Upright Integrated Relaxation Pressure Facilitates Characterization of Esophagogastric Junction Outflow Obstruction

Integrated Relaxation Pressure and Its Diagnostic Ability May Vary According to the Conditions Used for HREM Recording

Integrated Residual Pressure (IRP) measured under conditions alternative to supine single swallows may provide clinically useful information regarding EGJ relaxation. This study aimed to compare IRP values obtained under different situations and explore their potential clinical utility. We analyzed and compared the values of IRP obtained from healthy volunteers and patients with suspected achalasia during supine single swallows (Ssup-IRP), sitting single swallows (Ssit-IRP), supine multiple rapid swallows (Msup-IRP), and sitting multiple rapid swallows (Msit-IRP). We analyzed the HREM recordings of 40 healthy volunteers and 53 patients with suspected achalasia. The four metrics were significantly different from each other in healthy volunteers (Ssup-IRP > Msup-IRP > Ssit-IRP > Msit-IRP) and their corresponding 95th percentiles were substantially distinct (Ssup-IRP: 25.3 mmHg, Ssit-IRP: 20.9 mmHg, Msup-IRP: 15.9 mmHg, and Msit-IRP: 11.9 mm Hg, respectively). Complete agreement among the four metrics in predicting abnormal IRP was found in 39 of the 47 patients with suspected achalasia who completed the protocol. Optimal cutoffs derived from ROC curve analysis demonstrated ≥ 0.95 specificities for detection of impaired EGJ relaxation among patients with suspected achalasia. Among the eight patients with suspected achalasia with normal Ssup-IRP, five demonstrated abnormal Msit-IRP and four abnormal Ssit-IRP. Significant differences of IRP exist depending on the measurement situation, indicating that correct interpretation of IRP values requires specific cutoffs for each situation.The sensitivities of Ssit-IRP and Msit-IRP in detecting defective EGJ relaxation appear to be slightly higher than that of Ssup-IRP.

Impaired esophagogastric junction relaxation and lung transplantation outcomes

The implications of impaired esophagogastric junction relaxation (i.e. esophagogastric junction outflow obstruction and achalasia) in lung transplants recipients (LTRs) are unclear. Thus, we examined the prevalence and clinical outcomes of LTRs with an abnormally elevated integrated relaxation pressure (IRP) on high-resolution manometry before lung transplantation (LTx). After IRB approval, we reviewed data on LTRs who underwent LTx between January 2019 and August 2022 with a preoperative median IRP >15 mmHg. Differences in overall survival and chronic lung allograft dysfunction (CLAD)-free survival between LTRs with a normalized median IRP after LTx (N-IRP) and those with persistently high IRP (PH-IRP) were assessed using Kaplan-Meier curves and the log-rank test. During the study period, 352 LTx procedures were performed; 44 (12.5%) LTRs had an elevated IRP before LTx, and 37 (84.1%) completed a postoperative manometry assessment (24 [70.6%] males; mean age, 65.2 ± 9.1 years). The median IRP before and after LTx was 18.7 ± 3.8 mmHg and 12 ± 5.6 mmHg, respectively (P < 0.001); the median IRP normalized after LTx in 24 (64.9%) patients. Two-year overall survival trended lower in the N-IRP group than the PH-IRP group (77.2% vs. 92.3%, P = 0.086), but CLAD-free survival (P = 0.592) and rates of primary graft dysfunction (P = 0.502) and acute cellular rejection (P = 0.408) were similar. An abnormally elevated IRP was common in LTx candidates; however, it normalized in roughly two-thirds of patients after LTx. Two-year survival trended higher in the PH-IRP group, despite similar rates of primary graft dysfunction and acute cellular rejection as well as similar CLAD-free survival between the groups.

The functional lumen imaging probe contractile response pattern is the best predictor of botulinum toxin response in esophagogastric junction outflow obstruction

BACKGROUND

Esophagogastric junction outflow obstruction (EGJOO) is a heterogenous disorder in which the correct management strategy is unclear. We assessed whether functional lumen imaging probe (FLIP) topography data could select EGJOO, which would benefit from lower esophageal sphincter Botulinum toxin (Botox) injection.

METHODS

This was a single-center prospective study of adult patients meeting Chicago Classification (CC) v3.0 criteria for EGJOO. We assessed differences in pretreatment physiologic measurements on high-resolution manometry (HRM) and FLIP and other relevant clinical variables in predicting Botox response (>50% in BEDQ at 2 months).

KEY RESULTS

Sixty-nine patients were included (ages 33-90, 73.9% female). Of these, 42 (61%) were Botox responders. Majority of physiologic measures on HRM and FLIP and esophageal emptying were not different based on Botox response. However, a spastic-reactive (SR) FLIP contractile response (CR) pattern predicted a Botox response with OR 25.6 (CI 2.9-229.6) when compared to antegrade FLIP CR; and OR for impaired-disordered/absent CR was 22.5 (CI 2.5-206.7). Logistic regression model using backward elimination (p value = 0.0001, AUC 0.79) showed that a SRCR or IDCR/absent response and the upright IRP predicted Botox response. Response rates in tiered diagnostic groups were: (i) CCv3.0 EGJOO (60.9%), (ii) CCv4.0 EGJOO (73.1%), (iii) CCv4.0 + FLIP REO (80%), (iv) CCv4.0, FLIP REO, and abnormal FLIP CR (84.2%), and (v) CCv4.0, FLIP REO, and SR FLIP CR (90%).

CONCLUSIONS AND INFERENCES

FLIP helps identify patients with EGJOO who are likely to response to LES Botox therapy. An abnormal FLIP contractile response pattern is the single-most important predictor of a Botox response.

Esophagogastric Junction Outflow Obstruction (EGJOO): A Manometric Phenomenon or Clinically Impactful Problem

PURPOSE OF REVIEW

Esophagogastric junction outflow obstruction (EGJOO), defined manometrically by impaired esophagogastric junction relaxation (EGJ) with preserved peristalsis, can be artifactual, due to secondary etiologies (mechanical, medication-induced), or a true motility disorder. The purpose of this review is to go over the evolving approach to diagnosing and treating clinically relevant EGJOO.

RECENT FINDINGS

Timed barium esophagram (TBE) and the functional lumen imaging probe (FLIP) are useful to identify clinically relevant EGJOO that merits lower esophageal sphincter (LES) directed therapies. There are no randomized controlled trials evaluating EJGOO treatment. Uncontrolled trials show effectiveness for pneumatic dilation and peroral endoscopic myotomy to treat confirmed EGJOO; Botox and Heller myotomy may also be considered but data for confirmed EGJOO is more limited. Diagnosis of clinically relevant idiopathic EGJOO requires symptoms, exclusion of mechanical and medication-related etiologies, and confirmation of EGJ obstruction by TBE or FLIP. Botox LES injection has limited durability, it can be used in patients who are not candidates for other treatments. PD and POEM are effective in confirmed EGJOO, Heller myotomy may also be considered but data for confirmed EGJOO is limited. Randomized controlled trials are needed to clarify optimal management of EGJOO.

Esophagogastric Junction Outflow Obstruction: A Diagnosis in Evolution

Esophagogastric junction outflow obstruction (EGJOO) is a rapidly evolving diagnosis that can represent early or variant achalasia. Since the publication of the Chicago Classification version 4.0, the criteria for this diagnosis have been more stringent. Currently, the criteria include an elevated median integrated relaxation pressure (IRP) in both the supine and upright positions, elevated intrabolus pressure in at least 20% of supine swallows, dysphagia and/or chest pain, as well as an abnormal timed barium esophagram and/or impedance planimetry testing. Additionally, other secondary causes may result in an elevated IRP and must be excluded. The management of conclusive EGJOO is targeted therapy to the lower esophageal sphincter (LES), although treatment is not straightforward. Overall, adjuvant testing and data should be scrutinized for appropriateness of LES disruption. The spectrum of treatment options includes simple monitoring as well as more invasive therapies such as endoscopic dilation and myotomy. This article explores the newest criteria and management options for clinically relevant EGJOO.

