Chicago Classification of Esophageal Motility Disorders: Lessons Learned. Curr Gastroenterol Rep. 2017;19:37. [PMID: 28730503 PMCID: PMC5519653 DOI: 10.1007/s11894-017-0576-7]

Results of sleeve gastrectomy conversion to Roux-en-Y gastric bypass on gastroesophageal reflux disease symptoms and proton pump inhibitors use evolution over time

BACKGROUND

Although sleeve gastrectomy (SG) is associated with excellent results in the short term, it has been shown that it is plagued by weight regain and new onset or worsening of gastroesophageal reflux disease (GERD). These 2 clinical conditions are currently the 2 most frequent indications for revisional surgery. To date, only a few studies have focused exclusively on GERD. In a selected series of patients complaining of GERD symptoms after SG as a main complaint, we analyzed the efficacy of conversion to Roux-en-Y gastric bypass (RYGB), with a standardized surgical technique.

METHODS

This is a retrospective study including all consecutive cases of SG to RYGB conversion for GERD not controlled by medical treatment. We excluded all patients undergoing conversion for weight regain without GERD. Quality of life and GERD symptoms were evaluated at outpatient's clinic visits before and after surgery with 2 standardized questionnaires (Gastroesophageal Reflux Disease Questionnaire and Simplified Form 6).

RESULTS

This study showed that 70% of patients had complete resolution of GERD symptoms and 60% had completely discontinued proton pump inhibitors (PPIs). The conversion to RYGB resulted in a significant decrease in the rate of patients presenting daily symptoms of GERD and use of PPIs (10% and 16.6%, respectively; P < .019) and a dramatic increase in those without symptoms and no need for PPIs (70% and 60%, respectively; P < .001).

CONCLUSION

Conversion to RYGB is a good option for GERD complications after SG providing a high rate of symptom remission and PPI discontinuation. Conversion to RYGB in the setting of GERD complications after SG improves postoperative outcomes decreasing GERD symptoms and improving quality of life.

Esophageal Dysphagia in Adults: When It Sticks

Esophageal dysphagia is a common yet difficult to diagnose condition. This article underscores the role of detailed patient history and physical examinations, including prompt endoscopic evaluation, for accurate differentiation between esophageal and oropharyngeal dysphagia. The authors discuss the heightened importance of early intervention in certain patient groups, such as elderly individuals and patients with head and neck cancer, to mitigate the risk of malnutrition and infection. The authors delve into etiologic factors highlighting the complexity of clinical presentations and the significance of tailored management strategies.

Esophagogastroduodenoscopy findings that do no not explain dysphagia are associated with underutilization of high-resolution manometry

In patients with dysphagia that is not explained by upper endoscopy, high-resolution esophageal manometry (HRM) is the next logical step in diagnostic testing. This study investigated predictors of failure to refer for HRM after an upper endoscopy that was performed for but did not explain dysphagia. This was a retrospective cohort study of patients >18 years of age who underwent esophagogastroduodenoscopy (EGD) for dysphagia from 2015 to 2021. Patients with EGD findings that explained dysphagia (e.g. esophageal mass, eosinophilic esophagitis, Schatzki ring, etc.) were excluded from the main analyses. The primary outcome was failure to refer for HRM within 1 year of the index non-diagnostic EGD. We also investigated delayed referral for HRM, defined as HRM performed after the median. Multivariable logistic regression modeling was used to identify risk factors that independently predicted failure to refer for HRM, conditioned on the providing endoscopist. Among 2132 patients who underwent EGD for dysphagia, 1240 (58.2%) did not have findings to explain dysphagia on the index EGD. Of these 1240 patients, 148 (11.9%) underwent HRM within 1 year of index EGD. Endoscopic findings (e.g. hiatal hernia, tortuous esophagus, Barrett's esophagus, surgically altered anatomy not involving the gastroesophageal junction, and esophageal varices) perceived to explain dysphagia were independently associated with failure to refer for HRM (adjusted odds ratio 0.45, 95% confidence interval 0.25-0.80). Of the 148 patients who underwent HRM within 1 year of index EGD, 29.7% were diagnosed with a disorder of esophagogastric junction outflow, 17.6% with a disorder of peristalsis, and 2.0% with both disorders of esophagogastric outflow and peristalsis. The diagnosis made by HRM was similar among those who had incidental EGD findings that were non-diagnostic for dysphagia compared with those who had completely normal EGD findings. Demographic factors including race/ethnicity, insurance type, and income were not associated with failure to refer for HRM or delayed HRM. Patients with dysphagia and endoscopic findings unrelated to dysphagia have a similar prevalence of esophageal motility disorders to those with normal endoscopic examinations, yet these patients are less likely to undergo HRM. Provider education is indicated to increase HRM referral in these patients.

Magnesium and Esophageal Pain After Peroral Endoscopic Myotomy of the Esophagus: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Postoperative esophageal pain occurs in 67% of patients after peroral endoscopic esophageal myotomy (POEM). Magnesium can act as a smooth muscle relaxant. This study investigated whether intraoperative magnesium can reduce postoperative esophageal pain in patients undergoing POEM.

METHODS

In this double-blind, placebo-controlled trial, 92 patients were randomized to receive either magnesium sulfate as a 50 mg.kg-1 (total body weight) bolus followed by an infusion at 25 mg.kg-1.hr-1, or 0.9% saline. Intraoperative analgesia was standardized in all patients. The primary outcome was the score from a validated, modified Esophageal Symptoms Questionnaire (ESQ) in the postanesthesia care unit (PACU). Pain scores, opioid requirements, and questionnaire scores were collected through postoperative day 1.

RESULTS

ESQ scores were significantly lower in the magnesium group in the PACU (median [25th-75th], 24 [18-31] vs 35 [28-42]; median difference [95% confidence interval, CI], 10 [6-13]; P < .0001) and on postoperative day 1 (16 [14-23] vs 30 [24-35]; P < .0001). Less opioids were needed in the magnesium group in the PACU (mean ± standard deviation [SD] [99% CI], 4.7 ± 10 [1-9] mg vs 29 ± 21 [21-37] mg; P < .0001) and on postoperative day 1 (1 ± 3.7 [0-2.5] mg vs 13 ± 23 [4-23] mg; P = .0009). Pain scores were lower in the magnesium group in the PACU (0 [0-3] vs 5 [5-7]; P < .0001) and on postoperative day 1 (0 [0-2] vs 4 [3-5]; P < .0001).

CONCLUSIONS

Patients undergoing POEM randomized to receive intraoperative magnesium had sustained reductions in esophageal discomfort severity and opioid requirements 24 hours after surgery.

Association of esophageal motility disorder symptoms with Chicago classification versions 3.0 and 4.0 using high-resolution esophageal manometry: A single-center experience from Saudi Arabia

BACKGROUND

Esophageal motility disorders (EMDs) can significantly impact patients' quality of life. The Chicago Classification (CC) was developed as a robust framework to enable clinicians to better understand and classify the nature of motility disorders. Previous studies have primarily focused on the CC version 3.0 (CCv3.0), and data regarding the correlation between symptoms and CC version 4.0 (CCv4.0) in the Saudi Arabian population are lacking. This study aimed to assess the correlation between symptoms and CCv3.0 and CCv4.0 using high-resolution esophageal manometry (HRM) in Saudi Arabia, to evaluate the diagnostic performance of both classifications.

METHODS

A total of 182 patients presenting with esophageal symptoms were included in this study. HRM was performed to assess esophageal motility, and patients' reported symptoms were recorded. The association between HRM findings and symptomatic variables was analyzed using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

Variability was observed in the diagnostic performance of symptomatic variables for major EMDs. CCv4.0 demonstrated a higher sensitivity for dysphagia than CCv3.0; however, it exhibited lower sensitivity to atypical gastroesophageal reflux disease (GERD) symptoms. Noncardiac chest pain (NCCP) exhibited the highest specificity and PPV, whereas typical GERD symptoms showed lower specificity.

CONCLUSION

CCv4.0 demonstrated potential improvements in sensitivity for dysphagia, but lower sensitivity for atypical GERD symptoms, compared with CCv3.0. These insights provide guidance for clinicians in Saudi Arabia and contribute to understanding the diagnostic performance of CCv3.0 and CCv4.0.

