Esophageal motor abnormalities in gastroesophageal reflux disorders

Gastroesophageal reflux disease (GERD), a prevalent condition with multifactorial pathogenesis, involves esophageal motor dysmotility as a key contributing factor to its development. When suspected GERD patients have an inadequate response to proton-pump inhibitor (PPI) therapy and normal upper endoscopy results, high-resolution manometry (HRM) is utilized to rule out alternative diagnosis such as achalasia spectrum disorders, rumination, or supragastric belching. At present, HRM continues to provide supportive evidence for diagnosing GERD and determining the appropriate treatment. This review focuses on the existing understanding of the connection between esophageal motor findings and the pathogenesis of GERD, along with the significance of esophageal HRM in managing GERD patients. The International GERD Consensus Working Group introduced a three-step method, assessing the esophagogastric junction (EGJ), esophageal body motility, and contraction reserve with multiple rapid swallow (MRS) maneuvers. Crucial HRM abnormalities in GERD include frequent transient lower esophageal sphincter relaxations, disrupted EGJ, and esophageal body hypomotility. Emerging HRM metrics like EGJ-contractile integral and innovative provocative maneuver like straight leg raise have the potential to enhance our understanding of factors contributing to GERD, thereby increasing the value of HRM performed in patients who experience symptoms suspected of GERD.

High-resolution manometry with impedance for the study of pharyngeal motility and the upper esophageal sphincter: Keys for its use in the study of the pathophysiology of oropharyngeal dysphagia

Oropharyngeal dysphagia (OD) is a pathology with a high prevalence in different patient phenotypes. High-resolution pharyngoesophageal manometry (HRPM) with impedance (HRPM-I) has become in recent years a fundamental technique for better understanding the pathophysiology of pharynx and upper oesophageal sphincter (UES) dysfunctions in patients with OD. Various groups of experts have proposed a methodology for the practice of the HRPM-I and for the standardization of the different metrics for the study of pharyngeal motility and UES dysfunctions based on the quantification of 3main phenomena: relaxation of the UES, resistance to flow through the UES and propulsion of the bolo through the pharynx into the oesophagus. According to the alterations of these metrics, 3patterns of dysfunction are proposed that allow a specific therapeutic approach: (a) UES flow restriction with normal pharyngeal propulsión; (b) UES flow restriction with ineffective pharyngeal propulsion, and (c) ineffective pharyngeal contraction with normal relaxation of the UES. We present a practical review of the methodology and metrics used by the main working groups together with the description of the main patterns of dysfunction according to our experience to highlight the usefulness of the HRPM-I in the study of the pathophysiology and selection of a specific treatment in patients with OD.

[Help, I can't burp! A brief overview and case discussion of retrograde cricopharyngeal dysfunction]

In this short communication, we discuss the recently described syndrome of retrograde cricopharyngeal dysfunction (R-CPD) with its first description in 2019 by the laryngologist Dr. Bastian. Diagnosis is generally based on typical clinical symptoms, e.g., the inability to belch, a bloated abdomen and retrosternal gurgling noises. We also describe high-resolution esophageal manometry as a new tool to further secure the diagnosis of R‑CPD, as well as therapeutic options such as botulinum toxin injections in the cricopharyngeal muscle or cricopharyngeal myotomy and the published data thereon.

Role of Preoperative High-Resolution Manometry in the Identification of Patients at High Risk of Postoperative GERD Symptoms 1 Year After Sleeve Gastrectomy

PURPOSE

Sleeve gastrectomy (SG) has become the most common bariatric procedure, but it is often characterized by the onset of postoperative gastroesophageal reflux disease (GERD). High-resolution manometry (HRM) is a useful tool to detect risk factors for GERD. The aim of this study was to evaluate preoperative manometric parameters as possible predictors of postoperative GERD.

MATERIALS AND METHODS

This was a monocentric retrospective study. We analyzed 164 patients, with preoperative esophagitis/GERD symptoms who underwent preoperative HRM and were submitted to SG (July 2020-February 2022).

RESULTS

Postoperative GERD was observed in 60 patients (36.6%): 41 of them (68%) already had preoperative GERD symptoms, whereas the remaining 19 patients (32%) developed postoperative symptoms. Female patients developed postoperative GERD in a significantly higher fraction of cases as compared to male patients (82% versus 18%; p < 0.001). DCI (distal contractile integral) was identified as the only HRM parameter correlating with the presence of GERD. Patients with DCI ≤ 1623 mmHg*cm*s developed postoperative GERD in 46% of cases (n = 43/94), as compared to 24% of cases (n = 17/70) among patients with DCI > 1623 mmHg*cm*s (p = 0.005). At multivariable analysis, female sex (OR 3.402, p = 0.002), preoperative GERD symptoms (OR 2.489, p = 0.013), and DCI ≤ 1623 mmHg*s*cm (OR 0.335, p = 0.003) were identified as independent determinants of postoperative GERD.

CONCLUSION

All the patients with preoperative risk factors for reflux, such as GERD symptoms or esophagitis on EGDS (esophagogastroduodenoscopy), should be considered for an HRM. Moreover, when a DCI ≤ 1623 mmHg*s*cm is found, a bariatric procedure different from SG might be considered.