Compartmentalized pressurization is a novel prognostic factor for hypercontractile esophagus

BACKGROUND

Hypercontractile esophagus (HE) is a disorder of increased esophageal body contractile strength on high-resolution esophageal manometry (HREM). Compartmentalized pressurization (CP) is a pattern with an isobaric contour of >30 mmHg extending from the contractile front to the lower esophageal sphincter on HREM. The relevance of CP to HE has yet to be explored.

METHODS

A retrospective review was performed on 830 HREM studies of patients to identify HE. HE patients' CP status and symptoms by Eckardt score (ES) were reviewed. Diagnoses were made using Chicago Classification (CC) v4.0.

KEY RESULTS

Forty-seven patients (5.6%) were identified as having HE by CCv3, 30 (3.6%) of which had HE by CCv4. 11/30 HE patients had CP, and 19/30 did not. CP was associated with chronic opioid use (36.4% vs. 5.3% p = 0.047). Presenting ES was greater for HE patients with CP (7 vs. 4). Seven HE patients with CP and 11 without CP were managed medically. ES after medical therapy was higher in HE patients with CP compared to those without CP (9 vs. 0). No HE patients with CP responded to medical therapy. Kaplan-Meier analysis demonstrated significance of this association over time. 83% of all HE patients had all-cause symptom remission.

CONCLUSIONS & INFERENCES

HE patients with CP are associated with a higher presenting ES. HE patients with CP do not respond to medical therapy, while HE patients without CP frequently do respond. CP in HE may have prognostic value in determination of treatment strategy for patients with HE.

Current Approach to Dysphagia: A Review Focusing on Esophageal Motility Disorders and Their Treatment

Background

Dysphagia is a prevalent condition which may severely impact the patient's quality of life. However, there are still lacking standardized therapeutic options for esophageal motility disorders.

Summary

Dysphagia is defined as a subjective sensation of difficulty swallowing which can result from oropharyngeal or esophageal etiologies. Regarding esophageal dysphagia, after excluding structural causes and esophageal mucosal lesions, high-resolution manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. HRM has not only improved the sensitivity for detecting achalasia but has also expanded our understanding of spastic and hypomotility disorders of the esophageal body. The Chicago Classification v4.0 uses a hierarchical approach and provides a standardized diagnosis of esophageal motility disorders, allowing a tailored therapeutic approach. Dysphagia is often a long-term health problem that broadly impacts health and well-being and leads to physical and psychosocial disability, namely, malnutrition and aspiration pneumonia, as well as social isolation, depression, and anxiety. Apart from achalasia, most esophageal motility disorders tend to have a benign long-term course with symptoms of dysphagia and noncardiac chest pain that can improve significantly over time. Patient-reported outcomes (PROs) are self-assessment tools that capture the patients' illness experience and help providers better understand symptoms from the patients' perspective. Therefore, PROs have a critical role in providing patient-centered care.

Key Messages

Motility disorders should be ruled out in the presence of nonobstructive esophageal dysphagia, and treatment options should be considered according to the severity of symptoms reported by the patient.

Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy with Dor Fundoplication for Esophagogastric Junction Outflow Obstruction (EGJOO): a Comparison of Outcomes and Impact on Physiology

INTRODUCTION

Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation with preserved peristalsis. Studies have shown that Heller myotomy with Dor fundoplication (HMD) and per oral endoscopic myotomy (POEM) are effective treatments for EGJOO. However, there is paucity of data comparing the efficacy and impact of these two procedures. Therefore, the aim of this study was to compare outcomes and impact on esophageal physiology in patients undergoing HMD or POEM for primary EGJOO.

METHODS

This was a retrospective review of patients who underwent either HMD or POEM for primary EGJOO at our institution between 2013 and 2021. Favorable outcome was defined as an Eckardt score ≤ 3 at 1 year after surgery. GERD-HRQL questionnaire, endoscopy, pH monitoring, and high-resolution manometry (HRM) results at baseline and 1 year after surgery were compared pre- and post-surgery and between groups. Objective GERD was defined as DeMeester score > 14.7 or LA grade C/D esophagitis.

RESULTS

The final study population consisted of 52 patients who underwent HMD (n = 35) or POEM (n = 17) for EGJOO. At a mean (SD) follow-up of 24.6 (15.3) months, favorable outcome was achieved by 30 (85.7%) patients after HMD and 14 (82.4%) after POEM (p = 0.753). After HMD, there was a decrease GERD-HRQL total score (31 (22-45) to 4 (0-19); p < 0.001), and objective reflux (54.2 to 25.9%; p = 0.033). On manometry, there was a decrease in LES resting pressure (48 (34-59) to 13 (8-17); p < 0.001) and IRP (22 (17-28) to 8 (3-11); p < 0.001), but esophageal body characteristics did not change (p > 0.05). Incomplete bolus clearance improved (70% (10-90) to 10% (0-40); p = 0.010). After POEM, there was no change in the GERD-HRQL total score (p = 0.854), but objective reflux significantly increased (0 to 62%; p < 0.001). On manometry, there was a decrease in LES resting pressure (43 (30-68) to 31 (5-34); p = 0.042) and IRP (23 (18-33) to 12 (10-32); p = 0.048), DCI (1920 (1600-5500) to 0 (0-814); p = 0.035), with increased failed swallows (0% (0-30) to 100% (10-100); p = 0.032). Bolus clearance did not improve (p = 0.539). Compared to HMD, POEM had a longer esophageal myotomy length (11 (7-15)-vs-5 (5-6); p = 0.001), more objective reflux (p = 0.041), lower DCI (0 (0-814)-vs-1695 (929-3101); p = 0.004), and intact swallows (90 (70-100)-vs-0 (0-40); p = 0.006), but more failed swallows (100 (10-100); p = 0.018) and incomplete bolus clearance (90 (90-100)-vs-10 (0-40); p = 0.004).

CONCLUSION

Peroral endoscopic myotomy and Heller myotomy with Dor fundoplication are equally effective at relieving EGJOO symptoms. However, POEM causes worse reflux and near complete loss of esophageal body function.

A Short History of High-Resolution Esophageal Manometry

High-resolution esophageal manometry (HRM) utilizes sufficient pressure sensors such that intraluminal pressure is monitored as a continuum along luminal length, similar to time viewed as a continuum on polygraph tracings in 'conventional' manometry. When HRM is coupled with pressure topography plotting, and pressure amplitude is transformed into spectral colors with isobaric areas indicated by same-colored regions, "Clouse plots" are generated. HRM has several advantages compared to the technology that it replaced: (1) the contractility of the entire esophagus can be viewed simultaneously in a uniform standardized format, (2) standardized objective metrics of peristaltic and sphincter function can be systematically applied for interpretation, and (3) topographic patterns of contractility are more easily recognized with greater reproducibility. Leveraging these advantages led to the current standard for the interpretation of clinical esophageal HRM studies, the Chicago Classification (CC), now in its fourth iteration. Compared to conventional manometry, HRM has vastly improved the sensitivity for detecting achalasia, largely due to the objectivity and accuracy of identification of impaired esophagogastric junction (EGJ) relaxation. Additionally, it has led to the subcategorization of achalasia into three clinically relevant subtypes, differentiated by the contractile function of the esophageal body, and identified an additional disorder of EGJ outflow obstruction wherein esophageal peristalsis is preserved. Headway has also been made in understanding hypocontractile and hypercontractile conditions. In summary, HRM and the CC process have revolutionized our understanding of esophageal motility and motility disorders. Moving forward, there will always be remaining challenges, but we now have the tools to meet them.

Functional Lumen Imaging Probe Panometry Helps Identify Clinically Relevant Esophagogastric Junction Outflow Obstruction per Chicago Classification v4.0

INTRODUCTION

Esophagogastric junction (EGJ) outflow obstruction (EGJOO) per Chicago Classification v4.0 (CCv4.0) represents a high-resolution manometry (HRM) diagnosis with uncertain clinical significance. This study aimed to evaluate functional lumen imaging probe (FLIP) panometry among patients with EGJOO on HRM/CCv4.0 to assess clinical/manometric associations and treatment outcomes.

