Esophageal motor disorders: recent advances

Selective dysfunction of the crural diaphragm in patients with chronic restrictive and obstructive lung disease

BACKGROUND

Gastroesophageal reflux (GER) is known to be associated with chronic lung diseases. The driving force of GER is the transdiaphragmatic pressure (Pdi) generated mainly by costal and crural diaphragm contraction. The latter also enhances the esophagogastric junction (EGJ) pressure to guard against GER.

METHODS

The relationship between Pdi and EGJ pressure was determined using high resolution esophageal manometry in patients with interstitial lung disease (ILD, n = 26), obstructive lung disease (OLD, n- = 24), and healthy subjects (n = 20).

KEY RESULTS

The patient groups did not differ with respect to age, gender, BMI, and pulmonary rehabilitation history. Patients with ILD had significantly higher Pdi but lower EGJ pressures as compared to controls and OLD patients (p < 0.001). In control subjects, the increase in EGJ pressure at all-time points during inspiration was greater than Pdi. In contrast, the EGJ pressure during inspiration was less than Pdi in 14 patients with ILD and 7 patients with OLD. The drop in EGJ pressure was usually seen after the peak Pdi in ILD group (p < 0.0001) and before the peak Pdi in OLD group, (p = 0.08). Nine patients in the ILD group had sliding hiatus hernia, compared to none in control subjects (p = 0.003) and two patients in the OLD, (p = 0.04).

CONCLUSIONS AND INFERENCES

A higher Pdi and low EGJ pressure, and dissociation between Pdi and EGJ pressure temporal relationship suggests selective dysfunction of the crural diaphragm in patients with chronic lung diseases and may explain the higher prevalence of GERD in ILD as seen in previous studies.

A Procedure for the Automatic Analysis of High-Resolution Manometry Data to Support the Clinical Diagnosis of Esophageal Motility Disorders

OBJECTIVE

Degenerative phenomena may affect esophageal motility as a relevant social-health problem. The diagnosis of such disorders is usually performed by the analysis of data from high-resolution manometry (HRM). Inter- and intraobserver variability frequently affects the diagnosis, with potential interpretative and thus therapeutic errors, with unnecessary or worse treatments. This may be avoided with automatic procedures that minimize human intervention in data processing.

METHODS

In order to support the traditional diagnostic process, an automatic procedure was defined considering a specific physiomechanical model that is able to objectively interpret data from HRM. A training set (N = 226) of healthy volunteers and pathological subjects was collected in order to define the model parameters distributions of the different groups of subjects, providing a preliminary database. A statistical algorithm was defined for an objective identification of the patient's healthy or pathological condition by comparing patient parameters with the database.

RESULTS

A collection of HRMs including subjects of the training set has been built. Statistical relationships between parameters and pathologies have been established leading to a preliminary database. An automatic diagnosis procedure has been developed to compare model parameters of a specific patient with the database. The procedure was able to match the correct diagnosis up to 86% of the analyzed subjects.

CONCLUSION

The success rate of the automatic procedure addresses the suitability of the developed algorithms to provide a valid support to the clinicians for the diagnostic activity.

SIGNIFICANCE

The objectivity of developed tools increases the reliability of data interpretation and, consequently, patient acceptance.

A physiological model for the investigation of esophageal motility in healthy and pathologic conditions

Recent technological advances in esophageal manometry allowed the definition of new classification methods for the diagnosis of disorders of esophageal motility and the implementation of innovative computational tools for the autonomic, reliable and unbiased detection of different disorders. Computational models can be developed aiming to interpret the mechanical behavior and functionality of the gastrointestinal tract and to summarize the results from clinical measurements, as high-resolution manometry pressure plots, into model parameters. A physiological model was here developed to interpret data from esophageal high-resolution manometry. Such model accounts for parameters related to specific physiological properties of the biological structures involved in the peristaltic mechanism. The identification of model parameters was performed by minimizing the discrepancy between clinical data from high-resolution manometry and model results. Clinical data were collected from both healthy volunteers ( n = 35) and patients with different motor disorders, such as achalasia patterns 1 ( n = 13), 2 ( n = 20) and 3 ( n = 5), distal esophageal spasm ( n = 69), esophago-gastric junction outflow obstruction ( n = 25), nutcracker esophagus ( n = 11) and normal motility ( n = 42). The physiological model that was formulated in this work can properly explain high-resolution manometry data, as confirmed by the evaluation of the coefficient of determination R² = 0.83 - 0.96. The study finally led to identify the statistical distributions of model parameters for each healthy or pathologic conditions considered, addressing the applicability of the achieved results for the implementation of autonomic diagnosis procedures to support the medical staff during the traditional diagnostic process.

