Identification of impaired oesophageal bolus transit and clearance by secondary peristalsis in patients with non-obstructive dysphagia

Age Affects Esophageal Secondary Peristalsis More Than Primary as Assessed by FLIP Panometry and High-resolution Manometry

Age-related changes in esophageal function involve increased rates of dysmotility with advancing age (sometimes described as presbyesophagus).1-4 Specifically, advanced age has been associated with increased lower esophageal sphincter (LES) pressure and decreased peristaltic vigor.1-4 However, the mechanisms underlying these changes, including the relative relationship of primary peristalsis and secondary peristalsis over the lifespan, remain incompletely understood. Current approaches assess primary peristalsis using high-resolution manometry (HRM), with esophageal motility disorders defined using the Chicago Classification version 4.0 (CCv4.0), and secondary peristalsis using functional lumen imaging probe (FLIP) panometry.5,6 Although HRM and FLIP panometry motility diagnoses are often analogous, they can sometimes differ. For example, abnormal secondary peristalsis can occur when primary peristalsis is normal, which has been associated with reflux and non-obstructive dysphagia.7,8 This study aimed to examine the effect of age on primary peristalsis and secondary peristalsis.

Superficial oesophageal mucosal innervation may contribute to severity of symptoms in oesophageal motility disorders

BACKGROUND

Mechanisms underlying perception of dysphagia and chest pain have not been completely elucidated, although oesophageal mucosal afferent nerves might play an important role.

AIMS

To evaluate the relationship between oesophageal mucosal afferent nerves and the severity of dysphagia and chest pain in oesophageal motility disorders.

METHODS

We prospectively recruited patients with oesophageal motility disorders having dysphagia and/or chest pain from whom oesophageal biopsies were obtained. High-resolution manometry classified patients into disorders of oesophagogastric junction (OGJ) outflow and disorders of peristalsis. Symptom severity was assessed using validated questionnaires including Brief Oesophageal Dysphagia Questionnaire (BEDQ). Immunohistochemistry was performed on oesophageal biopsies to evaluate the location of calcitonin gene-related peptide (CGRP)-immunoreactive mucosal afferent nerves. Findings were compared to existing data from 10 asymptomatic healthy volunteers.

RESULTS

Of 79 patients, 61 patients had disorders of OGJ outflow and 18 had disorders of peristalsis. CGRP-immunoreactive mucosal nerves were more superficially located in the mucosa of patients with oesophageal motility disorders compared to healthy volunteers. Within disorders of OGJ outflow, the location of CGRP-immunoreactive nerves negatively correlated with BEDQ score both in the proximal (ρ = -0.567, p < 0.001) and distal oesophagus (ρ = -0.396, p = 0.003). In the proximal oesophagus, strong chest pain was associated with more superficially located mucosal nerves than weak chest pain (p = 0.04). Multivariate analysis showed superficial nerves in the proximal oesophagus was independently associated with severe dysphagia in disorders of OGJ outflow (p = 0.008).

CONCLUSIONS

Superficial location of mucosal nerves in the proximal oesophagus might contribute to symptoms, especially severe dysphagia, in disorders of OGJ outflow.

Predictors of reflux aspiration and laryngo-pharyngeal reflux

BACKGROUND

Gastro-esophageal reflux disease (GERD) can present with typical or atypical or laryngo-pharyngeal reflux (LPR) symptoms. Pulmonary aspiration of gastric refluxate is one of the most serious variants of reflux disease as its complications are difficult to diagnose and treat. The aim of this study was to establish predictors of pulmonary aspiration and LPR symptoms.

METHODS

Records of 361 consecutive patient from a prospectively populated database were analyzed. Patients were categorized by symptom profile as predominantly LPR or GERD (98 GER and 263 LPR). Presenting symptom profile, pH studies, esophageal manometry and scintigraphy and the relationships were analyzed.

RESULTS

Severe esophageal dysmotility was significantly more common in the LPR group (p = 0.037). Severe esophageal dysmotility was strongly associated with isotope aspiration in all patients (p = 0.001). Pulmonary aspiration on scintigraphy was present in 24% of patients. Significant correlation was established between total proximal acid on 24-h pH monitoring and isotope aspiration in both groups (p < 0.01). Rising pharyngeal curves on scintigraphy were the strongest predictors of isotope aspiration (p < 0.01).

