, Shigematsu T, Ohno T, Fujishima I. Effect of Bridge Position Swallow on Esophageal Motility in Healthy Individuals Using High-Resolution Manometry. Dysphagia 2020; 36:551-557. [PMID: 32749546 PMCID: PMC8289772 DOI: 10.1007/s00455-020-10169-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 07/28/2020] [Indexed: 12/29/2022]
Abstract
Recently, there has been clinical interest in the effect of different body positions on esophageal motility. This study aimed to identify the effect of three different body positions on esophageal motility using high-resolution manometry. Thirteen healthy adults swallowed 5 mL of water in the upright, supine, and bridge positions. For the bridge position, each subject raised their waist against gravity, placed a cushion under their back, and bent their knees. The proximal contractile integral (PCI) and distal contractile integral (DCI), integrated relaxation pressure (IRP), distal latency (DL), peristaltic breaks (PBs), intrabolus pressure (IBP), and expiratory and inspiratory esophagoesophageal junction (EGJ) pressure were measured. In the bridge position, PCI, DCI, IRP, and expiratory and inspiratory EGJ pressure were significantly higher than those in the upright position (bridge PCI vs. upright PCI [p = 0.001], bridge DCI vs. upright DCI [p < 0.001], bridge IRP vs. upright IRP [p = 0.018], bridge EGJ pressure vs. upright EGJ pressure [expiratory: p = 0.001] [inspiratory: p < 0.001]). PBs were significantly shorter and DL was significantly longer in the bridge position compared to upright (bridge PBs vs. upright PBs [p = 0.001], bridge DL vs. upright DL [p = 0.001]). IBP was significantly higher in the bridge position compared to supine (bridge IBP vs. supine IBP [p = 0.01]). These results demonstrated changes in esophageal motility according to changes in position while swallowing, where esophageal contractions became stronger against gravity. Further study is required to examine the effectiveness of swallowing in the bridge position.
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Affiliation(s)
- Kei Aoyama
- The Department of Rehabilitation Medicine, Chikamori Rehabilitation Hospital, 2-22 Nijudaimachi, Kochi, 780-0843, Kochi, Japan.
| | - Kenjiro Kunieda
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
- The Department of Rehabilitation Medicine, Hamamatsu City Rehabilitation Hospital, Hamamatsu, Shizuoka, Japan
| | - Takashi Shigematsu
- The Department of Rehabilitation Medicine, Hamamatsu City Rehabilitation Hospital, Hamamatsu, Shizuoka, Japan
- The Department of Rehabilitation Medicine, Seirei Awaji Hospital, Awaji, Hyogo, Japan
| | - Tomohisa Ohno
- The Department of Dentistry, Hamamatsu City Rehabilitation Hospital, Hamamatsu, Shizuoka, Japan
| | - Ichiro Fujishima
- The Department of Rehabilitation Medicine, Hamamatsu City Rehabilitation Hospital, Hamamatsu, Shizuoka, Japan
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24
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Riva CG, Siboni S, Ferrari D, Sozzi M, Capuzzo M, Asti E, Ogliari C, Bonavina L. Effect of Body Position on High-resolution Esophageal Manometry Variables and Final Manometric Diagnosis. J Neurogastroenterol Motil 2020; 26:335-343. [PMID: 32606256 PMCID: PMC7329148 DOI: 10.5056/jnm20010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/10/2020] [Indexed: 12/29/2022] Open
Abstract
Background/Aims According to the Chicago classification version 3.0, high-resolution manometry (HRM) should be performed in the supine position. However, with the patient in the upright/sitting position, the test could more closely simulate real-life behavior and may be better tolerated. We performed a systematic review of the literature to search whether the manometric variables and the final diagnosis are affected by positional changes. Methods A literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies published in English that compared HRM results in different body positions were included. Moreover, the change in diagnosis of esophageal motility disorders according to the shift of body position was investigated. Results Seventeen studies including 1714 patients and healthy volunteers met the inclusion criteria. Six studies showed a significant increase in lower esophageal sphincter basal pressure in the supine position. Integrated relaxation pressure was significantly higher in the supine position in 10 of 13 studies. Distal contractile index was higher in the supine position in 9 out of 10 studies. One hundred and fifty-one patients (16.4%) out of 922 with normal HRM in the supine position were diagnosed with ineffective esophageal motility (IEM) when the test was performed in the upright position (P < 0.001). Conclusions Performing HRM in the upright position affects some variables and may change the final manometric diagnosis. Further studies to determine the normal values in the sitting position are needed.
