Ineffective esophageal motility: clinical, manometric, and outcome characteristics in patients with and without abnormal esophageal acid exposure

The prevalence of gastroesophageal reflux disease and laryngopharyngeal reflux in patients with dysphagia after radiotherapy for nasopharyngeal carcinoma

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) in post-irradiated patients with nasopharyngeal carcinoma (NPC) is unknown.

MATERIALS AND METHODS

In a cross-sectional study, 31 NPC and 12 control patients completed questionnaires for GERD/LPR before esophageal manometry and 24-h pH monitoring. The DeMeester score and reflux finding score (RFS) were used to define GERD and LPR, respectively. Risk factors were identified.

RESULTS

51.6% of NPC and 8.3% of control patients, and 77.4% of NPC and 33% of control patients, were GERD-positive and LPR-positive, respectively. The GERD/LPR questionnaire failed to identify either condition in patients with NPC. No parameter differences in esophageal manometry or pneumonia incidence were noted between GERD/LPR-positive and GERD/LPR-negative patients. Post radiotherapy duration, high BMI, lack of chemotherapy, and dysphagia were positive risk factors for GERD/LPR.

CONCLUSIONS

A high prevalence of GERD/LPR in patients with post-irradiated NPC exists, but reflux symptoms are inadequate for diagnosis.

Chicago Classification Version 4.0 Improves Stratification of Ineffective Esophageal Motility Patients into Clinically Meaningful Subtypes: A Two-Center International Study

The 4th iteration of the Chicago Classification (CC v4.0) for esophageal motility disorders offers more restrictive criteria for the diagnosis of Ineffective Esophageal Motility (IEM) compared to version 3.0 (CC v3.0). In light of the updated criteria for IEM, we aimed to characterize and compare the patients who retained their IEM diagnosis to those who were reclassified as normal motility, and to evaluate the clinical impact of the newly introduced CC v4.0. We performed a retrospective case-control study. We included all individuals who underwent a high-resolution manometry (HRM) between 2020 and 2021 at two centers. Consecutive studies reported as IEM according to the CC v3.0 were reanalyzed according to the CC v4.0. We compared demographics, clinical, manometry, and pH-monitoring parameters. Out of 452 manometry studies, 154 (34%) met criteria for IEM as per the CC v3.0 (CC v3.0 IEM group). Of those, 39 (25%) studies were reclassified as normal studies according to the CC v4.0 (CC v4.0 normal group), while the remaining 115 studies (25% of the overall cohort) retained an IEM diagnosis (CC v4.0 IEM group). The CC v4.0 normal group had more recovered contractions during solid swallows (p = 0.01), less ineffective swallows (p = 0.04), and lower acid exposure time (p = 0.02) compared to the CC4.0 IEM group. Under CC v4.0 criteria, fewer patients are diagnosed with IEM. Those diagnosed with IEM had worse esophageal function and higher acid burden. Though further studies are needed to confirm these findings, our results indicate that CC v4.0 criteria restrict the IEM diagnosis to a more clinically meaningful population.

Esophageal motor abnormalities in gastroesophageal reflux disorders

Gastroesophageal reflux disease (GERD), a prevalent condition with multifactorial pathogenesis, involves esophageal motor dysmotility as a key contributing factor to its development. When suspected GERD patients have an inadequate response to proton-pump inhibitor (PPI) therapy and normal upper endoscopy results, high-resolution manometry (HRM) is utilized to rule out alternative diagnosis such as achalasia spectrum disorders, rumination, or supragastric belching. At present, HRM continues to provide supportive evidence for diagnosing GERD and determining the appropriate treatment. This review focuses on the existing understanding of the connection between esophageal motor findings and the pathogenesis of GERD, along with the significance of esophageal HRM in managing GERD patients. The International GERD Consensus Working Group introduced a three-step method, assessing the esophagogastric junction (EGJ), esophageal body motility, and contraction reserve with multiple rapid swallow (MRS) maneuvers. Crucial HRM abnormalities in GERD include frequent transient lower esophageal sphincter relaxations, disrupted EGJ, and esophageal body hypomotility. Emerging HRM metrics like EGJ-contractile integral and innovative provocative maneuver like straight leg raise have the potential to enhance our understanding of factors contributing to GERD, thereby increasing the value of HRM performed in patients who experience symptoms suspected of GERD.

Fifteen-year symptomatic outcome of patients with nonactionable motor findings on high-resolution manometry

BACKGROUND

High-resolution manometry (HRM) is performed for evaluation of esophageal symptoms, but patient outcome is unclear when no actionable motor disorder is identified. We evaluated long-term symptomatic outcome of patients with nonactionable HRM findings.

METHODS

Patients who underwent (HRM) studies in 2006-2008 were tracked. Patients with achalasia spectrum disorders, foregut surgery before or after HRM, and incomplete symptom documentation were excluded. Symptom questionnaires assessing dominant symptom intensity (DSI, product of symptom severity and frequency recorded on 5-point Likert scales) and global symptom severity (GSS, from 10 cm visual analog scale) were repeated. Change in symptom burden was compared against HRM motor findings using Chicago Classification 4.0 (CCv4.0), applied retroactively to 2006-2008 data.

