Indications and interpretation of esophageal function testing

Gastro-esophageal diagnostic workup before bariatric surgery or endoscopic treatment for obesity: position statement of the International Society of Diseases of the Esophagus

Obesity is a chronic and multifactorial condition characterized by abnormal weight gain due to excessive adipose tissue accumulation that represents a growing worldwide challenge for public health. In addition, obese patients have an increased risk of hiatal hernia, esophageal, and gastric dysfunction, as well as gastroesophageal reflux disease, which has a prevalence over 40% in those seeking endoscopic or surgical intervention. Surgery has been demonstrated to be the most effective treatment for severe obesity in terms of long-term weight loss, comorbidities, and quality of life improvements and overall mortality decrease. The recent emergence of bariatric endoscopic techniques promises less invasive, more cost-effective, and reproducible approaches to the treatment of obesity. With the endorsement of the International Society for Diseases of the Esophagus, we started a Delphi process to develop consensus statements on the most appropriate diagnostic workup to preoperatively assess gastroesophageal function before bariatric surgical or endoscopic interventions. The Consensus Working Group comprised 11 international experts from five countries. The group consisted of gastroenterologists and surgeons with a large expertise with regard to gastroesophageal reflux disease, bariatric surgery and endoscopy, and physiology. Ten statements were selected, on the basis of the agreement level and clinical relevance, which represent an evidence and experience-based consensus of the International Society for Diseases of the Esophagus.

De Novo Gastroesophageal Reflux Disease Symptoms Are Infrequent after Sleeve Gastrectomy at 2-Year Follow-Up Using a Comprehensive Preoperative Esophageal Assessment

Pathological obesity is a growing public health concern, and its association with gastroesophageal reflux disease (GERD) poses challenges in selecting the appropriate bariatric procedure. Sleeve gastrectomy (SG) has become a popular choice due to its simplicity and effectiveness in weight loss. However, concerns regarding postoperative GERD have been raised. This study aimed to evaluate the association between preoperative assessment of esophageal function and the risk of developing postoperative GERD in patients undergoing SG. A comprehensive evaluation was conducted, including symptom assessment, upper endoscopy, high-resolution esophageal manometry (HRM), and 24 h esophageal pH impedance monitoring (MII-pH). A total of 500 obese patients were included, and their data were compared with 25 healthy volunteers. This study revealed that patients without GERD symptoms, normal endoscopy, HRM, and MII-pH were suitable candidates for SG, with low risk of developing postoperative GERD. The addition of fundoplication techniques to SG may be considered in patients with mild reflux or those at risk of developing it. This study emphasizes the importance of preoperative evaluation in selecting the appropriate bariatric procedure to minimize the risk of postoperative GERD and expand the indications for SG in obese patients.

Effects of Helicobacter pylori eradication on esophageal motility, esophageal acid exposure, and gastroesophageal reflux disease symptoms

Background

The effects of Helicobacter pylori (HP) eradication on gastroesophageal reflux disease (GERD) are yet to be fully elucidated. Few studies have investigated the mechanisms underlying the correlations between HP and GERD with prospective methods. The objective of this prospective clinical study was to explore the effects of HP eradication on GERD.

Methods

Patients diagnosed with both GERD and HP were included. High-resolution esophageal manometry (HRM), 24-h esophageal pH monitoring, and the Gastroesophageal Reflux Disease Questionnaire (GerdQ) were performed before and after the successful eradication of HP, and the data were compared using statistical analysis.

Results

Sixty-eight patients diagnosed with both GERD and HP were included. The After HP eradication group showed significantly decreased median distal contractile integral (DCI) [610.40 (847.45) vs. 444.90 (559.60)] and significantly increased median inefficient esophageal motility (IEM) [36.00 (50.00) vs. 60.00 (57.00)] in the HRM compared with those of the Before HP eradication group, indicating that HP eradication reduced esophageal peristalsis. The 24-h esophageal pH monitoring showed that the longest reflux event, the percentage of time that the pH was <4, the number of reflux episodes, and the DeMeester score were all significantly different between the Before and After HP eradication groups (P < 0.05), suggesting that HP eradication increased esophageal acid exposure. The After HP eradication group also had a significantly higher GerdQ score than that of the Before HP eradication group (P < 0.05).

Conclusions

HP eradication reduced esophageal peristalsis, enhanced esophageal acid exposure, and aggravated GERD symptoms, suggesting that HP infection may be a protective factor for GERD.

Dietary factors involved in GERD management

Gastroesophageal reflux disease (GERD) is extremely common, and even modest weight gain has been associated with higher symptom burden as well as objective evidence of reflux on endoscopy and physiological measurement. Certain trigger foods, especially citrus, coffee, chocolate, fried food, spicy food and red sauces are frequently reported to worsen reflux symptoms, although hard evidence linking these items to objective GERD is lacking. There is better evidence that large meal volume and high calorie content can increase esophageal reflux burden. Conversely, sleeping with the head end of the bed raised, avoiding lying down close to meals, sleeping on the left side and weight loss can improve reflux symptoms and objective reflux evidence, especially when the esophagogastric junction 'reflux barrier' is compromised (e.g., in the presence of a hiatus hernia). Consequently, attention to diet and weight loss are both important elements of management of GERD, and need to be incorporated into management plans.

Ambulatory pH-Impedance Findings Confirm That Grade B Esophagitis Provides Objective Diagnosis of Gastroesophageal Reflux Disease

INTRODUCTION

The Lyon Consensus designates Los Angeles (LA) grade C/D esophagitis or acid exposure time (AET) >6% on impedance-pH monitoring (MII-pH) as conclusive for gastroesophageal reflux disease (GERD). We aimed to evaluate proportions with objective GERD among symptomatic patients with LA grade A, B, and C esophagitis on endoscopy.