Update on the Diagnosis and Treatment of Achalasia

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.

Myasthenia gravis with achalasia secondary to thymoma: a case report and literature review

Background

Myasthenia gravis is an autoimmune neuromuscular junction disorder characterized by fatigable muscle weakness and autoantibodies. Frequent associations exist between myasthenia gravis and thymic abnormalities, including hyperplasia and thymoma. Several autoimmune illnesses have been identified to be associated with thymoma; however, a few case reports have linked thymoma and achalasia, and the underlying mechanism is unknown.

Case report

A 43-year-old man with thymoma-associated myasthenia gravis presented with dysphagia that was refractory to conventional treatment of myasthenia gravis. This dysphagia was challenging to diagnose even after multiple gastroenterology consults and upper endoscopy. The diagnosis of achalasia type II was established after a comprehensive evaluation, including upper endoscopy, barium swallow, and high-resolution esophageal manometry. The patient underwent elective pneumatic balloon dilatation, which successfully alleviated his dysphagia.

Conclusion

This case confirmed the association between myasthenia gravis secondary to thymoma and achalasia and showed how the diagnosis of achalasia was challenging. Awareness of this association is crucial for early diagnosis and treatment, improving affected patients' quality of life.

High-resolution esophageal manometry in children

Functional disorders of the esophagus are known as esophageal dysmotility disorders. Esophageal manometry can be used to study swallowing disorders, feeding problems, non-obstructive dysphagia, and lower esophageal dysfunction. This paper discusses the recent advances in and reviews the use of high-resolution esophageal manometry in children. The Chicago 4.0 classification should be used judiciously in children. Manometric studies can guide the proper management of dysmotility in children.

Novel description on esophageal timed barium swallow: a correlation between advanced parametrization and esophageal X-ray images

Aim

The TBS-derived image processing method, based on the observer's diagnosis, has been developed in the current investigation. Image parametrization is proposed for both novel description and convergent shreds of evidence.

Background

Condensed X-ray images of the esophageal timed barium swallow (TBS) provide substantial implications for elucidating the pathophysiological dimensions of esophageal motility disorders.

Methods

Through the simultaneous study on TBS and high-resolution manometry (HRM) findings, we performed a retrospective cohort study on 252 patients from March 2018 to October 2019. Interventions, irrelevant information, and insufficient patient data were excluded. Only subjects with adequate data and acceptable test accuracy were considered for participation. We reviewed 117 Dicom (digital imaging and communications in medicine) X-ray images from patients with confirmed diagnoses of achalasia type II, esophagogastric junction outflow obstruction (EGJOO), or non-achalasia.

Results

The results suggested a cut-off level of 47% in DDi (dilated diameter index) as a sign of the dilated body. In achalasia type II patients (n=66 images), the mean DDi was 55.6%. Our method presented a sensitivity of 95% and a specificity of 93% compared to images of the non-achalasia findings. The mean DDi in EGJOO patients was 50.4%, according to the 27 images. Moreover, results from EGJOO patients provided a sensitivity of 85% and specificity of 87%.

Conclusion

TBS is an efficacious method and a prominent component in the process of achalasia diagnosis. Standard parametrization might develop radiological exports proposed by DDi. Our method could assist in obtaining a non-invasive medical diagnosis and help advance diagnostic reports to identify achalasia subtypes somewhat earlier. To the best of our knowledge, this interface is an innovative parametrization for TBS image review.

Multiple Esophageal Leiomyoma Presenting with Clinical Dysphagia from Mechanical Obstruction and Motility Disorder

Esophageal leiomyoma is uncommon. However, this tumor is the most common subepithelial tumor affecting the esophagus, comprising approximately two-thirds of benign esophageal tumors. Leiomyomas of the esophagus rarely cause symptoms when they are single and <5 cm. The mainstay of treatment is esophagectomy for symptomatic patients. A 68-year-old male patient presented with progressive dysphagia for 4 months. The degree of dysphagia and chest discomfort was more severe on solid rather than liquid diet. The CT scan of the chest showed multiple well-defined, submucosal nodules, up to 1.9 cm in diameter located at the middle esophagus. The barium swallow study illustrated multiple, well-defined, smooth, semilunar filling defects along the mid to distal esophagus. Meanwhile, esophagogastroduodenoscopy revealed 8 smooth subepithelial masses. Moreover, the radial EUS showed multiple hypoechoic masses arising from the 4th layer, with some of the tumors connected to others as a horseshoe-like shape causing narrowed lumen. Last, high-resolution esophageal manometry revealed ineffective esophageal motility. We report a rare case of numerous esophageal leiomyomas which caused dysphagia as a result of both mechanical obstruction and hypomotility disorder. The histopathology confirmed the diagnosis of esophageal leiomyoma. Symptoms improved significantly after lifestyle modifications and adherence to dietary advice on the part of the patient.

Type II Achalasia Is Increasing in Prevalence

BACKGROUND

Three manometric subtypes of achalasia were defined in the Chicago Classification approximately 10 years ago: type I (aperistalsis), type II (pan-pressurization), and type III (spastic). Since the widespread use of this classification scheme, the evolving prevalence of these subtypes has not been elucidated. We aim to determine the prevalence of each subtype a decade after the adoption of the Chicago Classification.