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Affiliation(s)
- Carlo G Riva
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
| | - Stefano Siboni
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
| | - Davide Ferrari
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
| | - Marco Sozzi
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
| | - Matteo Capuzzo
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
| | - Emanuele Asti
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
| | - Cristina Ogliari
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
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Kim E, Yoo IK, Yon DK, Cho JY, Hong SP. Characteristics of a Subset of Achalasia With Normal Integrated Relaxation Pressure. J Neurogastroenterol Motil 2020; 26:274-280. [PMID: 32102139 PMCID: PMC7176497 DOI: 10.5056/jnm19130] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/25/2019] [Accepted: 09/20/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Integrated relaxation pressure (IRP) is a critical diagnostic criterion to define achalasia. However, there are some cases with typical symptoms and signs of achalasia but with normal IRP. The aim of this study is to evaluate the clinical characteristics of patients with achalasia with normal IRP and outcomes after peroral endoscopic myotomy (POEM). Methods Patients with achalasia were collected in whom POEM was performed from November 2014 to April 2018 at CHA Bundang Medical Center. Achalasia with normal IRP was defined by findings compatible to achalasia in Eckardt score, endoscopy with endoscopic ultrasound, high-resolution manometry, impedance planimetry (EndoFlip), and timed esophagogram. Results POEM was performed in 89 patients with achalasia; among them, 24 (27%) patients were diagnosed with achalasia with normal IRP. Patients with achalasia with normal IRP were older, had longer duration of symptom, and had a more tortuous esophagus. In EndoFlip, the distensibility index and cross-sectional area were higher in patients with normal IRP. Therapeutic outcomes showed no statistically significant differences. On correlation analysis, IRP had negative correlations with age, disease duration, and distensibility index. Conclusions Patients with achalasia of normal IRP value were older and had longer disease duration and higher distensibility index and cross-sectional area than patients with achalasia with abnormal relaxation of lower esophageal sphincter. Therapeutic outcomes were not different between the 2 groups.
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Affiliation(s)
- Eunju Kim
- Department of Gastroenterology, Cha Bundang Medical Center, Cha University College of Medicine, Seongnam, Gyeonggi-do, Korea
| | - In Kyung Yoo
- Department of Gastroenterology, Cha Bundang Medical Center, Cha University College of Medicine, Seongnam, Gyeonggi-do, Korea
| | - Dong Keon Yon
- Department of Pediatrics, Cha Bundang Medical Center, Cha University College of Medicine, Seongnam, Gyeonggi-do, Korea
| | - Joo Young Cho
- Department of Gastroenterology, Cha Bundang Medical Center, Cha University College of Medicine, Seongnam, Gyeonggi-do, Korea
| | - Sung Pyo Hong
- Department of Gastroenterology, Cha Bundang Medical Center, Cha University College of Medicine, Seongnam, Gyeonggi-do, Korea
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Misselwitz B, Hollenstein M, Bütikofer S, Ang D, Heinrich H, Fox M. Prospective serial diagnostic study: the effects of position and provocative tests on the diagnosis of oesophageal motility disorders by high-resolution manometry. Aliment Pharmacol Ther 2020; 51:706-718. [PMID: 32056267 DOI: 10.1111/apt.15658] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 11/17/2019] [Accepted: 01/21/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Standard high-resolution manometry (HRM) protocols are based on 10 single water swallows acquired in the supine position. AIMS To assess the impact of position, rapid drink challenge and solid test meal on the diagnosis of oesophageal motility disorders. METHODS Seventy-two healthy volunteers (20-76 years) and 366 consecutive patients (18-90 years) completed HRM with 10 single water swallows in the supine and upright positions. Rapid drink challenge was performed twice, before and after the solid test meal. Diagnosis based on single water swallows in the supine position (Chicago Classification v3.0) was compared with results in the upright position and with provocative tests. RESULTS Overall, diagnostic agreement in the supine and upright positions was present in 296/438 (67.6%) subjects. This increased to 90.0% when ineffective oesophageal motility was considered with normal motility. Integrated relaxation pressure was 4 mm Hg higher in the supine position. There was a higher prevalence of inconsistent, likely false positive, diagnoses of outlet obstruction in the supine compared to the upright position (16/20 vs 1/4 patients, P = 0.0007). Similarly, the difference in concordance for the diagnosis of oesophago-gastric junction obstruction or achalasia between single water swallows in the supine and upright positions with solid test meal was significant (12/29 (41.4%) vs 12/14 (85.7%), P = 0.0087). CONCLUSION Diagnostic agreement for oesophageal motility disorders based on single water swallows in the upright and supine positions was moderate, with frequent discordant findings for ineffective motility and outlet obstruction. HRM studies can be performed in either position, using appropriate reference values. Rapid drink challenge or solid test meal can resolve diagnostic discrepancies.
