Comparison of bolus transit patterns identified by esophageal impedance to barium esophagram in patients with dysphagia

Is esophageal manometry essential for the diagnosis of achalasia? Identifying patients with achalasia by the esophageal clearance method

BACKGROUND AND AIM

Achalasia is a disease characterized by inadequate relaxation of the lower esophageal sphincter (LES) and impaired peristalsis, for which esophageal motor function testing is essential in making a definitive diagnosis. However, the diffusion rate of esophageal pressure testing in Japan is low. We, therefore, examined whether achalasia could be identified by esophageal clearance testing with low-density barium (Timed Barium Esophagogram: TBE).

MATERIALS AND METHODS

126 cases (62 males, median age of 46 years), excluding those who had not undergone TBE during their initial laparoscopic Heller-Dor surgery, were chosen as the subjects from among those who were diagnosed with achalasia from November 2012 when HRM was introduced. The type of dilation, maximum esophageal transverse diameter, and esophageal clearance measurements by TBE were retrospectively examined. With respect to TBE, 200 mL of 45 weight% low-density barium was ingested as quickly as possible, after which the barium column heights (H0, H1, H2, and H5) were measured 1 min, 2 min, and 5 min following ingestion.

RESULTS

The types of dilation indicated included: straight type (105 cases, 83%); sigmoid type (20 cases, 16%); and advanced sigmoid type (1 case, 1%). The maximum transverse diameter of the esophagus was 45 (34-54) mm, with Grade I (d < 30 mm) in 33 cases, Grade II (35 mm < d < 60 mm) in 75 cases, and Grade III (d < 60 mm) in 18 cases. The values for H0, H1, H2, and H5 were 162 (117-201) mm, 142 (98-199) mm, 130 (94-183) mm, and 119 (77-178) mm, respectively. 114 cases (90.5%) were not cleared after 5 min, while 12 cases (9.5%) were cleared by 5 min later (H1 = 0 + H2 = 0 + H5 = 0) and 7 cases (5.6%) by 2 min later (H1 = 0 + H2 = 0), with only 6 cases (4.8%) having complete clearance within 1 min (H1 = 0). Moreover, the degree of dilatation in patients with complete clearance within 1 min was three patients (2.4%) each for Grade I and Grade II, respectively.

CONCLUSIONS

Approximately 2.4% of achalasia cases had mostly normal esophageal clearance and no esophageal dilation. Based on the state of esophageal clearance by TBE and the maximum transverse diameter of the esophagus, it seems by and large possible to identify achalasia cases.

New parameter for quantifying bolus transit with high-resolution impedance manometry: A comparison with simultaneous esophagogram

BACKGROUND

Esophageal bolus transit can be assessed using esophagogram or high-resolution impedance manometry (HRIM). The three-dimensional volume of inverted impedance (VII) has been developed to quantify the residual bolus between each swallow through spatiotemporal analysis. However, this novel metric has not been validated against simultaneous esophagogram.

METHODS

A total of nine healthy volunteers (Seven males, aged 19-45 years) were prospectively evaluated with HRIM and barium esophagogram. In addition, 21 symptomatic patients (12 males, aged 20-85 years) without major motility disorder were also included. The VII was estimated from HRIM data using MATLAB program and was compared with residual bolus volume in the esophagus estimated from simultaneous esophagogram.

KEY RESULTS

A total of 80 swallows (24 in controls and 56 in patients) were analyzed. Results from the VII method were concordant with the bolus transit pattern estimated from the esophagogram in 91.3% (73/80) of swallows. The correlation between quantitative data from VII and the volume of residual bolus estimated from esophagogram was strong in both groups with a Pearson's correlation coefficient of 0.805 for healthy volunteers and 0.730 for symptomatic patients. The intraclass correlation coefficient of VII between the three swallows within a subject was 0.901 in healthy subjects and 0.705 in patients, indicating a modest reliability of this method.

CONCLUSIONS AND INFERENCES

The newly developed VII method is a reliable method in assessing residual bolus volume in the esophagus based on comparison with bolus volume estimated from simultaneous esophagogram.

Assessment of Esophageal High-Resolution Impedance Manometry in Patients with Nonobstructive Dysphagia

Background

High-resolution impedance manometry (HRIM) can calculate the bolus motion parameters and the ratio of complete esophageal transit besides the conventional esophageal dynamic parameters; therefore, we could better manage the patients with nonobstructive dysphagia (NOD) clinically.

