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Edeani F, Massey B. Esophageal motility disorder - has Chicago classification v4.0 simplified our management? Curr Opin Otolaryngol Head Neck Surg 2023; 31:374-381. [PMID: 37820073 DOI: 10.1097/moo.0000000000000936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
REVIEW PURPOSE Addressing dysphagia is vital due to its prevalence and impact on healthcare expenditure. While high resolution manometry (HRM) effectively evaluates esophageal dysphagia, its role in oropharyngeal dysphagia and upper esophageal sphincter (UES) dysfunction remains debated. The fourth iteration of the Chicago classification (CC) offers an algorithmic approach for diagnosing abnormal motor patterns via HRM. This review assesses the CC's impact on dysphagia management. RECENT INSIGHTS The Chicago classification version 4.0 emphasizes auxiliary and provocative techniques when the algorithm falls short of a conclusive diagnosis. It introduces stricter criteria for previously ambiguous conditions like ineffective motility and esophagogastric junction outflow obstruction. This version also introduces the concept of conclusive and inconclusive classifications based on symptoms, provocation maneuvers, and supportive testing minimizing ambiguity. SUMMARY The Chicago classification v4.0 remains a useful tool for the diagnosis of well characterized esophageal motility disorders. However, major limitations include reliance on HRM and a focus on distal esophagus contractile characteristics without considering proximal esophagus or upper esophageal sphincter, both of which can sometimes be the only evident abnormality in patients with dysphagia. Despite efforts to reduce ambiguity, diagnostic challenges persist. These limitations can be addressed in future updates.
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Affiliation(s)
- Francis Edeani
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Wisconsin, USA
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2
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Choi SI. [Chicago Classification ver. 4.0: Diagnosis of Peristaltic Disorder]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 79:66-71. [PMID: 35232921 DOI: 10.4166/kjg.2022.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 01/28/2022] [Accepted: 01/31/2022] [Indexed: 11/03/2022]
Abstract
The Chicago Classification is being revised continuously for the accurate diagnosis of esophageal peristaltic disorders in which the etiology is unclear, and the disease behavior is heterogeneous. The ver. 4.0 was recently updated. A representative change in the diagnosis of esophageal peristaltic disorders of the ver. 4.0 showed that the distinction between major and minor disorders was eliminated and was divided into the following four diagnoses: absent contractility, distal esophageal spasm (DES), hypercontractile esophagus (HE), and ineffective esophageal motility. Compared to the ver. 3.0, it recommended a more detailed protocol of high-resolution esophageal manometry and methods of interpreting manometric. In addition, it emphasized the clinically relevant symptoms in diagnosing DES and HE, and presented provocative tests (e.g., multiple rapid swallow and rapid drinking challenge), as well as additional testing, including impedance, timed barium esophagogram and functional lumen imaging probe, which may provide more standardized and rigorous criteria for peristaltic patterns and to minimize the ambiguity in diagnosis. Although it will take time and effort to apply this revised Chicago Classification in clinical practice, it may help diagnose and manage patients with esophageal peristalsis disorder in the future.
