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Canakis A, Lee DU, Grossman JL, Hwang DG, Wellington J, Yang AH, Fan GH, Kim GE, Kim RE. Anesthesia choice and its potential impact on endoluminal functional lumen imaging probe measurements in esophageal motility disorders. Gastrointest Endosc 2024; 99:702-711.e6. [PMID: 38052328 DOI: 10.1016/j.gie.2023.11.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 11/20/2023] [Accepted: 10/10/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND AND AIMS The widespread use of peroral endoscopic myotomy (POEM) has revolutionized the management of esophageal motility disorders (EMDs). The introduction of an endoluminal functional lumen imaging probe (EndoFLIP, Medtronic, Dublin, Ireland) can serve as a complementary diagnostic tool to assess the mechanical properties (ie, pressure, diameter, distensibility, topography) of the esophagus. During EndoFLIP measurements, different anesthesia techniques may induce variable degrees of neuromuscular blockade, potentially affecting esophageal motility and altering the results of EndoFLIP metrics. The aim of this study was to compare the impact of using total intravenous anesthesia (TIVA) versus general anesthesia with inhalational anesthetics (GAIA) on diagnostic EndoFLIP measurements. METHODS This retrospective study included all adult patients (≥18 years) undergoing EndoFlip during the POEM procedure at our institution between February 2017 and February 2022. Differences in pressure, diameter, and distensibility index were obtained by using propofol-based TIVA versus sevoflurane-based GAIA with a 30 mL and a 60 mL balloon. The differences were divided into terciles and compared between diagnoses by using univariate comparisons and logistic regression models. RESULTS A total of 49 patients were included (39% type I achalasia, 43% type II or III achalasia, and 18% jackhammer esophagus [JE]). Compared with spastic disorders (types II and III achalasia and JE), type I had lower values of pressure differences at 60 mL in univariate (3.75 vs 15.20, P = .001) and multivariate (adjusted odds ratio, .89; 95% confidence interval, .82-.978) analyses. Compared with type I, types II and III achalasia had higher rates of pressure differences at 60 mL in the univariate (9.85 vs 3.75, P = .04) analysis and nearly reached significance in the multivariate analysis (1.09; 95% confidence interval, 1-1.20). Compared with type I achalasia, JE exhibited higher values in pressure differences at 60 mL (27.7 vs 3.75, P < .001). CONCLUSIONS Esophageal pressure, as measured by EndoFLIP, was significantly reduced when patients were sedated with sevoflurane-based GAIA. The use of sevoflurane-based GAIA for diagnostic EndoFLIP may potentially lead to the misclassification of spastic disorders as type I achalasia. Propofol-based TIVA should therefore be considered over sevoflurane-based GAIA for sedation during the diagnostic test.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David U Lee
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jennifer L Grossman
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Daniel G Hwang
- Division of Gastroenterology, Kaiser Permanente, Bellevue, Washington, USA
| | - Jennifer Wellington
- Atrium Health Gastroenterology and Hepatology, Charlotte, North Carolina, USA
| | - Alexander H Yang
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Grace E Kim
- Division of Gastroenterology & Hepatology, University of Chicago, Chicago, Illinois, USA
| | - Raymond E Kim
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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Savarino EV, Salvador R, Ghisa M, Mari A, Forattini F, Costantini A, De Giorgio R, Zaninotto G. Research gap in esophageal achalasia: a narrative review. Dis Esophagus 2024:doae024. [PMID: 38525929 DOI: 10.1093/dote/doae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/08/2024] [Indexed: 03/26/2024]
Abstract
In recent years, new translational evidence, diagnostic techniques, and innovative therapies have shed new light on esophageal achalasia and revamped the attention on this relatively rare motility disorder. This narrative review aims to highlight the most recent progress and the areas where further research is needed. The four senior authors identified five topics commonly discussed in achalasia management: i.e. pathogenesis, role of functional lumen imaging probe in the diagnostic flow chart of achalasia, how to define the outcome of achalasia treatments, how to manage persistent chest pain after the treatment, and if achalasia patients' may benefit from a regular follow-up. We searched the bibliographic databases to identify systematic reviews, meta-analyses, randomized control trials, and original research articles in English up to December 2023. We provide a summary with the most recent findings in each of the five topics and the critical points where to address future research, such as the immune-genetic patterns of achalasia that might explain the transition among the different phenotypes, the need for a validated clinical definition of treatment success, the use of neuromodulators to manage chest pain, and the need for identifying achalasia patients at risk for cancer and who may benefit of long-term follow-up. Although undoubtedly, progress has been made on the definition and management of achalasia, unmet needs remain. Debated aspects range from mechanistic insights, symptoms, objective measure relationships, and accurate clinical responses to therapeutic interventions. Translational research is eagerly awaited to answer these unresolved questions.
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Affiliation(s)
- Edoardo Vincenzo Savarino
- Gastroenterology Unit, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Renato Salvador
- Chirurgia Generale 1, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Matteo Ghisa
- Gastroenterology Unit, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Amir Mari
- Gastroenterology Unit, Nazareth Hospital EMMS, The Azrieli Faculty of Medicine, Bar-Ilan University, Tel Aviv, Israel
| | - Francesca Forattini
- Chirurgia Generale 1, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Andrea Costantini
- Chirurgia Generale 1, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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Patel P, Rogers BD, Rengarajan A, Elsbernd B, O'Brien ER, Gyawali CP. Identification of Achalasia Within Absent Contractility Phenotypes on High-Resolution Manometry: Prevalence, Predictive Factors, and Treatment Outcome. Am J Gastroenterol 2024:00000434-990000000-01009. [PMID: 38299616 DOI: 10.14309/ajg.0000000000002694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/24/2024] [Indexed: 02/02/2024]
Abstract
INTRODUCTION Absent contractility on high-resolution manometry (HRM) defines severe hypomotility but needs distinction from achalasia. We retrospectively identified achalasia within absent contractility using HRM provocative maneuvers, barium esophagography, and functional lumen imaging probe (FLIP). METHODS Adult patients with absent contractility on HRM during the 4-year study period were eligible for inclusion. Inadequate studies, achalasia after therapy, or prior foregut surgery were exclusions. Upright integrated relaxation pressure (IRP) >12 mm Hg, panesophageal pressurization, and/or elevated IRP on multiple rapid swallows and rapid drink challenge (RDC) were considered abnormal. Esophageal barium retention and abnormal esophagogastric junction distensibility index (<2.0 mm 2 /mm Hg) on FLIP defined achalasia. Clinical, endoscopic, and motor characteristics of patients with achalasia were compared with absent contractility without obstruction. RESULTS Of 164 patients, 20 (12.2%) had achalasia (17.9% of 112 patients with adjunctive testing), while 92 did not, and 52 did not undergo adjunctive tests. Achalasia was diagnosed regardless of IRP value, but the median supine IRP was higher (odds ratio 1.196, 95% confidence interval 1.041-1.375, P = 0.012). Patients with achalasia were more likely to present with dysphagia (80.0% vs 35.9%, P < 0.001), with obstructive features on HRM maneuvers (83.3% vs 48.9%, P = 0.039), but lower likelihood of GERD evidence (20.0% vs 47.3%, P = 0.027) or large hiatus hernia (15.0% vs 43.8%, P = 0.002). On multivariable analysis, dysphagia presentation ( P = 0.006) and pressurization on RDC ( P = 0.027) predicted achalasia, while reflux and presurgical evaluations and lack of RDC obstruction predicted absent contractility without obstruction. DISCUSSION Despite HRM diagnosis of absent contractility, achalasia is identified in more than 1 in 10 patients regardless of IRP value.
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Affiliation(s)
- Parth Patel
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Arvind Rengarajan
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin Elsbernd
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas VA Medical Center, Dallas, Texas, USA
- Gastroenterology and Hepatology, Dallas VA Medical Center, Dallas, Texas, USA
| | - Elizabeth R O'Brien
- Department of Medicine, Sydney South West Local Health District, Sydney, New South Wales, Australia
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
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Reddy CA, Ellison A, Cipher DJ, Mendoza R, Souza RF, Spechler SJ, Konda VJA, Nguyen AD. Frequent discrepancies among diagnostic tests for detecting lower esophageal sphincter-related obstruction. Neurogastroenterol Motil 2024; 36:e14729. [PMID: 38129627 DOI: 10.1111/nmo.14729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/19/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND There are frequent discrepancies among high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and esophagram in identifying lower esophageal sphincter (LES)-related obstruction. We aimed to determine the frequency of those discrepancies and how they influenced clinical treatment/outcomes. METHODS We identified patients who had all three tests (HRM, FLIP, and esophagram) and endoscopy performed for evaluation of esophageal symptoms in our Center for Esophageal Diseases. Discrepancies among the tests for the presence of LES obstruction were noted, and the performance of individual tests was compared against a consensus opinion rendered by a panel of esophagologists. Binary logistical regression was performed, and ROC curves were generated for prediction of the consensus clinical diagnosis of LES obstruction. KEY RESULTS A total of 126 patients (mean age 57.9 ± 17.0 years; 67% female) met inclusion criteria. All three tests agreed on the presence or absence of LES obstruction in only 72 (57%) patients [no LES obstruction in 57 (45%), LES obstruction in 15 (12%)]. Thirteen patients (10%) had a change in management based on additional findings on FLIP +/- esophagram not seen on HRM with 69% having symptomatic improvement after LES-directed intervention. FLIP was the strongest predictor of a consensus diagnosis of LES obstruction by logistic regression and ROC (OR 23.36, AUC 0.796), followed by HRM (OR 15.41, AUC 0.764). CONCLUSIONS & INFERENCE High-resolution manometry, functional lumen imaging probe, and esophagram each have considerable limitations for identifying LES obstruction, and discrepancies among these tests occur frequently. Multimodal testing is often required for adequate evaluation of LES-related obstruction.
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Affiliation(s)
- Chanakyaram A Reddy
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Ashton Ellison
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Daisha J Cipher
- College of Nursing and Health Innovation, The University of Texas at Arlington, Arlington, Texas, USA
| | - Roseann Mendoza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Rhonda F Souza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Stuart J Spechler
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Vani J A Konda
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Anh D Nguyen
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
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Miller JD, Kemple BP, Evans JK, Clayton SB. A Comparison of Functional Luminal Imaging Probe With High-resolution Manometry, Timed Barium Esophagram, and pH Impedance Testing to Evaluate Functional Luminal Imaging Probe's Diagnostic Capabilities. J Clin Gastroenterol 2024:00004836-990000000-00253. [PMID: 38227842 DOI: 10.1097/mcg.0000000000001966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 12/11/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE The aims of this study are to determine the functional luminal imaging probe's (FLIP) diagnostic utility by comparing FLIP measurements with results from other esophageal evaluation standards. BACKGROUND The FLIP is an esophageal evaluation technique performed at the time of endoscopy. Few studies have evaluated FLIP diagnostic capabilities compared with the established testing techniques, including high-resolution manometry (HRIM), time barium esophagram (TBE), and 24-hour impedance-pH monitoring. PATIENTS AND METHODS A retrospective review was performed for 413 preintervention patients who underwent FLIP testing during endoscopy. Data from HRIM, 24-hour pH monitoring, and TBE were compared. RESULTS Abnormal Distensibility Index (DI) was associated with abnormal integrated relaxation pressure (IRP; P = 0.003). Average DI was higher in patients with abnormal IRP (>15 mm Hg) when a hiatal hernia was present (P = 0.025). The total agreement between correlated diagnoses from FLIP and HRIM was 33.5%. DI was not associated with acid exposure time on pH monitoring. Agreement between FLIP and TBE was 49% with a sensitivity of 98.1% and a specificity of 36.5%. A 60 mL distension had a significantly lower detection rate than 40 mL and 50 mL for active peristalsis and was unaffected by pressure (P < 0.05). CONCLUSIONS FLIP as an adjunct to HRIM is supported by strong metric correlation. FLIP was not correlated to pH monitoring findings, suggesting FLIP is not useful in reflux assessment. The agreement between FLIP and TBE was lower than in previous studies. Hiatal hernia impacted the normality between DI and IRP, not between FLIP and TBE. We suggest analyzing peristaltic patterns on panometry at all fill volumes to optimize detection.
