Assessment of esophageal dysfunction and symptoms during and after a standardized test meal: development and clinical validation of a new methodology utilizing high-resolution manometry

The Diagnostic Yield of Laboratory Tests in Chronic Constipation in Adults

BACKGROUND

Chronic constipation is a common gastrointestinal complaint characterized by infrequent or difficult bowel movements, significantly affecting patients' quality of life. Laboratory markers offer potential diagnostic value in identifying physiological changes associated with chronic constipation, yet their effectiveness remains underexplored.

OBJECTIVES

The objective of this study was to evaluate the diagnostic value of various laboratory tests in identifying the underlying causes of chronic constipation among adults.

PATIENTS AND METHODS

A cross-sectional study was conducted at Kurdistan Private Hospital and Jeen Clinics in Duhok, Kurdistan, Iraq, from December 2022 to May 2024. A total of 132 patients meeting the Rome IV criteria for chronic constipation were included. Data collection involved demographic information, lifestyle factors, and laboratory tests, including complete blood count (CBC), thyroid stimulating hormone (TSH), serum calcium, serum potassium, serum glucose, serum creatinine, parathyroid hormone (PTH), and vitamin D levels.

RESULTS

The study population consisted of 56 males (42.4%) and 76 females (57.6%) with a mean age of 46.5 years (SD=17 years) and a range of 18-81 years. Regular exercise was performed by only 56 (42.4%) patients, 85 (64.4%) patients were drinking less than 2 liters of water per day, and 108 (81.8%) were overweight or obese. Of the study population, hypothyroidism was detected in 27 (20.4%), hyperparathyroidism in 27 (20.4%), anemia in 58 (44%), leukocytosis in 24 (18.2%), renal impairment in 48 (36.4%), hypokalemia in four (3%), hyperkalemia in 12 (9.1%), hypocalcemia in 10 (7.6%), hypercalcemia in 12 (9.1%), impaired fasting glucose in 46 (34.8%), hyperglycemia in 21 (15.9%), and vitamin D deficiency in 80 (60.6%). Of the study population, 40 (30%) patients had normal laboratory investigations panel.

CONCLUSION

In chronic constipation, laboratory tests have high diagnostic yield in adults and are essential for ruling out secondary causes of chronic constipation. Unhealthy lifestyles are prevalent in patients with chronic constipation.

Laparoscopic floppy Nissen fundoplication with valve calibration: a safe and efficient procedure

PURPOSES

A floppy Nissen fundoplication with valve calibration (FNF-VC) performed by laparotomy has been described, to reduce postoperative dysphagia and gas bloating after 360°-fundoplication. As laparoscopy is the gold standard for fundoplication, this study reports the first results of a modified FNF-VC adapted for laparoscopy (LFNF).

METHODS

Seventy-two consecutive patients, who underwent LFNF for refractory GERD between 2012 and 2021, were included. Postoperative outcomes and quality of life (QoL) by GERSS, GERD-HRQL, and GIQLI scores before and after surgery were assessed.

RESULTS

The main symptoms were pyrosis (81%), regurgitation (39%), Ear-Nose-Throat symptoms (22%), and thoracic pain (24%). Hiatal hernia was present in 85% (n = 61) of the patients. There was no postoperative mortality, and the severe postoperative morbidity rate (Dindo-Clavien ≥ III) was 6%. After a median follow-up of 3.6 years, only 8% of patients were still taking proton-pump inhibitors. Long-term residual dysphagia was noted in 15% of the patients, but none required reoperation or interventional endoscopic procedures. QoL improved, with a significant reduction in GERSS and GERD-HRQL scores and a postoperative GIQLI of 101.75 (75-117.5).

CONCLUSION

This series reports the safety and efficacy of an FNF-VC adapted for laparoscopy to treat GERD with a limited rate of residual dysphagia.

A complex case of dysphagia with dual aetiology

A woman in her early 60s was referred with dysphagia and chest pain to a tertiary referral centre specialising in oesophageal disorders. Cardiac symptom origin and sinister oesophageal pathology had been excluded at her local hospital in NHS Scotland. Under multidisciplinary team oversight, reinvestigation of mucosal pathology and oesophageal motility ultimately uncovered both Type III achalasia and eosinophilic oesophagitis. This case demonstrates the benefit of including provocative testing during high-resolution manometry to reproduce relevant dysphagia and the importance of stopping proton-pump inhibitors long enough to uncover excessive eosinophils which could otherwise be masked. Ultimately, tailored management for both conditions separately was required to achieve symptoms resolution.

The yield of solid swallows in high resolution esophageal manometry among patients with dysphagia and gastro-esophageal reflux symptoms

BACKGROUND

Swallowing disorders are frequently reported esophageal symptoms and represent a common cause for referrals to gastroenterology consultations. Esophageal high-resolution manometry (HRM) is considered the gold standard modality for the evaluation of esophageal peristalsis and esophageal sphincter. The standard protocol of HRM includes water swallows only, that may not assess appropriately esophageal function and symptoms. Hence, we investigated the diagnostic yield of combining solid food swallows (SFS) to standard HRM.

METHODS

We conducted a retrospective study at the Unit of Gastroenterology of EMMS Nazareth Hospital, Israel. Patients who underwent manometry mainly due to dysphagia or reflux symptoms between November 2019 and November 2020 were enrolled. All patients underwent routine HRM and completed ten 5 mL water swallows and 5 bread swallows. Analysis and reports were done by an expert gastroenterologist, based on the Chicago Classification version 3.

RESULTS

Overall, 99 patients (45.5% men, mean age 52.1±16 years) who underwent HRM were included. The addition of solid swallows to the test changed manometry results in 43 patients (43.4%) (P<0.005). Furthermore, SFS improved the contractility in 26/42 cases of ineffective and/or absent motility (61%) (P<0.005). Finally, SFS aggravated symptoms in 44 patients (44.6% more aggravation than in liquid only) (P<0.005).

CONCLUSIONS

Combining SFS to HRM can improve the diagnostic yield of the study. Adding solid swallows is of special value in cases of ineffective esophageal motility but induces a high rate of symptoms aggravation.

Assessing the diagnostic yield of achalasia using provocative testing in high-resolution esophageal manometry: Serial diagnostic study

BACKGROUND

Chicago Classification v4.0 recommends that if achalasia is demonstrated with single water swallows (SWS); provocative testing is not required. We determine whether provocative testing in patients with suspected achalasia can change manometric findings and reproduce symptoms.

METHODS

Between 2016 and 2022, 127 consecutive manometry studies of patients with achalasia were retrospectively analyzed. All patients underwent SWS, a solid meal (SM) and/or a rapid drink challenge (RDC). Demographic data, fluoroscopy, gastroscopy, and pre-and post-treatment Eckardt scores were collated.

KEY RESULTS

Of 127 achalasia patients (50.6 ± 16.6 years and 54.6% male), all completed a SM and 116 (91.3%) completed RDC; overall 83 were naïve (65.4%) to previous therapy. 15.4% patients with normal integrated relaxation pressure (IRP) on SWS demonstrated obstruction with RDC. SM gave a different achalasia phenotype in 44.9% of patients (p ⟨ 0.001). Twelve patients with normal IRP during SWS had persistent/recurrent obstruction during provocative testing; 83.3% had previous achalasia therapy. None of 13 patients with Type III (TIII) achalasia with SWS exhibited a change in manometric findings with provocative testing. Impedance bolus heights were lower in patients with TIII achalasia and those with normal IRP with SWS. During the SM, symptoms were reproduced in 56.7% of patients. Forty-six of 103 patients (44.7%) underwent therapy based upon the final achalasia subtype which was defined by the provocative test result of the high-resolution manometry (HRM) study. All treatments were effective, regardless of the achalasia subtype.

CONCLUSIONS AND INFERENCES

Manometric findings remain unchanged when TIII achalasia is diagnosed with SWS. In patients with normal IRP, Type I, or Type II achalasia during SWS, provocative testing can alter achalasia phenotype or uncover achalasia where diagnosis is unclear. Further, it can reproduce symptoms. Such findings can personalize and guide effective therapeutic decisions.