Safety and efficacy of the modified peroral endoscopic myotomy with shorter myotomy for achalasia patients: a prospective study

Peroral endoscopic myotomy (POEM) has been developed as a minimally invasive endoscopic treatment for achalasia for years. However, the optimal length of submucosal tunnel and myotomy of muscle bundles during procedure of POEM has not yet been determined, so we aim to assess safety and efficacy of modified POEM with shorter myotomy of muscle bundles in achalasia patients. Consecutive achalasia patients had been performed modified POEM with shorter myotomy, and assessed by symptoms, high-resolution manometry, and barium swallow examinations before and 3 months after POEM for safety and efficacy evaluation. Modified POEM with shorter submucosal tunnel (mean length 6.8 cm) and endoscopic myotomy of muscle bundles (total mean length 5.4 cm) were completed in 46 consecutive achalasia patients. During the 3-month follow up in all cases, significant improvement of symptoms (a significant drop in the Eckardt score 8.4 ± 3.2 vs. 2.7 ± 1.9; P < 0.001), decreased lower esophageal sphincter pressure (39.4 ± 10.1 vs. 24.4 ± 9.1 mmHg; P < 0.001) and integrated relaxation pressure (38.6 ± 10.4 vs. 25.7 ± 9.6 mmHg; P < 0.01), and a drop in height of esophagus barium-contrast column (5.4 ± 3.1 vs. 2.6 ± 1.8 cm; P < 0.001) were observed. The frequencies of adverse events were lower in those under endotracheal anesthesia and CO2 insufflations compared with intravenous anesthesia and air insufflations. Only three patients were found to have gastroesophageal reflux disease on follow up. Modified POEM with shorter myotomy under endotracheal anesthesia and CO2 insufflations shows its good safety and excellent short-term efficacy in the treatment of achalasia. But further studies are warranted to assess the long-term efficacy.

Clinical applications of gastrointestinal manometry in children

Manometry is a noninvasive diagnostic tool for identifying motility dysfunction of the gastrointestinal tract. Despite the great technical advances in monitoring motility, performance of the study in pediatric patients has several limitations that should be considered during the procedure and interpretation of the test results. This article reviews the clinical applications of conventional esophageal and anorectal manometries in children by describing a technique for performing the test. This review will develop the uniformity required for the methods of performance, the parameters for measurement, and interpretation of test results that could be applied in pediatric clinical practice.

Postnatal changes in vagal control of esophageal muscle contractions in rats

AIMS

Replacement of smooth muscles by striated muscles occurs in the esophagus during the early postnatal period. The aim of this study was to clarify postnatal changes in vagal control of esophageal muscle contractions in rats.

MAIN METHODS

An isolated segment of the neonatal rat esophagus was placed in an organ bath and the contractile responses were recorded using a force transducer.

KEY FINDINGS

Electrical stimulation of the vagus trunk evoked a biphasic contractile response in the neonatal esophageal segment. The first and second components of the contractions were inhibited by α-bungarotoxin and atropine, respectively. Ganglion blockers, hexamethonium and mecamylamine, did not affect vagally mediated contractions. The first component gradually enlarged with age in days, whereas the second component declined during the first week after birth. Application of d-tubocurarine or acetylcholine caused an apparent contraction in the esophageal striated muscle at postnatal day 0, but responses to these drugs were not observed at 1 week after birth. The neonatal esophagus expressed the γ-subunit of nicotinic acetylcholine receptors. In contrast, the ε-subunit was dominantly expressed in the adult esophagus.

SIGNIFICANCE

The vagus nerves directly innervate both the esophageal striated muscles and smooth muscles in the early neonatal period. During the process of muscle rearrangement, the property of the striated muscles is altered substantially. The specific features of striated muscles in the neonatal rat esophagus might compensate for immature formation of neuromuscular junctions. Unsuccessful conversion of the striated muscle property during postnatal muscle rearrangement would be related to disorders of esophageal motility.