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Affiliation(s)
| | - Brendan P Kemple
- Wake Forest University School of Medicine
- Department of Medicine, Medical College of Georgia
| | - Joni K Evans
- Biostatistics and Data Science, Wake Forest University School of Medicine
| | - Steven B Clayton
- Department of Medicine, Section on Gastroenterology, Wake Forest University School of Medicine
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Kamal AN, Kathpalia P, Leiman DA, Bredenoord AJ, Clarke JO, Gyawali CP, Katzka DA, Lazarescu A, Pandolfino JE, Penagini R, Roman S, Savarino E, Vela MF, Otaki F. Quality Indicator Development for the Approach to Ineffective Esophageal Motility: A Modified Delphi Study. J Clin Gastroenterol 2024:00004836-990000000-00251. [PMID: 38227852 DOI: 10.1097/mcg.0000000000001963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 12/11/2023] [Indexed: 01/18/2024]
Abstract
GOALS Develop quality indicators for ineffective esophageal motility (IEM). BACKGROUND IEM is identified in up to 20% of patients undergoing esophageal high-resolution manometry (HRM) based on the Chicago Classification. The clinical significance of this pattern is not established and management remains challenging. STUDY Using RAND/University of California, Los Angeles Appropriateness Methods, we employed a modified-Delphi approach for quality indicator statement development. Quality indicators were proposed based on prior literature. Experts independently and blindly scored proposed quality statements on importance, scientific acceptability, usability, and feasibility in a 3-round iterative process. RESULTS All 10 of the invited esophageal experts in the management of esophageal diseases invited to participate rated 12 proposed quality indicator statements. In round 1, 7 quality indicators were rated with mixed agreement, on the majority of categories. Statements were modified based on panel suggestion, modified further following round 2's virtual discussion, and in round 3 voting identified 2 quality indicators with comprehensive agreement, 4 with partial agreement, and 1 without any agreement. The panel agreed on the concept of determining if IEM is clinically relevant to the patient's presentation and managing gastroesophageal reflux disease rather than the IEM pattern; they disagreed in all 4 domains on the use of promotility agents in IEM; and had mixed agreement on the value of a finding of IEM during anti-reflux surgical planning. CONCLUSION Using a robust methodology, 2 IEM quality indicators were identified. These quality indicators can track performance when physicians identify this manometric pattern on HRM. This study further highlights the challenges met with IEM and the need for additional research to better understand the clinical importance of this manometric pattern.
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Affiliation(s)
- Afrin N Kamal
- Division of Gastroenterology and Hepatology, Stanford University, Redwood City
| | - Priya Kathpalia
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA
| | - David A Leiman
- Division of Gastroenterology, Duke University School of Medicine & Duke Clinical Research Institute, Durham, NC
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, Utrecht, The Netherlands
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University, Redwood City
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington in St. Louis, St. Louis, MO
| | - David A Katzka
- Division of Gastroenterology, Columbia University, New York, NY
| | - Adriana Lazarescu
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - John E Pandolfino
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Roberto Penagini
- Gastroenterology Unit, University of Milan, Fondazione IRCCS Cà Granda Ospedale Policlinico, Milan, Italy
| | - Sabine Roman
- Digestive Physiology, Lyon I Hospices Civils de Lyon, Lyon, France
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology,University of Padua, Padua, Veneto, Italy
| | - Marcelo F Vela
- Division of Gastroenterology, Mayo Clinic, Scottsdale, AZ
| | - Fouad Otaki
- Division of Gastroenterology & Hepatology, Oregon Health & Science University, Portland, OR
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Wakim El-Khoury J, Pandolfino JE, Kahrilas PJ, Godo B, Farina DA, Kou W, Carlson DA. Relaxation of the lower esophageal sphincter in response to reduced volume distension during FLIP Panometry. Neurogastroenterol Motil 2023; 35:e14663. [PMID: 37691556 DOI: 10.1111/nmo.14663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND The esophageal response to stepwise distension during the functional lumen imaging probe (FLIP) Panometry study often parallels high-resolution manometry (HRM) motility diagnoses. This study aimed to describe the changes in FLIP metrics during FLIP emptying, that is, reduced volume distension. METHODS Adult patients who completed FLIP and HRM for esophageal motility evaluation were included. Esophagogastric junction (EGJ) opening parameters were assessed during stepwise FLIP filling to volumes of 60 mL ("filling 60 mL"), then 70 mL, and then back to 60 mL ("emptying 60 mL"). HRM studies were analyzed per Chicago classification version 4.0 (CCv4.0). KEY RESULTS Among 265 patients included, HRM/CCv4.0 diagnoses included achalasia in 80 patients (30%), normal motility in 70 (26%), and ineffective esophageal motility (IEM) in 43 (16%). EGJ-distensibility index (DI) and EGJ diameter were greater during emptying 60 mL than filling 60 mL in achalasia, normal motility, and IEM (p values <0.002). If applying the emptying 60 mL EGJ-DI (vs. filling 60 mL EGJ-DI), EGJ opening classification changed from reduced EGJ opening to borderline EGJ opening in 31% of achalasia patients and in 2% of patients with normal motility or IEM. EGJ opening classification was unchanged in 69% achalasia and 96% of normal motility/IEM. CONCLUSIONS AND INFERENCES This study suggests that isotonic or auxotonic relaxation of the lower esophageal sphincter occurs with reduced volume distension in patients with achalasia and normal motility. The study also supports the importance of utilizing a standardized FLIP motility study protocol (i.e., controlled, stepwise filling to 50 mL, 60 mL, then 70 mL) to provide reliable and generalizable FLIP metrics to facilitate diagnosis of esophageal motility disorders.
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Affiliation(s)
- Jeanine Wakim El-Khoury
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Bidemi Godo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Domenico A Farina
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
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Ikebuchi Y, Sato H, Ikeda H, Abe H, Ominami M, Shiota J, Sato C, Fukuda H, Ogawa R, Tatsuta T, Yokomichi H, Isomoto H, Inoue H. Clinical characteristics of absent contractility and ineffective esophageal motility: a multicenter study in Japan. J Gastroenterol Hepatol 2023; 38:1926-1933. [PMID: 37391859 DOI: 10.1111/jgh.16268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 04/04/2023] [Accepted: 06/06/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND AND AIM Absent contractility (AC) and ineffective esophageal motility (IEM) are esophageal hypomotility disorders diagnosed using high-resolution manometry (HRM). Patient characteristics and disease course of these conditions and differential diagnosis between AC and achalasia are yet to be elucidated. METHODS A multicenter study involving 10 high-volume hospitals was conducted. Starlet HRM findings were compared between AC and achalasia. Patient characteristics including underlying disorders and disease courses were analyzed in AC and IEM. RESULTS Fifty-three patients with AC and 92 with IEM were diagnosed, while achalasia was diagnosed in 1784 patients using the Chicago classification v3.0 (CCv3.0). The cut-off integrated relaxation pressure (IRP) value at 15.7 mmHg showed maximum sensitivity (0.80) and specificity (0.87) for differential diagnosis of AC from type I achalasia. While most ACs were based on systemic disorders such as scleroderma (34%) and neuromuscular diseases (8%), 23% were sporadic cases. The symptom severity of AC was not higher than that of IEM. Regarding the diagnosis of IEM, the more stringent CCv4.0 excluded 14.1% of IEM patients than the CCv3.0, although patient characteristics did not change. In patients with the hypomotile esophagus, concomitance of reflux esophagitis was associated with low distal contractile integral and IRP values. AC and IEM transferred between each other, paralleling with the underlying disease course, although no transition to achalasia was observed. CONCLUSION A successful determination of the optimal cut-off IRP value was achieved using the starlet HRM system to differentiate AC and achalasia. Follow-up HRM is also useful for differentiating AC from achalasia. Symptom severity may depend on underlying diseases instead of hypomotility severity.
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Affiliation(s)
- Yuichiro Ikebuchi
- Department of Multidisciplinary Internal Medicine, Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Haruo Ikeda
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hirofumi Abe
- Department of Gastroenterology, Kobe University Hospital, Kobe, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Junya Shiota
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Chiaki Sato
- Division of Advanced Surgical Science and Technology, School of Medicine, Tohoku University, Sendai, Japan
| | - Hisashi Fukuda
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Graduate School of Medicine, Hirosaki University, Hirosaki, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
| | - Hajime Isomoto
- Department of Multidisciplinary Internal Medicine, Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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10
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Pesce M, Pagliaro M, Sarnelli G, Sweis R. Modern Achalasia: Diagnosis, Classification, and Treatment. J Neurogastroenterol Motil 2023; 29:419-427. [PMID: 37814432 PMCID: PMC10577462 DOI: 10.5056/jnm23125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 10/11/2023] Open
Abstract
Achalasia is a major esophageal motor disorder featured by the altered relaxation of the esophagogastric junction in the absence of effective peristaltic activity. As a consequence of the esophageal outflow obstruction, achalasia patients present with clinical symptoms of dysphagia, chest pain, weight loss, and regurgitation of indigested food. Other less specific symptoms can also present including heartburn, chronic cough, and aspiration pneumonia. The delay in diagnosis, particularly when the presenting symptoms mimic those of gastroesophageal reflux disease, may be as long as several years. The widespread use of high-resolution manometry has permitted earlier detection and uncovered achalasia phenotypes which can have prognostic and therapeutic implications. Other tools have also emerged to help define achalasia severity and which can be used as objective measures of response to therapy including the timed barium esophagogram and the functional lumen imaging probe. Such diagnostic innovations, along with the increased awareness by clinicians and patients due to the availability of alternative therapeutic approaches (laparoscopic and robotic Heller myotomy, and peroral endoscopic myotomy) have radically changed the natural history of the disorder. Herein, we report the most recent advances in the diagnosis, classification, and management of esophageal achalasia and underline the still-grey areas that needs to be addressed by future research to reach the goal of personalizing treatment.
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Affiliation(s)
- Marcella Pesce
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Marta Pagliaro
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Giovanni Sarnelli
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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11
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Sanagapalli S, Plumb A, Lord RV, Sweis R. How to effectively use and interpret the barium swallow: Current role in esophageal dysphagia. Neurogastroenterol Motil 2023; 35:e14605. [PMID: 37103465 DOI: 10.1111/nmo.14605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND The barium swallow is a commonly performed investigation, though recent decades have seen major advances in other esophageal diagnostic modalities. PURPOSE The purpose of this review is to clarify the rationale for components of the barium swallow protocol, provide guidance on interpretation of findings, and describe the current role of the barium swallow in the diagnostic paradigm for esophageal dysphagia in relation to other esophageal investigations. The barium swallow protocol, interpretation, and reporting terminology are subjective and non-standardized. Common reporting terminology and an approach to their interpretation are provided. A timed barium swallow (TBS) protocol provides more standardized assessment of esophageal emptying but does not evaluate peristalsis. Barium swallow may have higher sensitivity than endoscopy for detecting subtle strictures. Barium swallow has lower overall accuracy than high-resolution manometry for diagnosing achalasia but can help secure the diagnosis in cases of equivocal manometry. TBS has an established role in objective assessment of therapeutic response in achalasia and helps identify the cause of symptom relapse. Barium swallow has a role in the evaluating manometric esophagogastric junction outflow obstruction, in some cases helping to identify where it represents an achalasia-like syndrome. Barium swallow should be performed in dysphagia following bariatric or anti-reflux surgery, to assess for both structural and functional postsurgical abnormality. Barium swallow remains a useful investigation in esophageal dysphagia, though its role has evolved due to advancements in other diagnostics. Current evidence-based guidance regarding its strengths, weaknesses, and current role are described in this review.
