High-resolution manometry changes our views of gastrointestinal motility

Quantitative Analysis of Small Intestinal Motility in 3D Cine-MRI Using Centerline-Aware Motion Estimation

BACKGROUND

Currently available tools for noninvasive motility quantification of the small intestine are limited to dynamic 2D MRI scans, which are limited in their ability to differentiate between types of intestinal motility.

PURPOSE

To develop a method for quantification and characterization of small intestinal motility in 3D, capable of differentiating motile, non-motile and peristaltic motion patterns.

STUDY TYPE

Prospective.

SUBJECTS

Fourteen healthy volunteers (127 small intestinal segments) and 10 patients with Crohn's disease (87 small intestinal segments).

FIELD STRENGTH/SEQUENCE

3.0 T, 3D balanced fast field echo sequence, 1 volume per second.

ASSESSMENT

Using deformable image registration between subsequent volumes, the local velocity within the intestinal lumen was quantified. Average velocity and average absolute velocity along intestinal segments were used with linear classifiers to differentiate motile from non-motile intestines, as well as erratic motility from peristalsis. The mean absolute velocity of small intestinal content was compared between healthy volunteers and Crohn's disease patients, and the discriminative power of the proposed motility metrics for detecting motility and peristalsis was determined. The consensus of two observers was used as referenced standard.

STATISTICAL TESTS

Student's t-test to assess differences between groups; area under the receiver operating characteristic curve (AUC) to assess discriminative ability. P < 0.001 was considered significant.

RESULTS

A significant difference in the absolute velocity of intestinal content between Crohn's patients and healthy volunteers was observed (median [IQR] 1.06 [0.61, 1.56] mm/s vs. 1.84 [1.37, 2.43] mm/s), which was consistent with manual reference annotations of motile activity. The proposed method had a strong discriminative performance for detecting non-motile intestines (AUC 0.97) and discernible peristalsis (AUC 0.81).

DATA CONCLUSION

Analysis of 3D cine-MRI using centerline-aware motion estimation has the potential to allow noninvasive characterization of small intestinal motility and peristaltic motion in 3D.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Relationship Between Colonic Transit Response to Eating With Self-reported Constipation Severity in Constipated Patients According to the Phenotype

Background/Aims

Eating is the major synchronizer of gastrointestinal motility and secretions. The present study aims to evaluate the interplay between self-perceived constipation severity (CS) and colonic response to eating in constipated patients according to the phenotype.

Methods

We included 387 consecutive outpatients complaining of Rome IV chronic idiopathic constipation. Likert scales for CS, abdominal pain severity, bloating severity, depression and anxiety assessment, total and segmental colonic transit time (CTT), and colonic transit response to eating (CTRE) were performed in all patients.

Results

Of the 387 patients included (49.7 ± 16.4 years), 320 (83%) were female, 203 had irritable bowel syndrome with constipation (IBS-C), 184 as functional constipation (FC), and 283 had defecation disorders (DD). The female gender was characterized by increased bloating severity (P = 0.011) and decreased Bristol stool form (P = 0.002). In IBS-C and FC patients, CS was related with bloating severity (P < 0.001 in both groups) and total CTT (P = 0.007 in IBS-constipation, P = 0.040 in FC). In IBS-C patients, CS was also associated with abdominal pain severity (P = 0.003) and Bristol stool form (P = 0.004). In contrast, in FC, CS was only related to left CTRE (P = 0.006), and in patients with DD, CS was associated with total CTT (P < 0.001) and left CTRE (P = 0.002).

Conclusion

Colonic transit response to eating was not associated to CS in IBS-C patients, but left CTRE was associated with constipation severity in FC and DD patients.

Contractility patterns and gastrointestinal movements monitored by a combined magnetic tracking and motility testing unit

BACKGROUND

Ingestible wireless capsules, including the 3D-transit magnetic capsule and the wireless motility capsule (WMC), describe gastrointestinal (GI) motility from changes in position or pressure. This study aimed to combine information on contractile events in terms of position (assessed with the 3D-transit) and change in pressure (assessed with the WMC) throughout the entire GI tract.