METHODS

This is a retrospective cohort analysis of patients diagnosed with achalasia on high-resolution manometry (HRM) at two major academic medical centers between 2015 and 2018. Patients were excluded if they had a diagnosis of another esophageal motility disorder, previously treated achalasia, or foregut surgery. Demographic data, manometric subtype, and esophageal dilatation grade on endoscopy were obtained. Prevalence of achalasia subtypes was compared with a published historical control population (2004-2007). Fischer's exact and t tests were used for analysis.

RESULTS

Of 147 patients in the contemporary cohort and 99 in the historical control cohort, the prevalence of type I achalasia was 8% versus 21%, type II 63% versus 50%, and type III 29% versus 29%, respectively (p = 0.01). The mean age in our population was 58 years compared to 57 years in the historical control, and the proportion of men 48% versus 47%, respectively (p = 0.78). Mean endoscopic dilatation grade in the contemporary cohort was 1.5 for type I patients, 0.9 for type II, and 0.4 for type III, compared with 1.5, 0.6, and 0.4, respectively. Overall mean dilatation grade was 0.8 in our cohort versus 0.7 in the historical control (p = 0.58).

CONCLUSION

The prevalence of type II achalasia was significantly greater and prevalence of type I significantly less in our patient population compared to our predefined historical control. Other characteristics such as age and sex did not appear to contribute to these differences. Histopathological evidence has suggested that type II achalasia may be an earlier form of type I; thus, the increased prevalence of type II achalasia may be related to earlier detection of the disease. The adoption of HRM, widespread use of the Chicago Classification, and increased disease awareness in the past decade may be contributing to these changes in epidemiology.

Impact of patient position on esophageal motility disorders using high-resolution esophageal manometry with impedance (HREMI): supine versus upright swallows

BACKGROUND

High-resolution esophageal manometry with impedance (HREMI) performed with supine patient positioning is used to evaluate patients for esophageal dysmotility. However, most patients experience symptoms related to esophageal dysmotility when eating or drinking upright. The aims of this study are to: (1) compare HREMI metrics in supine versus upright position; and (2) determine if upright position alters motility characterization of patients.

METHODS

HREMI of twelve wet swallows in supine position and five wet swallows in upright position were performed on normal subjects (NS) and consecutive patients. Chicago Classification v3.0 (CC) diagnoses were evaluated in the supine position and a modified version of the Chicago Classification system was used in the upright position using normative upright values for DCI and IRP.

RESULTS

DCI decreased in NS by 414 mmHg × cm × sec (p = 0.001) and patients by 613 mmHg × cm × sec (p < 0.001). IRP decreased in NS by 6.2 mmHg (p < 0.001) and patients by 4.6 mmHg (p < 0.001). The rate of successful bolus clearance decreased in the upright position in patients by 11% (p < 0.001), but no statistically significant differences were observed in NS. 82 of 200 patients (41%) had a change in CC diagnosis in the upright position. Bolus clearance in the upright position varied in patients depending on their diagnosis in the upright position.

CONCLUSIONS

Upright swallows had lower LES, IRP, DCI and UES pressures in both normal subjects and patients with decreased bolus clearance in patients. Upright positioning can alter esophageal motility patterns and enhance diagnostic yield. Thus, upright swallows supplement supine swallows to help characterize esophageal dysmotility.

Utility of a new automated diagnostic program in high-resolution esophageal manometry

BACKGROUND

A new automated diagnostic program for high-resolution esophageal manometry (HREM) has been developed. This diagnostic program could detect locations of landmarks and could make final diagnoses automatically. However, the accuracy of the program is not known. The aim of this study was to evaluate the accuracy of the automated diagnostic program for HREM.

METHODS

A total of 445 studies were enrolled. An HREM system (Starlet®) was used, and esophageal motility was diagnosed using the Chicago classification v3.0. First, the locations of the upper esophageal sphincter, transition zone, lower esophageal sphincter, esophago-gastric junction, crural diaphragm and stomach were determined, and each swallow was checked manually. Then, the parameters of the Chicago classification were calculated using an analytic program of the Starlet, and diagnoses were made by three experts. Second, all study raw data were analyzed again by the automated diagnostic program. Diagnoses made by the program were compared to those made by experts to evaluate the accuracy of the diagnoses.

RESULTS

The new diagnostic program could identify the landmarks of each swallow, calculate the parameters and make a final diagnosis within 10 s. The diagnoses made by the automated diagnostic program were not matched to those made by experts in only 10 studies, and the overall accuracy of the new automated diagnostic program thus reached 97.8% (435/445).

CONCLUSIONS

The new automated diagnostic program for HREM is clinically useful in terms of high diagnostic accuracy and time-saving.

Do Preoperative Esophageal pH Monitoring and High-Resolution Manometry Predict Symptoms of GERD After Sleeve Gastrectomy?

BACKGROUND

Predictive factors of evolution or appearance of gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) have not been identified to date. We aimed to assess the evolution of GERD symptoms 1 year after SG and to determine preoperative predictive factors using high-resolution manometry (HRM) and ambulatory 24-h esophageal pH monitoring (APM).