METHODS

An observational cohort study was performed on patients who completed FLIP during endoscopy and had an HRM/CCv4.0 diagnosis of EGJOO, i.e., HRM-EGJOO (inconclusive). Abnormal FLIP panometry motility classifications were applied to identify FLIP-confirmed conclusive EGJOO. Rapid drink challenge on HRM and timed barium esophagram were also assessed. Clinical management plan was determined by treating physicians and assessed through chart review. Clinical outcome was defined using the Eckardt score (ES) during follow-up evaluation: ES < 3 was considered a good outcome.

RESULTS

Of 139 adult patients with manometric EGJOO (inconclusive per CCv4.0), a treatment outcome ES was obtained in 55 after achalasia-type treatment (i.e., pneumatic dilation, peroral endoscopic myotomy, laparoscopic Heller myotomy, or botulinum toxin injection) and 36 patients after other nonachalasia-type treatment. Among patients with conclusive EGJOO by HRM-FLIP complementary impression, 77% (33/43) had a good outcome after achalasia-type treatment, whereas 0% (0/12) of patients had a good outcome after nonachalasia-type treatment. Of patients with normal EGJ opening on FLIP, one-third of patients treated with achalasia-type treatment had a good outcome, while 9 of the 10 treated conservatively had a good outcome.

DISCUSSION

FLIP panometry provides a useful complement to clarify the clinical significance of an HRM/CCv4.0 EGJOO diagnosis and help direct management decisions.

High-resolution manometry with additional maneuvers using the Starlet system: normative thresholds and diagnostic yields for relevant esophagogastric junction outflow disorders

BACKGROUND

Chicago classification version 4.0 suggests additional maneuvers, such as upright testing, multiple rapid swallows (MRS), and the rapid drink challenge (RDC), for high-resolution manometry (HRM) to minimize ambiguity in the diagnosis of esophageal motility disorders. The present study investigated normative thresholds for these new metrics using the Starlet system as well as their diagnostic yields for relevant esophagogastric outflow disorders (EGJOD).

METHODS

In study 1, 30 asymptomatic volunteers prospectively performed HRM including MRS and RDC in the supine/upright positions. We calculated normative thresholds for the new metrics, such as upright integrated relaxation pressure (IRP), upright intrabolus pressure (IBP), and IRP during RDC (RDC-IRP). In study 2, we retrospectively analyzed the HRM tracings of 82 patients who underwent HRM in both positions at our hospital to assess the diagnostic yields of HRM metrics.

RESULTS

Based on the results of study 1, we adopted the following normative thresholds: upright IRP < 20 mmHg, upright IBP < 21 mmHg, and RDC-IRP < 16 mmHg. In study 2, 45 patients with dysphagia or chest pain were included in the analysis to identify predictive factors for clinically relevant esophagogastric outflow disorders (true EGJOD). Supine/upright IRP, RDC-IRP, and pan-esophageal pressurization > 20 mmHg during RDC (RDC-PEP) predicted true EGJOD with RDC-PEP with the highest sensitivity of 91.7%.

CONCLUSIONS

HRM with additional maneuvers may facilitate the diagnosis of clinically relevant EGJOD.

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.

Chicago classification v4.0 protocol improves specificity and accuracy of diagnosis of oesophagogastric junction outflow obstruction

BACKGROUND

Chicago classification version 4.0 (CCv4.0) introduced stringent diagnostic criteria for oesophagogastric junction outflow obstruction (EGJOO), in order to increase the clinical relevance of the diagnosis, although this has not yet been demonstrated.

AIMS

To determine the prevalence of EGJOO using CCv4.0 criteria in patients with CCv3.0-based EGJOO, and to assess if provocative manoeuvres can predict a conclusive CCv4.0 diagnosis of EGJOO.

METHODS

Clinical presentation, high resolution manometry (HRM) with rapid drink challenge (RDC), and timed barium oesophagogram (TBE) data were extracted for patients diagnosed with EGJOO as per CCv3.0 between 2018 and 2020. Patients were then re-classified according to CCv4.0 criteria, using clinically relevant symptoms (dysphagia and/or chest pain), and abnormal barium emptying at 5 min on TBE. Receiver operating characteristic (ROC) analyses identified HRM predictors of EGJOO.

RESULTS

Of 2010 HRM studies, 144 (7.2%) fulfilled CCv3.0 criteria for EGJOO (median age 61 years, 56.9% female). Upon applying CCv4.0 criteria, EGJOO prevalence decreased to 1.2%. On ROC analysis, integrated relaxation pressure during RDC (RDC-IRP) was a significant predictor of a conclusive EGJOO diagnosis by CCv4.0 criteria (area under the curve: 96.1%). The optimal RDC-IRP threshold of 16.7 mm Hg had 87% sensitivity, 97.1% specificity, 95.7% negative predictive value and 91.3% positive predictive value for a conclusive EGJOO diagnosis; lower thresholds (10 mmHg, 12 mmHg) had better sensitivity but lower specificity.

CONCLUSION

CCv4.0 criteria reduced the prevalence of EGJOO by 80%, thereby refining the diagnosis and identifying clinically relevant outflow obstruction. Elevated RDC-IRP can predict conclusive EGJOO per CCv4.0.

How provocative tests in addition to wet swallows during high-resolution manometry can direct clinical management

PURPOSE OF REVIEW

Provocative tests have been advocated to address limitations of high-resolution manometry (HRM) with wet swallows. We describe the commonly used provocative manometric manoeuvres [rapid drink challenge (RDC), multiple rapid swallows (MRS), solid swallows and the solid test meal (STM)], compare their diagnostic yield and accuracy to wet swallows, and outline their role in directing clinical management.

RECENT FINDINGS

Provocative testing with RDC and STM identifies a proportion of achalasia cases missed by standard testing, and RDC can play a similar role to radiology in the evaluation of treatment response. In EGJOO, provocative testing with RDC and STM not only increase the diagnostic yield, but can also help differentiate between spurious cases and those representing true outflow obstruction likely to respond to achalasia-type therapies. MRS and STM can help determine the clinical relevance (or otherwise) of ineffective oesophageal motility, and in this setting, MRS may predict the likelihood of postfundoplication dysphagia. RDC and STM can help identify cases of postfundoplication dysphagia more likely to respond to dilatation.

SUMMARY

Provocative testing has been shown to increase diagnostic yield of HRM, clarify inconclusive diagnoses, allows corroboration of dysmotility with patient symptoms and helps direct clinical management.

Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics

Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.

Nonachalasic esophageal motor disorders, from diagnosis to therapy

INTRODUCTION

Investigations conducted using conventional manometry and, recently, using high-resolution manometry (HRM), allowed us to explore the field of esophageal motility and understand the potential link between motor features and gastroesophageal reflux disease (GERD) pathogenesis. The management of patients with nonachalasic esophageal motor disorders is often challenging, due to the clinical heterogeneous presentation and the multifactorial nature of the mechanisms underlying symptoms.

AREAS COVERED

Several studies, carried out using HRM, have better interpreted the esophageal motor function in patients with esophagogastric junction outflow obstruction (EGJOO), distal esophageal spasm (DES), hypertensive esophagus, and hypomotility disorders. Moreover, HRM studies have shown a direct correlation between reduced esophageal motility, disruption of the esophagogastric junction, and gastroesophageal reflux burden.

EXPERT OPINION

Pathogenesis, clinical presentation, diagnosis, and treatment of nonachalasic esophageal motor disorders still represent a challenging area, requiring future evaluation by multicenter outcome studies carried out in a large cohort of patients and asymptomatic subjects. However, we believe that an accurate clinical, endoscopic, and HRM evaluation is, nowadays, helpful in addressing patients with nonachalasic esophageal motor disorders to optimal treatment options.