Aim

To analyze the HRIM parameter results of NOD patients and evaluate the characteristics of their esophageal motility and transit function.

Methods

In total, 58 NOD patients were assessed and the clinical diagnoses were determined. HRIM was performed, and both conventional high-resolution manometry and esophageal transit parameters were analyzed.

Results

In 58 NOD patients, 28 patients had achalasia, 3 esophagogastric junction outflow obstruction, and 20 nonspecific esophageal motility disorders, and 7 were normal. Impedance results demonstrated that all the patients with achalasia exhibited incomplete esophageal transit (ICET), three patients with esophagogastric junction outflow obstruction showed ICET, and the average bolus transit time (BTT) was 6.6 ± 1.2 sec. In 20 nonspecific esophageal motility disorders, 13 patients with gastroenterologly reflux disease (GERD) presented ineffective esophageal motility and fragmented peristalsis, and 65.0% swallows had exhibited ICET. However, 49.1% swallows of 7 nonspecific esophageal motility disorder patients with non-GERD had exhibited ICET. The average BTT in 13 GERD patients was longer than that in the non-GERD patients (8.1 ± 1.1 sec versus 5.5 ± 0.3 sec, P < 0.05). And in the seven patients with normal esophagus function, 3.5% swallows showed ICET and BTT was 5.6 ± 0.3 sec.

Conclusion

Achalasia was the most common esophageal dysmotility in NOD patients, followed by nonspecific esophageal motility disorders. The clinical diagnoses of NOD were mostly achalasia and GERD. Impedance assessments showed that all achalasia cases exhibited ICET, and other esophageal motility abnormalities that represented ICET were associated with contraction break and ineffective swallow. Compared to non-GERD patients, BTT was significantly prolonged in patients with GERD.

Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia

BACKGROUND AND AIMS

Our aim is to review the literature and provide guidelines for the assessment of uninvestigated dysphagia.

METHODS

A systematic literature search identified studies on dysphagia. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Statements were discussed and revised via small group meetings, teleconferences, and a web-based platform until consensus was reached by the full group.

RESULTS

The consensus includes 13 statements focused on the role of strategies for the assessment of esophageal dysphagia. In patients presenting with dysphagia, oropharyngeal dysphagia should be identified promptly because of the risk of aspiration. For patients with esophageal dysphagia, history can be used to help differentiate structural from motility disorders and to elicit alarm features. An empiric trial of proton pump inhibitor therapy should be limited to four weeks in patients with esophageal dysphagia who have reflux symptoms and no additional alarm features. For patients with persistent dysphagia, endoscopy, including esophageal biopsy, was recommended over barium esophagram for the assessment of structural and mucosal esophageal disease. Barium esophagram may be useful when the availability of endoscopy is limited. Esophageal manometry was recommended for diagnosis of esophageal motility disorders, and high-resolution was recommended over conventional manometry.

CONCLUSIONS

Once oropharyngeal dysphagia is ruled out, patients with symptoms of esophageal dysphagia should be assessed by history and physical examination, followed by endoscopy to identify structural and inflammatory lesions. If these are ruled out, then manometry is recommended for the diagnosis of esophageal dysmotility.

Dysphagia: Thinking outside the box

Dysphagia is a common symptom that is important to recognise and appropriately manage, given that causes include life threatening oesophageal neoplasia, oropharyngeal dysfunction, the risk of aspiration, as well as chronic disabling gastroesophageal reflux (GORD). The predominant causes of dysphagia varies between cohorts depending on the interplay between genetic predisposition and environmental risk factors, and is changing with time. Currently in white Caucasian societies adopting a western lifestyle, obesity is common and thus associated gastroesophageal reflux disease is increasingly diagnosed. Similarly, food allergies are increasing in the west, and eosinophilic oesophagitis is increasingly found as a cause. Other regions where cigarette smoking is still prevalent, or where access to medical care and antisecretory agents such as proton pump inhibitors are less available, benign oesophageal peptic strictures, Barrett's oesophagus, adeno- as well as squamous cell carcinoma are endemic. The evaluation should consider the severity of symptoms, as well as the pre-test probability of a given condition. In young white Caucasian males who are atopic or describe heartburn, eosinophilic esophagitis and gastroesophageal reflux disease will predominate and a proton pump inhibitor could be commenced prior to further investigation. Upper gastrointestinal endoscopy remains a valid first line investigation for patients with suspected oesophageal dysphagia. Barium swallow is particularly useful for oropharyngeal dysphagia, and oesophageal manometry mandatory to diagnose motility disorders.