A Comparison between Chicago Classification Versions 3.0 and 4.0 and Their Impact on Manometric Diagnoses in Esophageal High-Resolution Manometry Cases

High-resolution manometry (HRM) facilitates the detailed evaluation of esophageal motility. In December 2020, Chicago classification (CC) version 4.0 introduced modifications to improve consistency and accuracy. We conducted this study to compare the differences in the interpretations of HRM examinations between CC 3.0 and 4.0. Consecutive HRM records at a Taiwan tertiary medical center, including wet swallows and MRS performed in both supine and sitting positions from October 2019 to May 2021, were retrospectively reviewed and analyzed using both CC versions 3.0 and 4.0. A total of 105 patients were enrolled, and 102 patients completed the exam, while three could not tolerate HRM sitting up. Refractory gastroesophageal reflux disease (GERD) symptoms (n = 65, 63.7%) and dysphagia (n = 37, 36.3%) were the main indications. A total of 18 patients (17.6%) were reclassified to new diagnoses using CC 4.0. Of the 11 patients initially diagnosed with absent contractility, 3 (27.3%) were reclassified as having Type 1 achalasia. Of the 18 patients initially diagnosed with IEM, 6 (33.3%) were reclassified as normal. The incidence of diagnosis changes was similar in both the dysphagia and refractory GERD symptoms groups (21.6% versus 15.3%, p = 0.43). The use of CC 4.0 led to changes in the diagnoses of esophageal motility disease, irrespective of examination indications. Early adoption improves the accuracy of diagnoses and affects patient management.

Real-Life Patient Educational Recording Before Esophageal Manometry

High-resolution esophageal manometry (HREM) is a fundamental diagnostic tool in esophagology. Educational tools for this procedure have remained scarce. This quality improvement project aimed to develop an enhanced digital recording about HREM and assess the effect on patient knowledge, anxiety, satisfaction, and procedure abortion rates. The Institute for Healthcare Improvement Model for Improvement and the self-regulation theory guided this project. An interprofessional team was formed. A video recording of the pre-, peri-, and post-HREM care was created. Participants were recruited in the following four cycles: Baseline, Workstation, Manometry, and Home. Questionnaires were collected pre- and postvideo education. The results demonstrated a significant increase in knowledge from 60% to 96% ( p < .001), 58% to 96% ( p < .001), 79% to 96% ( p < .001), and 92% to 97% ( p = .02) and reductions in anxiety from 7.1 to 5.5 ( p = .003), 7.6 to 6.1 ( p = .003), 7.1 to 6.5 ( p < .001), and 6.4 to 6.1 ( p = .03) in all four groups. Almost all (99.5%) participants liked the recorded education and only 2.6% of cases were aborted during the 1-year project implementation period from June 2020 to May 2021. Findings from this project support the positive impact of recorded patient education. An educational recording is standardized and has the potential to be implemented in variable settings.

Endoscopic impedance planimetry versus high-resolution manometry (HRM) for pre-operative motility evaluation in anti-reflux surgery

INTRODUCTION

Pre-operative evaluation of patients with gastroesophageal reflux disease (GERD) includes assessment of esophageal motility. High-resolution manometry (HRM) is the gold standard; endoscopic impedance planimetry (IP) with Endoflip 2.0 is increasingly utilized in esophageal disorders of motility. We hypothesized that normal IP motility would correlate with normal HRM motility and tested this in a prospective cohort study.

METHODS

Patients presenting for surgical evaluation of GERD between 9/2020 and 10/2021 were prospectively enrolled under an IRB-approved protocol. Patients with prior esophageal/gastric surgery, known motility disorders, or large paraesophageal hernias were excluded. All underwent HRM and IP, with normal motility defined by Chicago 3.0 classification for HRM and the presence of repetitive antegrade contractions for IP. Logistic regression and t test were used to analyze the data; p value < 0.05 was considered significant.

RESULTS

Of 63 patients enrolled, 48 completed both IP and HRM testing. The cohort was 50% male with a median age of 52.5 [42.0, 66.0] years, mostly ASA class 1-2 (75.1%, n = 36) and had an average BMI of 31.4 ± 6.3 kg/m2. Normal motility tracings were in 62.5% of IP and 75% of HRM tests. Using HRM as the gold standard, IP detected normal motility with a sensitivity of 65.8% and a specificity of 50% (positive predictive value 83.3%, negative predictive value 27.8%). Normal IP was not statistically significant in predicting normal HRM (OR 3.182, 95% CI 0.826-12.262, p = 0.0926). Tolerability of IP was significantly better than HRM with lower rates of discomfort (10.9% vs. 93.4%, p < 0.0001) and higher willingness to repeat testing (100% vs. 47.8%, p < 0.0001).

CONCLUSION

Esophageal motility testing with Endoflip 2.0 is well tolerated by patients. The low specificity (50%), poor negative predictive value (27.8%), and lack of statistically significant concordance between IP and HRM raises concern for the reliability of this test as a stand-alone replacement for HRM in the pre-operative evaluation for GERD.

Threshold level of Peptest in diagnosing gastroesophageal reflux disease with extraesophageal symptoms: Evidence from Vietnam

Background and Aim

We aimed to evaluate the application of Peptest, a novel technique to detect pepsin in the saliva, and identify its threshold level for the diagnosis of gastroesophageal reflux disease (GERD) with extraesophageal symptoms.

Methods

A cross-sectional study was conducted in two groups: patients with extraesophageal GERD symptoms (symptomatic group divided into GERD and non-GERD groups according to 24-h esophageal pH-impedance monitoring [pH-I] results) and healthy controls. For the symptomatic group, endoscopy, pH 24 h, high-resolution manometry (HRM), and salivary Peptest were performed. For the healthy control group, only Peptest was done. The accuracy of Peptest was compared with that of pH-I by the Lyon consensus criteria.

Results

Chronic laryngitis was the most frequent extraesophageal symptom. On saliva testing, the GERD group had a higher prevalence of positive samples and pepsin concentration than the control group. Between GERD and non-GERD groups, the optimal threshold level was 31.2 ng/mL, with a sensitivity of 86.7% and specificity of 27.5%. The optimal threshold level was 31.4 ng/mL to differentiate GERD from healthy controls, with a sensitivity of 86.7% and specificity of 66.0%. Age, number of total refluxes, DeMeester score, post-reflux swallow-induced peristaltic wave (PSPW) index, and mean nocturnal baseline impedence (MNBI) were associated with pepsin concentration. Regarding HRM metrics, there was no significant difference of pepsin concentration between low/normal upper esophageal sphincter (UES) resting pressure, low/normal lower esophageal sphincter (LES) resting pressure, low/normal 4-s integrated relaxation pressure (IRP4s), and hypomotility/normal motility.

Conclusion

Patients with extraesophageal symptoms had a higher prevalence of positive Peptest. The optimum threshold level of 31.4 ng/mL had high sensitivity and moderate specificity to differentiate between patients with GERD and healthy controls.

Can esophageal symptoms be associated with sleep disorders in esophageal rare diseases? A prospective case-control study across achalasia, eosinophilic esophagitis and gastroesophageal reflux disease

BACKGROUND

The association between sleep disorders and gastroesophageal reflux disease (GERD) has been the subject of several studies; however, quality of sleep has been under investigated in adult patients with eosinophilic esophagitis (EoE) and achalasia (Ach). This study aims to evaluate the prevalence of sleep disturbances in patients with EoE and Ach compared to GERD patients and their associations with esophageal symptoms.

METHODS

Thirty Ach patients and 20 EoE patients were consecutively enrolled and compared to a control group of 46 GERD patients. All patients underwent a standardized questionnaire investigating the intensity-frequency scores (from 0 to 6) of esophageal symptoms, Pittsburgh Sleep Quality Index (PSQI) questionnaire to assess sleep quality, a SF-36 survey to investigate health-related quality of life (both physical (PCS) and mental (MCS) component scales), Beck Depression Inventory-II (BDI-II) and State Trait Anxiety Inventory (STAI) to assess the presence of depression and anxiety.

RESULTS

The prevalence of sleep disturbances was 66.7% in Ach, 50% in EoE, and 60% in GERD patients (P=0.5). PCS and MCS significantly correlated with depression and anxiety levels. Ach patients showed significantly higher intensity-frequency scores of dysphagia for solids (Scheffè P<0.001) and liquids (Scheffè P<0.001) than EoE and GERD patients. No differences were found in the intensity-frequency scores of the esophageal symptoms among the three groups. There was a significant association between worst quality of sleep and higher intensity-frequency scores of regurgitation.

CONCLUSIONS

Sleep disturbances are common with Ach and EoE, similar to GERD patients. Moreover, there is a significant association between regurgitation, a typical GERD symptom, and poor quality of sleep, independent from diagnosis.

Oesophageal stasis is a risk factor for chronic lung allograft dysfunction and allograft failure in lung transplant recipients

Background

Morbidity and mortality in lung transplant recipients are often triggered by recurrent aspiration events, potentiated by oesophageal and gastric disorders. Previous small studies have shown conflicting associations between oesophageal function and the development of chronic lung allograft dysfunction (CLAD). Herein, we sought to investigate the relationship between oesophageal motility disorders and long-term outcomes in a large retrospective cohort of lung transplant recipients.

Methods

All lung transplant recipients at the Toronto Lung Transplant Program from 2012 to 2018 with available oesophageal manometry testing within the first 7 months post-transplant were included in this study. Patients were categorised according to the Chicago Classification of oesophageal disorders (v3.0). Associations between oesophageal motility disorders with the development of CLAD and allograft failure (defined as death or re-transplantation) were assessed.

