Classifying esophageal motility by pressure topography characteristics: a study of 400 patients and 75 controls

Systematic analysis of esophageal pressure topography in high-resolution manometry of 68 normal volunteers

The introduction of high-resolution manometry (HRM) has been a significant advance in esophageal diagnostics. Normative values however are currently based upon a single set of published reference values, and multiple new metrics have been added over the past several years. Our goal was to provide a second set of 'normal-values' and to include all current metrics suggested by the 2012 Chicago classification. Sixty-eight subjects without foregut symptoms or previous surgery (median age 25.5 years, ranging from 20-58 years, 53% female) underwent esophageal motility assessment via an established standardized protocol. Normative thresholds were calculated for esophago-gastric junction (EGJ) characteristics (resting, relaxation, intrabolus pressure, and lengths) as well as for esophageal body strength (contraction amplitudes at multiple levels, distal contractile integral, integrity of peristalsis) and wave propagation (contractile front velocity, distal latency). Overall, our findings where strikingly similar to the previously described metrics derived from 75 control subjects of the Northwestern group. This suggests a high degree of reproducibility of HRM.

Influence of the catheter diameter on the investigation of the esophageal motility through solid-state high-resolution manometry

Past studies have shown that catheter diameter is one of the device-dependent problems which influence the manometric results in the conventional water perfusion esophageal manometry. High-resolution solid-state manometry which abandons water perfusion is thought as an improved manometry method benefited from more pressure sensors, and it is gradually widely used in many present esophageal motility studies. There was no research to evaluate the influence of catheter diameter on the solid-state high-resolution manometry results. The aim of this study was to investigate whether solid-state high-resolution catheters of different diameter provide different data and results. Nine asymptomatic volunteers and 18 gastroesophageal reflux disease patients accepted high-resolution manometry examinations with two solid-state catheters of different outer diameter (4.2 mm and 2.7 mm). Every examination contained 5 minutes resting pressure, 10 water swallows and 10 bread swallows. Some important parameters of the esophageal sphincters and esophageal body peristalsis were analyzed. They included the locations and resting pressure of sphincters, the distal contractile integral, the 4-second integrated relaxation pressure etc. Then, these parameters and the diagnosis of each swallow based on them provided by the two different diameter catheters were compared. (i) The 4.2 mm thick catheter provided higher upper esophageal sphincter resting pressure than the 2.7 mm thick catheter (59.4 ± 21.1 mmHg vs. 49.7 ± 21.4 mmHg); (ii) the 2.7 mm thick catheter provided higher 4-second integrated relaxation pressure than the 4.2 mm thick catheter (10.9 ± 4.5 mmHg vs. 8.5 ± 3.8 mmHg) in water swallows; (iii) the mean distal contractile integral of the water and bread swallows in the large diameter catheter were higher than in the small diameter catheter (989.2 ± 650.0 mmHg/cm/s vs. 806.3 ± 563.7 mmHg/cm/s in water swallows, 1762.5 ± 1440.6 mmHg/cm/s vs. 1275.7 ± 982.0 mmHg/cm/s in bread swallows); (iv) on the lower esophageal sphincter resting pressure, most parameters in bread swallows provided by the two catheters were of no statistical significance; (v) the 2.7 mm thick catheter detected more hypotensive peristalsis swallows than the other catheter in water swallows; and (vi) the final diagnosis of about half of the subjects provided by the two catheters were different. The 2.7 mm thick solid-state high-resolution manometry catheter provides somewhat different data from the usually used 4.2 mm thick catheter. It is needed to set up different and independent series of normative value for the solid-state high-resolution manometry catheters of different outer diameter. The normative value and diagnostic criterion got from one catheter is not universal and acceptable for researches with catheter of different diameter.

A comparison of symptom severity and bolus retention with Chicago classification esophageal pressure topography metrics in patients with achalasia

BACKGROUND & AIMS

We compared findings from timed barium esophagrams (TBEs) and esophageal pressure topography studies among achalasia subtypes and in relation to symptom severity.

METHODS

We analyzed data from 50 patients with achalasia (31 men; age, 20-79 y) who underwent high-resolution manometry (HRM), had TBE after a 200-mL barium swallow, and completed questionnaires that determined Eckardt Scores. Twenty-five patients were not treated, and 25 patients were treated (11 by pneumatic dilation, 14 by myotomy). Nonparametric testing was used to assess differences among groups of treated patients (10 had type 1 achalasia and 15 had type 2 achalasia), and the Pearson correlation was used to assess their relationship.

RESULTS

There were no significant differences in TBE measurements between patient groups. Of the 25 patients who received treatment, 10 had a manometric pattern consistent with persistent achalasia after treatment (6 patients with type 1 and 4 patients with type 2 achalasia), whereas 15 appeared to have resolved the achalasia pattern (peristalsis was absent in 8 patients and weak in 7 patients). The height of the barium column at 5 minutes and Eckardt Scores were reduced significantly in patients who had resolved their achalasia pattern, based on HRM. The integrated relaxation pressure and the TBE column height correlated at 5 minutes (r = 0.422; P < .05).

CONCLUSIONS

Patients who resolved their achalasia pattern, based on HRM, showed improved emptying based on TBE measurements and improved symptom scores. There was no significant difference between patients with type 1 or type 2 achalasia in TBEs. These findings indicate that normalization of the integrated relaxation pressure on HRM is a clinically relevant objective of treatment for achalasia.

Evaluation of esophageal motor function in clinical practice

Esophageal motor function is highly coordinated between central and enteric nervous systems and the esophageal musculature, which consists of proximal skeletal and distal smooth muscle in three functional regions, the upper and lower esophageal sphincters, and the esophageal body. While upper endoscopy is useful in evaluating for structural disorders of the esophagus, barium esophagography, radionuclide transit studies, and esophageal intraluminal impedance evaluate esophageal transit and partially assess motor function. However, esophageal manometry is the test of choice for the evaluation of esophageal motor function. In recent years, high-resolution manometry (HRM) has streamlined the process of acquisition and display of esophageal pressure data, while uncovering hitherto unrecognized esophageal physiologic mechanisms and pathophysiologic patterns. New algorithms have been devised for analysis and reporting of esophageal pressure topography from HRM. The clinical value of HRM extends to the pediatric population, and complements preoperative evaluation prior to foregut surgery. Provocative maneuvers during HRM may add to the assessment of esophageal motor function. The addition of impedance to HRM provides bolus transit data, but impact on clinical management remains unclear. Emerging techniques such as 3-D HRM and impedance planimetry show promise in the assessment of esophageal sphincter function and esophageal biomechanics.

The effect of luminal content and rate of occlusion on the interpretation of colonic manometry

BACKGROUND

Manometry is commonly used for diagnosis of esophageal and anorectal motility disorders. In the colon, manometry is a useful tool, but clinical application remains uncertain. This uncertainty is partly based on the belief that manometry cannot reliably detect non-occluding colonic contractions and, therefore, cannot identify reliable markers of dysmotility. This study tests the ability of manometry to record pressure signals in response to non-lumen-occluding changes in diameter, at different rates of wall movement and with content of different viscosities.

METHODS

A numerical model was built to investigate pressure changes caused by localized, non-lumen-occluding reductions in diameter, similar to those caused by contraction of the gut wall. A mechanical model, consisting of a sealed pressure vessel which could produce localized reductions in luminal diameter, was used to validate the model using luminal segments formed from; (i) natural latex; and (ii) sections of rabbit proximal colon. Fluids with viscosities ranging from 1 to 6800 mPa s(-1) and luminal contraction rates over the range 5-20 mmHg s(-1) were studied.