[Chicago Classification ver. 4.0: Diagnosis of Achalasia and Esophagogastric Junction Outflow Obstruction]

Achalasia is a common esophageal motility disorder characterized by inappropriate relaxation of the lower esophageal sphincter and a loss of normal peristalsis in the esophageal body. The newly suggested Chicago Classification ver. 4.0 recommends conclusive diagnoses of types 1, 2, and 3. A conclusive diagnosis of type 3 achalasia requires no appreciable peristalsis compared to the previously used ver. 3.0. In the case of inconclusive diagnosis of achalasia, additional tests, including timed barium esophagogram (TBE) or functional lumen imaging probe (FLIP), are strongly recommended in ver. 4.0. Esophagogastric junction outflow obstruction (EGJOO) in Chicago Classification ver. 3.0 was defined as an elevated median integrated relaxation pressure (IRP) without evidence of achalasia. On the other hand, the diagnosis of EGJOO in Chicago Classification ver. 4.0 requires elevated IRP in both positions, elevated intrabolus pressure, positive clinical symptoms, and additional positive test by TBE or FLIP. The newly suggested Chicago Classification Classification ver. 4.0 will be helpful in an accurate diagnosis of esophageal motility disorders, including achalasia and EGJOO.

Can FLIP guide therapy in idiopathic esophagogastric junction outflow obstruction?

BACKGROUND

Esophagogastric junction outflow obstruction (EGJOO) has a variable disease course. Currently, barium swallow (BaS) and manometric parameters are used to characterize clinically significant EGJOO. The esophagogastric junction distensibility index (EGJ-DI) measured via functional lumen imaging probe (FLIP) can provide complementary information. Our aim was to assess symptom response in patients with EGJOO and an abnormal EGJ-DI after botulinum toxin (BT) treatment.

METHODS

A prospective cohort study of adults with idiopathic EGJOO was performed from September 2019 to March 2021. Patients with dysphagia underwent upper endoscopy with FLIP. If the EGJ-DI was abnormally low, BT was injected. Data examined included demographics, medical history, endoscopic and FLIP findings, BaS, manometry, and Eckardt score (ES). ES improvement was assessed via paired samples t-test. Pearson's chi-square tests were used to assess for associations.

RESULTS

Of the 20 patients, 75% had an abnormal EGJ-DI and underwent BT injections. Mean ES for patients with abnormal EGJ-DIs significantly improved from baseline to 1, 3, and 6 month follow-up (P-values: 0.01, 0.05, and 0.02, respectively). There was a significant association between an abnormal EGJ-DI with delayed bolus transit and presence of rapid drink challenge panesophageal pressurization on manometry: P = 0.03 and P = 0.03.

CONCLUSION

This prospective study revealed that an abnormal EGJ-DI can guide BT as assessed via symptomatic response. Additionally, abnormal EGJ-DI measurements were significantly associated with other parameters used previously to determine clinically relevant EGJOO. Larger follow-up studies are warranted to further elucidate guidance for therapy in EGJOO.

Dysphagia: Novel and Emerging Diagnostic Modalities

Among recent advances in diagnostics for dysphagia and esophageal motility disorders is the update to the Chicago Classification (version 4.0) for interpretation of high-resolution manometry (HRM) and diagnosis of esophageal motility disorders. The update incorporates application of complementary testing strategies during HRM, such as provocative HRM maneuvers, and recommendation for barium esophagram or functional luminal imaging probe (FLIP) panometry to help clarify inconclusive HRM findings. FLIP panometry also represents an emerging technology for evaluation of esophageal distensibility and motility at the time of endoscopy.

Making Sense of Nonachalasia Esophageal Motor Disorders

Achalasia is the prototypical obstructive motor disorder diagnosed using HRM, but non-achalasia motor disorders are often identified in symptomatic patients. The clinical relevance of these disorders are assessed using ancillary HRM maneuvers (multiple rapid swallows, rapid drink challenge, solid swallows) that augment the standard supine HRM evaluation by challenging peristaltic function. Finding obstructive motor physiology in non-achalasia motor disorders may raise the option of invasive management akin to achalasia. Certain non-achalasia disorders, particularly hypermotility disorders, may manifest as epiphenomena seen with esophageal hypersensitivity. Symptomatic management is offered for superimposed reflux disease, psychological disorders, functional esophageal disorders, and behavioral disorders.

Clinical usefulness of esophageal high resolution manometry and adjunctive tests: An update

High resolution manometry (HRM), developed from conventional manometry, is the gold standard for assessment of esophageal motor function worldwide. The Chicago Classification, now in its fourth iteration, is the modern standard for HRM categorization of esophageal motility disorders. The HRM protocol has expanded from the original 10 supine swallow standard, to include upright swallows, and provocative maneuvers such as multiple rapid swallows, rapid drink challenge and standardized test meal. Impedance has been incorporated into HRM for visualization of bolus clearance. Futhermore, barium radiography and functional lumen imaging probe complement HRM when evidence of esophagogastric junction obstruction is inconclusive. The biggest impact of HRM is in the improved diagnosis and subtyping of achalasia spectrum disorders, with implications on management. Spastic disorders and absent contractility are better characterized. Within the reflux spectrum, HRM provides definition of morphology and tone of the esophagogastric junction, and assesses integrity of esophageal body peristalsis, which have pathophysiologic implications for reflux and its clearance. HRM provides characterization of behavioral disorders such as supragastric belching and rumination syndrome, which can mimic reflux disease. Thus, HRM has revolutionized the evaluation of esophageal motor function, and has expanded the utility of esophageal manometry in clinical practice.

Prediction of Esophageal Retention: A Study Comparing High-Resolution Manometry and Functional Luminal Imaging Probe Panometry

INTRODUCTION

High-resolution manometry (HRM) is generally considered the primary method to evaluate esophageal motility; functional luminal imaging probe (FLIP) panometry represents a novel method to do so and is completed during sedated endoscopy. This study aimed to compare HRM and FLIP panometry in predicting esophageal retention on timed barium esophagram (TBE).

METHODS

A total of 329 adult patients who completed FLIP, HRM, and TBE for primary esophageal motility evaluation were included. An abnormal TBE was defined by a 1-minute column height >5 cm or impaction of a 12.5-mm barium tablet. The integrated relaxation pressure (IRP) on HRM was assessed in the supine and upright patient positions. Esophagogastric junction (EGJ) opening was evaluated with 16-cm FLIP performed during sedated endoscopy through EGJ-distensibility index and maximum EGJ diameter.

RESULTS

Receiver operating characteristic curves to identify an abnormal TBE demonstrated AUC (95% confidence interval) of 0.79 (0.75-0.84) for supine IRP, 0.79 (0.76-0.86) for upright IRP, 0.84 (0.79-0.88) for EGJ-distensibility index, and 0.88 (0.85-0.92) for maximum EGJ diameter. Logistic regression to predict abnormal TBE showed odds ratios (95% confidence interval) of 1.8 (0.84-3.7) for consistent IRP elevation and 39.7 (16.4-96.2) for reduced EGJ opening on FLIP panometry. Of 40 patients with HRM-FLIP panometry discordance, HRM-IRP was consistent with TBE in 23% while FLIP panometry was consistent with TBE in 78%.

DISCUSSION

FLIP panometry provided superior detection of esophageal retention over IRP on HRM. However, application of a complementary evaluation involving FLIP panometry, HRM, and TBE may be necessary to accurately diagnose esophageal motility disorders.

Chicago Classification Version 4.0 and Its Impact on Current Clinical Practice

High-resolution manometry (HRM) has revolutionized esophageal motility testing, and the evolving Chicago Classification has been critical in codifying HRM metrics and definitions of old and new motility disorders. The latest Chicago Classification (version 4.0) is the result of a working group of 52 members (10 women) from 20 countries. Two critical new elements are the expansion of the normal database from 75 to 469 healthy volunteers and the recommendation of ancillary function tests (timed barium esophagram, functional lumen imaging planimetry, and/or impedance) to help with inconclusive HRM metrics, especially in cases of suspected achalasia, esophagogastric junction outflow obstruction (EGJOO), and ineffective esophageal motility (IEM). Important changes relevant to clinical practice include (1) refinement of the diagnosis criteria for EGJOO, which now require elevated integrated relaxation pressure in an upright position along with primary symptoms of dysphagia/noncardiac chest pain and obstruction at the esophago-gastric junction; (2) exclusion of mechanical obstruction in cases of suspected distal esophageal spasm and hypercontractile esophagus; and (3) a shift to a more restrictive metric (>70% ineffective peristalsis) for a diagnosis of IEM. In addition, the working group urged caution in using treatments such as pneumatic dilation or myotomy, which can irreversibly destroy lower esophageal sphincter competency and peristalsis, as the natural history of EGJOO/hypercontractile esophagus is poorly understood and spontaneous symptom resolution is common. Future versions should address the routine use of impedance with HRM, the role of HRM in pharyngeal/upper esophageal sphincter diseases, and the need for better criteria to determine which subsets of spastic disorders warrant aggressive treatment, as is done with achalasia.