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Affiliation(s)
- Soo In Choi
- Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Madigan KE, Smith JS, Evans JK, Clayton SB. Elevated average maximum intrabolus pressure on high-resolution manometry is associated with esophageal dysmotility and delayed esophageal emptying on timed barium esophagram. BMC Gastroenterol 2022; 22:74. [PMID: 35189822 PMCID: PMC8859877 DOI: 10.1186/s12876-022-02165-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intrabolus pressure (IBP) recorded by high-resolution manometry (HRM) portrays the compartmentalized force on a bolus during esophageal peristalsis. HRM may be a reliable screening tool for esophageal dysmotility in patients with elevated average maximum IBP (AM-IBP). Timed barium esophagram (TBE) is a validated measure of esophageal emptying disorders, such as esophagogastric junction outflow obstruction and achalasia. This study aimed to determine if an elevated AM-IBP correlates with esophageal dysmotility on HRM and/or delayed esophageal emptying on TBE. METHODS A retrospective analysis of all HRM (unweighted sample n = 155) performed at a tertiary referral center from 09/2015-03/2017 yielded a case group (n = 114) with abnormal AM-IBP and a control group (n = 41) with a normal AM-IBP (pressure < 17 mmHg) as consistent with Chicago Classification 3. All patients received a standardized TBE, with abnormalities classified as greater than 1 cm of retained residual liquid barium in the esophagus at 1 and 5 min or as tablet retention after 5 min. RESULTS AM-IBP was significantly related to liquid barium retention (p = 0.003) and tablet arrest on timed barium esophagram (p = 0.011). A logistic regression model correctly predicted tablet arrest in 63% of cases. Tablet arrest on AM-IBP correlated with an optimal prediction point at 20.1 mmHg on HRM. Patients with elevated AM-IBP were more likely to have underlying esophageal dysmotility (95.6% vs. 70.7% respectively; p < 0.001), particularly esophagogastric junction outflow obstruction disorders. Elevated AM-IBP was associated with incomplete liquid bolus transit on impedance analysis (p = 0.002). CONCLUSIONS Our findings demonstrate that an elevated AM-IBP is associated with abnormal TBE findings of esophageal tablet retention and/or bolus stasis. An abnormal AM-IBP (greater than 20.1 mm Hg) was associated with a higher probability of retaining liquid bolus or barium tablet arrest on TBE and esophageal dysmotility on HRM. This finding supports the recent incorporation of IBP in Chicago Classification v4.0.
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Affiliation(s)
- Katelyn E Madigan
- Department of Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - J Shawn Smith
- Department of Medicine, Prisma Health, Greenville School of Medicine, Greenville, USA
| | - Joni K Evans
- Department of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, USA
| | - Steven B Clayton
- Department of Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
- Department of Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston-Salem, USA
- Department of Medicine, Section on Gastroenterology, Greenville School of Medicine, Greenville, USA
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Roman S, Hebbard G, Jung KW, Katz P, Tutuian R, Wong R, Wu J, Yadlapati R, Sifrim D. Chicago Classification Update (v4.0): Technical review on diagnostic criteria for distal esophageal spasm. Neurogastroenterol Motil 2021; 33:e14119. [PMID: 33666299 DOI: 10.1111/nmo.14119] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/09/2021] [Accepted: 02/14/2021] [Indexed: 01/18/2023]
Abstract
Distal esophageal spasm (DES) is defined as a manometric pattern of at least 20% of premature contractions in a context of normal esophago-gastric junction relaxation in a patient with dysphagia or non-cardiac chest pain. The definition of premature contraction requires the measurement of the distal latency and identification of the contractile deceleration point (CDP). The CDP can be difficult to localize, and alternative methods are proposed. Further, it is important to differentiate contractile activity and intrabolus pressure. Multiple rapid swallows are a useful adjunctive test to perform during high-resolution manometry to search for a lack of inhibition that is encountered in DES. The clinical relevance of the DES-manometric pattern was raised as it can be secondary to treatment with opioids or observed in patients referred for esophageal manometry before antireflux surgery in absence of dysphagia and non-cardiac chest pain. Further idiopathic DES is rare, and one can argue that when encountered, it could be part of type III achalasia spectrum. Medical treatment of DES can be challenging. Recently, endoscopic treatments with botulinum toxin and peroral endoscopic myotomy have been evaluated, with conflicting results while rigorously controlled studies are lacking. Future research is required to determine the role of contractile vigor and lower esophageal sphincter hypercontractility in the occurrence of symptoms in patients with DES. The role of impedance-combined high-resolution manometry also needs to be evaluated.