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Affiliation(s)
- Benjamin Misselwitz
- Clinic of Visceral Surgery and Medicine, Inselspital Bern and Bern University, Bern, Switzerland
| | - Michael Hollenstein
- Clinic of Gastroenterology and Hepatology, Zurich University Hospital and University of Zurich, Zürich, Switzerland
| | - Simon Bütikofer
- Clinic of Gastroenterology and Hepatology, Zurich University Hospital and University of Zurich, Zürich, Switzerland
| | - Daphne Ang
- Department of Gastroenterology, Changi General Hospital, Singapore
| | - Henriette Heinrich
- Clinic of Gastroenterology and Hepatology, Zurich University Hospital and University of Zurich, Zürich, Switzerland
| | - Mark Fox
- Clinic of Visceral Surgery and Medicine, Inselspital Bern and Bern University, Bern, Switzerland.,Digestive Function: Basel, Laboratory and Clinic for disorders of gastrointestinal motility and function, Center for Integrative Gastroenterology, Arlesheim, Switzerland
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27
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Kawami N, Hoshino S, Hoshikawa Y, Takenouchi N, Hanada Y, Tanabe T, Goto O, Kaise M, Iwakiri K. Validity of the Cutoff Value for Integrated Relaxation Pressure Used in the Starlet High-Resolution Manometry System. J NIPPON MED SCH 2020; 86:322-326. [PMID: 31434840 DOI: 10.1272/jnms.jnms.2019_86-608] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Noriyuki Kawami
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
| | - Shintaro Hoshino
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
| | - Yoshimasa Hoshikawa
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
| | - Nana Takenouchi
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
| | - Yuriko Hanada
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
| | - Tomohide Tanabe
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
| | - Osamu Goto
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine
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Kuribayashi S, Iwakiri K, Shinozaki T, Hosaka H, Kawada A, Kawami N, Hoshino S, Takenouchi N, Shimoyama Y, Kawamura O, Kusano M, Uraoka T. Clinical impact of different cut-off values in high-resolution manometry systems on diagnosing esophageal motility disorders. J Gastroenterol 2019; 54:1078-1082. [PMID: 31388756 DOI: 10.1007/s00535-019-01608-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 07/31/2019] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Shiko Kuribayashi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan.
- Clinical Investigation and Research Unit, Gunma University Hospital, Maebashi, Japan.
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School Hospital, Tokyo, Japan
| | - Tomohiro Shinozaki
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Tokyo, Japan
| | - Hiroko Hosaka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Akiyo Kawada
- Medical Examination Center of Chubu Medical Association, Chatan-cho, Japan
| | - Noriyuki Kawami
- Department of Gastroenterology, Nippon Medical School Hospital, Tokyo, Japan
| | - Shintaro Hoshino
- Department of Gastroenterology, Nippon Medical School Hospital, Tokyo, Japan
| | - Nana Takenouchi
- Department of Gastroenterology, Nippon Medical School Hospital, Tokyo, Japan
| | - Yasuyuki Shimoyama
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Osamu Kawamura
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Motoyasu Kusano
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Toshio Uraoka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan
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Nikaki K, Sawada A, Ustaoglu A, Sifrim D. Neuronal Control of Esophageal Peristalsis and Its Role in Esophageal Disease. Curr Gastroenterol Rep 2019; 21:59. [PMID: 31760496 DOI: 10.1007/s11894-019-0728-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Esophageal peristalsis is a highly sophisticated function that involves the coordinated contraction and relaxation of striated and smooth muscles in a cephalocaudal fashion, under the control of central and peripheral neuronal mechanisms and a number of neurotransmitters. Esophageal peristalsis is determined by the balance of the intrinsic excitatory cholinergic, inhibitory nitrergic and post-inhibitory rebound excitatory output to the esophageal musculature. RECENT FINDINGS Dissociation of the longitudinal and circular muscle contractions characterizes different major esophageal disorders and leads to esophageal symptoms. Provocative testing during esophageal high-resolution manometry is commonly employed to assess esophageal body peristaltic reserve and underpin clinical diagnosis. Herein, we summarize the main factors that determine esophageal peristalsis and examine their role in major and minor esophageal motility disorders and eosinophilic esophagitis.
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Affiliation(s)
- K Nikaki
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK
| | - A Sawada
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK
| | - A Ustaoglu
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK
| | - D Sifrim
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK.
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Trudgill NJ, Sifrim D, Sweis R, Fullard M, Basu K, McCord M, Booth M, Hayman J, Boeckxstaens G, Johnston BT, Ager N, De Caestecker J. British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring. Gut 2019; 68:1731-1750. [PMID: 31366456 PMCID: PMC6839728 DOI: 10.1136/gutjnl-2018-318115] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 06/13/2019] [Accepted: 06/16/2019] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Nigel J Trudgill
- Sandwell and West Birmingham Hospitals NHS Trust, West Bomwich, UK
| | - Daniel Sifrim
- Centre of Gastroenterology Research, Queen Mary University London, London, UK
| | - Rami Sweis
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Fullard
- West Hertfordshire Hospitals NHS Trust, Watford, Hertfordshire, UK
| | - Kumar Basu
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - John Hayman
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Guy Boeckxstaens
- Gastroenterology, University Hospital, KU Leuven, Leuven, Belgium
| | - Brian T Johnston
- Department of Gastroenterology, Belfast Health and Social Care Trust, Belfast, UK
| | - Nicola Ager
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
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31
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Babaei A, Shad S, Szabo A, Massey BT. Pharmacologic interrogation of patients with esophagogastric junction outflow obstruction using amyl nitrite. Neurogastroenterol Motil 2019; 31:e13668. [PMID: 31236998 PMCID: PMC6693956 DOI: 10.1111/nmo.13668] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Chicago Classification of esophageal motility includes a group of patients who show evidence of esophagogastric junction outflow obstruction (EGJOO) as demonstrated by elevated integrated relaxation pressure (IRP) and preserved peristalsis. Our aim is to classify EGJOO patients based on response to amyl nitrite (AN) during high-resolution manometry. METHODS Patients were considered to have true EGJOO if elevated IRP during supine swallow persisted in the upright position and was associated with high intrabolus pressure. The EGJ response to AN was compared between patients with achalasia type 2 (A2) and normal esophageal motility. Based on the relaxation gain (deglutitive IRP-AN IRP) value that best discriminated these two groups (10 mm Hg), patients with true EGJOO were categorized as being in either the AN-responsive (AN-R) or AN-unresponsive (AN-U) subgroups. KEY RESULTS In the group of 49 patients with true EGJOO, the AN response classified 27 patients (IRP = 25 ± 10 mm Hg) with AN-R and 22 patients (IRP = 20 ± 5 mm Hg) with AN-U (P = 0.2). In AN-R, AN produced a relaxation gain and rebound after-contraction response at the EGJ comparable to A2 patients. AN-U patients had an elevated IRP after AN and a relaxation gain similar to normal esophageal motility patients. AN-U patients were obese and had higher prevalence of sleep apnea (P < 0.05). CONCLUSIONS Among patients with true EGJOO, only half have pharmacologic evidence of impaired LES relaxation. Pharmacologic interrogation of the EGJ is thus necessary to identify the subgroup of EGJOO patients who could be expected to benefit from LES ablative therapies.