Esophageal Impedance Monitoring: Clinical Pearls and Pitfalls

The development of intraluminal esophageal impedance monitoring has improved our ability to detect and measure gastroesophageal reflux without dependence on acid content. This ability to detect previously unrecognized weak or nonacid reflux episodes has had important clinical implications in the diagnosis and management of gastroesophageal reflux disease (GERD). In addition, with the ability to assess bolus transit within the esophageal lumen, impedance monitoring has enhanced the recognition and characterization of esophageal motility disorders in patients with nonobstructive dysphagia. The assessment of the intraluminal movement of gas and liquid has also been proven to be of diagnostic value in conditions such as rumination syndrome and excessive belching. Further, alternative applications of impedance monitoring, such as the measurement of mucosal impedance, have provided novel insights into assessing esophageal mucosal integrity changes as a consequence of inflammatory change. Future applications for esophageal impedance monitoring also hold promise in esophageal conditions other than GERD. However, despite all of the clinical benefits afforded by esophageal impedance monitoring, important clinical and technical shortcomings limit its diagnostic value and must be considered when interpreting study results. Overinterpretation of studies or application of impedance monitoring in patients can have deleterious clinical implications. This review will highlight the clinical benefits and limitations of esophageal impedance monitoring and provide clinical pearls and pitfalls associated with this technology.

Dysphagia among adult patients who underwent surgery for esophageal atresia at birth

BACKGROUND

Clinical experiences of adults who underwent surgery for esophageal atresia at birth is limited. There is some evidence that suggests considerable long-term morbidity, partly because of dysphagia, which has been reported in up to 85% of adult patients who undergo surgery for esophageal atresia. The authors hypothesized that dysphagia in this population is caused by dysmotility and⁄or anatomical anomalies.

OBJECTIVE

To determine the motor and anatomical causes of dysphagia.

METHODS

A total of 41 adults, followed at the Esophageal Atresia Clinic at Hôpital Saint-Luc (Montreal, Quebec), were approached to particpate in the present prospective study. Evaluation was completed using upper endoscopy, manometry and barium swallow for the participants who consented. The medical charts of respondents were systematically reviewed from the neonatal period to 18 years of age to assess medical and surgical history.

RESULTS

All 41 patients followed at the clinic consented and were included in the study. Dysphagia was present in 73% of patients. Esophagogastroduodenoscopy was performed in 32 patients: hiatal hernia was present in 62% (n=20); esophageal diverticulum in 13% (n=4); macroscopic Barrett esophagus in 31% (n=10); and esophagitis in 19% (n=6). Histological esophagitis was present in 20% and intestinal metaplasia in 10%. There were no cases of dysplagia or adenocarcinoma. Esophageal manometry was performed on 56% of the patients (n=23). Manometry revealed hypomotility in 100% of patients and included an insufficient number of peristaltic waves in 96%, nonpropagating peristalsis in 78% and low-wave amplitude in 95%. Complete aperistalsis was present in 78%. The lower esophageal sphincter was abnormal in 12 (52%) patients, with incomplete relaxation the most common anomaly. Of the 41 patients, 29 (71%) consented to a barium swallow, which was abnormal in 13 (45%). The anomalies found were short esophageal dilation in 28%, delay in esophageal emptying in 14%, diverticula in 14% and stenosis in 7% of patients. There was more than one anomaly in 14% of patients.

CONCLUSION

Dysphagia was a highly prevalent symptom in adults who underwent surgery for esophageal atresia. The present study is the first to demonstrate that motor and anatomical abnormalities may be implicated in causes of dysphagia in this population. Furthermore, these anomalies may be demonstrated with simple investigations such as endoscopy, manometry and barium swallow.