Results

Of 487 patients, 57 (12%) had oesophagogastric junction outflow obstruction (OGJOO) and 47 (10%) had a disorder of peristalsis (eight major, 39 minor). In a multivariable analysis, OGJOO was associated with an increased risk of CLAD (HR 1.71, 95% CI 1.15-2.55, p=0.008) and allograft failure (HR 1.69, 95% CI 1.13-2.53, p=0.01). Major disorders of peristalsis were associated with an increased risk of CLAD (HR 1.55, 95% CI 1.01-2.37, p=0.04) and allograft failure (HR 3.33, 95% CI 1.53-7.25, p=0.002). Minor disorders of peristalsis were not significantly associated with CLAD or allograft failure.

Conclusion

Lung transplant recipients with oesophageal stasis characterised by OGJOO or major disorders of peristalsis were at an increased risk of adverse long-term outcomes. These findings will help with risk stratification of lung transplant recipients and personalisation of treatment for aspiration prevention.

Safety and Tolerability of High-Resolution Esophageal Manometry in Children and Adults

INTRODUCTION

While high-resolution manometry (HRM) is widely accepted as a safe procedure, no study has assessed the safety profile of HRM in clinical practice. This study aimed to determine the safety and tolerability of HRM and to investigate potential determinants of intolerability.

METHODS

We obtained HRM procedure reports, demographics, and clinical data (2005-2022) at a tertiary center using electronic chart review. Our primary outcome was HRM tolerability. Multivariable regression was performed to identify associations between the outcome and covariates including age, sex, race, and comorbidities.

RESULTS

A total of 5,107 patients (60.3% female) were included. Of them, 5,050 patients (98.9%) tolerated HRM well and 57 patients (1.1%) did not. Age had a statistically significant effect on tolerance: those younger than 18 years had more than a 5-fold increase in not tolerating HRM compared with those aged 18-79 years (5.77% vs 0.99%; odds ratio [OR] = 5.44, 95% confidence interval [CI] 1.60-18.45; P = 0.007), and those aged 80 years or older were also more likely to terminate HRM (2.43% vs 0.99%; OR = 2.56, 95% CI 1.13-5.76; P = 0.024). While prior foregut surgery had a significant effect on tolerance (OR = 8.06, 95% CI 2.29-28.39; P = 0.001), other factors of race, sex, body mass index, and psychological or cognitive disorders had no significant impact. No serious complications were identified.

DISCUSSION

HRM is safe and well-tolerated with approximately 1 in every 100 patients being unable to tolerate HRM. Intolerance was more commonly seen in children and seniors due to minor symptoms of discomfort without serious complications. These data points are crucial to counsel patients in whom HRM is being considered.

Achalasia Quality Indicator Adherence

BACKGROUND

Quality indicators (QIs) are formal ways to track health care performance and outcomes, guide quality improvement, and identify gaps in care delivery. We developed twelve quality indicators for achalasia management which cover the domains of patient education, diagnosis, and treatment of achalasia.

AIM

To determine adherence to established quality indicators for achalasia management.

METHODS

We performed a retrospective, multicenter evaluation of care patterns for adult patients greater than 18 years old with newly diagnosed achalasia from January 2018 to May 2020. A balanced random patient sample was obtained at four large academic medical centers. Independent electronic health record chart abstraction was performed using a standardized form to determine adherence to applicable QIs. Pooled and de-identified data were analyzed to identify gaps in care.

RESULTS

A total of 120 patients were included and the overall adherence to applicable quality indicators across all centers was 86%. The median follow-up for all patients from time of diagnosis to end of study was 511 days. Clinicians adhered to all applicable quality indicators in 49 patients (39%). The quality indicator domain with the poorest adherence was patient education (67%), with 50% of patients having had a documented discussion of the risks of gastroesophageal reflux disease following surgical or endoscopic myotomy.

CONCLUSIONS

Gaps in the quality of achalasia care delivery were identified, the largest of which relates to patient education about treatment risks. These findings highlight a potential area for future quality improvement studies and form the basis for developing fully specified quality measures.

Three-dimensional laparoscopic approach to distal oesophageal diverticula: Single-centre experience

Background

Epiphrenic oesophageal diverticula are rare and often asymptomatic. When symptoms are present, minimally invasive diverticulectomy is considered the gold standard of treatment. While there is an agreement on the pre-operative assessment, no consensus is achieved when it comes to surgical technique. In the present study, we report our experience and propose a standardised approach to manage this rare oesophageal disorder.

Materials and Methods

We prospectively analysed data of all consecutive patients who underwent three-dimensional (3D) laparoscopic distal oesophageal diverticulum resection during 2015-2020 at Upper gastrointestinal surgical department, St Thomas' Hospital, regarding pre-operative assessment, surgical technique, peri-and post-operative outcomes.

Results

Six patients were submitted to 3D laparoscopic diverticulectomy, five of which with additional anterior myotomy and fundoplication and one with additional hiatal hernia repair only. Three patients followed a specific diet in preparation for surgery. Median pre-operative Eckardt symptom score was five. Two patients had normal manometry. Median operative time was 180 min, median estimated blood loss was <100 ml, neither intraoperative complications nor conversions to open approach occurred. All patients reported a complete resolution of symptoms directly after surgery. Median follow-up was 66 months. Five patients have none or minimal residual symptoms. One had recurrence requiring a revision operation for intermittent dysphagia.

Conclusions

3D laparoscopic diverticulectomy offers a reasonable chance of treatment in patients with epiphrenic diverticula. Optimal selection of patients, optimisation for surgery, gaining the surgical experience of carrying out these techniques and impact on short- and long-term results are issues that still remain under debate.

Evaluation of Therapeutic Effect of Buspirone in Improving Dysphagia in Patients with GERD and Ineffective Esophageal Motility: A Randomized Clinical Trial

Background: Ineffective esophageal motility (IEM) is the most common esophageal motility disorder associated with low-to-moderate amplitude contractions in the distal esophagus in manometric evaluations. Despite recent new conceptions regarding the pathophysiology of esophageal motility and IEM, there are still no effective therapeutic interventions for the treatment of this disorder. This study aimed to investigate the effect of buspirone in the treatment of concomitant IEM and GERD. Methods and Materials: The present study was a randomized clinical trial conducted at the Imam Khomeini Hospital, Tehran. Patients with a history of gastroesophageal reflux disease and dysphagia underwent upper endoscopy to rule out any mechanical obstruction and were diagnosed with an ineffective esophageal motility disorder based on high-resolution manometry. They were given a package containing the desired medication(s); half of the packets contained 10 mg (for 30 days) of buspirone and 40 mg (for 30 days) of pantoprazole, and the other half contained only 40 mg (for 30 days) of pantoprazole. Dysphagia was scored based on the Mayo score, as well as a table of dysphagia severity. Manometric variables were recorded before and after the treatment. Results: Thirty patients (15 pantoprazole and 15 pantoprazole plus buspirone) were included. Females comprised 63.3% of the population, with a mean age of 46.33 ± 11.15. The MAYO score and resting LES pressure significantly changed after treatment. The MAYO and Swallowing Disorder Questionnaire scores significantly decreased after treatment in both groups of patients. Our results revealed that the post-intervention values of manometric variables differed significantly between the two groups after controlling for the baseline values of the variables. This analysis did not demonstrate the superiority of buspirone. Conclusion: Buspirone seems to have no superiority over PPI. Treatment with concomitant IEM and GERD using proton pump inhibitors improves the patient’s clinical condition and quality of life. However, adding buspirone to the treatment regimen did not appear to make a significant difference in patient treatment.

Esophageal Manifestations of Dermatological Diseases, Diagnosis and Management

Purpose of Review

The purpose of this article is to discuss the diagnosis and treatment of diseases that affect both the skin and the esophagus.

Recent Findings

The diagnosis of dermatological conditions that affect the esophagus often requires endoscopy and biopsy with some conditions requiring further investigation with serology, immunofluorescence, manometry, or genetic testing. Many conditions that affect the skin and esophagus can be treated successfully with systemic steroids and immunosuppressants including pemphigus, pemphigoid, HIV, esophageal lichen planus, and Crohn's disease. Many conditions are associated with esophageal strictures which are treated with endoscopic dilation. Furthermore, many of the diseases are pre-malignant and require vigilance and surveillance endoscopy.

Summary

Diseases that affect the skin and esophagus can be grouped by their underlying etiology: autoimmune (scleroderma, dermatomyositis, pemphigus, pemphigoid), infectious (herpes simplex virus, cytomegalovirus, human immunodeficiency virus), inflammatory (lichen planus and Crohn's disease), and genetic (epidermolysis bullosa, Cowden syndrome, focal dermal hypoplasia, and tylosis). It is important to consider primary skin conditions that affect the esophagus when patients present with dysphagia of unknown etiology and characteristic skin findings.

