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Biermann M, Obineme C, Godiers M, Kundu S, Jain AS. The functional lumen imaging probe contractile response pattern is the best predictor of botulinum toxin response in esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2024; 36:e14859. [PMID: 38988105 PMCID: PMC11321917 DOI: 10.1111/nmo.14859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/12/2024] [Accepted: 06/26/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Esophagogastric junction outflow obstruction (EGJOO) is a heterogenous disorder in which the correct management strategy is unclear. We assessed whether functional lumen imaging probe (FLIP) topography data could select EGJOO, which would benefit from lower esophageal sphincter Botulinum toxin (Botox) injection. METHODS This was a single-center prospective study of adult patients meeting Chicago Classification (CC) v3.0 criteria for EGJOO. We assessed differences in pretreatment physiologic measurements on high-resolution manometry (HRM) and FLIP and other relevant clinical variables in predicting Botox response (>50% in BEDQ at 2 months). KEY RESULTS Sixty-nine patients were included (ages 33-90, 73.9% female). Of these, 42 (61%) were Botox responders. Majority of physiologic measures on HRM and FLIP and esophageal emptying were not different based on Botox response. However, a spastic-reactive (SR) FLIP contractile response (CR) pattern predicted a Botox response with OR 25.6 (CI 2.9-229.6) when compared to antegrade FLIP CR; and OR for impaired-disordered/absent CR was 22.5 (CI 2.5-206.7). Logistic regression model using backward elimination (p value = 0.0001, AUC 0.79) showed that a SRCR or IDCR/absent response and the upright IRP predicted Botox response. Response rates in tiered diagnostic groups were: (i) CCv3.0 EGJOO (60.9%), (ii) CCv4.0 EGJOO (73.1%), (iii) CCv4.0 + FLIP REO (80%), (iv) CCv4.0, FLIP REO, and abnormal FLIP CR (84.2%), and (v) CCv4.0, FLIP REO, and SR FLIP CR (90%). CONCLUSIONS AND INFERENCES FLIP helps identify patients with EGJOO who are likely to response to LES Botox therapy. An abnormal FLIP contractile response pattern is the single-most important predictor of a Botox response.
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Affiliation(s)
- Maya Biermann
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Chuma Obineme
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marie Godiers
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Suprateek Kundu
- Department of Medicine, Data Analytics and Biostatistics Core, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anand S Jain
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Takahashi K, Sato H, Shimamura Y, Abe H, Shiwaku H, Shiota J, Sato C, Hamada K, Ominami M, Hata Y, Fukuda H, Ogawa R, Nakamura J, Tatsuta T, Ikebuchi Y, Terai S, Inoue H. Novel scale for evaluating the therapeutic efficacy of per-oral endoscopic myotomy in achalasia. J Gastroenterol 2024; 59:658-667. [PMID: 38811423 DOI: 10.1007/s00535-024-02119-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 05/23/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Symptom scales for achalasia after per-oral endoscopic myotomy (POEM) are lacking. This study aimed to propose a new scale based on the conventional Eckardt score (c-ES) and evaluate persistent symptoms that impair patients' quality of life (QOL) post-POEM. METHODS Dysphagia, regurgitation, and chest pain frequencies were assessed using a 6-point scale modified-ES (m-ES) after POEM, with "occasional" symptoms on the c-ES further subdivided into three-period categories on m-ES. Symptom severity was further evaluated using a 5-point scale ranging from 1 to 5 points, with a score ≥ 3 points defined as persistent symptoms impairing QOL. We analyzed the correlation between the m-ES and severity score, diagnostic performance of the m-ES for persistent symptoms, and overlaps between each residual symptom. RESULTS Overall, 536 patients (median follow-up period, 2.9 years) post-POEM were included in this multicenter study. Significant correlations were observed between the m-ES and severity scores for dysphagia (r = 0.67, p < 0.01), regurgitation (r = 0.73, p < 0.01), and chest pain (r = 0.85, p < 0.01). Twenty-six patients (4.9%) had persistent symptoms post-POEM, and 23 of them had m-ES-specific symptom frequency ≥ once a month, which was determined as the optimal frequency threshold for screening persistent symptoms. The total m-ES predicted persistent symptoms more accurately than the total c-ES (area under the curve: 0.95 vs. 0.79, p < 0.01). Furthermore, dysphagia and chest pain were the major residual symptoms post-POEM covering 91.4% of regurgitation. CONCLUSIONS The new post-POEM scale successfully evaluated the QOL-based patient symptom severities. Our study implied the possibility of a simpler scale using residual dysphagia and chest pain.
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Affiliation(s)
- Kazuya Takahashi
- Division of Gastroenterology & Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 757-1, Asahimachidori, Chuo-Ku, Niigata, Niigata, 951-8510, Japan
| | - Hiroki Sato
- Division of Gastroenterology & Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 757-1, Asahimachidori, Chuo-Ku, Niigata, Niigata, 951-8510, Japan.
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hirofumi Abe
- Department of Gastroenterology, Kobe University Hospital, Kobe, Japan
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Junya Shiota
- Department of Gastroenterology & Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Chiaki Sato
- Division of Advanced Surgical Science and Technology, Tohoku University School of Medicine, Miyagi, Japan
| | - Kenta Hamada
- Department of Practical Gastrointestinal Endoscopy, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hisashi Fukuda
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yuichiro Ikebuchi
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine Tottori University Faculty of Medicine, Tottori, Japan
| | - Shuji Terai
- Division of Gastroenterology & Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 757-1, Asahimachidori, Chuo-Ku, Niigata, Niigata, 951-8510, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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Pitisuttithum P, Goudie E, Araujo IK, Halder S, Carlson DA, Pandolfino JE, Kou W. Four-dimensional impedance manometry volume metrics for predicting abnormal bolus retention. Neurogastroenterol Motil 2024; 36:e14803. [PMID: 38676387 DOI: 10.1111/nmo.14803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND The objective measurement for esophageal bolus volume and bolus clearance could classify abnormal high-resolution manometry (HRM) beyond the current Chicago classification. We aimed to compare the novel four-dimensional impedance manometry (4D HRM) volume metrics with timed barium esophagram (TBE). METHODS Adults with esophageal symptoms undergoing HRM and TBE were included. A custom-built program for 4D HRM analysis measured esophageal luminal cross-sectional area (CSA) from impedance and subsequently derived esophageal bolus volume and clearance. 4D HRM volume metrics included pre-swallow residual volume, maximal volume, retention volume, and clearance ratio defined as 1.0-retention volume divided by the maximal volume. An abnormal TBE was defined as a column height >5 cm at 1 min or 5 min. KEY RESULTS A total of 95 patients (normal motility: 33%; ineffective esophageal motility: 12%; absent contractility: 10%; esophagogastric junction outflow obstruction: 30%; type I achalasia: 5%; type II achalasia: 12%) were categorized into normal TBE (58%), abnormal TBE at 1 min (17%), and abnormal TBE at 5 min (25%). The AUROC demonstrated that, among all 4D HRM volume metrics, the clearance ratio had the best performance in predicting abnormal TBE at 5 min (AUROC, 95% confidence interval: 0.89, 0.82-0.96), and exhibited a strong negative correlation with TBE at 5 min (r = -0.65; p < 0.001). CONCLUSIONS & INFERENCES Novel 4D HRM volume metrics provide objective measurement of esophageal bolus volume and bolus clearance. The clearance ratio has a strong correlation with TBE and could potentially serve as a substitute for TBE to measure esophageal retention.
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Affiliation(s)
- Panyavee Pitisuttithum
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Eric Goudie
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Thoracic Surgery, Department of Surgery, Université de Montréal, Montréal, Quebec, Canada
| | - Isis K Araujo
- Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Sourav Halder
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Wenjun Kou
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Rugaitienė M, Lesauskaitė V, Ulozienė I, Smičius L, Damulevičienė G. Impact of Modified Diet, Swallowing Exercises, and Electrostimulation on Quality of Life of Older Patients Suffering from Oropharyngeal Dysphagia. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1021. [PMID: 39064450 PMCID: PMC11278523 DOI: 10.3390/medicina60071021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 06/13/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Oropharyngeal dysphagia is defined as a swallowing disorder in which it becomes difficult to form a bolus and move food from the mouth to the proximal part of the esophagus. Several factors can cause this disorder in geriatric patients. With oropharyngeal dysphagia, the patient's social isolation and the risk of depression increase, while the quality of life deteriorates. Materials and Methods: In this study, oropharyngeal dysphagia was suspected based on the EAT-10 questionnaire and diagnosed with the water drink test and endoscopic swallowing evaluation, which assesses the aspiration risk by using an eight-point Penetration-Aspiration scale. Patients with oropharyngeal dysphagia received complex treatment: exercises to strengthen the swallowing muscles, electrostimulation of the swallowing muscles, and a modified diet. The quality of life of 64 patients was assessed by using the DHI, SWAL-QoL, and EAT-10 questionnaires before complex treatment and after treatment. The results show that the quality of life improved after the complex treatment of oropharyngeal dysphagia. Results: The mean age of patients was 77.8 (9.1) years, and 56.3% of patients were women. At baseline, mild oropharyngeal dysphagia was found in 18.8% of patients; moderate-in 51.6%; and severe-in 29.7%. Aspiration risk was low in 28.1% of patients; medium-in 39.1%; and high-in 32.8%. The severity of oropharyngeal dysphagia and aspiration risk significantly decreased after treatment (p = 0.002). The EAT-10 score mean was 15.23 (8.92) points before treatment and decreased to 11.50 (6.12) points after treatment (p < 0.001). Before treatment, the DHI physical score was 15.75 (6.813), the DHI functional score was 14.56 (8.659), and the DHI emotional score was 11.06 (7.848) (p < 0.001), and after complex treatment, the DHI physical score was 14.56 (8.659), the DHI functional score was 9.74 (7.165), and the DHI emotional score was 7.94 (6.588) (p < 0.001). The total SWAL-QoL score mean was 132.71 (34.392) points before treatment and increased to 152.42 (30.547) points after treatment (p < 0.001). Conclusions: Complex treatment of oropharyngeal dysphagia plays an important role in improving the quality of life and reducing aspiration risk in older people affected by this condition.
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Affiliation(s)
- Margarita Rugaitienė
- Clinical Department of Geriatrics, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania (G.D.)
| | - Vita Lesauskaitė
- Clinical Department of Geriatrics, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania (G.D.)
| | - Ingrida Ulozienė
- Department of Otorhinolaryngology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Lukas Smičius
- Department of Infectious Diseases, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Gytė Damulevičienė
- Clinical Department of Geriatrics, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania (G.D.)