METHODS

The 3D-transit capsule and WMC were combined into a single-wireless unit system. Three-dimensional space-time coordinates, pressure, and pH data from a pilot case were analyzed as the combined unit passed the GI tract. Two single and three continuous contraction patterns were defined according to pressure changes and quantified through the GI tract.

KEY RESULTS

The combined unit was well tolerated and provided information on contractions throughout the gut. Single contraction patterns with no significant progressive movement of the unit were most prevalent in the stomach and the rectosigmoid colon. During the continuous contraction patterns, the unit moved in an antegrade or retrograde direction. Longer distance and higher velocity were seen during antegrade than during retrograde movements. The motility indices (as measured with WMC) in combined ascending, transverse and descending colon showed a positive linear association (r = 0.7) to the capsule movements (as measured with 3D-transit).

CONCLUSIONS & INFERENCES

The combined system provides synchronous information about movements and gut contractions. These measurements can be used to extract more information from existing recordings and may enhance our understanding of GI motility in health and disease.

Propagation patterns of jejunal motor activity measured by high-resolution water-perfused manometry

BACKGROUND

The manometric diagnosis of severe intestinal dysmotility is performed at most institutions using catheters with 2-8 sensors 5-10 cm apart. The recent application of high-resolution manometry catheters with closely spaced sensors to other gut segments has been highly successful. The objective of the present study was to determine the feasibility of a jejunal high-resolution manometry method and to carry out a descriptive analysis of normal jejunal motor function.

METHODS

A 36-channel high-resolution water-perfused manometry catheter (MMS-Laborie, Enschede, The Netherlands) was orally placed in the jejunum of 18 healthy subjects (10 men, eight women; 21-38 age range). Intestinal motility was recorded during 5 h, 3 during fasting, and 2 after a 450 kcal solid-liquid meal. Analysis of motility patterns was supported by computerized tools.

KEY RESULTS

All healthy subjects except one showed at least one complete migrating motor complex during the 3 h fasting period. Phase III activity lasted 5 ± 1 min and migrated aborally at a velocity of 7 ± 3 cm/min. High-resolution spatial analysis showed that during phase III each individual contraction propagated rapidly (75 ± 37 cm/min) over a 32 ± 10 cm segment of the jejunum. During phase II, most contractile activity corresponded to propagated contractile events which increased in frequency from early to late phase II (0.5 ± 0.9 vs 2.5 ± 1.3 events/10 min, respectively; p < 0.001). After meal ingestion, non-propagated activity increased, whereas propagated events were less frequent than during late phase II.

CONCLUSIONS & INFERENCES

Jejunal motility analysis with high-resolution manometry identifies propagated contractile patterns which are not apparent with conventional manometric catheters.

WHEN SHOULD BE CONVERTED LAPAROSCOPIC SLEEVE GASTRECTOMY TO LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS DUE TO GASTROESOPHAGEAL REFLUX?

Background:

Gastroesophageal reflux (GER) is one of the most common indications for conversion of sleeve gastrectomy (LSG) to laparoscopic Roux-en-Y gastric bypass (LRYGBP). Objective evaluations are necessary in order to choose the best definitive treatment for these patients.

Aim:

To present and describe the findings of the objective studies for gastroesophageal reflux disease performed before LSG conversion to LRYGBP in order to support the indication for surgery.

Method:

Thirty-nine non-responder patients to proton pump inhibitors treatment after LSG were included in this prospective study. They did not present GER symptoms, esophagitis or hiatal hernia before LSG. Endoscopy, radiology, manometry, 24 h pH monitoring were performed.

Results:

The mean time of appearance of reflux symptoms was 26.8+24.08 months (8-71). Erosive esophagitis was found in 33/39 symptomatic patients (84.6%) and Barrett´s esophagus in five. (12.8%). Manometry and acid reflux test were performed in 38/39 patients. Defective lower esophageal sphincter function was observed independent the grade of esophagitis or Barrett´s esophagus. Pathologic acid reflux with elevated DeMeester´s scores and % of time pH<4 was detected in all these patients. more significant in those with severe esophagitis and Barrett´s esophagus. Radiologic sleeve abnormalities were observed in 35 patients, mainly cardia dilatation (n=18) and hiatal hernia (n=11). Middle gastric stricture was observed in only six patients.

