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Lu Y, Lv L, Yang J, Yi Z. Contraction reserve in high resolution manometry is correlated with lower esophageal acid exposure time in patients with normal esophageal motility: A retrospective observational study. PLoS One 2023; 18:e0291010. [PMID: 37917671 PMCID: PMC10621955 DOI: 10.1371/journal.pone.0291010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/21/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND In high resolution manometry (HRM), distal contractile integral post multiple rapid swallow augmentation is considered as contraction reserve. The relationship between contraction reserve and esophageal acid reflux remains unclear. The aim of this study was to explore the correlation between contraction reserve and esophageal acid exposure in ineffective esophageal motility (IEM) and normal HRM. METHODS Patients who underwent HRM and ambulatory reflux monitoring were retrospectively screened. Those with diagnosis of normal HRM or IEM were included in the analysis. The proportion of patients with abnormal acid exposure time (AET) was compared between patients with and without contraction reserve. Multivariate regression analysis was performed to determine the predictors of abnormal AET and contraction reserve. RESULTS A total of 338 patients, including 264 normal HRM and 74 IEM, were included in the analysis. In patients with normal HRM, proportion of abnormal total AET (AET > 6.0%) was significantly lower in patients with supine contraction reserve than patients without contraction reserve (13.85% vs. 24.63%, p = 0.027). Multivariate regression analysis showed that supine contraction reserve could independently predict abnormal total AET (OR = 0.468, 95% CI: 0.249-0.948, p = 0.034), while upright contraction reserve trended strongly (OR = 0.558, 95% CI: 0.290-1.071, p = 0.079). Subgroup analysis showed that upright contraction reserve was an independent predictor of abnormal total AET in patients with 50-70% infective swallows (OR = 0.205, 95% CI: 0.051-0.821, p = 0.025), whereas supine contraction reserve did not have predictive value (p = 0.359). CONCLUSIONS Supine contraction reserve correlates with esophageal acid reflux in patients with normal HRM, while only upright contraction reserve correlates with esophageal acid reflux in patients with infective swallows of 50-70%.
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Affiliation(s)
- Yaoyao Lu
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | - Linling Lv
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | - Jinlin Yang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhihui Yi
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
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Bredenoord AJ, Babaei A, Carlson D, Omari T, Akiyama J, Yadlapati R, Pandolfino JE, Richter J, Fass R. Esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2021; 33:e14193. [PMID: 34120375 DOI: 10.1111/nmo.14193] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 12/13/2022]
Abstract
In the Chicago Classification version 4.0 (CCv4), esophagogastric junction outflow obstruction (EGJOO) is manometrically defined as an elevated median integrated relaxation pressure (IRP) and elevated intrabolus pressure (IBP) during supine wet swallows, and persistently elevated median IRP in the upright position. A clinically relevant conclusive diagnosis of EGJOO requires a manometric diagnosis of EGJOO and associated symptoms such as dysphagia and/or chest pain with at least one of the following supportive investigations (pharmacologic provocation, timed barium esophagogram, and/or endoflip). The Chicago Classification is intended for diagnosis of primary esophageal motor disorders, and thus history and endoscopic evaluation are important to exclude conditions (eg, previous surgery, strictures, or masses) that can secondarily generate the EGJOO pattern on HRM. While a manometric finding of EGJOO is often made and can be an early sign of achalasia, more often it is a manometric finding without clinical implications. The proposed changes in CC4.0 have attempted to make the diagnosis more specific, in order to reduce the number of clinically irrelevant diagnoses and avoid confusion by patients and physicians alike.