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Affiliation(s)
- Santosh Sanagapalli
- Department of Gastroenterology and Hepatology, St. Vincent's Hospital Sydney, Darlinghurst, Australia
- School of Clinical Medicine, St. Vincent's Healthcare Campus, University of New South Wales, Sydney, Australia
| | - Andrew Plumb
- Centre for Medical Imaging, University College London Hospital, London, UK
| | - Reginald V Lord
- Department of Surgery, University of Notre Dame School of Medicine, Sydney, Australia
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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12
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White E, Mutalib M. Use of endolumenal functional lumen imaging probe in investigating paediatric gastrointestinal motility disorders. World J Clin Pediatr 2023; 12:162-170. [PMID: 37753495 PMCID: PMC10518749 DOI: 10.5409/wjcp.v12.i4.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/09/2023] [Accepted: 08/23/2023] [Indexed: 09/06/2023] Open
Abstract
Investigating gastrointestinal (GI) motility disorders relies on diagnostic tools to assess muscular contractions, peristalsis propagation and the integrity and coordination of various sphincters. Manometries are the gold standard to study the GI motor function but it is increasingly acknowledged that manometries do not provide a complete picture in relation to sphincters competencies and muscle fibrosis. Endolumenal functional lumen imaging probe (EndoFLIP) an emerging technology, uses impedance planimetry to measure hollow organs cross sectional area, distensibility and compliance. It has been successfully used as a complementary tool in the assessment of the upper and lower oesophageal sphincters, oesophageal body, the pylorus and the anal canal. In this article, we aim to review the uses of EndoFLIP as a tool to investigate GI motility disorders with a special focus on paediatric practice. The majority of EndoFLIP studies were conducted in adult patients but the uptake of the technology in paediatrics is increasing. EndoFLIP can provide a useful complementary data to the existing GI motility investigation in both children and adults.
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Affiliation(s)
- Emily White
- Department of Paediatric Gastroenterology, Evelina London Children’s Hospital, London SE1 7EH, United Kingdom
| | - Mohamed Mutalib
- Department of Paediatric Gastroenterology, Evelina London Children’s Hospital, London SE1 7EH, United Kingdom
- Faculty of Life Sciences and Medicine, King’s College London, London SE1 7EH, United Kingdom
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13
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Ran P, Li M, Zhang K, Sun D, Lai Y, Liu W, Zhong Y, Li Z. Development and Evaluation of a Flexible PVDF-Based Balloon Sensor for Detecting Mechanical Forces at Key Esophageal Nodes in Esophageal Motility Disorders. Biosensors (Basel) 2023; 13:791. [PMID: 37622877 PMCID: PMC10452430 DOI: 10.3390/bios13080791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/26/2023]
Abstract
Prevailing methods for esophageal motility assessments, such as perfusion manometry and probe-based function imaging, frequently overlook the intricate stress fields acting on the liquid-filled balloons at the forefront of the probing device within the esophageal lumen. To bridge this knowledge gap, we innovatively devised an infusible flexible balloon catheter, equipped with a quartet of PVDF piezoelectric sensors. This design, working in concert with a bespoke local key-node analytical algorithm and a sensor array state analysis model, seeks to shed new light on the dynamic mechanical characteristics at pivotal esophageal locales. To further this endeavor, we pioneered a singular closed balloon system and a complementary signal acquisition and processing system that employs a homogeneously distributed PVDF piezoelectric sensor array for the real-time monitoring of dynamic mechanical nuances in the esophageal segment. An advanced analytical model was established to scrutinize the coupled physical fields under varying degrees of balloon inflation, thereby facilitating a thorough dynamic stress examination of local esophageal nodes. Our rigorous execution of static, dynamic, and simulated swallowing experiments robustly substantiated the viability of our design, the logical coherence of our esophageal key-point stress analytical algorithm, and the potential clinical utility of a flexible esophageal key-node stress detection balloon probe outfitted with a PVDF array. This study offers a fresh lens through which esophageal motility testing can be viewed and improved upon.
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Affiliation(s)
- Peng Ran
- School of Bioinformatics, Chongqing University of Posts and Telecommunications, Chongqing 400065, China; (P.R.); (K.Z.); (D.S.); (W.L.); (Y.Z.)
- Chongqing Engineering Research Center of Medical Electronics and Information Technology, Chongqing 400065, China;
| | - Minchuan Li
- School of Bioinformatics, Chongqing University of Posts and Telecommunications, Chongqing 400065, China; (P.R.); (K.Z.); (D.S.); (W.L.); (Y.Z.)
- Chongqing Engineering Research Center of Medical Electronics and Information Technology, Chongqing 400065, China;
| | - Kunlin Zhang
- School of Bioinformatics, Chongqing University of Posts and Telecommunications, Chongqing 400065, China; (P.R.); (K.Z.); (D.S.); (W.L.); (Y.Z.)
| | - Daming Sun
- School of Bioinformatics, Chongqing University of Posts and Telecommunications, Chongqing 400065, China; (P.R.); (K.Z.); (D.S.); (W.L.); (Y.Z.)
- Chongqing Engineering Research Center of Medical Electronics and Information Technology, Chongqing 400065, China;
| | - Yingbing Lai
- School of Bioinformatics, Chongqing University of Posts and Telecommunications, Chongqing 400065, China; (P.R.); (K.Z.); (D.S.); (W.L.); (Y.Z.)
| | - Wei Liu
- School of Bioinformatics, Chongqing University of Posts and Telecommunications, Chongqing 400065, China; (P.R.); (K.Z.); (D.S.); (W.L.); (Y.Z.)
| | - Ying Zhong
- School of Bioinformatics, Chongqing University of Posts and Telecommunications, Chongqing 400065, China; (P.R.); (K.Z.); (D.S.); (W.L.); (Y.Z.)
| | - Zhangyong Li
- Chongqing Engineering Research Center of Medical Electronics and Information Technology, Chongqing 400065, China;
- School of Optoelectronic Engineering, Chongqing University of Posts and Telecommunications, Chongqing 400065, China
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14
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Abstract
Achalasia is a rare disease of the esophagus with impaired relaxation of the lower esophageal sphincter and aperistalsis. The etiology is unknown but speculations include a viral or autoimmune etiology. All specialists dealing with swallowing and esophageal diseases should recognize the classic symptoms of dysphagia for solids/liquids, regurgitation, and choking, especially at night. High-resolution manometry is critical for the diagnosis with endoscopy and barium esophagram having a supportive role. The disease cannot be cured but most can return to near normal swallowing and a regular diet with appropriate therapy. Treatment includes smooth muscle relaxants, botulinum toxin injections to the lower sphincter, pneumatic dilation, Heller myotomy, and peroral endoscopic myotomy. One treatment does not fit all and a tailored approach through a multidiscipline team will give the best long-term outcomes.
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Affiliation(s)
- Wojciech Blonski
- Division of Gastroenterology, James A. Haley VA Hospital, Tampa, FL, USA
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA
| | - Samuel Slone
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA
| | - Joel E Richter
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA.
- Joy McCann Culverhouse Center for Esophageal Diseases, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
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15
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Hoshikawa Y, Momma E, Kawami N, Ikeda M, Kuribayashi S, Iwakiri K. High-resolution manometry with additional maneuvers using the Starlet system: normative thresholds and diagnostic yields for relevant esophagogastric junction outflow disorders. Esophagus 2023; 20:150-157. [PMID: 36102992 DOI: 10.1007/s10388-022-00956-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 09/07/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Chicago classification version 4.0 suggests additional maneuvers, such as upright testing, multiple rapid swallows (MRS), and the rapid drink challenge (RDC), for high-resolution manometry (HRM) to minimize ambiguity in the diagnosis of esophageal motility disorders. The present study investigated normative thresholds for these new metrics using the Starlet system as well as their diagnostic yields for relevant esophagogastric outflow disorders (EGJOD). METHODS In study 1, 30 asymptomatic volunteers prospectively performed HRM including MRS and RDC in the supine/upright positions. We calculated normative thresholds for the new metrics, such as upright integrated relaxation pressure (IRP), upright intrabolus pressure (IBP), and IRP during RDC (RDC-IRP). In study 2, we retrospectively analyzed the HRM tracings of 82 patients who underwent HRM in both positions at our hospital to assess the diagnostic yields of HRM metrics. RESULTS Based on the results of study 1, we adopted the following normative thresholds: upright IRP < 20 mmHg, upright IBP < 21 mmHg, and RDC-IRP < 16 mmHg. In study 2, 45 patients with dysphagia or chest pain were included in the analysis to identify predictive factors for clinically relevant esophagogastric outflow disorders (true EGJOD). Supine/upright IRP, RDC-IRP, and pan-esophageal pressurization > 20 mmHg during RDC (RDC-PEP) predicted true EGJOD with RDC-PEP with the highest sensitivity of 91.7%. CONCLUSIONS HRM with additional maneuvers may facilitate the diagnosis of clinically relevant EGJOD.
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Affiliation(s)
- Yoshimasa Hoshikawa
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| | - Eri Momma
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Noriyuki Kawami
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Masaomi Ikeda
- Oral Prosthetic Engineering, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
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16
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Jung KW. The Clinical Usefulness of Functional Luminal Imaging Probe in Esophageal Dysmotility Disorder. J Neurogastroenterol Motil 2022; 28:509-511. [PMID: 36250356 PMCID: PMC9577584 DOI: 10.5056/jnm22135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/07/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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17
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Tatsuta T, Sato H, Fujiyoshi Y, Abe H, Shiwaku A, Shiota J, Sato C, Ominami M, Hata Y, Fukuda H, Ogawa R, Nakamura J, Ikebuchi Y, Yokomichi H, Fukuda S, Inoue H. Subtype of Achalasia and Integrated Relaxation Pressure Measured Using the Starlet High-resolution Manometry System: A Multicenter Study in Japan. J Neurogastroenterol Motil 2022; 28:562-571. [PMID: 36250363 PMCID: PMC9577579 DOI: 10.5056/jnm21254] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/25/2022] [Indexed: 11/25/2022] Open
Abstract
Background/Aims ManoScan and Sandhill high-resolution manometry (HRM) systems are used worldwide; however, the diagnosis of achalasia on the Starlet HRM system is not fully characterized. Furthermore, the impact of calcium channel blockers and nitrites in treating achalasia has not been investigated using HRM. Management of recurrent cases is a priority issue, although few studies have examined patient characteristics. Methods We conducted a multicenter, large-scale database analysis. First, the diagnosis of treatment-naive achalasia in each HRM system was investigated. Next, patient characteristics were compared between type I-III achalasia, and the impact of patient characteristics, including calcium channel blocker and nitrite use for integrated relaxation pressure (IRP) values, were analyzed. Finally, patient characteristics with recurrent achalasia were elucidated. Results The frequency of type I achalasia with Starlet was significantly higher than that with ManoScan and Sandhill HRM systems. In achalasia, multivariate analysis identified male sex, advanced age, long disease duration, obesity, type I achalasia, and sigmoid type as risk factors related to normal IRP values (< 26 mmHg). Calcium channel blockers and nitrites use had no significant impact on the IRP values, although achalasia symptoms were indicated to be alleviated. In recurrent cases, the IRP value was significantly lower, and advanced age, long disease duration, and sigmoid type were more common than in treatment-naive patients. Conclusions We should cautiously interpret the type of achalasia and IRP values in the Starlet HRM system. Symptoms of recurrent cases are related to disease progression rather than IRP values, which should be considered in decision making.