METHODS

We included 160 patients who underwent SG between 2013 and 2017 and performed preoperative APM and HRM. Positive APM was defined according to the Lyon consensus. Symptoms of GERD, proton pump inhibitors (PPI) use, weight loss (WL), and diet were recorded in all patients before and 1 year after surgery.

RESULTS

One year after surgery, 58 patients (36.3%) complained of GERD symptoms compared to 52 patients (32.5%) preoperatively (p=0.48). Among patients with preoperative GERD symptoms, only 26/52 patients (50%) still had symptoms, whereas 32/108 (29.6%) asymptomatic patients developed de novo GERD symptoms after surgery. PPI use increased after surgery reaching 36.9% of patients against 15.0% before (p<0.0001). Only preoperative symptoms of GERD were predictive of postoperative symptoms (OR= 2.47 [1.14-5.45]; p=0.023) in multivariate analysis. Preoperative manometric parameters, postoperative diet, and WL were not related to postoperative symptoms. In asymptomatic patients before surgery, silent GERD (positive APM without symptom) was predictive of postoperative GERD symptoms (OR=2.69 [1.00-7.25]; p=0.049).

CONCLUSION

Evolution of GERD symptoms after SG reveals improvement for half of the patients and de novo GERD symptoms in one-third of patients. Predictive factors of postoperative symptoms are preoperative symptoms and positive preoperative APM in asymptomatic patients.

Chicago Classification of esophageal motility disorders: Past, present, and future

The Chicago Classification (CC) is a dynamic, evolving classification scheme created by a diverse group of international esophageal experts. Its application has transformed the way esophageal motor data are used to define motility disorders, each iteration seeking to advance, simplify, and standardize the way clinicians worldwide diagnose esophageal dysmotility. The most recent update, CC version 4.0 (CCv4.0), emphasizes the importance of clinical context and distinguishes clinically relevant, conclusive manometric diagnoses from irrelevant manometric observations. Future iterations of CC may refine the classification of spastic esophageal disorders and incorporate machine learning and physics-based modeling to improve metrics.

Diagnostic Criteria for Gastro-esophageal Reflux Following Sleeve Gastrectomy

Background

Gastro-esophageal reflux disease (GERD) post-sleeve gastrectomy (SG) is a controversial issue and diagnostic dilemma. Strong heterogeneity exists in the assessment of reflux post-SG, and better diagnostic tools are needed to characterize symptomatic reflux. We aimed to determine the discriminant factors of symptomatic reflux and establish diagnostic thresholds for GERD following SG.

Materials and Methods

Patients post-SG were categorized into asymptomatic and symptomatic cohorts and completed validated symptom questionnaires. All patients underwent stationary esophageal manometry and 24-h ambulatory pH monitoring. Univariate and multivariate analyses were conducted to determine the strongest discriminant factors for GERD.

Results

Baseline characteristics of the asymptomatic cohort (n = 48) and symptomatic cohort (n = 76) were comparable. The median post-operative duration was 7.3 (14.1) vs 7.5 (10.7) months (p = 0.825). The symptomatic cohort was more female predominant (90.8 vs 72.9%, p = 0.008). Reflux scores were significantly higher in the symptomatic group (36.0 vs 10.5, p = 0.003). Stationary manometry parameters were similar, including hiatus hernia prevalence and impaired esophageal motility. The symptomatic cohort had significantly higher total acid exposure, especially while supine (11.3% vs 0.6%, p < 0.001). Univariate and multivariate regressions delineated reflux score and supine acid exposure as discriminant factors for symptomatic reflux. The thresholds for distinguishing symptomatic reflux are as follows: reflux score of 11.5 (sensitivity 84.0%, specificity 68.2%) and supine acid exposure of 2.65% (sensitivity 67.1%, specificity 70.8%).

Conclusion

A reflux score of 11.5 or more or supine acid exposure of 2.65% or more should be considered diagnostic in defining symptomatic reflux following SG.

Radio-induced esophageal motility disorders: An unrecognized diagnosis

PURPOSE

Esophageal motility disorders (EMD) after cervical or thoracic radiation therapy (RT) may represent a late impairment and appear under-diagnosed. This study aimed to assess the prevalence of EMD, diagnosed by high-resolution esophageal manometry (HREM) after cervical or thoracic RT. In this retrospective, single-centre study, all patients whom received cervical or thoracic RT and underwent HREM were eligible.

MATERIAL AND METHODS

Oncologic data were collected: site of neoplasia, type of cancer, oncologic management (surgery and chemotherapy). EMD were classified according to the new Chicago Classification.

RESULTS

Twenty patients (14 females), of mean age 62.33±11.14 years were included. Breast cancer was the most represented indication for RT (40%). Other cancers were lung tumor, head and neck tumors and Hogdkin's lymphoma. Dysphagia was the most frequent symptom justifying HREM (70%). Patients received a mean of 51±19.27 Gy, 70% of them (14/20) had radiation therapy concomitantly with chemotherapy. The delay between last radiation therapy session and HERM was 10.68±12.42 years. Twelve (60%) patients had an abnormal pattern at on HERM. Among them, 3 patients (15%) presented with a major motility disorder. The most frequent motility disorder was ineffective esophageal motility in 8 (40%) patients, 1 (5%) patient presented with type II achalasia.