METHODS

Demographics, clinical data, endoscopy findings, and objective proton-pump inhibitor response were collected from symptomatic prospectively enrolled patients from 2 referral centers. Off-therapy MII-pH parameters included AET, number of reflux episodes, mean nocturnal baseline impedance, and postreflux swallow-induced peristaltic wave index. Objective GERD evidence was compared between LA grades.

RESULTS

Of 155 patients (LA grade A: 74 patients, B: 61 patients, and C: 20 patients), demographics and presentation were similar across LA grades. AET >6% was seen in 1.4%, 52.5%, and 75%, respectively, in LA grades A, B, and C. Using additional MII-pH metrics, an additional 16.2% with LA grade A and 47.5% with LA grade B esophagitis had AET 4%-6% with low mean nocturnal baseline impedance and postreflux swallow-induced peristaltic wave index; there were no additional gains using the number of reflux episodes or symptom-reflux association metrics. Compared with LA grade C (100% conclusive GERD based on endoscopic findings), 100% of LA grade B esophagitis also had objective GERD but only 17.6% with LA grade A esophagitis ( P < 0.001 compared with each). Proton-pump inhibitor response was comparable between LA grades B and C (74% and 70%, respectively) but low in LA grade A (39%, P < 0.001).

DISCUSSION

Grade B esophagitis indicates an objective diagnosis of GERD.

Value of 96-hour ambulatory esophageal pH monitoring in the assessment of patients with refractory acid reflux symptoms and their response to anti-reflux diet

Ambulatory esophageal pH monitoring is a diagnostic tool in patients with heartburn and regurgitation. The aim of this study is to evaluate 96-hour esophageal pH monitoring in patients with gastroesophageal reflux disease (GERD), at baseline and under diet that impedes GER. We hypothesized that diet would potentially reduce pathologic acid exposure time (AET). Retrospective series of 88 patients with GERD undergoing wireless 96-hour pH monitoring. Two-day (48 hours) tandem periods, one on liberal, followed by another on restricted diet assessed esophageal AET. Primary end point was >30% reduction in AET while on anti-GER diet. Of the 88 patients, 16 were excluded because of probe migration. Endoscopy and biopsies assessed erosive esophagitis (EE) and Barrett's esophagus (BE), or normal esophagus. Abnormal AET (% pH < 4.0 ≥ 6) further defined nonerosive reflux disease (NERD), whereas normal AET (% pH < 4.0 < 6) with normal endoscopy defined patients as functional heartburn (FH). There were 6 patients with EE (n = 5) and BE (n = 1), 23 with NERD and 43 with FH. Anti-GER diet led to >30% reduction in AET in EE and NERD patients, but not in those with FH. Most patients (n = 43/72; 60%) had FH and could have avoided acid suppression. Furthermore, (14/23; 61%) of patients with NERD completely normalized AET with diet, potentially negating acid suppression. Ninety-six-hour esophageal pH distinguishes GERD patients from those with FH. Fifty percent of EE/BE patients and 61% of those with NERD completely normalize AET with diet. If pathologic AET occurs despite diet, acid suppression is indicated.

Concise Review: Applicability of High-resolution Manometry in Gastroesophageal Reflux Disease

Manometry, particularly high-resolution manometry is the preferred diagnostic tool used to evaluate esophageal motor function. This investigation is strongly indicated in the setting of dysphagia, but is also useful in gastroesophageal reflux disease (GERD), especially in case of failure of conventional treatment to exclude alternative diagnoses and prior to anti-reflux surgery. Moreover, ineffective esophagogastric junction barrier function and esophageal motor dysfunction are pathophysiological mechanisms in GERD and can be identified by manometry. The recent international guidelines have positioned high-resolution manometry as an important part of functional diagnostic work up in GERD in order to identify the GERD phenotype to guide specific treatment. The proposed manometric identification and measurement is based on the Chicago classification version 4.0 adding with new established metrics for GERD evaluation.

Chicago classification v4.0 protocol improves specificity and accuracy of diagnosis of oesophagogastric junction outflow obstruction

BACKGROUND

Chicago classification version 4.0 (CCv4.0) introduced stringent diagnostic criteria for oesophagogastric junction outflow obstruction (EGJOO), in order to increase the clinical relevance of the diagnosis, although this has not yet been demonstrated.

AIMS

To determine the prevalence of EGJOO using CCv4.0 criteria in patients with CCv3.0-based EGJOO, and to assess if provocative manoeuvres can predict a conclusive CCv4.0 diagnosis of EGJOO.

METHODS

Clinical presentation, high resolution manometry (HRM) with rapid drink challenge (RDC), and timed barium oesophagogram (TBE) data were extracted for patients diagnosed with EGJOO as per CCv3.0 between 2018 and 2020. Patients were then re-classified according to CCv4.0 criteria, using clinically relevant symptoms (dysphagia and/or chest pain), and abnormal barium emptying at 5 min on TBE. Receiver operating characteristic (ROC) analyses identified HRM predictors of EGJOO.

RESULTS

Of 2010 HRM studies, 144 (7.2%) fulfilled CCv3.0 criteria for EGJOO (median age 61 years, 56.9% female). Upon applying CCv4.0 criteria, EGJOO prevalence decreased to 1.2%. On ROC analysis, integrated relaxation pressure during RDC (RDC-IRP) was a significant predictor of a conclusive EGJOO diagnosis by CCv4.0 criteria (area under the curve: 96.1%). The optimal RDC-IRP threshold of 16.7 mm Hg had 87% sensitivity, 97.1% specificity, 95.7% negative predictive value and 91.3% positive predictive value for a conclusive EGJOO diagnosis; lower thresholds (10 mmHg, 12 mmHg) had better sensitivity but lower specificity.

CONCLUSION

CCv4.0 criteria reduced the prevalence of EGJOO by 80%, thereby refining the diagnosis and identifying clinically relevant outflow obstruction. Elevated RDC-IRP can predict conclusive EGJOO per CCv4.0.