KEY RESULTS

Overall, 134 patients (median age 68 years, 64.5% female) could be contacted. The majority (73.1%) had normal motility; others had ineffective esophageal motility (8.2%), esophagogastric junction outflow obstruction (13.4%), hypercontractile esophagus (3.0%), or absent contractility (2.2%), none managed invasively. Over 15 years of follow-up, DSI decreased from 8.0 (4.0-16.0) to 1.0 (0.0-6.0) (p < 0.001) and GSS improved from 5.5 (3.3-7.7) to 2.0 (0.0-4.0) (p < 0.001); improvement was consistent across CCv4.0 diagnoses and subgroups. The majority (82.8%) reported improvement over time, and antisecretory medication was the most effective intervention (83.0% improvement). There was no difference in medication efficacy (p = 0.75) or improvement in symptoms (p = 0.20) based on CCv4 diagnosis.

CONCLUSIONS AND INFERENCES

Esophageal symptoms improve with conservative symptomatic management over long-term follow-up when no conclusive obstructive motor disorders or achalasia spectrum disorders are found on HRM.

Latin American consensus on diagnosis of gastroesophageal reflux disease

BACKGROUND

Diagnosing gastroesophageal reflux disease (GERD) can be challenging given varying symptom presentations, and complex multifactorial pathophysiology. The gold standard for GERD diagnosis is esophageal acid exposure time (AET) measured by pH-metry. A variety of additional diagnostic tools are available. The goal of this consensus was to assess the individual merits of GERD diagnostic tools based on current evidence, and provide consensus recommendations following discussion and voting by experts.

METHODS

This consensus was developed by 15 experts from nine countries, based on a systematic search of the literature, using GRADE (grading of recommendations, assessment, development and evaluation) methodology to assess the quality and strength of the evidence, and provide recommendations regarding the diagnostic utility of different GERD diagnosis tools, using AET as the reference standard.

KEY RESULTS

A proton pump inhibitor (PPI) trial is appropriate for patients with heartburn and no alarm symptoms, but nor for patients with regurgitation, chest pain, or extraesophageal presentations. Severe erosive esophagitis and abnormal reflux monitoring off PPI are clearly indicative of GERD. Esophagram, esophageal biopsies, laryngoscopy, and pharyngeal pH monitoring are not recommended to diagnose GERD. Patients with PPI-refractory symptoms and normal endoscopy require reflux monitoring by pH or pH-impedance to confirm or exclude GERD, and identify treatment failure mechanisms. GERD confounders need to be considered in some patients, pH-impedance can identify supragrastric belching, impedance-manometry can diagnose rumination.

CONCLUSIONS

Erosive esophagitis on endoscopy and abnormal pH or pH-impedance monitoring are the most appropriate methods to establish a diagnosis of GERD. Other tools may add useful complementary information.

Mixed Esophageal Disease (MED): A New Concept

We define mixed esophageal disease (MED) as a disorder of esophageal structure and/or function that produces variable signs or symptoms, simulating-fully or in part other well-defined esophageal conditions, such as gastroesophageal reflux disease, esophageal motility disorders, or even neoplasia. The central premise of the MED concept is that of an overlap syndrome that incorporates selected clinical, endoscopic, imaging, and functional features that alter the patient's quality of life and affect natural history, prognosis, and management. In this article, we highlight MED scenarios frequently encountered in medico-surgical practices worldwide, posing new diagnostic and therapeutic challenges. These, in turn, emphasize the need for better understanding and management, aiming towards improved outcomes and prognosis. Since MED has variable and sometimes time-evolving clinical phenotypes, it deserves proper recognition, definition, and collaborative, multidisciplinary approach, be it pharmacologic, endoscopic, or surgical, to optimize therapeutic outcomes, while minimizing iatrogenic complications. In this regard, it is best to define MED early in the process, preferably by teams of clinicians with expertise in managing esophageal diseases. MED is complex enough that is increasingly becoming the subject of virtual, multi-disciplinary, multi-institutional meetings.

The Impact of Ineffective Esophageal Motility on Patients Undergoing Magnetic Sphincter Augmentation

OBJECTIVE

To evaluate and characterize outcomes of MSA in patients with IEM.

SUMMARY BACKGROUND DATA

MSA improves patients with gastroesophageal reflux and normal motility. However, many patients have IEM, which could impact the outcomes of MSA and discourage use.

METHODS

An international, multi-institutional case control study of IEM patients undergoing MSA matched to normal patients was performed. Primary outcomes were new onset dysphagia and need for postoperative interventions.