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Affiliation(s)
- Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.,Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, OH, USA
| | - Yusuke Fujiyoshi
- 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 and 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 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, 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
| | - 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
| | - Shinsaku Fukuda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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18
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Nguyen AD, Ellison A, Reddy CA, Mendoza R, Podgaetz E, Ward MA, Souza RF, Spechler SJ, Konda VJA. Spastic secondary contractile patterns identified by FLIP panometry in symptomatic patients with unremarkable high-resolution manometry. Neurogastroenterol Motil 2022; 34:e14321. [PMID: 35075734 DOI: 10.1111/nmo.14321] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Functional lumen imaging probe (FLIP) panometry can show spastic secondary contractile patterns of unclear significance in symptomatic patients who have no esophageal obstructive disorders, and no motility disorders on high-resolution manometry (HRM). METHODS We retrospectively analyzed non-obstructed, symptomatic patients with HRM findings of no motility disorder or ineffective esophageal motility (IEM) for whom spastic secondary contractile patterns identified by FLIP panometry were used to guide treatment. Symptoms were scored using the Brief Esophageal Dysphagia Questionnaire (BEDQ). KEY RESULTS We identified ten symptomatic patients treated at our medical center who met inclusion criteria (seven women; mean age 56 years; eight no motility disorder, two IEM). On FLIP panometry, seven had spastic secondary contractions at 60 ml, two at 40 ml, and one at both 40 ml and 60 ml balloon volumes. Eight patients (80%) had improvement in BEDQ scores with therapies that targeted the spastic secondary contractile patterns identified by FLIP (five botulinum toxin injection, two Esoflip dilation, and one Heller myotomy). Interestingly, review of HRM tracings revealed that all patients had a novel HRM finding of mid-vertical pressurization in at least 20% swallows, with seven exhibiting this finding in >50% of swallows. CONCLUSIONS This case series demonstrates that treatments targeting spastic secondary contractions identified by FLIP panometry can result in symptomatic improvement in patients with no obstructive disorder and no diagnostic motility disorder on HRM. In such patients, we have identified the novel HRM finding of mid-vertical pressurization, which might be the manometric manifestation of spasm limited to the mid-esophagus.
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Affiliation(s)
- Anh D Nguyen
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Ashton Ellison
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Chanakyaram A Reddy
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Roseann Mendoza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Eitan Podgaetz
- Department of Surgery, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Marc A Ward
- Department of Surgery, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Rhonda F Souza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Stuart J Spechler
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Vani J A Konda
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
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19
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Abstract
Achalasia is a rare disorder of the oesophageal smooth muscle characterized by impaired relaxation of the lower oesophageal sphincter (LES) and absent or spastic contractions in the oesophageal body. The key pathophysiological mechanism is loss of inhibitory nerve function that probably results from an autoimmune attack targeting oesophageal myenteric nerves through cell-mediated and, possibly, antibody-mediated mechanisms. Achalasia incidence and prevalence increase with age, but the disorder can affect all ages and both sexes. Cardinal symptoms consist of dysphagia, regurgitation, chest pain and weight loss. Several years can pass between symptom onset and an achalasia diagnosis. Evaluation starts with endoscopy to rule out structural causes, followed by high-resolution manometry and/or barium radiography. Functional lumen imaging probe can provide complementary evidence. Achalasia subtypes have management and prognostic implications. Although symptom questionnaires are not useful for diagnosis, the Eckardt score is a simple symptom scoring scale that helps to quantify symptom response to therapy. Oral pharmacotherapy is not particularly effective. Botulinum toxin injection into the LES can temporize symptoms and function as a bridge to definitive therapy. Pneumatic dilation, per-oral endoscopic myotomy and laparoscopic Heller myotomy can provide durable symptom benefit. End-stage achalasia with a dilated, non-functioning oesophagus may require oesophagectomy or enteral feeding into the stomach. Long-term complications can, rarely, include oesophageal cancer, but surveillance recommendations have not been established.
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Affiliation(s)
- Edoardo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova (AOUP), Padua, Italy. .,Department of Surgery, Oncology and Gastroenterology (DiSCOG), University of Padua, Padua, Italy.
| | - Shobna Bhatia
- Department of Gastroenterology, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Sabine Roman
- Hospices Civils de Lyon, Digestive Physiology, Hopital E Herriot, Lyon, France.,Université Lyon 1, Villeurbanne, France.,Inserm U1032, LabTAU, Lyon, France
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | - Jan Tack
- Division of Gastroenterology, University Hospital of Leuven, Leuven, Belgium
| | - Sarah K Thompson
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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20
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Rengarajan A, Rogers BD, Wong Z, Tolone S, Sifrim D, Serra J, Savarino E, Roman S, Remes-Troche JM, Ramos R, Perez de la Serna J, Pauwels A, Leguizamo AM, Lee YY, Kawamura O, Hayat J, Hani A, Gonlachanvit S, Cisternas D, Carlson D, Bor S, Bhatia S, Abrahao L, Pandolfino J, Gyawali CP. High-Resolution Manometry Thresholds and Motor Patterns Among Asymptomatic Individuals. Clin Gastroenterol Hepatol 2022; 20:e398-406. [PMID: 33144149 DOI: 10.1016/j.cgh.2020.10.052] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Sato C, Sato H, Kamei T, Shimamura Y, Tanaka S, Shiwaku H, Shiota J, Ogawa R, Yokomichi H, Inoue H. Characteristics of patients with esophageal motility disorders on high-resolution manometry and esophagography-a large database analysis in Japan. Esophagus 2022; 19:182-8. [PMID: 34478005 DOI: 10.1007/s10388-021-00875-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND With the development of high-resolution manometry (HRM) and peroral endoscopy, more patients with esophageal motility disorders (EMDs) including achalasia are diagnosed and treated. The characteristics of Japanese patients with EMDs are unknown and should be elucidated. METHODS A large-scale database analysis was performed at seven high-volume centers in Japan. EMDs between 2010 and 2019 were analyzed. RESULTS A total of 1900 patients were diagnosed with treatment naïve achalasia on esophagography. A long disease history was related to the sigmoid and dilated esophagus, and patients' symptom severity declined as achalasia progressed to the sigmoid type. Among 1700 patients received starlet HRM, 1476 (86.8%) completed the examination. Long disease history and sigmoid achalasia were identified as risk factors for the failure of HRM examination. Type I achalasia was the most common type found on starlet HRM, and 45.1% of patients with achalasia had lower esophageal sphincter (LES) pressure within the normal range. Type III had a high age of onset and mild symptom severity, compared to the other two subtypes. Type III achalasia, esophagogastric outflow obstruction (EGJ-OO), jackhammer esophagus (JE), and diffuse esophageal spasm (DES) were relatively rare compared to type I-II achalasia. The clinical characteristics of EGJ-OO, JE, and DES were generally close to those of achalasia. CONCLUSION This first large-scale database analysis indicates that more Japanese patients with achalasia are type I and have a normal range of LES pressure on starlet HRM. Failure of HRM is not rare; therefore, esophagography continuously has a complementary role in achalasia diagnosis.
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23
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Ramchandani M, Pal P, Singla N, Reddy DN. Post-per-oral endoscopic myotomy heartburn: It's not always reflux: Expert review. Dig Endosc 2022; 34:325-333. [PMID: 34390053 DOI: 10.1111/den.14106] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/10/2021] [Indexed: 12/13/2022]
Abstract
Patients with achalasia frequently develop gastroesophageal reflux (GER)-related symptoms and complications after per-oral endoscopic myotomy (POEM). Reflux symptoms are thought to be due to GER and the current treatment of post-POEM GER focuses on acid suppression with proton pump inhibitors (PPI). However, reflux symptoms in achalasia patients post-POEM can be due to true reflux, nonreflux esophageal acidification due to stasis or acid fermentation, or esophageal hypersensitivity to chemical or mechanical stimuli. True acidic reflux is not always the cause of reflux symptoms. Twenty-four-hour pH monitoring with impedance is essential to differentiate causes of esophageal acidification. PPI is useful only in true acidic reflux. Detection of acid fermentation requires manual review of a 24-h pH study, as automated review often overestimates acid exposure time due to its inability to differentiate true reflux from fermentation. Stasis of ingested acidic food warrants evaluation of esophageal emptying by timed barium esophagogram. In cases of inadequate emptying, esophagogastric junction (EGJ) distensibility can be evaluated by a functional lumen imaging probe. Impaired distensibility with inadequate esophageal emptying suggests treatment failure and may require retreatment. In treatment-refractory patients, esophageal hypersensitivity should be considered and treated with neuromodulators. Thus, the diagnostic approach to post-POEM reflux symptoms should evolve to identify various patterns of esophageal acidification, esophageal emptying patterns, EGJ distensibility, and hypersensitivity. Consequently, the treatment of GER post-POEM should not be limited to treating esophageal acidification by reflux, but should encompass other causes of acidification and esophageal hypersensitivity.
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Affiliation(s)
| | - Partha Pal
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Neeraj Singla
- Asian Institute of Gastroenterology, Hyderabad, India
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24
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Abstract
Objective Esophageal diverticulum is rare, and the concomitance of esophageal motility disorders (EMDs) and the efficacy of novel endoscopic treatment have not been investigated in Japan. Methods An examination including high-resolution manometry (HRM) was performed for patients with both EMDs and epiphrenic diverticulum. EMD-related epiphrenic diverticulum and Zenker's diverticulum were treated using salvage peroral endoscopic myotomy (s-POEM) and endoscopic diverticulotomy, respectively. Results Six cases of epiphrenic diverticulum were diagnosed in this study. Among 125 patients with achalasia and spastic disorders, concomitant epiphrenic diverticulum was observed in 4 (3.2%). Of these, three showed a normal lower esophageal sphincter pressure on HRM, although gastroscopy and esophagography revealed typical findings of an impaired lower esophageal sphincter relaxation. These four patients were successfully treated with s-POEM, and the Eckardt score improved from 6.3 to 0.25 at 32.5 (range: 13-56) months of follow-up, with equivalent treatment efficacy to that observed for achalasia and spastic disorders without epiphrenic diverticulum. In contrast, the two remaining cases of epiphrenic diverticulum had normal esophageal motility. Six cases of Zenker's diverticulum were diagnosed, and endoscopic diverticulotomy was successfully performed in all. The dysphagia score decreased from 2.8 to 0.17 at 14.8 (range: 2-36) months of follow-up. Overall, 12 endoscopic treatments were performed for esophageal diverticulum; no adverse events were observed. Conclusion In epiphrenic diverticulum patients, concomitant EMDs are not rare and should be carefully diagnosed. A normal lower esophageal sphincter pressure on HRM does not always mean a normal lower esophageal sphincter relaxation. S-POEM and endoscopic diverticulotomy are effective minimally invasive treatment options for EMD-related epiphrenic diverticulum and Zenker's diverticulum.
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Affiliation(s)
- Hiroki Sato
- Division of Gastroenterology, Niigata University Faculty of Medical Graduate School of Medical and Dental Science, Japan
| | - Manabu Takeuchi
- Division of Gastroenterology, Nagaoka Red Cross Hospital, Japan
| | - Kazuya Takahashi
- Division of Gastroenterology, Niigata University Faculty of Medical Graduate School of Medical and Dental Science, Japan
| | - Ken-Ichi Mizuno
- Division of Gastroenterology, Niigata University Faculty of Medical Graduate School of Medical and Dental Science, Japan
| | - Koichi Furukawa
- Division of Gastroenterology, Niigata City General Hospital, Japan
| | - Akito Sato
- Division of Gastroenterology, Nagaoka Chuo General Hospital, Japan
| | - Nao Nakajima
- Division of Gastroenterology, Niigata University Faculty of Medical Graduate School of Medical and Dental Science, Japan
| | - Junji Yokoyama
- Division of Gastroenterology, Niigata University Faculty of Medical Graduate School of Medical and Dental Science, Japan
| | - Shuji Terai
- Division of Gastroenterology, Niigata University Faculty of Medical Graduate School of Medical and Dental Science, Japan
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Abstract
Among recent advances in diagnostics for dysphagia and esophageal motility disorders is the update to the Chicago Classification (version 4.0) for interpretation of high-resolution manometry (HRM) and diagnosis of esophageal motility disorders. The update incorporates application of complementary testing strategies during HRM, such as provocative HRM maneuvers, and recommendation for barium esophagram or functional luminal imaging probe (FLIP) panometry to help clarify inconclusive HRM findings. FLIP panometry also represents an emerging technology for evaluation of esophageal distensibility and motility at the time of endoscopy.