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Affiliation(s)
- Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Arash Babaei
- Division of Gastroenterology, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Dustin Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Taher Omari
- College or Medicine & Public Health, Flinders University, Adelaide, SA, Australia
| | - Jun Akiyama
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Rena Yadlapati
- Division of Gastroenterology & Hepatology, Center for Esophageal Diseases, University of California San Diego, La Jolla, CA, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joel Richter
- Joy McCann Culverhouse Center for Esophageal Diseases, University of South Florida College of Medicine, Tampa, FL, USA
| | - Ronnie Fass
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Metrohealth Medical System, Case Western Reserve University, Cleveland, OH, USA
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Distal contractile integral measurement and vascular compression in the esophagus: a problem unsolved? Esophagus 2020; 17:502-507. [PMID: 32356213 DOI: 10.1007/s10388-020-00740-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 04/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Distal contractile integral (DCI) is influenced by factors other than esophageal smooth muscle contractility, such as intrabolus pressure and vascular and respiratory movements' artifacts. We aimed to determine the size of the contribution of pressures generated by vascular compression on the esophagus to the DCI measured in HRM recordings in symptomatic patients. METHODS HRM manometry recordings obtained from 383 subjects referred to the GI motility laboratory at a tertiary center (2012-2016) were evaluated by visual inspection for evidence of strong vascular compression (SVC) of the esophagus. Clinical, demographic, manometric, and serologic data for Chagas disease were obtained. Subjects were classified, respectively, as asymptomatics (ASYM) or symptomatics (SYMP). DCI and SVC-DCI were measured, and the SVC-DCI/DCI ratio was expressed as a percentage and the difference between DCI and SVC-DCI (neat-DCI) was calculated. DCI, SVC-DCI, SVC-DCI/DCI % and neat-DCI from SYMP and ASYM were compared. RESULTS SVC was conspicuous in 42 of 383 subjects (11%). In 33 subjects, SVC was detected only in supine position. SVC was localized in middle esophagus in 21 subjects (50%), in distal esophagus in 12 subjects (29%) and in both regions in 9 subjects (21%). In 9 subjects, SVC vanished from the swallowing window analysis (21%). CONCLUSIONS SVC is a common finding in esophageal HRM study, particularly in the supine position. Occasionally, its contribution to DCI value is sufficiently great to masquerade esophageal hypocontractility. Different manometric protocols may be required in patients with SVC.
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Riva CG, Siboni S, Ferrari D, Sozzi M, Capuzzo M, Asti E, Ogliari C, Bonavina L. Effect of Body Position on High-resolution Esophageal Manometry Variables and Final Manometric Diagnosis. J Neurogastroenterol Motil 2020; 26:335-343. [PMID: 32606256 PMCID: PMC7329148 DOI: 10.5056/jnm20010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/10/2020] [Indexed: 12/29/2022] Open
Abstract
Background/Aims According to the Chicago classification version 3.0, high-resolution manometry (HRM) should be performed in the supine position. However, with the patient in the upright/sitting position, the test could more closely simulate real-life behavior and may be better tolerated. We performed a systematic review of the literature to search whether the manometric variables and the final diagnosis are affected by positional changes. Methods A literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies published in English that compared HRM results in different body positions were included. Moreover, the change in diagnosis of esophageal motility disorders according to the shift of body position was investigated. Results Seventeen studies including 1714 patients and healthy volunteers met the inclusion criteria. Six studies showed a significant increase in lower esophageal sphincter basal pressure in the supine position. Integrated relaxation pressure was significantly higher in the supine position in 10 of 13 studies. Distal contractile index was higher in the supine position in 9 out of 10 studies. One hundred and fifty-one patients (16.4%) out of 922 with normal HRM in the supine position were diagnosed with ineffective esophageal motility (IEM) when the test was performed in the upright position (P < 0.001). Conclusions Performing HRM in the upright position affects some variables and may change the final manometric diagnosis. Further studies to determine the normal values in the sitting position are needed.