KEY RESULTS

Manometry recorded non-occluding reductions in diameter, provided that they occurred with sufficiently viscous content. The measured signal was linearly dependent on the rate of reduction in luminal diameter and also increased with increasing viscosity of content (R(2) = 0.62 and 0.96 for 880 and 1760 mPa s(-1), respectively).

CONCLUSIONS & INFERENCES

Manometry reliably registers non-occluding contractions in the presence of viscous content, and is therefore a viable tool for measuring colonic motility. Interpretation of colonic manometric data, and definitions based on manometric results, must consider the viscosity of luminal content.

Effect of acid swallowing on esophageal contraction in patients with heartburn related to hypersensitivity

BACKGROUND AND AIM

There are heterogeneous subgroups among those with heartburn, and data on these individuals are relatively scant. We aimed to evaluate the effect of acid challenge on the segmental contractions of esophageal smooth muscle in endoscopy-negative patients with normal esophageal acid exposure.

METHODS

High-resolution esophageal manometry (HRM) was performed on 30 endoscopy-negative patients with heartburn accompanied by normal esophageal acid exposure using 10 water swallows followed by 10 acidic pomegranate juice swallows. Patients were classified into functional heartburn (FH) and hypersensitive esophagus (HE) groups based on the results of 24-hr impedance pH testing. HRM topographic plots were analyzed and maximal wave amplitude and pressure volumes were measured for proximal and distal smooth muscle segments.

RESULTS

The pressure volume of the distal smooth muscle segment in the HE group measured during acidic swallows was higher than during water swallows (2224.1 ± 68.2 mmHg/cm per s versus 2105.6 ± 66.4 mmHg/cm per s, P = 0.027). A prominent shift in the pressure volume to the distal smooth muscle segment was observed in the HE group compared with the FH group (segmental ratio: 2.72 ± 0.08 versus 2.39 ± 0.07, P = 0.005). Manometric measurements during acidic swallows revealed that this shift was augmented in the HE group. The optimal ratio of pomegranate juice swallowing for discrimination of FH from HE was 2.82, with a sensitivity of 88.9% and a specificity of 100%.

CONCLUSIONS

Hypercontractile response of distal smooth muscle segment to acid swallowing was more prominent in the HE group than the FH group.

Multiple rapid swallow responses segregate achalasia subtypes on high-resolution manometry

BACKGROUND

Multiple rapid swallows (MRS) inhibit esophageal peristalsis and lower esophageal sphincter (LES) tone; a rebound excitatory response then results in an exaggerated peristaltic sequence. Multiple rapid swallows responses are dependent on intact inhibitory and excitatory neural function and could vary by subtype in achalasia spectrum disorders.

METHODS

Consecutive subjects with incomplete LES relaxation on high-resolution manometry (HRM) (Sierra Scientific, Los Angeles, CA, USA) in the absence of mechanical obstruction were prospectively identified. Achalasia spectrum disorders were classified and HRM plots reviewed according to Chicago criteria. Esophageal peristaltic performance and LES function were assessed after 10 wet swallows and MRS (five 2 mL water swallows 2-3 s apart). Findings were compared with 18 healthy controls (28.5 ± 0.6 years, 44% women).

KEY RESULTS

A total of 46 subjects (57.1 ± 2.1 years, 52.2% women) met inclusion criteria. There was complete failure of peristalsis with MRS in all subjects with achalasia subtypes 1 and 2. In contrast, 80% of achalasia subtype 3 and incomplete LES relaxation (EGJ outflow obstruction) with preserved esophageal body peristalsis had a contractile response to MRS (P < 0.001 compared with subtypes 1 and 2); controls demonstrated 94.4% peristalsis. Percent decrease in LES residual pressure during MRS (compared to wet swallows) segregated achalasia subtypes; those with aperistalsis (subtypes 1 and 2) had a lesser decline (22.6%) compared to those with retained esophageal body peristalsis (40.5%) and controls (51.3%, P < 0.001 across groups).

CONCLUSIONS & INFERENCES

Multiple rapid swallow responses segregate achalasia spectrum disorders into two patterns differentiated by presence or absence of esophageal body contraction response to wet swallows. These findings support subtyping of achalasia, with pathophysiologic implications.

The effect of a sitting vs supine posture on normative esophageal pressure topography metrics and Chicago Classification diagnosis of esophageal motility disorders

BACKGROUND

Although, the current protocol for high resolution manometry (HRM) using the Chicago Classification is based on the supine posture, some practitioners prefer a sitting posture. Our aims were to establish normative esophageal pressure topography data for the sitting position and to determine the effect of applying those norms to Chicago Classification diagnoses.

METHODS

Esophageal pressure topography studies including test swallows in both a supine and sitting position of 75 healthy volunteers and 120 patients were reviewed. Integrated relaxation pressure (IRP), distal contractile integral (DCI), contractile front velocity (CFV), and distal latency were measured and compared between postures. Normative ranges were established from the healthy volunteers and the effect of applying sitting normative values to the patients was analyzed.

KEY RESULTS

Normative values of IRP, DCI, and CFV all decreased significantly in the sitting posture. Applying normative sitting metrics to patient studies [27% reduction in IRP (15 to 11 mmHg), 69% reduction in DCI (8000-2500 mmHg-s-cm)] reclassified 13/120 (11%) patients as having abnormal esophagogastric junction relaxation and 26/120 (22%) as hypercontractile. Three patients with an abnormal supine IRP normalized when sitting with elimination of a vascular artifact.

CONCLUSIONS & INFERENCES

Clinical HRM studies should include both a supine and sitting position to minimize misdiagnoses attributable to anatomical factors. However, until outcome studies demonstrating the significance of isolated abnormalities of IRP or DCI in the sitting position are available, the Chicago Classification of esophageal motility disorders should continue to be based on supine swallows using normative data from the supine posture.

Characteristics of achalasia subtypes in untreated Chinese patients: a high-resolution manometry study

OBJECTIVE

To evaluate and compare the clinical characteristics, manometric results and treatment outcomes of different subtypes of achalasia in untreated Chinese patients using high-resolution esophageal manometry.

METHODS

A total of 75 achalasia patients and 34 healthy controls were enrolled in the study, and three achalasia subtypes were determined based on the Chicago classification. Clinical characteristics, manometric and treatment outcomes were compared.

RESULTS

In all, 25 patients were classified as type I, 46 as type II and 4 as type III. The mean overall length of lower esophageal sphincter (LES) in type III was significantly longer than those in the controls and type I patients (P < 0.05), and abdominal LES length was significantly longer in type III than those in controls, type I and type II patients. All subtypes of achalasia had higher resting and residual LES pressures than those found in healthy controls (P < 0.05). Resting upper esophageal sphincter (UES) pressure in type III patients was significantly lower than those in healthy controls and type I patients, whereas types I and II patients had higher residual UES pressures compared with healthy controls (P < 0.05). Type II patients had a better response to the treatment than type I and III patients.

CONCLUSIONS

Type II is more common in untreated Chinese achalasia patients, and type II patients had better treatment outcomes than other types of patients. Large-sample multicenter trials are necessary in the future.