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26
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Abstract
Achalasia is a rare chronic esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter and abnormal peristalsis. This abnormal motor function leads to impaired bolus emptying and symptoms of dysphagia, regurgitation, chest pain, or heartburn. After an upper endoscopy to exclude structural causes of symptoms, the gold standard for diagnosis is high-resolution esophageal manometry. However, complementary diagnostic tools include barium esophagram and functional luminal impedance planimetry. Definitive treatments include pneumatic dilation, Heller myotomy with fundoplication, and peroral endoscopic myotomy.
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Affiliation(s)
- Sydney Pomenti
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, 630 West 168th Street, Suite 3-401, New York, NY 10032, USA
| | - John William Blackett
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, 630 West 168th Street, Suite 3-401, New York, NY 10032, USA
| | - Daniela Jodorkovsky
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, 630 West 168th Street, Suite 3-401, New York, NY 10032, USA.
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27
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Rogers BD, Gyawali CP. Making Sense of Nonachalasia Esophageal Motor Disorders. Gastroenterol Clin North Am 2021; 50:885-903. [PMID: 34717877 DOI: 10.1016/j.gtc.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Achalasia is the prototypical obstructive motor disorder diagnosed using HRM, but non-achalasia motor disorders are often identified in symptomatic patients. The clinical relevance of these disorders are assessed using ancillary HRM maneuvers (multiple rapid swallows, rapid drink challenge, solid swallows) that augment the standard supine HRM evaluation by challenging peristaltic function. Finding obstructive motor physiology in non-achalasia motor disorders may raise the option of invasive management akin to achalasia. Certain non-achalasia disorders, particularly hypermotility disorders, may manifest as epiphenomena seen with esophageal hypersensitivity. Symptomatic management is offered for superimposed reflux disease, psychological disorders, functional esophageal disorders, and behavioral disorders.
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Affiliation(s)
- Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA; Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, 550 South Preston Street, Louisville, KY 40202, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA.
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Gyawali CP, Penagini R. Clinical usefulness of esophageal high resolution manometry and adjunctive tests: An update. Dig Liver Dis 2021; 53:1373-80. [PMID: 33994122 DOI: 10.1016/j.dld.2021.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 12/11/2022]
Abstract
High resolution manometry (HRM), developed from conventional manometry, is the gold standard for assessment of esophageal motor function worldwide. The Chicago Classification, now in its fourth iteration, is the modern standard for HRM categorization of esophageal motility disorders. The HRM protocol has expanded from the original 10 supine swallow standard, to include upright swallows, and provocative maneuvers such as multiple rapid swallows, rapid drink challenge and standardized test meal. Impedance has been incorporated into HRM for visualization of bolus clearance. Futhermore, barium radiography and functional lumen imaging probe complement HRM when evidence of esophagogastric junction obstruction is inconclusive. The biggest impact of HRM is in the improved diagnosis and subtyping of achalasia spectrum disorders, with implications on management. Spastic disorders and absent contractility are better characterized. Within the reflux spectrum, HRM provides definition of morphology and tone of the esophagogastric junction, and assesses integrity of esophageal body peristalsis, which have pathophysiologic implications for reflux and its clearance. HRM provides characterization of behavioral disorders such as supragastric belching and rumination syndrome, which can mimic reflux disease. Thus, HRM has revolutionized the evaluation of esophageal motor function, and has expanded the utility of esophageal manometry in clinical practice.
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29
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Carlson DA, Baumann AJ, Prescott JE, Schauer JM, Krause A, Donnan EN, Kou W, Kahrilas PJ, Pandolfino JE. Prediction of Esophageal Retention: A Study Comparing High-Resolution Manometry and Functional Luminal Imaging Probe Panometry. Am J Gastroenterol 2021; 116:2032-41. [PMID: 34388142 DOI: 10.14309/ajg.0000000000001402] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/15/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION High-resolution manometry (HRM) is generally considered the primary method to evaluate esophageal motility; functional luminal imaging probe (FLIP) panometry represents a novel method to do so and is completed during sedated endoscopy. This study aimed to compare HRM and FLIP panometry in predicting esophageal retention on timed barium esophagram (TBE). METHODS A total of 329 adult patients who completed FLIP, HRM, and TBE for primary esophageal motility evaluation were included. An abnormal TBE was defined by a 1-minute column height >5 cm or impaction of a 12.5-mm barium tablet. The integrated relaxation pressure (IRP) on HRM was assessed in the supine and upright patient positions. Esophagogastric junction (EGJ) opening was evaluated with 16-cm FLIP performed during sedated endoscopy through EGJ-distensibility index and maximum EGJ diameter. RESULTS Receiver operating characteristic curves to identify an abnormal TBE demonstrated AUC (95% confidence interval) of 0.79 (0.75-0.84) for supine IRP, 0.79 (0.76-0.86) for upright IRP, 0.84 (0.79-0.88) for EGJ-distensibility index, and 0.88 (0.85-0.92) for maximum EGJ diameter. Logistic regression to predict abnormal TBE showed odds ratios (95% confidence interval) of 1.8 (0.84-3.7) for consistent IRP elevation and 39.7 (16.4-96.2) for reduced EGJ opening on FLIP panometry. Of 40 patients with HRM-FLIP panometry discordance, HRM-IRP was consistent with TBE in 23% while FLIP panometry was consistent with TBE in 78%. DISCUSSION FLIP panometry provided superior detection of esophageal retention over IRP on HRM. However, application of a complementary evaluation involving FLIP panometry, HRM, and TBE may be necessary to accurately diagnose esophageal motility disorders.
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Nabi Z, Ramchandani M, Reddy DN. Optional Management of Achalasia in 2021: Dilatation or Myotomy. Journal of Digestive Endoscopy 2021. [DOI: 10.1055/s-0041-1731626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractAchalasia cardia is a primary motility disorder of the esophagus, defined by lack of normal esophageal peristalsis along with inadequate relaxation of lower esophageal sphincter . The mainstay of management in achalasia includes pneumatic dilatation, Heller’s myotomy and peroral endoscopic myotomy (POEM). Pneumatic dilatation and Heller’s myotomy have gained maturity over several decades. The current best practice with regard to pneumatic dilatation is graded and on-demand dilatation in appropriately selected cases with type I and II achalasia. Laparoscopic Heller’s myotomy plus partial fundoplication is minimally invasive with reduced postoperative reflux and has virtually replaced open Heller’s myotomy with or without fundoplication. The subtyping of achalasia using high-resolution manometry bears prognostic significance and may help in choosing appropriate therapeutic modality in these patients. Since all the three modalities are effective for type I and II achalasia, the choice among these depends on the availability, expertise, and patient’s preferences. On the other hand, POEM is more effective than pneumatic dilatation and Heller’s myotomy and, therefore, preferred in type III achalasia. Although POEM is effective across the spectrum of esophageal motility disorders, the incidence of gastroesophageal reflux is high and needs to be considered while choosing among various options in these patients. In cases with failed POEM, redo POEM appears to be effective in alleviating symptoms.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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31
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Abstract
Until recently, gastric motility measurements in humans were mostly limited to accommodation (using barostat or 3-dimensional imaging studies of gastric volume) and gastric emptying tests, the latter being the only one performed in routine clinical care. Accurate and easy to use techniques were lacking to assess pyloric function in health and disease. Recently, pyloric distensibility has been developed and validated to assess pyloric opening. Several studies confirmed that pyloric distensibility was decreased in gastroparesis and correlated with gastric emptying as well as gastroparesis symptoms. In addition, pyloric distensibility may predict outcome of endoscopic techniques targeting the pylorus, namely intrapyloric botulinum toxin injection and gastric per-oral pyloromyotomy. Pyloric distensibility appears therefore to be a promising and useful new tool in the workup of gastroparesis patients.
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Affiliation(s)
- Fabien Wuestenberghs
- Department of Physiology, Institut National de la Santé et de la Recherche Médicale Unit 1073 and Clinical Investigation Centre-Centre de Ressource Biologiqu 1404, Rouen University Hospital, UNIROUEN, Normandie University, Rouen, France.,Department of Gastroenterology and Hepatology, Centre Hospitalier Universitaire UCLouvain Namur, Godinne University Hospital, UCLouvain, Yvoir, Belgium
| | - Guillaume Gourcerol
- Department of Physiology, Institut National de la Santé et de la Recherche Médicale Unit 1073 and Clinical Investigation Centre-Centre de Ressource Biologiqu 1404, Rouen University Hospital, UNIROUEN, Normandie University, Rouen, France
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Gyawali CP, Zerbib F, Bhatia S, Cisternas D, Coss-Adame E, Lazarescu A, Pohl D, Yadlapati R, Penagini R, Pandolfino J. Chicago Classification update (V4.0): Technical review on diagnostic criteria for ineffective esophageal motility and absent contractility. Neurogastroenterol Motil 2021; 33:e14134. [PMID: 33768698 DOI: 10.1111/nmo.14134] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/24/2021] [Accepted: 03/09/2021] [Indexed: 12/12/2022]
Abstract
Esophageal hypomotility disorders manifest with abnormal esophageal body contraction vigor, breaks in peristaltic integrity, or failure of peristalsis in the context of normal lower esophageal sphincter relaxation on esophageal high-resolution manometry (HRM). The Chicago Classification version 4.0 recognizes two hypomotility disorders, ineffective esophageal motility (IEM) and absent contractility, while fragmented peristalsis has been incorporated into the IEM definition. Updated criteria for ineffective swallows consist of weak esophageal body contraction vigor measured using distal contractile integral (DCI, 100-450 mmHg·cm·s), transition zone defects >5 cm measured using a 20 mmHg isobaric contour, or failure of peristalsis (DCI < 100 mmHg·cm·s). More than 70% ineffective swallows and/or ≥50% failed swallows are required for a conclusive diagnosis of IEM. When the diagnosis is inconclusive (50%-70% ineffective swallows), supplementary evidence from multiple rapid swallows (absence of contraction reserve), barium radiography (abnormal bolus clearance), or HRM with impedance (abnormal bolus clearance) could support a diagnosis of IEM. Absent contractility requires 100% failed peristalsis, consistent with previous versions of the classification. Consideration needs to be given for the possibility of achalasia in absent contractility with dysphagia despite normal IRP, and alternate complementary tests (including timed upright barium esophagram and functional lumen imaging probe) are recommended to confirm or refute the presence of achalasia. Future research to quantify esophageal bolus retention on stationary HRM with impedance and to understand contraction vigor thresholds that predict bolus clearance will provide further refinement to diagnostic criteria for esophageal hypomotility disorders in future iterations of the Chicago Classification.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, Bordeaux, France
| | - Shobna Bhatia
- Department of Gastroenterology, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Daniel Cisternas
- Clínica Alemana de Santiago, Facultad de Medicina, Universidad del Desarrollo, Santiago de Chile, Chile
| | - Enrique Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Tlalpan, Mexico
| | - Adriana Lazarescu
- Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Rena Yadlapati
- Center for Esophageal Diseases, University of California, San Diego, CA, USA
| | - Roberto Penagini
- Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Lee JM, Yoo IK, Kim E, Hong SP, Cho JY. The Usefulness of the Measurement of Esophagogastric Junction Distensibility by EndoFLIP in the Diagnosis of Gastroesophageal Reflux Disease. Gut Liver 2021; 15:546-552. [PMID: 33115968 PMCID: PMC8283286 DOI: 10.5009/gnl20117] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/22/2020] [Accepted: 07/29/2020] [Indexed: 12/16/2022] Open
Abstract
Background/Aims Increased esophagogastric junction (EGJ) relaxation is the most important mechanism involved in gastroesophageal reflux disease (GERD). An endoscopic functional luminal imaging probe (EndoFLIPⓇ) is a device used to quantify EGJ distensibility in routine endoscopy. The aim of the current study was to assess the usefulness of EndoFLIPⓇ for the diagnosis of GERD compared to normal controls. Methods We analyzed EndoFLIPⓇ data from 204 patients with erosive reflux disease (ERD), 310 patients with nonerosive reflux disease (NERD), and 277 normal subjects. EndoFLIPⓇ uses impedance planimetry to measure 16 cross-sectional areas (CSAs) in conjunction with the corresponding intrabag pressure within a 4.6 cm cylindrical segment of a fluid-filled bag. The EGJ distensibility was assessed using 40 mL volume-controlled distensions. Results The mean distensibility index values were 13.98 mm2/mm Hg in ERD patients, 11.42 mm2/mm Hg in NERD patients, and 9.1 mm2/mm Hg in normal subjects. There were significant differences in EGJ distensibility among the three groups (p<0.001). In addition, the CSAs were significantly higher in the ERD (291.03±160.77 mm2) and NERD groups (285.87±155.47 mm2) than in the control group (249.78±144.76 mm2, p=0.004). We determined the distensibility index cutoff value of EGJ as 10.95 for the diagnosis of GERD by receiver operating characteristic curve analysis. Conclusions The EGJ distensibilities of GERD patients were higher than those of normal subjects, regardless of the presence of reflux esophagitis. Thus, the measurement of EGJ distensibility using the EndoFLIPⓇ system could be useful in the diagnosis of GERD.
