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Elsheikh M, Akanbi L, Selby L, Ismail B. Esophageal Motility Abnormalities in Lung Transplant Recipients With Esophageal Acid Reflux Are Different From Matched Controls. J Neurogastroenterol Motil 2024; 30:156-165. [PMID: 38062800 PMCID: PMC10999846 DOI: 10.5056/jnm23017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/10/2023] [Accepted: 07/07/2023] [Indexed: 04/06/2024] Open
Abstract
Background/Aims There is an increased incidence of gastroesophageal reflux disease (GERD) after lung transplantation (LT) that can be associated with graft dysfunction. It is unclear if the underlying esophageal motility changes in GERD are different following LT. This study aimed to use esophageal high-resolution manometry (HRM) to explore GERD mechanisms in LT recipients compared to matched controls. Methods This was a retrospective study including patients with pathologic acid reflux who underwent HRM and pH testing at our healthcare facility July 2012 to October 2019. The study included 12 LT recipients and 36 controls. Controls were matched in a 1:3 ratio for age, gender, and acid exposure time (AET). Results LT recipients had less hypotensive esophagogastric junction (EGJ) (mean EGJ-contractile integral 89.2 mmHg/cm in LT vs 33.9 mmHg/cm in controls, P < 0.001). AET correlated with distal contractile integral and total EGJ-contractile integral only in LT group (r = -0.79, P = 0.002 and r = -0.57, P = 0.051, respectively). Conclusions Following LT, acid reflux is characterized by a less hypotensive EGJ compared to controls with similar AET. The strongest correlation with AET after LT was found to be esophageal peristaltic vigor. These results add to the understanding of reflux after LT and may help tailor an individualized treatment plan.
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Affiliation(s)
- Mazen Elsheikh
- Department of Internal Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Lekan Akanbi
- Department of Gastroenterology and Hepatology, University of Missouri Health Care, Columbia, MO, USA
| | - Lisbeth Selby
- Division of Digestive Diseases and Nutrition, University of Kentucky, Lexington, KY, USA
| | - Bahaaeldeen Ismail
- Division of Digestive Diseases and Nutrition, University of Kentucky, Lexington, KY, USA
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Li Y, Wang L, Yang D, Zhang Z, Sun X, Geng X, Lin J, Duan Z. Esophageal chemical clearance and mucosa integrity values in refractory gastroesophageal reflux disease patients with different esophageal dynamics. Scand J Gastroenterol 2023; 58:322-330. [PMID: 36259257 DOI: 10.1080/00365521.2022.2132534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Esophageal post-reflux swallow-induced peristaltic wave index (PSPWI) and mean nocturnal baseline impedance (MNBI), novel impedance-based markers of reflux burden, are associated with esophageal dynamics. We aim to investigate the characteristics of PSPWI and MNBI in Chinese refractory gastroesophageal reflux disease (RGERD) patients with different esophageal dynamic changes. MATERIALS AND METHODS 201 RGERD and 76 functional heartburn patients, undergone off-PPI endoscopy, esophageal manometry and impedance-pH monitoring, were included. Comparisons of conventional and novel impedance-pH metrics were made among different esophageal dynamics groups. Receiver operating-characteristic analyses were utilized to evaluate the diagnostic efficacy of PSPWI and MNBI in differentiating abnormal esophageal dynamics. Correlations were used to investigate their associated factors. RESULTS PSPWI and MNBI of RGERD with esophagogastric junction (EGJ) injury and esophageal dysmotility were lower than EGJ injury alone or normal dynamics (p < 0.05 for both comparisons). PSPWI with esophageal peristalsis abnormality was lower than EGJ injury (p = 0.049), while MNBI showed no statistical difference. PSPWI, MNBI and their combination have auxiliary diagnostic values for esophageal peristalsis [area under the curves (AUCs): 0.683, 0.656, 0.708)] while only their combination for EGJ injury (AUC: 0.610). And they positively correlated with esophageal motility while negatively correlated with ineffective swallows and acid reflux events. CONCLUSIONS PSPWI and MNBI, indicating impairment of esophageal chemical clearance and mucosa integrity, were lower in RGERD patients with multiple esophageal dynamic injuries than single injuries or normal dynamics. Moreover, they provided useful contributing information for potential dynamic injuries if manometry has already been found normal or marginal.