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Lu MM, Kahrilas PJ, Teitelbaum EN, Pandolfino JE, Carlson DA. Secondary peristalsis and esophagogastric junction distensibility in symptomatic post-fundoplication patients. Neurogastroenterol Motil 2024; 36:e14746. [PMID: 38263867 DOI: 10.1111/nmo.14746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/12/2024] [Accepted: 01/14/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND The impact of esophageal dysmotility among patients with post-fundoplication esophageal symptoms is not fully understood. This study aimed to investigate secondary peristalsis and esophagogastric junction (EGJ) opening biomechanics using functional lumen imaging probe (FLIP) panometry in symptomatic post-fundoplication patients. METHODS Eighty-seven adult patients post-fundoplication who completed FLIP for symptomatic esophageal evaluation were included. Secondary peristaltic contractile response (CR) patterns and EGJ opening metrics (EGJ distensibility index (EGJ-DI) and maximum EGJ diameter) were evaluated on FLIP panometry and analyzed against high-resolution manometry (HRM), patient-reported outcomes, and fundoplication condition seen on esophagram and/or endoscopy. KEY RESULTS FLIP CR patterns included 14 (16%) normal CR, 30 (34%) borderline CR, 28 (32%) impaired/disordered CR, 13 (15%) absent CR, and 2 (2%) spastic reactive CR. Compared with normal and borderline CRs (i.e., CR patterns with distinct, antegrade peristalsis), patients with impaired/disordered and absent CRs demonstrated significantly greater time since fundoplication (2.4 (0.6-6.8) vs. 8.9 (2.6-14.5) years; p = 0.002), greater esophageal body width on esophagram (n = 50; 2.3 (2.0-2.8) vs. 2.9 (2.4-3.6) cm; p = 0.013), and lower EGJ-DI (4.3 (2.7-5.4) vs. 2.6 (1.7-3.7) mm2/mmHg; p = 0.001). Intact fundoplications had significantly higher rates of normal CRs compared to anatomically abnormal (i.e., tight, disrupted, slipped, herniated) fundoplications (9 (28%) vs. 5 (9%); p = 0.032), but there were no differences in EGJ-DI or EGJ maximum diameter. CONCLUSIONS & INFERENCES Symptomatic post-fundoplication patients were characterized by frequent abnormal secondary peristalsis after fundoplication, potentially worsening with time after fundoplication or related to EGJ outflow resistance.
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Affiliation(s)
- Michelle M Lu
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Ezra N Teitelbaum
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Carlson DA, Hirano I, Gonsalves N, Kahrilas PJ, Araujo IK, Yang M, Tetreault MP, Pandolfino JE. Composite score of physiomechanical esophageal function using functional lumen imaging probe panometry in eosinophilic esophagitis. Gastrointest Endosc 2024; 99:499-510.e1. [PMID: 37890596 PMCID: PMC11090643 DOI: 10.1016/j.gie.2023.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/16/2023] [Accepted: 10/22/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND AND AIMS The evaluation provided by functional lumen imaging probe (FLIP) panometry includes esophageal distensibility/compliance (mechanics) of the esophageal body and esophagogastric junction (EGJ) and esophageal motility (secondary peristalsis). We developed a composite score using these parameters to characterize physiomechanical function in patients with eosinophilic esophagitis (EoE). METHODS Two hundred fifteen adult patients with EoE who completed FLIP panometry during sedated endoscopy with esophageal biopsy sampling were included. FLIP metrics of esophageal body Compliance, Contractile response, Distensibility plateau, and maximum EGJ Diameter (C2D2) were scored as 0 for normal versus 1 or 2 for increasing degree of abnormality. Scores were summed to calculate the composite C2D2 score. RESULTS The C2D2 score had a significant positive correlation with mucosal eosinophil count (ρ = .241) and total Endoscopic EoE Reference Score (ρ = .467). Among 46 patients off treatment at the baseline evaluation, future proton pump inhibitor (PPI) responders (ie, achieved mucosal eosinophil count <15 per high-powered field after PPI treatment) had lower C2D2 scores than PPI nonresponders (median, 2 [interquartile range, 1-3] vs 4 [interquartile range, 2-6], respectively; P = .003). A regression model (that controlled for age, sex, and baseline eosinophil count) showed a C2D2 score ≤3 had an odds ratio of 14.5 (95% confidence interval, 2.6-85) to predict future PPI response. However, total Endoscopic EoE Reference Scores (P = .142) and baseline eosinophil count (P = .480) did not differ between PPI responders and PPI nonresponders. CONCLUSIONS This composite score of FLIP panometry metrics, the C2D2 score, may facilitate characterizing physiomechanical function in EoE and serve as an objective outcome measure.
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Affiliation(s)
- Dustin A Carlson
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Ikuo Hirano
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nirmala Gonsalves
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Isis K Araujo
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA; Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Mira Yang
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Marie-Pier Tetreault
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Reddy CA, Ellison A, Cipher DJ, Mendoza R, Souza RF, Spechler SJ, Konda VJA, Nguyen AD. Frequent discrepancies among diagnostic tests for detecting lower esophageal sphincter-related obstruction. Neurogastroenterol Motil 2024; 36:e14729. [PMID: 38129627 DOI: 10.1111/nmo.14729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/19/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND There are frequent discrepancies among high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and esophagram in identifying lower esophageal sphincter (LES)-related obstruction. We aimed to determine the frequency of those discrepancies and how they influenced clinical treatment/outcomes. METHODS We identified patients who had all three tests (HRM, FLIP, and esophagram) and endoscopy performed for evaluation of esophageal symptoms in our Center for Esophageal Diseases. Discrepancies among the tests for the presence of LES obstruction were noted, and the performance of individual tests was compared against a consensus opinion rendered by a panel of esophagologists. Binary logistical regression was performed, and ROC curves were generated for prediction of the consensus clinical diagnosis of LES obstruction. KEY RESULTS A total of 126 patients (mean age 57.9 ± 17.0 years; 67% female) met inclusion criteria. All three tests agreed on the presence or absence of LES obstruction in only 72 (57%) patients [no LES obstruction in 57 (45%), LES obstruction in 15 (12%)]. Thirteen patients (10%) had a change in management based on additional findings on FLIP +/- esophagram not seen on HRM with 69% having symptomatic improvement after LES-directed intervention. FLIP was the strongest predictor of a consensus diagnosis of LES obstruction by logistic regression and ROC (OR 23.36, AUC 0.796), followed by HRM (OR 15.41, AUC 0.764). CONCLUSIONS & INFERENCE High-resolution manometry, functional lumen imaging probe, and esophagram each have considerable limitations for identifying LES obstruction, and discrepancies among these tests occur frequently. Multimodal testing is often required for adequate evaluation of LES-related obstruction.
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Affiliation(s)
- Chanakyaram A Reddy
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Ashton Ellison
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Daisha J Cipher
- College of Nursing and Health Innovation, The University of Texas at Arlington, Arlington, Texas, USA
| | - Roseann Mendoza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Rhonda F Souza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Stuart J Spechler
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Vani J A Konda
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Anh D Nguyen
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
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Biermann M, Hersh M, Kline M, Fowler H, Calderon L, Godiers M, Kundu S, Jain AS. Functional lumen imaging probe topography identifies patients with normal acid exposure and esophageal hypervigilance amongst proton-pump inhibitor non-responders. Surg Endosc 2024; 38:291-299. [PMID: 37991572 PMCID: PMC11270151 DOI: 10.1007/s00464-023-10556-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 10/20/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Multiple factors contribute to symptom generation and treatment response in proton-pump inhibitor non-responders (PPI-NRs). We aimed to test whether PPI-NRs with normal acid exposure have a higher degree of esophageal hypersensitivity and hypervigilance and can be identified using functional lumen imaging probe (FLIP) topography at the time of endoscopy. METHODS Data from PPI-NRs whom underwent endoscopy, FLIP and wireless 96-h pH-metry were retrospectively analyzed. Patients were grouped according to acid exposure time (AET) as (a) 0 days abnormal (AET > 6%), (b) 1-2 days abnormal, or (c) 3-4 days abnormal. The esophageal hypervigilance and anxiety scale (EHAS) score and other symptom scores were compared between groups. The discriminatory ability of the esophagogastric junction (EGJ) distensibility index (DI) and max EGJ diameter in identifying patients with 0 days abnormal AET was tested via receiver-operating-characteristic (ROC) curve analysis. RESULTS EHAS score was 38.6 in the 0 days abnormal AET group, 30.4 in the 1-2 days abnormal AET group (p = 0.073 when compared to 0 days abnormal) and 28.2 in the 3-4 days abnormal AET group (p = 0.031 when compared to 0 days abnormal). Area-under-the-curve (AUC) for the DI in association with 0 days AET > 6% was 0.629. A DI of < 2.8 mm2/mmHg had a sensitivity of 83.3%, and negative predictive value of 88% in classifying patients with 0 days abnormal acid exposure (p = 0.004). CONCLUSIONS FLIP complements prolonged wireless pH-metry in distinguishing the subset of PPI-NRs with completely normal acid exposure and a higher burden of esophageal hypervigilance. Proper identification of patients along the functional heartburn spectrum can improve overall surgical outcomes.
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Affiliation(s)
- Maya Biermann
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Marc Hersh
- Department of Medicine, Division of Digestive Diseases, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Meredith Kline
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Halley Fowler
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1365 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Lucie Calderon
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1365 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Marie Godiers
- Physician Assistant Program, Emory University School of Medicine, Atlanta, GA, USA
| | - Suprateek Kundu
- Data Analytics and Biostatistics Core, Emory University Department of Medicine, Atlanta, GA, USA
| | - Anand S Jain
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, 1365 Clifton Rd NE, Atlanta, GA, 30322, USA.
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Sawada A, Zhang M, Ustaoglu A, Nikaki K, Lee C, Woodland P, Yazaki E, Takashima S, Ominami M, Tanaka F, Ciafardini C, Nachman F, Ditaranto A, Agotegaray J, Bilder C, Savarino E, Gyawali CP, Penagini R, Fujiwara Y, Sifrim D. Superficial oesophageal mucosal innervation may contribute to severity of symptoms in oesophageal motility disorders. Aliment Pharmacol Ther 2024; 59:100-112. [PMID: 37845817 DOI: 10.1111/apt.17773] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/31/2023] [Accepted: 10/07/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Mechanisms underlying perception of dysphagia and chest pain have not been completely elucidated, although oesophageal mucosal afferent nerves might play an important role. AIMS To evaluate the relationship between oesophageal mucosal afferent nerves and the severity of dysphagia and chest pain in oesophageal motility disorders. METHODS We prospectively recruited patients with oesophageal motility disorders having dysphagia and/or chest pain from whom oesophageal biopsies were obtained. High-resolution manometry classified patients into disorders of oesophagogastric junction (OGJ) outflow and disorders of peristalsis. Symptom severity was assessed using validated questionnaires including Brief Oesophageal Dysphagia Questionnaire (BEDQ). Immunohistochemistry was performed on oesophageal biopsies to evaluate the location of calcitonin gene-related peptide (CGRP)-immunoreactive mucosal afferent nerves. Findings were compared to existing data from 10 asymptomatic healthy volunteers. RESULTS Of 79 patients, 61 patients had disorders of OGJ outflow and 18 had disorders of peristalsis. CGRP-immunoreactive mucosal nerves were more superficially located in the mucosa of patients with oesophageal motility disorders compared to healthy volunteers. Within disorders of OGJ outflow, the location of CGRP-immunoreactive nerves negatively correlated with BEDQ score both in the proximal (ρ = -0.567, p < 0.001) and distal oesophagus (ρ = -0.396, p = 0.003). In the proximal oesophagus, strong chest pain was associated with more superficially located mucosal nerves than weak chest pain (p = 0.04). Multivariate analysis showed superficial nerves in the proximal oesophagus was independently associated with severe dysphagia in disorders of OGJ outflow (p = 0.008). CONCLUSIONS Superficial location of mucosal nerves in the proximal oesophagus might contribute to symptoms, especially severe dysphagia, in disorders of OGJ outflow.