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Affiliation(s)
- Jung Min Lee
- Department of Gastroenterology, Wonkwang University Sanbon Medical Center, Gunpo, Korea
| | - In Kyung Yoo
- Department of Gastroenterology, CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, Korea
| | - Eunju Kim
- Department of Gastroenterology, CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, Korea
| | - Sung Pyo Hong
- Department of Gastroenterology, CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, Korea
| | - Joo Young Cho
- Department of Gastroenterology, CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, Korea
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Khan A, Yadlapati R, Gonlachanvit S, Katzka DA, Park MI, Vaezi M, Vela M, Pandolfino J. Chicago Classification update (version 4.0): Technical review on diagnostic criteria for achalasia. Neurogastroenterol Motil 2021; 33:e14182. [PMID: 34190376 DOI: 10.1111/nmo.14182] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 04/27/2021] [Accepted: 05/03/2021] [Indexed: 12/14/2022]
Abstract
The recommended diagnostic criteria for achalasia have been recently updated by Chicago Classification version 4.0 (CCv4.0), the widely accepted classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). CCv4.0 continued upon prior versions by subtyping achalasia into type I, type II, and type III on HRM. The achalasia subgroup of the CCv4.0 Working Group developed both conclusive and inconclusive statements for the HRM diagnoses of achalasia subtypes. Conclusive achalasia on HRM is defined as an abnormal median integrated relaxation pressure (IRP) in the primary position of wet swallows along with 100% failed peristalsis, with type I achalasia having 100% failed peristalsis without panesophageal pressurization (PEP), type II achalasia with PEP in at least 20% of swallows, and type III achalasia having at least 20% of swallows premature with no appreciable peristalsis. An inconclusive HRM diagnosis of achalasia can arise when there is an integrated relaxation pressure (IRP) that is borderline or at the upper limit of normal in at least one position, there is an abnormal IRP in both positions but evidence of peristalsis with PEP or premature swallows, or there is peristalsis in the secondary position after apparent achalasia in the primary position. In patients with dysphagia and an inconclusive HRM diagnosis of achalasia, supportive testing beyond HRM such as a timed barium esophagram (TBE) for functional lumen imaging probe (FLIP) is recommended. The review recommends a diagnostic algorithm for achalasia, discusses therapeutic options for the disease, and outlines future needs on this topic.
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Affiliation(s)
- Abraham Khan
- Center for Esophageal Health, NYU Langone Health, New York, NY, USA
| | - Rena Yadlapati
- Center for Esophageal Diseases, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, CA, USA
| | - Sutep Gonlachanvit
- Center of Excellence on Neurogastroenterology and Motility, Division of Gastroenterology, Chulalongkorn University, Bangkok, Thailand
| | | | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Michael Vaezi
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - John Pandolfino
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Oude Nijhuis RAB, Zaninotto G, Roman S, Boeckxstaens GE, Fockens P, Langendam MW, Plumb AA, Smout A, Targarona EM, Trukhmanov AS, Weusten B, Bredenoord AJ. European guidelines on achalasia: United European Gastroenterology and European Society of Neurogastroenterology and Motility recommendations. United European Gastroenterol J 2021; 8:13-33. [PMID: 32213062 PMCID: PMC7005998 DOI: 10.1177/2050640620903213] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Achalasia is a primary motor disorder of the oesophagus characterised by absence of peristalsis and insufficient lower oesophageal sphincter relaxation. With new advances and developments in achalasia management, there is an increasing demand for comprehensive evidence-based guidelines to assist clinicians in achalasia patient care. METHODS Guidelines were established by a working group of representatives from United European Gastroenterology, European Society of Neurogastroenterology and Motility, European Society of Gastrointestinal and Abdominal Radiology and the European Association of Endoscopic Surgery in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument. A systematic review of the literature was performed, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Recommendations were voted upon using a nominal group technique. RESULTS These guidelines focus on the definition of achalasia, treatment aims, diagnostic tests, medical, endoscopic and surgical therapy, management of treatment failure, follow-up and oesophageal cancer risk. CONCLUSION These multidisciplinary guidelines provide a comprehensive evidence-based framework with recommendations on the diagnosis, treatment and follow-up of adult achalasia patients.
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Affiliation(s)
- R A B Oude Nijhuis
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - S Roman
- Digestive Physiology, Hôpital Edouard Herriot, Lyon, France
| | - G E Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Centre for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - P Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - M W Langendam
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - A A Plumb
- Centre for Medical Imaging, University College London, London, UK
| | - Ajpm Smout
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - E M Targarona
- Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - A S Trukhmanov
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Blam Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
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Zerbib F, Luna D, Marin I, Serra J. The added value of symptom analysis during a rapid drink challenge in high-resolution esophageal manometry. Neurogastroenterol Motil 2021; 33:e14008. [PMID: 33043538 DOI: 10.1111/nmo.14008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Patients with esophageal symptoms often remain with an uncertain diagnosis after high-resolution manometry. AIM To determine the added value of concomitant pressure and symptom analysis in response to a rapid drink challenge (RDC). METHODS In consecutive patients referred for esophageal manometry, a RDC consisting in free drinking of 200 ml of water as quick as possible was performed after the standard single water swallows manometry. Both pressure patterns and usual symptoms induced by the RDC were analyzed. RESULTS A total of 1319 patients were included, (64.7% women, mean age 58.2 years, range 11-90). There were significant differences in pressure responses between patients with obstructive disorders, major hypercontractile disorders, esophageal hypomotility disorders and normal motility. The RDC provoked usual symptoms in 388 (29.4%) patients, associated with hyperpressive and obstructive patterns in 14.0% and 16.6%, respectively. Reproduction of dysphagia and regurgitation (not pain) was significantly associated with abnormal pressure responses during the RDC (p < 0.001 and p = 0.002, respectively). The RDC elicited both abnormal pressure patterns and symptoms in 6.2%, 1.6%, and 20.8% of patients with normal motility, ineffective esophageal motility, and esophago-gastric junction outflow obstruction, respectively. CONCLUSION Concomitant evaluation of symptoms and pressure responses to a RDC may increase the specificity of esophageal motor testing in patients with inconclusive diagnosis or normal esophageal motility.
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Affiliation(s)
- Frank Zerbib
- Motility and Functional Gut Disorders Unit, University Hospital Germans Trias i Pujol, Centro de Investigación Biomedica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Autonomous University of Barcelona, Badalona, Spain.,Gastroenterology Department, CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Daniel Luna
- Motility and Functional Gut Disorders Unit, University Hospital Germans Trias i Pujol, Centro de Investigación Biomedica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Autonomous University of Barcelona, Badalona, Spain
| | - Ingrid Marin
- Motility and Functional Gut Disorders Unit, University Hospital Germans Trias i Pujol, Centro de Investigación Biomedica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Autonomous University of Barcelona, Badalona, Spain
| | - Jordi Serra
- Motility and Functional Gut Disorders Unit, University Hospital Germans Trias i Pujol, Centro de Investigación Biomedica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Autonomous University of Barcelona, Badalona, Spain
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Abstract
Achalasia is a rare esophageal motility disorder characterized by the incomplete
relaxation of the lower esophageal sphincter (LES) and impaired peristaltic
activity. The advent of high-resolution manometry (HRM) and the rapidly evolving
role of therapeutic endoscopy have revolutionized the approach to the diagnosis
and management of achalasia patients in the last decade. With advances in HRM
technology and methodology, fluoroscopy and EndoFlip, achalasia can be
differentiated into therapeutically meaningful phenotypes with a high degree of
accuracy. Further, the newest treatment option, per-oral endoscopic myotomy
(POEM), has become a staple therapy following the last 10 years of experience,
and recent randomized trials appear to show no difference between POEM, graded
pneumatic dilatation and surgical Heller myotomy in terms of short- and
long-term efficacy or complication rate. On the other hand, how treatment
outcomes are measured as well as the risk of reflux following therapy remain
areas of contention. This review aims to summarize the recent advancements in
achalasia testing and therapy, describes the recent randomized clinical trials
as well as their potential setbacks, and touches on the future of personalizing
achalasia treatment.
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Affiliation(s)
- Marcella Pesce
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Naples, Italy
| | - Rami Sweis
- University College London Hospital, GI Services, 235 Euston Rd, London, NW1 2BU, UK
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Masuda T, Yano F, Omura N, Tsuboi K, Hoshino M, Yamamoto S, Akimoto S, Sakashita Y, Fukushima N, Kashiwagi H. Optimal cutoff value of integrated relaxation pressure on the esophagogastric junction to detect outflow obstruction using starlet high-resolution manometry system. J Gastroenterol 2021; 56:231-9. [PMID: 33423114 DOI: 10.1007/s00535-020-01757-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 12/19/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Achalasia and esophagogastric junction outflow obstruction (EGJOO) are idiopathic esophageal motility disorders characterized by impaired deglutitive relaxation of the lower esophageal sphincter (LES). High-resolution manometry (HRM) provides integrated relaxation pressure (IRP) which represents adequacy of LES relaxation. The Starlet HRM system is widely used in Japan; however, IRP values in achalasia/EGJOO patients assessed with the Starlet system have not been well studied. We propose the optimal cutoff of IRP for detecting achalasia/EGJOO using the Starlet system. METHODS Patients undergone HRM test using the Starlet system at our institution between July 2018 and September 2020 were included. Of these, we included patients with either achalasia or EGJOO and those who had normal esophageal motility without hiatal hernia. Abnormally impaired LES relaxation (i.e., achalasia and EGJOO) was diagnosed if prolonged esophageal emptying was evident based on timed barium esophagogram (TBE). RESULTS A total of 111 patients met study criteria. Of these, 48 patients were diagnosed with achalasia (n = 45 [type I, n = 20; type II, n = 22; type III, n = 3]) or EGJOO (n = 3). In the 48 patients who had a prolonged esophageal clearance based on TBE, IRP values distributed along a wide-range of minimal 14.1 to a maximal of 72.2 mmHg. The optimal cutoff value of IRP was 24.7 mmHg with sensitivity of 89.6% and specificity of 84.1% (AUC 0.94). CONCLUSION The optimal cutoff value of IRP to distinguish achalasia/EGJOO was ≥ 25 mmHg using the Starlet HRM system in our cohort. This indicates that the current proposed cutoff of 26 mmHg appears to be relevant.