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Affiliation(s)
- Carlo G Riva
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
| | - Stefano Siboni
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
| | - Davide Ferrari
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
| | - Marco Sozzi
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
| | - Matteo Capuzzo
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
| | - Emanuele Asti
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
| | - Cristina Ogliari
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy
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Lis S, Vachhani H, Tanner S, Leopold A, Zitomer S, Bhuta R, Schey R, Malik Z, P Parkman H. Vascular pressure bands on high-resolution esophageal manometry with impedance studies. Dis Esophagus 2020; 33:5673266. [PMID: 31825486 DOI: 10.1093/dote/doz093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/24/2019] [Accepted: 08/03/2019] [Indexed: 12/11/2022]
Abstract
Horizontal pressure bands on high-resolution esophageal manometry with impedance (HREMI) tracings are often seen and thought to be due to cardiovascular structures compressing the esophagus. The aim of this study was to determine the prevalence and location of vascular pressure bands on HREMI studies and correlate these pressure bands to bolus clearance. HREMI studies in supine and upright positions from patients and normal volunteers were reviewed. Pressure bands were defined as bands of horizontal pressure greater than the 20 mmHg isobaric contour. Each swallow was reviewed with impedance to determine if bolus transit was impaired by the band. 38.6% of 251 patients and 36.4% of 11 normal controls had a pressure band present. There were a greater number of bands in supine versus upright position (patients: 130 vs. 25, P < 0.001 and controls: 6 vs. 1). Patients with pressure bands had similar demographics (age, gender, BMI) compared to those without. Average distal contractile integral of bands was greater in supine compared to upright (133 ± 201 vs. 60 ± 148 mmHg cm s, P < 0.05). Bands were commonly located clustered at 46 and 72% of esophageal length. Bolus transit was impaired by bands in 20.4% of supine and 14.0% of upright swallows. Vascular pressure bands can have a prominent appearance on HREMI studies, present in, being more prevalent and having greater pressure in the supine than the upright position. These vascular bands, when present, may impair esophageal transit.
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Affiliation(s)
- Steffen Lis
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Herit Vachhani
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Samuel Tanner
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Andrew Leopold
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Samantha Zitomer
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Rajiv Bhuta
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Ron Schey
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Zubair Malik
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Henry P Parkman
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
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Srinivas M, Jain M, Bawane P, Jayanthi V. Normative Values for Esophageal Motility Assessed in the Physiological Seated Position for 16-Channel Water Perfused High-resolution Esophageal Manometry System and Postural Variations in Healthy Volunteers. J Neurogastroenterol Motil 2020; 26:61-66. [PMID: 31917914 PMCID: PMC6955184 DOI: 10.5056/jnm19082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/04/2019] [Accepted: 09/20/2019] [Indexed: 12/14/2022] Open
Abstract
Background/Aims Consensus guidelines for performance and analysis of high-resolution esophageal manometry (HREM) recommend use of equipment, population and posture specific normative values. To provide normative values for Chicago classification (CC) metrics in the physiological seated position for a 16-channel water perfused system (Dentsleeve HREM catheter, Advanced Manometry Systems, Melbourne, Australia) widely used in India and other countries with limited access to solid-state equipment. The results are compared with published CC metrics in supine position done using the same system and volunteers. Methods HREM tracings of ten 5 mL water swallows in sitting posture were acquired in healthy volunteers and normative values for CC version 3.0 metrics calculated. Individual swallows were paired with previously reported supine swallows for postural variations (Wilcoxon sign rank test) and concordance of CC diagnoses (Pearson coefficient). Results Analysis of 530 sitting posture water swallows (53 subjects) and comparison with their supine data revealed significantly higher integrated relaxation pressure (IRP; median 6.7 mmHg vs 6.1 mmHg) but lower distal latency (DL; mean 6.3 seconds vs 6.8 seconds) and distal contractile integral (DCI; mean 1224 mmHg sec cm vs 1456 mmHg sec cm). Sitting posture normal was defined as: IRP < 13.9, DL > 4.5, and DCI = 115–4500 (absent contractility: DCI < 30). CC diagnoses concordance using posture-specific cut-offs was moderate (k = 0.47). Conclusions This paper provides normative values for the Advanced Manometry Systems 16-channel water perfused system in the physiological seated position for CC metrics. Our findings of higher IRP and lower DCI in sitting posture than previously reported supine CC cut-offs, confirm the need to use posture-specific cut-offs for reporting HREM tracings.