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Affiliation(s)
- Akinari Sawada
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Mengyu Zhang
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Ahsen Ustaoglu
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Kornilia Nikaki
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Chung Lee
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Philip Woodland
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Etsuro Yazaki
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Shingo Takashima
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Clorinda Ciafardini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Nachman
- Fundacion Favaloro Hospital, Buenos Aires, Argentina
| | | | | | | | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
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Sykes C, Dervin H, Sweis R. Editorial: Is there a relationship between dysphagia, chest pain and mucosal innervation in patients with oesophageal motility disorders? Aliment Pharmacol Ther 2024; 59:134-135. [PMID: 38085942 DOI: 10.1111/apt.17808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
LINKED CONTENTThis article is linked to Sawada et al paper. To view this article, visit https://doi.org/10.1111/apt.17773
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Affiliation(s)
- Catherine Sykes
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Humayra Dervin
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Rami Sweis
- University College London Hospitals NHS Foundation Trust, London, UK
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11
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Mittal RK, Le C, Ledgerwood M, Jung DK, Gandu V, Zifan A. Esophageal Symptoms and Lumbosacral Back Pain. GASTRO HEP ADVANCES 2023; 3:292-299. [PMID: 38645466 PMCID: PMC11027073 DOI: 10.1016/j.gastha.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/08/2023] [Indexed: 04/23/2024]
Abstract
BACKGROUND AND AIMS Esophageal symptoms, that is, heartburn, regurgitation, dysphagia, and chest pain are common in the general population. Also common are symptoms of back pain related to pathology in the lumbosacral spine. The right crus of the diaphragm that forms the esophageal hiatus, originates from lumbar spine, may be affected by lumbar spine pathology resulting in esophageal symptoms. We studied whether there was an association between esophageal symptoms and spine symptoms. METHODS Two patient groups of 150 each were investigated: group 1 (ES); patients referred to the esophageal manometry study for assessment of esophageal symptoms, group 2 (SC); patients undergoing screening colonoscopy (control group). Both groups completed standardized questionnaires assessing esophageal and spine symptoms. RESULTS Back pain was reported by 74% of patients in the ES group as compared to 55% of patients in the SC group. Thirty percent of patients in the SC group reported one or more esophageal symptoms and these patients were regrouped with the ES group, resulting in 2 groups, ES1 and SC1, with and without esophageal symptoms, respectively. The ES1 group was 3.3 times more likely to experience back pain compared to the SC1 group (95% confidence interval: 1.95-5.46). Thoracolumbar was the most common site of pain in both groups. Pain score was greater for the group with esophageal symptoms compared to controls. Narcotic intake for most patients in the ES1 group was for back pain. CONCLUSION A strong association between esophageal symptoms and thoracolumbar back pain raises the possibility that structural and functional changes in the esophageal hiatus muscles related to thoracolumbar spine pathology lead to esophageal dysmotility and symptoms.
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Affiliation(s)
- Ravinder K. Mittal
- Division of Gastroenterology, Department of Medicine University of California San Diego, San Diego, California
| | - Charlie Le
- Division of Gastroenterology, Department of Medicine University of California San Diego, San Diego, California
| | - Melissa Ledgerwood
- Division of Gastroenterology, Department of Medicine University of California San Diego, San Diego, California
| | - Da Kyung Jung
- Division of Gastroenterology, Department of Medicine University of California San Diego, San Diego, California
| | - Vignesh Gandu
- Division of Gastroenterology, Department of Medicine University of California San Diego, San Diego, California
| | - Ali Zifan
- Division of Gastroenterology, Department of Medicine University of California San Diego, San Diego, California
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12
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Leiman DA, Jones HN, North R, Porter Starr KN, Pieper CF, Cohen SM. Self-Reported Dysphagia and Psychosocial Health Among Community-Dwelling Older Adults: Results of a National Study. J Gen Intern Med 2023; 38:3329-3338. [PMID: 37254012 PMCID: PMC10681967 DOI: 10.1007/s11606-023-08232-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/08/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND The risk of dysphagia increases with age, affecting up to 33% of adults over the age of 65. Older adults with dysphagia are at increased risk for negative physical health outcomes such as aspiration pneumonia and death. However, the relationship between dysphagia and psychosocial health is uncertain in this population. OBJECTIVE We aimed to assess the associations between dysphagia and psychosocial health among older adults (≥ 65) with self-reported dysphagia. DESIGN We performed a cross-sectional assessment of the National Health and Aging Trends Study (NHATS) conducted in 2019. MAIN MEASURES Weighted logistic and linear regression models were used to assess the relationship between self-reported dysphagia and psychosocial health using established patient-reported outcome measures including those for depression, anxiety, and social isolation previously used in NHATS analyses, while adjusting for demographics, comorbid conditions, and risk factors for dysphagia identified by purposeful selection. KEY RESULTS Among the 4041 adults in this cohort, almost half (40%) were between 70 and 74 years old, more than half were female (55%), and a significantly higher proportion were White, non-Hispanic respondents (78.1%, p < 0.01) compared with other races and ethnicities. There were 428 (10.5%) respondents reporting dysphagia symptoms within the previous month. In the multivariable model, dysphagia was associated with significantly increased odds of anxiety (OR 1.33 [1.06, 1.67]) and a significantly decreased sense of well-being (coefficient - 1.10 [- 1.66, - 0.54]), but no association was detected for social isolation. CONCLUSIONS When accounting for factors associated with underlying physical health status, self-reported dysphagia is independently associated with negative psychosocial health and warrants attention by healthcare providers. Future studies should aim to identify causal factors and the extent to which interventions may mitigate these factors.
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Affiliation(s)
- David A Leiman
- Division of Gastroenterology, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
| | - Harrison N Jones
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Rebecca North
- Center for the Study of Aging, Duke University School of Medicine, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Kathryn N Porter Starr
- Center for the Study of Aging, Duke University School of Medicine, Durham, NC, USA
- Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA
- Geriatrics Research, Education, and Clinical Center, Durham VA Health Care Center, Durham, NC, USA
| | - Carl F Pieper
- Center for the Study of Aging, Duke University School of Medicine, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Seth M Cohen
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, USA
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Wakim El-Khoury J, Pandolfino JE, Kahrilas PJ, Godo B, Farina DA, Kou W, Carlson DA. Relaxation of the lower esophageal sphincter in response to reduced volume distension during FLIP Panometry. Neurogastroenterol Motil 2023; 35:e14663. [PMID: 37691556 DOI: 10.1111/nmo.14663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND The esophageal response to stepwise distension during the functional lumen imaging probe (FLIP) Panometry study often parallels high-resolution manometry (HRM) motility diagnoses. This study aimed to describe the changes in FLIP metrics during FLIP emptying, that is, reduced volume distension. METHODS Adult patients who completed FLIP and HRM for esophageal motility evaluation were included. Esophagogastric junction (EGJ) opening parameters were assessed during stepwise FLIP filling to volumes of 60 mL ("filling 60 mL"), then 70 mL, and then back to 60 mL ("emptying 60 mL"). HRM studies were analyzed per Chicago classification version 4.0 (CCv4.0). KEY RESULTS Among 265 patients included, HRM/CCv4.0 diagnoses included achalasia in 80 patients (30%), normal motility in 70 (26%), and ineffective esophageal motility (IEM) in 43 (16%). EGJ-distensibility index (DI) and EGJ diameter were greater during emptying 60 mL than filling 60 mL in achalasia, normal motility, and IEM (p values <0.002). If applying the emptying 60 mL EGJ-DI (vs. filling 60 mL EGJ-DI), EGJ opening classification changed from reduced EGJ opening to borderline EGJ opening in 31% of achalasia patients and in 2% of patients with normal motility or IEM. EGJ opening classification was unchanged in 69% achalasia and 96% of normal motility/IEM. CONCLUSIONS AND INFERENCES This study suggests that isotonic or auxotonic relaxation of the lower esophageal sphincter occurs with reduced volume distension in patients with achalasia and normal motility. The study also supports the importance of utilizing a standardized FLIP motility study protocol (i.e., controlled, stepwise filling to 50 mL, 60 mL, then 70 mL) to provide reliable and generalizable FLIP metrics to facilitate diagnosis of esophageal motility disorders.
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Affiliation(s)
- Jeanine Wakim El-Khoury
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Bidemi Godo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Domenico A Farina
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
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Koop AH, Kahrilas PJ, Schauer J, Pandolfino JE, Carlson DA. The impact of primary peristalsis, contractile reserve, and secondary peristalsis on esophageal clearance measured by timed barium esophagogram. Neurogastroenterol Motil 2023; 35:e14638. [PMID: 37417394 DOI: 10.1111/nmo.14638] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Primary and secondary peristalsis facilitate esophageal bolus transport; however, their relative impact for bolus clearance remains unclear. We aimed to compare primary peristalsis and contractile reserve on high-resolution manometry (HRM) and secondary peristalsis on functional lumen imaging probe (FLIP) Panometry with emptying on timed barium esophagogram (TBE) and incorporate findings into a comprehensive model of esophageal function. METHODS Adult patients who completed HRM with multiple rapid swallows (MRS), FLIP, and TBE for esophageal motility evaluation and without abnormal esophagogastric junction outflow/opening or spasm were included. An abnormal TBE was defined as a 1-min column height >5 cm. Primary peristalsis and contractile reserve after MRS were combined into an HRM-MRS model. Secondary peristalsis was combined with primary peristalsis assessment to describe a complementary neuromyogenic model. KEY RESULTS Of 89 included patients, differences in rates of abnormal TBEs were observed with primary peristalsis classification (normal: 14.3%; ineffective esophageal motility: 20.0%; absent peristalsis: 54.5%; p = 0.009), contractile reserve (present: 12.5%; absent: 29.3%; p = 0.05), and secondary peristalsis (normal: 9.7%; borderline: 17.6%; impaired/disordered: 28.6%; absent contractile response: 50%; p = 0.039). Logistic regression analysis (akaike information criteria, area under the receiver operating curve) demonstrated that the neuromyogenic model (80.8, 0.83) had a stronger relationship predicting abnormal TBE compared to primary peristalsis (81.5, 0.82), contractile reserve (86.8, 0.75), or secondary peristalsis (89.0, 0.78). CONCLUSIONS AND INFERENCES Primary peristalsis, contractile reserve, and secondary peristalsis were associated with abnormal esophageal retention as measured by TBE. Added benefit was observed when applying comprehensive models to incorporate primary and secondary peristalsis supporting their complementary application.