CONCLUSIONS

Severe esophageal dysmotility correlates with LPR symptoms and reflux aspiration in LPR and GERD. Abnormal proximal acid score on 24-h pH monitoring associated with pulmonary aspiration in reflux patients. Pharyngeal contamination on scintigraphy was the strongest predictor of pulmonary aspiration.

Esophageal motility classification can be established at the time of endoscopy: a study evaluating real-time functional luminal imaging probe panometry

BACKGROUND AND AIMS

A novel device that provides real-time depiction of functional luminal image probe (FLIP) panometry (ie, esophagogastric junction [EGJ] distensibility and distension-induced contractility) was evaluated. We aimed to compare real-time FLIP panometry interpretation at the time of sedated endoscopy with high-resolution manometry (HRM) in evaluating esophageal motility.

METHODS

Forty consecutive patients (aged 24-81 years; 60% women) referred for endoscopy with a plan for future HRM from 2 centers were prospectively evaluated with real-time FLIP panometry during sedated upper endoscopy. The EGJ distensibility index and contractility profile were applied to derive a FLIP panometry classification at the time of endoscopy and again (post-hoc) using a customized program. HRM was classified according to the Chicago classification.

RESULTS

Real-time FLIP panometry motility classification was abnormal in 29 patients (73%), 19 (66%) of whom had a subsequent major motility disorder on HRM. All 9 patients with an HRM diagnosis of achalasia had abnormal real-time FLIP panometry classifications. Eleven patients (33%) had normal motility on real-time FLIP panometry and 8 (73%) had a subsequent HRM without a major motility disorder. There was excellent agreement (κ = .939) between real-time and post-hoc FLIP panometry interpretation of abnormal motility.

CONCLUSIONS

This prospective, multicentered study demonstrated that real-time FLIP panometry could detect abnormal esophageal motility, including achalasia, at the endoscopic encounter. Additionally, normal motility on FLIP panometry was predictive of a benign HRM. Thus, real-time FLIP panometry incorporated with endoscopy appears to provide a suitable and well-tolerated point-of-care esophageal motility assessment.

Prevalence and Associated Impacts of Cervical Esophageal Clearance Issues Post Chemoradiotherapy for Nasopharyngeal Carcinoma (NPC)

At present, the nature and extent of upper esophageal stage clearance issues following nonsurgical management of nasopharyngeal cancer (NPC) is not well elucidated. The aim of this study was to conduct an initial retrospective study of the prevalence and severity of upper esophageal clearance impairments in a cohort of patients post-NPC management. A secondary aim was to explore any observed relationship between severity of impairment with both (a) aspiration and (b) temporal oropharyngeal swallowing measures. A cohort of 134 NPC patients who received curative intent (chemo)radiotherapy (C/RT) and completed a videofluoroscopic swallowing study (VFSS) between 2012 and 2015 were reviewed. An Esophageal Clearance parameter, based on the scale used in MBSImP was used to classify the presence and severity of esophageal impairment on thin liquid and semisolids. Data on oral and pharyngeal temporal measures, pharyngeal constriction, and penetration/aspiration were also collected. The prevalence of cervical esophageal clearance impairment was high with ratings > 0 observed among 83% and 97% of patients on thin liquid and semisolids, respectively. With the increasing impairment, significantly (p < 0.05) increased oral transit times were observed for liquid swallows, and increased pharyngeal transit times for semisolids. Significantly higher proportions of patients presented with penetration/aspiration in the group with more severe esophageal clearance impairment. Results confirm that cervical esophageal clearance impairment is highly prevalent post-C/RT treatment for NPC. Causality cannot be determined from this study; however, this initial evidence supports that esophageal impairment may coexist in patients post NPC, presenting with more severe oral/pharyngeal deficits, and the impact of this on swallow function needs to be considered. Further systematic research is required.

Roles of High-resolution Manometry in Predicting Incomplete Bolus Transit in Patients With Dysphagia

BACKGROUND

High-resolution manometry (HRM) is used to assess esophageal motility diseases. Abnormalities in a number of HRM parameters have been reported in patients with dysphagia. However, it is unclear whether some of abnormal HRM parameters are predictive of dysphagia. The aim of this retrospective study was to investigate the roles of HRM parameters in predicting incomplete bolus clearance (IBC) in patients with dysphagia using high-resolution impedance manometry.

METHODS

A total of 644 wet swallows were reviewed and analyzed in 63 patients with symptoms of dysphagia or reflux who underwent a clinical high-resolution impedance manometry test. IBC was defined based on impedance measurement. The relationship of each of abnormal HRM parameters with IBC was analyzed and their roles in predicting IBC were determined.