Clinical applications of esophageal impedance monitoring and high-resolution manometry

Esophageal impedance monitoring and high-resolution manometry (HRM) are useful tools in the diagnostic work-up of patients with upper gastrointestinal complaints. Impedance monitoring increases the diagnostic yield for gastroesophageal reflux disease in adults and children and has become the gold standard in the diagnostic work-up of reflux symptoms. Its role in the work-up for belching disorders and rumination seems promising. HRM is superior to other diagnostic tools for the evaluation of achalasia and contributes to a more specific classification of esophageal disorders in patients with non-obstructive dysphagia. The role of HRM in patients with dysphagia after laparoscopic placement of an adjustable gastric band seems promising. Future studies will further determine the clinical implications of the new insights which have been acquired with these techniques. This review aims to describe the clinical applications of impedance monitoring and HRM.

Fragmented esophageal smooth muscle contraction segments on high resolution manometry: a marker of esophageal hypomotility

BACKGROUND

Esophageal peristalsis consists of a chain of contracting striated and smooth muscle segments on high resolution manometry (HRM). We compared smooth muscle contraction segments in symptomatic subjects with reflux disease to healthy controls.

METHODS

High resolution manometry Clouse plots were analyzed in 110 subjects with reflux disease (50 ± 1.4 years, 51.5% women) and 15 controls (27 ± 2.1 years, 60.0% women). Using the 30 mmHg isobaric contour tool, sequences were designated fragmented if either smooth muscle contraction segment was absent or if the two smooth muscle segments were separated by a pressure trough, and failed if both smooth muscle contraction segments were absent. The discriminative value of contraction segment analysis was assessed.

KEY RESULTS

A total of 1115 swallows were analyzed (reflux group: 965, controls: 150). Reflux subjects had lower peak and averaged contraction amplitudes compared with controls (P < 0.0001 for all comparisons). Fragmented sequences followed 18.4% wet swallows in the reflux group, compared with 7.5% in controls (P < 0.0001), and were seen more frequently than failed sequences (7.9% and 2.5%, respectively). Using a threshold of 30% in individual subjects, a composite of failed and/or fragmented sequences was effective in segregating reflux subjects from control subjects (P = 0.04).

CONCLUSIONS & INFERENCES

Evaluation of smooth muscle contraction segments adds value to HRM analysis. Specifically, fragmented smooth muscle contraction segments may be a marker of esophageal hypomotility.

The Chicago criteria for esophageal motility disorders: what has changed in the past 5 years?

PURPOSE OF REVIEW

The Chicago Classification for esophageal motility disorders was developed to complement the enhanced characterization of esophageal motility provided by high-resolution esophageal pressure topography (HREPT) as this new technology has emerged within clinical practice. This review aims to summarize the evidence supporting the evolution of the classification scheme since its inception.

RECENT FINDINGS

Studies examining the specific esophageal motility disorders in regards to HREPT metrics, clinical characteristics, and responses to treatments have facilitated updates of the diagnostic scheme and criteria. These studies have demonstrated variation in treatment responses associated with subclassification of achalasia, the use of distal latency in the diagnosis of distal esophageal spasm, and the development of diagnoses including esophagogastric junction outflow obstruction and hypercontractile esophagus.

SUMMARY

The diagnostic criteria described in the Chicago Classification have evolved to demonstrate a greater focus on distinct clinical phenotypes. Future evaluation of the natural history and treatment outcomes will assist in further refinement of this diagnostic scheme and management of esophageal motility disorders.

Functional aspects of distal oesophageal spasm: the role of onset velocity and contraction amplitude on bolus transit

BACKGROUND

Distal oesophageal spasm is a rare and under-investigated motility abnormality. Recent studies indicate effective bolus transit in varying percentages of distal oesophageal spasm patients.

AIM

Explore functional aspects including contraction onset velocity and contraction amplitude cut-off values for simultaneous contractions to predict complete bolus transit.

METHODS

We re-examined data from 107 impedance-manometry recordings with a diagnosis of distal oesophageal spasm. Receiver operating characteristic analysis was conducted, regarding effects of onset velocity on bolus transit taking into account distal oesophageal amplitude and correcting for intra-individual repeated measures.

RESULTS

Mean area under the receiver operating characteristic curve for saline and viscous swallows were 0.84±0.05 and 0.84±0.04, respectively. Velocity criteria of >30 cm/s when distal oesophageal amplitude>100 mmHg and 8 cm/s when distal oesophageal amplitude<100 mmHg for saline and 32cm/s when distal oesophageal amplitude>100 mmHg and >7 cm/s when distal oesophageal amplitude<100 mmHg for viscous had a sensitivity of 75% and specificity of 80% to identify complete bolus transit. Using these criteria, final diagnosis changed in 44.9% of patients. Abnormal bolus transit was observed in 50.9% of newly diagnosed distal oesophageal spasm patients versus 7.5% of patients classified as normal. Distal oesophageal spasm patients with distal oesophageal amplitude>100 mmHg suffered twice as often from chest pain than those with distal oesophageal amplitude<100 mmHg.

CONCLUSION

The proposed velocity cut-offs for diagnosing distal oesophageal spasm improve the ability to identify patients with spasm and abnormal bolus transit.

Segmental changes in smooth muscle contraction as a predictive factor of the response to high-dose proton pump inhibitor treatment in patients with functional chest pain

BACKGROUND AND AIMS

High-dose proton pump inhibitor (PPI) treatment leads to relatively little symptomatic improvement in patients with functional chest pain (FCP). This study was to evaluate the use of smooth muscle segmental changes in esophageal contraction as measured by topographical plots of high resolution manometry (HRM) as predictive factors of the response to high-dose PPI treatment in FCP patients.

METHODS

Thirty patients diagnosed with FCP were treated with rabeprazole 20 mg twice daily for 2 weeks and classified as positive and negative responders based on symptom intensity score. HRM topographical plots were analyzed for segment lengths, maximal wave amplitudes, and pressure volumes of the proximal and distal smooth muscle segments.

RESULTS

A positive response was observed in 23.3% of the patients. While the pressure volume of the proximal segment was significantly higher in the positive responders than the negative responders (900.4 ± 91.5 mm Hg/cm per s vs. 780.5 ± 133.3 mm Hg/cm per s, P = 0.017), the pressure volume of the distal segment was significantly lower in the positive responders (1914.0 ± 159.8 mm Hg/cm per s vs. 2140.5 ± 276.2 mm Hg/cm per s, P = 0.014). A prominent shifting in pressure volume to the distal segment was observed in the negative responders compared with the positive responders (segmental ratio of pressure volume (SRPV): 2.9 ± 0.5 vs. 2.1 ± 0.1, P < 0.001), and 2.39 was found to be the SRPV that best differentiated positive and negative responders.

CONCLUSIONS

A low SRPV was associated with a positive response to high-dose PPI treatment in patients with FCP.

Treatment of the patient with achalasia

PURPOSE OF REVIEW

In recent years, several studies on the treatment and follow-up of achalasia have been published. This review aims at highlighting interesting publications from the recent years.