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Affiliation(s)
- Andree H Koop
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jacob Schauer
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
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15
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Carlson DA, Hirano I, Gonsalves N, Kahrilas PJ, Araujo IK, Yang M, Tetreault MP, Pandolfino JE. A PhysioMechanical Model of Esophageal Function in Eosinophilic Esophagitis. Gastroenterology 2023; 165:552-563.e4. [PMID: 37263308 PMCID: PMC10527622 DOI: 10.1053/j.gastro.2023.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis (EoE) is characterized by eosinophilic inflammation, but also heterogeneous presentations involving fibrostenotic esophageal remodeling and esophageal dysmotility. We aimed to define and evaluate phenotypes of EoE using functional lumen imaging probe (FLIP) panometry (ie, a PhysioMechanical classification of EoE). METHODS Patients with EoE who completed FLIP during endoscopy were included in a cross-sectional study. FLIP studies were analyzed for distensibility plateau and compliance of the esophageal body, maximum esophagogastric junction diameter, and contractile response pattern. These FLIP features were then applied to define PhysioMechanical classifications. RESULTS A total of 215 patients with EoE (mean [standard deviation] age 38 [12] years; 31% female) were included. Seven PhysioMechanical classifications were identified that differed by various clinical characteristics, including symptom duration (P < .001) and Endoscopic EoE Reference Scores (EREFS) (P < .001). In particular, patients with "nonreactive fibrostenosis" (n = 14), had greater symptom duration (median [interquartile range] 20 [10-30] years) and more frequently had EREFS grade 2 or 3 ring scores (14 of 14 patients) than patients with a "normal" PhysioMechanical classification (symptom duration: 3 [1-8] years; 4 of 50 [8%] had EREFS grade 2 or 3 rings). In addition, among patients off treatment at cross-sectional evaluation (n = 46), there was a difference between PhysioMechanical classifications in future proton pump inhibitor (PPI) response rates (ie, achieving peak mucosal eosinophil count <15 per high-powered field after PPI treatment); P = .009. PPI response ranged from 87% (13 of 15 patients) with "isolated esophagogastric junction outflow obstruction" to 11% (1 of 9 patients) with "spastic-reactive fibrostenosis." CONCLUSIONS Classifying PhysioMechanical esophageal function in EoE based on FLIP panometry features may facilitate defining disease severity and directing management in EoE.
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Affiliation(s)
- Dustin A Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Ikuo Hirano
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Nirmala Gonsalves
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Peter J Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Isis K Araujo
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Mira Yang
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Marie-Pier Tetreault
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John E Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Ribieras AJ, Monzon Canales EJ, Manzur-Pineda K, Cuesta M, Kutlu O, De La Cruz-Munoz N. Comparison of upper gastrointestinal series and symptom questionnaires with intraoperative diagnosis of hiatal hernia during sleeve gastrectomy. Surg Obes Relat Dis 2023; 19:843-849. [PMID: 36813635 DOI: 10.1016/j.soard.2022.12.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/13/2022] [Accepted: 12/31/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Hiatal hernias are common in bariatric surgery patients, but the utility of preoperative hiatal hernia diagnosis prior to sleeve gastrectomy (SG) is debated. OBJECTIVE This study compared preoperative and intraoperative hiatal hernia detection rates in patients undergoing laparoscopic SG. SETTING University hospital, United States. METHODS As part of a randomized trial evaluating the role of routine crural inspection during SG, an initial cohort was prospectively studied to assess the correlation between preoperative upper gastrointestinal (UGI) series, reflux and dysphagia symptoms, and intraoperative hiatal hernia diagnosis. Preoperatively, patients completed the Gastroesophageal Reflux Disease Questionnaire (GerdQ), the Brief Esophageal Dysphagia Questionnaire (BEDQ), and a UGI series. Intraoperatively, patients with an anteriorly visible defect underwent hiatal hernia repair followed by SG. All others were randomized to standalone SG or posterior crural inspection with repair of any hiatal hernia identified prior to SG. RESULTS Between November 2019 and June 2020, 100 patients (72 female patients) were enrolled. Preoperative UGI series identified hiatal hernia in 28% (26 of 93) of patients. Intraoperatively, hiatal hernia was diagnosed during initial inspection in 35 patients. Diagnosis was associated with older age, lower body mass index, and Black race but did not correlate with GerdQ or BEDQ. Using the standard conservative approach, compared with intraoperative diagnosis, sensitivity and specificity of the UGI series were 35.3% and 80.7%, respectively. Hiatal hernia was identified in an additional 34% (10 of 29) of patients randomized to posterior crural inspection. CONCLUSION Hiatal hernias are highly prevalent in SG patients. However, GerdQ, BEDQ, and a UGI series unreliably identify hiatal hernia in the preoperative setting and should not influence intraoperative evaluation of the hiatus during SG.
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Affiliation(s)
- Antoine J Ribieras
- DeWitt Daughtry Family Department of Surgery, Division of Laparoendoscopic and Bariatric Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Eli J Monzon Canales
- DeWitt Daughtry Family Department of Surgery, Division of Laparoendoscopic and Bariatric Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Karen Manzur-Pineda
- DeWitt Daughtry Family Department of Surgery, Division of Laparoendoscopic and Bariatric Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Melissa Cuesta
- DeWitt Daughtry Family Department of Surgery, Division of Laparoendoscopic and Bariatric Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Onur Kutlu
- DeWitt Daughtry Family Department of Surgery, Division of Laparoendoscopic and Bariatric Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Nestor De La Cruz-Munoz
- DeWitt Daughtry Family Department of Surgery, Division of Laparoendoscopic and Bariatric Surgery, University of Miami Miller School of Medicine, Miami, Florida.
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Le KHN, Low EE, Yadlapati R. Evaluation of Esophageal Dysphagia in Elderly Patients. Curr Gastroenterol Rep 2023; 25:146-159. [PMID: 37312002 PMCID: PMC10726678 DOI: 10.1007/s11894-023-00876-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE OF REVIEW While guidelines exist for the evaluation and management of esophageal dysphagia in the general population, dysphagia disproportionately affects the elderly. In this article, we reviewed the literature on evaluating esophageal dysphagia in elderly patients and proposed a diagnostic algorithm based on this evidence. RECENT FINDINGS In older patients, dysphagia is often well compensated for by altered eating habits and physiologic changes, underreported by patients, and missed by healthcare providers. Once identified, dysphagia should be differentiated into oropharyngeal and esophageal dysphagia to guide diagnostic workup. For esophageal dysphagia, this review proposes starting with endoscopy with biopsies, given its relative safety even in older patients and potential for interventional therapy. If endoscopy shows a structural or mechanical cause, then further cross-sectional imaging should be considered to assess for extrinsic compression, and same session endoscopic dilation should be considered for strictures. If biopsies and endoscopy are normal, then esophageal dysmotility is more likely, and high-resolution manometry and additional workup should be performed following the updated Chicago Classification. Even after diagnosis of the root cause, complications including malnutrition and aspiration pneumonia should also be assessed and monitored, as they both result from and can further contribute to dysphagia. The successful evaluation of esophageal dysphagia in elderly patients requires a thorough, standardized approach to collecting a history, selection of appropriate diagnostic workup, and assessment of risk of potential complications, including malnutrition and aspiration.
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Affiliation(s)
| | - Eric E Low
- Department of Gastroenterology and Hepatology, University of California, San Diego, CA, USA
| | - Rena Yadlapati
- Department of Gastroenterology and Hepatology, University of California, San Diego, CA, USA.
- , La Jolla, CA, USA.
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18
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Taft TH, Carlson DA, Marchese SH, Pandolfino JE. Initial assessment of medical post-traumatic stress among patients with chronic esophageal diseases. Neurogastroenterol Motil 2023; 35:e14540. [PMID: 36703507 PMCID: PMC10133015 DOI: 10.1111/nmo.14540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/20/2022] [Accepted: 01/11/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND Diagnosis and management of chronic esophageal disease requires the use of potentially traumatic medical procedures, performed with or without sedation. Medical trauma and post-traumatic stress (PTS) are emerging as important considerations in patients with digestive illness. To date, no study assesses medical PTS from procedures in patients with esophageal disease. METHODS Adult patients with achalasia, eosinophilic esophagitis, gastroesophageal reflux disease, or functional esophageal disease at a university-based gastroenterology clinic completed: Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5), Gastroesophageal Disease Questionnaire, Brief Esophageal Dysphagia Questionnaire, Northwestern Esophageal Quality of Life scale (HRQoL), NIH-PROMIS Depression scale, and a study-specific questionnaire about esophageal procedures (endoscopy with sedation; functional lumen imaging probe (FLIP) with sedation; high-resolution manometry (HRM); wireless pH testing; or 24-h pH-impedance testing). KEY RESULTS Half of 149 participants reported at least one traumatic procedure, with HRM most often cited. Only 2.7% met the cutoff for PTS on PCL-5. This increased to 7.1% for patients with a traumatic procedure combined with experiencing intense fear. Rates of moderate-severe PTS ranged from 7.4%-12% for all patients and 14%-29% for those with a traumatic procedure with fear. Medical PTS was associated with poorer HRQoL, and increased esophageal symptoms, depression, and hypervigilance and symptom anxiety. CONCLUSIONS & INFERENCES Preliminary evidence suggests medical PTS affects few patients with esophageal disease. However traumatic procedures, most often associated with HRM, significantly increase PTS symptoms. The potential impacts of medical PTS on esophageal patient assessment and outcomes are considerable and warrants further study.
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Affiliation(s)
- Tiffany H Taft
- Division of Gastroenterology & Hepatology Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology & Hepatology Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sara H Marchese
- Division of Gastroenterology & Hepatology Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John E Pandolfino
- Division of Gastroenterology & Hepatology Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Moosavi S, Shehata C, Kou W, Hirano I, Gonsalves N, Peterson S, Pandolfino JE, Carlson DA. Measuring esophageal compliance using functional lumen imaging probe to assess remodeling in eosinophilic esophagitis. Neurogastroenterol Motil 2023; 35:e14525. [PMID: 36600494 PMCID: PMC10171050 DOI: 10.1111/nmo.14525] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/17/2022] [Accepted: 12/10/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is associated with fibrostenotic remodeling that can be objectively assessed using the functional lumen imaging probe (FLIP). This is typically done using a metric called distensibility plateau (DP). We aimed to describe a novel measure of compliance of the esophageal body and evaluate the associated clinical characteristics in EoE. METHODS One hundred seventy-one adult patients with EoE (mean (SD) age 38 (12) years), 31% female and 35 healthy, asymptomatic controls who completed 16-cm functional luminal imaging probe (FLIP) during endoscopy, were evaluated in a cross-sectional study. The esophageal body DP and compliance were measured using a customized analysis program, with compliance calculated as (Δ esophageal body volume)/(Δ pressure) between two FLIP-filled volumes. RESULTS In controls, the median (5-95th percentile) DP was 19.8 mm (17.9-21) and esophageal body compliance was 0.37 ml/mmHg (0.18-1.1), which was greater than in EoE (DP 19 (11-21)), compliance 0.19 (0.02-0.71), p-values <0.001. Among EoE patients, 70 (41%) had normal compliance (>0.2 ml/mmHg) and normal DP (>17 mm); 11 (6%) had normal compliance and reduced DP; 34 (20%) had reduced compliance and normal DP; and 56 (33%) had reduced compliance and reduce DP. Patients with both reduced compliance and DP had the greatest proportion of severe rings (61% with EREFS score 2-3) and stricture (100%). CONCLUSION FLIP provides an objective evaluation of biomechanical properties of the esophageal wall that appears enhanced by complementary application of metrics of DP and esophageal body compliance.