RESULTS

Patients with symptoms of both dysphagia and reflux showed the highest IBC rate, and patients with symptoms of reflux had the lowest IBC rate. The IBC was more prevalent in the distal esophagus. Premature contractions and peristalsis with large breaks were associated with a higher IBC rate in the proximal esophagus (P<0.05); large breaks, ineffective peristalsis, and abnormalities of the esophageal gastric junction functions were associate with higher IBC rates in the distal esophagus (P<0.05). Abnormalities in a number of motility parameters were able to predict IBC with high specificities and/or high sensitivity, such as pan esophageal pressurization, ineffective peristalsis, and large breaks. Abnormal integrative relaxation pressure of the lower esophageal sphincter with concurrent pan esophageal pressurization, ineffective peristalsis, or large breaks is predictive of IBC with nearly 100% of specificity.

CONCLUSIONS

Abnormalities in a number of HRM parameters are not only useful in diagnosing esophageal motility diseases, but also valuable in predicting IBC during swallowing.

Altered oesophageal mechanosensitivity of secondary peristalsis as a pathophysiological marker in patients with globus sensation

OBJECTIVE

Secondary peristalsis is important for clearance of retained food bolus and refluxate from the oesophagus. We aimed to investigate whether patients with globus sensation have altered physiological characteristics of secondary peristalsis.

DESIGN

Prospective case-controlled study SETTING: Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.

PARTICIPANTS

Seventeen globus patients and 18 healthy controls.

MAIN OUTCOME MEASURES

After a baseline recording of primary peristalsis, secondary peristalsis was stimulated with slow and rapid mid-oesophageal injections of air. Distension thresholds and peristaltic activities of secondary peristalsis were analysed and compared between the patients and healthy controls.

RESULTS

The threshold volume for generating secondary peristalsis during slow air distension did not differ between the patient and control groups (P = .55). The threshold volume for generating secondary peristalsis during rapid air distension was significantly greater in patients with globus than healthy controls (7.0 ± 0.9 vs 5.0 ± 0.3 mL, P = .04). Secondary peristalsis was triggered less frequently in globus patients as compared with healthy control after rapid air distension (40% [30%-65%] vs 60% [60%-83%], P = .001). There was no difference in any of peristaltic parameters for primary and secondary peristalsis between the groups.

CONCLUSIONS

Our work identifies functional defects of oesophageal secondary peristalsis in patients with globus sensation and such defects are characterised with defective triggering of secondary peristalsis during rapid air distension. Whether current findings have therapeutic implication in the management of patients with globus sensation warrants further investigation.

Utilizing functional lumen imaging probe topography to evaluate esophageal contractility during volumetric distention: a pilot study

BACKGROUND

The functional lumen imaging probe (FLIP) measures luminal cross-sectional area and pressure during volumetric distension. By applying novel customized software to produce FLIP topography plots, organized esophageal contractility can be visualized and analyzed. We aimed to describe the stimulus thresholds and contractile characteristics for distension-induced esophageal body contractility using FLIP topography in normal controls.

METHODS

Ten healthy controls were evaluated during endoscopy with FLIP. During stepwise bag distension, simultaneous intra-bag pressure and luminal diameter measurements were obtained and exported to a MatLab program to generate FLIP topography plots. The distension volume, intra-bag pressure, and maximum esophageal body diameters were measured for the onset and cessation of repetitive antegrade contractions (RACs). Contraction duration, interval, magnitude, and velocity were measured at 8 and 3-cm proximal to the esophagogastric junction.

KEY RESULTS

Eight of ten subjects demonstrated RACs at a median onset volume of 29 mL (IQR: 25-38.8), median intra-bag pressure of 10.7 mmHg (IQR: 8.6-15.9), and median maximum esophageal body diameter of 18.5 mm (IQR: 17.5-19.6). Cessation of RACs occurred prior to completion of the distension protocol in three of the eight subjects exhibiting RACs. Values of the RAC-associated contractile metrics were also generated to characterize these events.

CONCLUSIONS & INFERENCES

Distension-induced esophageal contractions can be assessed utilizing FLIP topography. RACs are a common finding in asymptomatic controls in response to volume distention and have similar characteristics to secondary peristalsis and repetitive rapid swallows.

