Contribution of standard oesophageal manometry in sliding hiatal hernia: from the gastro-oesophageal pressure gradient to the diagnosis

ACG Clinical Guidelines: Clinical Use of Esophageal Physiologic Testing

Esophageal symptoms are common and may indicate the presence of gastroesophageal reflux disease (GERD), structural processes, motor dysfunction, behavioral conditions, or functional disorders. Esophageal physiologic tests are often performed when initial endoscopic evaluation is unrevealing, especially when symptoms persist despite empiric management. Commonly used esophageal physiologic tests include esophageal manometry, ambulatory reflux monitoring, and barium esophagram. Functional lumen imaging probe (FLIP) has recently been approved for the evaluation of esophageal pressure and dimensions using volumetric distension of a catheter-mounted balloon and as an adjunctive test for the evaluation of symptoms suggestive of motor dysfunction. Targeted utilization of esophageal physiologic tests can lead to definitive diagnosis of esophageal disorders but can also help rule out organic disorders while making a diagnosis of functional esophageal disorders. Esophageal physiologic tests can evaluate obstructive symptoms (dysphagia and regurgitation), typical and atypical GERD symptoms, and behavioral symptoms (belching and rumination). Certain parameters from esophageal physiologic tests can help guide the management of GERD and predict outcomes. In this ACG clinical guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to describe performance characteristics and clinical value of esophageal physiologic tests and provide recommendations for their utilization in routine clinical practice.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

THE ROLE OF THE TRANSDIAPHRAGMATIC PRESSURE GRADIENT IN THE PATHOPHYSIOLOGY OF GASTROESOPHAGEAL REFLUX DISEASE

ABSTRACT Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract in the Western world. GERD pathophysiology is multifactorial. Different mechanisms may contribute to GERD including an increase in the transdiaphragmatic pressure gradient (TPG). The pathophysiology of GERD linked to TPG is not entirely understood. This review shows that TPG is an important contributor to GERD even when an intact esophagogastric barrier is present in the setting of obesity and pulmonary diseases.

High-resolution Manometry Findings in Patients with an Intrathoracic Stomach

Intrathoracic stomach is a rare finding. The real value of the high-resolution manometry (HRM) in the preoperative evaluation of these patients has not yet being fully tested. This study aims to evaluate: 1) the HRM pattern of patients with an intrathoracic stomach; and 2) HRM findings as predictors for prosthetic reinforcement of the hiatus. We reviewed 33 patients (27 women, mean age 66 years) with an intrathoracic stomach who underwent HRM. Fifteen patients did the HRM as part of preoperative workup and were operated on in our institution. All patients were submitted to a laparoscopic Nissen fundoplication. HRM results show that the lower esophageal sphincter (LES) was transposed in all patients. Hiatal hernia was diagnosed in 21 (63%) patients. The length of the hernia was 4 ± 2 cm (range, 1 to 9 cm). LES oscillation was observed in 23 (69%) patients with a mean of 1 ± 0.4 cm (range, 0.4 to 2 cm). Hiatal mesh reinforcement was necessary in five (33%) of the operated patients. HRM findings did not predict hiatal mesh reinforcement. Our results show that: 1) HRM has a poor sensibility for hiatal hernia diagnosis; 2) half of the patients with an intrathoracic stomach have a normal HRM; and 3) HRM does not predict mesh hiatal hernia repair.

Diagnosis of Type-I hiatal hernia: a comparison of high-resolution manometry and endoscopy