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Affiliation(s)
| | - Mayank Jain
- GI Motility Unit, Gleneagles Global Health City, Chennai, India
| | - Piyush Bawane
- GI Motility Unit, Gleneagles Global Health City, Chennai, India
| | - Venkataraman Jayanthi
- GI Motility Unit, Gleneagles Global Health City, Chennai, India.,Sri Ramachandra Institute of Higher Education and Research, Chennai, India
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Babaei A, Shad S, Szabo A, Massey BT. Pharmacologic interrogation of patients with esophagogastric junction outflow obstruction using amyl nitrite. Neurogastroenterol Motil 2019; 31:e13668. [PMID: 31236998 PMCID: PMC6693956 DOI: 10.1111/nmo.13668] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Chicago Classification of esophageal motility includes a group of patients who show evidence of esophagogastric junction outflow obstruction (EGJOO) as demonstrated by elevated integrated relaxation pressure (IRP) and preserved peristalsis. Our aim is to classify EGJOO patients based on response to amyl nitrite (AN) during high-resolution manometry. METHODS Patients were considered to have true EGJOO if elevated IRP during supine swallow persisted in the upright position and was associated with high intrabolus pressure. The EGJ response to AN was compared between patients with achalasia type 2 (A2) and normal esophageal motility. Based on the relaxation gain (deglutitive IRP-AN IRP) value that best discriminated these two groups (10 mm Hg), patients with true EGJOO were categorized as being in either the AN-responsive (AN-R) or AN-unresponsive (AN-U) subgroups. KEY RESULTS In the group of 49 patients with true EGJOO, the AN response classified 27 patients (IRP = 25 ± 10 mm Hg) with AN-R and 22 patients (IRP = 20 ± 5 mm Hg) with AN-U (P = 0.2). In AN-R, AN produced a relaxation gain and rebound after-contraction response at the EGJ comparable to A2 patients. AN-U patients had an elevated IRP after AN and a relaxation gain similar to normal esophageal motility patients. AN-U patients were obese and had higher prevalence of sleep apnea (P < 0.05). CONCLUSIONS Among patients with true EGJOO, only half have pharmacologic evidence of impaired LES relaxation. Pharmacologic interrogation of the EGJ is thus necessary to identify the subgroup of EGJOO patients who could be expected to benefit from LES ablative therapies.
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Affiliation(s)
- Arash Babaei
- Division of Gastroenterology, Department of Medicine, National Jewish Health, Denver, CO, USA,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sadaf Shad
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aniko Szabo
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benson T. Massey
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Babaei A, Mittal R. Cholecystokinin induces esophageal longitudinal muscle contraction and transient lower esophageal sphincter relaxation in healthy humans. Am J Physiol Gastrointest Liver Physiol 2018; 315:G734-G742. [PMID: 29902066 PMCID: PMC6293254 DOI: 10.1152/ajpgi.00127.2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Cholecystokinin (CCK) is known to cause lower esophageal sphincter (LES) relaxation through the activation of inhibitory motor neurons. CCK receptor agonists increase the frequency of transient LES relaxation through a peripheral mechanism. Recent studies show that the longitudinal muscle contraction (LMC)-related axial stretch might play a role in the LES relaxation by activating the mechanosensitive inhibitory motor neurons. The aim of our study was to determine whether the CCK-induced LES relaxation and the characteristics of LMC resemble those seen with spontaneous transient LES relaxation in humans. Nine healthy volunteers (5 Fr, 40 ± 12 yr) received escalating doses of CCK-octapeptide (CCK-8) (5, 10, 20, and 40 ng/kg). All subjects demonstrated a monophasic response to 5 ng/kg of CCK-8. In the majority of subjects, this response consisted of partial LES relaxation. All subjects showed a biphasic response to 40 ng/kg of CCK-8. The latter in most subjects consisted of 1) a period of partial relaxation followed by 2) complete LES relaxation along with crural diaphragm inhibition. The length of the esophagus decreased by 0.9 ± 0.4 cm, and muscle thickness increased by 40 ± 14% to 1.4 ± 0.2 mm ( P < 0.05) during initial partial LES relaxation. During complete LES relaxation there was greater LMC, as demonstrated by an esophageal shortening of 1.9 ± 0.5 cm and an increase in muscle thickness of 100 ± 16% ( P < 0.01). The complete phase 2 LES relaxation typically terminated with a robust after-contraction. Atropine significantly attenuated the CCK-induced esophageal LMC, prevented crural diaphragm inhibition, and abolished the phase 2 complete LES relaxation. NEW & NOTEWORTHY The phenotypic features of CCK-induced longitudinal muscle contraction (LMC), complete lower esophageal sphincter (LES) relaxation, and crural diaphragm inhibition, followed by a robust after-contraction, resemble those seen during spontaneous transient LES relaxation. A strong temporal relationship between the LMC and complete transient LES relaxation supports our hypothesis that the LMC plays an important role in the LES relaxation and crural diaphragmatic inhibition.
