1
|
Pomenti S, Nathanson J, Phipps M, Aneke-Nash C, Katzka D, Freedberg D, Jodorkovsky D. Esophagogastroduodenoscopy findings that do no not explain dysphagia are associated with underutilization of high-resolution manometry. Dis Esophagus 2024; 37:doae028. [PMID: 38582609 DOI: 10.1093/dote/doae028] [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: 04/24/2023] [Revised: 03/15/2024] [Accepted: 03/17/2024] [Indexed: 04/08/2024]
Abstract
In patients with dysphagia that is not explained by upper endoscopy, high-resolution esophageal manometry (HRM) is the next logical step in diagnostic testing. This study investigated predictors of failure to refer for HRM after an upper endoscopy that was performed for but did not explain dysphagia. This was a retrospective cohort study of patients >18 years of age who underwent esophagogastroduodenoscopy (EGD) for dysphagia from 2015 to 2021. Patients with EGD findings that explained dysphagia (e.g. esophageal mass, eosinophilic esophagitis, Schatzki ring, etc.) were excluded from the main analyses. The primary outcome was failure to refer for HRM within 1 year of the index non-diagnostic EGD. We also investigated delayed referral for HRM, defined as HRM performed after the median. Multivariable logistic regression modeling was used to identify risk factors that independently predicted failure to refer for HRM, conditioned on the providing endoscopist. Among 2132 patients who underwent EGD for dysphagia, 1240 (58.2%) did not have findings to explain dysphagia on the index EGD. Of these 1240 patients, 148 (11.9%) underwent HRM within 1 year of index EGD. Endoscopic findings (e.g. hiatal hernia, tortuous esophagus, Barrett's esophagus, surgically altered anatomy not involving the gastroesophageal junction, and esophageal varices) perceived to explain dysphagia were independently associated with failure to refer for HRM (adjusted odds ratio 0.45, 95% confidence interval 0.25-0.80). Of the 148 patients who underwent HRM within 1 year of index EGD, 29.7% were diagnosed with a disorder of esophagogastric junction outflow, 17.6% with a disorder of peristalsis, and 2.0% with both disorders of esophagogastric outflow and peristalsis. The diagnosis made by HRM was similar among those who had incidental EGD findings that were non-diagnostic for dysphagia compared with those who had completely normal EGD findings. Demographic factors including race/ethnicity, insurance type, and income were not associated with failure to refer for HRM or delayed HRM. Patients with dysphagia and endoscopic findings unrelated to dysphagia have a similar prevalence of esophageal motility disorders to those with normal endoscopic examinations, yet these patients are less likely to undergo HRM. Provider education is indicated to increase HRM referral in these patients.
Collapse
Affiliation(s)
- Sydney Pomenti
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - John Nathanson
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Meaghan Phipps
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Chino Aneke-Nash
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - David Katzka
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Daniel Freedberg
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Daniela Jodorkovsky
- Department of Medicine, Division of Digestive Diseases, Mount Sinai Doctors, New York, NY, USA
| |
Collapse
|
2
|
Davis TA, Rogers BD, Llanos-Chea A, Krasaelap A, Banks D, Ambartsumyan L, Sanchez RE, Yacob D, Baker C, Rey AP, Desai C, Rottier A, Jayaraman M, Khorrami C, Dorfman L, El-Chammas K, Mansi S, Chiou E, Chumpitazi BP, Balakrishnan K, Puri NB, Rodriguez L, Garza JM, Saps M, Gyawali CP, Patel D. Ineffective esophageal motility: Characterization and outcomes across pediatric neurogastroenterology and motility centers in the United States. J Pediatr Gastroenterol Nutr 2024. [PMID: 39010786 DOI: 10.1002/jpn3.12324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 06/03/2024] [Accepted: 06/28/2024] [Indexed: 07/17/2024]
Abstract