Clinical utility of the solid meal test during high-resolution esophageal manometry. A study in a Latin American population

INTRODUCTION AND AIMS

The solid test meal (STM) is a challenge test that is done during esophageal manometry and appears to increase the diagnostic yield of the study. The aim of our analysis was to establish the normal values for STM and evaluate its clinical utility in a group of Latin American patients with esophageal disorders versus healthy controls.

MATERIAL AND METHODS

A cross-sectional study was conducted on a group of healthy controls and consecutive patients that underwent high-resolution esophageal manometry, in which STM was done at the final part of the study and consisted of asking the subjects to eat 200 g of precooked rice. The results were compared during the conventional protocol and the STM.

RESULTS

Twenty-five controls and 93 patients were evaluated. The majority of the controls (92%) completed the test in under 8 min. The STM changed the manometric diagnosis in 38% of the cases. The STM diagnosed 21% more major motor disorders than the conventional protocol; it doubled the cases of esophageal spasm and quadrupled the cases of jackhammer esophagus, whereas it demonstrated normal esophageal peristalsis in 43% of the cases with a previous diagnosis of ineffective esophageal motility.

CONCLUSIONS

Our study confirms the fact that complementary STM during esophageal manometry adds information and enables a more physiologic assessment of esophageal motor function to be made, compared with liquid swallows, in patients with esophageal motor disorders.

A Short History of High-Resolution Esophageal Manometry

High-resolution esophageal manometry (HRM) utilizes sufficient pressure sensors such that intraluminal pressure is monitored as a continuum along luminal length, similar to time viewed as a continuum on polygraph tracings in 'conventional' manometry. When HRM is coupled with pressure topography plotting, and pressure amplitude is transformed into spectral colors with isobaric areas indicated by same-colored regions, "Clouse plots" are generated. HRM has several advantages compared to the technology that it replaced: (1) the contractility of the entire esophagus can be viewed simultaneously in a uniform standardized format, (2) standardized objective metrics of peristaltic and sphincter function can be systematically applied for interpretation, and (3) topographic patterns of contractility are more easily recognized with greater reproducibility. Leveraging these advantages led to the current standard for the interpretation of clinical esophageal HRM studies, the Chicago Classification (CC), now in its fourth iteration. Compared to conventional manometry, HRM has vastly improved the sensitivity for detecting achalasia, largely due to the objectivity and accuracy of identification of impaired esophagogastric junction (EGJ) relaxation. Additionally, it has led to the subcategorization of achalasia into three clinically relevant subtypes, differentiated by the contractile function of the esophageal body, and identified an additional disorder of EGJ outflow obstruction wherein esophageal peristalsis is preserved. Headway has also been made in understanding hypocontractile and hypercontractile conditions. In summary, HRM and the CC process have revolutionized our understanding of esophageal motility and motility disorders. Moving forward, there will always be remaining challenges, but we now have the tools to meet them.

Transient Hiatal Separation During Straight Leg Raise Can Predict Reflux Burden in Gastroesophageal Reflux Disease Patients With Ineffective Esophageal Motility

Background/Aims

Straight leg raise (SLR) can be utilized to evaluate the integrity of the esophagogastric junction during high-resolution manometry (HRM). We aim to assess the value of transient hiatal separation during SLR in symptomatic reflux patients.

Methods

Consecutive reflux patients undergoing esophageal HRM and pH monitoring were included. Transient hiatal separation was defined by a ≥ 1 cm separation between the lower esophageal sphincter and crural diaphragm during SLR. We compared esophageal motor patterns and reflux monitoring parameters between patients with normal, transiently abnormal and consistently abnormal esophagogastric junction morphology during SLR.

Results

Of 85 (56.3% female, mean age: 46.7 ± 12.3 years) completed SLR, esophagogastric junction morphology was normal in 31 (36.5%), transient hiatal separation in 19 (22.3%), and consistently hiatal hernia in 35 (41.2%). The values of total acid exposure time (P = 0.016), longest acid reflux episodes (P = 0.024), and DeMeester scores (P = 0.016) were higher in hiatal hernia compared to patients with non-transient hiatal separation, but there were no differences between those with and without transient hiatal separation. Within ineffective esophageal motility, the presence of transient hiatal separation during SLR significantly associated with a higher total acid exposure time (P = 0.014), higher DeMeester scores (P = 0.019), higher total acid reflux events (P = 0.037), and higher longest acid reflux episodes (P = 0.006).

Conclusion

Our work suggests that SLR may have value as a provocative test during HRM, and future outcome studies are warranted to elucidate the clinical relevance of motor abnormalities depicted from SLR.

How provocative tests in addition to wet swallows during high-resolution manometry can direct clinical management

PURPOSE OF REVIEW

Provocative tests have been advocated to address limitations of high-resolution manometry (HRM) with wet swallows. We describe the commonly used provocative manometric manoeuvres [rapid drink challenge (RDC), multiple rapid swallows (MRS), solid swallows and the solid test meal (STM)], compare their diagnostic yield and accuracy to wet swallows, and outline their role in directing clinical management.

RECENT FINDINGS

Provocative testing with RDC and STM identifies a proportion of achalasia cases missed by standard testing, and RDC can play a similar role to radiology in the evaluation of treatment response. In EGJOO, provocative testing with RDC and STM not only increase the diagnostic yield, but can also help differentiate between spurious cases and those representing true outflow obstruction likely to respond to achalasia-type therapies. MRS and STM can help determine the clinical relevance (or otherwise) of ineffective oesophageal motility, and in this setting, MRS may predict the likelihood of postfundoplication dysphagia. RDC and STM can help identify cases of postfundoplication dysphagia more likely to respond to dilatation.

SUMMARY

Provocative testing has been shown to increase diagnostic yield of HRM, clarify inconclusive diagnoses, allows corroboration of dysmotility with patient symptoms and helps direct clinical management.

The semirecumbent position for high-resolution esophageal manometry. Results of a feasibility study

OBJECTIVE

Normative values for high-resolution manometry (HRM) have been obtained with the patient lying supine. The aim of the study was to compare supine, semirecumbent and sitting positions during HRM in terms of variation in normative metrics, diagnostic yield, and patient's comfort.

METHODS

A prospective, single-center feasibility study was planned in consecutive patients referred to the esophageal function laboratory. In each of the three positions, 10 consecutive 5 ml water swallows and three 10 ml multiple rapid swallows were administered. Validated reflux questionnaires were administered prior to the test, and a visual analogue scale (VAS) assessing the patient's comfort after the test.

RESULTS

Twenty patients presenting with gastroesophageal reflux symptoms completed the study protocol. The intra-abdominal segment of the lower esophageal sphincter was significantly longer in the sitting position (P = 0.013), and the multiple rapid swallow distal contractile integral was lowest in the supine position (P = 0.012). The VAS comfort score did not significantly differ in the three body positions (P = 0.295). The concordance in the final diagnosis was 80% for semirecumbent vs. sitting (kappa = 0.15; P = 0.001), 70% for supine vs. sitting and 65.0% for semirecumbent vs. supine.

CONCLUSION

Compared to the supine position, both the semirecumbent and sitting position seems to provide similar advantages. HRM metrics and the final manometric diagnosis may be affected by body position, but complementary maneuvers, such are the rapid drink challenge, can resolve diagnostic discrepancies and improve the overall accuracy of the test.

Clinical usefulness of esophageal high resolution manometry and adjunctive tests: An update

High resolution manometry (HRM), developed from conventional manometry, is the gold standard for assessment of esophageal motor function worldwide. The Chicago Classification, now in its fourth iteration, is the modern standard for HRM categorization of esophageal motility disorders. The HRM protocol has expanded from the original 10 supine swallow standard, to include upright swallows, and provocative maneuvers such as multiple rapid swallows, rapid drink challenge and standardized test meal. Impedance has been incorporated into HRM for visualization of bolus clearance. Futhermore, barium radiography and functional lumen imaging probe complement HRM when evidence of esophagogastric junction obstruction is inconclusive. The biggest impact of HRM is in the improved diagnosis and subtyping of achalasia spectrum disorders, with implications on management. Spastic disorders and absent contractility are better characterized. Within the reflux spectrum, HRM provides definition of morphology and tone of the esophagogastric junction, and assesses integrity of esophageal body peristalsis, which have pathophysiologic implications for reflux and its clearance. HRM provides characterization of behavioral disorders such as supragastric belching and rumination syndrome, which can mimic reflux disease. Thus, HRM has revolutionized the evaluation of esophageal motor function, and has expanded the utility of esophageal manometry in clinical practice.