CONCLUSION

EMD should be suspected in patients with a history of cervical or thoracic RT in case of upper GI symptoms with normal endoscopy. In these particular patients, a manometric diagnosis that can explain their symptoms is of particular importance to limit anxiety linked to unexplained troubles.

Three-Dimensional High-Resolution Esophageal Manometry Study of the Esophagogastric Junction in Patients with Achalasia

BACKGROUND

A novel three-dimensional high-resolution esophageal manometry provides a dynamic 360° representation of the pressure at the esophagogastric junction.

AIMS

To describe the three-dimensional high-resolution esophageal manometry patterns of achalasia.

METHODS

We retrospectively included all consecutive patients who underwent three-dimensional high-resolution esophageal manometry before and after treatment (pneumatic dilatation or per-oral endoscopic myotomy) for achalasia between November 2016 and July 2017. The distribution of the pressures at the esophagogastric junction on three-dimensional high-resolution esophageal manometry was determined.

RESULTS

Eighteen patients were included. Mean integrated relaxation pressure was 20.7 mmHg, and median (range) Eckardt score was 7 (4-10). Nine patients were treated by pneumatic dilatation and seven by myotomy. Nine patients underwent three-dimensional high-resolution esophageal manometry after treatment. Before treatment, the esophagogastric junction pressure distribution was best observed at end expiration and during the 4 s of the integrated relaxation pressure measurement. During the integrated relaxation pressure, the lower esophageal sphincter was asymmetric in 12 patients with a high-pressure zone between the left and the posterior side of the esophagogastric junction. After treatment, five patients had a residual high-pressure point on the left or the posterior side of the esophagogastric junction.

CONCLUSIONS

Three-dimensional high-resolution esophageal manometry allows a simple assessment of the pressure topography at the EGJ. In patients with achalasia, we found the esophagogastric junction pressure to be asymmetric with a peak pressure on the greater curvature side. Three-dimensional high-resolution esophageal manometry has the potential to guide initial and redo treatments.

Upper esophageal sphincter abnormalities on high-resolution esophageal manometry and treatment response of type II achalasia

BACKGROUND

Little is known about the clinical significance of upper esophageal sphincter (UES) motility disorders and their association with the treatment response of type II achalasia. None of the three versions of the Chicago Classification of Esophageal Motility Disorders has defined UES abnormality metrics or their function. UES abnormalities exist in some patients and indicate a clinically significant problem in patients with achalasia.

AIM

To demonstrate the manometric differentiation on high-resolution esophageal manometry between subjects with abnormal UES and normal UES, and the association between UES type and the treatment response of type II achalasia.

METHODS

In total, 498 consecutive patients referred for high-resolution esophageal manometry were analyzed retrospectively. The patients were divided into two groups, those with normal and abnormal UES function. UES parameters were analyzed after determining lower esophageal sphincter (LES) function. Patients with type II achalasia underwent pneumatic dilation for treatment. Using mixed model analyses, correlations between abnormal UES and treatment response were calculated among subjects with type II achalasia.

RESULTS

Of the 498 consecutive patients, 246 (49.40%) were found to have UES abnormalities. Impaired relaxation alone was the most common UES abnormality (52.85%, n = 130). The incidence rate of type II achalasia was significantly higher in subjects with abnormal UES than those with normal UES (9.77% vs 2.58%, P = 0.01). After pneumatic dilation, LES resting pressure, LES integrated relaxation pressure, and UES residual pressure were significantly decreased (41.91 ± 9.20 vs 26.18 ± 13.08, 38.94 ± 10.28 vs 16.71 ± 5.65, and 11.18 ± 7.93 vs 5.35 ± 4.77, respectively, P < 0.05). According to the Eckardt score, subjects with type II achalasia and abnormal UES presented a significantly poorer treatment response than those with normal UES (83.33% vs 0.00%, P < 0.05).

CONCLUSION

Impaired relaxation alone is the most common UES abnormality. The incidence of type II achalasia is associated with abnormal UES. Type II achalasia with abnormal UES has a poorer treatment response, which is a potentially prognostic indicator of treatment for this disease.

Esophagogastric Junction Outflow Obstruction: Current Approach to Diagnosis and Management

PURPOSE OF REVIEW

We summarize the current epidemiology, presentation, diagnostic workup, and treatment of esophagogastric junction outflow obstruction (EGJOO). We also propose a treatment algorithm based upon the literature and our personal clinical experience.

RECENT FINDINGS

EGJOO can be caused by functional obstruction (akin to achalasia), mechanical obstruction, medications, or artifact. High-resolution esophageal manometry is currently the gold standard of diagnosis. Recent research on FLIP (functional lumen imaging probe) and timed barium support use as adjunctive testing. The diagnostic yield of cross-sectional imaging is low. Current diagnostic testing and treatment should be targeted to the suspected underlying etiology and clinical presentation of EGJOO. If functional obstruction is present with significant and persistent dysphagia, and either an abnormal FLIP or timed barium swallow, we consider therapy aimed at LES disruption (similar to achalasia). Pharmacologic therapy has a limited role. More research is needed on diagnostic and treatment modalities.