OBJECTIVES Ineffective esophageal motility (IEM) on high-resolution manometry (HRM) is not consistently associated with specific clinical syndromes or outcomes. We evaluated the prevalence, clinical features, management, and outcomes of pediatric IEM patients across the United States. METHODS Clinical and manometric characteristics of children undergoing esophageal HRM during 2021-2022 were collected from 12 pediatric motility centers. Clinical presentation, test results, management strategies, and outcomes were compared between children with IEM and normal HRM. RESULTS Of 236 children (median age 15 years, 63.6% female, 79.2% Caucasian), 62 (23.6%) patients had IEM, and 174 (73.7%) patients had normal HRM, with similar demographics, medical history, clinical presentation, and median symptom duration. Reflux monitoring was performed more often for IEM patients (25.8% vs. 8.6%, p = 0.002), but other adjunctive testing was similar. Among 101 patients with follow-up, symptomatic cohorts declined in both groups in relation to the initial presentation (p > 0.107 for each comparison) with management targeting symptoms, particularly acid suppression. Though prokinetics were used more often and behavioral therapy less often in IEM (p ≤ 0.015 for each comparison), symptom outcomes were similar between IEM and normal HRM. Despite a higher proportion with residual dysphagia on follow-up in IEM (64.0% vs. 39.1%, p = 0.043), an alternate mechanism for dysphagia was identified more often in IEM (68.8%) compared to normal HRM (27.8%, p = 0.017). CONCLUSIONS IEM is a descriptive manometric pattern rather than a clinical diagnosis requiring specific intervention in children. Management based on clinical presentation provides consistent symptom outcomes.
Collapse
Affiliation(s)
- Trevor A Davis
- Division of Pediatric Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
- Division of Gastroenterology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Alejandro Llanos-Chea
- Division of Pediatric Gastroenterology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Amornluck Krasaelap
- Division of Pediatric Gastroenterology, Children's Mercy, Kansas City, Missouri, USA
| | - Darnna Banks
- Division of Pediatric Gastroenterology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lusine Ambartsumyan
- Division of Pediatric Gastroenterology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Raul E Sanchez
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Desale Yacob
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Corey Baker
- Division of Pediatric Gastroenterology, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Adriana Prada Rey
- Division of Pediatric Gastroenterology, Universidad El Bosque, Bogotá, Colombia
| | - Chaitri Desai
- Division of Pediatric Gastroenterology, Children's Mercy, Kansas City, Missouri, USA
| | - Aaron Rottier
- Division of Gastroenterology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Mayuri Jayaraman
- Division of Pediatric Gastroenterology, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Camila Khorrami
- Division of Pediatric Gastroenterology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Lev Dorfman
- Division of Pediatric Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Khalil El-Chammas
- Division of Pediatric Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sherief Mansi
- Division of Pediatric Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Eric Chiou
- Division of Pediatric Gastroenterology, Texas Children's Hospital, Houston, Texas, USA
| | - Bruno P Chumpitazi
- Division of Pediatric Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kesha Balakrishnan
- Division of Pediatric Gastroenterology, Texas Children's Hospital, Houston, Texas, USA
| | - Neetu B Puri
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Leonel Rodriguez
- Division of Pediatric Gastroenterology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jose M Garza
- Division of Pediatric Gastroenterology, Neurogastroenterology and Motility Program at Children's Healthcare of Atlanta & GI Care for Kids, Atlanta, Georgia, USA
| | - Miguel Saps
- Division of Pediatric Gastroenterology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Chandra Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Dhiren Patel
- Division of Pediatric Gastroenterology, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| |
Collapse
|
3
|
Debourdeau A, Gonzalez JM, Barthet M, Vitton V. Dysphagia in Children, Do Not Blame Eosinophils Too Quickly. CHILDREN (BASEL, SWITZERLAND) 2022; 10:children10010063. [PMID: 36670614 PMCID: PMC9856664 DOI: 10.3390/children10010063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/30/2022] [Accepted: 12/12/2022] [Indexed: 12/29/2022]
Abstract
Dysphagia in children is a relatively frequent symptom in childhood, and the main causes are congenital and linked to ear-nose-throat etiologies. However, non-congenital esophageal dysphagia is less common, and the main cause in such cases is eosinophilic esophagitis (EoE). When there is no response to a well-conducted treatment, with normalization of histology, the diagnosis of EoE must then be reconsidered. Here, we present the case of a 10-year-old patient whose initial diagnosis of eosinophilic esophagitis delayed the diagnosis of type III achalasia.