A Comparative Assessment of the Diagnosis of Swallowing Impairment and Gastroesophageal Reflux in Canines and Humans

Swallowing impairment is a highly prevalent and clinically significant problem affecting people and dogs. There are myriad causes of swallowing impairment of which gastroesophageal reflux is the most common in both species. Similarities in anatomy and physiology between humans and canines results in analogous swallowing disorders including cricopharyngeus muscle achalasia, esophageal achalasia, hiatal herniation, and gastroesophageal reflux with secondary esophagitis and esophageal dysmotility. Accordingly, the diagnostic approach to human and canine patients with swallowing impairment is similar. Diagnostic procedures such as swallowing fluoroscopy, high-resolution manometry, pH/impedance monitoring, and endolumenal functional luminal imaging probe can be performed in both species; however, nasofacial conformation, increased esophageal length, and the difficulty of completing several of these procedures in awake dogs are inherent challenges that need to be considered. Human patients can convey their symptoms and respond to verbal cues, whereas veterinarians must rely on clinical histories narrated by pet owners followed by comprehensive physical examination and observation of the animal eating different food consistencies and drinking water. Dogs may also be unwilling to drink or eat in the hospital setting and may be resistant to physical restraint during diagnostic procedures. Despite the species differences and diagnostic challenges, dogs are a natural animal model for many oropharyngeal and esophageal disorders affecting people, which presents a tremendous opportunity for shared learnings. This manuscript reviews the comparative aspects of esophageal anatomy and physiology between humans and canines, summarizes the diagnostic assessment of swallowing impairment in both species, and discusses future considerations for collaborative medicine and translational research.

High-Resolution Manometry Thresholds and Motor Patterns Among Asymptomatic Individuals

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Clinical use of mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index for the diagnosis of gastro-esophageal reflux disease

The clinical diagnosis of gastro-esophageal reflux disease (GERD) is based on the presence of typical esophageal troublesome symptoms. In clinical practice, heartburn relief following a proton pump inhibitor (PPI) trial or endoscopy can confirm a diagnosis of GERD. In cases of diagnostic uncertainty or before anti-reflux interventions, combined impedance-pH monitoring (MII-pH) provides a comprehensive assessment of both physical and chemical properties of the refluxate, allowing to achieve a conclusive diagnosis of GERD. Recently, the Lyon Consensus proposed the use of mean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic wave index (PSPW-I) as novel MII-pH metrics to support the diagnosis of GERD. The calculation of MNBI and PSPW-I currently needs to be performed manually, but artificial intelligence systems for the automated analysis of MII-pH tracings are being developed. Several studies demonstrated the increased diagnostic yield MNBI and PSPW-I for the categorization of patients with GERD at both on- and off-PPI MII-pH monitoring. Accordingly, we performed a narrative review on the clinical use and diagnostic yield of MNBI and PSPW-I when the diagnosis of GERD is uncertain. Based on currently available evidence, we strongly support the evaluation of PSPW-I and MNBI as part of the standard assessment of MII-pH tracings for the evaluation of GERD, especially in patients with endoscopy-negative heartburn.

ESOPHAGEAL FUNCTIONAL DISORDERS IN THE PRE-OPERATORY EVALUATION OF BARIATRIC SURGERY

BACKGROUND

Obesity is an independent risk factor for esophageal symptoms, gastroesophageal reflux disease (GERD), and motor abnormalities. When contemplating bariatric surgery, patients with obesity type III undergo esophagogastroduodenoscopy (EGD) and also esophageal manometry (EMN), and prolonged pHmetry (PHM) as part of their pre-operative evaluation.

OBJECTIVE

Description of endoscopy, manometry and pHmetry findings in patients with obesity type III preparing for bariatric surgery, and correlation of these findings with the presence of typical GERD symptoms.

METHODS

Retrospective study in which clinical symptoms of GERD were assessed, focusing on the presence of heartburn and regurgitation. All patients underwent EMN, PHM and most of them EGD.

RESULTS

114 patients (93 females-81%), average age 36 years old, average BMI of 45.3, were studied. Typical GERD symptoms were referred by 43 (38%) patients while 71 (62%) were asymptomatic. Eighty two patients (72% of total) underwent EGD and 36 (42%) evidenced esophageal abnormalities. Among the abnormal findings, hiatal hernia was seen in 36%, erosive esophagitis (EE) in 36%, and HH+EE in 28%. An abnormal EMN was recorded in 51/114 patients (45%). The main abnormality was a hypotensive lower esophageal sphincter (LES) in 32%, followed by ineffective esophageal motility in 25%, nutcracker esophagus in 19%, IEM + hypotensive LES in 10%, intra-thoracic LES (6%), hypertensive LES (4%), aperistalsis (2%) and achalasia (2%). Among the 43 symptomatic patients, 23 (53%) had abnormal EMN and 31/71 asymptomatic cases (44%) also presented this finding (P=0.30). PHM showed abnormal reflux in 60/114 patients (53%), with a predominance of bi-positional reflux (42%), followed by supine reflux (33%) and upright reflux (25%). Abnormal PHM was found in 26/43 symptomatic cases (60%) and also among 34/71 asymptomatic cases (48%) (P=0.19).

CONCLUSION

Manometric abnormalities were common in obesity type III patients, the most frequent being hypotensive LES, followed by IEM. Most patients were asymptomatic. There was no correlation between the finding of motor abnormalities and the presence of symptoms. More than half the patients had abnormal reflux at PHM. We found no significant correlation between abnormal reflux and the presence of symptoms.

Erosive Esophagitis and Symptoms of Gastroesophageal Reflux Disease in Patients with Morbid Obesity with and without Type 2 Diabetes: a Cross-sectional Study

BACKGROUND

Type 2 diabetes (T2DM) is associated with gastroesophageal reflux disease (GERD) in the general population, but the relationship between these conditions in candidates for bariatric surgery is uncertain. We compared the prevalence of GERD and the association between GERD symptoms and esophagitis among bariatric candidates with and without T2DM.