RECENT FINDINGS

Treatment of achalasia aims at relieving functional obstruction at the level of the esophagogastric junction. Several treatment options such as pneumodilation and laparoscopic Heller myotomy (LHM) are available for this purpose. A large prospective randomized trial comparing pneumodilation and LHM demonstrated comparable success rates and quality of life for the two treatment options. Long-term data demonstrate comparable treatment success rates, when redilation in case of recurrent symptoms after pneumodilation is accepted. The most important risk factor for treatment failure is the manometric subtype, with a worse outcome for type I and type III compared with type II achalasia. Recently, peroral endoscopic myotomy (POEM) has been described with high success rates. Comparative studies with longer follow-up are awaited. A prospective study assessing the risk of esophageal carcinoma in patients with achalasia showed a 28-fold increased risk to develop carcinoma.

SUMMARY

Either LHM or pneumodilation have high comparable short-term clinical success rates. Based on the increased risk to develop esophageal carcinoma, a screening program may be indicated. POEM is a new interesting treatment but longer follow-up data are awaited.

Esophageal motor disorders: how to bridge the gap between advanced diagnostic tools and paucity of therapeutic modalities?

High-resolution manometry has added significantly to our current understanding of esophageal motor function by providing improved detail and a data analysis paradigm that is more akin to an imaging format. Esophageal pressure topography provides a seamless dynamic representation of the pressure profile through the entire esophagus and thus, is able to eliminate movement artifact and also assess intrabolus pressure patterns as a surrogate for bolus transit mechanics. This has led to improved identification of anatomic landmarks and measurement of important physiological parameters (esophagogastric junction relaxation, distal latency, and contractile integrity). This research has bridged the gap into clinical practice by defining physiologically relevant phenotypes that may have prognostic significance and improve treatment decisions in achalasia, spasm, and hypercontractile disorders. However, more work is needed in determining the etiology of symptom generation in the context of normal or trivial motor dysfunction. This research will require new techniques to assess visceral hypersensitivity and alterations in central modulation of pain and discomfort.

The Kagoshima consensus on esophageal achalasia

Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and a lower esophageal sphincter that fails to relax appropriately in response to swallowing. This article summarizes the most salient issues in the diagnosis and management of achalasia as discussed in a symposium that took place in Kagoshima, Japan, in September 2010 under the auspices of the International Society for Diseases of the Esophagus.

High-resolution manometry patterns of lower esophageal sphincter complex in symptomatic post-fundoplication patients

INTRODUCTION

There has been an increase in the number of patients seeking treatment after an anti-reflux surgical procedure. The objective of this study is to describe high-resolution manometry (HRM) topography as it relates to the post-fundoplication anatomy.

METHODS

Retrospective review of a prospectively maintained database was conducted to identify patients who underwent esophagogastroduodenoscopy and HRM at Creighton University Medical Center (CUMC) between November 2008 and October 2010, for symptoms after a previous fundoplication. Patients were categorized as having intact, intrathoracic, disruptured, twisted, or slipped fundoplication based on endoscopic findings.

RESULTS

Sixty-one patients {intact, 17(28%), disrupted, 2(3%), twisted, 3(5%), intra-thoracic, 18(30%), slipped, 21(34%)} are included in this study. A double high-pressure zone (HPZ) configuration was identified in both intra-thoracic and slipped fundoplication. This was not noted in appropriately positioned fundoplications. In intra-thoracic fundoplications, the HPZ below the fundoplication was lower pressure and showed respiratory variations. In slipped fundoplication, the higher HPZ had lower pressure and no respiratory variations. In appropriately positioned fundoplication, the lower esophageal sphincter (LES) pressure and extent of relaxation in the single HPZ correlated with intact (normal pressure and good relaxation), disrupted (low pressure and good relaxation), and twisted (high pressure with incomplete relaxation) fundoplication. Patients with only a recurrent para-esophageal hernia had characteristics of an appropriately positioned fundoplication.

CONCLUSION

LES complex HRM findings correlate well with anatomical status of the fundoplication.

Esophageal spasm: demographic, clinical, radiographic, and manometric features in 108 patients

Diffuse esophageal spasm (DES) remains insufficiently understood. Here we aimed to summarize the demographic, clinical, radiographic, and manometric features in a large cohort of patients with DES. We identified all consecutive patients diagnosed with DES from 2000 to 2006 at Mayo Clinic Florida. The computerized records of these patients were reviewed to extract relevant information. We performed 2654 esophageal motilities during that period. There were 108 patients with esophageal spasm, and 55% were female. Median age was 71 years. The most common leading symptom was dysphagia in 55, followed by chest pain in 31. Weight loss occurred in 28 patients. The median of time from onset of symptoms to diagnosis was 48 months (range 0-480), with a median of time from the first medical consultation to diagnosis of 8 months (range 0-300). The most frequent comorbidities were hypertension and psychiatric problems. At presentation, 81 patients were taking acid-reducing medications, and 49 patients were taking psychotropic drugs. An abnormal esophagogram was noted in 46 of 76 patients with this test available, but most radiographic findings were nonspecific with the typical 'corkscrew' appearance seen in only three patients. Gastroesophageal reflux disease (GERD) was diagnosed by pH testing or endoscopy in 41 patients. We did not find any difference between the rate of simultaneous contractions or esophageal amplitude between patients with a leading symptom of dysphagia and those with chest pain. DES is an uncommon motility disorder that often goes unrecognized for years. Physicians should be aware of the clinical heterogeneity of DES and consider motility testing early in the course of unexplained esophageal symptoms. Given the high prevalence of GERD in DES, the role of GERD and the impact of acid-reducing therapy in DES deserve further study.

High-resolution impedance manometry findings in patients with nutcracker esophagus

BACKGROUND AND AIM

The objective of this study was to evaluate the association between high-resolution manometry (HRM) and impedance findings and symptoms in patients with nutcracker esophagus (NE).

METHODS

After institutional review board approval retrospective review of a prospectively maintained database identified patients who were diagnosed with NE as per the Chicago classification (distal contractile integral [DCI] > 5000 mmHg-s-cm) at Creighton University between October 2008 and October 2010. Patients with achalasia or a history of previous foregut surgery were excluded. NE patients were sub-divided into: (i) Segmental (mean distal esophageal amplitude [DEA] at 3 and 8 cm above lower esophageal sphincter [LES] < 180 mmHg) (ii) Diffuse (mean DEA at 3 and 8 cm above LES > 180 mmHg) and (iii) Spastic (DCI > 8000 mmHg-s-cm).

RESULTS

Forty-one patients (segmental: 13, diffuse: 4, spastic: 24) satisfied study criteria. Patients with segmental NE would have been missed by conventional manometry criteria as their DEA < 180 mmHg. A higher percentage of patients with spastic NE (63%) had chest pain when compared to patients with segmental NE (23%) and diffuse NE (25%). There was a significant positive correlation between chest pain severity score and DCI while there was no significant correlation between dysphagia severity and DCI.

CONCLUSIONS

In patients diagnosed with NE using the Chicago classification presence and intensity of chest pain increases with increasing DCI. The present criteria (> 5000 mmHg-s-cm) seems to be too sensitive and has poor symptom correlation. Adjusting the criteria to 8000 mmHg-s-cm is more relevant clinically.

Evaluation of esophageal contractile propagation using esophageal pressure topography

BACKGROUND

High-resolution manometry and esophageal pressure topography have enhanced our ability to analyze esophageal motor disturbances by improving the detail and accuracy of measurements of peristaltic activity.This has been extremely helpful in the evaluation of disorders of rapid propagation as the technique is able to define important time points and physiologic landmarks that are crucial in defining peristaltic velocity and latency intervals.