Collapse
Affiliation(s)
- Antoine Debourdeau
- Gastroenterology and Endoscopy Unit, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille, Aix Marseille Université, 13015 Marseille, France
- Endoscopy Unit, CHU Montpellier, Montpellier University, 34000 Montpellier, France
- Gastroenterology Unit, CHU de Nîmes, Montpellier University MUSE, 30000 Nîmes, France
- Correspondence:
| | - Jean-Michel Gonzalez
- Gastroenterology and Endoscopy Unit, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille, Aix Marseille Université, 13015 Marseille, France
| | - Marc Barthet
- Gastroenterology and Endoscopy Unit, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille, Aix Marseille Université, 13015 Marseille, France
| | - Véronique Vitton
- Gastroenterology and Endoscopy Unit, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille, Aix Marseille Université, 13015 Marseille, France
| |
Collapse
|
4
|
Prachasitthisak N, Purcell M, Krishnan U. Role of Esophageal High-Resolution Manometry in Pediatric Patients. Pediatr Gastroenterol Hepatol Nutr 2022; 25:300-311. [PMID: 35903488 PMCID: PMC9284111 DOI: 10.5223/pghn.2022.25.4.300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 01/23/2022] [Accepted: 05/02/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Dysphagia, vomiting and feeding difficulties are common symptoms, with which children present. Esophageal function testing with high resolution manometry can help in diagnosing and treating these patients. We aim to access the clinical utility of high-resolution manometry of esophagus in symptomatic pediatric patients. METHODS A retrospective chart review was done on all symptomatic patients who underwent esophageal high-resolution manometry between 2010 and 2019 at Sydney Children's Hospital, Australia. Manometry results were categorized based on Chicago classification. Demographic data, indication of procedure, manometric findings, and details of treatment changes were obtained and analyzed. RESULTS There were 62 patients with median age of 10 years (9 months-18 years). The main indication for the procedure was dysphagia (56%). Thirty-two percent of patients had a co-morbid condition, with esophageal atresia accounting for 16%. The majority (77%) of patients had abnormal manometry which included, ineffective esophageal motility in 45.2%. In esophageal atresia cohort, esophageal pressurization was seen in 50%, aperistalsis in 40% and 10% with prior fundoplication had esophago-gastric junction obstruction. Patients with esophago-gastric junction obstruction or achalasia were treated by either pneumatic dilation or Heller's myotomy. Patients with ineffective esophageal motility and rumination were treated with a trial of prokinetics/dietary texture modification and diaphragmatic breathing. CONCLUSION Esophageal high-resolution manometry has a role in the evaluation of symptomatic pediatric patients. The majority of our patients had abnormal results which led to change in treatments, with either medication, surgery and/or feeding modification with resultant improvement in symptoms.
Collapse
Affiliation(s)
- Noparat Prachasitthisak
- Department of Pediatric Gastroenterology, Sydney Children's Hospital, Randwick, Australia.,Division of Gastroenterology, Department of Pediatrics, Queen Sirikit National Institute of Child Health, Ministry of Public Health, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Michael Purcell
- Department of Pediatric Gastroenterology, Sydney Children's Hospital, Randwick, Australia
| | - Usha Krishnan
- Department of Pediatric Gastroenterology, Sydney Children's Hospital, Randwick, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| |
Collapse
|
5
|
Caruso AM, Milazzo M, Tulone V, Acierno C, Girgenti V, Amoroso S, Bommarito D, Calcaterra V, Pelizzo G. High Resolution Manometry Guidance During Laparoscopic Fundoplication in Pediatric Surgically "Fragile" Patients: Preliminary Report. CHILDREN-BASEL 2020; 7:children7110215. [PMID: 33171722 PMCID: PMC7695016 DOI: 10.3390/children7110215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022]
Abstract
Background: High resolution manometry (HRM), has been recently introduced in clinical practice to detect esophageal intraluminal pressure and esophageal motor function. We evaluated the feasibility and usefulness of intraoperative esophageal HRM during antireflux laparoscopic procedures in pediatric cases with neurological impairment (NI) or esophageal atresia (EA). Methods: From January to November 2019, seven children (5 NI, 2 EA) with gastroesophageal reflux (GER) were enrolled. Data on intraoperative pressure changes of the esophagogastric junction (EGJ) and postoperative follow-up data were collected. Results: Average preoperative LES pressures were not significantly different from postoperative pressures. A sliding hernia was detected in all patients as evidenced by EGJ double peak pressures. Hernia correction after esophageal traction was complete in 71.4% of the patients, and residual hernia (<2 cm) was detected in 28.6%. Postoperative EGJ pressures were higher compared to preoperative sphincteric pressures (p < 0.001); in NI patients, higher postoperative values were noted compared to EA (p = 0.05). No sliding hernia and/or GER relapses were recorded. Two patients reported dysphagia postoperatively. Conclusions: Intraoperative HRM may optimize esophageal pressure changes during laparoscopic fundoplication. Further studies are needed to confirm the usefulness of a tailored surgical approach to reduce postoperative complications.