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.

Esophagogastric junction outflow obstruction

In the Chicago Classification version 4.0 (CCv4), esophagogastric junction outflow obstruction (EGJOO) is manometrically defined as an elevated median integrated relaxation pressure (IRP) and elevated intrabolus pressure (IBP) during supine wet swallows, and persistently elevated median IRP in the upright position. A clinically relevant conclusive diagnosis of EGJOO requires a manometric diagnosis of EGJOO and associated symptoms such as dysphagia and/or chest pain with at least one of the following supportive investigations (pharmacologic provocation, timed barium esophagogram, and/or endoflip). The Chicago Classification is intended for diagnosis of primary esophageal motor disorders, and thus history and endoscopic evaluation are important to exclude conditions (eg, previous surgery, strictures, or masses) that can secondarily generate the EGJOO pattern on HRM. While a manometric finding of EGJOO is often made and can be an early sign of achalasia, more often it is a manometric finding without clinical implications. The proposed changes in CC4.0 have attempted to make the diagnosis more specific, in order to reduce the number of clinically irrelevant diagnoses and avoid confusion by patients and physicians alike.

Diagnosis and Management of Achalasia: Updates of the Last Two Years

Achalasia is a rare neurodegenerative disorder causing dysphagia and is characterized by abnormal esophageal motor function as well as the loss of lower esophageal sphincter (LES) relaxation. The assessment and management of achalasia has significantly progressed in recent years due to the advances in high-resolution manometry (HRM) technology along with the improvements and innovations of therapeutic endoscopy procedures. The recent evolution of HRM technology with the inclusion of an adjunctive test, fluoroscopy, and EndoFLIP has enabled more precise diagnoses of achalasia to be made and the subgrouping into therapeutically meaningful subtypes. Current management possibilities include endoscopic treatments such as Botulinum toxin injected to the LES and pneumatic balloon dilation. Surgical treatment includes laparoscopic Heller myotomy and esophagectomy. Furthermore, in recent years, per oral endoscopic myotomy (POEM) has established itself as a principal endoscopic therapeutic alternative to the traditional laparoscopic Heller myotomy. The latest randomized trials report that POEM, pneumatic balloon dilatation, and laparoscopic Heller's myotomy have comparable effectiveness and complications rates. The aim of the current review is to provide a practical clinical approach to dysphagia and to shed light on the most recent improvements in diagnostics and treatment of achalasia over the last two years.

Normal Values of High-resolution Manometry Parameters With Provocative Maneuvers

Background/Aims

Incorporation of complementary and provocative test swallows to the high-resolution manometry (HRM) protocol offers potential to address limitations posed by HRM protocols that involve only a single swallow type. The aim of this study is to describe normal findings of a comprehensive HRM testing protocol performed on healthy asymptomatic volunteers.

Methods

Thirty healthy asymptomatic volunteers completed HRM with 5-mL liquid swallows in the supine position. They also completed 5-mL liquid swallows in the upright position, viscous swallows, solid test swallows, multiple rapid swallows, and a rapid drink challenge. HRM studies were analyzed via Chicago classification version 3.0.

Results

The median (5th-95th percentiles) for integrated relaxation pressure (IRP) on supine swallows was 11 (4-16) mmHg; IRP was lower than supine on upright liquid 9 (0-17) mmHg, viscous 6 (0-15) mmHg, solid 9 (1-19) mmHg, multiple rapid swallows 3 (0-12) mmHg, and rapid drink challenge 5 (–3-12) mmHg; P < 0.005. While an “elevated” IRP value was observed on 1 to 2 test maneuvers in 8/30 (27%) subjects, all 30 subjects had an IRP value < 12 mmHg on at least one of the test maneuvers.

Conclusions

Normal values and findings from a comprehensive HRM testing protocol are reported based on evaluation of 30 healthy asymptomatic volunteers. Isolated “abnormalities” of IRP and contractile parameters were observed in the majority (80%) of these asymptomatic subjects, while all subjects also had normal features observed. Thus, the definition of “normal” should be recalibrated to focus on the entirety of the study and not individual metrics.

Upright Integrated Relaxation Pressure Predicts Symptom Outcome for Esophagogastric Junction Outflow Obstruction

Background/Aims

Esophagogastric junction outflow obstruction (EGJOO) is characterized by elevated integrated relaxation pressure (IRP) and preserved esophageal peristalsis. The clinical significance of EGJOO is uncertain. This study aim to describe the clinical characteristics of these patients and to find out potential parameters to predict patients’ symptom outcome.

Methods

Consecutive patients who received high-resolution manometry examination in our hospital in 2013-2019 and met the diagnostic criteria of EGJOO were retrospectively included. Motility and reflux parameters as well as endoscopy and barium esophagogram results were studied and compared. Patients were also followed up to record their treatment methods and symptom outcomes.

Results

A total of 138 EGJOO (accounting for 5.2% of total patients taking high-resolution manometry examination in our hospital) patients were included. Only 2.9% of these patients had persistent dysphagia. A total of 81.8% of EGJOO patients had symptom resolution during follow-up. Patients with persistent dysphagia had significantly higher upright IRP (16.6 [10.3, 19.8] vs 7.8 [3.2, 11.5]; P = 0.026) than those without. Upright IRP can effectively distinguished patients with persistent dysphagia (area under curve 0.826; P = 0.026) using optimal cut-off value of 9.05 mmHg.

Conclusion

EGJOO patients with persistent dysphagia and higher upright IRP (median > 9.05 mmHg) needs further evaluation and aggressive management.

Coexisting Abnormal Esophageal Body Motility Predicts Clinical Symptoms and Bolus Transit in Patients With Esophagogastric Junction Outflow Obstruction (EGJOO)

GOAL

The goal of this study was to compare the clinical presentations of esophagogastric junction outflow obstruction (EGJOO) with coexisting abnormal esophageal body motility (EBM) to isolated EGJOO.

BACKGROUND

The clinical significance and management of EGJOO remain debated, as patients may have varied to no symptoms. The effect of coexisting abnormal EBM in EGJOO is unclear. We hypothesized that a concomitant EBM disorder is associated with clinical symptoms of EGJOO.

STUDY

This was a retrospective cohort study of consecutive adults diagnosed with EGJOO on high-resolution impedance-manometry (HRIM) at 2 academic centers in March 2018 to September 2018. Patients with prior treatment for achalasia, foregut surgery, or evidence of obstruction were excluded. Subjects were divided into EGJOO with abnormal EBM per Chicago classification v3.0 and isolated EGJOO. Statistical analyses were performed using Fisher-exact or Student t test (univariate) and logistic or linear regression (multivariate).

RESULTS

Eighty-two patients (72% women, age 61.1±10.7 y) were included. Thirty-one (37.8%) had abnormal EBM, including 16 (19.5%) ineffective esophageal motility and 15 (18.2%) hypercontractile esophagus. Esophageal symptoms (heartburn, regurgitation, chest pain, dysphagia) were more prevalent among those with abnormal EBM (90.3% vs. 64.7%, P=0.01). On logistic regression adjusting for age, gender, body mass index, and opioid use, abnormal EBM remained predictive of esophageal symptoms (adjusted odds ratio [aOR] 7.51, P=0.007). On separate models constructed, HE was associated with chest pain (aOR 7.45, P=0.01) and regurgitation (aOR 4.06, P=0.046), while ineffective esophageal motility was predictive of heartburn (aOR 5.84, P=0.009) and decreased complete bolus transit (β-coefficient -0.177, P=0.04).