PURPOSE

The goal of the current review will be to assess how esophageal pressure topography has impacted our ability to define important phenotypes of rapid propagation. Additionally, this review will also be utilized to complement the description of the Chicago Classification of Esophageal Motor Disorders, which is presented in this supplement issue.

Esophageal hypertensive peristaltic disorders

BACKGROUND

Esophageal motility abnormalities include a series of manometric findings that differ to a significant degree from findings in normal, asymptomatic volunteers.

METHODS

Current review summarizes conventional and high-resolution esophageal manometry criteria used to define and characterize esophageal hypertensive motility abnormalities.

KEY RESULTS

In the conventional esophageal manometry classification scheme hypertensive esophageal motility abnormalities include nutcracker esophagus (average distal contraction amplitude >180 mmHg), hypertensive lower esophageal sphincter (average resting LES pressure >45 mmHg) and poorly relaxing lower esophageal sphincter (average LES residual pressure >8 mmHg). The new, high resolution esophageal manometry scheme includes in the group of hypertensive peristaltic disorders hypertensive peristalsis ("nutcracker esophagus": mean DCI >5000 mmHg*sec*cm) and hypercontractile esophagus ("jackhammer esophagus": at least one contraction with DCI > 8,000 mmHg*sec*cm) and defines a separate group for disorders with impaired esophageal-gastric junction relaxation (mean integrated residual (LES) pressure >15 mmHg).

CONCLUSIONS & INFERENCES

Hypertensive motility disorders represent a heterogeneous condition subdivided into hypercontractile esophagus and hypertensive peristalsis. Further studies are required to determine the clinical relevance of this new classification.

Technical aspects of clinical high-resolution manometry studies

A number of commercial and research systems are available for making high-resolution manometry recordings. purpose: In this document, we review the standard equipment, patient preparation and routine protocol for high-resolution manometry. The major differences between HRM systems lie in the method of signal transduction, with solid-state catheter systems recording form intraluminal transducers and water perfusion systems recording pressures from external transducers via a perfused silicone catheter. The variations in recording systems result in different mechanical and electrical characteristics which dictate different techniques for setting up and using equipment. These issues are relevant in terms of costs and day to day management, but have little clinical significance. After the equipment is prepared for a manometric study, the esophagus is intubated transnasally with the manometric catheter and the catheter is positioned so that the UES and LES/diaphragm are visualized on the recording screen. The subject then undergoes 10 5 ml water swallows in the supine position. Manometric data may be integrated with other data streams such as multichannel impedance or images from fluoroscopy to increase the power of the technique in difficult cases.

Future directions in esophageal motility and function - new technology and methodology

BACKGROUND

Symptom based diagnosis is not reliable in patients with swallowing problems, heartburn, and other dyspeptic complaints. The aim of investigation is to provide clinically relevant measurements of gastrointestinal structure and function that explain the cause of symptoms, identify pathology, and guide effective management. Current practice rarely meets these ideals.

PURPOSE

This review considers recent advances in technology such as high-resolution manometry (HRM) with esophageal pressure topography (EPT), HRM with impedance, high frequency ultrasound, and endoscopic functional luminal impedance planimetry (Endo-FLIP) that provide new opportunities to identify the pathophysiologic basis of esophageal symptoms and disease. As experience with these new devices increases researchers are developing new methodologies that maximize their utility in clinical practice. For example, application of HRM to assess motility and function during and after a test meal can identify the causes of swallowing problems, reflux and other postprandial symptoms and intra-operative application of Endo-FLIP may help surgeons perform antireflux surgery. These examples illustrate the potential of physiologic measurement to direct rational and effective clinical management for individual patients.

Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography

BACKGROUND

The Chicago Classification of esophageal motility was developed to facilitate the interpretation of clinical high resolution esophageal pressure topography (EPT) studies, concurrent with the widespread adoption of this technology into clinical practice. The Chicago Classification has been an evolutionary process, molded first by published evidence pertinent to the clinical interpretation of high resolution manometry (HRM) studies and secondarily by group experience when suitable evidence is lacking.

PURPOSE

This publication summarizes the state of our knowledge as of the most recent meeting of the International High Resolution Manometry Working Group in Ascona, Switzerland in April 2011. The prior iteration of the Chicago Classification was updated through a process of literature analysis and discussion. The major changes in this document from the prior iteration are largely attributable to research studies published since the prior iteration, in many cases research conducted in response to prior deliberations of the International High Resolution Manometry Working Group. The classification now includes criteria for subtyping achalasia, EGJ outflow obstruction, motility disorders not observed in normal subjects (Distal esophageal spasm, Hypercontractile esophagus, and Absent peristalsis), and statistically defined peristaltic abnormalities (Weak peristalsis, Frequent failed peristalsis, Rapid contractions with normal latency, and Hypertensive peristalsis). The Chicago Classification is an algorithmic scheme for diagnosis of esophageal motility disorders from clinical EPT studies. Moving forward, we anticipate continuing this process with increased emphasis placed on natural history studies and outcome data based on the classification.

The relationship between dysphagia, pump function, and lower esophageal sphincter pressures on high-resolution manometry

INTRODUCTION

Study objective was to compare high-resolution impedance manometry (HRIM) findings between patients with and without dysphagia.

METHODS

After Institutional Review Board approval, a prospectively maintained database was reviewed to identify patients who underwent HRIM. Patients without upper endoscopy within 7 days of manometry, patients with achalasia, history of previous foregut surgery, esophageal strictures, or a large hiatus hernia were excluded. A new parameter called lower esophageal sphincter pressure integral (LESPI) was compared between patients with and without dysphagia. For subanalysis, subjects were categorized: (a) group A: no dysphagia and <60% hypocontractile or absent waves, (b) group B: dysphagia and <60% hypocontractile or absent waves, and (c) group C: ≥ 60% hypocontractile or absent waves.

RESULTS

One hundred thirteen patients satisfied study criteria. Patients with dysphagia had a significantly higher LESPI and distal contractile integral (DCI). On multivariate regression analysis, the following were associated with dysphagia: (a) ≥ 60% hypocontractile or absent waves, (b) LESPI >400 mmHg s cm, and (c) DCI >3,000 mmHg s cm. However, 32% of patients with <60% hypocontractile or absent waves (group B) had dysphagia. These patients had a significantly higher DCI and LESPI than group A. Group C had a significantly lower DCI than all other patients.

CONCLUSIONS

Dysphagia in patients with ≥ 60% hypocontractile or absent waves is indicative of an intrinsic pump failure as they have low DCI, while dysphagia in patients with <60% hypocontractile or absent waves is more indicative of significant outflow obstruction as they have high LESPI and integrated relaxation pressure.

Interrater and intrarater agreement of the chicago classification of achalasia subtypes using high-resolution esophageal manometry

OBJECTIVES

Subclassification of achalasia based on high-resolution manometry (HRM) may be clinically relevant because response to therapy may vary by subtype. However, the consistency and reliability of subtyping achalasia patients based on HRM remains undefined. The objectives of this study were to assess interrater and intrarater agreement (reliability) of achalasia subtyping using the Chicago classification, and to evaluate the diagnostic consistency between clinicians interpreting HRM.

METHODS

After receiving training on the classification criteria, five raters classified 20 achalasia and 10 non-achalasia cases in separate sessions 1 week apart. To further assess agreement, two raters classified all 101 available achalasia HRMs. Agreement for the classification of subtypes of achalasia was calculated using Cohen's κ and Krippendorff's α-reliability estimate.