Impedance as an adjunct to manometric testing to investigate symptoms of dysphagia: What it has failed to do and what it may tell us in the future

Dysphagia is a common reason for referral for investigations of oesophageal motility. Impedance measurement has now been incorporated into commercially available diagnostic manometry systems for more than a decade. This innovation, which offered the ability to record patterns of bolus transport without the need for simultaneous radiology, has for the most part failed to live up to expectations, offering few additional diagnostic insights. This review examines the potential pitfalls related to how impedance patterns are currently analysed and introduces and discusses the new concept of pressure-flow analysis integrating pressure and impedance measurements to derive new metrics linked to the pressures occurring within and around the bolus as it is being transported.

Influence of repeated infusion of capsaicin-contained red pepper sauce on esophageal secondary peristalsis in humans

BACKGROUND

The transient receptor potential vanilloid 1 has been implicated as a target mediator for heartburn perception and modulation of esophageal secondary peristalsis. Our aim was to determine the effect of repeated esophageal infusion of capsaicin-contained red pepper sauce on heartburn perception and secondary peristalsis in healthy adults.

METHODS

Secondary peristalsis was performed with mid-esophageal injections of air in 15 healthy adults. Two separate protocols including esophageal infusion with saline and capsaicin-contained red pepper sauce and 2 consecutive sessions of capsaicin-contained red pepper sauce were randomly performed.

KEY RESULTS

After repeated infusion of capsaicin-contained red pepper sauce, the threshold volume to activate secondary peristalsis was significantly increased during slow (p < 0.001) and rapid air injections (p = 0.004). Acute infusion of capsaicin-contained red pepper sauce enhanced heartburn perception (p < 0.001), but the intensity of heartburn perception was significantly reduced after repeated capsaicin-contained red pepper sauce infusion (p = 0.007). Acute infusion of capsaicin-contained red pepper sauce significantly increased pressure wave amplitudes of distal esophagus during slow (p = 0.003) and rapid air injections (p = 0.01), but repeated infusion of capsaicin-contained red pepper sauce significantly decreased pressure wave amplitude of distal esophagus during slow (p = 0.0005) and rapid air injections (p = 0.003).

CONCLUSIONS & INFERENCES

Repeated esophageal infusion of capsaicin appears to attenuate heartburn perception and inhibit distension-induced secondary peristalsis in healthy adults. These results suggest capsaicin-sensitive afferents in modulating sensorimotor function of secondary peristalsis in human esophagus.

Impairment of secondary peristalsis in Barrett’s esophagus by transnasal endoscopy-based testing

AIM: To investigate dysfunctions in esophageal peristalsis and sensation in patients with Barrett’s esophagus following acid infusion using endoscopy-based testing.

METHODS: First, physiological saline was infused into the esophagus of five healthy subjects, at a rate of 10 mL/min for 10 min, followed by infusion of HCl. Esophageal contractions were analyzed to determine whether the contractions observed by endoscopy and ultrasonography corresponded to the esophageal peristaltic waves diagnosed by manometry. Next, using nasal endoscopy, esophageal sensations and contractions were investigated in patients with, as well as controls without, Barrett’s esophagus using the same infusion protocol.

RESULTS: All except one of the propulsive contractions identified endoscopically were recorded as secondary peristaltic waves by manometry. Patients with long segment Barrett’s esophagus (LSBE) tended to have a shorter lag time than the control group, although the difference did not reach statistical significance (88 ± 54 s vs 162 ± 150 s respectively, P = 0.14). Furthermore, patients with LSBE had significantly fewer secondary contractions following the infusion of both saline and HCl than did either the control group or patients with short segment Barrett’s esophagus (4.1 ± 1.2 vs 8.0 ± 2.8, P < 0.001 and 7.3 ± 3.2, P < 0.01, respectively, following saline infusion; 5.3 ± 1.2 vs 8.4 ± 2.4 and 8.1 ± 2.9 respectively, P < 0.01 for both, following infusion of HCl).

CONCLUSION: Using nasal endoscopy and a simple acid-perfusion study, we were able to demonstrate disorders in secondary peristalsis in patients with LSBE.

Effect of Cold Water on Esophageal Motility in Patients With Achalasia and Non-obstructive Dysphagia: A High-resolution Manometry Study

Background/Aims

Swallowing of cold liquids decreases amplitude and velocity of peristalsis in healthy subjects, using standard manometry. Patients with achalasia and non obstructive dysphagia may have degeneration of sensory neural pathways, affecting motor response to cooling. To elucidate this point, we used high-resolution manometry.