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Affiliation(s)
- Arash Babaei
- Division of Gastroenterology, Department of Medicine, National Jewish Health, Denver, CO, USA,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sadaf Shad
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aniko Szabo
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benson T. Massey
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Xiang X, Wang A, Tu L, Xie X, Ke M, Yang Y, Jiang B, Lin L, Dai N, Zhang S, Tao L, Xu H, Liang X, Fang X, Xia Z, Wang X, Wu J, Wang M, Zhang H, Fang Y, Shen C, Wang J, Peng L, Li W, Wang Z, Wang K, Liu N, Hou X. The differences in the esophageal motility between liquid and solid bolus swallows: A multicenter high-resolution manometry study in Chinese asymptomatic volunteers. Neurogastroenterol Motil 2019; 31:e13574. [PMID: 30821105 DOI: 10.1111/nmo.13574] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 01/31/2019] [Accepted: 01/31/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND The results of the esophageal body motility differences between liquid and solid swallows from high-resolution manometry (HRM) studies are not consistent. The information of the frequency of ineffective liquid and solid bolus swallows in healthy individuals during HRM procedure is limited. The normative values of the HRM parameters of both liquid and solid swallows for Chinese population are lacking. METHODS The esophageal HRM data of 101 healthy volunteers from multicenters in China were analyzed. The values of the HRM parameters were summarized and compared between liquid and solid swallows. The frequencies of ineffective liquid and solid swallows were summarized. RESULTS Esophagus contracted stronger and slower in solid bolus swallows than water swallows with HREM. Ineffective water swallow (DCI < 450 mm Hg.s.cm) and ineffective bread swallow (DCI < 800 mm Hg.s.cm) were frequently seen in asymptomatic individuals. The adding of bread swallows to the HREM procedure might cause diagnostic change in about 15.8% (16/101) of the asymptomatic individuals. CONCLUSIONS The vigor and velocity of the esophageal peristalsis between liquid and solid bolus swallows are different. Ineffective water and solid bolus swallows are not rare. Adding solid bolus swallows brings diagnostic change, and it may be needed routinely for the HRM procedure.
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Affiliation(s)
- Xuelian Xiang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ao Wang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Tu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoping Xie
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meiyun Ke
- Division of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunsheng Yang
- Division of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Bo Jiang
- Division of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lin Lin
- Division of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ning Dai
- Division of Gastroenterology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Shengsheng Zhang
- Division of Gastroenterology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Lin Tao
- Division of Gastroenterology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Hong Xu
- Division of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - Xiaomei Liang
- Division of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiucai Fang
- Division of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhiwei Xia
- Division of Gastroenterology, Peking University Third Hospital, Beijing, China
| | - Xin Wang
- State Key Laboratory of Cancer Biology and Xijing Hospital of Digestive Disease, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jianuan Wu
- Division of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Meifeng Wang
- Division of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongjie Zhang
- Division of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yanfei Fang
- Division of Gastroenterology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Chen Shen
- Division of Gastroenterology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Jing Wang
- Division of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - Lihua Peng
- Division of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Wenyan Li
- Division of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhifeng Wang
- Division of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kun Wang
- Division of Gastroenterology, Peking University Third Hospital, Beijing, China
| | - Na Liu
- State Key Laboratory of Cancer Biology and Xijing Hospital of Digestive Disease, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiaohua Hou
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Song BG, Min YW, Lee H, Min BH, Lee JH, Rhee PL, Kim JJ. Combined Multichannel Intraluminal Impedance and High-resolution Manometry Improves Detection of Clinically Relevant Esophagogastric Junction Outflow Obstruction. J Neurogastroenterol Motil 2019; 25:75-81. [PMID: 30646478 PMCID: PMC6326198 DOI: 10.5056/jnm18148] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/05/2018] [Accepted: 10/25/2018] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND/AIMS Esophagogastric junction outflow obstruction (EGJOO) is a diagnostically heterogeneous group with variable clinical relevance. We studied whether evaluation of bolus transit by multichannel intraluminal impedance (MII) is useful for discriminating clinically relevant EGJOO. METHODS A total 169 patients diagnosed as having EGJOO between June 2011 and February 2018 were analyzed. All the patients received a combined MII and high-resolution manometry (CMII-HRM). MII was reported as having abnormal liquid bolus transit (LBT) if < 80% of swallows had complete bolus transit. EGJOO was defined as a median integrated relaxation pressure of > 20 mmHg and when the criteria for achalasia were not met. Patients who progress to achalasia, show significant passage disturbance, or require pneumatic dilatation were defined as having a clinically relevant EGJOO. RESULTS Among the patients with EGJOO (n = 169), the clinically relevant group (n = 10) is more likely to have dysphagia (100% vs 25.2%, P < 0.001), compartmentalized pressurization (CP; 90.0% vs 22.0%, P < 0.001), and abnormal LBT (100% vs 66.7%, P = 0.032) compared to the non-relevant group (n = 159). The combination of dysphagia, CP, and abnormal LBT showed the best predictive power for clinically relevant EGJOO (sensitivity 90%, specificity 92.5%, positive predictive value 42.9%, negative predictive value 99.3%, positive likelihood ratio 11.9, and negative likelihood ratio 0.1). When CMII-HRM was used, an additional 8.3% of clinically relevant EGJOO cases were identified as compared with HRM alone. CONCLUSION Clinically relevant EGJOO can be predicted using CMII-HRM.