RESULTS

A total of 105 IEM patients underwent MSA with matching controls. At 1 year after MSA: GERD-Health Related Quality of Life was similar; DeMeester scores in IEM patients improved to 15.7 and 8.5 in controls ( P = 0.021); and normalization of the DeMeester score for IEM = 61.7% and controls = 73.1% ( P = 0.079).In IEM patients, 10/12 (83%) with preop dysphagia had resolution; 11/66 (17%) had new onset dysphagia and 55/66 (83%) never had dysphagia. Comparatively, in non-IEM patients, 22/24 (92%) had dysphagia resolve; 2/24 (8%) had persistent dysphagia; 7/69 (10%) had new onset dysphagia, and 62/69 (90%) never had dysphagia.Overall, 19 (18%) IEM patients were dilated after MSA, whereas 12 (11%) non-IEM patients underwent dilation ( P = 0.151). Nine (9%) patients in both groups had their device explanted.

CONCLUSIONS

Patients with IEM undergoing MSA demonstrate improved quality of life and reduction in acid exposure. Key differences in IEM patients include lower rates of objective GERD resolution, lower resolution of existing dysphagia, higher rates of new onset dysphagia and need for dilation. GERD patients with IEM should be counselled about these possibilities.

Relationship Between Esophageal Disease and Pulmonary Fibrosis

Esophageal disorders are prevalent among patients with chronic lung diseases, including idiopathic pulmonary fibrosis (IPF). Gastroesophageal reflux disease (GERD) has been associated with IPF prevalence, severity, and respiratory decline. The pathophysiologic relationship between GERD and IPF is likely bidirectional, with aspiration of refluxate leading to lung inflammation and fibrosis, while the restrictive pulmonary physiology may contribute to altered transdiaphragmatic pressure gradient and increased reflux. Esophageal symptoms are frequently absent and do not predict esophageal dysfunction or pathologic reflux in patients with IPF, and objective diagnostic tools including upper endoscopy, ambulatory reflux monitoring, and high-resolution manometry are often needed. Impedance-based testing that identifies both weakly/non-acidic and acid reflux may provide important additional diagnostic value beyond pH-based acid testing alone. Novel metrics and maneuvers, including advanced impedance measures on impedance-pH study and provocative testing on HRM, may hold promise to future diagnostic advancements. The main treatment options include medical therapy with acid suppressants and anti-reflux surgery, although their potential benefits in pulmonary outcomes of IPF require further validations. Future directions of research include identifying phenotypes of IPF patients who may benefit from esophageal testing and treatment, determining the optimal testing strategy and protocol, and prospectively assessing the value of different esophageal therapies to improve outcomes while minimizing risks. This review will discuss the pathophysiology, evaluation, and management of esophageal diseases, particularly GERD, in patients with IPF, as informed by the most recent publications in the field, in hopes of identifying targets for future study and research.

Comparing Patients Diagnosed With Ineffective Esophageal Motility by the Chicago Classification Version 3.0 and Version 4.0 Criteria

Background

The Chicago Classification version 4.0 (CCv4.0) of ineffective esophageal motility (IEM) is more stringent than the Chicago Classification version 3.0 (CCv3.0) definition. We aimed to compare the clinical and manometric features of patients meeting CCv4.0 IEM criteria (group 1) versus patients meeting CCv3.0 IEM but not CCv4.0 criteria (group 2).

Methods

We collected retrospective clinical, manometric, endoscopic, and radiographic data on 174 adults diagnosed with IEM from 2011 to 2019. Complete bolus clearance was defined as evidence of exit of the bolus by impedance measurement at all distal recording sites. Barium studies included barium swallow, modified barium swallow, and barium upper gastrointestinal series studies, and collected data from these reports include abnormal motility and delay in the passage of liquid barium or barium tablet. These data along with other clinical and manometric data were analyzed using comparison and correlation tests. All records were reviewed for repeated studies and the stability of the manometric diagnoses.

Results

Most demographic and clinical variables were not different between the groups. A lower mean lower esophageal sphincter pressure was correlated with greater percent of ineffective swallows in group 1 (n = 128) (r = -0.2495, P = 0.0050) and not in group 2. In group 1, increased percent of failed contractions on manometry was associated with increased incomplete bolus clearance (r = 0.3689, P = 0.0001). No such association was observed in group 2. A lower median integrated relaxation pressure was correlated with greater percent of ineffective contractions in group 1 (r = -0.1825, P = 0.0407) and not group 2. Symptom of dysphagia was more prevalent (51.6% versus 69.6%, P = 0.0347) in group 2. Dysphagia was not associated with intrabolus pressure, bolus clearance, barium delay, or weak or failed contractions in either group. In the small number of subjects with repeated studies, a CCv4.0 diagnosis appeared more stable over time.

Conclusions

CCv4.0 IEM was associated with worse esophageal function indicated by reduced bolus clearance. Most other features studied did not differ. Symptom presentation cannot predict if patients are likely to have IEM by CCv4.0. Dysphagia was not associated with worse motility, suggesting it may not be primarily dependent on bolus transit.

Clinical Characteristics of Patients With Ineffective Esophageal Motility by Chicago Classification Version 4.0 Compared to Chicago Classification Version 3.0

Background/Aims

Chicago classification version 4.0 (CCv4.0) of esophageal motility disorders developed a more stringent diagnostic criteria for ineffective esophageal motility (IEM) than version 3.0. We studied the implications of the new diagnostic criteria on the prevalence of IEM, and clinically characterized and compared the population of patients who no longer meet diagnostic criteria for IEM to those who retain the diagnosis.