Sliding Type-I hiatal hernia is commonly diagnosed using upper endoscopy, barium swallow or less commonly, esophageal manometry. Current data suggest that endoscopy is superior to barium swallow or esophageal manometry. Recently, high-resolution manometry has become available for the assessment of esophageal motility. This novel technology is capable of displaying spatial and topographic pressure profiles of gastroesophageal junction and crural diaphragm in real time. The objective of the current study was to compare the specificity and sensitivity of high-resolution manometry and endoscopy in the diagnosis of sliding hiatal hernia in patients with gastroesophageal reflux disease. Data were analyzed retrospectively for 83 consecutive patients (61% females, mean age 52 ± 13.2 years) with objective gastroesophageal reflux disease who were considered for laparoscopic antireflux surgery between January 2006 and January 2009 and had preoperative high-resolution manometry and endoscopy. Manometrically, hiatal hernia was defined as separation of the gastroesophageal junction >2.0 cm from the crural diaphragm. Intraoperative diagnosis of hiatal hernia was used as the gold standard. Sensitivity, specificity and likelihood ratios of a positive test and a negative test were used to compare the performance of the two diagnostic modalities. Forty-two patients were found to have a Type-I sliding hiatal hernia (>2 cm) during surgery. Twenty-two patients had manometric criteria for a hiatal hernia by high-resolution manometry, and 36 patients were described as having a hiatal hernia by preoperative endoscopy. False positive results were significantly fewer (higher specificity) with high-resolution manometry as compared with endoscopy (4.88% vs. 31.71%, P= 0.01). There were no significant differences in the false negative results (sensitivity) between the two diagnostic modalities (47.62% vs. 45.24%, P= 0.62). Analysis of likelihood ratios of a positive and negative test demonstrated that high-resolution manometry is better than endoscopy both to rule out and rule in a hiatal hernia. A significant discordance was also observed between the two tests (P= 0.033). High-resolution manometry has better specificity and ability to rule out an overt Type-I sliding hiatal hernia (greater likelihood ratio of a positive test) in patients with GERD. Because of high false negative results, both high-resolution manometry and endoscopy are unreliable for ruling in a hiatal hernia. Negative result for a hiatal hernia by either modality mandates additional testing.

Gastroesophageal reflux disease is inversely related with glycemic control in morbidly obese patients

BACKGROUND

The link between diabetes mellitus and gastroesophageal reflux disease (GERD) is controversial. We assessed the relationship between glycemic control (GC) and GERD in morbidly obese patients.

METHODS

Consecutive patients with morbid obesity (n = 86) underwent manometry, pH-metry, endoscopy, and contrasted X-ray after responding to a GERD questionnaire and dosing fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c). Patients with poor GC (HbA1c, 6.1-10% and FPG < 140 mg/dl) and those with very poor GC (HbA1c > 10% or FPG > 140 mg/dl) were compared.

RESULTS

There were 63 patients with poor GC and 17 with very poor GC. Compared to patients with very poor GC, patients with poor GC showed higher heartburn scores [8 (0-12) vs. 0 (0-4); P = 0.003]; higher total esophageal acid exposure [5.2% (2.5-10.5%) vs. 2.3% (0.8-7.5%); P = 0.041]; lower distal esophageal amplitude (105 ± 38 vs. 134 ± 63 mmHg; P = 0.019); higher expiratory gastroesophageal pressure gradient (GEPG, 7 ± 3.4 vs. 5.2 ± 3 mmHg; P = 0.050); lower ventilatory gradient (inspiratory-expiratory GEPG, 10.9 ± 3.8 vs. 13.6 ± 4.1 mmHg; P = 0.012); lower waist-to-hip ratio (0.95 vs. 1; P = 0.040); and more hiatal hernia (38% vs. 6%; P = 0.016).

CONCLUSIONS

This study suggests an inverse relation between glycemic control and GERD in morbidly obese patients. This can be partially explained by a lower frequency of hiatal hernia in patients with very poor glycemic control.

Determination of pH turning point with pH mapping of the gastroesophageal junction: an alternative technique to orientate esophageal pH monitoring

Manometric location of the lower esophageal sphincter (LES) has been mandatory before esophageal pH monitoring, despite costs and discomfort related with esophageal manometry. The aims of the study were: (i) to map the pH of the gastroesophageal junction (GEJ) to determine a pH turning point (PTP) and its relation with LES; and (ii) to test the feasibility of this technique to orientate esophageal pH monitoring. We studied 310 adult patients who underwent esophageal manometry and pH monitoring off acid-suppressive therapy. GEJ pH mapping was carried out by step-pulling the pH sensor from 5 cm below to 5 cm above LES, and a PTP was determined when pH changed from below to above 4, in centimeters from the nostril. Thirty-six patients referred only for pH monitoring were studied with pH sensor placed at 5 cm above the PTP. Out of 310 patients, a PTP was found in 293 (94.5%): inside LES in 86.3%, into the stomach in 8.2% and in the esophageal body in 5.5% of patients. The median distance between PTP and place where pH sensor monitored reflux was 8 cm. Among 36 patients who performed pH monitoring without LES manometry, there was no gastric monitoring during reflux testing. In adult patients investigated off acid suppressive therapy, GEJ pH mapping with reflux monitoring 5 cm above the PTP can be an alternative technique to perform esophageal pH monitoring when LES manometry is not available. Additional studies are needed before the widespread use of GEJ pH mapping in the clinical practice.

