Markedly Effective Steroid Treatment of Three Patients with Allergy-related Jackhammer Esophagus

We experienced marked efficacy with steroid treatment of three patients with jackhammer esophagus (JHE). An esophageal biopsy revealed eosinophilic esophagitis (EoE) in two patients. One of the patients without EoE had eosinophilia and an increased serum immunoglobulin E level, and endoscopic ultrasonography revealed thickening of the esophageal muscularis propria. Esophageal manometry was used to diagnose all cases of JHE. Treatment consisted of steroid administration, which improved the symptoms and resolved the esophageal muscularis propria thickening in all patients. The esophageal manometry findings also normalized following treatment. Allergic diseases, including EoE, were assumed to have caused JHE.

High-resolution manometry findings after Linx procedure for gastro-esophageal reflux disease

BACKGROUND

Magnetic sphincter augmentation with the Linx^® system is a novel laparoscopic procedure for the treatment of gastro-esophageal reflux disease (GERD). Only few data are available regarding the impact of Linx on high-resolution manometry (HRM) variables.

METHODS

The prospectively collected database of patients who underwent Linx procedure at a single institution was queried. All patients who completed pre- and postoperative HRM, GERD health-related quality of life (GERD-HRQL) questionnaire, and functional outcome swallowing scale (FOSS) questionnaire were included in the study.

KEY RESULTS

Forty-five out of 304 patients were included. At a median follow-up of 12 months (IQR 10) after surgery, a statistically significant increase of lower esophageal sphincter (LES) total length (P = .002), intra-abdominal length (P = .001), integrated relaxation pressure (IRP), intrabolus pressure (IBP), and esophagogastric contractile integral (EGJ-CI) was noted (P < .001). Distal esophageal amplitude (P = .004), mean distal contractile integral (DCI) (P < .001), post multiple repeated swallows DCI (P = .001), and the percent of normal peristalsis increased (P = .040). All patients were relieved of reflux symptoms. Ineffective esophageal motility reversed to normal in 36% of patients after surgery. The only factor significantly associated with postoperative dysphagia was preoperative dysphagia (P = .006). Postoperatively, a significant correlation between IRP and DCI (r = 0.361 and P = .019) and between IBP and DCI (r = 0.443 and P = .003) was found.

CONCLUSIONS AND INFERENCES

The Linx procedure had a remarkable effect on esophageal motility in the short-term follow-up. It appears that the overall postoperative increase of IRP and IBP may justify the higher DCI values. Preoperative dysphagia was the only factor associated with postoperative dysphagia.

Correlation between reflux burden, peristaltic function, and mucosal integrity in GERD patients

BACKGROUND

Mean nocturnal baseline impedance (MNBI) augments the diagnostic yield of multichannel intraluminal impedance-pH (MII-pH) monitoring. While acid exposure time (AET) correlates with MNBI, it remains unclear whether esophageal motility affects MNBI values. The present study was aimed at evaluating the respective roles of esophageal motor function and AET on MNBI.

METHODS

High-resolution manometry (HRM) studies and ambulatory 24-hour MII-pH monitoring tracings were retrospectively analyzed from consecutive endoscopy-negative GERD patients with typical symptoms responsive to previous acid-suppressive therapy from three tertiary care centers. Univariate and multivariate analyses were performed to determine predictors of pathologic MNBI values at 3 cm and 5 cm above the lower esophageal sphincter (LES).

KEY RESULTS

Patients with pathological AET displayed lower MNBI values at 3 cm and 5 cm (P < .01) compared to patients with non-pathological AET. Similarly, significantly lower MNBI values were also noted at both sites with type 3 EGJ compared to type 1 EGJ (P ≤ .02 for each comparison), and with absent contractility compared to normal peristalsis (P ≤ .02 for each comparison). On multivariate analysis, the presence of type 2 or 3 EGJ and absent contractility were associated with a significantly higher probability of pathological MNBI values at 3 cm and 5 cm above the LES.

CONCLUSIONS AND INFERENCES

Disruption of the EGJ and absent contractility on HRM are both associated with lower MNBI values. HRM findings complement reflux testing using MII-pH monitoring.

Validity of the Cutoff Value for Integrated Relaxation Pressure Used in the Starlet High-Resolution Manometry System

BACKGROUND

In a previous study that used the Starlet high-resolution manometry system to assess integrated relaxation pressure (IRP) in healthy adults, the predicted cutoff value was about 26 mm Hg. However, some patients with achalasia have an IRP value of <26 mm Hg. This study examined the validity of the Starlet IRP cutoff value in patients with achalasia.