Clinical Symptom Presentation of Hypercontractile Peristalsis in the Era of High-Resolution Manometry: A Single-Center Experience

BACKGROUND

Hypercontractile motility of the esophagus is occasionally noted on high-resolution manometry (HRM), but its clinical correlations are unclear. We compared symptom severity and clinical presentation of patients with hypercontractile motility of the esophagus.

METHODS

This was a retrospective cohort study. We queried a prospectively maintained database for patients who underwent esophageal function testing from October 1, 2016, to October 30, 2018. We included patients with jackhammer esophagus (JE; ≥2 swallows with distal contractile integral [DCI] ≥8,000 mm Hg∙cm∙s), nutcracker esophagus (NE; mean DCI 5,000-8,000 mm Hg∙cm∙s without meeting JE criteria), or esophagogastric junction outflow obstruction ([EGJOO]: abnormal median integrated relaxation pressure (>15 mm Hg) without meeting achalasia criteria, with JE [EGJOO-h], or normal motility [EGJOO-n]). HRM, endoscopy, barium esophagram, ambulatory pH studies, and symptom questionnaires were reevaluated for further analysis. Clinical parameters were analyzed using Spearman Rho correlation. Categorical variables were assessed with Fisher exact or chi-square test.

RESULTS

Altogether, 85 patients met inclusion criteria. They were divided into 4 subgroups: 28 with JE, 18 with NE, 15 with EGJOO-h, and 24 with EGJOO-n. Patients with EGJOO-h were the most symptomatic overall. No correlation was seen between symptoms and mean DCI (p ≥ 0.05 all groups) or number of hypercontractile swallows (≥8,000 mm Hg∙cm∙s, p ≥ 0.05). A significant correlation was noted between dysphagia and lower esophageal sphincter pressure (LESP) and LESP integral (p ≤ 0.05).

CONCLUSION

The number of hypercontractile swallows and mean DCI were not associated with patient-reported symptoms. Elevated LESP may be a more relevant contributor to dysphagia.

Multiple Rapid Swallows (MRS) Complements Single-Swallow (SS) Analysis for High-Resolution Esophageal Manometry (HREM)

BACKGROUND

Multiple rapid swallows (MRS) during HREM assess post-deglutitive inhibition, LES relaxation, and subsequent esophageal contraction.

AIMS

(1) To determine the relationship between MRS and single-swallow (SS) responses and (2) to determine if MRS provides information for symptomatic patients.

METHODS

Healthy volunteers (HVs) and patients underwent HREM [30-s landmark, ten 5-mL SS, MRS (5 consecutive 2-mL swallows every 2-3 s)] and were analyzed with ManoView software version 3 with CC version 3.0.

RESULTS

In 20 HVs, MRS response consisted of: (1) reduction in GEJ pressure; (2) absence of esophageal contractile activity during MRS; and (3) post-MRS peristaltic contraction greater than SS contractions. In 20 HVs and 403 patients, MRS IRP correlated with SS IRP (r = 0.65; p < 0.0001) and post-MRS contraction DCI correlated with SS DCI (r = 0.76; p < 0.0001). Abnormally elevated MRS IRP was seen in 68% type 2 achalasia, 50% type 3 achalasia, 47% EGJOO, and 9% jackhammer. Increased MRS DCI was seen in 53% type 2 achalasia, 92% type 3 achalasia, 10% EGJOO, 22% jackhammer, and 18% DES. Increased DCI post-MRS was seen in 38% patients with jackhammer, 8% type 3 achalasia, 12% EGJOO, and 9% DES. 14 out of 143 (10%) patients with normal or indeterminate results on SS analysis had at least one abnormality on MRS.

CONCLUSIONS

MRS IRP correlated with SS IRP, and post-MRS DCI correlated with SS DCI. Patients with defined CC disorders have abnormalities on MRS. There were MRS abnormalities in some patients with normal SS studies, most notably suggesting impaired LES relaxation and/or spastic esophageal motility. MRS may complement the baseline SS study analysis.

Ineffective Esophageal Motility Is Associated with Impaired Bolus Clearance but Does Not Correlate with Severity of Dysphagia

BACKGROUND

Ineffective esophageal motility (IEM) is defined as a distal contractile integral < 450 mmHg/s/cm in at least 50% of ten liquid swallows on high-resolution esophageal manometry (HREM). Whether this latest definition correlates with degree of symptoms has not been studied.

METHODS

Patients presenting for HREM prospectively rated their symptoms using the Eckardt score. Topography plots were retrospectively reviewed and classified according to the latest Chicago Classification. Patients with non-obstructive dysphagia and an Eckardt score of at least 1 were included. Patients with major motility disorders were excluded. Scores between patients with IEM (group A) and patients with normal classification (group B) were compared using two-tailed t-tests. Spearman's correlation coefficient was calculated to determine correlation between symptoms and percent bolus clearance.