CONCLUSION

Coexisting abnormal EBM is associated with esophageal symptoms and bolus transit in patients with EGJOO.

Management of the patient with esophagogastric junction outflow obstruction

PURPOSE OF REVIEW

Esophagogastric junction outflow obstruction (EGJOO), defined as elevated integrated residual pressure (IRP) with preservation of esophageal peristalsis, is a common finding on high-resolution esophageal manometry.

RECENT FINDINGS

The recent Chicago classification version 4.0 proposes changes to the criteria for diagnosing EGJOO, making this diagnosis more restrictive to now include elevated IRP in both supine and upright positions (with preservation of esophageal peristalsis), presence of obstructive symptoms, and confirmatory tests for EGJOO, such as timed barium esophagram with barium tablet or functional lumen imaging probe.

SUMMARY

Once the diagnosis of EGJOO is established, secondary causes need to be ruled out, especially the use of opioid medications. Upper endoscopy is needed for evaluation of EGJOO patients, though cross-sectional imaging is usually not necessary. Many patients improve without intervention; thus, expectant management is recommended for patients with mild or atypical symptoms. There seems to be a limited role for medical treatment. Botox injection into the lower esophageal sphincter is often used to see if the patient improves before committing to more definitive treatments, such as pneumatic dilation, peroral endoscopic myotomy, or Heller myotomy.

The effects of different postures and provocative swallow materials on the normative Chicago 3.0 metrics in a healthy Asian population

BACKGROUND AND AIM

Variations in the Chicago 3.0 normative metrics may exist with different postures and with different provocative swallow materials in a healthy Asian population.

METHOD

Eligible healthy Malay volunteers were invited to undergo the high-resolution esophageal manometry (inSIGHT Ultima, Diversatek Healthcare, Milwaukee, WI, USA). In recumbent and standing positions, test swallows were performed using liquid, viscous, and solid materials. Metrics including integrated relaxation pressure 4 s (IRP-4 s, mmHg), distal contractile integral (DCI, mmHg s cm), distal latency (DL, s), and peristaltic break (PB, cm) were reported in median and 95th percentile.

RESULTS

Fifty of 57 screened participants were recruited, and 586 saline, 265 viscous, and 261 solid swallows were analyzed. Per-patient wise, in the recumbent position, 95th percentile for IRP-4 s, DCI, DL, and PB were 16.5 mmHg, 2431 mmHg s cm, 8.5 s, and 7.2 cm, respectively. We observed that with each posture, the use of viscous swallows led to changes in DL, but the use of solid swallows led to more changes in the metrics including DCI and length of PB. Compared with a recumbent posture, anupright posture led to lower IRP-4 s and DCI values. Both per-patient analysis and per-swallow analyses yielded almost similar results when comparing the different postures and types of swallows. No major motility disorders were observed in this cohort of asymptomatic population. However, more motility disorders were reported in the upright position.

CONCLUSIONS

Variations in metrics can be observed in different postures and with different provocative swallow materials in a healthy population. The normative Chicago 3.0 metrics are also determined for the Malay population.

Alteration in Integrated Relaxation Pressure During Successive Swallows in Subjects With Normal Manometry Versus Those With Esophagogastric Junction Outflow Obstruction

Background/Aims

Integrated relaxation pressure (IRP) is defined as the average minimum esophagogastric junction pressure for 4 seconds of relaxation (contiguous or noncontiguous) within 10 seconds of swallowing. The durability of IRP values during successive swallows in the supine position remains to be elucidated. The aim is to determine alteration in IRP values during successive swallows among subjects with normal esophageal manometry versus those with esophagogastric junction outflow obstruction (EGJOO).

Methods

Consecutive subjects, who underwent high-resolution esophageal manometry (HREM) were included in the study. Individuals had to have either normal manometry or EGJOO. A total of 10 wet swallows of 5 mL water were performed after an adaptation period of a minimum of 3 minutes. Mean IRP was analyzed for both subject groups for each individual swallow.

Results

Thirty-one patients with EGJOO and seventy patients with normal manometry were included. As expected, the median IRP was higher in EGJOO patients compared to those with normal HREM (mean 23.92 vs 5.34, P < 0.001). The mean IRP of the last swallow was 40% lower than the mean IRP of the first swallow in the normal subjects (P = 0.015). In contrast, the difference in the mean IRP value in the EGJOO group between the first and the last swallow was 19% (P = 0.018).

Conclusions

This study demonstrated that there is a significant decline in the mean IRP during successive swallows in subjects with normal esophageal manometry and those with EGJOO, despite adequate adaptation periods. This decline in IRP was less pronounced in EGJOO.

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.

Chicago classification version 4.0© technical review: Update on standard high-resolution manometry protocol for the assessment of esophageal motility

The Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). A key feature of CCv.4.0 is the more rigorous and expansive protocol that incorporates single wet swallows acquired in different positions (supine, upright) and provocative testing, including multiple rapid swallows and rapid drink challenge. Additionally, solid bolus swallows, solid test meal, and/or pharmacologic provocation can be used to identify clinically relevant motility disorders and other conditions (eg, rumination) that occur during and after meals. The acquisition and analysis for performing these tests and the evidence supporting their inclusion in the Chicago Classification protocol is detailed in this technical review. Provocative tests are designed to increase the diagnostic sensitivity and specificity of HRM studies for disorders of esophageal motility. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification, decrease the proportion of HRM studies that deliver inconclusive diagnoses and increase the number of patients with a clinically relevant diagnosis that can direct effective therapy. Another aim in establishing a standard manometry protocol for motility laboratories around the world is to facilitate procedural consistency, improve diagnostic reliability, and promote collaborative research.

Blown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia

BACKGROUND AND AIMS

Although laparoscopic Heller myotomy (LHM) or peroral endoscopic myotomy (POEM) is highly effective, 10% to 20% of patients with achalasia remain symptomatic after treatment. In evaluating such patients, we have observed a pattern of failure associated with a pseudodiverticulum, or blown-out myotomy (BOM), in the distal esophagus. We aimed to assess risk factors and patient-reported outcomes associated with a BOM.

METHODS

We reviewed our manometry database for patients with achalasia previously treated with LHM or POEM. We included patients who had a post-treatment esophagram within 1 year of their follow-up manometry. A BOM was defined radiographically as a wide-mouthed outpouching (>50% increase in esophageal diameter) in the area of the myotomy.

RESULTS

One hundred twenty-nine patients with achalasia who underwent treatment were included; 23 (17.8%) had a BOM. Comparing patients with a BOM with those without, post-treatment Eckardt scores were significantly greater (5 vs 2, P = .002), type III achalasia was more common (39.1% vs 14.2%, P = .005), and LHM was more common than POEM (73.9% vs 26.1%, P = .013). The integrated relaxation pressure was also significantly greater in the BOM group (15.0 mm Hg vs 11.0 mm Hg, P = .025).

CONCLUSIONS

BOM is a common adverse event after myotomy for achalasia but is not seen after pneumatic dilation. Pretreatment type III achalasia, LHM as opposed to POEM, and a greater post-treatment integrated relaxation pressure were risk factors for developing a BOM. We speculate that esophageal wall strain in the area weakened by myotomy, whether from residual spastic contractility or continued esophageal outflow obstruction, may be the underlying mechanism of BOM development.

Multiple rapid swallows and rapid drink challenge in patients with esophagogastric junction outflow obstruction on high-resolution manometry

BACKGROUND

Esophagogastric junction outflow obstruction (EGJOO) as defined by Chicago Classification of esophageal motility disorders (CCv3.0) encompasses a broad range of diagnoses, thus posing clinical challenges. Our aims were to evaluate multiple rapid swallow (MRS) and rapid drink challenge (RDC) during high-resolution manometry (HRM) to aid identifying clinically relevant EGJOO.

METHODS

Patients with a HRM diagnosis of EGJOO based on CCv3.0 that also completed MRS and RDC during HRM and barium esophagram were retrospectively identified. Radiographic EGJOO (RAD-EGJOO) was defined by either liquid barium retention or delayed passage of a barium tablet on barium esophagram. Thirty healthy asymptomatic controls that completed HRM were also included. MRS involved drinking 2 mL for 5 successive swallows. RDC involved rapid drinking of 200 mL liquid. Integrated relaxation pressure (IRP) and presence of panesophageal pressurization (PEP) during MRS and RDC were assessed.