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Affiliation(s)
- Sabine Roman
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon and Lyon I University, Lyon, France
| | - Geoff Hebbard
- Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Phil Katz
- Weill Cornell Medicine, New York, NY, USA
| | - Radu Tutuian
- Clinic for Gastroenterology and Hepatology, Bürgerspital Solothurn, Solothurn, Switzerland.,University of Berne, Berne, Switzerland
| | - Reuben Wong
- Yong Loo Lin of Medicine, National University of Singapore, Singapore, Singapore
| | - Justin Wu
- The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Rena Yadlapati
- Division of Gastroenterology, Center for Esophageal Diseases, University of California San Diego, La Jolla, CA, USA
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
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Nikaki K, Sawada A, Ustaoglu A, Sifrim D. Neuronal Control of Esophageal Peristalsis and Its Role in Esophageal Disease. Curr Gastroenterol Rep 2019; 21:59. [PMID: 31760496 DOI: 10.1007/s11894-019-0728-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Esophageal peristalsis is a highly sophisticated function that involves the coordinated contraction and relaxation of striated and smooth muscles in a cephalocaudal fashion, under the control of central and peripheral neuronal mechanisms and a number of neurotransmitters. Esophageal peristalsis is determined by the balance of the intrinsic excitatory cholinergic, inhibitory nitrergic and post-inhibitory rebound excitatory output to the esophageal musculature. RECENT FINDINGS Dissociation of the longitudinal and circular muscle contractions characterizes different major esophageal disorders and leads to esophageal symptoms. Provocative testing during esophageal high-resolution manometry is commonly employed to assess esophageal body peristaltic reserve and underpin clinical diagnosis. Herein, we summarize the main factors that determine esophageal peristalsis and examine their role in major and minor esophageal motility disorders and eosinophilic esophagitis.
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Affiliation(s)
- K Nikaki
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK
| | - A Sawada
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK
| | - A Ustaoglu
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK
| | - D Sifrim
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK.
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Abstract
Prevalence, clinical manifestations and of modern classifications of achalasia are reviewed in the article. Diagnosis and treatment of this pathology were analyzed by using of 58 references.
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Affiliation(s)
- A M Gasanov
- Sklifosovsky Research Institute for Emergency Medicine of Moscow Healthcare Department, Moscow, Russia
| | - N A Aliev
- Sklifosovsky Research Institute for Emergency Medicine of Moscow Healthcare Department, Moscow, Russia
| | - Sh N Danielyan
- Sklifosovsky Research Institute for Emergency Medicine of Moscow Healthcare Department, Moscow, Russia
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Khalaf M, Chowdhary S, Elias PS, Castell D. Distal Esophageal Spasm: A Review. Am J Med 2018; 131:1034-1040. [PMID: 29605413 DOI: 10.1016/j.amjmed.2018.02.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/23/2018] [Accepted: 02/24/2018] [Indexed: 12/28/2022]
Abstract
Distal esophageal spasm is a rare motility disorder presenting principally with nonobstructive dysphagia and noncardiac chest pain. In symptomatic patients, the manometric diagnosis is made when >10% of the wet swallows have simultaneous and/or premature contractions intermixed with normal peristalsis. We characterize manometry and barium as complementary diagnostic approaches, and given the intermittent nature of the disorder, one should be always aware that it is almost impossible to rule out spasm. Treatment is difficult; we propose an approach beginning with the least invasive intervention.
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Affiliation(s)
- Mohamed Khalaf
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston.
| | | | - Puja Sukhwani Elias
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston
| | - Donald Castell
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston
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Kim JH, Kim SE, Cho YK, Lim CH, Park MI, Hwang JW, Jang JS, Oh M. Factors Determining the Inter-observer Variability and Diagnostic Accuracy of High-resolution Manometry for Esophageal Motility Disorders. J Neurogastroenterol Motil 2018; 24:58-69. [PMID: 29291608 PMCID: PMC5753904 DOI: 10.5056/jnm17064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 09/14/2017] [Accepted: 10/13/2017] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Although high-resolution manometry (HRM) has the advantage of visual intuitiveness, its diagnostic validity remains under debate. The aim of this study was to evaluate the diagnostic accuracy of HRM for esophageal motility disorders. Methods Six staff members and 8 trainees were recruited for the study. In total, 40 patients enrolled in manometry studies at 3 institutes were selected. Captured images of 10 representative swallows and a single swallow in analyzing mode in both high-resolution pressure topography (HRPT) and conventional line tracing formats were provided with calculated metrics. Results Assessments of esophageal motility disorders showed fair agreement for HRPT and moderate agreement for conventional line tracing (κ = 0.40 and 0.58, respectively). With the HRPT format, the κ value was higher in category A (esophagogastric junction [EGJ] relaxation abnormality) than in categories B (major body peristalsis abnormalities with intact EGJ relaxation) and C (minor body peristalsis abnormalities or normal body peristalsis with intact EGJ relaxation). The overall exact diagnostic accuracy for the HRPT format was 58.8% and rater’s position was an independent factor for exact diagnostic accuracy. The diagnostic accuracy for major disorders was 63.4% with the HRPT format. The frequency of major discrepancies was higher for category B disorders than for category A disorders (38.4% vs 15.4%; P < 0.001). Conclusions The interpreter’s experience significantly affected the exact diagnostic accuracy of HRM for esophageal motility disorders. The diagnostic accuracy for major disorders was higher for achalasia than distal esophageal spasm and jackhammer esophagus.