Swallow evaluation during multichannel intraluminal impedance and pH: an alternate method to assess esophageal transit

BACKGROUND

Twenty-four-hour multichannel intraluminal impedance and pH (MII-pH) esophageal monitoring allows detection of both acid and nonacid gastroesophageal reflux episodes. The MII-pH catheter contains 6 impedance segments placed 3, 5, 7, 9, 15, and 17 cm above the lower esophageal sphincter (LES), plus a pH electrode at 5 cm. Multichannel intraluminal impedance and esophageal manometry (MII-EM) allows both functional and manometric evaluation of the esophagus. The MII-EM catheter contains 4 impedance measuring segments (5, 10, 15, and 20 cm above LES) and 5 solid state pressure transducers (within the LES and 5, 10, 15, and 20 cm above LES). Five milliliter saline boluses are given in the recumbent position when performing an MII-EM study. In our laboratory, all patients have an MII-EM study performed before an MII-pH study. In many laboratories, MII-pH is done without earlier MII-EM.

AIM

To assess accuracy of swallows given before ambulatory MII-pH monitoring in detecting esophageal transit abnormalities.

MATERIALS AND METHODS

Hundred consecutive adult patients, prospectively studied (64 female; mean age = 52.6 y), presenting to our laboratory for MII-EM and 24-hours MII-pH study, also received 10 saline swallows in the recumbent position at the beginning of the MII-pH study. Impedance for these swallows was assessed for the presence of complete or incomplete transit; defined as presence of bolus entry in the 17 cm segment and bolus exit in the 15, 9, and 5 cm segments; defined by a rise in impedance above 50% between baseline and the nadir, and remaining above this value for at least 5 seconds. Of 10 swallows, the presence of 8 or more complete swallows satisfies the MII-EM criterion for diagnosis of complete transit. These findings were blindly compared with those of the 10 saline swallows on the MII-EM study.

RESULTS

In 93% of patients, the MII-pH swallows gave identical transit diagnosis to the MII-EM. In 2 patients, the diagnosis changed from incomplete transit on MII-EM to complete on MII-pH, and in 5 patients from complete transit on MII-EM to incomplete on MII-pH. With both methods, there were 64 patients with complete transit and 29 with incomplete transit. Thus, MII-pH swallows had a sensitivity of 94% and a specificity of 93% for detection of esophageal transit abnormalities.Comparing the swallow diagnosis for each patient, we found that there was a highly significant correlation (P < 0.0001) for the number swallows with complete (Pearson r = 0.89) and incomplete bolus transits (Pearson r = 0.89). There was also a significant correlation (P < 0.0001) in bolus transit time between both methods (Pearson r = 0.64).

CONCLUSIONS

Use of 10 saline swallows at the beginning of MII-pH studies is accurate, missing bolus transit abnormality in only 2 of 100 patients. It is also highly sensitive and specific for detection of esophageal transit abnormalities. This method allows detection of patients in whom further evaluation of esophageal function may be warranted.

A case of symptomatic diffuse esophageal spasm during multiple rapid swallowing test on high-resolution manometry

Diffuse esophageal spasm (DES) is an uncommon motility disorder of unknown etiology in which the abnormal motility has been offered as a possible cause for the patient's dysphagia or chest pain. Esophageal manometry is the gold standard for the diagnosis of DES and the diagnostic hallmark is identification of simultaneous contractions in at least 20% of wet swallows, alternating with normal peristalsis. Recently, a new diagnostic technique, high-resolution manometry has been reported to improve the accuracy and detail in describing esophageal function. We report a female patient with intermittent dysphagia and chest pain occurring only when swallowing a large amount of water. On HRM, this patient had esophageal spasms, increased pressurization front velocity attributable to rapid contractile wave front, associated with symptoms, which were provoked by a multiple rapid swallowing test, and thereby was diagnosed with DES.

Treatments for pediatric achalasia: Heller myotomy or pneumatic dilatation?

AIM

The treatment of achalasia consists of reducing distal esophageal obstruction by either Heller myotomy surgery or endoscopic pneumatic dilatation. The aim of the present study was to evaluate the short- and middle-term results of these procedures in children.

METHODOLOGY

For technical reasons, children under six years old (n=8) were treated by surgery only, whereas patients over six years old (n=14) were treated by either Heller myotomy or pneumatic dilatation.

RESULTS

Of the children aged under six years, 75% were symptom-free at six months and 83% at 24 months of follow-up. Of the patients aged over six years, complete remission was achieved by Heller myotomy in 44.5% vs. 55.5% by pneumatic dilatation after six months, and in 40% vs. 65%, respectively, after 24 months. Both pneumatic dilatation and Heller myotomy showed significant rates of failure.

CONCLUSION

These results suggest that pneumatic dilatation may be considered a primary treatment in children over six years old. Also, where necessary, Heller myotomy and pneumatic dilatation may be used as complementary treatments.