METHODS

Among 37 patients with achalasia, the percentage of patients with a Starlet IRP value ≥26 mm Hg was calculated. Patients were then classified as IRP-high (IRP ≥26 mm Hg) and IRP-low (IRP <26 mm Hg), and the groups were compared in relation to basal lower esophageal sphincter (LES) pressure, Chicago classification achalasia subtype, and esophagography subtype.

RESULTS

Twenty (54%) of the 37 patients had an IRP of ≥26 mm Hg. Basal LES pressure was significantly higher in the IRP-high group than in the IRP-low group. Chicago classification Type II achalasia was most common in the IRP-high group, whereas Type I was most common in the IRP-low group. No significant difference was noted in the distribution of esophagography subtypes between groups.

CONCLUSIONS

It is difficult to determine an IRP cutoff value with Starlet. When diagnosing achalasia with Starlet, comprehensive assessment must consider findings other than IRP values. In addition, IRP was associated with Chicago classification type.

Chaotic peak propagation in patients with Jackhammer esophagus

BACKGROUND

The contractile activity of Jackhammer esophagus(JE) is heterogeneous and abnormalities in the balance of pre- and post-peak contractile activity has been reported. We observed that the progression of the peak contraction is disordered in JE patients, which reflect underlying abnormalities in the inhibitory and excitatory influence in esophageal contraction. In order to better define this abnormality, we developed novel time metrics to define trajectory of the pressure wave peak and assessed it in healthy controls and JE patients.

METHODS

38 patients with JE (ages 43-70, 19 females) and 71 asymptomatic controls (ages 19-48; 33 females) were retrospectively evaluated. High resolution manometry was performed in all subjects with 10 supine liquid swallows. The first 5 intact supine swallows and supine swallow with the greatest DCI were analyzed using ManoView™ software and customized MATLAB program. The time distance, negative time distance sum and chaotic ratio were calculated. JE patients were subcategorized by the Brief Esophageal Dysphagia Questionnaire (BEDQ) with cut-off of 6.

KEY RESULTS

Jackhammer patients had longer time distance, longer negative time distance, and higher chaotic ratio than controls( p < 0.001). The distribution of the number of negative time distances differed between JE patients with BEDQ>6 and BEDQ≤6.

CONCLUSIONS & INFERENCES

The trajectory of the pressure wave peak propagation commonly occurred in an unordered fashion in JE, but rarely in controls. Additionally, differences in pressure propagation trajectory was associated with higher symptom scores thus trajectory of the pressure wave peak may be an important marker of abnormal esophageal motor function.

Botox injection into the lower esophageal sphincter induces hiatal paralysis and gastroesophageal reflux

Endoscopic intrasphincteric injection of Botox (ISIB) is used routinely for the treatment of achalasia esophagus and other spastic motor disorders. Studies show that the ISIB reduces the smooth muscle lower esophageal sphincter (LES) pressure. The esophageal hiatus, formed by the right crus of diaphragm, surrounds the cranial half of the LES and works like an external LES. We studied the effects of ISIB on the LES and hiatal contraction and gastroesophageal reflux (GER). Fourteen patients treated with ISIB were studied. Esophageal manometry-impedance recordings were performed before and after the ISIB. Hiatal contraction was assessed during tidal inspiration, forced inspiration, Müller's maneuver, and straight leg raise. In 6 subjects, the manometry were repeated 6-12 mo after the ISIB. The esophagogastric junction (EGJ) pressure was measured at end expiration (LES pressure) and at the peak of maneuvers (hiatal contraction). Transdiaphragmatic pressure (pdi; force of diaphragmatic contraction) was measured at the peak of forced inspiration. GER was measured from the impedance recordings. The EGJ pressure at end expiration (LES pressure) decreased significantly after the Botox injection. The peak EGJ pressure at tidal inspiration, forced inspiration, Müller's maneuver, and straight leg raise was also dramatically reduced by the ISIB. There was no effect of Botox on the pdi during forced inspiration. Seven of 10 subjects demonstrated GER during maneuvers following the ISIB. Six to 12 mo after ISIB, the LES and hiatal contraction pressure returned to the pre-ISIB levels. ISIB, in addition to decreasing LES pressure, paralyzes the esophageal hiatus (crural diaphragm) and induces GER.NEW & NOTEWORTHY The sphincter mechanism at the lower end of the esophagus comprises smooth muscle lower esophageal sphincter (LES) and skeletal muscle crural diaphragm (hiatus). Current thinking is that the endoscopic intrasphincteric injection of Botox (ISIB), used routinely for the treatment of achalasia esophagus, reduces LES pressure. Our study shows that ISIB, even though injected into the LES, diffuses into the hiatus and causes its paralysis. These findings emphasize the importance of esophageal hiatus as an important component of the antireflux barrier and that the ISIB is refluxogenic.