METHODS

Cross-sectional study of baseline data from the Oseberg study in Norway. Both groups underwent gastroduodenoscopy and completed validated questionnaires: Gastrointestinal Symptom Rating Scale and Gastroesophageal Reflux Disease Questionnaire. Participants with T2DM underwent 24-h pH-metry.

RESULTS

A total of 124 patients with T2DM, 81 women, mean (SD) age 48.6 (9.4) years and BMI 42.3 (5.5) kg/m², and 64 patients without T2DM, 46 women, age 43.0 (11.0) years and BMI 43.0 (5.0) kg/m², were included. The proportions of patients reporting GERD-symptoms were low (< 29%) and did not differ significantly between groups, while the proportions of patients with esophagitis were high both in the T2DM and non-T2DM group, 58% versus 47%, p = 0.16. The majority of patients with esophagitis did not have GERD-symptoms (68-80%). Further, 55% of the patients with T2DM had pathologic acid reflux. Among these, 71% also had erosive esophagitis, whereof 67% were asymptomatic.

CONCLUSIONS

The prevalence of GERD was similar in bariatric patients with or without T2DM, and the proportion of patients with asymptomatic GERD was high independent of the presence or absence of T2DM. Accordingly, GERD may be underdiagnosed in patients not undergoing a preoperative endoscopy or acid reflux assessment.

TRIAL REGISTRATION

Clinical Trials.gov number NCT01778738.

Bile reflux in patients with nerd is associated with more severe heartburn and lower values of mean nocturnal baseline impedance and chemical clearance

BACKGROUND

Mean nocturnal baseline impedance (MNBI) and postreflux swallow-induced peristaltic wave (PSPW) index are novel impedance-based markers of reflux, but the effect of bile reflux on these metrics is unknown. The aim of this study was to evaluate bile reflux, MNBI, and PSPW index in patients with endoscopy-negative GERD partially responsive to PPI therapy.

METHODS

All patients underwent off-PPI endoscopy, esophageal manometry, multichannel intraluminal impedance pH (MII-pH), and bile reflux monitoring. Abnormal esophageal acid exposure time (AET) was required for inclusion. Symptom intensity (using 10-cm visual analog scales), and conventional and novel MII-pH metrics were compared between patients with and without abnormal bile reflux.

KEY RESULTS

We evaluated 42 NERD patients (29 males, mean age: 53.4 ± 13. years), mean AET 6.1 ± 2%, of which 21 had abnormal bile reflux (Group A, 10.2 ± 4.9%), and 21 had normal bile reflux (Group B, 0.4 ± 0.1%, P < .05 compared with Group A). Heartburn reporting on PPI was higher in Group A (7.2 ± 2.1 vs 5.8 ± 0.9; P = .002), but AET, number of reflux events (acidic and weakly acidic), did not differ between the two groups. However, both PSPW index and MNBI were lower in Group A (P < .001). A strong inverse linear correlation was found between bile reflux and both MNBI (Pearson's test; R = -0.714; P < .001) and PSPW index (R = -0.722; P < .001).

CONCLUSIONS AND INFERENCES

Compared to acid reflux alone, the presence of bile in an acidic esophageal environment is associated with more severe heartburn, lesser relief from PPI therapy, higher impairment of esophageal mucosal integrity and less effective chemical clearance.

Prolonged Wireless pH Monitoring in Patients With Persistent Reflux Symptoms Despite Proton Pump Inhibitor Therapy

BACKGROUND & AIMS

Wireless pH monitoring measures esophageal acid exposure time (AET) for up to 96 hours. We evaluated competing methods of analysis of wireless pH data.

METHODS

Adult patients with persisting reflux symptoms despite acid suppression (n = 322, 48.5 ± 0.9 years, 61.7% women) from 2 tertiary centers were evaluated using symptom questionnaires and wireless pH monitoring off therapy, from November 2013 through September 2017; 30 healthy adults (control subjects; 26.9 ± 1.5 years; 60.0% women) were similarly evaluated. Concordance of daily AET (physiologic <4%, borderline 4%-6%, pathologic>6%) for 2 or more days constituted the predominant AET pattern. Each predominant pattern (physiologic, borderline, or pathologic) in relation to data from the first day, and total averaged AET, were compared with other interpretation paradigms (first 2 days, best day, or worst day) and with symptoms.

RESULTS

At least 2 days of AET data were available from 96.9% of patients, 3 days from 90.7%, and 4 days from 72.7%. A higher proportion of patients had a predominant pathologic pattern (31.4%) than control subjects (11.1%; P = .03). When 3 or more days of data were available, 90.4% of patients had a predominant AET pattern; when 2 days of data were available, 64.1% had a predominant AET pattern (P < .001). Day 1 AET was discordant with the predominant pattern in 22.4% of patients and was less strongly associated with the predominant pattern compared with 48 hour AET (P = .059) or total averaged AET (P = .02). Baseline symptom burden was higher in patients with a predominant pathologic pattern compared with a predominant physiologic pattern (P = .02).

CONCLUSIONS

The predominant AET pattern on prolonged wireless pH monitoring can identify patients at risk for reflux symptoms and provides gains over 24 hours and 48 hours recording, especially when results from the first 2 days are discordant or borderline.

Esophageal reflux hypersensitivity: Non-GERD or still GERD?