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Affiliation(s)
- Arash Babaei
- 1Division of Gastroenterology, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Ravinder Mittal
- 2Division of Gastroenterology, University of California, San Diego, California
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Chaudhry NA, Zahid K, Keihanian S, Dai Y, Zhang Q. Transmitted cardiovascular pulsations on high resolution esophageal impedance manometry, and their significance in dysphagia. World J Gastroenterol 2017; 23:7840-7848. [PMID: 29209125 PMCID: PMC5703913 DOI: 10.3748/wjg.v23.i44.7840] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 08/08/2017] [Accepted: 09/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the behavior of pulsatile pressure zones (PPZ’s) as noted on high resolution esophageal impedance manometry (HREIM), and determine their association with dysphagia.
METHODS Retrospective, single center case control design screening HREIM studies for cases (dysphagia) and controls (no dysphagia). Thoracic radiology studies were reviewed further in cases for (thoracic cardiovascular) thoracic cardiovascular (TCV) structures in esophageal proximity to compare with HREIM findings. Manometric data was collected for number, location, axial length, PPZ pressure and esophageal clearance function (impedance).
RESULTS Among 317 screened patients, 56% cases and 64% controls had PPZ’s. Fifty cases had an available thoracic radiology comparison. The distribution of PPZ’s in these 50 cases and 59 controls was similar (average 1.4 PPZ/patient). Controls (mean 31.2 ± SD 12 years) were a significantly younger population than cases (mean 67.3 ± SD 14.9 years) with P < 0.0001. The upright posture PPZ pressure was higher in controls (15.7 ± 10.0 mmHg) than cases (10.8 ± 9.7 mmHg). Although statistically significant (P = 0.005), it was a weak predictor using logistic regression and ROC model (AUC = 0.65). Three dysphagia patients had partial compression from external TCV on radiology (1 aberrant subclavian artery, 2 dilated left atrium). The posture (supine vs upright) with more prominent PPZ’s impaired bolus clearance in 9 additional cases by > 20%.
CONCLUSION Transmitted TCV pulsations observed in HREIM bear no significant impact on swallowing. However, in older adults with dysphagia, evidence of impaired bolus clearance on impedance should be evaluated for external TCV compression. These associations have never been explored previously in literature, and are novel.