KEY RESULTS

One hundred one patients, mean (SD) age 56 (16) years, were included; 32% had RAD-EGJOO, 68% did not. RAD-EGJOO patients more frequently had elevated (>12 mmHg) upright IRP (100%), MRS-IRP (56%), RDC-IRP (53%), and PEP during RDC (66%) than both controls [17%; 0%; 7%; 3%] and patients without RAD-EGJOO [83%; 35%; 39%; 41%] Having IRP >12 mmHg during both MRS and RDC was twice as likely to be associated with RAD-EGJOO (19%) than those without RAD-EGJOO (9%) among patients with upright IRP >12 mmHg.

CONCLUSIONS AND INFERENCES

Adjunctive HRM maneuvers MRS and RDC appear to help identify clinically significant EGJOO. While future outcome studies are needed, comprehensive multimodal evaluation helps clarify relevance of EGJOO on HRM.

[Diagnosis of Dysphagia: High Resolution Manometry & EndoFLIP]

Esophageal motility disorders were re-defined when high-resolution manometry was employed to better understand their pathogenesis. Newly developed parameters including integrated relaxation pressure (IRP), distal contractile integral, and distal latency showed better diagnostic yield compared with previously used conventional parameters. Therefore, Chicago classification was formulated, and its diagnostic cascade begins by assessing the IRP value. However, IRP showed limitation due to its inconsistency, and other studies have tried to overcome this. Recent studies showed that provocative tests, supplementing the conventional esophageal manometry protocol, have improved the diagnostic yield of the esophageal motility disorders. Therefore, position change from supine to upright, solid or semi-solid swallowing, multiple rapid swallows, and the rapid drink challenge were newly added to the manometry protocol in the revised Chicago classification version 4.0. Impedance planimetry enables measurement of bag cross-sectional area at various locations. The functional lumen imaging probe (FLIP) has been applied to assess luminal distensibility. This probe can also measure pressure, serial cross-sectional areas, and tension-strain relationship. The esophagogastric junction's distensibility is decreased in achalasia. Therefore, EndoFLIP can be used to assess contractility and distensibility of the esophagus in the patients with achalasia, including repetitive antegrade or retrograde contractions. EndoFLIP can detect achalasia patients with relatively low IRP, which was difficult to diagnose using the current high-resolution manometry. EndoFLIP also provides information on the contractile activity and distensibility of the esophageal body in patients with achalasia. The use of provocative tests, newly added in Chicago classification 4.0 version, and EndoFLIP can expand understanding of esophageal motility disorders.

The Clinical Utility of Provocative Maneuvers at Esophageal High-resolution Manometry (HRM)

Esophageal high-resolution manometry (HRM) assesses esophageal motor function and is indicated both for evaluation of esophageal symptoms and before antireflux interventions. HRM studies are interpreted and esophageal motor diagnoses made according to the Chicago Classification, version 3.0 algorithm, which is based on ten 5 mL supine water swallows. However, this practice of single liquid swallows performed in the supine position does not reflect typical "real-life" swallowing, and may not reproduce the patient's presenting symptoms. Therefore, provocative maneuvers at HRM-beyond these 10 standard swallows-can afford additional insights into esophageal motor function with clinically significant implications, and represent areas of exciting investigation and innovation. Accordingly, the 2020 American College of Gastroenterology Guidelines on Esophageal Physiologic Testing conditionally recommend their inclusion in the HRM protocol. In this clinical review, we discuss the supporting data for and clinical utility of provocative maneuvers at HRM that include changes in body position or accessories (upright swallows, "bridge" position, straight leg raise, abdominal compression), bolus consistency (solid swallows, test meals, postprandial high-resolution impedance manometry), bolus frequency (multiple rapid swallows), the volume of bolus (rapid drink challenge/multiple water swallows), and the use of pharmacological agents.

The Clinical Relevance of Manometric Esophagogastric Junction Outflow Obstruction Can Be Determined Using Rapid Drink Challenge and Solid Swallows

INTRODUCTION

Esophagogastric junction outflow obstruction (EGJOO) defined on high-resolution esophageal manometry (HRM) poses a management dilemma given marked variability in clinical manifestations. We hypothesized that findings from provocative testing (rapid drink challenge and solid swallows) could determine the clinical relevance of EGJOO.

METHODS

In a retrospective cohort study, we included consecutive subjects between May 2016 and January 2020 with EGJOO. Standard HRM with 5-mL water swallows was followed by provocative testing. Barium esophagography findings were obtained. Cases with structural obstruction were separated from functional EGJOO, with the latter categorized as symptom-positive or symptom-negative. Only symptom-positive subjects were considered for achalasia-type therapies. Sensitivity and specificity for clinically relevant EGJOO during 5-mL water swallows, provocative testing, and barium were calculated.

RESULTS

Of the 121 EGJOO cases, 76% had dysphagia and 25% had holdup on barium. Ninety-seven cases (84%) were defined as functional EGJOO. Symptom-positive EGJOO subjects were more likely to demonstrate abnormal motility and pressurization patterns and to reproduce symptoms during provocative testing, but not with 5-mL water swallows. Twenty-nine (30%) functional EGJOO subjects underwent achalasia-type therapy, with symptomatic response in 26 (90%). Forty-eight (49%) functional EGJOO cases were managed conservatively, with symptom remission in 78%. Although specificity was similar, provocative testing demonstrated superior sensitivity in identifying treatment responders from spontaneously remitting EGJOO (85%) compared with both 5-mL water swallows (54%; P < 0.01) and barium esophagography (54%; P = 0.02).

DISCUSSION

Provocative testing during HRM is highly accurate in identifying clinically relevant EGJOO that benefits from therapy and should be routinely performed as part of the manometric protocol.

Normal Functional Luminal Imaging Probe Panometry Findings Associate With Lack of Major Esophageal Motility Disorder on High-Resolution Manometry

BACKGROUND & AIMS

A normal esophageal response to distension on functional luminal imaging probe (FLIP) panometry during endoscopy might indicate normal esophageal motor function. We aimed to investigate the correlation of normal FLIP panometry findings with esophageal high-resolution manometry (HRM) and outcomes of discrepant patients.

METHODS

We performed a retrospective study using data from a registry of patients who completed FLIP during sedated endoscopy. We identified 111 patients with normal FLIP panometry findings (mean age, 42 y; 69% female) and corresponding HRM data. A normal FLIP panometry was defined as an esophagogastric junction (EGJ) distensibility index greater than 3.0 mm2/mm Hg, an absence of repetitive retrograde contractions, and a repetitive antegrade contraction pattern that met the Rule-of-6s: ≥6 consecutive antegrade contractions of ≥6-cm in length, at a rate of 6 ± 3 contractions per minute. HRM findings were classified by the Chicago classification system version 3.0.

RESULTS

HRM results were classified as normal motility in 78 patients (70%), ineffective esophageal motility in 10 patients (9%), EGJ outflow obstruction in 20 patients (18%), and 3 patients (3%) as other. In patients with EGJ outflow obstruction based on HRM, the integrated relaxation pressure normalized on adjunctive swallows in 16 of 20 patients (80%), and in 8 of 9 patients (88%) who completed a barium esophagram and had normal barium clearance. Thus, although 23 of 111 patients (21%) with normal FLIP panometry had abnormal HRM findings, these HRMs often were considered to be false-positive or equivocal results. All patients with an abnormal result from HRM were treated conservatively.

CONCLUSIONS

In a retrospective cohort study, we found that patients with normal FLIP panometry results did not have a clinical impression of a major esophageal motor disorder. Normal FLIP panometry results can exclude esophageal motility disorders at the time of endoscopy, possibly negating the need for HRM in select patients.

Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0©

Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diagnostic criteria for ineffective esophageal motility and description of baseline EGJ metrics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for patterns of disorders of peristalsis and obstruction at the EGJ.