Methods

We included all consecutively performed high-resolution esophageal impedance manometries from 2014 to 2021. Three cohorts of patients with IEM were created: Patients with IEM by Chicago classification version 3.0 (CCv3.0; CC3 group), by CCv4.0 only (CC4 group), and by CCv3.0 who are now considered normal (Normal group). Demographics, manometric and reflux parameters, and clinical outcomes were compared.

Results

A total of 594 manometries were analyzed. Of those, 66 (11.1%) met criteria for IEM by CCv3.0 (CC3), 41 (62.0%) retained an IEM diagnosis using CCv4.0 criteria (CC4), while 25 (38.0%) patients no longer met criteria for IEM (Normal). The CC4 group had higher esophageal acid exposure, especially supine (% time - 18.9% vs 2.2%; P = 0.005), less adequate peristaltic reserve (22.0% vs 88.0%; P = 0.003), and higher Demeester score (49.0 vs 21.2; P = 0.017) compared to the Normal group. There was no difference in bolus clearance between the groups.

Conclusions

IEM under CCv4.0 has a stronger association with pathologic reflux, especially supine reflux, and inadequate peristaltic reserve, but impairment in bolus clearance is unchanged when compared with IEM diagnosed based on CCv3.0. Further studies are required to determine the implications of these findings on management strategies.

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

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

Empirical Dilation of Non-obstructive Dysphagia: Current Understanding and Future Directions

Non-obstructive dysphagia (NOD) is defined as symptomatic dysphagia in patients with negative endoscopic and radiographic workup. The management of NOD remains controversial as there is a discrepancy between different guidelines and clinical practice. Despite the lack of high-quality studies, empiric dilation for NOD is a common clinical practice among endoscopists and the approach varies between different clinical centers. In this review, we summarize the published literature on empiric dilation for NOD and propose a management algorithm for offering empiric dilation to patients presenting with dysphagia.

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.

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

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

Modified Peroral Endoscopic Myotomy Technique for Type II Achalasia: A Multicenter Retrospective Study

Aim

This retrospective study is aimed at evaluating the outcomes of a modified peroral endoscopic myotomy (POEM) technique in patients with type II achalasia.

Methods

We performed a modified POEM procedure, which involved a shorter (total myotomy length = 4 cm), full-thickness myotomy, on 31 patients with type II achalasia. Clinical success rates, technical success rates, pre- and postoperative esophageal manometry results, complications, and reflux-related adverse events were evaluated.

Results

The clinical success (Eckardt score ≤ 3) rates were 100% and 88.9% within 2 years and beyond 2 years postoperatively, respectively. The median lower esophageal sphincter pressures (LESP) decreased from 31.6 (26.7-49.7) mmHg preoperatively to 13.4 (10.5-21.6) and 11.8 (7.4-16.7) mmHg (P < 0.001) at 6 and 12 months postoperatively, respectively. The median integrated relaxation pressure (IRP) decreased from 27.8 (20.6-37.5) mmHg preoperatively to 12.9 (11.3-23.4) and 11.6 (9.6-16.8) mmHg (P < 0.001) at 6 and 12 months after POEM, respectively. Only one case (3.2%) of mucosal injury, four (12.9%) cases of reflux esophagitis, and two (6.5%) cases of gastroesophageal reflux symptoms were reported.

Conclusions

The modified POEM technique showed excellent outcomes in patients with type II achalasia.

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.

Pathophysiology of Pediatric Gastroesophageal Reflux Disease: Similarities and Differences With Adults

Gastroesophageal reflux (GOR) is defined as "the passage of gastric contents into the esophagus with or without regurgitation and vomiting" and gastroesophageal reflux disease (GORD) is defined "when GOR leads to troublesome symptoms affecting the daily functioning and/or complications." This definition was first developed in 2006 by the Montreal consensus group (1) and later on adopted by pediatric gastroenterology societies such as ESPGHAN and NASPGHAN in 2009 (2). The definition of gastroesophageal reflux reveals little about its pathophysiology and is focused on symptomatology. In this way, it acts as an umbrella term for the multifactorial causes of the disease and the various phenotypes encountered; from functional heartburn to hypersensitive esophagus and nonerosive reflux disease, to erosive esophagitis and Barrett's esophagus. This article is devoted to the pathophysiology of pediatric GORD in comparison to adult GORD and is divided in 2 parts. In the first part, we will systematically describe the different mechanisms for the generation and clearance of reflux events, while on the second part we will discuss the mechanisms involved in symptoms generation. Finally, we will discuss the similarities and differences between pediatric and adult GORD.