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Affiliation(s)
- Naueen A Chaudhry
- Department of Medicine, Division of Gastroenterology, University of Florida, Gainesville, FL 32610, United States
| | - Kamran Zahid
- Department of Medicine, Division of Hospital Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Sara Keihanian
- Department of Medicine, Division of Gastroenterology, University of Florida, Gainesville, FL 32610, United States
| | - Yunfeng Dai
- Department of Biostatistics, University of Florida, Gainesville, FL 32610, United States
| | - Qing Zhang
- Department of Medicine, Division of Gastroenterology, University of Florida, Gainesville, FL 32610, United States
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do Carmo GC, Jafari J, Sifrim D, de Oliveira RB. Normal esophageal pressure topography metrics for data derived from the Sandhill-Unisensor high-resolution manometry assembly in supine and sitting positions. Neurogastroenterol Motil 2015; 27:285-92. [PMID: 25557525 DOI: 10.1111/nmo.12501] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 12/03/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Normal values of the esophageal motor function parameters for high-resolution manometry (HRM-EPT) adopted by the Chicago classification were established using the proprietary system of Given Imaging. It is conceivable that normal values of a system do not apply to data from others. Most studies using HRM were based on supine swallows, whereas deglutition occurs mostly in the upright position. We wished to establish normal values for HRM-EPT parameters obtained with the Sandhill's HRM-EPT system and compare the results in supine and sitting positions. METHODS Sixty-nine healthy volunteers, 38 females, median age 27 years, were included in this study. All underwent supine HRM, and 34 of them underwent sitting HRM, with at least 10 single 5-mL swallows for analysis obtained in each position. KEY RESULTS The normal range (5-95th percentiles) for the following parameters was calculated: distal contractile integral (DCI), 606-4998 mmHg·s·cm; contractile front velocity (CFV), 2.0-6.5 cm/s; distal latency (DL), 5.1-8.8 s; intrabolus pressure (IBP), 1.9-17.6 mmHg; upper esophageal sphincter (UES) pressure, 45.2-186.9 mmHg; esophagogastric junction (EGJ) length, 1.8-4 cm; EGJ resting pressure, 8.1-61.6 mmHg, and integrated relaxation pressure (IRP) 2.5-23.5 mmHg. Normal values of EGJ resting pressure, IRP, DCI, and IBP but not CFV, DL, and UES resting pressure were significantly lower in the sitting posture. CONCLUSIONS & INFERENCES Studies performed with Sandhill's HRM-EPT system should use its own specific normal data. Normal values should be established for different study.
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Affiliation(s)
- G C do Carmo
- Department of Medicine, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
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Gyawali CP, Patel A. Esophageal motor function: technical aspects of manometry. Gastrointest Endosc Clin N Am 2014; 24:527-43. [PMID: 25216901 DOI: 10.1016/j.giec.2014.06.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
High-resolution manometry (HRM) has advanced the understanding of esophageal peristaltic mechanisms and has simplified esophageal motor testing. In this article the technical aspects of HRM are addressed, focusing on test protocols, in addition to concerns and pitfalls in performing esophageal motor studies. Specifically, catheter positioning, equipment-related artifacts, basal data acquisition, adequate swallows, and provocative maneuvers are discussed.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, Saint Louis, MO 63110, USA.
| | - Amit Patel
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, Saint Louis, MO 63110, USA
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Gyawali CP, Bredenoord AJ, Conklin JL, Fox M, Pandolfino JE, Peters JH, Roman S, Staiano A, Vaezi MF. Evaluation of esophageal motor function in clinical practice. Neurogastroenterol Motil 2013; 25:99-133. [PMID: 23336590 DOI: 10.1111/nmo.12071] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Esophageal motor function is highly coordinated between central and enteric nervous systems and the esophageal musculature, which consists of proximal skeletal and distal smooth muscle in three functional regions, the upper and lower esophageal sphincters, and the esophageal body. While upper endoscopy is useful in evaluating for structural disorders of the esophagus, barium esophagography, radionuclide transit studies, and esophageal intraluminal impedance evaluate esophageal transit and partially assess motor function. However, esophageal manometry is the test of choice for the evaluation of esophageal motor function. In recent years, high-resolution manometry (HRM) has streamlined the process of acquisition and display of esophageal pressure data, while uncovering hitherto unrecognized esophageal physiologic mechanisms and pathophysiologic patterns. New algorithms have been devised for analysis and reporting of esophageal pressure topography from HRM. The clinical value of HRM extends to the pediatric population, and complements preoperative evaluation prior to foregut surgery. Provocative maneuvers during HRM may add to the assessment of esophageal motor function. The addition of impedance to HRM provides bolus transit data, but impact on clinical management remains unclear. Emerging techniques such as 3-D HRM and impedance planimetry show promise in the assessment of esophageal sphincter function and esophageal biomechanics.
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Affiliation(s)
- C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA.