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Affiliation(s)
- Byeong Geun Song
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Jae J Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
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Samo S, Qayed E. Esophagogastric junction outflow obstruction: Where are we now in diagnosis and management? World J Gastroenterol 2019; 25:411-417. [PMID: 30700938 PMCID: PMC6350167 DOI: 10.3748/wjg.v25.i4.411] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/06/2018] [Accepted: 12/14/2018] [Indexed: 02/06/2023] Open
Abstract
Esophagogastric junction outflow obstruction (EGJOO) is a major motility disorder based on the Chicago Classification of esophageal motility disorders. This entity involves a heterogenous group of underlying etiologies. The diagnosis is reached by performing high-resolution manometry. This reveals evidence of obstruction at the esophagogastric junction, manifested by an elevated integrated relaxation pressure (IRP) above a cutoff value (IRP threshold varies by the manometric technology and catheter used), with preserved peristalsis. Further tests like endoscopy, timed barium esophagram, and cross-sectional imaging can help further elucidate the underlying etiology and rule out mechanical causes. Treatment is tailored to the underlying cause. Similar to achalasia, treatment targeting lower esophageal sphincter disruption like pneumatic dilation, peroral endoscopic myotomy, and botulinum injection are used in patients with functional EGJOO and persistent symptoms.
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Affiliation(s)
- Salih Samo
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Emad Qayed
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, United States
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Höhne S, Arndt M, Hesse V. The Esophageal Manometry with Gas-perfused Catheters. Open Med (Wars) 2018; 13:232-236. [PMID: 29915812 PMCID: PMC6004517 DOI: 10.1515/med-2018-0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 04/21/2018] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Sven Höhne
- Martin-Luther-University Halle-Wittenberg, University Hospital, Clinic of Pediatric Surgery, 06120, Halle, Ernst-Grube Street 40, Germany
| | - Martin Arndt
- Martin-Luther-University Halle-Wittenberg, Department of Operative and Conservative Medicine in Children and Adolescents, Clinic of Pediatric Surgery, Laboratory of Function Diagnostic, Halle, Germany
| | - Viola Hesse
- Martin-Luther-University Halle-Wittenberg, Department of Operative and Conservative Medicine in Children and Adolescents, Clinic of Pediatric Surgery, Laboratory of Function Diagnostic, Halle, Germany
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36
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Song BG, Min YW, Lee H, Min BH, Lee JH, Rhee PL, Kim JJ. Clinicomanometric factors associated with clinically relevant esophagogastric junction outflow obstruction from the Sandhill high-resolution manometry system. Neurogastroenterol Motil 2018; 30. [PMID: 29024314 DOI: 10.1111/nmo.13221] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 09/07/2017] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- B G Song
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Y W Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - H Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - B-H Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - J H Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - P-L Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - J J Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Vettori S, Tolone S, Capocotta D, Chieffo R, Giacco V, Valentini G, Docimo L. Esophageal high-resolution impedance manometry alterations in asymptomatic patients with systemic sclerosis: prevalence, associations with disease features, and prognostic value. Clin Rheumatol 2018; 37:1239-1247. [PMID: 29442260 DOI: 10.1007/s10067-018-4026-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/30/2018] [Accepted: 02/02/2018] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Serena Vettori
- Rheumatology Section, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", c/o II Policlinico, via Pansini 5, 80131, Naples, Italy.