Current Advancement on the Dynamic Mechanism of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common clinical disease associated with upper gastrointestinal motility disorders. Recently, with improvements in living standards and changes in lifestyle and dietary habits, the incidence of GERD has been increasing yearly. However, the mechanism of GERD has not been fully elucidated due to its complex pathogenesis, and this had led to unsatisfactory therapeutic outcomes. Currently, the occurrence and development of GERD involve multiple factors. Its pathogenesis is mainly thought to be related to factors, such as lower esophageal sphincter pressure, transient lower esophageal sphincter relaxation, crural diaphragmatic dysfunction, hiatus hernia, and impaired esophageal clearance. Therefore, explaining the pathogenesis of GERD more clearly and systematically, exploring potential and effective therapeutic targets, and choosing the best treatment methods have gradually become the focus of scholars' attention. Herein, we reviewed current advancements in the dynamic mechanism of GERD to better counsel patients on possible treatment options.

Chicago Classification update (V4.0): Technical review on diagnostic criteria for ineffective esophageal motility and absent contractility

Esophageal hypomotility disorders manifest with abnormal esophageal body contraction vigor, breaks in peristaltic integrity, or failure of peristalsis in the context of normal lower esophageal sphincter relaxation on esophageal high-resolution manometry (HRM). The Chicago Classification version 4.0 recognizes two hypomotility disorders, ineffective esophageal motility (IEM) and absent contractility, while fragmented peristalsis has been incorporated into the IEM definition. Updated criteria for ineffective swallows consist of weak esophageal body contraction vigor measured using distal contractile integral (DCI, 100-450 mmHg·cm·s), transition zone defects >5 cm measured using a 20 mmHg isobaric contour, or failure of peristalsis (DCI < 100 mmHg·cm·s). More than 70% ineffective swallows and/or ≥50% failed swallows are required for a conclusive diagnosis of IEM. When the diagnosis is inconclusive (50%-70% ineffective swallows), supplementary evidence from multiple rapid swallows (absence of contraction reserve), barium radiography (abnormal bolus clearance), or HRM with impedance (abnormal bolus clearance) could support a diagnosis of IEM. Absent contractility requires 100% failed peristalsis, consistent with previous versions of the classification. Consideration needs to be given for the possibility of achalasia in absent contractility with dysphagia despite normal IRP, and alternate complementary tests (including timed upright barium esophagram and functional lumen imaging probe) are recommended to confirm or refute the presence of achalasia. Future research to quantify esophageal bolus retention on stationary HRM with impedance and to understand contraction vigor thresholds that predict bolus clearance will provide further refinement to diagnostic criteria for esophageal hypomotility disorders in future iterations of the Chicago Classification.

Esophageal acid burden in reflux patients with normal endoscopy: Does esophageal peristalsis matter?

BACKGROUND

A majority of patients with gastroesophageal reflux disease (GERD) have normal endoscopy. We aimed to investigate whether esophageal primary and secondary peristalsis influence esophageal reflux parameters in patients with normal endoscopy.

METHODS

We enrolled consecutive patients with typical reflux symptoms and normal endoscopy. All patients underwent High resolution manometry (HRM) and 24-h impedance-pH studies off therapy. During HRM, secondary peristalsis was evaluated using ten 20-mL rapid air infusions into the esophagus, while primary peristalsis was evaluated using ten 5-mL water swallows.

RESULTS

A total of 43 patients completed the study; 13 patients had normal motility, 20 had ineffective esophageal motility (IEM), and 10 had absent contractility. Acid exposure time (AET) (total, supine, and upright) was significantly higher in those with absent primary peristalsis (absent contractility) compared to normal motility (P = 0.001; 0.01; 0.007) and IEM (P = 0.002; 0.02; 0.03). Supine AET was significantly higher in patients without secondary peristalsis compared to those with secondary peristalsis (P = 0.04).

CONCLUSION

In the setting of normal endoscopy, acid reflux burden is more profound in patients with absent primary peristalsis, as well as in patients lacking a secondary peristaltic response to esophageal air distension.

Management of Ineffective Esophageal Hypomotility

Esophageal hypomotility in general and especially ineffective esophageal motility according to the Chicago criteria of primary motility disorders of the esophagus, is one of the most frequently diagnosed motility disorders on high resolution manometry and results in a large number of patients visiting gastroenterologists. Most patients with esophageal hypomotility present with gastroesophageal reflux symptoms or dysphagia. The clinical relevance of the motility pattern, however, is not well established but seems to be correlated with disease severity in reflux patients. The correlation with dysphagia is less clear. Prokinetic agents are commonly prescribed as first line pharmacologic intervention to target esophageal smooth muscle contractility and improve esophageal motor functions. However, the beneficial effects of these medications are limited and only confined to some specific drugs. Serotonergic agents, including buspirone, mosapride and prucalopride have been shown to improve parameters of esophageal motility although the effect on symptoms is less clear. Understanding on the complex correlation between esophageal hypomotility and esophageal symptoms as well as the limited evidence of prokinetic agents is necessary for physicians to appropriately manage patients with Ineffective Esophageal Motility (IEM).