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

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

Changes in the esophagogastric junction outflow obstruction manometric feature based on the Chicago Classification updates

BACKGROUND

The critical diagnostic criteria for esophagogastric junction outflow obstruction (EGJOO) were published in the latest Chicago Classification version 4.0 (CCv4.0). In addition to the previous criterion [elevated integrated relaxation pressure (IRP) in supine position], manometric diagnosis of EGJOO requires meeting the criteria of elevated median-IRP during upright wet swallows and elevated intrabolus pressure. However, with the diagnostic criteria modification, the change in manometric features of EGJOO remained unclear.

AIM

To evaluate the esophageal motility characteristics of patients with EGJOO and select valuable parameters for confirming the diagnosis of EGJOO.

METHODS

We performed a retrospective analysis of 370 patients who underwent high-resolution manometry with 5 mL water swallows × 10 in supine, × 5 in upright position and the rapid drink challenge (RDC) with 200 mL water from November 2016 to November 2021 at Peking University First Hospital. Fifty-one patients with elevated integrated supine IRP and evidence of peristalsis were enrolled, with 24 patients meeting the updated manometric EGJOO diagnosis (CCv4.0) as the EGJOO group and 27 patients not meeting the updated EGJOO criteria as the isolated supine IRP elevated group (either normal median IRP in upright position or less than 20% of supine swallows with elevated IBP). Forty-six patients with normal manometric features were collected as the normal high-resolution manometry (HRM) group. Upper esophageal sphincter (UES), esophageal body, and lower esophageal sphincter (LES) parameters were compared between groups.

RESULTS

Compared with the normal HRM group, patients with EGJOO (CCv4.0) had significantly lower proximal esophageal contractile integral (PECI) and proximal esophageal length (PEL), with elevated IRP on RDC (P < 0.05 for each comparison), while isolated supine IRP elevated patients had no such feature. Patients with EGJOO also had more significant abnormalities in the esophagogastric junction than isolated supine IRP elevated patients, including higher LES resting pressure (LESP), intrabolus pressure, median supine IRP, median upright IRP, and IRP on RDC (P < 0.05 for each comparison). Patients with dysphagia had significantly lower PECI and PEL than patients without dysphagia among the fifty-one with elevated supine IRP. Further multivariate analysis revealed that PEL, LESP, and IRP on RDC are factors associated with EGJOO. The receiver-operating characteristic analysis showed UES nadir pressure, PEL, PECI, LESP, and IRP on RDC are parameters supportive for confirming the diagnosis of EGJOO.

CONCLUSION

Based on CCv4.0, patients with EGJOO have more severe esophagogastric junction dysfunction and are implicated in the proximal esophagus. Additionally, several parameters are supportive for confirming the diagnosis of EGJOO.

Impact of Surgical Intervention on Nonobstructive Dysphagia: A Retrospective Study Based on High-Resolution Impedance Manometry in a Taiwanese Population at a Single Institution

Esophageal motility disorders account for a large proportion of nonobstructive dysphagia cases, which constitute a heterogeneous group of diagnoses that commonly result in peristaltic derangement and impaired relaxation of the lower esophageal sphincter. We performed a single-institution retrospective study enrolling consecutive patients with chief complaints of dysphagia who underwent HRIM from December 2014 to December 2019, and analyzed demographic, clinical, and manometric data using descriptive statistics. In total, 277 identified patients were included in the final analysis. Ineffective esophageal motility (n = 152, 24.5%) was the most common diagnosis by HRIM, followed by absent contractility, EGJ outflow obstruction, type II achalasia, and type I achalasia. Furthermore, surgery including exploratory, laparoscopic, and robotic myotomy, as well as POEM, is considered the most effective treatment for patients with non-spastic achalasia and EGJOO, due to its effective symptom palliation and prevention of disease progression; surgery also contributes to an obvious improvement of dysphagia compared with slightly less efficacy for other related symptoms. Our study aimed to elaborate the clinical characteristics of patients with nonobstructive dysphagia based on HRIM in a Taiwanese population, and to analyze the therapeutic outcomes of such patients who ultimately underwent surgical interventions.

Elevated average maximum intrabolus pressure on high-resolution manometry is associated with esophageal dysmotility and delayed esophageal emptying on timed barium esophagram

BACKGROUND

Intrabolus pressure (IBP) recorded by high-resolution manometry (HRM) portrays the compartmentalized force on a bolus during esophageal peristalsis. HRM may be a reliable screening tool for esophageal dysmotility in patients with elevated average maximum IBP (AM-IBP). Timed barium esophagram (TBE) is a validated measure of esophageal emptying disorders, such as esophagogastric junction outflow obstruction and achalasia. This study aimed to determine if an elevated AM-IBP correlates with esophageal dysmotility on HRM and/or delayed esophageal emptying on TBE.

METHODS

A retrospective analysis of all HRM (unweighted sample n = 155) performed at a tertiary referral center from 09/2015-03/2017 yielded a case group (n = 114) with abnormal AM-IBP and a control group (n = 41) with a normal AM-IBP (pressure < 17 mmHg) as consistent with Chicago Classification 3. All patients received a standardized TBE, with abnormalities classified as greater than 1 cm of retained residual liquid barium in the esophagus at 1 and 5 min or as tablet retention after 5 min.

RESULTS

AM-IBP was significantly related to liquid barium retention (p = 0.003) and tablet arrest on timed barium esophagram (p = 0.011). A logistic regression model correctly predicted tablet arrest in 63% of cases. Tablet arrest on AM-IBP correlated with an optimal prediction point at 20.1 mmHg on HRM. Patients with elevated AM-IBP were more likely to have underlying esophageal dysmotility (95.6% vs. 70.7% respectively; p < 0.001), particularly esophagogastric junction outflow obstruction disorders. Elevated AM-IBP was associated with incomplete liquid bolus transit on impedance analysis (p = 0.002).

CONCLUSIONS

Our findings demonstrate that an elevated AM-IBP is associated with abnormal TBE findings of esophageal tablet retention and/or bolus stasis. An abnormal AM-IBP (greater than 20.1 mm Hg) was associated with a higher probability of retaining liquid bolus or barium tablet arrest on TBE and esophageal dysmotility on HRM. This finding supports the recent incorporation of IBP in Chicago Classification v4.0.

Esophageal motility abnormalities in Egyptian patients using high resolution esophageal manometry: a descriptive study

Background and aim

For many years, esophageal manometry has been used for assessment of upper gastro-intestinal (GI) symptoms. Chicago classification is the key for diagnosis and managing motility disorders as it is considered as a standardized approach for categorization of esophageal abnormalities. The aim of this study is to analyze types of esophageal motility findings in Egyptian cases who were suffering from upper GI complaints. Methods: This descriptive study included 378 subjects who were suffering from upper GI complaints as dysphagia, vomiting, chest pain and regurgitation in the period between 10/2015–7/2020. Esophageal HRM study was performed for all patients (MMS Laborie device). The catheter was positioned and confirmed passing across the EGJ (esophago-gastric junction) using landmarks. Swallows and resting status were recorded. Anatomical landmarks were placed.

Results

Most of the patients were complaining of upper GI symptoms. Males were 49.2% of cases. Mean age was 41.3. Dysphagia was the prominent symptom while chest pain was the least symptom. Many manometry findings were observed including ineffective motility, achalasia, absent contractility, EGJ outflow obstruction, jackhammer esophagus and normal findings. Type II achalasia was the dominant type in achalasia patients while Type III was the least. LES was normotensive in most of the cases. Hiatus hernia (HH) was detected in 40.2% of the cases.

Conclusion

This is considered the first Egyptian descriptive study to determine the prevalence of esophageal motility abnormalities in Egyptian patients complaining of upper GI symptoms. HRM is very important for patients complaining of upper GI symptoms.

Lymphocytic Esophagitis: Current Understanding and Controversy

This review summarizes our current understanding of lymphocytic esophagitis (LE), a novel form of chronic esophagitis that incorporates distinctive histologic, clinical, and endoscopic features. First described as a histologic entity, a diagnosis of LE requires intraepithelial lymphocytosis without significant granulocytic inflammation and some evidence of epithelial damage; the rationale for and studies supportive of these histologic criteria are discussed within. Clinically, the majority of patients who present with histologically confirmed LE are older women or patients with underlying immunologic abnormalities, such as Crohn disease, rheumatologic disorders, or common variable immunodeficiency. The most common presenting symptom of LE is dysphagia, and the endoscopic findings can vary from normal mucosa to mucosal changes that resemble eosinophilic esophagitis: edema, rings, furrows, and plaques. The incidence of luminal strictures and the persistent dysphagia and/or lymphocytosis present in some patients provide evidence that LE is a chronic inflammatory disorder, at least within a subset of individuals. Several histologic mimics of LE are examined, as are disagreements surrounding the LE diagnosis.