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Affiliation(s)
- Sarvee Moosavi
- Division of Gastroenterology, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Christina Shehata
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Wenjun Kou
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Ikuo Hirano
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nirmala Gonsalves
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Stephanie Peterson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Carlson DA, Kahrilas PJ, Simlote A, Vespa E, Teitelbaum E, Hungness E, Kou W, Pandolfino JE. Identifying hiatal hernia with impedance planimetry during esophageal distension testing. Neurogastroenterol Motil 2023; 35:e14470. [PMID: 36168153 PMCID: PMC10078178 DOI: 10.1111/nmo.14470] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/29/2022] [Accepted: 09/12/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Functional luminal imaging probe (FLIP) Panometry evaluates the esophageal response to distension involving biomechanics and motility. We have observed that hiatus hernia (HH) is evident during FLIP studies as a separation between the crural diaphragm (CD) and lower esophageal sphincter (LES) like what is seen with high-resolution manometry (HRM). The aim of this study was to compare FLIP findings to endoscopy and HRM in the detection of HH. METHODS A total of 100 consecutive patients that completed FLIP during sedated endoscopy and HRM were included. LES-CD separation was assessed on FLIP and HRM with the presence of HH defined as LES-CD ≥1 cm. The agreement was evaluated using the kappa (κ) statistic. RESULTS Hiatal hernia was detected in 32% of patients on HRM and 44% of patients on FLIP with a substantial agreement between studies (84% agreement; κ = 0.667). On FLIP, a 'new' HH (i.e. HH not observed on HRM) occurred in 14 patients and an "enlarged" HH (i.e., LES-CD ≥2 cm larger than on HRM) occurred in 11 patients. Among patients that also completed, timed barium esophagogram (TBE), delayed esophageal emptying on TBE was more common in patients with new or enlarged HH on FLIP than those without: 7/11 (64%) versus 2/12 (17%); p = 0.017. CONCLUSION FLIP can detect HH with a substantial agreement with HRM, though esophageal distension with FLIP testing appeared to elicit and/or enlarge a HH in an additional 25% of patients. Although this unique response to esophageal distension may represent a mechanism of dysphagia or susceptibility to reflux, additional study is needed to clarify its significance.
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Affiliation(s)
- Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Aditi Simlote
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Edoardo Vespa
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Ezra Teitelbaum
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Eric Hungness
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Carlson DA, Schauer JM, Kou W, Kahrilas PJ, Pandolfino JE. Functional Lumen Imaging Probe Panometry Helps Identify Clinically Relevant Esophagogastric Junction Outflow Obstruction per Chicago Classification v4.0. Am J Gastroenterol 2023; 118:77-86. [PMID: 36002925 PMCID: PMC9822847 DOI: 10.14309/ajg.0000000000001980] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/10/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Esophagogastric junction (EGJ) outflow obstruction (EGJOO) per Chicago Classification v4.0 (CCv4.0) represents a high-resolution manometry (HRM) diagnosis with uncertain clinical significance. This study aimed to evaluate functional lumen imaging probe (FLIP) panometry among patients with EGJOO on HRM/CCv4.0 to assess clinical/manometric associations and treatment outcomes. METHODS An observational cohort study was performed on patients who completed FLIP during endoscopy and had an HRM/CCv4.0 diagnosis of EGJOO, i.e., HRM-EGJOO (inconclusive). Abnormal FLIP panometry motility classifications were applied to identify FLIP-confirmed conclusive EGJOO. Rapid drink challenge on HRM and timed barium esophagram were also assessed. Clinical management plan was determined by treating physicians and assessed through chart review. Clinical outcome was defined using the Eckardt score (ES) during follow-up evaluation: ES < 3 was considered a good outcome. RESULTS Of 139 adult patients with manometric EGJOO (inconclusive per CCv4.0), a treatment outcome ES was obtained in 55 after achalasia-type treatment (i.e., pneumatic dilation, peroral endoscopic myotomy, laparoscopic Heller myotomy, or botulinum toxin injection) and 36 patients after other nonachalasia-type treatment. Among patients with conclusive EGJOO by HRM-FLIP complementary impression, 77% (33/43) had a good outcome after achalasia-type treatment, whereas 0% (0/12) of patients had a good outcome after nonachalasia-type treatment. Of patients with normal EGJ opening on FLIP, one-third of patients treated with achalasia-type treatment had a good outcome, while 9 of the 10 treated conservatively had a good outcome. DISCUSSION FLIP panometry provides a useful complement to clarify the clinical significance of an HRM/CCv4.0 EGJOO diagnosis and help direct management decisions.
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Affiliation(s)
- Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jacob M. Schauer
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Wenjun Kou
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Peter J. Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
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22
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Patel D, Khodadadi A, Jadcherla A, Rengarajan A, Rogers BD, Gyawali CP. Chronic opioid users with dysphagia are indistinguishable from symptomatic nonusers on functional lumen imaging probe evaluation. Neurogastroenterol Motil 2022; 35:e14519. [PMID: 36578248 DOI: 10.1111/nmo.14519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/16/2022] [Accepted: 11/27/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Opioid-induced esophageal dysmotility (OIED) includes spastic esophageal motility disorders, increasingly recognized in the contemporary opioid epidemic. We assessed functional lumen imaging probe (FLIP) findings in diagnosing OIED. METHODS Symptomatic patients undergoing FLIP with no prior foregut surgery who completed validated questionnaires were identified and segregated into chronic opioid users and nonusers in this cohort study. Esophagogastric junction (EGJ) distensibility index (DI), EGJ diameter, and esophageal body contraction patterns were extracted. Symptom profiles were compared to FLIP findings between chronic opioid users and nonusers. Outcome was evaluated in a subset using the same validated questionnaires. RESULTS Over the 18-months study period, of 116 patients (median age 62 years, 70.7% female), 33 (28.4%) were chronic opioid users, with median morphine milligram equivalent of 30 mg. While presenting symptoms were similar, chronic opioid users reported higher perceptive symptoms (p = 0.008) and worse quality of life (p = 0.01) compared to nonusers. Median DI trended lower in chronic opioid users (p = 0.08), with more retrograde repetitive contractions (p < 0.001) and less absent contractility (p = 0.007), but final FLIP diagnoses were similar compared to nonusers. There was no correlation between opioid dose and FLIP metrics. In the subset with follow-up, perceptive symptoms trended higher in chronic opioid users (p = 0.08), but symptom improvement following therapy was similar in both groups. CONCLUSIONS & INFERENCES Symptomatic chronic opioid users have FLIP diagnoses that are similar to nonusers, despite higher perceptive symptoms and worse quality of life. Dominant symptoms improve both in chronic opioid users and nonusers following treatment directed by FLIP.
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Affiliation(s)
- Devan Patel
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Alexandra Khodadadi
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Aditya Jadcherla
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Arvind Rengarajan
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA.,Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
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High prevalence of gastrointestinal symptoms and undiagnosed eosino-philic esophagitis among allergic adults. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3325-3327.e1. [PMID: 36184025 DOI: 10.1016/j.jaip.2022.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/31/2022] [Accepted: 09/17/2022] [Indexed: 12/14/2022]
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Zifan A, Gandu V, Mittal RK. Esophageal wall compliance/stiffness during peristalsis in patients with functional dysphagia and high-amplitude esophageal contractions. Am J Physiol Gastrointest Liver Physiol 2022; 323:G586-G593. [PMID: 36283085 PMCID: PMC9678403 DOI: 10.1152/ajpgi.00075.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 10/14/2022] [Accepted: 10/18/2022] [Indexed: 01/31/2023]
Abstract
Recent studies that utilized distension/contraction plots to study peristalsis reveal poor distension of the esophagus in patients with functional dysphagia and high-amplitude contractions [high-amplitude esophageal contractions (HAECs)] even though the contraction phase of peristalsis is normal in these patients. Our goal was to determine biomechanical properties of the esophageal wall and bolus flow characteristics in patients with functional dysphagia and HAEC during primary peristalsis. Studies were performed on 30 healthy subjects, 30 patients with functional dysphagia, and 25 patients with HAEC. Subjects swallowed 10 mL, 0.5 N saline bolus in the Trendelenburg position to study primary peristalsis. A custom-built software (Dplots) determined peak distension from the impedance measurements, pressure at peak distension, wall tension (pressure × radius), wall distensibility [cross-sectional area (CSA)/pressure], and bolus flow (cm3/s) in four segments of esophagus (between upper and lower esophageal sphincter). Luminal CSA of distal esophagus was smaller, and average bolus flow rate was faster in patients with functional dysphagia and HAEC. Esophageal wall distensibility, a measure of esophageal wall compliance was lower and wall tension was higher in the distal esophagus of both patient groups compared with normal subjects. Ultrasound imaging confirmed poor distension of the esophagus. A trend toward greater wall thickness at the peak of distension was found in patients with functional dysphagia compared with normal subjects. A stiffer or noncompliant esophageal wall is the reason for poor distension of the esophagus during primary peristalsis in patients with functional dysphagia and HAEC.NEW & NOTEWORTHY We studied healthy asymptomatic subject, patients with functional dysphagia (FD), and patients with high-amplitude esophageal contractions (HAEC). Our data show that in patients with HAEC and functional dysphagia, luminal distension is smaller (low luminal CSA at peak distension), intraluminal pressure is higher, and liquid bolus travels faster through the esophagus as compared with normal subjects. We conclude that patients with functional dysphagia and HAEC have a stiffer distal esophageal wall during bolus transport related to primary peristalsis.
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Affiliation(s)
- Ali Zifan
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California
| | - Vignesh Gandu
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California
| | - Ravinder K Mittal
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California
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Chen K, Xing L, Xu B, Li Y, Liu T, Zhang T, Shi H, Lu H, Zhou W, Hou J, Shi H, Qin D. Research progress in the risk factors and screening assessment of dysphagia in the elderly. Front Med (Lausanne) 2022; 9:1021763. [PMID: 36419790 PMCID: PMC9676222 DOI: 10.3389/fmed.2022.1021763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 10/21/2022] [Indexed: 10/30/2023] Open
Abstract
With the aging of the population, the incidence of dysphagia has gradually increased and become a major clinical and public health issue. Early screening of dysphagia in high-risk populations is crucial to identify the risk factors of dysphagia and carry out effective interventions and health management in advance. In this study, the current epidemiology, hazards, risk factors, preventive, and therapeutic measures of dysphagia were comprehensively reviewed, and a literature review of screening instruments commonly used globally was conducted, focusing on their intended populations, main indicators, descriptions, and characteristics. According to analysis and research in the current study, previous studies of dysphagia were predominantly conducted in inpatients, and there are few investigations and screenings on the incidence and influencing factors of dysphagia in the community-dwelling elderly and of dysphagia developing in the natural aging process. Moreover, there are no unified, simple, economical, practical, safe, and easy-to-administer screening tools and evaluation standards for dysphagia in the elderly. It is imperative to focus on dysphagia in the community-dwelling elderly, develop unified screening and assessment tools, and establish an early warning model of risks and a dietary structure model for dysphagia in the community-dwelling elderly.