Collapse
Affiliation(s)
- Anna Maria Caruso
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Mario Milazzo
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Vincenzo Tulone
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Carlo Acierno
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Vincenza Girgenti
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Salvatore Amoroso
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Denisia Bommarito
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Valeria Calcaterra
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy;
- Pediatric Unit, “V. Buzzi” Children’s Hospital, University of Milano, 20154 Milano, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Unit, “V. Buzzi” Children’s Hospital, University of Milano, 20154 Milano, Italy
- Department of Biomedical and Clinical Science, “L. Sacco”, University of Milano, 20154 Milano, Italy
- Correspondence:
| |
Collapse
|
6
|
Omari TI, Krishnan U. What is the role of high-resolution oesophageal manometry in paediatrics? J Paediatr Child Health 2020; 56:1754-1759. [PMID: 33197976 DOI: 10.1111/jpc.15057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 12/21/2022]
Abstract
Abnormal oesophageal motility may impair oesophageal bolus transport leading to symptoms of chest pain and regurgitation. Oesophageal pathophysiology may include neuromuscular and/or structural defects leading to weak, incoordinate or absent peristalsis and impaired oesophago-gastric junction relaxation. Understanding these mechanisms is important to determine the appropriate course of therapy. Whilst, barium oesophagram is the mainstay for clinical investigation of oesophageal motility, high-resolution manometry is now more widely available. This review describes the potential value of high-resolution manometry in paediatric gastroenterology practise.
Collapse
Affiliation(s)
- Taher I Omari
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Usha Krishnan
- Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| |
Collapse
|
7
|
Diaz-Oliva SE, Aguilera-Matos I, Villa Jiménez OM, Escobedo AA. Oesophageal eosinophilia and oesophageal diseases in children: are the limits clear? BMJ Paediatr Open 2020; 4:e000680. [PMID: 32818156 PMCID: PMC7406026 DOI: 10.1136/bmjpo-2020-000680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/01/2020] [Accepted: 07/05/2020] [Indexed: 12/16/2022] Open
Abstract
Gastro-oesophageal reflux disease, eosinophilic oesophagitis and oesophageal motility disorders are among the most common diseases accompanying oesophageal eosinophilia. They have similarities and their limits are frequently not well defined. This article reviews the main characteristics relating to their similarities and differences, highlighting existing controversies among these diseases, in addition to current knowledge. In the case of a patient with symptoms of oesophageal dysfunction, it is suggested to carry out an integral analysis of the clinical features and diagnostic test results, including histology, while individualising each case before confirming a definitive diagnosis. Future investigation in paediatric patients is necessary to assess eosinophilic infiltration in the various layers of the oesophageal tissue, along with its clinical and pathophysiological implications.
Collapse
Affiliation(s)
| | | | | | - Angel A Escobedo
- Pediatric Gastroentrology, Institute of Gastroenterology, Havana, Cuba.,Research department, Epidemiology, Institute of Gastroenterology, Havana, Cuba
| |
Collapse
|