Is it necessary to perform a morphological assessment for an esophageal motility disorder? A retrospective descriptive study

BACKGROUND

Esophageal motility disorders are most often of primary origin but may be secondary to an occult malignancy or another etiology. High-resolution esophageal manometry cannot differentiate between secondary or primary origin. This study aimed at discussing the usefulness of a morphological assessment in the diagnosis of specific esophageal motility disorders, and to establish the predictive factors of a potential secondary origin.

METHODS

In this retrospective study, patients with suspected esophageal motility disorders who underwent an esophageal manometry were included. High-resolution manometry results were interpreted according to the Chicago Classification, 3rd version. The results of endoscopic ultrasound and computed tomography, assessed by a panel of experts, allowed to diagnose a secondary origin.

KEY RESULTS

Out of 2138 patients undergoing manometry, 502 patients had a esophageal motility disorder suspect to be from secondary origin; among them 182 patients underwent tomography or endoscopic ultrasound. According to experts, 16 patients (8.8%) had a secondary esophageal motility disorder: esophagogastric junction outflow obstruction (n = 7), jackhammer disorder (n = 4), achalasia (n = 3) and localized pressurization (n = 2). The etiology was malignant in 8 patients. Predictive factors suggesting potential secondary esophageal motility disorders were smoking, age ≥ 58 years and an Integrated Relaxation Pressure higher than 10 mmHg for water swallows.

CONCLUSION AND INFERENCES

Esophageal motility disorders with organic origin are not uncommon. A morphological assessment using endoscopic ultrasonography and/or computed tomography may be of use to diagnose a secondary origin, especially in the elderly and smokers.

Esophagogastric junction outflow obstruction

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.

Chicago Classification update (V4.0): Technical review on diagnostic criteria for ineffective esophageal motility and absent contractility

Esophageal hypomotility disorders manifest with abnormal esophageal body contraction vigor, breaks in peristaltic integrity, or failure of peristalsis in the context of normal lower esophageal sphincter relaxation on esophageal high-resolution manometry (HRM). The Chicago Classification version 4.0 recognizes two hypomotility disorders, ineffective esophageal motility (IEM) and absent contractility, while fragmented peristalsis has been incorporated into the IEM definition. Updated criteria for ineffective swallows consist of weak esophageal body contraction vigor measured using distal contractile integral (DCI, 100-450 mmHg·cm·s), transition zone defects >5 cm measured using a 20 mmHg isobaric contour, or failure of peristalsis (DCI < 100 mmHg·cm·s). More than 70% ineffective swallows and/or ≥50% failed swallows are required for a conclusive diagnosis of IEM. When the diagnosis is inconclusive (50%-70% ineffective swallows), supplementary evidence from multiple rapid swallows (absence of contraction reserve), barium radiography (abnormal bolus clearance), or HRM with impedance (abnormal bolus clearance) could support a diagnosis of IEM. Absent contractility requires 100% failed peristalsis, consistent with previous versions of the classification. Consideration needs to be given for the possibility of achalasia in absent contractility with dysphagia despite normal IRP, and alternate complementary tests (including timed upright barium esophagram and functional lumen imaging probe) are recommended to confirm or refute the presence of achalasia. Future research to quantify esophageal bolus retention on stationary HRM with impedance and to understand contraction vigor thresholds that predict bolus clearance will provide further refinement to diagnostic criteria for esophageal hypomotility disorders in future iterations of the Chicago Classification.

Variations in Clinical Practice of Esophageal High-resolution Manometry: A Nationwide Survey

Background/Aims

Esophageal high-resolution manometry (HRM) enables the comprehensive evaluation of the esophageal motor function. However, protocols are not uniform and clinical practices vary widely among institutions. This study aims to understand the current HRM practice in Korea.

Methods

The survey was sent via email through the Korean Society of Neurogastroenterology and Motility. The questions covered descriptive information, preparation, techniques, analysis, and reporting of esophageal HRM.

Results

The survey was completed in 32 (74.4%) out of 43 centers, including 24 tertiary and 8 secondary referral centers. Of the 32 centers, 25 (78.1%) performed HRM in a sitting position, while 7 centers (21.9%) reported performing HRM in a supine position. All the centers utilized single wet swallows as a standard, but the volume, frequency, and interval between swallows varied widely. Sixteen centers (50.0%) applied adjunctive tests, including multiple rapid swallows (n = 16) and rapid drink challenges (n = 9). Parameters assessed and documented in the report were similar. In addition to the assessment of the esophagogastric junction and esophageal body, 27 centers (84.8%) and 18 centers (56.3%) included measurements for the upper esophageal sphincter and the pharynx, respectively, in the HRM protocol.

Conclusions

We found a variation in the available HRM practice among centers, even though they broadly agreed in the data analysis. Efforts are needed to develop a standardized protocol for HRM measurement.

Onigiri esophagography as a screening test for esophageal motility disorders

Background/Aims

No screening test for esophageal motility disorder (EMD) has been established, the objective of this study is to examine the potential usefulness of our newly developed “Onigiri esophagography” combined with an obstruction level (OL) classification system in screening for EMD.

Methods

A total of 102 patients with suspected EMDs who underwent both high-resolution manometry (HRM) and Onigiri esophagography between April 2017 and January 2019 were examined. The EMD diagnosis was performed based on the Chicago classification version 3.0 by HRM. Onigiri esophagography was performed using a liquid medium (barium sulfate) followed by a solid medium, which consisted of an Onigiri (a Japanese rice ball) with barium powder. The extent of medium obstruction was assessed by the OL classification, which was defined in a stepwise fashion from OL0 (no obstruction) to OL4 (severe obstruction).

Results

The patients with OL0 (32.3%), OL1 (50.0%), OL2 (88.0%), OL3 (100.0%), and OL4 (100.0%) were diagnosed EMDs by HRM. The area under the curve, as determined by a receiver operating characteristic analysis, for the OL classification was 0.86. Using the cutoff value of OL1, the sensitivity and specificity were 87.3% and 61.3%, respectively, while using a cutoff value of OL2, the sensitivity and specificity were 73.2% and 90.3%, respectively.

Conclusion

In conclusion, Onigiri esophagography combined with the OL classification system can be used as a screening test for EMDs with a cutoff value of OL1.

Diagnostic yield of adding solid food swallows during high-resolution manometry in esophageal motility disorders

BACKGROUND

High-resolution manometry (HRM) is a key method to evaluate esophageal motility disorders. Current evaluation is usually performed with single water swallows (SWS) that may not challenge esophageal function or reproduce symptoms. Solid food swallows (SFS) could increase the diagnostic yield for clinically relevant disorders.

METHODS

Patients with dysphagia referred for esophageal HRM during a 2-year period in a single center were reviewed retrospectively and included if SFS was performed during HRM. Chicago classification v3.0 was used to define esophageal motility disorders.

KEY RESULTS

One hundred and four patients with dysphagia were included (59% women, mean age 57 years). Ineffective esophageal motility was the most frequent motility disorder. Compared to SWS, the diagnosis changed after SFS in 33 patients (31.7%) including a change from normal or minor diagnosis toward major motility disorders in 14 (13.4%). Fifteen subjects (14.4%) shifted from a minor disorder on SWS to normal after SFS. SFS changed the diagnosis in 53.8% of patients with previous surgery versus 29.5% of those without (p = 0.023). Pressurization during rapid drink challenge was more frequent when SFS changed the diagnosis to major motility disorders (69.2% vs. 37.3%, p = 0.033). Twenty-nine percent of patients reported symptoms during SFS, mostly those with diagnostic change to major disorders after SFS (71.4% of patients with changes to major disorders vs. 22.2% of patients without, p < 0.0001).

CONCLUSION & INFERENCES

Solid food swallows is a simple way to improve the diagnostic yield of HRM in patients with dysphagia and should be added to manometry protocol in daily clinical practice.