Videofluoroscopic swallowing study: esophageal alterations in patients with dysphagia

CONTEXT

Videofluoroscopic swallowing study is a dynamic exam and allows the evaluation of the complete swallowing process. However, most published studies have only reported alterations in the oropharynx and pharyngoesophageal transition, leaving the analysis of the esophagus as a secondary goal.

OBJECTIVES

The goal of this study was to investigate the prevalence of alterations in the esophageal phase thorough videofluoroscopic swallowing study in patients with dysphagia.

METHODS

Consecutive patients with dysphagia who underwent videofluoroscopic swallowing study including esophageal analysis between May 2010 and May 2012 had their exams retrospectively reviewed. Patients were classified into two groups: Group I - without a pre-established etiological diagnosis and Group II - with neurological disease. During the exam, the patients ingested three different consistencies of food (liquid, pasty and solid) contrasted with barium sulfate and 19 items were analyzed according to a protocol. The esophageal phase was considered abnormal when one of the evaluated items was compromised.

RESULTS

Three hundred and thirty-three (n = 333) consecutive patients were studied - 213 (64%) in Group I and 120 (36%) in Group II. Esophageal alterations were found in 104 (31%) patients, with a higher prevalence in Group I (36.2%), especially on the items esophageal clearance (16.9%) and tertiary contractions (16.4%). It was observed that 12% of individuals in Group I only presented alterations on the esophageal phase.

CONCLUSION

Evaluation of the esophageal phase of swallowing during videofluoroscopic swallowing study detects abnormalities in patients with cervical dysphagia, especially in the group without pre-established etiological diagnosis.

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.

High-resolution Impedance Manometry Criteria in the Sitting Position Indicative of Incomplete Bolus Clearance

BACKGROUND/AIMS

We used high-resolution impedance manometry (HRIM) to determine the length of breaks on the isobaric contour which would predict incomplete bolus clearance in patients in the sitting position.

METHODS

In total, 651 swallows in 71 patients with esophageal symptoms were studied using a solid-state HRIM system in the sitting position. Each swallow was classified as complete or incomplete bolus clearance by impedance criteria and peristaltic integrity was evaluated using 20- and 30-mmHg pressure topography isobaric contours. Correlations between the lengths of the breaks for 20- and 30-mmHg were analyzed.

RESULTS

Complete bolus clearance was observed in 83.3% (542/651) of swallows. Breaks of 3 and 7 cm or less were associated with a bolus clearance of 96.8% on the 20-mmHg and 94.7% on the 30-mmHg isobaric contour, respectively (P < 0.001). The areas under the ROC curves for the 20 and 30 mmHg isobaric contours were 0.900 and 0.950, respectively. The sensitivity and specificity for complete bolus clearance were 75.6% and 89.3% for breaks 3 cm or less on the 20-mmHg isobaric contour and 87.9% and 78.7% for breaks 7 cm or less on the 30-mmHg contour (P < 0.001).

CONCLUSIONS

Breaks of < 3 cm in the 20-mmHg isobaric contour or < 7 cm in the 30-mmHg isobaric contour were associated with com-plete bolus clearance. The threshold for breaks in the sitting position was greater than previous reports using the supine posi-tion and longer breaks predicted incomplete bolus clearance.(J Neurogastroenterol Motil 2014;20:491-496).

Evaluating esophageal bolus transit by impedance monitoring

The function of the esophagus is transporting nutrients from the oropharyngeal cavity to the stomach. This is achieved by coordinated contractions and relaxation of the tubular esophagus and the upper and lower esophageal sphincter. Multichannel intraluminal impedance monitoring offers quantification of esophageal bolus transit and/or retention without the use of ionizing radiation. Combined with conventional or high-resolution manometry, impedance measurements complement the quantification of esophageal body contraction and sphincter relaxation, offering a more comprehensive evaluation of esophageal function. Further studies evaluating the utility of quantifying bolus transit will help clarify the role and position of impedance measurements.

Dysphagia in the elderly

Dysphagia, or difficulty swallowing, is a common problem in the elderly. Based on the initial clinical history and physical examination, the dysphagia is assessed as either primarily oropharyngeal or esophageal in origin. Most oropharyngeal dysphagia is of neurologic origin, and management is coordinated with a clinical swallow specialist in conjunction with an ear, nose, and throat (ENT) physician if warning signs imply malignancy. Several structural and functional esophageal disorders can cause dysphagia. If a patient has likely esophageal dysphagia, a video barium esophagram is a good initial test, and referral to a gastroenterologist is generally warranted leading to appropriate treatment.