Ineffective esophageal motility assessment in patients with and without pathological esophageal acid reflux

Ineffective esophageal motility (IEM), defined as minor esophageal motility disorder, is also the most common esophageal motility disorder. The relationship between gastro-esophageal reflux disease is still controversial. Our aim in this study is to evaluate whether there are differences in terms of demographic, endoscopic, or motility findings between IEM patients with pathological esophageal acid reflux and physiological reflux.Patients diagnosed with IEM according to the Chicago classification v3 with high-resolution manometry (HRM) before acid monitoring constituted the study group of our investigation. The patients were divided into 2 groups as patients with pathological esophageal reflux and patients with physiological reflux according to 24-hour acid monitoring. Demographic data, endoscopic findings, and HRM findings were compared between 2 groups.A total of 62 patients who were diagnosed with IEM according to the Chicago classification v3 were included in the study. Patients in the physiological reflux group were 7 years younger on average than the pathological reflux group. Esophagitis rates were significantly higher in the pathological reflux group (P = .033). Lower esophageal sphincter resting pressure, integrated relaxation pressure, and the presence of hernia were found to be similar in the 2 groups (P = 392, P = 182, P = 657, respectively). The rate of severe IEM was also similar between the 2 groups (P = .143).The fact that the physiological reflux patient group is younger may suggest that the IEM develops in the early period and then reflux accompanies the picture with advancing age.

Manometric and pH-monitoring changes after laparoscopic sleeve gastrectomy: a systematic review

PURPOSE

Aim of this systematic review is to assess the changes in esophageal motility and acid exposure of the esophagus through esophageal manometry and 24-hours pH-monitoring before and after laparoscopic sleeve gastrectomy (LSG).

METHODS

Articles in which all patients included underwent manometry and/or 24-hours pH-metry or both, before and after LSG, were included. The search was carried out in the PubMed, Embase, Cochrane, and Web of Science databases, revealing overall 13,769 articles. Of these, 9702 were eliminated because they have been found more than once between the searches. Of the remaining 4067 articles, further 4030 were excluded after screening the title and abstract because they did not meet the inclusion criteria. Thirty-seven articles were fully analyzed, and of these, 21 further articles were excluded, finally including 16 articles.

RESULTS

Fourteen and twelve studies reported manometric and pH-metric data from 402 and 547 patients, respectively. At manometry, a decrease of the lower esophageal sphincter resting pressure after surgery was observed in six articles. At 24-hours pH-metry, a worsening of the DeMeester score and/or of the acid exposure time was observed in nine articles and the de novo gastroesophageal reflux disease (GERD) rate that ranged between 17.8 and 69%. A meta-analysis was not performed due to the heterogeneity of data.

CONCLUSIONS

After LSG a worsening of GERD evaluated by instrumental exams was observed such as high prevalence of de novo GERD. However, to understand the clinical impact of LSG and the burden of GERD over time further long-term studies are necessary.

The added value of symptom analysis during a rapid drink challenge in high-resolution esophageal manometry

INTRODUCTION

Patients with esophageal symptoms often remain with an uncertain diagnosis after high-resolution manometry.

AIM

To determine the added value of concomitant pressure and symptom analysis in response to a rapid drink challenge (RDC).

METHODS

In consecutive patients referred for esophageal manometry, a RDC consisting in free drinking of 200 ml of water as quick as possible was performed after the standard single water swallows manometry. Both pressure patterns and usual symptoms induced by the RDC were analyzed.

RESULTS

A total of 1319 patients were included, (64.7% women, mean age 58.2 years, range 11-90). There were significant differences in pressure responses between patients with obstructive disorders, major hypercontractile disorders, esophageal hypomotility disorders and normal motility. The RDC provoked usual symptoms in 388 (29.4%) patients, associated with hyperpressive and obstructive patterns in 14.0% and 16.6%, respectively. Reproduction of dysphagia and regurgitation (not pain) was significantly associated with abnormal pressure responses during the RDC (p < 0.001 and p = 0.002, respectively). The RDC elicited both abnormal pressure patterns and symptoms in 6.2%, 1.6%, and 20.8% of patients with normal motility, ineffective esophageal motility, and esophago-gastric junction outflow obstruction, respectively.

CONCLUSION

Concomitant evaluation of symptoms and pressure responses to a RDC may increase the specificity of esophageal motor testing in patients with inconclusive diagnosis or normal esophageal motility.

Ineffective esophageal motility and bolus clearance. A study with combined high-resolution manometry and impedance in asymptomatic controls and patients

BACKGROUND

The definition and relevance of ineffective esophageal motility (IEM) remains debated. Our aim was to determine motility patterns and symptoms associated with IEM defined as impaired bolus clearance.

METHODS

To define altered bolus clearance, normal range of swallows with complete bolus transit (CBT) on high-resolution impedance manometry (HRIM) was determined in 44 asymptomatic controls. The results were then applied to a cohort of 81 patients with esophageal symptoms to determine the motility patterns which best predicted altered bolus clearance. Subsequently, in a cohort of 281 consecutive patients the identified motility patterns were compared with patients' customary symptoms.