European Society for Neurogastroenterology and Motility (ESNM) recommendations for the use of high-resolution manometry of the esophagus

BACKGROUND

Several patients in gastroenterology practice present with esophageal symptoms, and in case of normal endoscopy with biopsies, high-resolution manometry (HRM) is often the next step. Our aim was to develop a European consensus on the clinical application of esophageal HRM, to offer the clinician guidance in selecting patients for HRM and using its results to optimize clinical outcome.

METHODS

A Delphi consensus was initiated with 38 multidisciplinary experts from 16 European countries who conducted a literature summary and voting process on 71 statements. Quality of evidence was evaluated using grading of recommendations assessment, development, and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 33 statements.

RESULTS

The process generated guidance on when to consider esophageal HRM, how to perform it, and how to generate the report. The Delphi process also identified several areas of uncertainty, such as the choice of catheters, the duration of fasting and the position in which HRM is performed, but recommended to perform at least 10 5-ml swallows in supine position for each study. Postprandial combined HRM impedance is considered useful for diagnosing rumination. There is a large lack of consensus on treatment implications of HRM findings, which is probably the single area requiring future targeted research.

CONCLUSIONS AND INFERENCES

A multinational and multidisciplinary group of European experts summarized the current state of consensus on technical aspects, indications, performance, analysis, diagnosis, and therapeutic implications of esophageal HRM.

Chicago classification version 4.0© technical review: Update on standard high-resolution manometry protocol for the assessment of esophageal motility

The Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). A key feature of CCv.4.0 is the more rigorous and expansive protocol that incorporates single wet swallows acquired in different positions (supine, upright) and provocative testing, including multiple rapid swallows and rapid drink challenge. Additionally, solid bolus swallows, solid test meal, and/or pharmacologic provocation can be used to identify clinically relevant motility disorders and other conditions (eg, rumination) that occur during and after meals. The acquisition and analysis for performing these tests and the evidence supporting their inclusion in the Chicago Classification protocol is detailed in this technical review. Provocative tests are designed to increase the diagnostic sensitivity and specificity of HRM studies for disorders of esophageal motility. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification, decrease the proportion of HRM studies that deliver inconclusive diagnoses and increase the number of patients with a clinically relevant diagnosis that can direct effective therapy. Another aim in establishing a standard manometry protocol for motility laboratories around the world is to facilitate procedural consistency, improve diagnostic reliability, and promote collaborative research.

The added value of symptom analysis during a rapid drink challenge in high-resolution esophageal manometry

INTRODUCTION

Patients with esophageal symptoms often remain with an uncertain diagnosis after high-resolution manometry.

AIM

To determine the added value of concomitant pressure and symptom analysis in response to a rapid drink challenge (RDC).

METHODS

In consecutive patients referred for esophageal manometry, a RDC consisting in free drinking of 200 ml of water as quick as possible was performed after the standard single water swallows manometry. Both pressure patterns and usual symptoms induced by the RDC were analyzed.

RESULTS

A total of 1319 patients were included, (64.7% women, mean age 58.2 years, range 11-90). There were significant differences in pressure responses between patients with obstructive disorders, major hypercontractile disorders, esophageal hypomotility disorders and normal motility. The RDC provoked usual symptoms in 388 (29.4%) patients, associated with hyperpressive and obstructive patterns in 14.0% and 16.6%, respectively. Reproduction of dysphagia and regurgitation (not pain) was significantly associated with abnormal pressure responses during the RDC (p < 0.001 and p = 0.002, respectively). The RDC elicited both abnormal pressure patterns and symptoms in 6.2%, 1.6%, and 20.8% of patients with normal motility, ineffective esophageal motility, and esophago-gastric junction outflow obstruction, respectively.

CONCLUSION

Concomitant evaluation of symptoms and pressure responses to a RDC may increase the specificity of esophageal motor testing in patients with inconclusive diagnosis or normal esophageal motility.

Solid Swallow Examination During High Resolution Manometry and EGJ-Distensibility Help Identify Esophageal Outflow Obstruction in Non-obstructive Dysphagia

Single water swallow (SWS) high-resolution manometry (HRM) may miss relevant esophageal motility disorders. Solid test meal (STM) during HRM and lately the functional lumen imaging probe (FLIP) have been shown to be of diagnostic value in the assessment of motility disorders. We aimed to assess the diagnostic yield of STM and FLIP in non-obstructive dysphagia (NOD). Patients assessed for dysphagia with both HRM and FLIP between April 2016 and August 2019 were analyzed for signs of non-obstructive EGJ outflow obstruction (EGJOO) according to Chicago Classification 3.0 (CCv3) and CC adapted for the use with solid swallows (CC-S), followed by an individual group-specific analysis. Five subjects without dysphagia served as control group. Standard HRM- and FLIP-values as well as esophagograms and Eckardt Scores were analyzed. Forty-two patients were identified (male/female, 14/36, median age 62). Twenty-five (59.5%) were diagnosed with EGJOO during STM only (= SWS-negative patients; CC-S). The EGJ distensibility index (EGJ-DI) of symptomatic patients was significantly lower compared to the control group (p = 0.006). EGJ-DI was < 3mm²/mmHg in 67% and 88% of patients diagnosed according to CC-S and CCv3, respectively. The IRP during STM showed a significant association to the corresponding EGJ-DI values (p < 0.001). Seventy-six percent of patients received treatment because of additional STM evaluation with a favorable clinical response rate of 89%. STM and FLIP identify EGJOO in symptomatic patients with normal SWS during HRM. STM resembles an inexpensive and clinically meaningful option to diagnose motility disorders and helps to select patients for interventional treatment.

Evaluation of the Esophagogastric Junction on High Resolution Manometry

The esophagogastric junction (EGJ) is a complex barrier between the thoracic and abdominal luminal gut compartments, comprised primarily of the lower esophageal sphincter (LES) and crural diaphragm. Although closed at rest, the EGJ relaxes to allow antegrade bolus transit and retrograde venting of air. Abnormal relaxation is the hallmark of achalasia spectrum disorders, while increased frequency of transient lower esophageal sphincter relaxations and/or EGJ disruption are seen in gastroesophageal reflux disease. High resolution manometry (HRM) is the modern day gold standard for assessment of EGJ morphology and function, with better performance characteristics compared with endoscopy and barium esophagography. Conventional LES metrics defining EGJ function include resting LES pressure as well as postswallow residual pressures. Newer HRM-based metrics include EGJ contractile integral, which measures static barrier function at rest, and EGJ morphology, which characterizes the relationship between LES and crural diaphragm. Provocative maneuvers assess dynamic EGJ function during physiological or pharmacologic stress. The most useful of these maneuvers, the rapid drink challenge, assesses for latent obstruction, while multiple rapid swallows evaluate adequacy of deglutitive inhibition. Amyl nitrate and cholecystokinin administration can segregate motor from structural obstruction. Newer provocative tests (straight leg raise maneuver, abdominal compression) and novel diagnostic tools (functional lumen imaging probe) complement HRM evaluation of the EGJ. Although current HRM metrics and maneuvers show promise in identifying clinically relevant EGJ abnormalities, future investigations evaluating management outcomes will improve segregation of normal from abnormal EGJ morphology and function.

The Clinical Relevance of Manometric Esophagogastric Junction Outflow Obstruction Can Be Determined Using Rapid Drink Challenge and Solid Swallows

INTRODUCTION

Esophagogastric junction outflow obstruction (EGJOO) defined on high-resolution esophageal manometry (HRM) poses a management dilemma given marked variability in clinical manifestations. We hypothesized that findings from provocative testing (rapid drink challenge and solid swallows) could determine the clinical relevance of EGJOO.

METHODS

In a retrospective cohort study, we included consecutive subjects between May 2016 and January 2020 with EGJOO. Standard HRM with 5-mL water swallows was followed by provocative testing. Barium esophagography findings were obtained. Cases with structural obstruction were separated from functional EGJOO, with the latter categorized as symptom-positive or symptom-negative. Only symptom-positive subjects were considered for achalasia-type therapies. Sensitivity and specificity for clinically relevant EGJOO during 5-mL water swallows, provocative testing, and barium were calculated.