A controversy that has been tough to swallow: is the treatment of achalasia now digested?

Esophageal achalasia is a rare neurodegenerative disease of the esophagus and the lower esophageal sphincter that presents within a spectrum of disease severity related to progressive pathological changes, most commonly resulting in dysphagia. The pathophysiology of achalasia is still incompletely understood, but recent evidence suggests that degeneration of the postganglionic inhibitory nerves of the myenteric plexus could be due to an infectious or autoimmune mechanism, and nitric oxide is the neurotransmitter affected. Current treatment of achalasia is directed at palliation of symptoms. Therapies include pharmacological therapy, endoscopic injection of botulinum toxin, endoscopic dilation, and surgery. Until the late 1980s, endoscopic dilation was the first line of therapy. The advent of safe and effective minimally invasive surgical techniques in the early 1990s paved the way for the introduction of laparoscopic myotomy. This review will discuss the most up-to-date information regarding the pathophysiology, diagnosis, and treatment of achalasia, including a historical perspective. The laparoscopic Heller myotomy with partial fundoplication performed at an experienced center is currently the first line of therapy because it offers a low complication rate, the most durable symptom relief, and the lowest incidence of postoperative gastroesophageal reflux.

Clinical predictors of achalasia

Limited access to esophageal manometry (EM) may delay identification and treatment of patients with achalasia. In order to assess predictors to fast-track patients for manometric confirmation of achalasia, we compared the clinical, radiographic, and endoscopic characteristics of achalasia patients to patients with functional dysphagia without manometric features of achalasia (controls). Patients referred for esophageal manometry to assess functional dysphagia prospectively identified over a 12-month period were asked to participate in this study. The Achalasia Symptom Questionnaire (ASQ), a structured 11-question survey (score: 0-best, 67-worst), was completed by all consenting patients. ASQ scores, esophago-gastro-duodenoscopy and upper gastro-intestinal (UGI) contrast study findings were compared between patents with subsequently confirmed achalasia and those in whom achalasia was excluded by EM. Univariate logistic regression identified predictors that were tested by multivariate logistic regression to generate the model. Of the 803 EM performed over this 12-month period, 95 patients were referred specifically to assess functional dysphagia. Of these, 50 were confirmed to have achalasia, and 45 had dysphagia without manometric evidence for achalasia and hence comprised the control group. ASQ scores were higher in achalasia patients (37+/-13 versus 23+/-10). Endoscopy and/or contrast esophagogram reports were available in 92% achalasia patients and 80% controls. Significant predictors for achalasia identified on univariate logistic regression included ASQ score, abnormal findings on endoscopy, and contrast UGI study. Using multivariate logistic regression, we were able to accurately predict the probability of achalasia to be P where P=ey/(1+ey) and y=5.6+(0.089xASQ)+(2.088xEGD)+(3.083xUGI), e=exponential constant 2.7182, esophagogastroduodenoscopy (EGD) and UGI=0 if normal and 1 if abnormal. Dropping the predictor ASQ, the formula changes to y=-2.7+(1.987xEGD)+(2.861xUGI). Using only noninvasive investigations (i.e. eliminating EGD), the formula changes to y=-4.9653+(0.0951xASQ)+(3.4312xUGI). The probability of achalasia can be calculated in patients with functional dysphagia based on clinical, endoscopic, and radiographic findings allowing for a prioritization of EM studies.

Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis

BACKGROUND

Although rare, esophageal achalasia is the best described primary esophageal motility disorder. Commonly used treatments are endoscopic botulin toxin injection (EBTI), endoscopic balloon dilation (EBD), and surgical myotomy with or without a fundoplication; however, reported outcomes mostly come from cohort studies.

OBJECTIVE

To summarize and compare the safety and efficacy of endoscopic and surgical treatments for esophageal achalasia.

METHODS

A systematic electronic Medline literature search of articles on esophageal achalasia. Treatment options reviewed included EBTI, EBD, and surgical myotomy using open and minimally invasive techniques. Main outcome measures were frequency of symptom relief, prevalence of post-treatment gastroesophageal reflux (GER), and complications. Outcome probability was estimated using weighted averages of the sample prevalence in each study, with weights equal to the number of patients. Outcomes, within or across studies, were compared using meta-analysis and meta-regression, respectively.