| | - Salvatore Tolone
- Division of General, Mini-Invasive and Bariatric Surgery, Department of Surgery, University of Campania "Luigi Vanvitelli", II Policlinico, Via Pansini 5, 80131, Naples, Italy
| | - Domenico Capocotta
- Rheumatology Section, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", c/o II Policlinico, via Pansini 5, 80131, Naples, Italy
| | - Rossella Chieffo
- Rheumatology Section, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", c/o II Policlinico, via Pansini 5, 80131, Naples, Italy
| | - Veronica Giacco
- Rheumatology Section, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", c/o II Policlinico, via Pansini 5, 80131, Naples, Italy
| | - Gabriele Valentini
- Rheumatology Section, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", c/o II Policlinico, via Pansini 5, 80131, Naples, Italy
| | - Ludovico Docimo
- Division of General, Mini-Invasive and Bariatric Surgery, Department of Surgery, University of Campania "Luigi Vanvitelli", II Policlinico, Via Pansini 5, 80131, Naples, Italy
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Höhne S, Hesse V. Standard values for gas-perfusion manometry of the esophagus. Medicine (Baltimore) 2018; 97:e9910. [PMID: 29465580 PMCID: PMC5841971 DOI: 10.1097/md.0000000000009910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The manometry with water-perfused or solid-state catheters is the predominant diagnostic procedure to detect motility disorders of the esophagus. Another method is the manometry using gas-perfused catheters. Although the high-resolution manometry is the method of first choice, the conventional manometry with helium has some advantages: the simple and hygienically unproblematic use and the absence of any artefacts by the perfusion medium compared with water-perfusion, and the considerably lower costs compared with the solid-state catheters. Every method has own normal values because of the specific pressure transmission and the design of the catheter probes. To our knowledge, normal values for gas-perfusion manometry of the esophagus have not yet been published.The esophageal manometry with helium-perfused catheters was performed in 30 healthy volunteers. The main parameters of the esophageal motility and the lower esophageal sphincter were analyzed by liquid and bolus-like swallows and compared with the previous published values in other manometric procedures.The values of the motility in the distal esophagus are consistent; the pressure of the lower esophageal sphincter is generally lower than with other methods. The distal wave amplitude and the propagation velocity are significant higher in the distal esophagus than in the middle. The perfusion medium is well tolerated by the investigated volunteers.
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39
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Hiranyatheb P, Chakkaphak S, Chirnaksorn S, Lekhaka P, Petsrikun K, Somboonpun K. Normal Values of High-Resolution Manometry in Supine and Upright Positions in a Thai Population. Dig Dis Sci 2018; 63:173-183. [PMID: 29143195 DOI: 10.1007/s10620-017-4838-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 11/03/2017] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Pitichote Hiranyatheb
- Division of General Surgery, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchatewe, Bangkok, 10400, Thailand. .,Endoscopic and Manometry Laboratory Unit, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Suriya Chakkaphak
- Division of General Surgery, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchatewe, Bangkok, 10400, Thailand.,Endoscopic and Manometry Laboratory Unit, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Supphamat Chirnaksorn
- Division of Gastroenterology and Tropical Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Endoscopic and Manometry Laboratory Unit, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pattaraporn Lekhaka
- Division of General Surgery, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchatewe, Bangkok, 10400, Thailand
| | - Kaimuk Petsrikun
- Endoscopic and Manometry Laboratory Unit, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kornkanok Somboonpun
- Surgical Research Unit, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Gyawali CP, Roman S, Bredenoord AJ, Fox M, Keller J, Pandolfino JE, Sifrim D, Tatum R, Yadlapati R, Savarino E. Classification of esophageal motor findings in gastro-esophageal reflux disease: Conclusions from an international consensus group. Neurogastroenterol Motil 2017; 29. [PMID: 28544357 DOI: 10.1111/nmo.13104] [Citation(s) in RCA: 128] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 04/10/2017] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - S Roman
- Digestive Physiology, Hospices Civils de Lyon and Lyon I University and Inserm U1032, LabTAU, Lyon, France
| | - A J Bredenoord
- Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - M Fox
- Department of Gastroenterology, Abdominal Center, St. Claraspital, Basel, Switzerland
| | - J Keller
- Department of Internal Medicine, Israelitic Hospital, University of Hamburg, Hamburg, Germany
| | - J E Pandolfino
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - D Sifrim
- Center for Digestive Diseases, Bart's and the London School and Dentistry, London, UK
| | - R Tatum
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - R Yadlapati
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - E Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, Padua, Italy
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High-resolution Impedance Manometry after Sleeve Gastrectomy: Increased Intragastric Pressure and Reflux are Frequent Events. Obes Surg 2017; 26:2449-56. [PMID: 26956879 DOI: 10.1007/s11695-016-2127-y] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION AND PURPOSE Sleeve gastrectomy (SG) is gaining ground in the field of bariatric surgery. Data are scarce on its impact on esophagogastric physiology. Our aim was to evaluate the impact of SG on esophagogastric motility with high-resolution impedance manometry (HRIM) and to assess the usefulness of HRIM in patients with upper gastrointestinal (GI) symptoms after SG. METHODS A retrospective analysis of 53 cases of HRIM performed after SG was conducted. Upper GI symptoms at the time of HRIM were scored. HRIM was analyzed according to the Chicago classification v3.0. A special attention was devoted to the occurrence of increased intragastric pressure (IIGP) after water swallows and reflux episodes as detected with impedance. A measurement of sleeve volume and diameter was performed with CT scan in a subgroup of patients. RESULTS IIGP occurred very frequently in patients after SG (77 %) and was not associated with any upper GI symptoms, specific esophageal manometric profile, or impedance reflux. Impedance reflux episodes were also frequently observed after SG (52 %): they were significantly associated with gastroesophageal reflux (GER) symptoms and ineffective esophageal motility. The sleeve volume and diameters were also significantly smaller in patients with impedance reflux episodes (p < 0.01). CONCLUSION SG significantly modified esophagogastric motility. IIGP is frequent, not correlated to symptoms, and should be regarded as a HRIM marker of SG. Impedance reflux episodes were also frequent, associated with GER symptoms and esophageal dysmotility. HRIM may thus have a clinical impact on the management of patients with upper GI symptoms after SG.