RESULTS

Of the 121 EGJOO cases, 76% had dysphagia and 25% had holdup on barium. Ninety-seven cases (84%) were defined as functional EGJOO. Symptom-positive EGJOO subjects were more likely to demonstrate abnormal motility and pressurization patterns and to reproduce symptoms during provocative testing, but not with 5-mL water swallows. Twenty-nine (30%) functional EGJOO subjects underwent achalasia-type therapy, with symptomatic response in 26 (90%). Forty-eight (49%) functional EGJOO cases were managed conservatively, with symptom remission in 78%. Although specificity was similar, provocative testing demonstrated superior sensitivity in identifying treatment responders from spontaneously remitting EGJOO (85%) compared with both 5-mL water swallows (54%; P < 0.01) and barium esophagography (54%; P = 0.02).

DISCUSSION

Provocative testing during HRM is highly accurate in identifying clinically relevant EGJOO that benefits from therapy and should be routinely performed as part of the manometric protocol.

Normative reference values for esophageal high-resolution manometry in healthy adults: A systematic review

Establishing normative values of high-resolution esophageal manometry is necessary for accurate interpretation and comparison of measurements. In this systematic review, we aimed to summarize normal values for different esophageal high-resolution manometry systems. Moreover, we assessed the effect of body position, bolus consistency, and provocative maneuvers on these normative thresholds. We searched Medline, Embase, and the Cochrane Library from January 1st, 2006, to January 20th, 2020, for studies that reported normative data of high-resolution manometry in healthy volunteers. We assessed methodological quality of the included studies and planned a descriptive analysis. We analyzed data from 54 articles describing normative thresholds in high-resolution manometry using solid-state or water-perfused systems. Forty-six studies performed the manometry study in the supine position with liquid swallows, whereas sixteen studies described normative values in the upright position. Twelve studies assessed normative values for different bolus consistencies, and nine studies evaluated different provocative maneuvers. There is a considerable variety of normative values for esophageal high-resolution manometry depending on the equipment used and the protocols performed to obtain measurements. This should be taken into account when evaluating measurements in clinical practice and when comparing results of published research studies.

Updates on diagnostic modalities for esophageal dysphagia

Esophageal dysphagia is a common symptom in adults. Fluoroscopic contrast studies, endoscopy, and esophageal manometry have been used in the diagnosis of esophageal dysphagia for many years. The diagnostic yield has been improved with new test protocols that highlight abnormal bolus transit in the esophagus and outflow obstruction, as well as new high-definition and high-resolution technical advances in equipment. Functional luminal impedance planimetry and the addition of impedance to high-resolution esophageal manometry have also allowed the assessment of new parameters to better understand esophageal structure and function. In this concise review, we describe the role and utility of various diagnostic modalities in the assessment of patients with esophageal dysphagia.

Enhancing High-Resolution Esophageal Manometry: Use of Ancillary Techniques and Maneuvers

High-resolution manometry evaluates esophageal motor function using 10 supine water swallows. Superimposing impedance over high-resolution manometry pressure topography assesses the relationship between contraction and bolus propulsion and identifies inadequate clearance. Ancillary techniques and maneuvers augment the standard supine high-resolution manometry evaluation by challenging peristaltic function. Increasing bolus volume (rapid drink challenge) and altering bolus consistency (standardized test meal, solid swallows) enhance identification of esophageal outflow obstruction syndromes. Physiologic maneuvers (multiple rapid swallows, abdominal compression) address the ability of the esophageal smooth muscle to augment contraction vigor. Pharmacologic challenge is less commonly used clinically, and elucidates pathophysiology of esophageal motor disorders.

High-Resolution Manometry-Observations After 15 Years of Personal Use-Has Advancement Reached a Plateau?

PURPOSE OF REVIEW

In the absence of mucosal or structural disease, the aim of investigating the oesophagus is to provide clinically relevant measurements of function that can explain the cause of symptoms, identify pathology and guide effective management. One of the most notable recent advances in the field of oesophageal function has been high-resolution manometry (HRM). This review explores how innovation in HRM has progressed and has far from reached a plateau.

RECENT FINDINGS

HRM technology, methodology and utility continue to evolve; simple additions to the swallow protocol (e.g. eating and drinking), shifting position, targeting symptoms and adding impedance sensors to the HRM catheter have led to improved diagnoses, therapeutic decision-making and outcomes. Progress in HRM persists and shows little sign of abating. The next iteration of the Chicago Classification of motor disorders will highlight these advances and will also identify opportunities for further research and innovation.

The Challenges of Esaphagogastric Junction Outflow Obstruction, Is It Really a Diagnosis? Creating a Systematic Clinical Approach for EGJOO

Esophagogastric junction outflow obstruction (EGJOO) is currently diagnosed according to the Chicago Classification V3 by an elevated median integrated relaxation pressure on high resolution manometry. However, EGJOO may not be an accurate diagnosis, as it may be based on abnormal IRP from an artifact, affected by narcotics, an achalasia variant, or a mechanical cause of obstruction. This heterogenous diagnosis can often lead to unnecessary testing and treatment. The purpose of this study is to develop a stepwise clinical management protocol on how to evaluate EGJOO. Motility studies were reviewed for the last 2 years and 39 patients were diagnosed with EGJOO. Clinical information was reviewed, and patients were classified into six stepwise categories to explain an elevated IRP resulting in EGJOO diagnosis: (1) underlying catheter artifact (2) opioid use (3) achalasia variant (4) jackhammer esophagus with obstruction (5) missed esophageal lesion (ex. Schatzki ring, EOE) and (6) extrinsic compression. 40% (n = 14) of patients with elevated IRP were due to an underlying catheter artifact. 8.6% (n = 3) were due to opioid use. 8.6% (n = 3) were due to achalasia variant. 31.4% (n = 11) were due to jackhammer esophagus with obstruction. 5.7% (n = 2) were due to missed esophageal lesion. 5.7% (n = 2) were due to external compression by cardiomegaly and aortic aneurism. EGJOO is not a diagnostic end point, but a heterogenous category with multiple underlying etiologies. We believe the use of a stepwise approach to these patients can help avoid further unnecessary testing.

Recommendations of the Russian Gastroenterological Association on Clinical Use of High-Resolution Manometry in Diagnosis of Esophageal Disorders

Aim. Current recommendations of the Russian Gastroenterological Association on clinical use of high-resolution manometry in diagnosis of esophageal disorders are intended to assist in clinical decision making, terminology standardisation and interpretation of clinical data.

Key points. In 2018, a joint meeting of the Russian Gastroenterological Association and Russian Neurogastroenterology and Motility Group approved unified terminology and classification of esophageal motor function disorders for high-resolution manometry diagnosis.

Gastrointestinal patient complaints typically concern esophageal disorders such as dysphagia, regurgitation, heart-burn, chest pain or belching. To exclude erosive and ulcerative lesions, eosinophilic esophagitis and organic changes, esophagogastroduodenoscopy and biopsy are recommended in pre-treatment. Upon excluding mucosal lesions and esophageal lumen obstruction as causal for symptoms, use of high-resolution manometry is recommended. This method of esophageal examination has become the “gold standard” in diagnosis of motor disorders.

High-resolution manometry enables detailed investigation of integral quantitative and qualitative characteristics of esophagus motor function and specific related disorders, analysis of esophageal contractile propagation and strictly coordinated synchronous peristalsis of upper esophageal sphincter, esophagus and lower esophageal sphincter, which malfunction may provoke development of achalasia, esophagospasm, hiatal hernia, ineffective eso pha geal motility and other motor disorders.

Conclusion. High-resolution manometry is a relatively new method for study of esophagus motor function gaining increasingly wide application in clinical practice. It enables a medical professional to obtain evidence that may critically affect the choice of optimal patient care strategy and effective treatment. Current recommendations are based on an extensive review of up-to-date information and will be updated with new corpus of clinical data and assessment emerging in evidential medicine to provide gastroenterologists country-wide with latest scientific and practical guidelines.

Prospective serial diagnostic study: the effects of position and provocative tests on the diagnosis of oesophageal motility disorders by high-resolution manometry

BACKGROUND

Standard high-resolution manometry (HRM) protocols are based on 10 single water swallows acquired in the supine position.

AIMS

To assess the impact of position, rapid drink challenge and solid test meal on the diagnosis of oesophageal motility disorders.