RESULTS

A total of 105 articles reporting on 7855 patients were selected, tabulated and reviewed. Symptom relief after EBD was better than after EBTI (68.2% vs. 40.6%; OR 3.4; 95% CI, 1.2-9.8; P = 0.02), and the need for additional therapy was greater for patients receiving EBTI (46.6% vs. 25%; OR, 2.6; 95% CI, 1.05-6.5; P = 0.04). Laparoscopic myotomy, when combined with an antireflux procedure, provided better symptom relief (90%) than all endoscopic and other surgical approaches and a low complication rate (6.3%). The incidence of postoperative GER was lower when a fundoplication was added to a laparoscopic myotomy (31.5% without a fundoplication vs. 8.8% with; OR, 6.3; 95% CI, 2.0-19.4; P = 0.003).

CONCLUSIONS

EBD is superior to EBTI. Laparoscopic myotomy with fundoplication was the most effective surgical technique and can be considered the operative procedure of choice.

Effects of anatomical position on esophageal transit time: A biomagnetic diagnostic technique

AIM: To study the esophageal transit time (ETT) and compare its mean value among three anatomical inclinations of the body; and to analyze the correlation of ETT to body mass index (BMI).

METHODS: A biomagnetic technique was implemented to perform this study: (1) The transit time of a magnetic marker (MM) through the esophagus was measured using two fluxgate sensors placed over the chest of 14 healthy subjects; (2) the ETT was assessed in three anatomical positions (at upright, fowler, and supine positions; 90º, 45º and 0º, respectively).

RESULTS: ANOVA and Tuckey post-hoc tests demonstrated significant differences between ETT mean of the different positions. The ETT means were 5.2 ± 1.1 s, 6.1 ± 1.5 s, and 23.6 ± 9.2 s for 90º, 45º and 0º, respectively. Pearson correlation results were r = -0.716 and P < 0.001 by subjects’ anatomical position, and r = -0.024 and P > 0.05 according the subject’s BMI.

CONCLUSION: We demonstrated that using this biomagnetic technique, it is possible to measure the ETT and the effects of the anatomical position on the ETT.

Current diagnosis and therapy for diffuse esophageal spasm

Diffuse esophageal spasm is a primary esophageal motility disorder characterized by incoordinate esophageal contraction. The etiology is still not clear. This study systemically elucidates the latest advancement in pathogenesis, diagnosis and therapy of diffuse esophageal spasm, and then gives an objective and analytic evaluation. In this article, we also provide new diagnostic and therapeutic strategies for patients with diffuse esophageal spasm.

T cells in the myenteric plexus of achalasia patients show a skewed TCR repertoire and react to HSV-1 antigens

OBJECTIVE

The loss of myenteric neurons in the lower esophageal sphincter (LES) characterizes achalasia, an esophageal motor disorder. Because the presence of lymphocytic infiltrates suggests an immuno-mediated mechanism ongoing at the sites of disease, we investigated the T-cell receptor (TCR) repertoire and the ability to recognize human herpes virus type 1 (HSV-1) antigens of LES-infiltrating T lymphocytes in achalasia patients.

METHODS

Fifty-nine patients with idiopathic achalasia and 38 heart-beating cadaveric multiorgan donors (controls) were studied. By flow cytometry evaluation and CDR3 length spectratyping analysis, the lymphocytes of 18 patients and 15 controls were analyzed, whereas 41 patients and 23 controls were employed for functional assays.

RESULTS

Achalasia patients were characterized by a significantly higher esophagus lymphocytic infiltrate than controls (24.71%+/- 3.11 and 9.54%+/- 1.34, respectively; P < 0.05), mainly represented by CD3+CD8+ T cells. The characterization of TCR beta chain repertoire of CD3+ cells showed the expression of a limited number of TCR beta variable (BV) gene families (from two to five out of 26), with highly restricted spectratypes, suggesting a disease-associated oligoclonal selection of T cells. Furthermore, lymphocytes from achalasia LES specifically responded to exposure to HSV-1 antigens in vitro as showed by increased proliferation and Th-1 type cytokines release.

CONCLUSIONS

These data suggest that the oligoclonal lymphocytic infiltrate within the LES of achalasia patients may represent the trace of an immune-inflammatory reaction triggered by HSV-1 antigens and that the Th1-type cytokines released by the activated lymphocytes may contribute to establish the neuronal damage accounting for the clinical features of idiopathic achalasia.

Value of spatiotemporal representation of manometric data

BACKGROUND & AIMS

High-resolution manometry with spatiotemporal representation of pressure data is a technique that has developed during the past 10-15 years. We compared spatiotemporal and traditional line plot representation of manometry data in a group of medical students in terms of the ability of the user to come to a rapid and accurate diagnosis and evaluated user preferences for the 2 forms of data display.