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Affiliation(s)
- Kerong Chen
- Department of Rehabilitation Medicine, The Third People’s Hospital of Yunnan Province, Kunming, China
| | - Liwei Xing
- The First School of Clinical Medicine, Yunnan University of Chinese Medicine, Kunming, China
| | - Bonan Xu
- School of Basic Medical Sciences, Yunnan University of Chinese Medicine, Kunming, China
| | - Yi Li
- Department of Rehabilitation Medicine, The Third People’s Hospital of Yunnan Province, Kunming, China
| | - Tianyun Liu
- Department of Rehabilitation Medicine, The Third People’s Hospital of Yunnan Province, Kunming, China
| | - Tingjuan Zhang
- Department of Rehabilitation Medicine, The Third People’s Hospital of Yunnan Province, Kunming, China
| | - Hongping Shi
- Department of Rehabilitation Medicine, The Third People’s Hospital of Yunnan Province, Kunming, China
| | - Hanmei Lu
- Department of Rehabilitation Medicine, The Third People’s Hospital of Yunnan Province, Kunming, China
| | - Wengang Zhou
- Department of Medical, The Third People’s Hospital of Yunnan Province, Kunming, China
| | - Jianhong Hou
- Department of Orthopedics, The Third People’s Hospital of Yunnan Province, Kunming, China
| | - Hongling Shi
- Department of Rehabilitation Medicine, The Third People’s Hospital of Yunnan Province, Kunming, China
| | - Dongdong Qin
- School of Basic Medical Sciences, Yunnan University of Chinese Medicine, Kunming, China
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Pandolfino JE, Carlson DA, McGarva J, Kahrilas PJ, Vaezi M, Katzka D, Taft TH. Validation of the Achalasia Patient-Reported Outcomes Questionnaire. Aliment Pharmacol Ther 2022; 56:1434-1443. [PMID: 36127750 PMCID: PMC9826373 DOI: 10.1111/apt.17230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/18/2022] [Accepted: 09/09/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Achalasia is a debilitating major motor disorder of the oesophagus. Hypervigilance and symptom-specific anxiety substantially impact dysphagia symptom reporting, and quality of life is a critical patient outcome. Earlier achalasia symptom scales did not consider these constructs in their psychometric development. AIM To develop a new symptom measure, the Achalasia Patient-Reported Outcomes (APRO) Questionnaire METHODS: Four gastroenterologists with achalasia expertise generated preliminary items. Patients reviewed items via cognitive interviews. Patients undergoing high-resolution manometry completed the APRO with Oesophageal Hypervigilance and Anxiety Scale, Northwestern Oesophageal Quality of Life Scale, and three measures of reflux and dysphagia. Full APRO psychometric assessment (reliability, validity, factor structure) was done. Cluster analysis evaluated APRO + symptom-anxiety/hypervigilance patient phenotypes. RESULTS We included 961 patients with normal motility and 296 with achalasia. The APRO yielded three subscales: dysphagia, reflux, chest pain with two items for weight change and diet modifications. Reliability and validity were excellent. Twenty-five percent of achalasia patients may have high levels of anxiety/hypervigilance despite low symptoms, while 8% may report severe symptoms with low anxiety/hypervigilance. The APRO significantly predicted quality of life, but less cognitive-affective processes. CONCLUSIONS The APRO is a reliable and valid measure of achalasia symptoms that addresses the limitations of existing questionnaires. Symptom anxiety and hypervigilance moderate the relationship between APRO and quality of life; 33% of patients with achalasia exhibit concerning patterns in symptom severity, anxiety and hypervigilance that may contribute to poorer outcomes.
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Affiliation(s)
- John E. Pandolfino
- Division of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Dustin A. Carlson
- Division of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Josie McGarva
- Division of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Peter J. Kahrilas
- Division of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Michael Vaezi
- Division of GastroenterologyVanderbildt University Medical CenterNashvilleTennesseeUSA
| | - David Katzka
- Division of GastroenterologyMayo ClinicRochesterMinnesotaUSA
| | - Tiffany H. Taft
- Division of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
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Dysphagia Worsens With Increasing Ineffective Swallows Among Patients With Ineffective Esophageal Motility. J Clin Gastroenterol 2022:00004836-990000000-00045. [PMID: 35960530 DOI: 10.1097/mcg.0000000000001738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 06/15/2022] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Ineffective esophageal motility (IEM) is the most common motility disorder identified on esophageal high-resolution manometry (HRM), but patients with this finding may be asymptomatic. Therefore, we aimed to identify specific HRM findings predictive of symptoms in IEM. METHODS Adult patients (≥18 y) who underwent HRM between March 2016 and July 2019 were retrospectively evaluated and reclassified according to Chicago Classification 4.0 (CC4.0). Demographic information, HRM parameters, and gastroesophageal reflux disease Health-Related Quality of Life Questionnaire responses were captured among those with normal manometry or IEM. We evaluated the association between heartburn, regurgitation, and dysphagia, with respect to HRM findings including ineffective swallows. RESULTS Of 379 patients, 243 (64.1%) had a normal manometry, 136 (35.9%) were on IEM spectrum, and 73 (19.3%) had conclusive IEM by CC4.0. Mean dysphagia scores were significantly higher in those with conclusive IEM compared with those with normal HRM (2.00 vs. 1.36, P=0.002), as was the percentage of individuals reporting dysphagia affecting daily activities (21.9% vs. 11.4%, P=0.02). Heartburn and regurgitation symptoms did not differ between groups. In a multivariable model of IEM patients, the percentage of ineffective swallows independently predicted a higher dysphagia burden (β regression coefficient: 0.032, P=0.04). CONCLUSIONS Applying the CC4.0 definition for conclusive IEM identifies a group of patients with worse dysphagia symptoms. Within this group, the percentage of ineffective swallows was an independent predictor of dysphagia severity. These findings may help practitioners and patients contextualize the heterogeneous diagnosis of IEM.
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Carlson DA, Shehata C, Gonsalves N, Hirano I, Peterson S, Prescott J, Farina DA, Schauer JM, Kou W, Kahrilas PJ, Pandolfino JE. Esophageal Dysmotility Is Associated With Disease Severity in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2022; 20:1719-1728.e3. [PMID: 34768010 PMCID: PMC9081296 DOI: 10.1016/j.cgh.2021.11.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/26/2021] [Accepted: 11/01/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS An association of eosinophilic esophagitis (EoE) with esophageal dysmotility has been described, however, the related mechanism remains unclear. We aimed to evaluate clinical and physiologic characteristics, including esophageal distensibility, associated with secondary peristalsis in patients with EoE. METHODS A total of 199 consecutive adult patients with EoE (age, 18-78 y; 32% female) who completed a 16-cm functional luminal imaging probe (FLIP) during endoscopy were evaluated in a cross-sectional study. FLIP panometry contractile response (CR) patterns were classified as normal CR or borderline CR if antegrade contractions were present, and abnormal CRs included impaired/disordered CR, absent CR, or spastic-reactive CR. The distensibility plateau of the esophageal body and esophagogastric junction distensibility was measured with FLIP. RESULTS FLIP CR patterns included 68 (34%) normal CR, 65 (33%) borderline CR, 44 (22%) impaired/disordered CR, 16 (8%) absent CR, and 6 (3%) spastic-reactive CR. Compared with normal CRs, abnormal CRs more frequently had reduced esophageal distensibility (distensibility plateau <17 mm in 56% vs 32%), greater total EoE reference scores (median, 5; interquartile range [IQR], 3-6 vs median, 4; IQR, 3-5) with more severe ring scores, and a greater duration of symptoms (median, 10 y; IQR, 4-23 y vs median, 7 y; IQR, 3-15 y). Mucosal eosinophil density, however, was similar between abnormal CRs and normal CRs (median, 34 eosinophils/high-power field [hpf]; IQR, 14-60 eosinophils/hpf vs median, 25 eosinophils/hpf; IQR, 5-50 eosinophils/hpf). CONCLUSIONS Although normal secondary peristalsis was observed frequently in this EoE cohort, abnormal esophageal CRs were related to EoE disease severity, especially features of fibrostenosis. This study evaluating secondary peristalsis in EoE suggests that esophageal wall remodeling, rather than eosinophilic inflammatory intensity, was associated with esophageal dysmotility in EoE.
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Affiliation(s)
- DA Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - C Shehata
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - N Gonsalves
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - I Hirano
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - S Peterson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - J Prescott
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - DA Farina
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - JM Schauer
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - W Kou
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - PJ Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - JE Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Carlson DA, Prescott JE, Baumann AJ, Schauer JM, Krause A, Donnan EN, Kou W, Kahrilas PJ, Pandolfino JE. Validation of Clinically Relevant Thresholds of Esophagogastric Junction Obstruction Using FLIP Panometry. Clin Gastroenterol Hepatol 2022; 20:e1250-e1262. [PMID: 34216821 PMCID: PMC8716679 DOI: 10.1016/j.cgh.2021.06.040] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/23/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS This study aimed to assess the accuracy of functional luminal imaging probe (FLIP) panometry to detect esophagogastric junction (EGJ) obstruction assigned by high-resolution manometry (HRM) and the Chicago Classification version 4.0 (CCv4.0). METHODS Six hundred eighty-seven adult patients who completed FLIP and HRM for primary esophageal motility evaluation and 35 asymptomatic volunteers (controls) were included. EGJ opening was evaluated with 16-cm FLIP during sedated endoscopy via EGJ-distensibility index (DI) and maximum EGJ diameter. HRM was classified according to CCv4.0 and focused on studies with a conclusive disorder of EGJ outflow (ie, achalasia subtypes I, II, or III; or EGJ outflow obstruction with abnormal timed barium esophagogram) or normal EGJ outflow. RESULTS All 35 controls had EGJ-DI >3.0 mm2/mmHg and maximum EGJ diameter >16 mm. Per HRM and CCv4.0, 245 patients had a conclusive disorder of EGJ outflow, and 314 patients had normal EGJ outflow. Among the 241 patients with reduced EGJ opening (EGJ-DI <2.0 mm2/mmHg and maximum EGJ diameter <12 mm) on FLIP panometry, 86% had a conclusive disorder of EGJ outflow per CCv4.0. Among the 203 patients with normal EGJ opening (EGJ-DI ≥2.0 mm2/mmHg and maximum EGJ diameter ≥16 mm) on FLIP panometry, 99% had normal EGJ outflow per CCv4.0. CONCLUSIONS FLIP panometry accurately identified clinically relevant conclusive EGJ obstruction as defined by CCv4.0 in patients evaluated for esophageal motor disorders. Thus, FLIP panometry is a valuable tool for both independent and complementary evaluation of esophageal motility.