METHODS

Seventy-two healthy volunteers (20-76 years) and 366 consecutive patients (18-90 years) completed HRM with 10 single water swallows in the supine and upright positions. Rapid drink challenge was performed twice, before and after the solid test meal. Diagnosis based on single water swallows in the supine position (Chicago Classification v3.0) was compared with results in the upright position and with provocative tests.

RESULTS

Overall, diagnostic agreement in the supine and upright positions was present in 296/438 (67.6%) subjects. This increased to 90.0% when ineffective oesophageal motility was considered with normal motility. Integrated relaxation pressure was 4 mm Hg higher in the supine position. There was a higher prevalence of inconsistent, likely false positive, diagnoses of outlet obstruction in the supine compared to the upright position (16/20 vs 1/4 patients, P = 0.0007). Similarly, the difference in concordance for the diagnosis of oesophago-gastric junction obstruction or achalasia between single water swallows in the supine and upright positions with solid test meal was significant (12/29 (41.4%) vs 12/14 (85.7%), P = 0.0087).

CONCLUSION

Diagnostic agreement for oesophageal motility disorders based on single water swallows in the upright and supine positions was moderate, with frequent discordant findings for ineffective motility and outlet obstruction. HRM studies can be performed in either position, using appropriate reference values. Rapid drink challenge or solid test meal can resolve diagnostic discrepancies.

British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring

These guidelines on oesophageal manometry and gastro-oesophageal reflux monitoring supersede those produced in 2006. Since 2006 there have been significant technological advances, in particular, the development of high resolution manometry (HRM) and oesophageal impedance monitoring. The guidelines were developed by a guideline development group of patients and representatives of all the relevant professional groups using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. A systematic literature search was performed and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool was used to evaluate the quality of evidence and decide on the strength of the recommendations made. Key strong recommendations are made regarding the benefit of: (i) HRM over standard manometry in the investigation of dysphagia and, in particular, in characterising achalasia, (ii) adjunctive testing with larger volumes of water or solids during HRM, (iii) oesophageal manometry prior to antireflux surgery, (iv) pH/impedance monitoring in patients with reflux symptoms not responding to high dose proton pump inhibitors and (v) pH monitoring in all patients with reflux symptoms responsive to proton pump inhibitors in whom surgery is planned, but combined pH/impedance monitoring in those not responsive to proton pump inhibitors in whom surgery is planned. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG.

Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium

BACKGROUND

Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450 mm Hg cm s) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). Ineffective esophageal motility is not consistently related to disease states or symptoms and may be seen in asymptomatic healthy individuals.

PURPOSE

A 1-day symposium of esophageal experts reviewed existing literature on IEM, and this review represents the conclusions from the symposium. Severe IEM (>70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.

The differences in the esophageal motility between liquid and solid bolus swallows: A multicenter high-resolution manometry study in Chinese asymptomatic volunteers

BACKGROUND

The results of the esophageal body motility differences between liquid and solid swallows from high-resolution manometry (HRM) studies are not consistent. The information of the frequency of ineffective liquid and solid bolus swallows in healthy individuals during HRM procedure is limited. The normative values of the HRM parameters of both liquid and solid swallows for Chinese population are lacking.

METHODS

The esophageal HRM data of 101 healthy volunteers from multicenters in China were analyzed. The values of the HRM parameters were summarized and compared between liquid and solid swallows. The frequencies of ineffective liquid and solid swallows were summarized.

RESULTS

Esophagus contracted stronger and slower in solid bolus swallows than water swallows with HREM. Ineffective water swallow (DCI < 450 mm Hg.s.cm) and ineffective bread swallow (DCI < 800 mm Hg.s.cm) were frequently seen in asymptomatic individuals. The adding of bread swallows to the HREM procedure might cause diagnostic change in about 15.8% (16/101) of the asymptomatic individuals.

CONCLUSIONS

The vigor and velocity of the esophageal peristalsis between liquid and solid bolus swallows are different. Ineffective water and solid bolus swallows are not rare. Adding solid bolus swallows brings diagnostic change, and it may be needed routinely for the HRM procedure.

Achalasia diagnosed despite normal integrated relaxation pressure responds favorably to therapy

BACKGROUND

Achalasia diagnosis requires elevated integrated relaxation pressure (IRP; manometric marker of lower esophageal sphincter [LES] relaxation). Yet, some patients exhibit clinical features of achalasia despite normal IRP and have LES dysfunction demonstrable by other means. We hypothesized these patients to exhibit equivalent therapeutic response compared to standard achalasia patients.

METHODS

Symptomatic achalasia-like cases, despite normal IRP, displayed evidence of impaired LES relaxation using rapid drink challenge (RDC), solid swallows during high-resolution manometry, and/or barium esophagogram; were treated with achalasia therapies and compared to standard achalasia patients with raised IRP. Outcomes included equivalence for short- and long-term symptom response and stasis on barium esophagogram.

KEY RESULTS

Twenty-nine normal IRP achalasia cases (14 males, median age 50 year, median Eckardt 6, barium stasis 12 ± 7 cm) and 29 consecutive standard achalasia controls underwent therapy. Among cases, LES dysfunction was most often identified by RDC and/or barium esophagogram. Short-term symptomatic success was equivalent in cases vs controls (90% vs 93%; 95% CI for difference: -19% to 13%). Median short-term (1 vs 1; 95% CI for difference: 0-1) and long-term Eckardt scores (2 vs 1; 95% CI for difference: 0-2) were similar in cases and controls, respectively. Adequate clearance was observed in 67% of cases vs 81% of controls on post-therapy esophagogram.

CONCLUSIONS AND INFERENCES

We described a subset of achalasia patients with normal IRP, but impaired LES relaxation identifiable only on additional provocative tests. These patients benefited from treatment, suggesting that such tests should be performed to increase the number of clinically relevant diagnoses.

Evaluation of Esophageal Contraction Reserve Using HRM in Symptomatic Esophageal Disease

Esophageal high resolution manometry (HRM) is the gold standard for assessment of esophageal motor disorders, but motor responses to the standard 5 mL water swallow protocol may not provide precision in defining minor motor disorders. Provocative maneuvers, particularly multiple rapid swallows (MRS), have been used to assess deglutitive inhibition during the repetitive swallows, and the contractile response following the final swallow of the sequence. The augmentation of esophageal smooth muscle contraction following MRS is termed contraction reserve. This is determined as the ratio between esophageal body contraction vigor (distal contractile integral, DCI) following MRS to the mean DCI after single swallows, which is ≥1 in the presence of contraction reserve. Reliable assessment of contraction reserve requires the performance of 3 MRS maneuvers during HRM. Absence of contraction reserve is associated with a higher likelihood of late postfundoplication dysphagia and may correlate with higher esophageal reflux burden on ambulatory reflux monitoring. Esophageal motor responses to abdominal compression, functional lumen imaging probe (FLIP) balloon distension, and pharmacologic testing (using edrophonium and cisapride) may correlate with contraction reserve. Other provocative tests useful during HRM include rapid drink challenge, solid and viscous swallows, and standardized test meals, which are more useful in evaluation of esophageal outflow obstruction and dysphagia syndromes than in identification of contraction reserve. Provocative maneuvers have been recommended as part of routine HRM protocols, and while useful clinical information can be gleaned from these maneuvers, further research is necessary to determine the precise role of provocative testing in clinical esophagology.

High-resolution Manometry Findings During Solid Swallows Correlate With Delayed Reflux Clearance and Acid Exposure Time in Non-erosive Reflux Disease Patients

Background/Aims

The role of esophageal motility in determining gastroesophageal reflux disease (GERD) severity has not been completely evaluated. A few studies have investigated high-resolution manometry (HRM) patterns during solid swallows. The present study evaluates the HRM patterns of non-erosive reflux disease (NERD) patients during both liquid and solid swallows and their correlation with the severity of GERD.

Methods

In 23 NERD patients and 15 healthy volunteers (HVs) HRM was performed during a standard solid meal in a seated position, followed by 24-hour impedance-pH monitoring.