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Affiliation(s)
- Ji Hyun Kim
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Yu Kyung Cho
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul-Hyun Lim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jin Won Hwang
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jae-Sik Jang
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Minkyung Oh
- Clinical Trial Center, Inje University College of Medicine, Busan, Korea
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Abstract
PURPOSE OF REVIEW High-resolution manometry (HRM) is increasingly performed worldwide, to study esophageal motility. The Chicago classification is subsequently applied to interpret the manometric findings and facilitate a diagnosis of esophageal motility disorders. This review will discuss new insights regarding the diagnosis and management using the Chicago classification. RECENT FINDINGS Recent studies have demonstrated that high-resolution manometry is superior to conventional manometry, and has a higher sensitivity to diagnose achalasia. Furthermore, the subclassification of achalasia as used in the Chicago classification has prognostic value and can be used to direct treatment. Diagnosis of esophageal spasm has been improved by using the distal latency as diagnostic criterion. Recently, criteria for minor disorders of peristalsis have been sharpened, leading to a lower rate of patients with abnormal results, thereby increasing the relevance of a diagnosis. High-resolution manometry is now considered the gold standard for diagnosis of esophageal motility disorders. The Chicago classification provides a standardized approach for analysis and categorization of abnormalities that has led to a significant increase in our knowledge regarding the diagnosis and management of motility disorders. Further refinement of the classification will be required.
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10
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Patel A, Cassell B, Sainani N, Wang D, Shahid B, Bennett M, Mirza FA, Munigala S, Gyawali CP. Comparison of motor diagnoses by Chicago Classification versions 2.0 and 3.0 on esophageal high-resolution manometry. Neurogastroenterol Motil 2017; 29:10.1111/nmo.13042. [PMID: 28229560 PMCID: PMC5466481 DOI: 10.1111/nmo.13042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/08/2017] [Accepted: 01/09/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND The Chicago Classification (CC) uses high-resolution manometry (HRM) software tools to designate esophageal motor diagnoses. We evaluated changes in diagnostic designations between two CC versions, and determined motor patterns not identified by either version. METHODS In this observational cohort study of consecutive patients undergoing esophageal HRM over a 6-year period, proportions meeting CC 2.0 and 3.0 criteria were segregated into esophageal outflow obstruction, hypermotility, and hypomotility disorders. Contraction wave abnormalities (CWA), and 'normal' cohorts were recorded. Symptom burden was characterized using dominant symptom intensity and global symptom severity. Motor diagnoses, presenting symptoms, and symptom burden were compared between CC 2.0 and 3.0, and in cohorts not meeting CC diagnoses. KEY RESULTS Of 2569 eligible studies, 49.9% met CC 2.0 criteria, but only 40.3% met CC 3.0 criteria (P<.0001). Between CC 2.0 and 3.0, 82.8% of diagnoses were concordant. Discordance resulted from decreasing proportions of hypermotility (4.4%) and hypomotility (9.0%) disorders, and increase in 'normal' designations (13.0%); esophageal outflow obstruction showed the least variation between CC versions. Symptom burden was higher with CC 3.0 diagnoses (P≤.005) but not with CC 2.0 diagnoses (P≥.1). Within 'normal' cohorts for both CC versions, CWA were associated with higher likelihood of esophageal symptoms, especially dysphagia, regurgitation, and heartburn, compared to truly normal studies (P≤.02 for each comparison). CONCLUSIONS AND INFERENCES Despite lower sensitivity, CC 3.0 identifies esophageal motor disorders with higher symptom burden compared to CC 2.0. CWA, which are associated with both transit and perceptive symptoms, are not well identified by either version.