RESULTS

A total of 241 patients were screened; 33 patients met criteria for group A and 44 patients for group B. There was no difference between the two groups in mean symptom severity for dysphagia (1.63 vs. 1.61, P = 0.89), chest pain (0.67 vs. 0.75, P = 0.64), regurgitation (1.06 vs. 0.85, P = 0.32), or weight loss (0.85 vs. 0.49, P = 0.11). The percent bolus clearance was significantly lower in group A (46.5% vs. 76.7%, P > 0.01). There was a moderate inverse correlation between dysphagia and percent bolus clearance (R = - 0.37) in group A, but none in group B (R = 0.09).

CONCLUSION

The classification of IEM did not discriminate from normal studies for symptom severity in our cohort. However, patients with IEM did have an inverse correlation between dysphagia score and bolus clearance, but those without IEM did not. Adding impedance information to the motor pattern classification should be considered in the symptom assessment in minor motility disorders.

A Rare Cause of Dysphagia and Weight Loss

Mixed connective tissue disease (MCTD) is a rare connective tissue disorder with clinical features that overlap with systemic lupus erythematous, systemic sclerosis, and polymyositis. We report the case of a patient who presented with dysphagia, 25-lb weight loss, difficulty opening her mouth, and joint pain. Dysphagia workup showed a normal barium swallow and normal-appearing EGD but esophageal manometry consistent with severe dysmotility. Through further laboratory and imaging studies, the patient met the diagnostic criteria for MCTD. She had marked improvement in her dysphagia with steroids, biologic therapy, and intravenous immunoglobulin.

Basal lower esophageal sphincter pressure in gastroesophageal reflux disease: An ignored metric in high-resolution esophageal manometry

Manometry and 24-h pH interpretation have seldom been studied. Our aim was to study these parameters as gold standard in reflux disease and to identify predictors of pathological acid reflux. Retrospective case record review of all patients with reflux disease evaluated using endoscopy, manometry, and 24-h pH testing from 2010 to 2016. Patients were categorized using Johnson-DeMeester score into two groups-group I (score > 14.7, normal study) and group II (< 14.7, normal study). These groups were compared for the above-mentioned parameters. Appropriate statistical tests were applied. P-value < 0.05 was considered significant. The study group includes 94 patients (median age 44 years, 63.8% males). Sixty (63.8%) and 34 patients belonged to groups I and II, respectively, 76.6% patients had normal endoscopy while the remaining had mild esophagitis. Peristalsis was normal in 66%, followed by ineffective esophageal motility (19.1%) and fragmented peristalsis (14.9%). Demography, symptoms, endoscopy findings, and peristalsis characteristics were similar between the two groups. Group II patients had significantly lower basal lower esophageal sphincter (LES) pressure (11.9 vs. 16.6; p < 0.02), lower integrated relaxation pressure (5.7 vs. 7.4; p < 0.01), and larger separation between LES and crural diaphragm (1.7 vs. 1.4 cm; p < 0.003). Basal LES pressure < 10 mmHg had the highest likelihood ratio (2.2) to predict an abnormal pH study. Basal LES pressure, integrated relaxation pressure, and hiatus size correlated with pathological acid reflux. Hypotensive basal lower esophageal sphincter pressure was the best predictor of an abnormal pH study but with negative linear correlation.

Esophagography in Patients With Esophageal Achalasia Diagnosed With High-resolution Esophageal Manometry

Background/Aims

High-resolution esophageal manometry (HREM) is considered to be the gold standard for the diagnosis of achalasia. However, the Japan Esophageal Society recommends that esophagography is also accurate in either diagnosing or excluding the disorder. Accordingly, we compared the efficacy of esophagography and HREM in diagnosing achalasia patients with upper gastrointestinal symptoms.

Methods

HREM was performed in 126 patients with dysphagia. The final diagnosis of achalasia was done using HREM. Demographic data, symptoms, quality of life (QOL) were also obtained. We assessed the patients who were not able to be diagnosed by esophagography and compared the diagnostic values for esophagography with HREM-based achalasia diagnosis as the gold standard.

Results

A total of 48 cases of patients with achalasia, including 21 men and 27 women (mean age, 48.4 ± 19.6 years), were included in the study. Two patients were excluded. Of the remaining 46 patients, 36 (78.3%) patients were diagnosed as having achalasia by esophagography. The diagnostic sensitivity, specificity, and accuracy of esophagography were 78.3%, 88.0%, and 83.0%, respectively. Patients with type III achalasia had significantly lower physical QOL score than those with type I or II achalasia. Although the mental QOL score in patients with type III achalasia tended to decrease compared with that in patients with type I and II achalasia, the difference was not statistically significant.

Conclusions

Diagnosing esophageal achalasia by using esophagography alone has limited yield. Therefore, HREM should be used in patients with dysphagia and in whom achalasia cannot be diagnosed using EGD or esophagography.

Myotomy length informed by high-resolution esophageal manometry (HREM) results in improved per-oral endoscopic myotomy (POEM) outcomes for type III achalasia

INTRODUCTION

High-resolution esophageal manometry (HREM) is essential in characterizing achalasia subtype and the extent of affected segment to plan the myotomy starting point during per-oral endoscopic myotomy (POEM). However, evidence is lacking that efficacy is improved by tailoring myotomy to the length of the spastic segment on HREM. We sought to investigate whether utilizing HREM to dictate myotomy length in POEM impacts postoperative outcomes.