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Nadaleto BF, Herbella FAM, Pinna BR, Patti MG. Upper esophageal sphincter motility in gastroesophageal reflux disease in the light of the high-resolution manometry. Dis Esophagus 2017; 30:1-5. [PMID: 28375485 DOI: 10.1093/dote/dox001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- B F Nadaleto
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - F A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - B R Pinna
- Department of Ear, Nose and Throat, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - M G Patti
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
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Costa TV, Dantas RO. ESOPHAGEAL MOTILITY IN MEN AND WOMEN EVALUATED BY HIGH-RESOLUTION MANOMETRY. ARQUIVOS DE GASTROENTEROLOGIA 2017; 54:145-147. [PMID: 28273277 DOI: 10.1590/s0004-2803.201700000-10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 11/14/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Esophageal motility has been described in the literature as having differences between men and women. Most of these investigations use the water perfusion method for esophageal manometry. In this investigation the esophageal motility of men and women was compared with high-resolution manometry of the esophagus. OBJECTIVE To compare the esophageal motility of men and women with the high-resolution manometry method for esophageal manometry, performed in the sitting position. The hypothesis was that men and women have differences in esophageal motility. METHODS High-resolution manometry was performed in normal volunteers, 10 men [mean age: 37.5 (8.1) years] and 12 women [mean age: 38.7 (7.5) years], in the sitting position and with 10 swallows of a 5 mL bolus of saline, with an interval of at least 30 seconds between consecutive swallows. We evaluated the integrated relaxation pressure of the lower esophageal sphincter, contraction front velocity, distal contraction integral, distal latency, proximal contraction extension, proximal contraction duration >30 mmHg, proximal contraction duration, proximal contraction integral and maximal upper esophageal sphincter pressure. RESULTS There was no significant difference between men and women in the variables measured. CONCLUSION There was no difference in esophageal motility of men and women evaluated by the high resolution manometry method, in the sitting position with swallows of a liquid bolus.
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Affiliation(s)
- Tarciana Vieira Costa
- Hospital Universitário Lauro Wanderley, Universidade Federal da Paraíba, João Pessoa, PB, Brazil
| | - Roberto Oliveira Dantas
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto SP, Brazil
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Cock C, Besanko L, Kritas S, Burgstad CM, Thompson A, Heddle R, Fraser RJL, Omari TI. Impaired bolus clearance in asymptomatic older adults during high-resolution impedance manometry. Neurogastroenterol Motil 2016; 28:1890-1901. [PMID: 27346335 DOI: 10.1111/nmo.12892] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/30/2016] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- C Cock
- Gastroenterology & Hepatology, Southern Adelaide Local Health Network, Bedford Park, SA, Australia.,School of Medicine, Flinders University of South Australia, Adelaide, SA, Australia
| | - L Besanko
- Gastroenterology & Hepatology, Southern Adelaide Local Health Network, Bedford Park, SA, Australia
| | - S Kritas
- Gastroenterology Unit, Women's and Children's Health Network, Adelaide, SA, Australia
| | - C M Burgstad
- Gastroenterology & Hepatology, Southern Adelaide Local Health Network, Bedford Park, SA, Australia
| | - A Thompson
- Gastroenterology & Hepatology, Southern Adelaide Local Health Network, Bedford Park, SA, Australia
| | - R Heddle
- Gastroenterology & Hepatology, Southern Adelaide Local Health Network, Bedford Park, SA, Australia
| | - R J L Fraser
- Gastroenterology & Hepatology, Southern Adelaide Local Health Network, Bedford Park, SA, Australia.,School of Medicine, Flinders University of South Australia, Adelaide, SA, Australia
| | - T I Omari
- School of Medicine, Flinders University of South Australia, Adelaide, SA, Australia.,Gastroenterology Unit, Women's and Children's Health Network, Adelaide, SA, Australia.,Department of Human Physiology, Flinders University, Adelaide, Australia
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Practice guidelines on the use of esophageal manometry - A GISMAD-SIGE-AIGO medical position statement. Dig Liver Dis 2016; 48:1124-35. [PMID: 27443492 DOI: 10.1016/j.dld.2016.06.021] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 06/21/2016] [Indexed: 12/11/2022]
Abstract
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.