Results

Of the 31 patients, 10 showed a pathological acid exposure time (AET; NERD patients), 13 a normal pH profile with positive symptom association probability (SAP; reflux hypersensitivity patients), and 8 normal AET and SAP (functional heartburn patients). Mean distal contractile integral and distal latency values, in all patient groups and HVs, were significantly higher during solid swallows. In the group of 10 NERD patients, the number of large breaks of the esophageal peristalsis was 16 out of 100 liquid swallows (16%) and 31 out of 171 solid swallows (18%). Fourteen out of 100 liquid swallows (14%) and 25 out of 171 solid swallows (15%) resulted ineffective. Mean reflux clearing time at multichannel intraluminal impedance-pH was 17.6 ± 3.7 seconds. NERD patients presented, during solid swallows, a significantly higher proportion of large peristaltic breaks and of ineffective swallows than reflux hypersensitivity and functional heartburn patients.

Conclusion

HRM during solid swallows reveals motor abnormalities, undetected during liquid swallows, which might be involved in delaying reflux and acid clearance in patients with GERD.

Abnormal esophageal motility during a solid test meal in systemic sclerosis-detection even in very early disease and association with disease progression

OBJECTIVE

This study assessed whether high-resolution manometry (HRM) with a test meal can detect clinically relevant, abnormal motility already in very early systemic sclerosis (SSc) and whether this finding is associated with subsequent disease progression.

METHODS

This prospective, longitudinal cohort study recruited 68 consecutive SSc patients (group #1: 32 established disease (ACR, American College of Rheumatology /EULAR, The European League against Rheumatism 2013 and ACR 1980 criteria fulfilled); group #2: 24 early disease (only ACR/EULAR 2013 fulfilled); group #3: 12 very early disease (clinical expert diagnosis of SSc) and 72 healthy controls. HRM evaluated esophageal motility for water swallows and a solid test meal.

RESULTS

Systemic sclerosis patients had less frequent effective esophageal contractions during the test meal compared to healthy controls even in very early disease (0.15, 1.0, 2.1 per minute for groups #1, #2, and #3, vs 2.5 per minute in health; P < 0.001, P < 0.001, and P < 0.0085, respectively). Ineffective motility at HRM was associated with a higher modified Rodnan skin score at baseline. Moreover, at mean 18 (10-31) months of follow-up, the presence of ineffective motility at baseline was associated with progression of skin disease (P = 0.01). Cox proportional hazard regression analysis identified hypotensive peristalsis in the test meal (<15% effective solid swallows) and low distal contractile integral (DCI; <400 mm Hg·cm·s) as predictors for skin aggravation, but not for new organ involvement.

CONCLUSION

Ineffective motility during a test meal is present already in patients with very early SSc. Findings on HRM studies are associated with disease severity at baseline, and low percentage of effective swallows in test meal and low mean DCI are both predictors of skin progression during follow-up.

The role of oesophageal physiological testing in the assessment of noncardiac chest pain

Oesophageal physiology testing plays an important role in the diagnosis of noncardiac chest pain (NCCP) after cardiac, structural and mucosal abnormalities have been ruled out. Endoscopy can establish the presence of structural causes of chest pain such as cancer, oesophageal webs and diverticula. Even if macroscopically normal, eosinophilic oesophagitis is a common cause of chest pain and needs to be ruled out with an adequate biopsy regimen. In the remaining cases, diagnosis is focused on the identification of often subtle mechanisms that lead to NCCP. The most common oesophageal aetiologies for NCCP are gastro-oesophageal reflux disease (GORD), oesophageal dysmotility and functional chest pain. Ambulatory pH studies (with or without impedance or wireless measurements) can establish the presence of GORD, nonerosive reflux as well any association with symptoms of chest pain. High-resolution manometry, particularly with the inclusion of adjunctive testing, can rule out major motility disorders such as spasm, hypercontraction or achalasia. The EndoFLIP device can help define disorders with reduced distensibility, not easily appreciated with endoscopy or manometry. When all tests remain negative, a diagnosis of oesophageal hypersensitivity is normally made and therapy is shifted from targeting a disease to treating symptoms and patient affect.

Clinical measurement of gastrointestinal motility and function: who, when and which test?

Symptoms related to abnormal gastrointestinal motility and function are common. Oropharyngeal and oesophageal dysphagia, heartburn, bloating, abdominal pain and alterations in bowel habits are among the most frequent reasons for seeking medical attention from internists or general practitioners and are also common reasons for referral to gastroenterologists and colorectal surgeons. However, the nonspecific nature of gastrointestinal symptoms, the absence of a definitive diagnosis on routine investigations (such as endoscopy, radiology or blood tests) and the lack of specific treatments make disease management challenging. Advances in technology have driven progress in the understanding of many of these conditions. This Review serves as an introduction to a series of Consensus Statements on the clinical measurements of gastrointestinal motility, function and sensitivity. A structured, evidence-based approach to the initial assessment and empirical treatment of patients presenting with gastrointestinal symptoms is discussed, followed by an outline of the contribution of modern physiological measurement on the management of patients in whom the cause of symptoms has not been identified with other tests. Discussions include the indications for and utility of high-resolution manometry, ambulatory pH-impedance monitoring, gastric emptying studies, breath tests and investigations of anorectal structure and function in day-to-day practice and clinical management.

Modern diagnosis of GERD: the Lyon Consensus

Clinical history, questionnaire data and response to antisecretory therapy are insufficient to make a conclusive diagnosis of GERD in isolation, but are of value in determining need for further investigation. Conclusive evidence for reflux on oesophageal testing include advanced grade erosive oesophagitis (LA grades C and D), long-segment Barrett's mucosa or peptic strictures on endoscopy or distal oesophageal acid exposure time (AET) >6% on ambulatory pH or pH-impedance monitoring. A normal endoscopy does not exclude GERD, but provides supportive evidence refuting GERD in conjunction with distal AET <4% and <40 reflux episodes on pH-impedance monitoring off proton pump inhibitors. Reflux-symptom association on ambulatory reflux monitoring provides supportive evidence for reflux triggered symptoms, and may predict a better treatment outcome when present. When endoscopy and pH or pH-impedance monitoring are inconclusive, adjunctive evidence from biopsy findings (histopathology scores, dilated intercellular spaces), motor evaluation (hypotensive lower oesophageal sphincter, hiatus hernia and oesophageal body hypomotility on high-resolution manometry) and novel impedance metrics (baseline impedance, postreflux swallow-induced peristaltic wave index) can add confidence for a GERD diagnosis; however, diagnosis cannot be based on these findings alone. An assessment of anatomy, motor function, reflux burden and symptomatic phenotype will therefore help direct management. Future GERD management strategies should focus on defining individual patient phenotypes based on the level of refluxate exposure, mechanism of reflux, efficacy of clearance, underlying anatomy of the oesophagogastric junction and psychometrics defining symptomatic presentations.

Esophageal provocation tests: Are they useful to improve diagnostic yield of high resolution manometry?

High resolution manometry (HRM) is the gold standard to diagnose esophageal motility disorders but has some limitations. The inclusion of provocative tests might enhance the diagnostic yield of HRM. These tests are easy to perform and to add to the regular manometry protocol. Multiple rapid swallows (MRS; 5 2-mL swallows) is useful to assess the contractile reserve and deglutitive inhibition. The optimal number of MRS to perform might be 3 as suggested by Mauro et al. in this issue of Neurogastroenterology & Motility. The absence of contractile reserve might be associated with gastro-esophageal reflux disease and with an increased risk of post fundoplication dysphagia. Single viscous and solid swallows might enhance the detection of esophageal motility disorders but are not significantly associated with symptom occurrence. Test meal has the advantage to represent a real-life scenario and is promising to depict significant motility findings responsible for esophageal symptoms. Post-prandial recording might also be of interest to diagnose rumination and belching disorders. The best indication of rapid drink challenge test (free drinking of 200 mL) is currently the diagnosis of esophago-gastric junction obstruction. Finally, abdominal compression might be an option to evaluate response of esophageal peristalsis in a context of outflow resistance as proposed by Brink et al. in this issue. These provocative maneuvers appear to provide a complementary role in the evaluation of esophageal motility but require prospective studies to determine the validity of the findings and whether they will lead to changes in clinical practice.