Prevalence of Different Types of Primary Esophageal Motility Disorders and Their Associated Factors in Patients Referring to Shariati Hospital during 2018-2019

BACKGROUND: Esophageal motility disorders (EMDs) are common in patients with dysphagia and are effectively diagnosed with high-resolution manometry (HREM). In this study, we aimed to evaluate the prevalence of different types of primary EMDs in patients referred for HREM and to further investigate the factors associated with EMDs. METHODS: In this cross-sectional study, all patients referred to the endoscopy section of Shariati Hospital during 2018-2019 (279 patients) were subjected to HREM and were evaluated according to their diagnosis, and the effect of each factor and each symptom on motility disorders was investigated. RESULTS: 84.5% (235) of the participants were diagnosed with at least one esophageal motility disorder; of them, achalasia was the most common form (52.6%). None of the predictive factors showed a statistically significant correlation with EMDs. However, regarding the symptoms, regurgitation and nocturnal cough were significantly more common in patients with EMD (P=0.001 and 0.009, respectively). CONCLUSION: This study demonstrates the high prevalence of EMDs in patients undergoing manometry. None of the factors studied, such as age, sex, diabetes, hypothyroidism, smoking, and alcohol and opium consumption, had a statistically significant correlation with EMDs.

Esophageal Dysfunction in Systemic Sclerosis: An Update

Esophageal motility disorders are prevalent in 90% of patients with systemic sclerosis [scleroderma (SSc)], with an increased mortality rate in patients with severe esophageal involvement. Esophageal smooth muscle damage caused by ischemia, nerve damage, and inflammatory factors may be responsible for discomfort and various complications in these patients. The clinical manifestations are diverse. Most hospitals still use traditional esophageal manometry and 24-h pH monitoring to diagnose esophageal function in patients with SSc. The aim of this review article is to provide an overview of SSc-related esophageal motility disorders and related research progress, including the pathogenesis and clinical features of these disorders and the progress made in endoscopic diagnosis. We also discuss the possible pathogenesis and potential therapeutic targets.

Novel Method of Sampling the Gastrointestinal Muscle Layer: Feasibility of Endoscopic Muscular Resection with a Ligation Device in an in Vivo Porcine Model

BACKGROUND

Gastrointestinal muscular sampling is useful in the histological assessment of functional gastrointestinal disorders. We devised a new sampling method to obtain a large volume of muscle tissues and then investigated the feasibility and safety of endoscopic muscular resection with a ligation device in an in vivo porcine model.

METHODS

After establishing a submucosal tunnel, a rubber band was placed on the muscle tissue by sucking the exposed muscle layer. Thereafter, the established pseudopolyp was removed using an electrocautery snare, and the entry site of the submucosal tunnel was closed endoscopically. This procedure was performed at three sites in the esophagus and stomach of two pigs. The technical success, histology, and survival rate on postoperative day 7 were examined postoperatively.

RESULTS

We successfully completed the mentioned procedure in 11 of the 12 sites (92%), without the occurrence of severe adverse events. The median diameters of obtained tissues from the esophagus and stomach, respectively, were 5 mm and 10 mm. Histologically, both the inner and outer muscle layers were included in all specimens. The postprocedural course was found uneventful in both pigs during the observatory period.

CONCLUSIONS

Endoscopic muscular resection using a ligation device enabled us to obtain large and thick muscle tissue samples. This approach may facilitate more precise histological assessments of functional gastrointestinal disorders.

Is it necessary to perform a morphological assessment for an esophageal motility disorder? A retrospective descriptive study

BACKGROUND

Esophageal motility disorders are most often of primary origin but may be secondary to an occult malignancy or another etiology. High-resolution esophageal manometry cannot differentiate between secondary or primary origin. This study aimed at discussing the usefulness of a morphological assessment in the diagnosis of specific esophageal motility disorders, and to establish the predictive factors of a potential secondary origin.

METHODS

In this retrospective study, patients with suspected esophageal motility disorders who underwent an esophageal manometry were included. High-resolution manometry results were interpreted according to the Chicago Classification, 3rd version. The results of endoscopic ultrasound and computed tomography, assessed by a panel of experts, allowed to diagnose a secondary origin.

KEY RESULTS

Out of 2138 patients undergoing manometry, 502 patients had a esophageal motility disorder suspect to be from secondary origin; among them 182 patients underwent tomography or endoscopic ultrasound. According to experts, 16 patients (8.8%) had a secondary esophageal motility disorder: esophagogastric junction outflow obstruction (n = 7), jackhammer disorder (n = 4), achalasia (n = 3) and localized pressurization (n = 2). The etiology was malignant in 8 patients. Predictive factors suggesting potential secondary esophageal motility disorders were smoking, age ≥ 58 years and an Integrated Relaxation Pressure higher than 10 mmHg for water swallows.

CONCLUSION AND INFERENCES

Esophageal motility disorders with organic origin are not uncommon. A morphological assessment using endoscopic ultrasonography and/or computed tomography may be of use to diagnose a secondary origin, especially in the elderly and smokers.

Diagnostic Yield of High-resolution Esophageal Manometry With Chicago Classification Version 3.0 in Thai Patients

Background/Aims

High-resolution manometry with the Chicago classification scheme has been introduced in clinical practice as a gold standard for esophageal motility test. This study aims to evaluate the diagnostic yield of high-resolution manometry in Thai patients.

Methods

All available high-resolution esophageal manometry (HREM) studies performed during the study period were retrospectively reviewed and interpreted according to the Chicago classification version 3.0. The main esophageal symptoms and coexisting factors were correlated with the HREM findings.

Results

Of the 201 patients, nearly half (49.8%) were documented to have dysphagia. The second most common condition was refractory reflux symptoms (17.4%). More than 70.0% of dysphagia patients showed abnormal esophageal motility, contrary to globus patients who mostly had normal test findings (65.4%). Dysphagia still was the most often correlated condition with major esophageal motility disorders (88.7%), particularly the elderly patients who have coexisting weight loss. Endoscopic and/or surgical procedures were revealed for the highest rate among patients with dysphagia but no one in the globus group needed this intervention. The sensitivity and specificity of dysphagia for major esophageal motility disorders were 70.0% and 67.0%. A much lower sensitivity and higher specificity were found in other non-dysphagia symptoms, especially nausea/vomiting or belching (3.0% or 89.0%). The highest positive likelihood ratio (2.10) to detect major abnormalities was also observed in dysphagia.

Conclusion

Esophageal manometry provided the highest yield in dysphagia; it was not a strongly beneficial test in patients presenting with nondysphagia to identify clinically relevant esophageal motor disorders.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Recovery of lower oesophageal barrier function: a pilot study comparing a mixture of atropine and neostigmine and sugammadex: A randomised controlled pilot study

BACKGROUND

The lower oesophageal sphincter (LOS) barrier serves to prevent regurgitation of gastric contents. Although general anaesthesia depresses its function, its recovery process during emergence from anaesthesia has not been systematically examined.

OBJECTIVE

To explore whether recovery of lower oesophageal barrier function differed between patients receiving a mixture of 1 mg atropine and 2 mg neostigmine and those receiving 2 mg kg-1 sugammadex during emergence from anaesthesia.

DESIGN

An unblinded randomised controlled pilot study.

SETTING

A single university hospital from January 2016 to December 2018.

PATIENTS

A total of 20 non-obese adult females undergoing minor surgery.

INTERVENTION

The patients were randomly assigned to a group either receiving atropine and neostigmine or sugammadex for reversal of rocuronium.

MAIN OUTCOME MEASURES

Through use of the high-resolution manometry technique, the lower oesophageal barrier pressure (PBAR: primary variable) defined as a pressure difference between pressures at the LOS and the stomach was measured at five distinguishable time points during emergence from total intravenous anaesthesia. A mixed effects model for repeated measures was used to test the hypothesis.

RESULTS

In all patients baseline PBAR values were positive even under muscle paralysis and general anaesthesia before administration of reversal agents, and did not differ between the groups (P = 0.299). During recovery from muscle paralysis and general anaesthesia, PBAR (mean ± SD) significantly increased (P = 0.004) from 17.0 ± 2.9 to 21.0 ± 5.0 mmHg in the atropine and neostigmine group (n = 8) and from 19.1 ± 9.0 to 24.5 ± 12.7 mmHg in the sugammadex group (n = 11). PBAR significantly increased immediately after return of consciousness in both groups, whereas return of muscle tone, lightening of anaesthesia and tracheal extubation did not change it.

CONCLUSION

Recovery of the lower oesophageal barrier function does not differ between patients receiving either atropine and neostigmine or sugammadex and is completed after recovery of consciousness from general anaesthesia.

TRIAL REGISTRATION

UMIN Clinical Trials Registry: UMIN000020500: https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&recptno=R000023594&type=summary&language=E.

Deep learning for tracing esophageal motility function over time

BACKGROUND AND OBJECTIVE

Esophageal high-resolution manometry (HRM) is widely performed to evaluate the representation of manometric features in patients for diagnosing normal esophageal motility and motility disorders. Clinicians commonly assess esophageal motility function using a scheme termed the Chicago classification, which is difficult, time-consuming and inefficient with large amounts of data.