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Affiliation(s)
- Yanqiu Li
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Lixia Wang
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Dong Yang
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhifeng Zhang
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaoyu Sun
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaoling Geng
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jiarong Lin
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhijun Duan
- Second Gastroenterology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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Zdrhova L, Bitnar P, Balihar K, Kolar P, Madle K, Martinek M, Pandolfino JE, Martinek J. Breathing Exercises in Gastroesophageal Reflux Disease: A Systematic Review. Dysphagia 2023; 38:609-621. [PMID: 35842548 PMCID: PMC9888515 DOI: 10.1007/s00455-022-10494-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 07/01/2022] [Indexed: 02/02/2023]
Abstract
The pathogenesis of gastroesophageal reflux disease (GERD) is multifactorial. The severity of abnormal reflux burden corresponds to the dysfunction of the antireflux barrier and inability to clear refluxate. The crural diaphragm is one of the main components of the esophagogastric junction and plays an important role in preventing gastroesophageal reflux. The diaphragm, as a skeletal muscle, is partially under voluntary control and its dysfunction can be improved via breathing exercises. Thus, diaphragmatic breathing training (DBT) has the potential to alleviate symptoms in selected patients with GERD. High-resolution esophageal manometry (HRM) is a useful method for the assessment of antireflux barrier function and can therefore elucidate the mechanisms responsible for gastroesophageal reflux. We hypothesize that HRM can help define patient phenotypes that may benefit most from DBT, and that HRM can even help in the management of respiratory physiotherapy in patients with GERD. This systematic review aimed to evaluate the current data supporting physiotherapeutic practices in the treatment of GERD and to illustrate how HRM may guide treatment strategies focused on respiratory physiotherapy.
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Affiliation(s)
- Lucie Zdrhova
- First Department of Internal Medicine, Pilsen University Hospital, Charles University in Prague, Alej Svobody 80, Pilsen, 304 06, Czech Republic.
- Pavel Kolar's Centre of Physical Medicine, Prague, Czech Republic.
| | - Petr Bitnar
- Department of Rehabilitation and Sports Medicine, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Karel Balihar
- First Department of Internal Medicine, Pilsen University Hospital, Charles University in Prague, Alej Svobody 80, Pilsen, 304 06, Czech Republic
| | - Pavel Kolar
- Pavel Kolar's Centre of Physical Medicine, Prague, Czech Republic
- Department of Rehabilitation and Sports Medicine, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Katerina Madle
- Pavel Kolar's Centre of Physical Medicine, Prague, Czech Republic
| | - Milan Martinek
- Faculty of Physical Education and Sport, Charles University in Prague, Prague, Czech Republic
| | - John Erik Pandolfino
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Evanston, USA
| | - Jan Martinek
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, IKEM, Prague, Czech Republic
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Dias NCB, Herbella FAM, Del Grande LM, Patti MG. The Transdiaphragmatic Pressure Gradient and the Lower Esophageal Sphincter in the Pathophysiology of Gastroesophageal Reflux Disease: an Analysis of 500 Esophageal Function Tests. J Gastrointest Surg 2022; 27:677-681. [PMID: 36376725 DOI: 10.1007/s11605-022-05529-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/04/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) pathophysiology is multifactorial. Greater importance has been attributed to a defective lower esophageal sphincter (LES) in comparison to an altered transdiaphragmatic pressure gradient (TPG). This study aims to evaluate the role of the TPG and LES disfunction in GERD pathogenesis. METHODS Five hundred consecutive esophageal function tests from patients with clinically suspected GERD were reviewed. Patients were classified according to the pH monitoring in GERD positive or GERD negative. Abdominal pressure, thoracic pressure, TPG (abdominal-thoracic pressures), LES resting pressure (mid-respiratory, expiratory, and EGJ-CI), and LES retention pressure (LES resting pressure-TPG) were determined. RESULTS GERD was present in 296 (59%) individuals. GERD-positive patients were mostly males. LES resting pressure (by all parameters) and thoracic pressure were not different between groups. Abdominal pressure and TPG were higher in GERD-positive patients. LES retention pressure (by all parameters) was lower in GERD-positive patients. DeMeester score had a positive correlation with LES resting pressure, TPG, and LES retention pressure (by all parameters) but not with abdominal pressure and thoracic pressure. CONCLUSIONS LES valvular competency as measured by absolute resting pressure was not reliable to predict GERD; however, it was associated with GERD severity. Relative LES pressure (LES retention pressure) predicted GERD presence and severity, but no parameter showed superiority. TPG plays an important role in the pathophysiology of GERD since it is related to GERD presence and severity; still TPG is altered mostly based on a higher abdominal pressure.