Diagnostic value of X-ray, endoscopy, and high-resolution manometry for hiatal hernia: A systematic review and meta-analysis

BACKGROUND AND AIM

Hiatal hernia (HH) has been found in a large number of people, but there has been no unified way to diagnose it. The aim of this study was to compare the diagnostic efficiency of X-ray, endoscopy, and high-resolution manometry (HRM) in the diagnosis of HH using surgical diagnosis of HH as the gold standard.

METHODS

Two biomedical databases (PubMed and EMBASE) were systematically searched through January 26, 2019. The pooled sensitivity, specificity, and area under the SROC curve (AUC) were calculated, and the AUC statistical significance was compared by Tukey's multiple comparisons test.

RESULTS

A total of 5337 patients in seven articles were included. The pooled sensitivity, specificity, and AUC for X-ray were 0.63 (0.46-0.77), 0.85 (0.69-0.94), and 0.80 (0.77-0.84), respectively, for diagnosing HH. The pooled estimates for endoscopy in diagnosing HH were as follows: sensitivity, 0.72 (0.39-0.91); specificity, 0.80 (0.70-0.87); and AUC, 0.82 (0.78-0.85). Similarly, the corresponding values for HRM were 0.77 (0.70-0.83); 0.92 (0.85-0.96), and 0.9527. Tukey's multiple comparisons tests were used to compare the AUCs of the three diagnostic methods: No significant differences were found between X-ray and endoscopy (P = 0.7293), and HRM was superior to X-ray (P = 0.0127) and endoscopy (P = 0.0442).

CONCLUSIONS

High-resolution manometry may exhibit a better diagnostic performance for hiatal hernia. In contrast, X-ray and endoscopy may not be the best methods, and there was no significant difference in diagnostic efficiency between the X-ray and endoscopy.

Achalasia in a Patient with Myotonic Dystrophy

Myotonic dystrophy is a progressive disorder mainly affecting the voluntary muscles. We herein report a rare case of myotonic dystrophy complicated with high-resolution manometry-defined achalasia, the pathology of which is absent relaxation of the smooth muscles of lower esophageal sphincter (LES). In the present case, achalasia was considered a complication of myotonic dystrophy instead of sporadic achalasia, as on performing high-resolution manometry, the finding of an impaired LES relaxation (myotonic phase) changed to a totally emaciated LES function (muscle weakness phase) as myotonic dystrophy progressed.

Lower oesophageal sphincter identification for gastro-oesophageal reflux monitoring: The step-up method revisited with use of basal impedance

Background

Oesophageal manometry is the gold standard for accurate positioning of multichannel intraluminal impedance pH (MII-pH) monitoring. The pH step-up method is not as accurate as oesophageal manometry and needs patients to be off proton pump inhibitor (PPI) therapy.

Objective

This study aimed to evaluate the feasibility of the impedance step-up method for lower oesophageal sphincter (LOS) localisation.

Methods

A total of 100 patients who underwent 24-hour MII-pH monitoring were enrolled. High-resolution manometry (HRM) was performed before MII-pH monitoring in order to locate the LOS by a different operator. The impedance step-up was defined as an increase of ≥50% with respect to gastric baseline. Lin's concordance correlation coefficient (ρ_c ) with 95% Bland-Altman limits of agreement (LOA) and Spearman's rho correlation coefficient were used when appropriate.

Results

The median impedance step-up was on average 0.8 cm caudal to the manometric upper border of the LOS. Agreement between two step-up impedance performances and inter-observer agreement were excellent (ρ_c  = 0.98 and 0.95), although the LOA ranges were wide (-2.4 to 4.0 cm). Impedance step-up performances were similar between patients off and on PPI.