METHODS

Comparative analysis of HREM-tailored to non-tailored patients from a prospectively collected database of all POEMs at our institution January 2011 through July 2017. A tailored myotomy is defined as extending at least the length of the diseased segment, as initially measured on HREM.

RESULTS

Forty patients were included (11 tailored versus 29 non-tailored). There were no differences in patient age (p = 0.6491) or BMI (p = 0.0677). Myotomy lengths were significantly longer for tailored compared to non-tailored overall (16.6 ± 2.2 versus 13.5 ± 1.8; p < 0.0001), and for only type III achalasia (15.9 ± 2.4 versus 12.7 ± 1.2; p = 0.0453), likely due to more proximal starting position in tailored cases (26.0 ± 2.2 versus 30.0 ± 2.7; p < 0.0001). Procedure success (Eckardt < 3) was equivalent across groups overall (p = 0.5558), as was postoperative Eckardt score (0.2 ± 0.4 versus 0.8 ± 2.3; p = 0.4004). Postoperative Eckardt score was significantly improved in the tailored group versus non-tailored for type III only (0.2 ± 0.4 versus 1.3 ± 1.5; p = 0.0435). A linear correlation was seen between increased length and greater improvement in Eckardt score in the non-tailored group (p = 0.0170).

CONCLUSIONS

Using HREM to inform surgeons of the proximal location of the diseased segment resulted in longer myotomies, spanning the entire affected segment in type III achalasia, and in lower postoperative Eckardt scores. Longer myotomy length is often more easily achieved with POEM than with Heller myotomy, which raises the question of whether POEM results in better outcomes for type III achalasia, as types I and II do not generally have measurable spastic segments.

Effect of mosapride combined with esomeprazole in non-erosive reflux disease patients

AIM: To evaluate the effect of mosapride combined with esomeprazole in the treatment of non-erosive reflux disease (NERD).

METHODS: Eighty patients with NERD treated from January 2011 to March 2014 were randomly and equally divided into two groups: and observation group and a control group. The observation group was treated with mosapride and esomeprazole for 8 wk, and the control group was treated with omeprazole and domperidone for 8 wk. Before and 8 wk after treatment, gastroesophageal reflux disease questionnaire (Gerd Q) survey and high-resolution esophageal manometry (including lower esophageal sphincter pressure and clearance ability of distal esophageal body) were performed, and clinical effects were compared between the two groups.

RESULTS: After treatment, Gerd Q scores in both the observation group and control group were significantly lower than pretreatment scores (9.8 ± 2.5 vs 7.0 ± 2.0; 10.1 ± 2.1 vs 8.3 ± 2.2; P < 0.05), and Gerd Q score was significantly lower in the observation group than in the control group (P < 0.05). The total effective rate was significantly higher in the observation group than in the control group (92.5% vs 72.5%, P < 0.05). Lower esophageal sphincter pressures in both groups were significantly increased after treatment (20.88 mmHg ± 3.91 mmHg vs 12.13 mmHg ± 5.89 mmHg; 17.59 mmHg ± 5.18 mmHg vs 11.85 mmHg ± 6.32 mmHg; P < 0.05), and the increase was more significant in the observation group (P < 0.05). The amplitude of the distal esophageal body in the observation group was significantly higher than pretreatment value (72.70 mmHg ± 29.37 mmHg vs 65.85 mmHg ± 25.53 mmHg, P < 0.05), and the posttreatment value in the control group (72.70 mmHg ± 29.37 mmHg vs 65.85 mmHg ± 25.53 mmHg, P < 0.05). The rates of effective contraction in both groups were significantly increased after treatment (92.5% vs 62.5%; 85.0% vs 65.0%; P < 0.05), and the increase was more significant in the observation group (P < 0.05).

CONCLUSION: Mosapride combined with esomeprazole can improve clinical symptoms (including reflux, heartburn and retrosternal pain), and increase the lower esophageal sphincter pressure and the clearance ability of diatal esophageal body in NERD patients.

Evaluation of esophageal sensation

Dramatic progress has been made over the past decade in the sophistication and availability of equipment to test esophageal motility and sensation. High-resolution esophageal manometry and impedance have moved from the research clinic into clinical practice. Some of the testing is costly and time consuming, and requires extensive experience to perform the testing and properly interpret the results. These sensory studies are valuable in the interpretation of clinical problems, and provide important research information. Clinicians should evaluate the research studies to advance their understanding of the pathophysiology of the esophagus.

Evaluating esophageal bolus transit by impedance monitoring

The function of the esophagus is transporting nutrients from the oropharyngeal cavity to the stomach. This is achieved by coordinated contractions and relaxation of the tubular esophagus and the upper and lower esophageal sphincter. Multichannel intraluminal impedance monitoring offers quantification of esophageal bolus transit and/or retention without the use of ionizing radiation. Combined with conventional or high-resolution manometry, impedance measurements complement the quantification of esophageal body contraction and sphincter relaxation, offering a more comprehensive evaluation of esophageal function. Further studies evaluating the utility of quantifying bolus transit will help clarify the role and position of impedance measurements.