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Affiliation(s)
- Natalya C B Dias
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Rua Diogo de Faria 1087 Cj 301, Sao Paulo, SP, 04037-003, Brazil
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Rua Diogo de Faria 1087 Cj 301, Sao Paulo, SP, 04037-003, Brazil.
| | - Leonardo M Del Grande
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Rua Diogo de Faria 1087 Cj 301, Sao Paulo, SP, 04037-003, Brazil
| | - Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
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Siboni S, Kristo I, Rogers BD, De Bortoli N, Hobson A, Louie B, Lee YY, Tee V, Tolone S, Marabotto E, Visaggi P, Haworth J, Ivy M, Greenan G, Facchini C, Masuda T, Yano F, Perry K, Balasubramanian G, Theodorou D, Triantafyllou T, Cusmai L, Boveri S, Schoppmann SF, Gyawali CP, Bonavina L. Improving the Diagnostic Yield of High-Resolution Esophageal Manometry for GERD: The "Straight Leg-Raise" International Study. Clin Gastroenterol Hepatol 2022:S1542-3565(22)00970-3. [PMID: 36270615 DOI: 10.1016/j.cgh.2022.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/30/2022] [Accepted: 10/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The straight leg raise (SLR) maneuver during high-resolution manometry (HRM) can assess esophagogastric junction (EGJ) barrier function by measuring changes in intraesophageal pressure (IEP) when intra-abdominal pressure is increased. We aimed to determine whether increased esophageal pressure during SLR predicts pathologic esophageal acid exposure time (AET). METHODS Adult patients with persistent gastroesophageal reflux disease (GERD) symptoms undergoing HRM and pH-impedance or wireless pH study off proton pump inhibitor were prospectively studied between July 2021 and March 2022. After the HRM Chicago 4.0 protocol, patients were requested to elevate 1 leg at 45º for 5 seconds while supine. The SLR maneuver was considered effective when intra-abdominal pressure increased by 50%. IEPs were recorded 5 cm above the lower esophageal sphincter at baseline and during SLR. GERD was defined as AET greater than 6%. RESULTS The SLR was effective in 295 patients (81%), 115 (39%) of whom had an AET greater than 6%. Hiatal hernia (EGJ type 2 or 3) was seen in 135 (46%) patients. Compared with patients with an AET less than 6%, peak IEP during SLR was significantly higher in the GERD group (29.7 vs 13.9 mm Hg; P < .001). Using receiver operating characteristic analysis, an increase of 11 mm Hg of peak IEP from baseline during SLR was the optimal cut-off value to predict an AET greater than 6% (area under the receiver operating characteristic curve, 0.84; sensitivity, 79%; and specificity, 85%), regardless of the presence of hiatal hernia. On multivariable analysis, an IEP pressure increase during the SLR maneuver, EGJ contractile integral, EGJ subtype 2, and EGJ subtype 3, were found to be significant predictors of AET greater than 6% CONCLUSIONS: The SLR maneuver can predict abnormal an AET, thereby increasing the diagnostic value of HRM when GERD is suspected. CLINICALTRIALS gov ID: NCT04813029.