Treatment experience with a novel 30-mm hydrostatic balloon in esophageal dysmotility: a multicenter retrospective analysis

BACKGROUND AND AIMS

The newest addition in the management of achalasia and esophagogastric junction outflow obstruction (EGJOO) is a 30-mm hydrostatic balloon dilator that uses impedance planimetry technology. It allows for the measurement of the diameter and cross-sectional area to determine effective dilation. We aimed to (1) determine the clinical success (defined as a decrease in Eckardt score to ≤3) in the treatment of esophageal motility disorders and (2) report the safety (rate/severity of adverse events).

METHODS

This retrospective multicenter study involved 4 centers. Patients with esophageal motility disorders who underwent hydrostatic balloon dilation between January 2015 and October 2018 were included.

RESULTS

Fifty-one patients (mean age, 54.1 years; women, 49%) underwent hydrostatic dilation for achalasia (n = 37) or EGJOO (n = 14) during the study period. Forty-seven patients had a median baseline Eckardt score of 5 (range, 3-8; achalasia, n = 35, 6 [range, 3-8]; EGJOO, n = 12, 4 [range, 3.25-6.5]). Clinical success was achieved in 60% of cases (achalasia vs EGJOO: 68.4% vs 33.3%, P = .18). Dilation resulted in a significant decrease in the median Eckardt score from 5 (range, 3-8) to 1.5 (range, 1-4.75; P < .001). Patients with achalasia had a decrease in Eckardt score from 6 (range, 3-8) to 1 (range, 1-4; P < .001), whereas those with EGJOO experienced no significant change. One patient had mild postprocedure chest pain.

CONCLUSIONS

The hydrostatic balloon dilator is a new tool in our armamentarium to treat esophageal motility disorders. This is the first multicenter study showing the device to be safe and moderately efficacious.

Clinical Functional Lumen Imaging Probe Testing in Esophageal Disorders: A Need for Better Quality Evidence

In their article "Use of the Functional Lumen Imaging Probe in Clinical Esophagology," Savarino et al. report the outcomes of a Grading of Recommendations Assessment, Development, and Evaluation analysis performed by experts in the use of functional lumen imaging probe (FLIP) evaluation of esophageal disorders. For essentially all clinical indications, the recommendation for use was conditional with a very low quality of evidence. FLIP is an expensive, invasive technology examining limited aspects of esophageal function. Its role in complementing or replacing existing technology is uncertain, particularly when compared with manometric testing with additional provocative studies. Performing properly designed studies to demonstrate FLIP's true effectiveness and cost-effectiveness will be costly.

High-resolution manometry in the upright position could improve the manometric evaluation of morbidly obese patients with esophagogastric junction outflow obstruction

BACKGROUND

Esophagogastric junction outflow obstruction (EGJOO) detected by manometry in the supine position is prevalent in patients with morbid obesity, but not all EGJOOs are clinically significant. We investigated whether including upright swallows during high-resolution manometry (HRM) could help identify non-clinically significant EGJOO in patients with morbid obesity.

METHODS

We performed a retrospective study of consecutive morbidly obese patients diagnosed with EGJOO by HRM from July 2012 through July 2018. The HRM protocol included 10 supine and five upright 5-mL water swallows. Endoscopy, esophagram, and computed tomography were performed to identify whether the patients should be diagnosed as having clinically significant EGJOO.

KEY RESULTS

A total of 230 patients with morbid obesity underwent HRM in the supine position during the study period. Fifty (21.7%) patients were diagnosed with EGJOO, among which 32 completed HRM both in the supine and upright positions. Only 8/32 patients were diagnosed with EGJOO in an upright position. Fewer artifacts were displayed in esophageal pressure topography in the upright position. None of the 32 patients could be diagnosed as clinically significant EGJOO based on all the examinations. Median esophageal gastric junction pressure, integrated relaxation pressure, and distal contractile integral were higher, and median distal latency was longer in the supine position compared with the upright position (all P < .05).

CONCLUSIONS AND INFERENCES

Esophagus manometry in the upright position could reduce EGJOO overdiagnosis in patients with morbid obesity. Prolongation of the HRM study with some swallows in the upright position could be recommended in obese patients.

Updates on diagnostic modalities for esophageal dysphagia

Esophageal dysphagia is a common symptom in adults. Fluoroscopic contrast studies, endoscopy, and esophageal manometry have been used in the diagnosis of esophageal dysphagia for many years. The diagnostic yield has been improved with new test protocols that highlight abnormal bolus transit in the esophagus and outflow obstruction, as well as new high-definition and high-resolution technical advances in equipment. Functional luminal impedance planimetry and the addition of impedance to high-resolution esophageal manometry have also allowed the assessment of new parameters to better understand esophageal structure and function. In this concise review, we describe the role and utility of various diagnostic modalities in the assessment of patients with esophageal dysphagia.

EndoFLIP in the Esophagus: Assessing Sphincter Function, Wall Stiffness, and Motility to Guide Treatment

The functional luminal imaging probe (FLIP) uses high-resolution planimetry to provide a three-dimensional image of the esophageal lumen by measuring diameter, volume, and pressure changes. Literature surrounding use of FLIP has demonstrated its clinical utility as a diagnostic tool and as a device to guide and measure response to therapy. FLIP can assess and guide treatments for esophageal disease states including gastroesophageal reflux disease, achalasia, and eosinophilic esophagitis. FLIP may become the initial test for patients with undifferentiated dysphagia at their index endoscopy. This article summarizes use of FLIP in assessing sphincter function, wall stiffness, and motility to guide treatments.

Enhancing High-Resolution Esophageal Manometry: Use of Ancillary Techniques and Maneuvers

High-resolution manometry evaluates esophageal motor function using 10 supine water swallows. Superimposing impedance over high-resolution manometry pressure topography assesses the relationship between contraction and bolus propulsion and identifies inadequate clearance. Ancillary techniques and maneuvers augment the standard supine high-resolution manometry evaluation by challenging peristaltic function. Increasing bolus volume (rapid drink challenge) and altering bolus consistency (standardized test meal, solid swallows) enhance identification of esophageal outflow obstruction syndromes. Physiologic maneuvers (multiple rapid swallows, abdominal compression) address the ability of the esophageal smooth muscle to augment contraction vigor. Pharmacologic challenge is less commonly used clinically, and elucidates pathophysiology of esophageal motor disorders.

Functional Luminal Imaging Probe Panometry Identifies Achalasia-Type Esophagogastric Junction Outflow Obstruction

BACKGROUND & AIMS

The etiologies of esophagogastric junction outflow obstruction (EGJOO) vary, as do their therapeutic implications. We aimed to identify patients with EGJOO most likely to benefit from achalasia-type treatment, based on findings from functional luminal imaging probe (FLIP) panometry.

METHODS

We performed a retrospective study of 34 patients who received a diagnosis of EGJOO from January 2015 through July 2017. Our analysis included patients who had been evaluated with timed barium esophagram, FLIP, or upper endoscopy.

RESULTS

Among the 34 patients with idiopathic EGJOO, 7 (21%) had a normal esophagogastric junction distensibility index (EGJ-DI), based on FLIP panometry, and all had repetitive antegrade contractions. None of the patients had radiographic evidence of EGJOO (RAD-EGJOO), defined as liquid barium retention and/or barium tablet impaction. On the other hand, all 18 patients with RAD-EGJOO had an EGJ-DI less than 2 mm²/mm Hg. Nine of the 18 patients with RAD-EGJOO and EGJ-DI less than 2 mm²/mm Hg underwent achalasia-type treatment, and 77.8% of these (7 of 9) had improvements in Eckardt score. Of the 6 patients with a normal EGJ-DI (>3 mm²/mm Hg) who were treated conservatively and followed up, 100% had improvements in subsequent Eckardt scores.

CONCLUSIONS

We found that FLIP is useful in identifying patients with EGJOO who are most likely to benefit from achalasia-type therapy. Patients with a low EGJ-DI responded well to achalasia-type treatment, whereas patients with normal results from FLIP panometry had good outcomes from conservative management. FLIP panometry might help select management strategies for this difficult population of patients.