The most recent iteration of the classifications for functional esophageal disorders, Rome IV, proposed relevant modifications of the previous definitions for Rome III. They specifically considered increased esophageal acid exposure as the marker of gastroesophageal reflux disease (GERD), including the remaining part of non-erosive reflux disease patients with normal acid in the group with functional alterations, considering both reflux hypersensitivity and functional heartburn. However, recent pathophysiological and therapeutic data suggest the need for a return to including reflux hypersensitivity in the GERD spectrum. Indeed, physiologic alterations in esophageal mucosal integrity and chemical clearance, the presence of microscopic esophagitis, and strict symptom-reflux association support the concept that reflux hypersensitivity pertains to GERD. Surgical anti-reflux therapy has resulted in positive outcomes, even in the long term, in patients with reflux hypersensitivity and not in those with functional heartburn. Moreover, clinical trials using neuromodulators have been scarce and provided conflicting results. As a result, the real progress of the Rome IV classifications is in dispute. This article aims to summarize the most recent knowledge of non-erosive reflux disease and reflux hypersensitivity to discuss the utility of Rome IV criteria in the identification and management of functional esophageal disorders.

Clinical Assessment of Gastrointestinal Involvement in Patients with Systemic Sclerosis

Systemic sclerosis (SSc) has the potential to affect any component of the gastrointestinal (GI) tract. GI involvement in SSc is a leading cause of morbidity and overall decreased quality of life in this patient population, identifying a need for a concise approach to work-up. This literature review aims to present a systematic, anatomical approach and differential diagnosis of GI involvement in SSc for the general internist and rheumatologist. Each component of the luminal GI tract has its own specified section, beginning with a review of a clinical approach to diagnosis that includes a differential for clinicians to consider, followed by a discussion of the literature surrounding objective evaluation of these conditions (i.e. serologic studies, imaging, endoscopy). Additionally there is a focused discussion on an approach to GI bleeding in the patient with SSc.

A SIGE-SINGEM-AIGO technical review on the clinical use of esophageal reflux monitoring

Patients with esophageal symptoms potentially associated with gastroesophageal reflux disease such as heartburn, regurgitation, chest pain, or cough represent one of the most frequent reasons for referral to gastroenterological evaluation. The utility of esophageal reflux monitoring in clinical practice is: (1) to accurately define reflux burden, (2) to segregate patients according to reflux monitoring results as true GERD, reflux hypersensitivity and functional heartburn, and (3) to establish a treatment plan. With this in mind, in the last decade, investigations and technical advances, with the introduction of impedance-pH monitoring and wireless pH capsule, have enhanced our understanding and management of GERD. The following recommendations were discussed and approved after a comprehensive review of the medical literature pertaining to reflux testing techniques and their recent application. This review created under the auspices of the Società Italiana di Gastroenterologia ed Endoscopia Digestiva (SIGE), Società Italiana di Neuro-Gastro-Enterologia e Motilità (SINGEM) and Associazione Italiana Gastroenterologi ed Endoscopisti Digestivi Ospedalieri (AIGO) is intended to help clinicians in applying reflux studies in the most fruitful manner within the context of their patients with esophageal symptoms.

Rethinking gastroesophageal reflux disorder

Gastroesophageal reflux disease (GERD) is a common clinical condition for which our understanding has evolved over the past decades. It is now considered a cluster of phenotypes with numerous anatomical and physiological abnormalities contributing to its pathophysiology. As such, it is important to first understand the underlying mechanism of the disease process for each patient before embarking on therapeutic interventions. The aim of our paper is to highlight the mechanisms contributing to GERD and review investigations and interpretation of these results. Finally, the paper reviews the available treatment modalities for this condition, ranging from medical intervention, endoscopic options through to surgery and its various techniques.

Ninety-Six Hour Wireless Esophageal pH Study in Patients with GERD Shows that Restrictive Diet Reduces Esophageal Acid Exposure

BACKGROUND

Prolonged (96 h) pH monitoring may explore the effect of diet on pH and symptoms in patients with GERD.

AIMS

To assess the usefulness of a 96 h esophageal pH study in patients with GER symptoms under different diets (pro- and anti-GER).

METHODS

Prospective study of 66 patients with GERD undergoing wireless 96 h pH monitoring. Two-day periods, one on liberal (pro-reflux) and another on restricted (anti-reflux) diet assessed esophageal acid exposure and symptoms. The primary end point was normalization of acid exposure time while on restricted diet. Secondary end point was a > 50% reduction in symptoms with restricted diet.

RESULTS

Normal (pH time < 4 of < 6%) was found in 34 patients (51.5%) while on the initial 48 h (liberal) diet [median % time < 4: 3.2 (95% CI, 1.9, 4.0)] and remained normal while on restricted diet [median % time < 4: 2.6 (95% CI, 0.8, 3.4)]. Abnormal acid exposure (% pH time < 4: > 6%) was found in 32 patients (48.5%) while on initial 48 h liberal diet [median % time < 4: 10.5, (95% CI 8.9, 12.6)], and decreased significantly with restricted diet [median % time < 4: 4.5 (95% CI 3.1, 7.3)] (p = 0.001), and normalized with anti-GERD diet in 21 patients (65.6%). Only 11/66 patients were candidates for proton pump inhibitor (PPI) use; 34 had either normal pH studies or normalized them with restricted diet (n = 21). Symptoms did not improve with restricted diet.

CONCLUSIONS

The 96-h esophageal pH study tests for GERD under pro- and anti-GER diets and allows minimization of PPI therapy to only 16.6% of patients.

Esophageal physiology-an overview of esophageal disorders from a pathophysiological point of view

The esophagus serves the principal purpose of transporting food from the pharynx into the stomach. A complex interplay between nerves and muscle fibers ensures that swallowing takes place as a finely coordinated event. Esophageal function can be tested by a variety of methods, endoscopy, manometry, and reflux monitoring being some of the most important. Regarding pathophysiology, motor disorders, such as achalasia, often cause dysphagia and/or chest pain. Functional esophageal disorders are a heterogeneous group with hypersensitivity as a dominant pathophysiological factor. Gastroesophageal reflux disease often causes symptoms, such as heartburn and regurgitation, and a spectrum of disease, ranging from minimal mucosal damage visible only in the microscope to esophageal ulcers and strictures in the most severe cases. Eosinophilic esophagitis is an immune-mediated condition that can result in significant dysphagia and associated luminal narrowing. In the following, we will provide an overview of the most common esophageal disorders from a combined pathophysiological and clinical view.