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Affiliation(s)
- Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jacqueline E Prescott
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alexandra J. Baumann
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jacob M. Schauer
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Amanda Krause
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Erica N. Donnan
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Wenjun Kou
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Peter J Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Savarino E, Bhatia S, Roman S, Sifrim D, Tack J, Thompson SK, Gyawali CP. Achalasia. Nat Rev Dis Primers 2022; 8:28. [PMID: 35513420 DOI: 10.1038/s41572-022-00356-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 02/07/2023]
Abstract
Achalasia is a rare disorder of the oesophageal smooth muscle characterized by impaired relaxation of the lower oesophageal sphincter (LES) and absent or spastic contractions in the oesophageal body. The key pathophysiological mechanism is loss of inhibitory nerve function that probably results from an autoimmune attack targeting oesophageal myenteric nerves through cell-mediated and, possibly, antibody-mediated mechanisms. Achalasia incidence and prevalence increase with age, but the disorder can affect all ages and both sexes. Cardinal symptoms consist of dysphagia, regurgitation, chest pain and weight loss. Several years can pass between symptom onset and an achalasia diagnosis. Evaluation starts with endoscopy to rule out structural causes, followed by high-resolution manometry and/or barium radiography. Functional lumen imaging probe can provide complementary evidence. Achalasia subtypes have management and prognostic implications. Although symptom questionnaires are not useful for diagnosis, the Eckardt score is a simple symptom scoring scale that helps to quantify symptom response to therapy. Oral pharmacotherapy is not particularly effective. Botulinum toxin injection into the LES can temporize symptoms and function as a bridge to definitive therapy. Pneumatic dilation, per-oral endoscopic myotomy and laparoscopic Heller myotomy can provide durable symptom benefit. End-stage achalasia with a dilated, non-functioning oesophagus may require oesophagectomy or enteral feeding into the stomach. Long-term complications can, rarely, include oesophageal cancer, but surveillance recommendations have not been established.
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Affiliation(s)
- Edoardo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova (AOUP), Padua, Italy. .,Department of Surgery, Oncology and Gastroenterology (DiSCOG), University of Padua, Padua, Italy.
| | - Shobna Bhatia
- Department of Gastroenterology, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Sabine Roman
- Hospices Civils de Lyon, Digestive Physiology, Hopital E Herriot, Lyon, France.,Université Lyon 1, Villeurbanne, France.,Inserm U1032, LabTAU, Lyon, France
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | - Jan Tack
- Division of Gastroenterology, University Hospital of Leuven, Leuven, Belgium
| | - Sarah K Thompson
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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Esophageal dysphagia in neuromuscular disorder patients with validity and reliability study of the brief esophageal dysphagia questionnaire. Acta Neurol Belg 2022; 122:315-324. [PMID: 33389721 DOI: 10.1007/s13760-020-01563-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
Esophageal dysphagia (ED) is often underestimated in neuromuscular disorders (NMD) and it is important to evaluate the esophageal phase of swallowing with an easy and rapid screening test. We aimed both to assess the prevalence of ED in NMD and to perform validity and reliability study of the brief easophageal dysphagia questionnaire (BEDQ) screening test in NMD patients. This prospective cross-sectional clinical study was performed on NMD patients. Demographic features and disease characteristics were recorded. Endoscopic evaluation for oropharyngeal dysphagia (OD) and high-resolution esophageal manometry for ED were performed. In addition, the BEDQ and the 10-item eating assessment tool (EAT-10) were used to all subjects. Cronbach's α and principle components factor analysis (PFCA) with varimax rotation were used for reliability. The Chicago Classification version 3 (CCv3) level (high-resolution esophageal manometry) and EAT-10 was used for validity. A total of 50 patients were included in the study. Thirty-four (68%) patients were diagnosed with myasthenia gravis and 16 (32%) patients were diagnosed with myopathy. Esophageal dysphagia according to the CCv3 was found in 33 (66%) of patients. While the Cronbach's α was excellent as 0.937 for test overall the T-BEDQ scale. The PCFA included all scale items and resulted in a single factor (eigenvalue = 5.72, 71.5%). The all BEDQ scores were demonstrated good correlation with EAT-10 score and very good correlation with CCv3 level. Evaluation of swallowing in patients with NMD should include not only the oropharyngeal phase of swallowing, but also esophageal phase. For this purpose, the BEDQ can be used as a rapid, valid, and reliable test for the evaluation of ED.
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Cisternas D, Taft T, Carlson DA, Glasinovic E, Monrroy H, Rey P, Hani A, Ardila-Hani A, Leguizamo AM, Bilder C, Ditaranto A, Varela A, Agotegaray J, Remes-Troche JM, de León AR, de la Serna JP, Marin I, Serra J. The Brief Esophageal Dysphagia Questionnaire shows better discriminative capacity for clinical and manometric findings than the Eckardt score: Results from a multicenter study. Neurogastroenterol Motil 2022; 34:e14228. [PMID: 34342075 DOI: 10.1111/nmo.14228] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/08/2021] [Accepted: 07/07/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Grading dysphagia is crucial for clinical management of patients. The Eckardt score (ES) is the most commonly used for this purpose. We aimed to compare the ES with the recently developed Brief Esophageal Dysphagia Questionnaire (BEDQ) in terms of their correlation and discriminative capacity for clinical and manometric findings and evaluate the effect of gastroesophageal reflux symptoms on both. METHODS Symptomatic patients referred for high-resolution manometry (HRM) were prospectively recruited from seven centers in Spain and Latin America. Clinical data and several scores (ES, BEDQ, GERDQ) were collected and contrasted to HRM findings. Standard statistical analysis was performed. KEY RESULTS 426 patients were recruited, 31.2% and 41.5% being referred exclusively for dysphagia and GERD symptoms, respectively. Both BEDQ and ES were independently associated with achalasia. Only BEDQ was independently associated with being referred for dysphagia and with relevant HRM findings. ROC curve analysis for achalasia diagnosis showed AUC of 0.809 for BEDQ and 0.765 for ES, with the main difference being higher BEDQ sensitivity (80.0% vs 70.8% for ES). GERDQ independently predicted ES but not BEDQ. In the absence of dysphagia (BEDQ = 0), GERD symptoms significantly determine ES. CONCLUSIONS AND INFERENCES Our study suggests both the BEDQ and ES can complementarily describe symptomatic burden in achalasia. BEDQ has several advantages over the ES in the dysphagia evaluation, basically due to its higher sensitivity for manometric diagnosis and independence of GERD symptoms. ES should be used as an achalasia-specific metric, while BEDQ is a better symptom-generic evaluating tool.
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Affiliation(s)
- Daniel Cisternas
- Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Tiffany Taft
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Esteban Glasinovic
- Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Hugo Monrroy
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Paula Rey
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Albis Hani
- San Ignacio Hospital, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Andres Ardila-Hani
- San Ignacio Hospital, Pontificia Universidad Javeriana, Bogota, Colombia
| | | | - Claudio Bilder
- Hospital Universitario, Escuela de Medicina, Fundación Favaloro, Buenos Aires, Argentina
| | - Andres Ditaranto
- Hospital Universitario, Escuela de Medicina, Fundación Favaloro, Buenos Aires, Argentina
| | - Amanda Varela
- Hospital Universitario, Escuela de Medicina, Fundación Favaloro, Buenos Aires, Argentina
| | - Joaquin Agotegaray
- Hospital Universitario, Escuela de Medicina, Fundación Favaloro, Buenos Aires, Argentina
| | | | | | | | - Ingrid Marin
- University Hospital Germans Trias i Pujol, Motility and Functional Gut Disorders Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universitat Autonoma de Barcelona, Badalona, Spain
| | - Jordi Serra
- Digestive System Research Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Hospital Vall d'Hebron, Barcelona, Spain
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Neuwald Pauletti R, Callegari-Jacques SM, Fornari L, de Moraes JI, Fornari F. Reduced masticatory function predicts gastroesophageal reflux disease and esophageal dysphagia in patients referred for upper endoscopy: A cross-sectional study. Dig Liver Dis 2022; 54:331-335. [PMID: 34645595 DOI: 10.1016/j.dld.2021.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The role of mastication on gastroesophageal reflux disease (GERD) is unknown. AIMS To assess whether reduced masticatory function predicts GERD and esophageal dysphagia in patients investigated with upper endoscopy. METHODS In this cross-sectional study, 179 adult patients referred for elective upper gastrointestinal endoscopy agreed to participate. Before endoscopy, an expert dentist performed an oral examination and scored chewing function in three levels (normal, regular, and reduced). Patients replied questionnaires for assessment of GERD (heartburn, regurgitation, and dysphagia), xerostomia, and mastication (normal, regular, and reduced). Poor chewing was defined when either oral examination or mastication questionnaire rated the chewing function as reduced. Associations of mastication with GERD and dysphagia were estimated using Poisson regression. RESULTS Eleven patients were excluded. Among 168 analyzed (aging 49.8 ± 15.5 years; 58.9% women), 46 had reduced masticatory function (27.4%), and 122 had regular/normal mastication (72.6%). Reduced mastication was associated with GERD [PR = 1.38 (95%CI 1.12 - 1.70)], adjusting for age, and with esophageal dysphagia [PR = 2.03 (95%CI 1.02 - 4.04)], adjusting for age and xerostomia. CONCLUSIONS In outpatients referred for upper gastrointestinal endoscopy, reduced masticatory function defined by an expert dentist may be a risk factor for GERD and esophageal dysphagia.
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Affiliation(s)
- Roberta Neuwald Pauletti
- Programa de Pós-Graduação em Odontologia, Faculdade de Odontologia, Universidade de Passo Fundo (UPF), Passo Fundo-RS, Brazil
| | | | | | | | - Fernando Fornari
- Programa de Pós-Graduação em Odontologia, Faculdade de Odontologia, Universidade de Passo Fundo (UPF), Passo Fundo-RS, Brazil; Faculdade de Medicina, UPF, Passo Fundo, Brazil; Clínica Endopasso, Passo Fundo, Brazil.
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Rhythmic contraction but arrhythmic distension of esophageal peristaltic reflex in patients with dysphagia. PLoS One 2022; 17:e0262948. [PMID: 35073388 PMCID: PMC8786162 DOI: 10.1371/journal.pone.0262948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 01/07/2022] [Indexed: 12/12/2022] Open
Abstract
Background Reason for dysphagia in a significant number of patients remains unclear even after a thorough workup. Each swallow induces esophageal distension followed by contraction of the esophagus, both of which move sequentially along the esophagus. Manometry technique and current system of classifying esophageal motility disorders (Chicago Classification) is based on the analysis of the contraction phase of peristalsis. Goal Whether patients with unexplained dysphagia have abnormalities in the distension phase of esophageal peristalsis is not known. Methods Using Multiple Intraluminal esophageal impedance recordings, which allow determination of the luminal cross-sectional area during peristalsis, we studied patients with nutcracker esophagus (NC), esophagogastric junction outflow obstruction (EGJOO), and functional dysphagia (FD). Results Distension contraction plots revealed that swallowed bolus travels significantly faster through the esophagus in all patient groups as compared to normals. The luminal cross-sectional area (amplitude of distension), and the area under the curve of distension were significantly smaller in patients with NC, EGJOO, and FD as compared to normals. Bolus traverses the esophagus in the shape of an “American Football” in normal subjects. On the other hand, in patients the bolus flow was fragmented. ROC curves revealed that bolus flow abnormalities during peristalsis are a sensitive and specific marker of dysphagia. Conclusion Our findings reveal abnormality in the distension phase of peristalsis (a narrow lumen esophagus) in patients with dysphagia. We propose that the esophageal contraction forcing the swallowed bolus through a narrow lumen esophagus is the cause of dysphagia sensation in patients with normal contraction phase of peristalsis.