KEY RESULTS

In asymptomatic controls, the normal range of swallows with CBT was 50%-100%. In patients, altered bolus transit (<50% CBT) was only associated with 30% or more failed contractions (P < .001). Neither weak peristalsis nor absence of contraction reserve (CR) was associated with altered bolus clearance. The patterns which best predicted altered bolus clearance were failed contractions ≥30% (specificity 88.2% and sensitivity of 84.6%), and ≥70% ineffective (failed + weak) contractions (sensitivity 84.6% and specificity 80.9%). No motility pattern was correlated to symptom scores.

CONCLUSIONS AND INFERENCES

Based on bolus clearance assessed by HRIM, ≥30% failed contractions and ≥70% ineffective contractions have the best sensitivity and specificity to predict altered bolus clearance. Weak contractions and absence of CR are not relevant with respect to bolus clearance.

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

Background/Aim

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

Methods and Patients

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

Results

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

Conclusions

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

Minor esophageal functional disorders: are they relevant?

PURPOSE OF REVIEW

High resolution esophageal manometry (HRM) has expanded understanding of esophageal motor function. The Chicago Classification scheme has allowed systematic categorization of the myriad of manometric parameters identified during HRM. Multichannel intraluminal impedance pH has enhanced ambulatory reflux monitoring through complete assessment of esophageal content transit. However, the clinical implications of identified minor esophageal functional disorders remain unclear.

RECENT FINDINGS

Esophagogastric junction outlet obstruction is defined by esophagogastric junction obstruction with preserved peristalsis and may be managed expectantly, or in a manner similar to achalasia. Hypercontractile esophagus has been associated with dysphagia and non-cardiac chest pain, but the clinical significance is unclear as a majority of patients will improve without specific therapy. Additionally, these findings may be confounded by chronic opiate use. Ineffective esophageal motility is characterized by diminished esophageal contraction amplitude, potentially causing dysphagia and GERD. However, this is commonly identified in asymptomatic volunteers and may represent a normal variant. The multiple rapid swallow sequence can assess esophageal contraction reserve, which may predict post fundoplication dysphagia. The post-swallow induced peristaltic wave can serve as a surrogate of gastric refluxate clearance, providing important prognostic value. However, the associated time burden and lack of alternative therapeutic options limit its clinical utility.

SUMMARY

Minor esophageal functional disorders provide new therapeutic targets for symptomatic patients. However, these findings have inconsistent associations with symptoms and poorly defined therapeutic options. Minor esophageal function disorders should not be interpreted in isolation, with management decisions accounting for clinical, endoscopic, and radiographic factors in addition.

Neuronal Control of Esophageal Peristalsis and Its Role in Esophageal Disease

PURPOSE OF REVIEW

Esophageal peristalsis is a highly sophisticated function that involves the coordinated contraction and relaxation of striated and smooth muscles in a cephalocaudal fashion, under the control of central and peripheral neuronal mechanisms and a number of neurotransmitters. Esophageal peristalsis is determined by the balance of the intrinsic excitatory cholinergic, inhibitory nitrergic and post-inhibitory rebound excitatory output to the esophageal musculature.

RECENT FINDINGS

Dissociation of the longitudinal and circular muscle contractions characterizes different major esophageal disorders and leads to esophageal symptoms. Provocative testing during esophageal high-resolution manometry is commonly employed to assess esophageal body peristaltic reserve and underpin clinical diagnosis. Herein, we summarize the main factors that determine esophageal peristalsis and examine their role in major and minor esophageal motility disorders and eosinophilic esophagitis.

Esophageal Dysphagia in the Elderly

PURPOSE OF REVIEW

With a globally aging population, dysphagia is a growing health concern among elderly. Increasing reflux disease has contributed to an increased prevalence of dysphagia from peptic strictures and esophageal cancer. Dysphagia can lead to malnutrition and aspiration pneumonia, causing considerable morbidity and mortality. This review article focuses on recent advances in the approach and management of esophageal dysphagia.

RECENT FINDINGS

Endoscopic functional luminal imaging probe is a novel test that complements upper endoscopy, esophagram, and esophageal manometry for evaluation of esophageal dysphagia. Opioid induced esophageal dysfunction (OIED) is an emerging clinical entity that can mimic achalasia. Strictures refractory to dilation can be treated with intralesional steroid injections, electrosurgical incision, or esophageal stents. Peroral endoscopic myotomy (POEM) is gaining in popularity for treatment of achalasia and other spastic disorders of esophagus. Treatment of esophageal dysphagia may include proton pump inhibitors, endoscopic dilation, or surgery and requires a personalized approach based on risks and benefits. POEM is a valuable therapy for achalasia, but further studies are needed to evaluate its use, and other alternatives, for treatment of OIED and spastic esophageal disorders.

Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium

BACKGROUND

Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450 mm Hg cm s) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). Ineffective esophageal motility is not consistently related to disease states or symptoms and may be seen in asymptomatic healthy individuals.

PURPOSE

A 1-day symposium of esophageal experts reviewed existing literature on IEM, and this review represents the conclusions from the symposium. Severe IEM (>70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.