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Savarino E, Ottonello A, Tolone S, Bartolo O, Baeg MK, Farjah F, Kuribayashi S, Shetler KP, Lottrup C, Stein E. Novel insights into esophageal diagnostic procedures. Ann N Y Acad Sci 2016; 1380:162-177. [PMID: 27681220 DOI: 10.1111/nyas.13255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/12/2016] [Accepted: 08/22/2016] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
| | - Andrea Ottonello
- Department of Surgical and Diagnostic Integrated Sciences, University of Genoa, Genoa, Italy
| | - Salvatore Tolone
- Division of General and Bariatric Surgery, Department of Surgery, Second University of Naples, Naples, Italy
| | - Ottavia Bartolo
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Myong Ki Baeg
- Division of Gastroenterology, Department of Internal Medicine, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, Incheon, South Korea
| | - Farhood Farjah
- Division of Cardiothoracic Surgery, Surgical Outcomes Research Center, University of Washington, Seattle, Washington
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology, Gunma University Hospital, Maebashi, Japan
| | - Katerina P Shetler
- Division of Gastroenterology, Palo Alto Medical Foundation, Mountain View, California
| | - Christian Lottrup
- Department of Gastroenterology and Hepatology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark.,Department of Medicine, North Jutland Regional Hospital, Hjørring, Denmark
| | - Ellen Stein
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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Bitnar P, Stovicek J, Andel R, Arlt J, Arltova M, Smejkal M, Kolar P, Kobesova A. Leg raise increases pressure in lower and upper esophageal sphincter among patients with gastroesophageal reflux disease. J Bodyw Mov Ther 2016; 20:518-24. [DOI: 10.1016/j.jbmt.2015.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 11/16/2015] [Accepted: 12/01/2015] [Indexed: 01/12/2023]
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Crespin OM, Tatum RP, Yates RB, Sahin M, Coskun K, Martin AV, Wright A, Oelschlager BK, Pellegrini CA. Esophageal hypermotility: cause or effect? Dis Esophagus 2016; 29:497-502. [PMID: 25893778 DOI: 10.1111/dote.12367] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nutcracker esophagus (NE), Jackhammer esophagus (JHE), distal esophageal spasm (DES), and hypertensive lower esophageal sphincter (HTLES) are defined by esophageal manometric findings. Some patients with these esophageal motility disorders also have abnormal gastroesophageal reflux. It is unclear to what extent these patients' symptoms are caused by the motility disorder, the acid reflux, or both. The aim of this study was to determine the effectiveness of laparoscopic Nissen fundoplication (LNF) on esophageal motility disorders, gastroesophageal reflux, and patient symptoms. Between 2007 and 2013, we performed high-resolution esophageal manometry on 3400 patients, and 221 patients were found to have a spastic esophageal motility disorder. The medical records of these patients were reviewed to determine the manometric abnormality, presence of gastroesophageal symptoms, and amount of esophageal acid exposure. In those patients that underwent LNF, we compared pre- and postoperative esophageal motility, gastroesophageal symptom severity, and esophageal acid exposure. Of the 221 patients with spastic motility disorders, 77 had NE, 2 had JHE, 30 had DES, and 112 had HTLES. The most frequently reported primary and secondary symptoms among all patients were: heartburn and/or regurgitation, 69.2%; respiratory, 39.8%; dysphagia, 35.7%; and chest pain, 22.6%. Of the 221 patients, 192 underwent 24-hour pH monitoring, and 103 demonstrated abnormal distal esophageal acid exposure. Abnormal 24-hour pH monitoring was detected in 62% of patients with heartburn and regurgitation, 49% of patients with respiratory symptoms, 36.8 % of patients with dysphagia, and 32.6% of patients with chest pain. Sixty-six of the 103 patients with abnormal 24-hour pH monitoring underwent LNF. Thirty-eight (13NE, 2JHE, 6 DES, and 17 HTLES) of these 66 patients had a minimum of 6-month postoperative follow-up that included clinical evaluation, esophageal manometry, and 24-hour pH monitoring. Postoperatively, all 38 patients had normal distal esophageal acid exposure. Of these 38 patients, symptoms resolved in 28 and improved in 10. Of six patients (one with NE, two JHE, and three with HTLES) that underwent postoperative esophageal manometry, five exhibited normal motility. Typical reflux symptoms are common among patients with esophageal hypermotility disorders. Abnormal 24-hour pH monitoring is present in the majority of patients with who report typical reflux symptoms and almost half of patients who report respiratory symptoms. Conversely, the majority of patients who report dysphagia or chest pain have normal distal esophageal acid exposure. Based on a small number of patients in this study, it also appears that motility disorders often improve after LNF. LNF is associated with resolution or improvement in reflux related symptoms and esophageal motility parameters in patients exhibiting abnormal esophageal acid exposure. This suggests that patient symptoms are due to abnormal acid exposure and not the motility disorder.
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Affiliation(s)
- O M Crespin
- University of Washington, Surgery, Seattle, WA, USA
| | - R P Tatum
- University of Washington, Surgery, Seattle, WA, USA
| | - R B Yates
- University of Washington, Surgery, Seattle, WA, USA
| | - M Sahin
- University of Washington, Surgery, Seattle, WA, USA
| | - K Coskun
- University of Washington, Surgery, Seattle, WA, USA
| | - A V Martin
- University of Washington, Surgery, Seattle, WA, USA
| | - A Wright
- University of Washington, Surgery, Seattle, WA, USA
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