METHODS

Deep learning is a promising approach for diagnosing disorders and has various attractive advantages. In this study, we effectively trace esophageal motility function with HRM by using a deep learning computational model, namely, EMD-DL, which leverages three-dimensional convolution (Conv3D) and bidirectional convolutional long-short-term-memory (BiConvLSTM) models. More specifically, to fully exploit wet swallowing information, we establish an efficient swallowing representation method by localizing manometric features and swallowing box regressions from HRM. Then, EMD-DL learns how to identify major motility disorders, minor motility disorders and normal motility. To the best of our knowledge, this is the first attempt to use Conv3D and BiConvLSTM to predict esophageal motility function over esophageal HRM.

RESULTS

Test experiments on HRM datasets demonstrated that the overall accuracy of the proposed EMD-DL model is 91.32% with 90.5% sensitivity and 95.87% specificity. By leveraging information across swallowing motor cycles, our model can rapidly recognize esophageal motility function better than a gastroenterologist and lays the foundation for accurately diagnosing esophageal motility disorders in real time.

CONCLUSIONS

This approach opens new avenues for detecting and identifying esophageal motility function, thereby facilitating more efficient computer-aided diagnosis in clinical practice.

European Society for Neurogastroenterology and Motility (ESNM) recommendations for the use of high-resolution manometry of the esophagus

BACKGROUND

Several patients in gastroenterology practice present with esophageal symptoms, and in case of normal endoscopy with biopsies, high-resolution manometry (HRM) is often the next step. Our aim was to develop a European consensus on the clinical application of esophageal HRM, to offer the clinician guidance in selecting patients for HRM and using its results to optimize clinical outcome.

METHODS

A Delphi consensus was initiated with 38 multidisciplinary experts from 16 European countries who conducted a literature summary and voting process on 71 statements. Quality of evidence was evaluated using grading of recommendations assessment, development, and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 33 statements.

RESULTS

The process generated guidance on when to consider esophageal HRM, how to perform it, and how to generate the report. The Delphi process also identified several areas of uncertainty, such as the choice of catheters, the duration of fasting and the position in which HRM is performed, but recommended to perform at least 10 5-ml swallows in supine position for each study. Postprandial combined HRM impedance is considered useful for diagnosing rumination. There is a large lack of consensus on treatment implications of HRM findings, which is probably the single area requiring future targeted research.

CONCLUSIONS AND INFERENCES

A multinational and multidisciplinary group of European experts summarized the current state of consensus on technical aspects, indications, performance, analysis, diagnosis, and therapeutic implications of esophageal HRM.

Preoperative physiological esophageal assessment for anti-reflux surgery: A guide for surgeons on high-resolution manometry and pH testing

Gastroesophageal reflux disease (GERD) is one of the most commonly encountered digestive diseases in the world, with the prevalence continuing to increase. Many patients are successfully treated with lifestyle modifications and proton pump inhibitor therapy, but a subset of patients require more aggressive intervention for control of their symptoms. Surgical treatment with fundoplication is a viable option for patients with GERD, as it attempts to improve the integrity of the lower esophageal sphincter (LES). While surgery can be as effective as medical treatment, it can also be associated with side effects such as dysphagia, bloating, and abdominal pain. Therefore, a thorough pre-operative assessment is crucial to select appropriate surgical candidates. Newer technologies are becoming increasingly available to help clinicians identify patients with true LES dysfunction, such as pH-impedance studies and high-resolution manometry (HRM). Pre-operative evaluation should be aimed at confirming the diagnosis of GERD, ruling out any major motility disorders, and selecting appropriate surgical candidates. HRM and pH testing are key tests to consider for patients with GERD like symptoms, and the addition of provocative measures such as straight leg raises and multiple rapid swallows to HRM protocol can assess the presence of underlying hiatal hernias and to test a patient’s peristaltic reserve prior to surgery.

Functional endoscopy in neurogenic dysphagia: a feasibility study focusing on the esophageal phase of swallowing

Background and study aims  Due to demographic transition, neurogenic dysphagia has become an increasingly recognized problem. Patients suffering from dysphagia often get caught between different clinical disciplines. In this study, we implemented a defined examination protocol for evaluating the whole swallowing process by functional endoscopy. Special focus was put on the esophageal phase of swallowing. Patients and methods  This prospective observational multidisciplinary study evaluated 31 consecutive patients with suspected neurogenic dysphagia by transnasal access applying an ultrathin video endoscope. Thirty-one patients with gastroesophageal reflux symptoms were used as a control group. We applied a modified approach including standardized endoscopic positions to compare our findings with fiberoptic endoscopic evaluation of swallowing and high-resolution manometry. The primary outcome measure was feasibility of functional endoscopy. Secondary outcome measures were adverse events (AEs), tolerability, and pathologic endoscopic findings. Results  Functional endoscopy was successfully performed in all patients. No AEs were recorded. A variety of disorders were documented by functional endoscopy: incomplete or delayed closure of the upper esophageal sphincter in retroflex view, clearance disturbance of tubular esophagus, esophageal hyperperistalsis, and hypomotility. Analysis of results obtained with the diagnostic tools showed some discrepancies. Conclusions  By interdisciplinary cooperation with additional assessment of the esophageal phase of deglutition using the innovative method of functional endoscopy, the diagnosis of neurogenic disorders including dysphagia may be significantly improved, leading to a better clinical understanding of complex dysfunctional patterns. To the best of our knowledge, this is the first study to show that a retroflex view of the ultrathin video endoscope within the esophagus can be safely performed. [NCT01995929].

Mast Cell Activation in the Systemic Sclerosis Esophagus

INTRODUCTION

Previously, we discovered similar esophageal gene expression patterns in patients with systemic sclerosis (SSc) and eosinophilic esophagitis (EoE) where eosinophil/mast cell-targeted therapies are beneficial. Because SSc and EoE patients experience similar esophageal symptoms, we hypothesized that eosinophil/mast cell-directed therapy may potentially benefit SSc patients. Herein, we determine the association between esophageal mast cell quantities, gene expression and clinical parameters in order to identify SSc patients who may benefit from eosinophil/mast cell-directed therapy.

METHODS

Esophageal biopsies from SSc patients and healthy participants were stained for tryptase, a mast cell marker, and associations with relevant clinical parameters including 24h esophageal pH testing were assessed. Intra-epithelial mast cell density was quantified by semi-automated microscopy. Microarray data were utilized for functional and gene set enrichment analyses and to identify intrinsic subset (IS) assignment, an SSc molecular classification system that includes inflammatory, proliferative, limited and normal-like subsets.

RESULTS

Esophageal biopsies from 40 SSc patients (39 receiving proton pump inhibition) and eleven healthy participants were studied. Mast cell numbers in both the upper esophagus (rs = 0.638, p = 0.004) and the entire (upper + lower) esophagus (rs = 0.562, p = 0.019) significantly correlated with acid exposure time percentage. The inflammatory, fibroproliferative, and normal-like ISs originally defined in skin biopsies were identified in esophageal biopsies. Although esophageal mast cell numbers in SSc patients and healthy participants were similar, gene expression for mast cell-related pathways showed significant upregulation in the inflammatory IS of SSc patients compared to patients classified as proliferative or normal-like.

DISCUSSION

Esophageal mast cell numbers are heterogeneous in SSc patients and may correlate with acid exposure. Patients with inflammatory IS profiles in the esophagus demonstrate more tryptase staining. Mast cell targeted therapy may be a useful therapeutic approach in SSc patients belonging to the inflammatory IS, but additional studies are warranted.

Clinical correlation and disease phenotype in patients with esophageal achalasia and comorbid autoimmune diseases

BACKGROUND

There is evidence that idiopathic achalasia has an autoimmune component and a significant association with several autoimmune comorbidities has been described. However, data regarding the prevalence of autoimmune diseases in achalasia are not well established, and few studies have explored this association.

OBJECTIVE

Our primary aim was to prospectively investigate the type and frequency of autoimmune comorbidities in a large cohort of consecutive achalasia patients. Our secondary aim was to investigate the effects of autoimmune comorbidities on achalasia phenotype (clinical features and manometric pattern).

METHODS

The study population consisted of 375 consecutive patients (215 females-median age 55 ± 17 years), referred at our tertiary referral center from January 2008 to January 2018, with clinical and instrumental (EGDS, barium esophagogram, and manometry) diagnosis of idiopathic achalasia. Gender- and age-matched subjects undergoing manometry and pH-impedance monitoring for typical gastroesophageal reflux (GERD) complaints served as controls. In all patients a detailed history taking was carried out, recording the presence and type of autoimmune comorbidities.