Conclusions

We have described an alternative new method for pH impedance probe positioning using impedance step-up. Although less accurate than HRM in locating the LOS, it has excellent intra- and inter-observer agreement.

Esophageal contractility increases and gastroesophageal reflux does not worsen after lung transplantation

Gastroesophageal reflux and esophageal dysmotility are common in patients with advanced lung disease and are associated with allograft dysfunction after lung transplantation. The effect of transplantation on reflux and esophageal motility is unclear. The aim of this study was to describe the changes in esophageal function occurring after lung transplantation. A retrospective cohort study was performed on lung transplant candidates evaluated at a tertiary care center between 2015 and 2016. A total of 76 patients who underwent lung transplantation had high-resolution manometry and ambulatory pH-metry before and after transplant. Demographic data, esophageal function testing results, and clinical outcomes such as pulmonary function testing were collected and analyzed using appropriate statistical tests and multivariable regression. Of the 76 patients, 59 (78%) received a bilateral transplant. There was a significant increase in esophageal contractility posttransplant, with an increase in median distal contractile integral from 1470 to 2549 mmHg cm s (P < 0.01). There were 19 patients with Jackhammer esophagus posttransplant, including 15 patients with normal motility pretransplant. Nine patients with ineffective or fragmented peristalsis pretransplant had normal manometry posttransplant. Abnormal pH-metry was observed in 35 (46%) patients pretransplant and 29 (38%) patients posttransplant (P = 0.33). Patients with gastroesophageal reflux disease posttransplant had less improvement in pulmonary function at one year, as measured by forced expiratory volume (P = 0.04). These results demonstrate that esophageal contractility increases significantly after lung transplantation, with an associated change in motility classification. In comparison, gastroesophageal reflux does not worsen, but is associated with worse pulmonary function, posttransplant.

Esophagogastric junction outflow obstruction on manometry: Outcomes and lack of benefit from CT and EUS

BACKGROUND

Esophagogastric junction outflow obstruction (EGJOO) is a manometric diagnosis based on the Chicago Classification defined by inadequate relaxation of the gastroesophageal junction (GEJ) with swallowing, but with sufficient peristalsis such that the criteria for achalasia are not met. Possible causes include anatomical and functional etiologies. Further investigations, including computed tomography (CT) of the chest and endoscopic ultrasound (EUS), to help elucidate the etiology of EGJOO have been suggested, but the utility of this approach has not been proven.

METHODS

All new diagnoses of EGJOO made in the calendar years 2015-2016 were included. A review was performed for each patient to assess clinical outcomes, diagnostic, and therapeutic interventions after the EGJOO diagnosis.

KEY RESULTS

107 EGJOO patients were included. Their primary complaints were dysphagia (68%), chest pain (12%), reflux (8%), pre-operative assessment (6%), regurgitation (3%), and cough (3%). The mean IRP was 21.8 mm Hg. After a mean follow-up period of 463 days, the etiology of EGJOO remained undetermined in 67% of patients. 48% of patients were investigated with cross-sectional imaging (and 10% with EUS to rule out external compression or malignancy as a cause of EGJOO; none of these tests provided any further useful information). In only two cases did the EGJOO progress to achalasia.

CONCLUSIONS & INFERENCES

EGJOO is a manometric diagnosis with unclear clinical significance and outcome. CT and EUS of the GEJ were unhelpful at determining the cause of this entity. In this series, very few appear to progress to achalasia, none were due to malignancy, and many resolved spontaneously.

Effects of GABA-B agonist baclofen on esophageal motility: Studies using high-resolution manometry

BACKGROUND/AIM

Baclofen inhibits transient lower esophageal sphincter (LES) relaxation. This study aimed to investigate the effect of baclofen on esophageal peristaltic function and contraction reserve in healthy adults using high-resolution manometry (HRM).

METHODS

Fifteen subjects underwent HRM with ten water swallows and five multiple rapid swallows (MRS) 90 minutes after oral intake of either baclofen or placebo on separate days at least 1 week apart. HRM parameters assessed included esophagogastric junction contractile integral (EGJ-CI), resting LES pressure, 4-second integrated relaxation pressure (IRP-4s), distal contractile integral (DCI), distal latency, peristaltic breaks, resting upper esophageal sphincter (UES) pressure, and contractile response to MRS.