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Cha B, Jung KW. [Diagnosis of Dysphagia: High Resolution Manometry & EndoFLIP]. Korean J Gastroenterol 2021; 77:64-70. [PMID: 33632996 DOI: 10.4166/kjg.2021.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/19/2021] [Accepted: 02/19/2021] [Indexed: 12/27/2022]
Abstract
Esophageal motility disorders were re-defined when high-resolution manometry was employed to better understand their pathogenesis. Newly developed parameters including integrated relaxation pressure (IRP), distal contractile integral, and distal latency showed better diagnostic yield compared with previously used conventional parameters. Therefore, Chicago classification was formulated, and its diagnostic cascade begins by assessing the IRP value. However, IRP showed limitation due to its inconsistency, and other studies have tried to overcome this. Recent studies showed that provocative tests, supplementing the conventional esophageal manometry protocol, have improved the diagnostic yield of the esophageal motility disorders. Therefore, position change from supine to upright, solid or semi-solid swallowing, multiple rapid swallows, and the rapid drink challenge were newly added to the manometry protocol in the revised Chicago classification version 4.0. Impedance planimetry enables measurement of bag cross-sectional area at various locations. The functional lumen imaging probe (FLIP) has been applied to assess luminal distensibility. This probe can also measure pressure, serial cross-sectional areas, and tension-strain relationship. The esophagogastric junction's distensibility is decreased in achalasia. Therefore, EndoFLIP can be used to assess contractility and distensibility of the esophagus in the patients with achalasia, including repetitive antegrade or retrograde contractions. EndoFLIP can detect achalasia patients with relatively low IRP, which was difficult to diagnose using the current high-resolution manometry. EndoFLIP also provides information on the contractile activity and distensibility of the esophageal body in patients with achalasia. The use of provocative tests, newly added in Chicago classification 4.0 version, and EndoFLIP can expand understanding of esophageal motility disorders.
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Affiliation(s)
- Boram Cha
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Murray FR, Fischbach LM, Schindler V, Schnurre L, Hente JM, Tatu A, Pohl D. Solid Swallow Examination During High Resolution Manometry and EGJ-Distensibility Help Identify Esophageal Outflow Obstruction in Non-obstructive Dysphagia. Dysphagia 2021; 37:168-176. [PMID: 33609164 PMCID: PMC8843924 DOI: 10.1007/s00455-021-10260-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/27/2021] [Indexed: 12/02/2022]
Abstract
Single water swallow (SWS) high-resolution manometry (HRM) may miss relevant esophageal motility disorders. Solid test meal (STM) during HRM and lately the functional lumen imaging probe (FLIP) have been shown to be of diagnostic value in the assessment of motility disorders. We aimed to assess the diagnostic yield of STM and FLIP in non-obstructive dysphagia (NOD). Patients assessed for dysphagia with both HRM and FLIP between April 2016 and August 2019 were analyzed for signs of non-obstructive EGJ outflow obstruction (EGJOO) according to Chicago Classification 3.0 (CCv3) and CC adapted for the use with solid swallows (CC-S), followed by an individual group-specific analysis. Five subjects without dysphagia served as control group. Standard HRM- and FLIP-values as well as esophagograms and Eckardt Scores were analyzed. Forty-two patients were identified (male/female, 14/36, median age 62). Twenty-five (59.5%) were diagnosed with EGJOO during STM only (= SWS-negative patients; CC-S). The EGJ distensibility index (EGJ-DI) of symptomatic patients was significantly lower compared to the control group (p = 0.006). EGJ-DI was < 3mm2/mmHg in 67% and 88% of patients diagnosed according to CC-S and CCv3, respectively. The IRP during STM showed a significant association to the corresponding EGJ-DI values (p < 0.001). Seventy-six percent of patients received treatment because of additional STM evaluation with a favorable clinical response rate of 89%. STM and FLIP identify EGJOO in symptomatic patients with normal SWS during HRM. STM resembles an inexpensive and clinically meaningful option to diagnose motility disorders and helps to select patients for interventional treatment.
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Affiliation(s)
- Fritz Ruprecht Murray
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Lara Maria Fischbach
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Valeria Schindler
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Larissa Schnurre
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Juliane Marie Hente
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Aurora Tatu
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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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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Baumann AJ, Donnan EN, Triggs JR, Kou W, Prescott J, Decorrevont A, Dorian E, Kahrilas PJ, Pandolfino JE, Carlson DA. Normal Functional Luminal Imaging Probe Panometry Findings Associate With Lack of Major Esophageal Motility Disorder on High-Resolution Manometry. Clin Gastroenterol Hepatol 2021; 19:259-268.e1. [PMID: 32205217 PMCID: PMC7502471 DOI: 10.1016/j.cgh.2020.03.040] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/19/2020] [Accepted: 03/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS A normal esophageal response to distension on functional luminal imaging probe (FLIP) panometry during endoscopy might indicate normal esophageal motor function. We aimed to investigate the correlation of normal FLIP panometry findings with esophageal high-resolution manometry (HRM) and outcomes of discrepant patients. METHODS We performed a retrospective study using data from a registry of patients who completed FLIP during sedated endoscopy. We identified 111 patients with normal FLIP panometry findings (mean age, 42 y; 69% female) and corresponding HRM data. A normal FLIP panometry was defined as an esophagogastric junction (EGJ) distensibility index greater than 3.0 mm2/mm Hg, an absence of repetitive retrograde contractions, and a repetitive antegrade contraction pattern that met the Rule-of-6s: ≥6 consecutive antegrade contractions of ≥6-cm in length, at a rate of 6 ± 3 contractions per minute. HRM findings were classified by the Chicago classification system version 3.0. RESULTS HRM results were classified as normal motility in 78 patients (70%), ineffective esophageal motility in 10 patients (9%), EGJ outflow obstruction in 20 patients (18%), and 3 patients (3%) as other. In patients with EGJ outflow obstruction based on HRM, the integrated relaxation pressure normalized on adjunctive swallows in 16 of 20 patients (80%), and in 8 of 9 patients (88%) who completed a barium esophagram and had normal barium clearance. Thus, although 23 of 111 patients (21%) with normal FLIP panometry had abnormal HRM findings, these HRMs often were considered to be false-positive or equivocal results. All patients with an abnormal result from HRM were treated conservatively. CONCLUSIONS In a retrospective cohort study, we found that patients with normal FLIP panometry results did not have a clinical impression of a major esophageal motor disorder. Normal FLIP panometry results can exclude esophageal motility disorders at the time of endoscopy, possibly negating the need for HRM in select patients.
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Affiliation(s)
- Alexandra J. Baumann
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Erica N. Donnan
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joseph R. Triggs
- Department of Medicine, Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wenjun Kou
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jacqueline Prescott
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alex Decorrevont
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Emily Dorian
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Peter J. Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Ponds FA, Oors JM, Smout AJPM, Bredenoord AJ. Reflux symptoms and oesophageal acidification in treated achalasia patients are often not reflux related. Gut 2021; 70:30-39. [PMID: 32439713 PMCID: PMC7788183 DOI: 10.1136/gutjnl-2020-320772] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE After treatment, achalasia patients often develop reflux symptoms. Aim of this case-control study was to investigate mechanisms underlying reflux symptoms in treated achalasia patients by analysing oesophageal function, acidification patterns and symptom perception. DESIGN Forty treated achalasia patients (mean age 52.9 years; 27 (68%) men) were included, 20 patients with reflux symptoms (RS+; Gastro-Oesophageal Reflux Disease Questionnaire (GORDQ) ≥8) and 20 without reflux symptoms (RS-: GORDQ <8). Patients underwent measurements of oesophagogastric junction distensibility, high-resolution manometry, timed barium oesophagogram, 24 hours pH-impedance monitoring off acid-suppression and oesophageal perception for acid perfusion and distension. Presence of oesophagitis was assessed endoscopically. RESULTS Total acid exposure time during 24 hours pH-impedance was not significantly different between patients with (RS+) and without (RS-) reflux symptoms. In RS+ patients, acid fermentation was higher than in RS- patients (RS+: mean 6.6% (95% CI 2.96% to 10.2%) vs RS-: 1.8% (95% CI -0.45% to 4.1%, p=0.03) as well as acid reflux with delayed clearance (RS+: 6% (95% CI 0.94% to 11%) vs RS-: 3.4% (95% CI -0.34% to 7.18%), p=0.051). Reflux symptoms were not related to acid in both groups, reflected by a low Symptom Index. RS+ patients were highly hypersensitive to acid, with a much shorter time to heartburn perception (RS+: 4 (2-6) vs RS-:30 (14-30) min, p<0.001) and a much higher symptom intensity (RS+: 7 (4.8-9) vs RS-: 0.5 (0-4.5) Visual Analogue Scale, p<0.001) during acid perfusion. They also had a lower threshold for mechanical stimulation. CONCLUSION Reflux symptoms in treated achalasia are rarely caused by gastro-oesophageal reflux and most instances of oesophageal acidification are not reflux related. Instead, achalasia patients with post-treatment reflux symptoms demonstrate oesophageal hypersensitivity to chemical and mechanical stimuli, which may determine symptom generation.
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Affiliation(s)
- Fraukje A Ponds
- Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jacobus M Oors
- Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - André J P M Smout
- Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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44
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Yadlapati R, Kahrilas PJ, Fox MR, Bredenoord AJ, Gyawali CP, Roman S, Babaei A, Mittal RK, Rommel N, Savarino E, Sifrim D, Smout A, Vaezi MF, Zerbib F, Akiyama J, Bhatia S, Bor S, Carlson DA, Chen JW, Cisternas D, Cock C, Coss-Adame E, de Bortoli N, Defilippi C, Fass R, Ghoshal UC, Gonlachanvit S, Hani A, Hebbard GS, Jung KW, Katz P, Katzka DA, Khan A, Kohn GP, Lazarescu A, Lengliner J, Mittal SK, Omari T, In Park M, Penagini R, Pohl D, Richter JE, Serra J, Sweis R, Tack J, Tatum RP, Tutuian R, Vela MF, Wong RK, Wu JC, Xiao Y, Pandolfino JE. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0 ©. Neurogastroenterol Motil 2021; 33:e14058. [PMID: 33373111 PMCID: PMC8034247 DOI: 10.1111/nmo.14058] [Citation(s) in RCA: 359] [Impact Index Per Article: 119.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/21/2020] [Accepted: 11/24/2020] [Indexed: 12/12/2022]
Abstract
Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diagnostic criteria for ineffective esophageal motility and description of baseline EGJ metrics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for patterns of disorders of peristalsis and obstruction at the EGJ.