Higher Esophageal Symptom Burden in Obese Subjects Results From Increased Esophageal Acid Exposure and Not From Dysmotility

BACKGROUND & AIMS

Esophageal motor disorders (EMD) and pathologic reflux are often identified in obese individuals, but it is not clear how obesity contributes to these symptoms. We examined the relationships among symptom burden, EMD, acid exposure time (AET), symptom association probability, and body mass index (BMI).

METHODS

We performed a retrospective study of 1089 consecutive patients who underwent high-resolution manometry, of which 426 patients also underwent reflux monitoring off acid suppression, over a 2-year period at a tertiary referral center. Symptom burden was assessed by questionnaires to determine dominant symptom intensity (DSI; product of symptom severity, and frequency, on 5-point Likert scales) and global symptom severity (GSS; global esophageal symptoms on 10-cm visual analog scales) at the time of esophageal testing; BMIs were recorded. We compared proportions of patients with EMD and abnormal reflux burden among BMI categories and correlated them with symptom burden.

RESULTS

Four-hundred thirty-three patients (39.8%) met the criteria for EMD. Esophageal outflow obstruction was observed in higher proportions of patients with low BMIs (underweight, 25.9%; normal, 14.1%; overweight, 13.9%; and obese, 9.8%; P = .037), but EMDs were less frequent in obese patients (P = .047), despite higher symptom burden compared with non-obese patients (DSI, 10.5 ± 0.3 vs 9.7 ± 0.2; P = .03 and GSS, 6.5 ± 1 vs 5.9 ± 1; P = .01). Among the 426 patients who underwent reflux monitoring, the proportions with total AET (P = .02), and upright AET (P < .001) increased among BMI categories, supine AET trended strongly (P = .06), in combination with increasing DSI and GSS (P ≤ .001 for each comparison). BMI correlated with symptom burden, higher AET, and positive symptom association probability (P < .01 for each analysis).

CONCLUSIONS

Increased symptom burden in obese individuals correlates with esophageal acid burden but not with motor disorders.

Changes in high-resolution manometric diagnosis over time: implications for clinical decision-making

Although High resolution esophageal manometry (HRM) is the gold standard to assess esophageal motility, little is known about the stability of the manometric diagnosis over time and its implications for management. To assess the stability and usefulness of repeat HRM in patients presenting with esophageal symptoms over time we performed this retrospective study of patients with esophageal symptoms. Medical records, questionnaires, and HRM tracing were independently reviewed using the Chicago classification. The primary objective was to assess the stability of the manometric diagnosis over time; secondary objective was its change (positive or negative). At least one repeat study was performed in 86 patients (36% women, ages 20-86, with mild to moderate symptoms), while 26 had a third procedure. Mean intervals between studies were 15 ± 1.6 months (for baseline v. first study) and 13 ± 0.8 months (for second to third study). Of the 27 patients initially with a normal study, 11 changed (five had esophago-gastric junction outflow obstruction [EGJOO], two diffuse esophageal spasm [DES], one jackhammer esophagus [JE], and three ineffective esophageal motility [IEM] [41% change]). Of the 24 patients with initial EGJOO, only nine retained it (65.2% change). Of nine patients with initial DES, four changed (44.4% change). Similarly, different diagnosis was seen in 7 of 24 initial IEM patients (22.7% change). Only one patient had achalasia initially and this remained stable. Additional changes were noted on a third HRM. Fluidity in the HRM diagnosis over time questions its validity at any timepoint and raises doubts about the need for intervention.

Mean Nocturnal Baseline Impedance Correlates With Symptom Outcome When Acid Exposure Time Is Inconclusive on Esophageal Reflux Monitoring

BACKGROUND & AIMS

Abnormal acid exposure time (AET) is associated with good outcomes of symptoms from antireflux therapy. Low esophageal mean nocturnal baseline impedance (MNBI) is an additional marker of reflux disease. We aimed to evaluate the value of MNBI when analysis of AET produces borderline or inconclusive results.

METHODS

We studied a retrospective cohort of 371 patients (mean age, 54.5 ± 0.7 y; 60.0% female) who had persistent reflux symptoms after treatment and underwent ambulatory pH-impedance monitoring off antisecretory therapy at 1 tertiary center in Europe or 1 in the United States. Total AET was determined from pH impedance studies (pathologic, >6%; physiologic, <4%; borderline or inconclusive, 4%-6%). Baseline impedance values were calculated at the 5-cm impedance channel at 3 nocturnal 10-minute periods and averaged to yield MNBI (abnormal, <2292 ohms). The primary outcome was response to antireflux therapy, defined as global symptom improvement of 50% or greater on patients' answers on standardized visual analog scales.

RESULTS

Among the 371 patients, 107 (28.8%) had pathologic AET and 234 (63.1%) had abnormal MNBI. Low MNBI was concordant in 99.1% of patients with pathologic AET, in 91.2% with borderline AET, and in 33.7% with physiologic AET. During 38.7 ± 0.8 months of follow-up evaluation, 43.0% of patients had improved symptoms with medical therapy and 76.2% had improved symptoms with surgical antireflux therapy (P < .0001). When MNBI was low, response to medical therapy did not differ significantly between patients with borderline AET and patients with pathologic AET (P = .44), but did differ significantly when each group was compared with patients with physiologic AET, regardless of whether MNBI was normal or low (P < .0001 for each comparison).

CONCLUSIONS

When low, MNBI identifies patients with pathologic and borderline AET who respond to antireflux therapy. MNBI analysis complements AET in defining esophageal reflux burden. MNBI correlates with response of symptoms to antireflux therapy.