RESULTS

Estimates of agreement among raters was good during both sessions (α=0.75; 95% confidence interval=0.69, 0.81 and α=0.75; 95% confidence interval=0.68, 0.81). Both interrater (κ=0.86-1.0) and intrarater (κ=0.86-1.0) agreement were very good for type III achalasia. Agreement between types I and II was more variable. Reliability was improved when type I and type II were combined (α=0.84; 95% confidence interval=0.78, 0.89). When all available cases were classified by two experienced raters, agreement was very good (κ=0.81; 95% confidence interval=0.71, 0.91).

CONCLUSIONS

Interobserver and intraobserver agreement for differentiating achalasia from non-achalasia patients using HRM and the Chicago classification was very good to excellent. More variability was seen in agreement when classifying achalasia subtypes. The most variation was observed in classification between type I and type II achalasia, which have similar characteristics. Clearly, differentiating between panesophageal pressurization and compartmentalization should improve discrimination between these subtypes.

Investigating the relationships between peristaltic contraction and fluid transport in the human colon using Smoothed Particle Hydrodynamics

Complex relationships exist between gut contractility and the flow of digesta. We propose here a Smoothed Particle Hydrodynamics model coupling the flow of luminal content and wall flexure to help investigate these relationships. The model indicates that a zone of muscular relaxation preceding the contraction is an important element for transport. Low pressures in this zone generate positive thrust for low viscosity content. The viscosity of luminal content controls the localization of the flow and the magnitude of the radial pressure gradient and together with contraction amplitude they control the transport rate. For high viscosity content, high lumen occlusion is required for effective propulsion.

Role of the lower esophageal sphincter on acid exposure revisited with high-resolution manometry

BACKGROUND

The objective of this study was to investigate the role of lower esophageal sphincter (LES) length and pressure on acid exposure with high-resolution manometry (HRM).

STUDY DESIGN

After Institutional Review Board approval, a retrospective review of a prospectively maintained database identified patients who had undergone HRM and 24-hour pH studies. Abdominal LES length (AL) ≤1 cm and overall LES length ≤2 cm were considered inadequate. A new parameter called lower esophageal sphincter pressure integral (LESPI) was analyzed in this study. Distal esophageal acid exposure was analyzed in relation to LES parameters.

RESULTS

One hundred eight patients (inadequate AL, n = 54; inadequate overall LES length, n = 54) satisfied study criteria. Patients with inadequate AL had considerably lower LESPI and LES pressure. They also had more severe acid exposure and higher DeMeester score. However, inadequate overall LES length was not associated with abnormal acid exposure. Patients with a positive pH study had considerably lower LESPI than patients with a negative pH study. Inadequate AL and low LESPI (<400 mmHg/s/cm) had a synergistic effect on acid reflux. Multivariate logistic regression analysis identified inadequate AL, low LESPI, and male sex as predictors of a positive pH study.

CONCLUSIONS

Using HRM, inadequate AL (≤1cm) and low LESPI (<400 mmHg/s/cm) are associated with gastroesophageal reflux disease and appear to have a synergistic effect on the severity of distal esophageal acid exposure. LESPI, which is a function of both sphincter length and pressure, appears to be the most sensitive HRM parameter for distal esophageal acid exposure.

Automated calculation of the distal contractile integral in esophageal pressure topography with a region-growing algorithm

BACKGROUND

The distal contractile integral (DCI) is an index of contractile vigor in high-resolution esophageal pressure topography (EPT) calculated as the product of amplitude, duration, and span of the distal esophageal contraction. The aim of this study was to develop an automated algorithm calculating DCI.

METHODS

The DCI was calculated conventionally using ManoView™ (Given Imaging, Los Angeles, CA, USA) software in EPT studies from 72 controls and 20 patients and compared to the calculation using a MATLAB™ (Version 7.9.0, R2009b; The MathWorks Inc., Natick, MA, USA) 'region-growing' algorithm. This algorithm first established the spatial limits of the distal contraction (the proximal pressure trough to either the distal pressure trough or to the superior margin of the lower esophageal sphincter at rest). Pixel-by-pixel horizontal line segments were then analyzed within this span starting at the pressure maximum and extending outward from that point. The limits of 'region-growing' were defined either by the spatial DCI limits or by encountering a pressure <20 mmHg. The DCI was then calculated as the total units of mmHg s cm greater than 20 mmHg within this domain.

KEY RESULTS

Excellent correlation existed between the two methods (r = 0.98, P < 0.001). The DCI values obtained with the conventional calculation were slightly but significantly greater than with the region-growing algorithm. Differences were attributed to the inclusion of vascular pressures in the conventional calculation or to differences in localization of the distal limit of the DCI.

CONCLUSIONS & INFERENCES

The proposed region-growing algorithm provides an automated method to calculate DCI that limits inclusion of vascular pressure artifacts and minimizes the need for user input in data analysis.

Phenotypes and clinical context of hypercontractility in high-resolution esophageal pressure topography (EPT)

OBJECTIVES

This study aimed to refine the criteria for esophageal hypercontractility in high-resolution esophageal pressure topography (EPT) and to examine the clinical context in which it occurs.

METHODS

A total of 72 control subjects were used to define the threshold for hypercontractility as a distal contractile integral (DCI) greater than observed in normals. In all, 2,000 consecutive EPT studies were reviewed to find patients exceeding this threshold. Concomitant EPT and clinical variables were explored.

RESULTS

The greatest DCI value observed in any swallow among the control subjects was 7,732 mm Hg-s-cm; the threshold for hypercontractility was established as a swallow with DCI >8,000 mm Hg-s-cm. A total of 44 patients were identified with a median maximal DCI of 11,077 mm Hg-s-cm, all with normal contractile propagation and normal distal contractile latency, thereby excluding achalasia and distal esophageal spasm. Hypercontractility was associated with multipeaked contractions in 82% of instances, leading to the name "Jackhammer Esophagus." Dysphagia was the dominant symptom, although subsets of patients had hypercontractility in the context of esophagogastric junction (EGJ) outflow obstruction, reflux disease, or as an apparent primary motility disorder.

CONCLUSIONS

We describe an extreme phenotype of hypercontractility characterized in EPT by the occurrence of at least a single contraction with DCI >8,000 mm Hg-s-cm, a value not encountered in control subjects. This phenomenon, branded "Jackhammer Esophagus," was usually accompanied by dysphagia and occurred both in association with other esophageal pathology (EGJ outflow obstruction, reflux disease) or as an isolated motility disturbance. Further studies are required to define the pathophysiology and treatment of this disorder.

High resolution manometry patterns distinguish acid sensitivity in non-cardiac chest pain

BACKGROUND

High resolution manometry (HRM) has demonstrated two distinct smooth muscle contraction segments in the esophageal body; changes in these segments typify certain esophageal disorders. We investigated segmental characteristics in subgroups of non-cardiac chest pain (NCCP).

METHODS

32 NCCP subjects were segregated into a GERD group (ambulatory pH testing off antisecretory therapy showing elevated total acid exposure time, AET≥4.0% and positive symptom association probability, SAP) and an acid sensitive group (normal AET and positive SAP). HRM Clouse plots were analyzed; smooth muscle segment lengths, pressure amplitude peaks were measured for segment 2 and segment 3 (proximal and distal smooth muscle segments). Pressure volumes were determined in mmHg cm(-1) s(-1) for each peristaltic segment, and ratios of segment 3:segment 2 calculated. Values were compared to a cohort of 14 normal controls.