Methods

Fifteen healthy subjects, 15 non-obstructive dysphagia and 15 achalasia patients, after pneumatic dilation, were studied. The 3 groups underwent eight 5 mL single swallows, two 20 mL multiple rapid swallows and 50 mL intraesophageal water infusion (1 mL/sec), using both water at room temperature and cold water, in a randomized order.

Results

In healthy subjects, cold water reduced distal contractile integral in comparison with water at room temperature during single swallows, multiple rapid swallows and intraesophageal infusion (ratio cold/room temperature being 0.67 [95% CI, 0.48-0.85], 0.56 [95% CI, 0.19-0.92] and 0.24 [95% CI, 0.12-0.37], respectively). A similar effect was seen in non-obstructive dysphagia patients (0.68 [95% CI, 0.51-0.84], 0.69 [95% CI, 0.40-0.97] and 0.48 [95% CI, 0.20-0.76], respectively), whereas no changes occurred in achalasia patients (1.06 [95% CI, 0.83-1.29], 1.05 [95% CI, 0.77-1.33] and 1.41 [95% CI, 0.84-2.00], respectively).

Conclusions

Our data suggest impairment of esophageal reflexes induced by cold water in patients with achalasia, but not in those with non obstructive dysphagia.

Observations of Acid Reflux and Motor Function in Distal Esophagus Using Simultaneous Measurements of Intra-esophageal pH and Pressure in 8 Directions With Novel Sensor Catheter - A Feasibility Study

Background/Aims

Esophagogastric junctional lesions, such as mucosal breaks with Los Angeles grade A or B reflux esophagitis, lacerations in Mallory Weiss syndrome, and short segment Barrett's esophagus, are mainly found in the right anterior wall of the distal esophagus. Asymmetrical lower esophageal sphincter pressure and resting radial asymmetrical acid reflux may be causes of this asymmetrical distribution of reflux esophagitis and short segment Barrett's esophagus. We developed a novel pH and pressure catheter to investigate the asymmetrical distributions of pH and intra-esophageal pressure in the distal esophagus.

Methods

One healthy male volunteer was enrolled in this study. Acid reflux and motor function in distal esophagus was investigated using simultaneous measurements of intra-esophageal pH and pressure in 8 directions with novel sensor catheter.

Results

Thirty-six acid and weak acid reflux events were observed, of which 22 were circumferential refluxes with pH drops in all channels and 14 were partial refluxes with pH drops in some channels. Increase in transient circumferential intraesophageal pressure was observed just after 72.7% of the circumferential reflux and 42.9% of the partial reflux events.

Conclusions

Using a novel sensor catheter, 2 different types of acid reflux events were identified in the present study.

The relationship between dysphagia, pump function, and lower esophageal sphincter pressures on high-resolution manometry

INTRODUCTION

Study objective was to compare high-resolution impedance manometry (HRIM) findings between patients with and without dysphagia.

METHODS

After Institutional Review Board approval, a prospectively maintained database was reviewed to identify patients who underwent HRIM. Patients without upper endoscopy within 7 days of manometry, patients with achalasia, history of previous foregut surgery, esophageal strictures, or a large hiatus hernia were excluded. A new parameter called lower esophageal sphincter pressure integral (LESPI) was compared between patients with and without dysphagia. For subanalysis, subjects were categorized: (a) group A: no dysphagia and <60% hypocontractile or absent waves, (b) group B: dysphagia and <60% hypocontractile or absent waves, and (c) group C: ≥ 60% hypocontractile or absent waves.

RESULTS

One hundred thirteen patients satisfied study criteria. Patients with dysphagia had a significantly higher LESPI and distal contractile integral (DCI). On multivariate regression analysis, the following were associated with dysphagia: (a) ≥ 60% hypocontractile or absent waves, (b) LESPI >400 mmHg s cm, and (c) DCI >3,000 mmHg s cm. However, 32% of patients with <60% hypocontractile or absent waves (group B) had dysphagia. These patients had a significantly higher DCI and LESPI than group A. Group C had a significantly lower DCI than all other patients.

CONCLUSIONS

Dysphagia in patients with ≥ 60% hypocontractile or absent waves is indicative of an intrinsic pump failure as they have low DCI, while dysphagia in patients with <60% hypocontractile or absent waves is more indicative of significant outflow obstruction as they have high LESPI and integrated relaxation pressure.