Barium esophagram: does it have a role in gastroesophageal reflux disease?

The barium esophagram is an integral part of the assessment and management of patients with gastroesophageal reflux disease (GERD) before, and especially after, antireflux procedures. While many of the findings on the examination can be identified with endosocopy, a gastric emptying study and an esophageal motility examination, the barium esophagram is better at demonstrating the anatomic findings after anti-reflux surgery, especially in symptomatic patients. These complementary examinations, when taken as a whole, fully evaluate a patient with suspected GERD as well as symptomatic patients after antireflux procedures.

Management of spastic disorders of the esophagus

The concept of esophageal spastic disorders encompasses spastic achalasia, distal esophageal spasm, and jackhammer esophagus. These are conceptually distinct in that spastic achalasia and distal esophageal spasm are characterized by a loss of neural inhibition, whereas jackhammer esophagus is associated with hypercontractility. Hypercontractility may also occur as a result of esophagogastric junction outflow obstruction or inflammation. The diagnosis of jackhammer esophagus as a primary motility disorder is based on the characteristic manometric findings after ruling out mechanical obstruction and eosinophilic esophagitis. Despite the differences in pathophysiology among the esophageal spastic disorders, their management is similar.

Oropharyngeal and Esophageal Swallowing Impairments: Their Association and the Predictive Value of the Modified Barium Swallow Impairment Profile and Combined Multichannel Intraluminal Impedance—Esophageal Manometry

Objectives:

Deglutition is a highly integrated process of neural signaling and coordinated muscular contraction that begins with bolus preparation in the oral cavity and ends with closure of the lower esophageal sphincter after bolus passage. The goal of this study was to examine the relationship between measures of oropharyngeal and esophageal swallow function.

Methods:

A retrospective review was performed of patients who underwent modified barium swallow study (MBSS) and multichannel intraluminal impedance–esophageal manometry (MII-EM) over 7 years at an academic institution. The MBSS was scored with the Modified Barium Swallow Impairment Profile (MBSImP). Associations between impairments as measured by the MBSImP and MII-EM were assessed with a 2-sided Fisher's exact test.

Results:

One hundred sixty-four patients met the inclusion criteria for the study. Comparison of MBSImPcomponent and oral and pharyngeal total regional scores to MII-EM scores revealed a significant association between abnormal esophageal clearance on MBSS (MBSImP component 17) and abnormal findings on MII-EM (p < 0.001). Delay in initiation of pharyngeal swallow (MBSImPcomponent 6) was significantly associated with abnormal esophageal clearance on MBSS (p = 0.023).

Conclusions:

Abnormal esophageal clearance on MBSS (MBSImP component 17) indicates a need for further esophageal testing. A functional interrelationship between abnormalities of oropharyngeal and esophageal swallowing does exist, illuminating the importance of thorough pharyngoesophageal examination for dysphagia symptoms.

Imaging evaluation of dogs and cats with Dysphagia

The current literature is reviewed in this paper regarding the application of diagnostic imaging in the evaluation of swallowing disorders of the dog. The applications of radiography, contrast radiography, and contrast videofluoroscopy are discussed with pertinent case examples provided for emphasis. The indications for image-guided interventions are also described.

Critical analysis of esophageal multichannel intraluminal impedance monitoring 20 years later

Multichannel intraluminal impedance (MII) for the evaluation of esophageal diseases was created in 1991 trying to solve previous limitations of esophageal function test. MII-pH is able to determine the physical characteristics of the refluxate (liquid, gas, or mixed) and nonacidic GER. MII-manometry can determine the presence of bolus and its relation with peristalsis. This paper makes a critical analysis of the clinical applications of MII 20 years after its creation. Literature review shows that MII made great contributions for the understanding of esophageal physiology; however, direct clinical applications are few. MII-pH was expected to identify patients with normal acid reflux and abnormal nonacidic reflux. These patients are rarely found off therapy, that is, nonacidic reflux parallels acid reflux. Furthermore, the significance of isolated nonacidic reflux is unclear. Contradictory MII-manometry and conventional manometry findings lack better understanding and clinical implication as well as the real significance of bolus transit.