KEY RESULTS

A distinctive shift in peak contraction amplitude to segment 3 was evident in the acid sensitive group (segment 2, 100.03±11.06mmHg, segment 3, 145.23± 10.29mmHg, P=0.006). Pressure volumes were similarly shifted to segment 3 (segment 2: 855.3 ± 135.1 mmHg cm(-1)  s(-1) , segment 3: 2115.2±218.6 mmHg cm(-1) s(-1) , P<0.005). In contrast, peak amplitude and pressure volume were near equal in the two segments in GERD and control groups. A threshold segment 3:segment 2 pressure volume ratio of 1.9 had the best performance characteristic for segregating acid sensitivity subjects from all GERD and control subjects.

CONCLUSIONS & INFERENCES

Shift in contractile vigor to the third peristaltic segment may be seen in acid sensitive subjects. HRM characteristics of smooth muscle contraction segments are of value in making this determination.

A 21st century look at the spectrum of gastrointestinal motility disorders. What is dysmotility; what is functional?

Taken together, the above examples indicate that physiology-based diagnosis has a substantial overlap with symptom-based diagnosis. Neither symptomatic treatment nor therapy aimed at restoring normal physiology has had much success. It is still uncertain if measurement of physiologic parameters facilitates the doctor-patient relationship, whether results are abnormal or normal. However, the addition of physiology parameters to the evaluation of therapeutic interventions aimed at symptom reduction in FGIDs can possibly facilitate the identification of subgroups with a higher probability of treatment success. Unfortunately, our experience from clinical trials in this area is that physiology testing usually disappears as a new drug moves from phase II to phase III trials. In the ideal situation, the development of measurement methods with better availability and standardization, like different ingestible capsules, will help us to merge physiology and symptoms regarding both diagnosis and treatment evaluation.

Challenges in the swallowing mechanism: nonobstructive dysphagia in the era of high-resolution manometry and impedance

Esophageal high-resolution manometry (HRM) improves the management of patients with nonobstructive dysphagia. It has increased the diagnostic yield for detecting achalasia and defined three clinically relevant achalasia subtypes. Esophagogastric junction (EGJ) outflow obstruction, defined as an impaired EGJ relaxation in association with some preserved peristalsis, might also represent an achalasia variant in some cases. Using the concept of distal latency, the criteria for defining distal esophageal spasm, have been revised as the occurrence of premature distal contractions. Finally, the combination of HRM and impedance monitoring allows for a functional definition of weak peristalsis associated with incomplete bolus transit.

The cutting edge in esophageal physiology testing: equipment, uses, and analysis

Advancements in foregut diagnostic technologies have led to improvements in the esophagologist's ability to accurately diagnose and classify esophageal pathophysiology and increased patient satisfaction and compliance in undergoing testing. The esophageal surgeon's ability to bring about a successful outcome is dependent on the proper application and interpretation of these diagnostic modalities. The ability to reliably and consistently differentiate foregut disorders from other potential contributors is an essential ingredient in assuring appropriate therapy and predicting success. The physician or surgeon treating esophageal disorders is well advised to keep abreast of ongoing advancements and to implement them into their diagnostic armamentarium.

The time course and persistence of "concurrent contraction" during normal peristalsis

Whereas conventional manometry depicts peristalsis as pressure variation over time, high-resolution manometry makes it equally feasible to depict pressure variation along the lumen (spatial pressure variation plots). This study analyzed the characteristics of spatial pressure variation plots during normal peristalsis. High-resolution manometry studies of 72 normal subjects were analyzed with custom MATLAB programs. A coordinate-based strategy was used to normalize both timing of peristalsis and esophageal length. A spatial pressure variation function was devised to localize the proximal (P) and the distal troughs (D) on each subject's composite pressure topography and track the length within the P-D segment contracting concurrently in the course of peristalsis. The timing at which this function peaked was compared with that of the contractile deceleration point (CDP). The length of concurrent contraction during normal peristalsis had an average span of 9.3 cm, encompassing 61% of the distal P-D length of the esophagus. The timing of the CDP position closely matched that of maximal length within the P-D segment contracting concurrently (r = 0.90, P < 0.001). The pressure morphology of the maximal concurrent contraction was that of a smooth curve, and it was extremely rare to see multiple peaks along the vertical axis (seen in 4 of 72 subjects). Concurrent contraction involving ∼60% of the P-D span occurred with normal peristalsis. The segment of concurrent contraction progressively increased as peristalsis progressed, peaked at the CDP, and then progressively decreased. How abnormalities of the extent or timing of concurrent contraction relate to clinical syndromes requires further investigation.

Distal esophageal spasm in high-resolution esophageal pressure topography: defining clinical phenotypes

BACKGROUND

The manometric diagnosis of distal esophageal spasm (DES) uses "simultaneous contractions" as a defining criterion, ignoring the concept of short latency distal contractions as an important feature. Our aim was to apply standardized metrics of contraction velocity and latency to high-resolution esophageal pressure topography (EPT) studies to refine the diagnosis of DES.

METHODS

Two thousand consecutive EPT studies were analyzed for contractile front velocity (CFV) and distal latency to identify patients potentially having DES. Normal limits for CFV and distal latency were established from 75 control subjects. Clinical data of patients with reduced distal latency and/or rapid CFV were reviewed.

RESULTS

Of 1070 evaluable patients, 91 (8.5%) had a high CFV and/or low distal latency. Patients with only rapid contractions (n = 186 [17.4%] using conventional manometry criteria; n = 85 [7.9%] using EPT criteria) were heterogeneous in diagnosis and symptoms, with the majority ultimately categorized as weak peristalsis or normal. In contrast, 96% of patients with premature contraction had dysphagia, and all (n = 24; 2.2% overall) were ultimately managed as spastic achalasia or DES.

CONCLUSIONS

The current DES diagnostic paradigm focused on "simultaneous contractions" identifies a large heterogeneous set of patients, most of whom do not have a clinical syndrome suggestive of esophageal spasm. Incorporating distal latency into the diagnostic algorithm of EPT studies improves upon this by isolating disorders of homogeneous pathophysiology: DES with short latency and spastic achalasia. We hypothesize that prioritizing measurement of distal latency will refine the management of these disorders, recognizing that outcomes trials are necessary.

Esophageal dysmotility associated with systemic sclerosis: a high-resolution manometry study

Esophageal involvement occurs in about 80% of patients with systemic sclerosis, with a marked diminution of peristaltic pressures in the distal two-thirds of the esophagus. Our aims were to more fully characterize esophageal motility disorders in systemic sclerosis using high-resolution manometry (HRM) and to determine predictive factors of esophageal involvement. Fifty-one patients (46 females) with systemic sclerosis were included in this retrospective study. Esophageal motility was characterized with HRM. The demographic data, esophageal symptoms, presence of other organ involvement, and autoantibody profile (anti-Scl70 antibodies [Scl70], anticentromere antibodies [ACA]) were recorded for all patients. Esophageal body dysmotility was present in 33 patients (67.3%) and was associated with hypotensive esophagogastric junction in 27 patients (55.1%). The velocity of proximal contractions was higher in patients with esophageal body dysmotility compared to patients with normal peristalsis (median 10.8 cm/s vs. 5.5, P = 0.04). The amplitude of middle esophageal contraction but not of distal esophageal contraction was reduced in patients with hypoperistalsis. Diffuse esophageal skin involvement, presence of Scl70 and absence of ACA were associated with esophageal involvement. Esophageal symptoms encountered in 87.5% of patients were not predictive of esophageal dysmotility. This HRM series confirms the high prevalence of esophageal body dysmotility in systemic sclerosis. Diffuse skin involvement, positive Scl70 and negative ACA, but not esophageal symptoms, may predict esophageal body dysmotility.