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Affiliation(s)
- Rena Yadlapati
- Center for Esophageal Diseases, University of California San Diego, La Jolla, CA, USA
| | - Peter J. Kahrilas
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark R. Fox
- University of Zürich, CH-8091 Zürich & Department of Gastroenterology, Klinik Arlesheim, CH-4144 Arlesheim
| | - Albert J. Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - C. Prakash Gyawali
- Division of Gastroenterology & Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sabine Roman
- Univ Lyon, Université Lyon I, Hospices Civils de Lyon, Digestive Physiology, F-69003, Lyon, France,Univ Lyon, Université Lyon I, Hospices Civils de Lyon, INSERM, LabTAU, F-69003, Lyon, France
| | | | - Ravinder K. Mittal
- Center for Esophageal Diseases, University of California San Diego, La Jolla, CA, USA,Veteran Affairs San Diego Healthcare System, La Jolla, CA, USA
| | - Nathalie Rommel
- University of Leuven, Neurosciences, Experimental ORL, Deglutology - University Hospitals Leuven Dept Gastroenterology, Neurogastroenterology & Motility
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Daniel Sifrim
- Wingate institute of Neurogastroenterology, Queen Mary University of London
| | - André Smout
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | | | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology department; Université de Bordeaux; INSERM CIC 1401; Bordeaux, France
| | | | | | - Serhat Bor
- Ege University School of Medicine, Div. Gastroenterology, Turkey
| | - Dustin A. Carlson
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Daniel Cisternas
- Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo. Santiago, Chile
| | | | - Enrique Coss-Adame
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”
| | - Nicola de Bortoli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa
| | | | - Ronnie Fass
- MetroHealth System and case Western Reserve University
| | - Uday C. Ghoshal
- Dept. of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sutep Gonlachanvit
- Excellence Center on Neurogastroenterology and Motility, Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Thailand
| | - Albis Hani
- Pontificia Universidad Javeriana-Hospital San Ignacio, Colombia
| | | | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | | | - Abraham Khan
- New York University, Langone Health, New York, NY, USA
| | | | | | | | | | - Taher Omari
- College of Medicine & Public Health, Flinders University, South Australia, Australia
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Roberto Penagini
- Gastroenterology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico and Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland
| | - Joel E. Richter
- University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Jordi Serra
- University Hospital Germans Trias i Pujol. Badalona. CIBERehd
| | - Rami Sweis
- University College London Hospital, United Kingdom
| | - Jan Tack
- TARGID, University of Leuven, Belgium
| | - Roger P. Tatum
- University of Washington Department of Surgery/VA Puget Sound HCS
| | - Radu Tutuian
- Bürgerspital Solothurn, University of Bern, University of Zurich, Switzerland
| | | | - Reuben K. Wong
- Yong Loo Lin of Medicine, National University of Singapore, Singapore
| | - Justin C. Wu
- The Chinese University of Hong Kong, Hong Kong SAR
| | - Yinglian Xiao
- Department of Gastroenterology, the First Affiliated Hospital, Sun Yat-sen University, China
| | - John E. Pandolfino
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Rieder E, Fernandez-Becker NQ, Sarosiek J, Guillaume A, Azagury DE, Clarke JO. Achalasia: physiology and diagnosis. Ann N Y Acad Sci 2020; 1482:85-94. [PMID: 33140485 DOI: 10.1111/nyas.14510] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 12/18/2022]
Abstract
Achalasia is a rare motility disorder with incomplete relaxation of the lower esophageal sphincter and ineffective contractions of the esophageal body. It has been hypothesized that achalasia does not result from only one pathway but rather involves a combination of infectious, autoimmune, and familial etiological components. On the basis of other observations, a novel hypothesis suggests that a muscular form of eosinophilic esophagitis is involved in the pathophysiology of achalasia in some patients. This appears to progressively diminish the myenteric plexus at stage III, gradually destroy it at stage II, and finally eliminate it at stage I, the most advanced and final stage of achalasia. Although high-resolution manometry has identified these three different types of achalasia, another subset of patients with a normal-appearing sphincter relaxation has been proposed. Provocative maneuvers, such as the rapid drinking challenge, have recently been demonstrated to improve diagnosis in certain borderline patients, but have to be studied in more detail. However, whether the different types of achalasia will have a long-term impact on tailored therapies is still a matter of debate. Additionally, novel aspects of the standard timed barium swallow appear to be an important adjunct of diagnosis, as it has been shown to have a diagnostic as well as a predictive value.
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Affiliation(s)
- Erwin Rieder
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Jerzy Sarosiek
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, Texas
| | - Alexandra Guillaume
- Gastrointestinal Motility Center, Renaissance School of Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Dan E Azagury
- Minimally Invasive & Bariatric Surgery, Stanford University School of Medicine, Palo Alto, California
| | - John O Clarke
- Department of Medicine, Stanford University, Redwood City, California
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Abstract
In their article "Use of the Functional Lumen Imaging Probe in Clinical Esophagology," Savarino et al. report the outcomes of a Grading of Recommendations Assessment, Development, and Evaluation analysis performed by experts in the use of functional lumen imaging probe (FLIP) evaluation of esophageal disorders. For essentially all clinical indications, the recommendation for use was conditional with a very low quality of evidence. FLIP is an expensive, invasive technology examining limited aspects of esophageal function. Its role in complementing or replacing existing technology is uncertain, particularly when compared with manometric testing with additional provocative studies. Performing properly designed studies to demonstrate FLIP's true effectiveness and cost-effectiveness will be costly.
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Affiliation(s)
- Benson T Massey
- GI Manometry Laboratory, Division of Gastroenterology & Hepatology, Medical College of Wisconsin, Hub for Collaborative Medicine, Milwaukee, Wisconsin, USA
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47
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Savarino E, di Pietro M, Bredenoord AJ, Carlson DA, Clarke JO, Khan A, Vela MF, Yadlapati R, Pohl D, Pandolfino JE, Roman S, Gyawali CP. Use of the Functional Lumen Imaging Probe in Clinical Esophagology. Am J Gastroenterol 2020; 115:1786-1796. [PMID: 33156096 PMCID: PMC9380028 DOI: 10.14309/ajg.0000000000000773] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The functional lumen imaging probe (FLIP) measures luminal dimensions using impedance planimetry, performed most often during sedated upper endoscopy. Mechanical properties of the esophageal wall and opening dynamics of the esophagogastric junction (EGJ) can be objectively evaluated in esophageal motor disorders, eosinophilic esophagitis, esophageal strictures, during esophageal surgery and in postsurgical symptomatic states. Distensibility index, the ratio of EGJ cross sectional area to intraballoon pressure, is the most useful FLIP metric. Secondary peristalsis from balloon distension can be displayed topographically as repetitive anterograde or retrograde contractile activity in the esophageal body, similar to high-resolution manometry. Real-time interpretation and postprocessing of FLIP metadata can complement the identification of esophageal outflow obstruction and achalasia, especially when findings are inconclusive from alternate esophageal tests in symptomatic patients. FLIP can complement the diagnosis of achalasia when manometry and barium studies are inconclusive or negative in patients with typical symptoms. FLIP can direct adequacy of disruption of the EGJ in achalasia when used during and immediately after myotomy and pneumatic dilation. Lumen diameter measured using FLIP in eosinophilic esophagitis and in complex strictures can potentially guide management. An abbreviated modification of the Grading of Recommendations Assessment, Development, and Evaluation was used to determine the quality of available evidence and recommendations regarding FLIP utilization. FLIP metrics that are diagnostic or suggestive of an abnormal motor pattern and metrics that define normal esophageal physiology were developed by consensus and are described in this review.
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Affiliation(s)
| | | | | | | | | | | | | | - Rena Yadlapati
- University of California in San Diego, La Jolla, California, USA
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48
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Lazarescu A, Chan WW, Gyawali CP, Lee YY, Xiao Y, Wu P. Updates on diagnostic modalities for esophageal dysphagia. Ann N Y Acad Sci 2020; 1481:108-116. [PMID: 32875574 DOI: 10.1111/nyas.14453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/26/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
Esophageal dysphagia is a common symptom in adults. Fluoroscopic contrast studies, endoscopy, and esophageal manometry have been used in the diagnosis of esophageal dysphagia for many years. The diagnostic yield has been improved with new test protocols that highlight abnormal bolus transit in the esophagus and outflow obstruction, as well as new high-definition and high-resolution technical advances in equipment. Functional luminal impedance planimetry and the addition of impedance to high-resolution esophageal manometry have also allowed the assessment of new parameters to better understand esophageal structure and function. In this concise review, we describe the role and utility of various diagnostic modalities in the assessment of patients with esophageal dysphagia.
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Affiliation(s)
- Adriana Lazarescu
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Yinglian Xiao
- Department of Gastroenterology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, PR China
| | - Peter Wu
- Department of Gastroenterology and Hepatology, St. George Hospital, Kogarah, New South Wales, Australia
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49
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Abstract
Esophageal symptoms are common and may indicate the presence of gastroesophageal reflux disease (GERD), structural processes, motor dysfunction, behavioral conditions, or functional disorders. Esophageal physiologic tests are often performed when initial endoscopic evaluation is unrevealing, especially when symptoms persist despite empiric management. Commonly used esophageal physiologic tests include esophageal manometry, ambulatory reflux monitoring, and barium esophagram. Functional lumen imaging probe (FLIP) has recently been approved for the evaluation of esophageal pressure and dimensions using volumetric distension of a catheter-mounted balloon and as an adjunctive test for the evaluation of symptoms suggestive of motor dysfunction. Targeted utilization of esophageal physiologic tests can lead to definitive diagnosis of esophageal disorders but can also help rule out organic disorders while making a diagnosis of functional esophageal disorders. Esophageal physiologic tests can evaluate obstructive symptoms (dysphagia and regurgitation), typical and atypical GERD symptoms, and behavioral symptoms (belching and rumination). Certain parameters from esophageal physiologic tests can help guide the management of GERD and predict outcomes. In this ACG clinical guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to describe performance characteristics and clinical value of esophageal physiologic tests and provide recommendations for their utilization in routine clinical practice.
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50
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Schnurre L, Murray FR, Schindler V, Runggaldier D, Fischbach L, Bordier V, Pohl D. Short-term outcome after singular hydraulic EsoFLIP dilation in patients with achalasia: A feasibility study. Neurogastroenterol Motil 2020; 32:e13864. [PMID: 32391635 DOI: 10.1111/nmo.13864] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Achalasia is a chronic esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter, determined by an elevated integrated relaxation pressure (IRP > 15 mm Hg) and absent peristalsis. Goal of treatment is facilitation of flow across the EGJ but minimizing postinterventional reflux. A new advanced hydraulic dilation technology, the esophageal functional luminal imaging probe (EsoFLIP), allows dynamic monitoring of hollow organ dimensions while performing hydraulic dilation. The aim of our study was to evaluate the treatment response after single EsoFLIP dilation in achalasia patients. METHODS Dilation was performed under endoscopic control with the EsoFLIP device using a self-developed dilation algorithm. Symptom scores were assessed by the Eckardt score (ES) before and 1-4 weeks after intervention. Esophageal emptying before and after intervention was recorded with timed barium esophagogram. KEY RESULTS We studied 28 consecutive untreated achalasia patients (8 female) with a median age of 43 years (range 19-82 years) undergoing their first dilation performed with the EsoFLIP, aiming at a maximum dilation diameter of 25 mm. Total ES was significantly reduced from 7 at baseline to 2 postintervention (P < .001). The median height of the barium column after 5 minutes was significantly reduced from 4.5 cm at baseline to 1.7 cm (P = .0087). No major complications occurred. CONCLUSIONS & INFERENCES We found good efficacy in both subjective and objective short-term treatment outcome after singular EsoFLIP dilation in treatment-naive achalasia patients. Our findings suggest that EsoFLIP is a promising dilation technology that should be further studied in a larger, controlled setting with longer follow-up.
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Affiliation(s)
- Larissa Schnurre
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Fritz Ruprecht Murray
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Valeria Schindler
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Runggaldier
- Ear, Nose and Throat Department, University Hospital Zurich, Zurich, Switzerland
| | - Lara Fischbach
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Valentine Bordier
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Pohl
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
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