Impaired motility in Barrett's esophagus: A study using high-resolution manometry with physiologic challenge

BACKGROUND

Esophageal dysmotility may predispose to Barrett's esophagus (BE). We hypothesized that high-resolution manometry (HRM) performed with additional physiologic challenge would better delineate dysmotility in BE.

METHODS

Included patients had typical reflux symptoms and underwent endoscopy, HRM with single water swallows and adjunctive testing with solids and rapid drink challenge (RDC) before ambulatory pH-impedance monitoring. BE and endoscopy-negative reflux disease (ENRD) subjects were compared against functional heartburn patient-controls (FHC). Primary outcome was incidence of HRM contractile abnormalities with standard and adjunctive swallows. Secondary outcomes included clearance measures and symptom association on pH-impedance.

KEY RESULTS

Seventy-eight patients (BE 25, ENRD 27, FHC 26) were included. Water swallow contractility was reduced in both BE (median DCI 87 mm Hg/cm/s) and ENRD (442 mm Hg/cm/s) compared to FHC (602 mm Hg/cm/s; P < .001 and .04, respectively). With the challenge of solid swallows and RDC, these parameters improved in ENRD (solids = 1732 mm Hg/cm/s), becoming similar to FHC (1242 mm Hg/cm/s; P = .93), whereas abnormalities persisted in BE (818 mm Hg/cm/s; P < .01 c.f. FHC). In BE and ENRD, reflux events (67 vs 57 events/24 hour) and symptom frequency were similar; yet symptom correlation was significantly better in ENRD compared to BE, which was comparable to FHC (symptom index 30% vs 4% vs 0%, respectively). Furthermore, bolus clearance and exposure times were more pronounced in BE (P < .01).

CONCLUSIONS & INFERENCES

Reduced contractile effectiveness persisted in BE with the more representative esophageal challenge of swallowing solids and free drinking; while in ENRD and FHC peristalsis usually improved, demonstrating peristaltic reserve. Furthermore, symptom association and refluxate clearance were reduced in BE. These factors may underlie BE pathogenesis.

An ANMS-NASPGHAN consensus document on esophageal and antroduodenal manometry in children

BACKGROUND

Upper gastrointestinal symptoms in children are common and motility disorders are considered in the differential diagnosis. High resolution esophageal manometry (HRM) has revolutionized the study of esophageal physiology, and the addition of impedance has provided new insights into esophageal function. Antroduodenal motility has provided insight into gastric and small bowel function.

PURPOSE

This review highlights some of the recent advances in pediatric esophageal and antroduodenal motility testing including indications, preparation, performance, and interpretation of the tests. This update is the second part of a two part series on manometry studies in children (first part was on anorectal and colonic manometry [Neurogastroenterol Motil. 2016;29:e12944]), and has been endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the American Neurogastroenterology and Motility Society (ANMS).

Classification of esophageal motor findings in gastro-esophageal reflux disease: Conclusions from an international consensus group

BACKGROUND

High-resolution manometry (HRM) has resulted in new revelations regarding the pathophysiology of gastro-esophageal reflux disease (GERD). The impact of new HRM motor paradigms on reflux burden needs further definition, leading to a modern approach to motor testing in GERD.

METHODS

Focused literature searches were conducted, evaluating pathophysiology of GERD with emphasis on HRM. The results were discussed with an international group of experts to develop a consensus on the role of HRM in GERD. A proposed classification system for esophageal motor abnormalities associated with GERD was generated.

KEY RESULTS

Physiologic gastro-esophageal reflux is inherent in all humans, resulting from transient lower esophageal sphincter (LES) relaxations that allow venting of gastric air in the form of a belch. In pathological gastro-esophageal reflux, transient LES relaxations are accompanied by reflux of gastric contents. Structural disruption of the esophagogastric junction (EGJ) barrier, and incomplete clearance of the refluxate can contribute to abnormally high esophageal reflux burden that defines GERD. Esophageal HRM localizes the LES for pH and pH-impedance probe placement, and assesses esophageal body peristaltic performance prior to invasive antireflux therapies and antireflux surgery. Furthermore, HRM can assess EGJ and esophageal body mechanisms contributing to reflux, and exclude conditions that mimic GERD.

CONCLUSIONS & INFERENCES

Structural and motor EGJ and esophageal processes contribute to the pathophysiology of GERD. A classification scheme is proposed incorporating EGJ and esophageal motor findings, and contraction reserve on provocative tests during HRM.

Expert consensus document: Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

High-resolution manometry (HRM) and new analysis algorithms, summarized in the Chicago Classification, have led to a restructured classification of oesophageal motility disorders. This advance has led to increased detection of clinically relevant disorders, in particular achalasia. It has become apparent that the cardinal feature of achalasia - impaired lower oesophageal sphincter (LES) relaxation - can occur in several disease phenotypes: without peristalsis (type I), with pan-oesophageal pressurization (type II), with premature (spastic) distal oesophageal contractions (type III), or with preserved peristalsis (outlet obstruction). Furthermore, no manometric pattern is perfectly sensitive or specific for achalasia caused by a myenteric plexopathy, and there is no biomarker for this pathology. Consequently, physiological testing reveals other syndromes not meeting achalasia criteria that also benefit from therapies formerly reserved for achalasia. These findings have become particularly relevant with the development of a minimally invasive technique for performing a long oesophageal myotomy, the per-oral endoscopic myotomy (POEM). Optimal management is to render treatment in a phenotype-specific manner; that is, POEM calibrated to patient-specific physiology for spastic achalasia and the spastic disorders, and more conservative strategies such as pneumatic dilation for the disorders limited to the LES. This Consensus Statement examines the effect of HRM on our understanding of oesophageal motility disorders, with a focus on the diagnosis, epidemiology and management of achalasia and achalasia-like syndromes.

Diagnostic yield of high-resolution manometry with a solid test meal for clinically relevant, symptomatic oesophageal motility disorders: serial diagnostic study

BACKGROUND

The use of high-resolution manometry (HRM) to diagnose oesophageal motility disorders is based on ten single water swallows (SWS); however, this approach might not be representative of oesophageal function during the ingestion of normal food. We tested whether inclusion of a standardised solid test meal (STM) to HRM studies increases test sensitivity for major motility disorders. Additionally, we assessed the frequency and cause of patient symptoms during STM.

METHODS

Consecutive patients who were referred for investigation of oesophageal symptoms were recruited at Nottingham University Hospitals (Nottingham, UK) in the development study and at University Hospital Zürich (Zürich, Switzerland) in the validation study. HRM was done in the upright, seated position with a solid-state assembly. During HRM, patients ingested ten SWS, followed by a standardised 200 g STM. Diagnosis of oesophageal motility disorders was based on the Chicago Classification validated for SWS (CCv3) and with STM (CC-S), respectively. These studies are registered with ClinicalTrials.gov, numbers NCT02407938 and NCT02397616.

FINDINGS

The development cohort included 750 patients of whom 360 (48%) had dysphagia and 390 (52%) had reflux or other symptoms. The validation cohort consisted of 221 patients, including 98 (44%) with dysphagia and 123 (56%) with reflux symptoms. More patients were diagnosed with a major motility disorder by use of an STM than with SWS in the development set (321 [43%] patients diagnosed via STM vs 163 [22%] via SWS; p<0·0001) and validation set (73 [33%] vs 49 [22%]; p=0·014). The increase was most evident in patients with dysphagia (241 [67%] of 360 patients on STM vs 125 [35%] patients on SWS in the development set, p<0·0001), but was also present in those referred with reflux symptoms (64 [19%] of 329 patients vs 32 [10%] patients in the development set, p=0·00060). Reproduction of symptoms was reported by nine (1%) of 750 patients during SWS and 461 (61%) during STM (p<0·0001). 265 (83%) of 321 patients with major motility disorders and 107 (70%) of 152 patients with minor motility disorders reported symptoms during the STM (p=0·0038), compared with 89 (32%) of 277 patients with normal motility as defined with CC-S (p<0·0001).

INTERPRETATION

The diagnostic sensitivity of HRM for major motility disorders is increased with use of the STM compared with SWS, especially in patients with dysphagia. Observations made during STM can establish motility disorders as the cause of oesophageal symptoms.

FUNDING

None.