RESULTS

The overall prevalence of autoimmune comorbidities was two times higher in achalasia than in control patients (12.3 vs. 5%, respectively). The presence of comorbidities did not significantly affect disease's phenotype, as the age of disease onset was similar in achalasia patients with and without comorbidities (50.13 ± 14.47 and 48.3 ± 18.71, respectively, P = NS).

CONCLUSIONS

Although larger epidemiologic studies are needed to confirm our data, our findings likely suggest that achalasia has a complex multifactorial pathophysiology with an autoimmune component.

Normative reference values for esophageal high-resolution manometry in healthy adults: A systematic review

Establishing normative values of high-resolution esophageal manometry is necessary for accurate interpretation and comparison of measurements. In this systematic review, we aimed to summarize normal values for different esophageal high-resolution manometry systems. Moreover, we assessed the effect of body position, bolus consistency, and provocative maneuvers on these normative thresholds. We searched Medline, Embase, and the Cochrane Library from January 1st, 2006, to January 20th, 2020, for studies that reported normative data of high-resolution manometry in healthy volunteers. We assessed methodological quality of the included studies and planned a descriptive analysis. We analyzed data from 54 articles describing normative thresholds in high-resolution manometry using solid-state or water-perfused systems. Forty-six studies performed the manometry study in the supine position with liquid swallows, whereas sixteen studies described normative values in the upright position. Twelve studies assessed normative values for different bolus consistencies, and nine studies evaluated different provocative maneuvers. There is a considerable variety of normative values for esophageal high-resolution manometry depending on the equipment used and the protocols performed to obtain measurements. This should be taken into account when evaluating measurements in clinical practice and when comparing results of published research studies.

ACHALASIA: DIAGNOSTIC FEATURES AND EFFECTIVE TREATMENT METHODS. REVIEW

Еsophageal achalasia is a neuromuscular disease of esophagus characterized by a distortion of the relaxation of the lower esophageal sphincter (LES) and manifested by marked clinical symptoms. To date, methods for diagnosing pathology and various surgical methods for its correction have been developed and actively used. In this review, the authors summarized all available data on principles of modern classification based on the identification of characteristic diagnostic criteria of the disease. The modern treatment methods are described in detail, the effectiveness of the presented methods is evaluated.

Endoscopic ultrasound: a powerful tool to modify treatment algorithms in opioid-induced achalasia

BACKGROUND

Opioid use in the U.S. has increased dramatically over the last 15 years, recently being declared a public health emergency. Opioid use is associated with esophageal dysmotility lending to a confusing clinical picture compared to true achalasia. Patients exhibit symptoms and elicit diagnostic results consistent with esophageal motility disorders, in particular type III achalasia. Modified therapeutic strategies and outcomes become challenging. Differentiating true achalasia from opioid-induced achalasia is critical. Conventional surgical interventions, i.e., myotomy, are ineffective in the absence of true achalasia. We assess the utility of esophageal muscle layer mapping with endoscopic ultrasound (EUS) in distinguishing primary from opioid-induced achalasia.

METHODS

From 2016 to 2019, patients with abnormal manometry and suspected achalasia underwent esophagogastroduodenoscopy and EUS mapping of esophageal round muscle layer thickness. Maximum round layer thickness and length of round muscle layer thickness > 1.8 mm were collected and compared between opioid users and non-opioid users using Wilcoxon Rank sum test.

RESULTS

45 patients were included: 12 opioid users, 33 non-opioid users. Mean age 56.8 years (range 24-93), 53.3% male patients. Mean BMI in the opioid-induced achalasia group was 30.2 kg/m², mean BMI in the primary achalasia group 26.8 kg/m² (p = 0.11). In comparing endoscopic maximum round layer thickness between groups, non-opioid patients had a thicker round muscle layer (2.7 mm vs 1.8 mm, p = 0.05). Length of abnormally thickened esophageal muscle (greater than 1.8 mm) also differed between the two groups; patients on opioids had a shorter length of thickening (4.0 cm vs 0.0 cm, p = 0.04). Intervention rate was higher in the non-opioid group (p = 0.79). Of the patients that underwent therapeutic intervention, symptom resolution was higher in the non-opioid group (p = 0.002), while re-intervention post-procedure for persistent symptomatology was elevated in the opioid subset (p = 0.06). Patients in the opioid group were less likely to undergo invasive treatment (Heller). As of 2017 all interventions in the opioid group have been endoscopic.

CONCLUSION

Endoscopic ultrasound is an essential tool that has improved our treatment algorithm for suspected achalasia in patients with chronic opioid usage. Incorporation of EUS findings into treatment approach may prevent unnecessary surgery in opioid users.

The Challenges of Esaphagogastric Junction Outflow Obstruction, Is It Really a Diagnosis? Creating a Systematic Clinical Approach for EGJOO

Esophagogastric junction outflow obstruction (EGJOO) is currently diagnosed according to the Chicago Classification V3 by an elevated median integrated relaxation pressure on high resolution manometry. However, EGJOO may not be an accurate diagnosis, as it may be based on abnormal IRP from an artifact, affected by narcotics, an achalasia variant, or a mechanical cause of obstruction. This heterogenous diagnosis can often lead to unnecessary testing and treatment. The purpose of this study is to develop a stepwise clinical management protocol on how to evaluate EGJOO. Motility studies were reviewed for the last 2 years and 39 patients were diagnosed with EGJOO. Clinical information was reviewed, and patients were classified into six stepwise categories to explain an elevated IRP resulting in EGJOO diagnosis: (1) underlying catheter artifact (2) opioid use (3) achalasia variant (4) jackhammer esophagus with obstruction (5) missed esophageal lesion (ex. Schatzki ring, EOE) and (6) extrinsic compression. 40% (n = 14) of patients with elevated IRP were due to an underlying catheter artifact. 8.6% (n = 3) were due to opioid use. 8.6% (n = 3) were due to achalasia variant. 31.4% (n = 11) were due to jackhammer esophagus with obstruction. 5.7% (n = 2) were due to missed esophageal lesion. 5.7% (n = 2) were due to external compression by cardiomegaly and aortic aneurism. EGJOO is not a diagnostic end point, but a heterogenous category with multiple underlying etiologies. We believe the use of a stepwise approach to these patients can help avoid further unnecessary testing.

Recommendations of the Russian Gastroenterological Association on Clinical Use of High-Resolution Manometry in Diagnosis of Esophageal Disorders

Aim. Current recommendations of the Russian Gastroenterological Association on clinical use of high-resolution manometry in diagnosis of esophageal disorders are intended to assist in clinical decision making, terminology standardisation and interpretation of clinical data.

Key points. In 2018, a joint meeting of the Russian Gastroenterological Association and Russian Neurogastroenterology and Motility Group approved unified terminology and classification of esophageal motor function disorders for high-resolution manometry diagnosis.

Gastrointestinal patient complaints typically concern esophageal disorders such as dysphagia, regurgitation, heart-burn, chest pain or belching. To exclude erosive and ulcerative lesions, eosinophilic esophagitis and organic changes, esophagogastroduodenoscopy and biopsy are recommended in pre-treatment. Upon excluding mucosal lesions and esophageal lumen obstruction as causal for symptoms, use of high-resolution manometry is recommended. This method of esophageal examination has become the “gold standard” in diagnosis of motor disorders.

High-resolution manometry enables detailed investigation of integral quantitative and qualitative characteristics of esophagus motor function and specific related disorders, analysis of esophageal contractile propagation and strictly coordinated synchronous peristalsis of upper esophageal sphincter, esophagus and lower esophageal sphincter, which malfunction may provoke development of achalasia, esophagospasm, hiatal hernia, ineffective eso pha geal motility and other motor disorders.

Conclusion. High-resolution manometry is a relatively new method for study of esophagus motor function gaining increasingly wide application in clinical practice. It enables a medical professional to obtain evidence that may critically affect the choice of optimal patient care strategy and effective treatment. Current recommendations are based on an extensive review of up-to-date information and will be updated with new corpus of clinical data and assessment emerging in evidential medicine to provide gastroenterologists country-wide with latest scientific and practical guidelines.

Effect of positive end-expiratory pressure on gastric insufflation during induction of anaesthesia when using pressure-controlled ventilation via a face mask: A randomised controlled trial

BACKGROUND

Face mask ventilation (FMV) during induction of anaesthesia is associated with risk of gastric insufflation that may lead to gastric regurgitation and pulmonary aspiration. A continuous positive airway pressure (CPAP) has been shown to reduce gastric regurgitation. We therefore hypothesised that CPAP followed by FMV with positive end-expiratory pressure (PEEP) during induction of anaesthesia would reduce the risk of gastric insufflation.

OBJECTIVE

The primary aim was to compare the incidence of gastric insufflation during FMV with a fixed PEEP level or zero PEEP (ZEEP) after anaesthesia induction. A secondary aim was to investigate the effects of FMV with or without PEEP on upper oesophageal sphincter (UES), oesophageal body and lower oesophageal sphincter (LES) pressures.

DESIGN

A randomised controlled trial.