Conclusion:

Patients with reflux symptoms and esophagitis or Barrett´s esophagus after SG present defective lower esophageal sphincter function and increased acid reflux. These conditions support the indication of conversion to LRYGBP.

1907-2020: more than one century of colonic mass movements in humans

Motility of the large bowel may be grossly subdivided in two types of contractile activity: low-amplitude single or cyclic propagated waves and high-amplitude propagated activity. The latter is mainly apt to shift relatively large amounts of colonic contents, and it is related to defecation. The main component of this propagated activity is represented by the radiologically identified mass movements that have a manometric equivalent known as high-amplitude propagated contractions (HAPC). The present article reviews origins and characterization of HAPC in the time course of colonic motility investigations, and correlates it with technological advancements in recent years, putting into perspective the future possible options to better detect and investigate these important physiological events.

Small Bowel Dysmotility, Pseudoobstruction, and Functional Correlation with Histopathology: Lessons Learned

PURPOSE OF REVIEW

Small bowel dysmotility is a broad heterogeneous term that encompasses a wide range of gastrointestinal disorders resulting from abnormal gut motility. Chronic intestinal pseudo-obstruction (CIPO) is a severe, rare, and complex small bowel motility disorder at the extreme end of this spectrum. It is characterized by failure of the intestinal tract to propel contents, which results in signs and symptoms of bowel obstruction albeit in the absence of any obstructive lesion(s). In this article, we discuss up-to-date diagnostic techniques, management options, and histopathological findings in CIPO.

RECENT FINDINGS

We will emphasize the latest diagnostic methodologies and therapeutic options as well as enteric histopathologic abnormalities in patients with CIPO. CIPO continues to be a clinical challenge. Several novel pharmacological agents hold promise including gastrointestinal hormone agonists and prokinetics. Furthermore, histopathologic findings may help guide therapy and provide further prognostic significance. At present, nutritional support, symptom management, and avoidance of long-term complications are the mainstay of treatment in CIPO.

Propagation Characteristics of Fasting Duodeno-Jejunal Contractions in Healthy Controls Measured by Clustered Closely-spaced Manometric Sensors

Background/Aims

High-resolution methods have advanced esophageal and anorectal manometry interpretation but are incompletely established for intestinal manometry. We characterized normal fasting duodeno-jejunal manometry parameters not measurable by standard techniques using clustered closely-spaced recordings.

Methods

Ten fasting recordings were performed in 8 healthy controls using catheters with 3–4 gastrointestinal manometry clusters with 1–2 cm channel spacing. Migrating motor complex phase III characteristics were quantified. Spatial-temporal contour plots measured propagation direction and velocity of individual contractions. Coupling was defined by pressure peak continuity within clusters.

Results

Twenty-three phase III complexes (11 antral, 12 intestinal origin) with 157 (95% CI, 104–211) minute periodicities, 6.99 (6.25–7.74) minute durations, 10.92 (10.68–11.16) cycle/minute frequencies, 73.6 (67.7–79.5) mmHg maximal amplitudes, and 4.20 (3.18–5.22) cm/minute propagation velocities were recorded. Coupling of individual contractions was 39.1% (32.1–46.1); 63.0% (54.4–71.6) of contractions were antegrade and 32.8% (24.1–41.5) were retrograde. Individual phase III contractions propagated > 35 fold faster (2.48 cm/sec; 95% CI, 2.25–2.71) than complexes themselves. Phase III complexes beyond the proximal jejunum were longer in duration (P = 0.025) and had poorer contractile coupling (P = 0.025) than proximal complexes. Coupling was greater with 1 cm channel spacing vs 2 cm (P < 0.001).

Conclusions

Intestinal manometry using clustered closely-spaced pressure ports characterizes novel antegrade and retrograde propagation and coupling properties which degrade in more distal jejunal segments. Coupling is greater with more closely-spaced recordings. Applying similar methods to dysmotility syndromes will define the relevance of these methods.