High-Resolution Manometry Diagnosis of Ineffective Esophageal Motility Is Associated with Higher Reflux Burden

INTRODUCTION

Ineffective esophageal motility (IEM) is the most commonly diagnosed abnormality on high-resolution manometry (HRM). However, the clinical significance of IEM and associated reflux burden remains unclear.

AIM

Our primary aim was to compare reflux patterns between IEM versus normal motility on HRM.

METHODS

HRM and reflux studies in patients with IEM and normal motility were retrospectively reviewed. Esophageal pressure topography parameters, reflux variables, and patient-reported outcome questionnaires were explored.

RESULTS

A total of 239 patients with IEM were explored. Of these, 146 underwent reflux monitoring. Additionally, 100 patients with normal HRM all of whom had undergone reflux monitoring were included. IEM patients were more likely to have an abnormal number of reflux events compared to normal (22.7% vs. 9.0%, p < 0.01). Including only off-proton pump inhibitor (PPI) testing, IEM patients had higher mean total acid exposure time (AET) and total reflux events compared to normal motility (p = 0.02). Within IEM patients, higher AET modestly correlated with increased percentage of impaired swallows. Increased reflux events modestly correlated with higher impaired swallows and decreased lower esophageal sphincter (LES) resting pressure. Reflux burden increased with higher esophagogastric junction (EGJ) subtype, driven mostly by subtype III, although there was no difference in the distribution of EGJ subtypes between the IEM and normal HRM cohorts.

CONCLUSIONS

Patients with HRM diagnosis of IEM may be more prone to acid reflux while off-PPI and non-acid reflux while on-PPI. Reflux burden appears to be worse in IEM patients who have lower resting LES pressure, higher EGJ subtype, or higher percentage of impaired swallows.

Role of esophageal manometry in children with refractory gastroesophageal reflux symptoms

BACKGROUND

We investigated the prevalence of psychiatric referral, frequency of repeat upper gastrointestinal (UGI) contrast studies, and esophagogastroduodenoscopy (EGD) in children with ineffective esophageal motility (IEM) before the confirmation of esophageal dysmotility.

METHODS

A total of 19 children (nine boys, 10 girls; mean age, 13.80 ± 5.10 years) with symptoms of refractory gastroesophageal reflux (GER) who underwent high-resolution esophageal impedance manometry (HRIM) were enrolled in this retrospective analysis. Refractory GER symptoms were defined as persistent symptoms even under acid-suppression therapy for 8 weeks in this study. Clinical data including age, gender, time from symptom onset to diagnosis, and number of UGI contrast studies and EGD before diagnosis were obtained. HRM parameters and the prevalence of psychiatric referral were also analyzed.

RESULTS

There are 14 children (73.68%) diagnosed with IEM by HRIM, and another 5 children (26.32%) diagnosed as GER disease (GERD) by EGD. A significant proportion of IEM children were misdiagnosed with psychological problems compared with the GERD children (78.57% vs 20.00%, P = 0.04). Three IEM children (21.43%) received antipsychotic and antidepressant agents before diagnosis of IEM, and all of them discontinued these medications after diagnosis. IEM children underwent a greater number of UGI contrast studies (1.07 ± 0.92 vs 0.20 ± 0.45; P = 0.02) and EGD (2.36 ± 2.50 vs 0.60 ± 0.55; P = 0.03) before HRM than GERD children.

CONCLUSIONS

Esophageal manometry for the diagnosis of IEM should be considered in children with GER symptoms refractory to acid-suppression therapy for 8 weeks to avoid repeat UGI contrast studies, EGD, and psychological therapy.

High-resolution esophageal manometry in a Mexican population: diagnostic outcome

High-resolution esophageal manometry (HREM) has become the method of choice for evaluation of esophageal motility disorders. There is a paucity of data with this technique from Hispanic countries. This study aims to characterize the diagnostic outcome of HREM in a large cohort of consecutive patients in Mexico.This study was conducted in Monterrey, Mexico from March 1, 2013 to March 31, 2015. Our diverse study population included patients from a major academic institution and the community. HREM was done applying the Chicago Classification 3. Diagnostic outcome was grouped as weak peristaltic disorders, gastroesophageal junction disorders, and hypertensive/uncoordinated peristalsis.We studied 670 consecutive patients, 57% were women, mean age was 43.8 years. The majority (465 [69%]) were referred for preoperative evaluation of gastroesophageal reflux disease (GERD), 365 (78%) of whom had a normal study. Overall, 193 (29%) patients had abnormal motility, the most common disorder being weak peristalsis (104 [54%]). In patients with dysphagia, the most frequent finding was achalasia (23/46 [50%]).To our knowledge, this is the first study to characterize the diagnostic outcome of HREM in a large cohort of Hispanic patients in Latin America. At our open access center, 69% of patients were referred for preoperative evaluation of GERD, reflecting the popularity of antireflux surgery. This study confirms the high prevalence of weak peristalsis and highlights the importance of addressing its pathophysiology and management. The finding of achalasia in 50% of our patients with dysphagia is consistent with recent reports regarding the rising incidence of this disorder and underscores the need of prompt motility testing in this population.