METHODS

After standardized paper-based and electronic tutorials, 60 medical students classified 30 typical examples of a range of motility disorders in both line plots (10 sensors, including a "virtual sleeve") and spatiotemporal plot format (derived from 16 sensors). Swallows were presented electronically in random order. The accuracy and speed of the assessment were compared between the 2 forms of data presentation, as well as a subjective rating of preference. Results are presented as mean +/- standard error of the mean.

RESULTS

Classifications based on data presented in spatiotemporal format were more often correct (89% +/- 1.2% vs 86% +/- 1.3%, P = .002), and correct diagnoses were provided more promptly (25 +/- 2.9 seconds vs 31 +/- 3.2 seconds, P < .001) than in line plot format. Sixty-eight percent of the study population preferred the spatiotemporal presentation.

CONCLUSIONS

The analysis of manometry data by manometry-naive individuals is faster and more accurate when data are presented in spatiotemporal than in line plot format. In addition, users preferred the spatiotemporal plots. Spatiotemporal presentation of manometric data is likely to be more easily understood by patients and the "non-expert" physician community.

Foramen magnum meningioma: Dysphagia of atypical etiology

INTRODUCTION

We present a case of a foramen magnum meningioma that highlights the importance of the neurologic exam when evaluating a patient with dysphagia. A 58-year-old woman presented with an 18-month history of progressive dysphagia, chronic cough and 30-pound weight loss. Prior gastroenterologic and laryngologic workup was unrevealing.

RESULTS

Her neurologic examination revealed an absent gag reflex, decreased sensation to light touch on bilateral distal extremities, hyperreflexia, and tandem gait instability. Repeat esophagogastroduodenoscopy was normal, whereas laryngoscopy and video fluoroscopy revealed marked hypopharyngeal dysfunction. Brain magnetic resonance imaging demonstrated a 3.1 x 2.7 x 2.9 cm foramen magnum mass consistent with meningioma. The patient underwent neurosurgical resection of her mass with near complete resolution of her neurologic symptoms. Pathology confirmed diagnosis of a WHO grade I meningothelial meningioma.

CONCLUSION

CNS pathology is an uncommon but impressive cause of dysphagia. Our case demonstrates the importance of a thorough neurologic survey when evaluating such a patient.

Transcutaneous cervical esophagus ultrasound in adults: Relation with ambulatory 24-h pH-monitoring and esophageal manometry

AIM: To determine the gastroesophageal refluxate in the cervical esophagus (CE) and measure transcutaneous cervical esophageal ultrasound (TCEUS) findings [anterior wall thickness (WT) of CE, esophageal luminal diameter (ELD), esophageal diameter (ED)]; to compare TCEUS findings in the patient subgroups divided according to 24-h esophageal pH monitoring and manometry; and to investigate possible cut-off values according to the TCEUS findings as a predictor of gastroesophageal reflux (GER).

METHODS: In 45/500 patients, refluxate was visualized in TCEUS. 38/45 patients underwent esophagogastroduodenoscopy (EGD), 24-h pH monitoring and manometry.

RESULTS: The 38 patients were grouped according to 24-h pH monitoring as follows: Group A: GER-positive (n = 20) [Includes Group B: isolated proximal reflux (PR) (n = 6), Group C: isolated distal reflux (DR) (n = 6), and Group D: both PR/DR (n = 8)]; Group E: no reflux (n = 13); and Group F: hypersensitive esophagus (HSE) (n = 5). Groups B + D indicated total PR patients (n = 14), Groups E + F reflux-negatives with HSE (n = 18), and Groups A + F reflux-positives with HSE (n = 25). When the 38 patients were grouped according to manometry findings, 24 had normal esophageal manometry; 7 had hypotensive and 2 had hypertensive lower esophageal sphincter (LES); and 5 had ineffective esophageal motility disorder (IEM). The ELD measurement was greater in group A + F than group E (P = 0.023, 5.0 ± 1.3 vs 3.9 ± 1.4 mm). In 27/38 patients, there was at least one pathologic acid reflux and/or pathologic manometry finding. The cut-off value for ELD of 4.83 mm had 79% sensitivity and 61% specificity in predicting the PR between Groups B + D and E (AUC = 0.775, P = 0.015).

CONCLUSION: Visualizing refluxate in TCEUS was useful as a pre-diagnostic tool for estimating GER or manometric pathology in 71.1% of adults in our study, but it was not diagnostic for CE WT.