Fragmented and failed swallows on esophageal high-resolution manometry associate with abnormal reflux burden better than weak swallows

BACKGROUND

Association between proportions of hypomotile swallows on esophageal high-resolution manometry (HRM) and esophageal reflux burden remains incompletely understood. We investigated relationships between hypomotility, acid exposure time (AET), and mean nocturnal baseline impedance (MNBI) on ambulatory reflux monitoring.

METHODS

Clinical data, HRM, and ambulatory pH-impedance studies (performed off acid suppression) from patients with persisting reflux symptoms were reviewed from five international centers. AET (abnormal > 6%) and MNBI (abnormal < 2292 ohms) were extracted from pH-impedance studies. Distal contractile integral (DCI) designated esophageal peristalsis into normal (DCI > 450 mmHg.cm.s), fragmented (DCI > 450 mmHg.cm.s with breaks > 5 cm), weak (DCI 100-450 mmHg.cm.s), and failed (DCI < 100 mm mmHg.cm.s) sequences. Univariate and multivariate analyses were performed to identify motor associations of abnormal reflux burden.

KEY RESULTS

Of 351 patients (52.1 ± 0.8 years, 67%F), 29.3% had AET > 6% and 61.8% had MNBI < 2292 ohms. On univariate analysis, both fragmented peristalsis and IEM associated with abnormal AET (P ≤ .01) and MNBI (P ≤ .03); reflux burden was more profound with >70% fragmented as well as ineffective sequences compared to ≤70% for each (P < .05 for each comparison). When weak and failed sequences within IEM were separately analyzed, ≥50% failed sequences predicted abnormal AET (P ≤ .009), and ≥50% weak sequences did not (P = .14). On multivariate regression, ≥50% failed sequences predicted abnormal AET (P = .02), and >70% ineffective sequences trended strongly (P = .069); >70% ineffective sequences predicted abnormal MNBI (P = .046), and >70% fragmented sequences trended strongly (P = .076).

CONCLUSIONS AND INFERENCES

Breaks in esophageal peristaltic integrity seen with fragmented and failed sequences are more relevant to abnormal esophageal acid burden than weak sequences.

Esophageal High-Resolution Manometry Can Unravel the Mechanisms by Which Different Bariatric Techniques Produce Different Reflux Exposures

INTRODUCTION

Bariatric surgery is increasingly performed. Since there are numerous surgical techniques, the effects of these on the esophageal function are still poorly understood. We aimed at assessing the effect of different techniques on esophagogastric junction (EGJ), esophageal peristalsis and reflux exposure using high-resolution manometry (HRM), and impedance-pH monitoring (MII-pH).

METHODS

All obese patients underwent symptomatic questionnaires, endoscopy, HRM, and MII-pH before and 1 year after surgery. Esophageal function and EGJ were classified according to Chicago Classification V. 3.0. Intragastric pressure (IGP) and gastroesophageal pressure gradient (GEPG) were assessed. Total acid exposure time (AET %), total number of refluxes, and symptom association probability (SAP) were assessed. A group of healthy volunteers (HVs) served as control.

RESULTS

One hundred and twelve obese subjects and 15 HVs (normal weight) were studied. Thirteen underwent endoscopic balloon placement (BIB), 12 gastric banding (GB), 26 sleeve gastrectomy (SG), 18 Roux-en-Y gastric bypass (RYGB), 15 mini-gastric bypass (MGB), 16 biliointestinal bypass (BIBP), and 12 biliopancreatic diversion (BPD). IGP and GEPG significantly decreased after RYGP, BPD, and BPBP, whereas they significantly increased after GB and SG. Post-operative greater AET (p < 0.05) and increased total number of reflux (p < 0.001) were present after GB and SG. RYGB and MGB showed a significant decrease in AET (p < 0.05) and total number of reflux (p < 0.001).

CONCLUSIONS

HRM verified that different bariatric techniques produced different modification of IGP and GEPG, leading to different reflux exposure. Only GB and SG can negatively impact on esophageal function and reflux exposure.

Jackhammer esophagus with and without esophagogastric junction outflow obstruction demonstrates altered neural control resembling type 3 achalasia

BACKGROUND

Esophageal hypercontractility can manifest with and without esophagogastric junction (EGJ) outflow obstruction. We investigated clinical presentations and motility patterns in patients with esophageal hypercontractile disorders.

METHODS

Esophageal HRM studies fulfilling Chicago Classification 3.0 criteria for jackhammer esophagus (distal contractile integral, DCI >8000 mmHg.cm.s in ≥ 20% swallows) with (n = 30) and without (n = 83) EGJ obstruction (integrated relaxation pressure, IRP > 15 mm Hg) were retrospectively reviewed from five centers (4 in Europe, 1 in US). Single swallows (SS) and multiple rapid swallows (MRS) were analyzed using HRM software tools (IRP, DCI, distal latency, DL); MRS: SS DCI ratio >1 defined contraction reserve. Comparison groups were achalasia type 3 (n = 72, positive control for abnormal inhibition and EGJ obstruction) and healthy controls (n = 18). Symptoms, HRM metrics, and MRS contraction reserve were analyzed within jackhammer subgroups and comparison groups.

KEY RESULTS

The esophageal smooth muscle was excessively stimulated at baseline in jackhammer subgroups, with lack of augmentation following MRS identified more often compared with controls (P = .003) and type 3 achalasia (P = .07). Consistently abnormal inhibition was identified in type 3 achalasia (47%), and to a lower extent in jackhammer with obstruction (37%, P = .33), jackhammer esophagus (28%, P = .01), and controls (11%, P < .01 compared with type 3 achalasia). Perceptive symptoms (heartburn, chest pain) were common in jackhammer esophagus (P < .01 compared with type 3 achalasia), while transit symptoms (dysphagia) were more frequent with presence of EGJ obstruction (P ≤ .01 compared with jackhammer without obstruction).