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Affiliation(s)
- Stefano Siboni
- Division of Foregut Surgery, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, University of Milan, Milan, Italy
| | - Ivan Kristo
- Upper GI Service, Medizinische Universität, Wien, Austria
| | - Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri; Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky
| | | | | | - Brian Louie
- Division of Thoracic Surgery, Swedish Medical Center, Digestive Health Institute, Seattle, Washington
| | - Yeong Yeh Lee
- School of Medical Sciences, GI Function and Motility Unit, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Vincent Tee
- School of Medical Sciences, GI Function and Motility Unit, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Salvatore Tolone
- Division of General, Mini-Invasive and Bariatric Surgery, University of Naples, Naples, Italy
| | - Elisa Marabotto
- Gastroenterology Unit, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Martino, Genoa, Italy
| | | | | | - Megan Ivy
- Division of Thoracic Surgery, Swedish Medical Center, Digestive Health Institute, Seattle, Washington
| | - Garrett Greenan
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Chiara Facchini
- Gastroenterology Unit, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Martino, Genoa, Italy
| | - Takahiro Masuda
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Fumiaki Yano
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Kyle Perry
- Division of General and Gastrointestinal Surgery, The Ohio State University, Columbus, Ohio
| | | | - Dimitrios Theodorou
- Foregut Surgery Unit, University of Athens School of Medicine, Athens, Greece
| | - Tania Triantafyllou
- Foregut Surgery Unit, University of Athens School of Medicine, Athens, Greece
| | - Lorenzo Cusmai
- Division of Foregut Surgery, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, University of Milan, Milan, Italy
| | - Sara Boveri
- Laboratory of Biostatistics and Data Management, Scientific Directorate, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Luigi Bonavina
- Division of Foregut Surgery, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, University of Milan, Milan, Italy.
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Ineffective esophageal motility in Chicago Classification version 4.0 better predicts abnormal acid exposure. Esophagus 2022; 19:197-203. [PMID: 34378104 DOI: 10.1007/s10388-021-00867-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/29/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The updated Chicago Classification version 4.0 (CCv4.0) establishes a more stringent criteria to diagnose ineffective esophageal motility (IEM). This study aims to investigate the clinical significance of IEM in CCv4.0 in the context of gastroesophageal reflux disease (GERD). METHODS A retrospective study was conducted among suspected GERD patients who had heartburn and/or regurgitation as their chief complaints and completed esophageal function tests in our center from 2017 to 2019. Patients were further grouped as "CCv3.0 IEM" and normal motility according to Chicago Classification version 3.0 (CCv3.0), and as "CCv4.0 IEM" and normal motility according to CCv4.0. The clinical characteristics, high-resolution manometry, esophageal reflux monitoring, and proton pump inhibitor (PPI) efficacy were compared between different groups. Multivariate analyses were performed to identify esophageal motility parameters associated with reflux burden and symptom outcome. RESULTS Of 172 subjects included, 93 patients were identified as CCv3.0 IEM, 69 as CCv4.0 IEM. IEM in either version was concomitant with elevated acid burden and impaired esophageal clearance as compared to normal motility in corresponding diagnostic criteria, while the only presence of IEM in CCv4.0 was predictive to abnormal acid exposure (AET > 6%: OR = 2.66, 95% CI [1.27-5.56], p < 0.01). The presence of "CCv3.0 IEM" and low EGJ-CI (EGJ-CI < 39.1 mmHg·cm) had no added value in predicting increased reflux burden. No interaction effect was found between the presence of IEM and a weakened EGJ. None of the manometric variables was capable of predicting PPI response. CONCLUSIONS Stringent criteria of IEM in CCv4.0 can better predict abnormal acid exposure as compared to CCv3.0.
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Ayazi S. Quantifying Esophagogastric Junction Barrier Competency Using High-Resolution Manometry. J Am Coll Surg 2020; 230:755-757. [PMID: 32334740 DOI: 10.1016/j.jamcollsurg.2020.02.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 11/17/2022]
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