SETTING

Single centre, Department of Anaesthesia and Intensive Care, Örebro University Hospital, Sweden.

PARTICIPANTS

Thirty healthy volunteers.

INTERVENTIONS

Pre-oxygenation without or with CPAP 10 cmH₂O, followed by pressure-controlled FMV with either ZEEP or PEEP 10 cmH₂O after anaesthesia induction.

MAIN OUTCOME MEASURES

A combined impedance/manometry catheter was used to detect the presence of gas and to measure oesophageal pressures. The primary outcome measure was the cumulative incidence of gastric insufflation, defined as a sudden anterograde increase in impedance of more than 1 kΩ over the LES. Secondary outcome measures were UES, oesophageal body and LES pressures.

RESULTS

The cumulative incidence of gastric insufflation related to peak inspiratory pressure (PIP), was significantly higher in the PEEP group compared with the ZEEP group (log-rank test P < 0.01). When PIP reached 30 cmH₂O, 13 out of 15 in the PEEP group compared with five out of 15 had shown gastric insufflation. There was a significant reduction of oesophageal sphincter pressures within groups comparing pre-oxygenation to after anaesthesia induction, but there were no significant differences in oesophageal sphincter pressures related to the level of PEEP.

CONCLUSION

Contrary to the primary hypothesis, with increasing PIP the tested PEEP level did not protect against but facilitated gastric insufflation during FMV. This result suggests that PEEP should be used with caution after anaesthesia induction during FMV, whereas CPAP during pre-oxygenation seems to be safe.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT02238691.

Fair reliability of eckardt scores in achalasia and non-achalasia patients: Psychometric properties of the eckardt spanish version in a multicentric study

BACKGROUND

Eckardt symptom score (ESS) is the most used tool for the evaluation of esophageal symptoms. Recent data suggest that it might have suboptimal reliability and validity. The aims of this study were as follows: (a) Develop and validate an international Spanish ESS version. (b) Perform psychometric ESS evaluation in patients with achalasia and non-achalasia patients.

METHODS

Eckardt symptom score translation was performed by Delphi process. ESS psychometric evaluation was done in two different samples of patients referred for manometry. First sample: 430 dysphagia non-achalasia patients. Second sample: 161 achalasia patients. Internal consistency was evaluated using Cronbach's α and Guttman coefficient (<0.5 = unacceptable. 0.5-0.7 = fair. >0.7 = acceptable).

KEY RESULTS

Our data show that in patients without and with achalasia, ESS behaves similarly. Both show a fair reliability with Cronbach's α of 0.57 and 0.65, respectively. Based on our results, we recommend interpretation of the Spanish ESS be done with caution. The psychometric quality of the ESS could not be improved by removal of any items based on the single-factor structure of the scale and no items meeting criteria for elimination.

CONCLUSIONS AND INFERENCES

Eckardt symptom score Spanish translation was developed. ESS showed a fair reliability for the evaluation of patients with any causes of dysphagia. Our results highlight the need for development and psychometric validation of new dysphagia scoring tools.

Durability of Esophageal Motor Disorders Identified on High-Resolution Esophageal Manometry: A Case Series

Background/Aim

Diagnosis of esophageal motor disorders using high-resolution esophageal manometry (HREM) may result in medical, endoscopic or surgical intervention. However, prior to any intervention, durability of the HREM findings should be established. The aim of this case series was to assess 25 patients who had undergone HREM twice, at least 6 months apart, and to determine the durability of the initial manometric diagnosis.

Methods and Patients

This is a case series of 25 patients who underwent HREM at least twice, 6 months apart, at a large safety net hospital. All patients were evaluated in between the tests for any clinical intervention. Demographics, patients’ indication for HREM and clinical presentation were documented as well.

Results

Of the 25 patients, HREM results improved in 32%, worsened in 20% and were unchanged in 48%. Some interventions were employed between the first and second HREM diagnosis. Those associated with an improved diagnosis included doubling the proton pump inhibitor (PPI) dose, re-starting a PPI, adding a histamine 2 blocker (H2 blocker) and use of empiric dilation.

Conclusions

In this case series, about half of the patients undergoing two esophageal manometries, at least 6 months apart, demonstrated lack of durability of their initially diagnosed esophageal motor disorder.

ALTERED ESOPHAGEAL MOTILITY DURING PERCEPTION OF BOLUS TRANSIT IN HEALTHY VOLUNTEERS

BACKGROUND

The perception of bolus transit through the thoracic esophagus may be caused by altered esophageal anatomy and function.

OBJECTIVE

To evaluate the hypothesis that, in healthy volunteers, swallows followed by perception of esophageal bolus transit are associated with changes in esophageal motility.

METHODS

Simultaneous evaluation of motility and perception of esophageal bolus transit was performed in 22 healthy volunteers. Esophageal motility was evaluated by high-resolution manometry with a 32-channel solid state catheter. Each volunteer performed, in the sitting position, 10 swallows of a 5 mL bolus of saline and 10 swallows of pieces of 1 cm3 of bread, with an interval of at least 30 seconds between swallows. After each swallow the volunteers were asked about the perception of bolus transit through the esophagus.

RESULTS

Perception of bolus transit occurred in 11.7% of liquid swallows and in 48.1% of solid swallows. In liquid swallows the perception was associated with higher distal contractile integral and shorter proximal contraction length. Perception of solid bolus transit was associated with a longer distal latency, longer proximal contraction length, lower proximal contractile integral and shorter proximal contraction duration.

CONCLUSION

The perception of swallowed bolus transit through the esophagus in healthy individuals is more frequent with solid than liquid swallows and is associated with changes in proximal esophageal contractions.

Peroral endoscopic myotomy for esophageal motility disorders

BACKGROUND

Esophageal motility disorders which include achalasia, esophagogastric junction outflow obstruction (EGJ outflow obstruction), jackhammer esophagus (JE), distal esophageal spasm (DES), etc. are rare disease of unknown causes. The diagnosis is based on endoscopy, barium meal, and high-resolution manometry (HRM). With the development of endoscopy, peroral endoscopic myotomy (POEM) has emerged as a standard method for the treatment of achalasia.

PURPOSE

The purpose of this article is to enable gastroenterologists to have a more comprehensive understanding of the application status, technical characteristics, clinical efficacy and future prospect of POEM in the treatment of esophageal motility disorders.

METHODS

Through a large number of reading literature, combined with clinical practice, summary and analysis of the indications, procedure, efficacy, complications, and controversies of POEM in the treatment of esophageal motility disorders, as well as the current and future perspectives of POEM were studied.

RESULTS

POEM is safe and effective in the treatment of esophageal motility disorders, but the GERD reflux rate is higher.

CONCLUSIONS

POEM can be a new option for the treatment of esophageal movement disorders, but large sample, multi-center, long-term study reports are needed, and it promotes the development of NOTES technology.

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.

Evaluation and Management of Premalignant Conditions of the Esophagus: A Systematic Survey of International Guidelines

Esophageal cancer represents one of the most lethal forms of malignancy. The growing incidence of esophageal adenocarcinoma represents an emerging public health concern. This review article summarizes current diagnostic, management, and therapeutic practices of premalignant conditions of the esophagus including Barrett's esophagus, tylosis, granular cell tumors, achalasia, and the ingestion of caustic substances. Our report provides clinicians and academics with a global clinical perspective regarding presentation, surveillance guidelines, and therapeutic management of these esophageal conditions.

The clinical significance of disorders of the motor function of the esophagus, stomach and duodenum

The purpose of the review is to determine the relationship between the clinical symptoms of diseases and disorders of the motor function of the esophagus, stomach and duodenal bulb, to present modern methods of their diagnosis and pathogenetic principles of treatment of diseases. Depending on the pathogenesis, it is possible to distinguish secondary motility disorders resulting from organic lesions, and primary (functional) changes. The emergence of clinical symptoms is associated with impaired motor - evacuation function of the digestive tract, which can be divided into two large groups: changes in the peristaltic activity of the organ wall and the work of the sphincter apparatus. The basis of the regulation of motility of the esophagus, stomach and duodenum is the interaction of nervous and humoral factors, the central processing of impulses is carried out in the cerebral cortex. In case of violation of the coordinated action of inhibitory and excitatory regulation systems, pathological contractile activity occurs, which manifests itself as hypo - or hyper - motor dyskinesia. X-ray, ultrasound, high resolution manometry of the esophagus, pH-meter, scintigraphy, computed tomography, antroduodenal manometry and a number of others are used to diagnose disorders of the motor function of the digestive tract, which can determine the mechanism of the development of symptoms and prescribe pathogenetic treatment to the patient. Thus, the occurrence of clinical symptoms is associated with changes in the motor - evacuation function of the digestive tract due to a violation of the coordinating action of inhibitory and excitatory factors. The use of modern diagnostic methods for the study of motor function makes it possible to determine the mechanism for the development of clinical symptoms, which allows the patient to prescribe an effective pathogenetic treatment.