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Affiliation(s)
- Amit Patel
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO,Division of Gastroenterology, Duke University School of Medicine and Durham Veterans Affairs Medical Center, Durham, NC
| | - Benjamin Cassell
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO,Division of Gastroenterology, University of Colorado, Denver, CO
| | - Nitin Sainani
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO
| | - Dan Wang
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO,Gastroenterology Department, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Basma Shahid
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO
| | - Michael Bennett
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO
| | - Faiz A. Mirza
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO
| | - Satish Munigala
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, MO
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Nikaki K, Ooi JLS, Sifrim D. Chicago Classification of Esophageal Motility Disorders: Applications and Limits in Adults and Pediatric Patients with Esophageal Symptoms. Curr Gastroenterol Rep 2016; 18:59. [PMID: 27738966 DOI: 10.1007/s11894-016-0532-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The Chicago classification (CC) is most valued for its systematic approach to esophageal disorders and great impact in unifying practice for esophageal manometric studies. In view of the ever-growing wealth of knowledge and experience gained by the expanding use of high-resolution manometry (HRM) in various clinical scenarios, the CC is regularly updated. Its clinical impact and ability to predict clinical outcome, both in adults and pediatrics, will be further promoted by recognizing its current limitations, incorporating new metrics in its diagnostic algorithms and adjusting the HRM protocols based on the clinical question posed. Herein, we discuss the current limitations of the CC and highlight some areas of improvement for the future.
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Affiliation(s)
- Kornilia Nikaki
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, E1 2AJ, London, UK
| | - Joanne Li Shen Ooi
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, E1 2AJ, London, UK
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, E1 2AJ, London, UK.
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12
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Barret M, Herregods TVK, Oors JM, Smout AJPM, Bredenoord AJ. Diagnostic yield of 24-hour esophageal manometry in non-cardiac chest pain. Neurogastroenterol Motil 2016; 28:1186-93. [PMID: 27018150 DOI: 10.1111/nmo.12818] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 02/10/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND In the past, ambulatory 24-h manometry has been shown useful for the evaluation of patients with non-cardiac chest pain (NCCP). With the diagnostic improvements brought by pH-impedance monitoring and high-resolution manometry (HRM), the contribution of ambulatory 24-h manometry to the diagnosis of esophageal hypertensive disorders has become uncertain. Our aim was to assess the additional diagnostic yield of ambulatory manometry to HRM and ambulatory pH-impedance monitoring in this patient population. METHODS All patients underwent 24-h ambulatory pressure-pH-impedance monitoring and HRM. Patients had retrosternal pain as a predominant symptom and no explanation after cardiologic and digestive endoscopic evaluations. Diagnostic measurements were analyzed by two independent physicians. KEY RESULTS Fifty-nine patients met the inclusion criteria; 37.3% of the patients had their symptoms explained by abnormalities on pH-impedance monitoring and 6.8% by ambulatory manometry. Functional chest pain was diagnosed in 52.5% of the patients. High-resolution manometry, using the Chicago Classification v3.0 criteria alone, did not identify any of the four patients with esophageal spasm on ambulatory manometry. However, taking into account other abnormalities, such as simultaneous (rapid) or repetitive contractions, HRM had a sensitivity of 75% and a specificity of 98.2% for the diagnosis of esophageal spasm. CONCLUSIONS & INFERENCES In the work-up of NCCP, ambulatory 24-h manometry has a low additional diagnostic yield. However, it remains the best technique to identify esophageal spasm as the cause of symptoms. This is particularly useful when an unequivocal diagnosis is needed before treatment.
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Affiliation(s)
- M Barret
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - T V K Herregods
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - J M Oors
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - A J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - A J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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