RESULTS

Baclofen significantly increased EGJ-CI (P = .007), IRP-4s (P = .003), and LES pressure (P = .004). UES pressure, latency, and DCI were similar between baclofen and placebo (P = .87, P = .84, and P = .54, respectively). There was no difference in contractile response and peristaltic augmentation following MRS between baclofen and placebo (93% vs 100%, P = .30; 53% vs. 73%, P = .26, respectively).

CONCLUSIONS

Baclofen increases resting LES pressure and EGJ barrier function, but has no effect on primary peristalsis or contraction reserve.

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

BACKGROUND

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

METHODS

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

KEY RESULTS

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

CONCLUSIONS AND INFERENCES

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

The importance of pH reflux monitoring test for the management of low-grade esophagitis in Chinese patients

BACKGROUND AND AIMS

Low-grade esophagitis (grade A and B) are no longer believed as confirmatory evidence of gastroesophageal reflux disease, but there were no data about the association of low-grade esophagitis with pathological acid reflux (PAR) in China. This study aimed to summarize the proportion of PAR in the patients with low-grade esophagitis and to explore the differential factors between low-grade esophagitis patients with and without PAR.

METHODS

Database of the patients accepted 24-hour pH monitoring in the motility laboratory of a tertiary center was retrospectively searched, and the patients were diagnosed as low-grade esophagitis before the procedure was recruited. The demographics, symptoms and high-resolution manometry and pH monitoring parameters were compared between the patients with pathological and physiological acid reflux and between patients with grade A and B esophagitis.

RESULTS

About 24% of grade A and 55% of grade B esophagitis patients had pathological acid reflux. The demographics, symptoms, and almost all high-resolution manometry findings were similar in patients with pathological and physiological acid reflux. About two-thirds of the participants with physiological acid reflux reported symptom improvement after PPI administration. All participants with PPI-resistant symptoms were with physiological acid reflux.

CONCLUSION

The proportion of PAR in low-grade esophagitis is not high. For patients with low-grade esophagitis in China, especially the patients with grade A esophagitis, regardless of symptom change, reflux monitoring is possibly needed for the patients whose esophageal mucosa break is not improved after 8 weeks of PPI treatment.

Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium

BACKGROUND

Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450 mm Hg cm s) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). Ineffective esophageal motility is not consistently related to disease states or symptoms and may be seen in asymptomatic healthy individuals.

PURPOSE

A 1-day symposium of esophageal experts reviewed existing literature on IEM, and this review represents the conclusions from the symposium. Severe IEM (>70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.

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

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

Upper esophageal sphincter metrics on high-resolution manometry differentiate etiologies of esophagogastric junction outflow obstruction

BACKGROUND

Upper esophageal sphincter (UES) metrics on high-resolution manometry (HRM), particularly nadir UES residual pressure (UES-RP), are abnormal in achalasia and may help characterize the underlying mechanism or predict management outcome in esophagogastric junction outflow obstruction (EGJOO).

METHODS

A database of consecutive patients undergoing esophageal HRM from 2008 to 2013 yielded 134 patients (59.8 ± 1.4 years, 68% F) with EGJOO. Final clinical diagnoses and treatment response were extracted from chart review. Esophageal body, UES, and lower esophageal sphincter (LES) metrics were compared between EGJOO and asymptomatic healthy controls (n = 16, 27.7 ± 0.7 years, 56% F). Logistic regression evaluated differences between HRM metrics amongst etiologies of EGJOO grouped into motor versus mechanical disorders.

KEY RESULTS

Distal contractile integral, distal latency, and nadir UES-RP were significantly different between EGJOO subgroups (P ≤ 0.01 for each comparison), but only nadir UES-RP remained independently predictive of subgroups (adjusted odds ratio 1.15, 95% confidence intervals 1.05-1.27, P < 0.01). Nadir UES-RP was highest in achalasia variants, and lowest in mechanical EGJOO and controls (P < 0.001). Of 19 patients who underwent LES myotomy, durable benefit was reported by 68.4% over mean 3.6 years of follow-up. Significantly higher nadir UES-RP was noted with symptom relief (3.4 vs -0.7 mm Hg with symptom recurrence, 95% confidence intervals of difference = 1.35-6.83). A threshold UES-RP of ≥2.0 mm Hg yielded a sensitivity of 84.6% and specificity of 83.3% in predicting symptom resolution following myotomy.