Utility of Esophageal High-Resolution Manometry in Clinical Practice: First, Do HRM

Esophageal high-resolution manometry (HRM) has advanced the understanding of esophageal motor function and the ability to diagnose and manage disorders of esophageal motility. In this review, we describe the indications for and the technical performance of HRM. The Chicago classification of esophageal motor function, now in its third iteration, streamlines and standardizes the nomenclature and basic interpretation of HRM data depicted as Clouse topographic plots. In clinical practice, HRM is an important diagnostic test for patients with dysphagia as well as patients with suspected gastroesophageal reflux disease (GERD), particularly in those patients with a suboptimal symptomatic response to antisecretory therapy. HRM can support diagnoses such as achalasia, as well as provide evidence for behavioral disorders such as rumination syndrome or supragastric belching with the assistance of postprandial HRM with impedance. Further, the GERD classification of motor function introduces a three-part hierarchical evaluation of esophageal motor function in GERD, highlighting the value of assessment of esophageal contractile reserve through provocative maneuvers during HRM such as multiple rapid swallows.

Preoperative diagnosis of hiatal hernia: barium swallow X-ray, high-resolution manometry, or endoscopy?

Background

The assessment of hiatal hernias (HH) is typically done with barium swallow X‑ray, upper endoscopy, and by high-resolution esophageal manometry (HRM). The aim of this study was to assess the clinical utility of these methods in terms of HH detection and their correlation to gastroesophageal reflux disease (GERD).

Methods

A retrospective comparative analysis of patients with symptoms of GERD was carried out. The performance of endoscopy and HRM in diagnosing HH was assessed, taking barium swallow X‑ray as a reference. Furthermore, statistically comparative analysis between detected hernias and the presence of reflux disease in ambulatory impedance-pH monitoring (MII) was performed.

Results

Overall, 112 patients were analyzed. Barium swallow X‑ray showed no correlation either to HR manometrically or to endoscopically assessed HH. Significant accordance in the detection rate of HH was proved between HRM and gastroesophagoscopy (p < 0.001). Only endoscopically assessed HH showed a significant correlation with GERD (p = 0.047). No correlation between detected hernias and GERD could be found either with HRM or with barium swallow X‑ray.

Conclusions

Barium swallow X‑ray provided the highest rate of HH detection (76.8%). For the reliable exclusion of HH prior to treatment, all three mentioned investigations appear to be necessary in order of low conformity.

Small Bowel Motility

PURPOSE OF REVIEW

Small bowel motility disorders constitute a relatively small but important segment of clinical gastroenterology. Presenting features encompass a broad range of symptom manifestations and severity: from chronic functional-type complaints to life-threatening nutritional impairment. Diagnostic assessment of patients with suspected intestinal motility disorders is often hampered by the complexity of measuring intestinal contractile activity in humans. In this review, we describe and critically comment the main current and forthcoming methodologies.

RECENT FINDINGS

Beyond conventional small bowel manometry, radiological methods, and intestinal transit tests that have been available for several decades, now we focus on novel methodologies such as high-resolution manometry, magnetic resonance methodology, and endoluminal capsule image analysis. Gradual introduction of new approaches to diagnostic investigation of patients with suspected intestinal motility disorders should facilitate a less invasive and more accurate characterization of disturbed motor function. Enhanced understanding of the pathophysiological basis of clinical conditions should allow better application of therapeutic approaches that are also highlighted in this review.

The use of colonic and anorectal high-resolution manometry and its place in clinical work and in research

BACKGROUND

In the esophagus, high-resolution manometry (HRM) has become a standard diagnostic tool in the investigation of suspected motility disorders. However, at the opposite end of the digestive tract (i.e., the colon and anorectum), the use of HRM still remains in its infancy, with relatively few published studies in the scientific literature. Further, the clinical utility of those studies that have been performed is largely undetermined.

PURPOSE

This review assesses all of the HRM studies published to date from both the colon and anorectum, explores the catheter types used, and attempts to determine the worth of HRM over traditional 'low-resolution' recordings from the same regions. Ultimately, this review addresses whether HRM currently provides information that will benefit patient diagnosis and treatment.