The role of gastro-oesophageal pressure gradient and sliding hiatal hernia on pathological gastro-oesophageal reflux in severely obese patients

BACKGROUND AND AIMS

The relationship between gastro-oesophageal pressure gradient (GOPG), sliding hiatal hernia (SHH) and gastro-oesophageal reflux disease (GORD) is under investigation. We assessed whether GOPG and SHH are predictors of pathological reflux in severely obese patients.

METHODS

Ninety-four consecutive patients were prospectively studied with oesophageal manometry, 24-h pH monitoring, upper gastrointestinal endoscopy and barium swallow X-ray. Inspiratory and expiratory GOPGs were measured at manometry testing, whereas SHH was characterized by X-ray. Patients were classified as having physiological or pathological reflux depending on pH monitoring. Patients with oesophagitis but normal pH testing were excluded.

RESULTS

Eighty-nine patients composed the study sample (25 men, 38.3+/-11.1 years; BMI 45+/-6.9 kg/m). Sixty-two patients (70%) had pathological reflux, whereas 27 patients (30%) had physiological reflux. Pathological reflux was predicted either by inspiratory GOPG [prevalence ratio (PR) =1.05; 95% confidence interval (CI): 1.03-1.08; P<0.001] or by expiratory GOPG (PR=1.07; 95% CI: 1.03-1.11; P=0.001). Accordingly, an increment of 1 mmHg in inspiratory and expiratory GOPGs raises the risk of pathological reflux in 5 and 7%, respectively. Pathological reflux was also predicted by SHH (PR: 1.54, 95% CI: 1.19-2.00; P=0.001), which increases the risk of abnormal reflux in 54%.

CONCLUSION

In severely obese patients, either inspiratory GOPG, expiratory GOPG or SHH are predictors of pathological reflux. These findings give pathophysiological support to the high prevalence of GORD in this population.

Clinical utility of endoscopy and barium swallow X-ray in the diagnosis of sliding hiatal hernia in morbidly obese patients: a study before and after gastric bypass

BACKGROUND

The main clinical consequence of sliding hiatal hernia (SHH) is gastroesophageal reflux disease (GERD). Endoscopy and barium swallow X-ray are commonly used to diagnose SHH. We aimed to assess the clinical utility of endoscopy and X-ray in the diagnosis of SHH in morbidly obese patients before and after gastric bypass (GBP).

METHODS

Ninety-two patients underwent reflux symptoms evaluation, upper gastrointestinal endoscopy, and barium swallow X-ray before and 6 months after banded GBP. The performance of endoscopy in diagnosing SHH was assessed, taking X-ray as reference. Endoscopy and X-ray were tested as predictors of SHH with GERD.

RESULTS

SHH was more prevalent when characterized by X-ray than endoscopy either before (33% vs. 17%; P = 0.017) or after GBP (26% vs. 7%; P = 0.001). Endoscopy showed low sensitivity (<or=40%) and high specificity (>or=94%) in diagnosing SHH. Before GBP, more patients with SHH had GERD compared to patients without SHH using either X-ray (83% vs. 58%; P = 0.016) or endoscopy (94% vs. 61%; P = 0.009). After GBP, only patients with radiologic evidence of SHH showed higher prevalence of GERD compared to patients without SHH (50% vs. 26%; P = 0.037). SHH patients also reported weekly or daily vomit more often than patients without SHH (59% vs. 32%; P = 0.026).

CONCLUSIONS

In morbidly obese patients, X-ray is superior to endoscopy in diagnosing SHH either before or after banded GBP. In patients treated with this technique, the utilization of X-ray may help in the management of reflux symptoms and frequent vomit.