CONCLUSIONS AND INFERENCES

Nadir UES-RP offers clues to differentiation of subtypes within EGJOO and may predict symptom outcome from myotomy.

Provocative testing in patients with jackhammer esophagus: evidence for altered neural control

Jackhammer esophagus (JE) is a hypercontractile disorder, the pathogenesis of which is incompletely understood. Multiple rapid swallows (MRS) and rapid drink challenge (RDC) are complementary tests used during high-resolution manometry (HRM) that evaluate inhibitory and excitatory neuromuscular function and latent obstruction, respectively. Our aim was to evaluate esophageal pathophysiology using MRS and RDC in 83 JE patients (28 men; median age: 63 yr; IQR: 54-70 yr). Twenty-one healthy subjects (11 men; median age: 28 yr; range: 26-30 yr) were used as a control group. All patients underwent solid-state HRM with ten 5-ml single swallows (SS) and one to three 10-ml MRS; 34 patients also underwent RDC. Data are shown as median (interquartile range). Abnormal motor inhibition was noted during at least one MRS test in 48% of JE patients compared with 29% of controls ( P = 0.29). Mean distal contractile integral (DCI) after MRS was significantly lower than after SS [6,028 (3,678-9,267) mmHg·cm·s vs. 7,514 (6,238-9,197) mmHg·cm·s, P = 0.02], as was highest DCI ( P < 0.0001). Consequently, 66% of JE patients had no contraction reserve. At least one variable of obstruction during RDC (performed in 34 patients) was outside the normal range in 25 (74%) of JE patients. Both highest DCI after SS and pressure gradient across the esophagogastric junction (EGJ) during RDC were higher in patients with dysphagia versus those without ( P = 0.04 and 0.01, respectively). Our data suggest altered neural control in JE patients with heterogeneity in inhibitory function. Furthermore, some patients had latent EGJ obstruction during RDC, which correlated with the presence of dysphagia. NEW & NOTEWORTHY Presence of abnormal inhibition was observed during multiple rapid swallows (MRS) in some but not all patients with jackhammer esophagus (JE). Unlike healthy subjects, JE patients were more strongly stimulated after single swallows than after MRS. An obstructive pattern was frequently observed during rapid drink challenge (RDC) and was related to presence of dysphagia. MRS and RDC during high-resolution manometry are useful to show individual pathophysiological patterns in JE and may guide optimal therapeutic strategies.

First genotype-phenotype study reveals HLA-DQβ1 insertion heterogeneity in high-resolution manometry achalasia subtypes

Background

Achalasia is a primary oesophageal motility disorder. Although aetiology remains mainly unknown, a genetic risk variant, rs28688207 in HLA-DQB1, showed strong achalasia association suggesting involvement of immune-mediated processes in the pathogenesis. High-resolution manometry recognises three types of achalasia. The aim of our study was to perform the first genotype-phenotype analysis investigating the frequency of rs28688207 across the high-resolution manometry subtypes.

Methods

This was a cross-sectional retrospective study. Achalasia patients from tertiary centres in the Czech Republic (n = 163), Germany (n = 114), Greece (n = 70) and controls were enrolled. All subjects were genotyped for the rs28688207 insertion. The Kruskal-Wallis test was used for the genotype-phenotype analysis.

Results

A total of 347 achalasia patients (type I - 89, II - 210, III - 48) were included. The overall frequency of the rs28688207 was 10.3%. The distribution of the insertion was significantly different across the high-resolution manometry subtypes (p = 0.038), being most prevalent in type I (14.6%), followed by type II (9.5%) and III (6.3%).

Conclusion

The frequency of the HLA-DQB1 insertion differs among high-resolution manometry achalasia subtypes. The insertion is most prevalent in type I, suggesting that immune-mediated mechanisms triggered by the insertion may play a more prominent role in the pathogenesis of this subtype.