CONCLUSIONS AND INFERENCES

The balance of excessive excitation and abnormal inhibition defines clinical and manometric manifestations in esophageal hypercontractile disorders.

Advancements in the use of manometry and impedance testing for esophageal functional disorders

The utilization of high-resolution manometry (HRM) has enhanced our understanding and assessment of esophageal motor disorders. Moreover, the combination of impedance technology with HRM (HRIM) has further improved our knowledge of esophageal physiology and the clinical evaluation of dysmotility, thanks to the addition of accurate measurement of bolus transit. Areas covered. This paper provides an overview of current knowledge in the use of HRIM for the study of esophageal functional disorders by reporting mainly the results of many publications and several systematic reviews in this field. Expert opinion. HRIM has represented a relevant improvement in the assessment of esophageal motility and has required the development of new metrics, such as the esophageal impedance integral ratio, the bolus flow time, the nadir impedance pressure and the impedance bolus height, which increase the evaluation of esophageal bolus transit. An extension of impedance is represented by functional lumen imaging probe (FLIP), which determines the biophysical properties and the distensibility of the esophagus and permits to detect contractility patterns not seen on HRM alone. We eagerly wait for a new and fruitful iteration of the Chicago Classification, now in version 3.0, which can cover the ongoing clinical experience of HRIM.

Opioid Treatment and Excessive Alcohol Consumption Are Associated With Esophagogastric Junction Disorders

Background/Aims

The influence of external factors such as opioids and alcohol has been extensively investigated for various segments of the gastrointestinal tract. However, the association between their use and the development of esophagogastric junction outflow obstruction disorders (EGJOODs) is unknown. Therefore, the aim of this study is to analyze prevalence and clinical relevance of opioids and alcohol intake in patients with EGJOODs.

Methods

In this single-center, retrospective study, we reviewed clinical and pharmacological data of 375 consecutive patients who had undergone high resolution impedance manometry for EGJOODs. EGJOODs were classified according to the Chicago classification version 3.0 and to recently published normal values for test meals. Demographics, manometric data, and symptoms were compared between different groups using Pearson’s chi-squared test, Fisher’s exact test, and multivariate analysis. A P < 0.05 was considered significant.

Results

EGJOOD was found in 30.7% (115/375) of all analyzed patients. The prevalence of opioids (14.8% vs 4.2%, P = 0.026) was significantly higher in patients with EGJOODs compared to patients without EGJOODs. Additionally, excessive alcohol consumption (12.2% vs 3.5%, P = 0.011) was associated with EGJOODs. Excessive alcohol consumption was especially frequent in the non-achalasia esophagogastric junction outflow obstruction subgroup (16.2%) and opioid use in the achalasia type III subgroup (20.0%).

Conclusions

We found a significant association between EGJOODs and opioid as well as excessive alcohol consumption. This underlines the importance of detailed history taking regarding medication and ethanol consumption in patients with dysphagia. Further prospective studies on mechanisms undelaying esophagogastric junction dysfunction due to opioids or alcohol are warranted.

Esophagogastric junction function and gastric pressure profile after minigastric bypass compared with Billroth II

BACKGROUND

Minigastric bypass (MGB) is being performed widely with effective weight loss and improvement in co-morbidities. Because of similarity to Billroth II (BII), there are concerns about bile reflux.

OBJECTIVES

To assess the esophagogastric junction (EGJ) function, esophageal peristalsis, and reflux exposure after MGB and BII.

SETTING

University Hospital, Italy; Public Hospital, Italy.

METHODS

Obese patients underwent symptom questioning, endoscopy, high-resolution impedance manometry, and impedance-pH monitoring, before and 1 year after MGB. Esophageal motor function, EGJ, EGJ-contractile integral, intragastric pressure (IGP), and gastroesophageal pressure gradient were determined. Acid exposure time, number of refluxes, and symptom-association probability were assessed. A group of patients who underwent BII were studied with the same protocol and served as controls.

RESULTS

Twenty-two MGB and 20 BII patients were studied. After surgery, none of the patients reported de novo heartburn or regurgitation. At endoscopic follow-up, esophagitis and bile findings were absent in all. High-resolution impedance manometry features did not vary significantly after MGB, whereas IGP and gastroesophageal pressure gradient statistically diminished (P < .01). BII patients had significantly lower values in IGP, sphincter pressure, and EGJ-contractile integral. In MGB patients, a marked decrease in number of refluxes (from median 41 to 7, P < .01) was observed, whereas BII patients had statistically significant higher acid exposure and number of refluxes (57, P < .001).

CONCLUSIONS

In contrast to BII, MGB does not increase any kind of reflux. Also, the differences in IGP and gastroesophageal pressure gradient suggest that bile reflux occurs more readily after BII than after MGB, and that these 2 operations share more differences than similarities.

Utility of Esophageal High-Resolution Manometry in Clinical Practice: First, Do HRM

Esophageal high-resolution manometry (HRM) has advanced the understanding of esophageal motor function and the ability to diagnose and manage disorders of esophageal motility. In this review, we describe the indications for and the technical performance of HRM. The Chicago classification of esophageal motor function, now in its third iteration, streamlines and standardizes the nomenclature and basic interpretation of HRM data depicted as Clouse topographic plots. In clinical practice, HRM is an important diagnostic test for patients with dysphagia as well as patients with suspected gastroesophageal reflux disease (GERD), particularly in those patients with a suboptimal symptomatic response to antisecretory therapy. HRM can support diagnoses such as achalasia, as well as provide evidence for behavioral disorders such as rumination syndrome or supragastric belching with the assistance of postprandial HRM with impedance. Further, the GERD classification of motor function introduces a three-part hierarchical evaluation of esophageal motor function in GERD, highlighting the value of assessment of esophageal contractile reserve through provocative maneuvers during HRM such as multiple rapid swallows.