High-resolution manometric characteristics help differentiate types of distal esophageal obstruction in patients with peristalsis

BACKGROUND

High-resolution manometry (HRM) can identify obstructive motor features at the esophagogastric junction and abnormalities in esophageal bolus transit. We sought to determine if HRM patterns can differentiate functional from organic mechanical lower esophageal sphincter (LES) obstruction.

METHODS

Segmental characteristics of peristalsis were examined using HRM in symptomatic subjects with elevated postdeglutitive residual pressure gradients across the LES (≥5mmHg). Sixteen consecutive patients with non-achalasic mechanical fixed obstruction were compared with 13 patients with elevated pressure gradients yet no mechanical obstruction and 14 asymptomatic controls. Pressure volumes were determined in mmHg cm s for peristaltic segments defined on HRM Clouse plots using an on-screen pressure volume measurement tool.

KEY RESULTS

Residual pressure gradients were similarly elevated in both patient groups. A visually conspicuous and distinctive shift in the proportionate pressure strengths of the second and third peristaltic segments was apparent across groups. Whereas the ratios of peak pressures and pressure volumes between second and third segments approached 1 in controls (0.92, 0.98), pressures shifted to the second segment in mechanical obstruction (peak pressure ratio: 1.2±0.4; pressure volume ratio: 1.8±0.9) and to the third segment in functional obstruction (peak ratio: 0.7±0.2; volume ratio: 0.5±0.2; P<0.02 for any comparison of either group with controls). A threshold volume ratio of 1.0 correctly segregated 93% of obstruction (P<0.0001); visual pattern inspection was equally effective.

CONCLUSIONS & INFERENCES

When elevated residual pressure gradients are present in non-achalasic patients, topographic characteristics of peristalsis can differentiate fixed mechanical obstruction from functional obstruction.

Obese patients have stronger peristalsis and increased acid exposure in the esophagus

BACKGROUND

Obesity is a risk factor for GERD and a potential modulator of esophageal motility.

AIM

To assess whether obese patients differ from non-obese patients in terms of esophageal motility and reflux.

METHODS

Patients (n = 332) were categorized in GERD and controls after clinical assessment, esophageal manometry, and pH monitoring. Non-obese (BMI 16-29.9) and obese (BMI 30-68) were compared in regard of distal esophageal amplitude (DEA), LES pressure (LESP), manometric diagnosis, and esophageal acid exposure (EAE).

RESULTS

Obese showed higher DEA in both controls (122 ± 53 vs. 97 ± 36 mmHg, p = 0.041) and GERD patients (109 ± 38 vs. 94 ± 46 mmHg, p < 0.001), higher LESP in GERD patients (20.5 ± 10.6 vs. 18.2 ± 10.6 mmHg, p = 0.049), higher frequency of nutcracker esophagus in controls (30 vs. 0%, p = 0.001), lower frequency of ineffective motility in GERD patients (6 vs. 20%, p = 0.001), and higher EAE in both controls [total EAE: 1.6% (0.7-5.1) vs. 0.9% (0.2-2.4), p = 0.027] and GERD patients [upright EAE: 6.5% (3.8-11.1) vs. 5.2% (1.5-10.6), p = 0.048]. Multiple linear regression showed that BMI was associated either with EAE (p < 0.001), DEA (p = 0.006), or LESP (in men, p = 0.007).

CONCLUSIONS

Obese patients differed from non-obese in terms of esophageal motility and reflux, regardless of the presence of GERD. Obese patients showed stronger peristalsis and increased acid exposure in the esophagus.

High-resolution esophageal pressure topography is superior to conventional sleeve manometry for the detection of transient lower esophageal sphincter relaxations associated with a reflux event

BACKGROUND

Transient lower esophageal sphincter relaxations (TLESRs) are the main mechanism underlying gastro-esophageal reflux and are detected during manometric studies using well defined criteria. Recently, high-resolution esophageal pressure topography (HREPT) has been introduced and is now considered as the new standard to study esophageal and lower esophageal sphincter (LES) function. In this study we performed a head-to-head comparison between HREPT and conventional sleeve manometry for the detection of TLESRs.

METHODS

A setup with two synchronized MMS-solar systems was used. A solid state HREPT catheter, a water-perfused sleeve catheter, and a multi intraluminal impedance pH (MII-pH) catheter were introduced in 10 healthy volunteers (M6F4, age 19-56). Subjects were studied 0.5 h before and 3 h after ingestion of a standardized meal. Tracings were blinded and analyzed by the three authors according to the TLESR criteria.

KEY RESULTS

In the HREPT mode 156 TLESRs were scored, vs 143 during sleeve manometry (P = 0.10). Hundred and twenty-three TLESRs were scored by both techniques. Of all TLESRs (177), 138 were associated with reflux (78%). High-resolution esophageal pressure topography detected significantly more TLESRs associated with a reflux event (132 vs 119, P = 0.015) resulting in a sensitivity for detection of TLESRs with reflux of 96% compared to 86% respectively. Analysis of the discordant TLESRs associated with reflux showed that TLESRs were missed by sleeve manometry due to low basal LES pressure (N = 5), unstable pharyngeal signal (N = 4), and residual sleeve pressure >2 mmHg (N = 10).

CONCLUSIONS & INFERENCES

The HREPT is superior to sleeve manometry for the detection of TLESRs associated with reflux. However, rigid HREPT criteria are awaited.

Anatomical registration and three-dimensional visualization of low and high-resolution pan-colonic manometry recordings

BACKGROUND

Colonic propagating sequences (PS) are important for the movement of colonic content and defecation, and aberrant PS patterning has been associated with slow transit constipation. However, because these motor patterns are typically recorded over long periods (24 h +), the visualization of PS spatiotemporal patterning is difficult. Here, we develop a novel method for displaying pan-colonic motility patterns.

METHODS

A 3D mesh representing the geometry of the human colon was created as follows: (i) Human colon images from the Visible Human Dataset were digitized to create a 3D data cloud, and (ii) A surface mesh was fitted to the cloud using a least-squares minimization technique. Colonic manometry catheters were placed in the ascending colon of healthy controls and patients with slow transit constipation (STC), with the aid of a colonoscope. The colonic manometry data were interpolated and mapped to the model according to the following anatomical landmarks: cecum, hepatic flexure, splenic flexure, sigmoid-descending junction, and anus.

KEY RESULTS

These 3D images clearly and intuitively communicate characteristics of normal and abnormal colonic motility. Specifically we have shown the reduced amplitude of the antegrade propagating pressure waves (PPW) throughout the colon and reduced frequency of PPWs at the mid-colon in patients with STC.

CONCLUSIONS AND INFERENCES

A novel method for the 3D visualization of PS is presented, providing an intuitive method for representing a large volume of physiological data. These techniques can be used to display frequency, amplitude or velocity data, and will help to convey regions of abnormally in patient populations.