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Xiao Y, Nicodème F, Kahrilas PJ, Roman S, Lin Z, Pandolfino JE. Optimizing the swallow protocol of clinical high-resolution esophageal manometry studies. Neurogastroenterol Motil 2012; 24:e489-96. [PMID: 22863083 PMCID: PMC3632389 DOI: 10.1111/j.1365-2982.2012.01989.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND The Chicago Classification (CC) of Esophageal Motility Disorders is based on 10 water swallows performed in the supine position. The aim of the study was to assess whether upright and provocative swallows (PS) provided important information beyond that obtained from the standard supine manometric protocol. METHODS Two independent investigators reviewed high-resolution manometry (HRM) studies of 148 patients with both supine and upright liquid swallows and additional studies from patients with PS (increased volume, viscosity, and a marshmallow) for a resultant change in CC diagnoses. Significant diagnostic changes were defined as a change from normal or borderline motor function to abnormal motor function, esophagogastric junction (EGJ) outflow obstruction, or achalasia. Discordant diagnoses were reviewed and the Kappa test was used to evaluate the agreement between diagnoses in the different protocols. KEY RESULTS The overall agreement in diagnosis between the five supine swallows and the five upright swallows was good (k = 0.583). Changing to the upright position elicited a significant diagnostic change in 10.1% (15/148) of cases. The PS suggested an alternative diagnosis from the supine position in 14 of 75 studies (18.7%); 11 of these changed to EGJ obstruction during viscous or solid bolus challenges. CONCLUSIONS & INFERENCES Changing position in HRM elicited a significant change in diagnosis in about 10% of studies, whereas provocative bolus challenges with viscous liquid and marshmallows increased the detection of EGJ outflow obstruction. Performing manometric evaluations in both positions with PS may increase the yield of standard HRM technique.
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Affiliation(s)
- Yinglian Xiao
- Department of Medicine, the Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Department of Gastroenterology and Hepatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Frédéric Nicodème
- Department of Medicine, the Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Department of Thoracic Surgery, Université de Montréal, Montréal, QC, Canada
| | - Peter J. Kahrilas
- Department of Medicine, the Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Sabine Roman
- Department of Medicine, the Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Department of Digestive physiology, Hopisces Civils de Lyon, Lyon l University, Lyon, France
| | - Zhiyue Lin
- Department of Medicine, the Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Department of Medicine, the Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Lin Z, Roman S, Pandolfino JE, Kahrilas PJ. Automated calculation of the distal contractile integral in esophageal pressure topography with a region-growing algorithm. Neurogastroenterol Motil 2012; 24:e4-10. [PMID: 21951921 PMCID: PMC3608518 DOI: 10.1111/j.1365-2982.2011.01795.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The distal contractile integral (DCI) is an index of contractile vigor in high-resolution esophageal pressure topography (EPT) calculated as the product of amplitude, duration, and span of the distal esophageal contraction. The aim of this study was to develop an automated algorithm calculating DCI. METHODS The DCI was calculated conventionally using ManoView™ (Given Imaging, Los Angeles, CA, USA) software in EPT studies from 72 controls and 20 patients and compared to the calculation using a MATLAB™ (Version 7.9.0, R2009b; The MathWorks Inc., Natick, MA, USA) 'region-growing' algorithm. This algorithm first established the spatial limits of the distal contraction (the proximal pressure trough to either the distal pressure trough or to the superior margin of the lower esophageal sphincter at rest). Pixel-by-pixel horizontal line segments were then analyzed within this span starting at the pressure maximum and extending outward from that point. The limits of 'region-growing' were defined either by the spatial DCI limits or by encountering a pressure <20 mmHg. The DCI was then calculated as the total units of mmHg s cm greater than 20 mmHg within this domain. KEY RESULTS Excellent correlation existed between the two methods (r = 0.98, P < 0.001). The DCI values obtained with the conventional calculation were slightly but significantly greater than with the region-growing algorithm. Differences were attributed to the inclusion of vascular pressures in the conventional calculation or to differences in localization of the distal limit of the DCI. CONCLUSIONS & INFERENCES The proposed region-growing algorithm provides an automated method to calculate DCI that limits inclusion of vascular pressure artifacts and minimizes the need for user input in data analysis.
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Affiliation(s)
- Z Lin
- Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611-2951, USA.
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