Achalasia: Insights into Diagnostic and Therapeutic Advances for an Ancient Disease

Achalasia is a chronic idiopathic disease characterized by the absence of esophageal body peristalsis and by defective lower esophageal sphincter (LES) relaxation. The incidence rate ranges from 1.07 to up to 2.8 new cases per year per 100,000 population. Presenting symptoms include dysphagia, regurgitation, vomiting, and weight loss. The diagnosis of achalasia has undergone a revolution in the last decade due to the advent of high-resolution manometry (HRM) and the consequent development of the Chicago Classification. Recent progress has allowed achalasia to be more precisely diagnosed and to be categorized into three subtypes, based on the prevalent manometric features of the esophageal peristalsis. Treatment options are pharmacotherapy, endoscopic management (Botox injection or pneumatic dilation), and surgery, e.g. laparoscopic Heller myotomy (LHM). More recently, a new endoscopic technique, per oral endoscopic myotomy (POEM), has developed as a less invasive approach alternative to the traditional LHM. Since the first POEM procedure was performed in 2008, increasing evidence is accumulating regarding its efficacy and safety profiles. Currently, POEM is being introduced as a reasonable therapeutic option, though randomized controlled trails are still lacking. The current review sheds light onto the diagnosis and management of achalasia, with special focus on the recent advances of HRM and POEM.

Recent advances in intestinal smooth muscle research: from muscle strips and single cells, via ICC networks to whole organ physiology and assessment of human gut motor dysfunction

Gastrointestinal smooth muscle research has evolved from studies on muscle strips to spatiotemporal mapping of whole organ motor and electrical activities. Decades of research on single muscle cells and small sections of isolated musculature from animal models has given us the groundwork for interpretation of human in vivo studies. Human gut motility studies have dramatically improved by high-resolution manometry and high-resolution electrophysiology. The details that emerge from spatiotemporal mapping of high-resolution data are now of such quality that hypotheses can be generated as to the physiology (in healthy subjects) and pathophysiology (in patients) of gastrointestinal (dys) motility. Such interpretation demands understanding of the musculature as a super-network of excitable cells (neurons, smooth muscle cells, other accessory cells) and oscillatory cells (the pacemaker interstitial cells of Cajal), for which mathematical modeling becomes essential. The developing deeper understanding of gastrointestinal motility will bring us soon to a level of precision in diagnosis of dysfunction that is far beyond what is currently available.

Derivation and measurement consistency of a novel biofluid dynamics measure of deglutitive bolus-driving function-pharyngeal swallowing power

BACKGROUND

The primary function of the pharyngeal swallowing mechanism is to drive ingested materials into the esophagus. Currently, a definitive measure of pharyngeal bolus-driving function that accounts for bolus movement remains lacking. The primary objectives of this study were to describe the derivation of a novel biofluid dynamics measure of deglutition-that is, pharyngeal swallowing power (PSP)-and to demonstrate the consistency of PSP in normal swallowing.

METHODS

The pharyngeal swallowing mechanism was conceptualized as a hydraulic power system with the upper esophageal sphincter (UES) as a conduit. PSP was calculated as the product of bolus pressure and flow across the UES. Thirty-four young healthy subjects swallowed materials consisting of two bolus volumes (10, 20 mL) and four bolus viscosities (thin liquid, nectar-thick liquid, honey-thick liquid, pudding). High-resolution impedance manometry was used for data collection. The consistency of PSP across specific bolus conditions was evaluated using standardized Cronbach's coefficient alpha.

KEY RESULTS

Standardized Cronbach's coefficient alphas in specific bolus conditions ranged between 0.85 and 0.93. Fisher weighted mean Cronbach's coefficient alphas for swallow trials across bolus volumes and across bolus viscosities ranged from 0.86 to 0.90. Fisher weighted mean Cronbach's coefficient alpha for overall consistency of PSP across all swallow trials was 0.88.

CONCLUSIONS AND INFERENCES

PSP estimates the output power of the pharyngeal bolus-driving mechanism during deglutition. PSP's high consistency indicates that it can be a useful biofluid dynamics measure of pharyngeal bolus-driving function. Current results also demonstrate that consistency in pharyngeal bolus propulsion is an important physiological target for the pharyngeal swallowing mechanism.

Abnormal esophageal motility during a solid test meal in systemic sclerosis-detection even in very early disease and association with disease progression

OBJECTIVE

This study assessed whether high-resolution manometry (HRM) with a test meal can detect clinically relevant, abnormal motility already in very early systemic sclerosis (SSc) and whether this finding is associated with subsequent disease progression.

METHODS

This prospective, longitudinal cohort study recruited 68 consecutive SSc patients (group #1: 32 established disease (ACR, American College of Rheumatology /EULAR, The European League against Rheumatism 2013 and ACR 1980 criteria fulfilled); group #2: 24 early disease (only ACR/EULAR 2013 fulfilled); group #3: 12 very early disease (clinical expert diagnosis of SSc) and 72 healthy controls. HRM evaluated esophageal motility for water swallows and a solid test meal.

RESULTS

Systemic sclerosis patients had less frequent effective esophageal contractions during the test meal compared to healthy controls even in very early disease (0.15, 1.0, 2.1 per minute for groups #1, #2, and #3, vs 2.5 per minute in health; P < 0.001, P < 0.001, and P < 0.0085, respectively). Ineffective motility at HRM was associated with a higher modified Rodnan skin score at baseline. Moreover, at mean 18 (10-31) months of follow-up, the presence of ineffective motility at baseline was associated with progression of skin disease (P = 0.01). Cox proportional hazard regression analysis identified hypotensive peristalsis in the test meal (<15% effective solid swallows) and low distal contractile integral (DCI; <400 mm Hg·cm·s) as predictors for skin aggravation, but not for new organ involvement.

CONCLUSION

Ineffective motility during a test meal is present already in patients with very early SSc. Findings on HRM studies are associated with disease severity at baseline, and low percentage of effective swallows in test meal and low mean DCI are both predictors of skin progression during follow-up.

Bolus volume and viscosity effects on pharyngeal swallowing power-How physiological bolus accommodation affects bolus dynamics

BACKGROUND

Pharyngeal swallowing power (PSP) is a novel measure of pharyngeal bolus-driving function derived from fluid dynamics principles. This study examined the impact of bolus volume and viscosity on PSP to determine bolus effects on pharyngeal bolus dynamics. The impact of bolus accommodation and physical characteristics of boluses were also explored.

METHODS

Thirty-four healthy subjects swallowed materials consisting of two bolus volumes (10 and 20 mL) and four bolus viscosities (thin liquid, nectar-thick liquid, honey-thick liquid and pudding). High-resolution impedance manometry was used for data collection. The pharyngeal swallowing mechanism was conceptualized as a hydraulic power system with the UES as a conduit, and PSP was calculated as the product of bolus pressure and flow across the UES. The impact of bolus characteristics on PSP was evaluated using a mixed model approach.

KEY RESULTS

Both bolus volume (F_1,32.8  = 412.73, P < 0.0001) and viscosity (F_3,84.7  = 28.94, P < 0.0001) were significant predictors of PSP. PSP for 20 mL bolus volume was greater than for 10 mL bolus volume. PSP was lowest in the thin liquid bolus condition and highest in the pudding bolus. All pairwise comparisons among bolus viscosities were significant except between thin liquid and nectar-thick liquid bolus viscosities. Test of linear trend across bolus viscosities was significant (F_1,97.2  = 77.25, P < 0.0001).

CONCLUSIONS & INFERENCES

Pharyngeal swallowing power variation across bolus conditions illustrates bolus-related changes in bolus dynamics. Bolus effects on PSP likely result from physiological bolus accommodation combined with physical characteristics of boluses.

Long-term outcome of myotomy and fundoplication based on intraoperative real-time high-resolution manometry in achalasia patients

Background

Current treatment options for achalasia of the esophagus predominantly consist of endoscopic myotomy or laparoscopic myotomy combined with a partial fundoplication. The intraoperative use of conventional manometry has previously been proposed with various results. The aim of the present study was to introduce the use of high-resolution manometry (HRM) during surgical treatment for achalasia and to assess the long-term outcome of this technique.

Methods

We enrolled achalasia patients within the time period November 2013 to July 2016 who underwent HRM and evaluation of Eckardt scores (ES) before and after tailored laparoscopic myotomy and fundoplication with intraoperative recording using HRM.

Results

Twenty patients were classified as having achalasia type I (20%), type II (55%), or type III (25%). During surgery, 9 myotomies were extended and 13 fundoplications were modified according to HRM findings. Mean resting (16.1 vs. 41.9 mmHg) and residual (9 vs. 28.7 mmHg) pressures of the lower esophageal sphincter and ES (0.7 vs. 6.9) were significantly eliminated postoperatively over a mean follow-up time of 17.7 months.

Conclusions

The use of intraoperative HRM gives us the advantage of simultaneous real-time estimation of intraluminal pressures of the esophagus and the ability to identify the exact points that produce pressure during laparoscopy. Consequently, it may be the key to the tailoring of the Heller-Dor technique and improving the outcomes for achalasia patients.