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Taft TH, Guadagnoli L, Carlson DA, Kou W, Keefer L, Pandolfino J. Validation of the Short-Form Esophageal Hypervigilance and Anxiety Scale. Clin Gastroenterol Hepatol 2022; 20:e64-e73. [PMID: 33348046 PMCID: PMC8275671 DOI: 10.1016/j.cgh.2020.12.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophageal hypervigilance and anxiety are emerging as important drivers of dysphagia symptoms and reduced quality of life across esophageal diagnoses. The esophageal hypervigilance and anxiety scale (EHAS) is a validated measure of these cognitive-affective processes. However, its length may preclude it from use in clinical practice. We aimed to create a short form version of the EHAS using established psychometric practices. METHODS A retrospective review of a registry of patients who visited a university-based esophageal motility clinic for diagnostic testing was conducted. Patients were included if they completed the 15-item EHAS and questionnaires assessing dysphagia severity and health-related quality of life (HRQOL) at the time of motility testing. Principle components factor analysis identified items for possible removal. Tests for reliability and concurrent validity were performed on the full EHAS and short-form version (EHAS-7). RESULTS 3,976 adult patients with confirmed esophageal disease were included: 30% with achalasia or EGJOO, 13% with EoE, 13% with GERD, 39% normal motility. Eight items were removed from the scale based on a factor loading of > 0.70, resulting in a single scale 7-item EHAS-7 scored from 0 to 28. The EHAS-7 demonstrated excellent internal consistency (α = 0.91) and split-half reliability (0.88) as was found in the full EHAS in the current study and prior validation. Concurrent validity existed between the EHAS-7 and measures of dysphagia (r = 0.33) and HRQOL (r = -0.73, both P < .001). CONCLUSIONS The EHAS-7 is a 7-item scale to assess esophageal hypervigilance and symptom-specific anxiety that performs as well as the original 15-item version. Shorter questionnaires allow for implementation in clinical practice. The EHAS-7 is a useful tool for clinicians to quickly assess how hypervigilance and anxiety may be contributing to their patients' clinical presentations.
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Affiliation(s)
- Tiffany H. Taft
- Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | | | - Dustin A. Carlson
- Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Walter Kou
- Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Laurie Keefer
- Mount Sinai Icahn School of Medicine, New York, NY USA
| | - John Pandolfino
- Northwestern University Feinberg School of Medicine, Chicago, IL USA
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Zifan A, Muta K, Mittal RK. Distension-contraction profile of peristalsis in patients with nutcracker esophagus. Neurogastroenterol Motil 2021; 33:e14138. [PMID: 33818858 PMCID: PMC8490481 DOI: 10.1111/nmo.14138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/10/2021] [Accepted: 03/09/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION High amplitude peristaltic esophageal contractions, that is, nutcracker esophagus, were originally described in association with "angina-like pain" of esophageal origin. However, significant number of nutcracker patients also suffer from dysphagia. High-resolution esophageal manometry (HRM) assesses only the contraction phase of peristalsis. The degree of esophageal distension during peristalsis is a surrogate of relaxation and can be measured from the intraluminal esophageal impedance measurements. AIMS Determine the amplitude of distension and temporal relationship between distension and contraction during swallow-induced peristalsis in nutcracker patients. METHODS HRM impedance (HRMZ) studies were performed and analyzed in 24 nutcracker and 30 normal subjects in the Trendelenburg position. A custom-built software calculated the numerical data of the amplitudes of distension and contraction, the area under the curve (AUC) of distension and contraction, and the temporal relationship between distension and contraction. RESULTS In normal subjects, the distension peaks similar to contraction traverse sequentially the esophagus. The amplitude of contraction is greater in the nutcracker esophagus but the amplitude of distension and area under the curve of distension are smaller in patients compared to controls. Distension peaks are aligned closely with contraction in normal subjects, but in patients, the bolus travels faster to the distal esophagus, resulting in a smaller time interval between the onset of swallow and distension peak. Receiver operative characteristics (ROC) curve reveals high sensitivity and specificity of the above parameters in patients. CONCLUSION Abnormalities in the distension phase of peristalsis are a possible mechanism of dysphagia in patients with nutcracker esophagus.
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Affiliation(s)
- Ali Zifan
- Division of Gastroenterology Department of Medicine University of California San Diego San Diego CA USA
| | - Kazumasa Muta
- Division of Gastroenterology Department of Medicine University of California San Diego San Diego CA USA
| | - Ravinder K. Mittal
- Division of Gastroenterology Department of Medicine University of California San Diego San Diego CA USA
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Predictors of Abnormal Functional Luminal Impedance Planimetry Findings in Non-mechanical Esophagogastric Junction Outflow Obstruction. Dig Dis Sci 2021; 66:3968-3975. [PMID: 33249528 PMCID: PMC8248766 DOI: 10.1007/s10620-020-06726-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/17/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Esophagogastric junction outflow obstruction (EGJOO) is a common but nonspecific motility pattern identified by esophageal high-resolution manometry (HRM). Functional luminal impedance planimetry (FLIP) provides information regarding lower esophageal sphincter (LES) mechanics, which can identify achalasia spectrum disorders and is useful in evaluating EGJOO. However, the relationship between HRM and FLIP parameters in EGJOO is not clearly defined. AIMS To identify predictors of abnormal FLIP findings in patients with non-mechanical EGJOO. METHODS This is a retrospective cohort study of patients with non-mechanical EGJOO who underwent FLIP between 10/1/16 and 7/1/19. Demographic data including age and gender, examination indication, concomitant medications, HRM parameters, symptom burden, and FLIP metrics of diameter and distensibility index (DI) were collected. DI was categorized as not low (DI > 2.8), borderline low (DI 1.1-2.8), and definitely low (DI ≤ 1). Kruskal-Wallis and Fisher's exact tests were used to assess the relationship between HRM and FLIP parameters and to identify predictors of abnormal FLIP. RESULTS Among the 44 patients studied, most were female (n = 33, 75%) and the median age was 63. The median IRP was 18.2, and 10 (23%) patients used chronic narcotics. Lower total heartburn and regurgitation scores, and LES diameter by FLIP are associated with definitely low DI. CONCLUSIONS In patients with non-mechanical EGJOO, reflux burden scores and FLIP diameters can aid in predicting DI. These results may provide useful adjunctive data to help in differentiating which patients have meaningful outflow obstruction.
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Xiao Y, Carlson DA, Pandolfino JE. Symptom Severity Related With Contraction Peaks in Patients With Jackhammer Esophagus. J Neurogastroenterol Motil 2021; 27:540-544. [PMID: 34642274 PMCID: PMC8521457 DOI: 10.5056/jnm20229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/05/2021] [Accepted: 04/23/2021] [Indexed: 11/20/2022] Open
Abstract
Background/Aims Jackhammer esophagus is an uncommon heterogeneous motility disorder associated with a distal contractile integral > 8000 mmHg∙sec∙cm. The spectrum of abnormality ranges from a relatively normal looking contraction to chaotic repetitive contractions akin to a jackhammer. Although previous studies have shown an uncertain correlation between peristaltic vigor and symptoms, we hypothesize that symptoms may be more severe with repetitive contractions as opposed to an elevated contractile measure. Thus, this study aims to investigate whether symptom severity is related to the contraction pattern in the patients with hypercontractile esophagus. Methods Patients with hypercontractile esophagus were retrospectively identified, their demographic and high-resolution manometry characteristics were collected. Contraction pattern on high-resolution manometry was categorized into single-peak and multiple-peak. Comparison was performed between patients with single-peak and multiple-peak. Results Altogether 35 patients (age range, 45-70 years; femalemale, 2411) were included. Seven patients presented with single-peak hypercontractile swallows, while 28 patients presented with multiple-peak hypercontractile swallows. The patients with multiple-peak showed higher Brief Esophageal Dysphagia Questionnaire scores compared with patients with single-peak. The jackhammer swallows with multiple-peak were associated with higher distal contractile integral values, longer distal latency intervals, and a lower integrated relaxation pressure. Conclusions Repetitive contractions akin to a jackhammer were common amongst patients with hypercontractile esophagus. Patients with the jackhammer pattern also presented with more severe symptoms. Further distinction of hypercontractile esophagus into a jackhammer dominant subtype may be warranted.
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Affiliation(s)
- Yinglian Xiao
- Department of Gastroenterology and Hepatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dustin A Carlson
- Department of Medicine, the Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E Pandolfino
- Department of Medicine, the Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Taft TH, Carlson DA, Simons M, Zavala S, Hirano I, Gonsalves N, Pandolfino JE. Esophageal Hypervigilance and Symptom-Specific Anxiety in Patients with Eosinophilic Esophagitis. Gastroenterology 2021; 161:1133-1144. [PMID: 34153298 PMCID: PMC8463417 DOI: 10.1053/j.gastro.2021.06.023] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/01/2021] [Accepted: 06/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patient symptom reporting often does not correlate with the pathophysiological markers of esophageal disease, including eosinophilic esophagitis (EoE). Esophageal hypervigilance and symptom-specific anxiety are emerging as important considerations in understanding symptom reporting. As such, we aimed to conduct the first study of these constructs in EoE. METHODS A retrospective review of an EoE patient registry was conducted and included eosinophils per high power field (from esophagogastroduodenoscopy biopsy: proximal, distal), endoscopic reference score, distal distensibility plateau (functional luminal imaging probe), Brief Esophageal Dysphagia Questionnaire, Visual Dysphagia Question of EoE Activity Index, Northwestern Esophageal Quality of Life scale, and the Esophageal Hypervigilance and Anxiety Scale. Correlational and regression analyses evaluated relationships of hypervigilance and anxiety with Brief Esophageal Dysphagia Questionnaire, Visual Dysphagia Question of EoE Activity Index, and Northwestern Esophageal Quality of Life scale when controlling for histology and endoscopic severity. RESULTS One hundred and three patients had complete data, 69.9% were male, and the mean (SD) age was 40.66 (13.85) years. Forty-one percent had elevated dysphagia and 46% had elevated hypervigilance and anxiety. Esophageal symptom-specific anxiety emerged as the most important predictor of Brief Esophageal Dysphagia Questionnaire severity (44.8% of the variance), Visual Dysphagia Question of EoE Activity Index severity (26%), and poor health-related quality of life (HRQoL) (55.3%). Hypervigilance was also important, but to a lesser extent. Pathophysiological variables did not significantly predict symptoms or HRQoL. Recent food impaction can predict symptom-specific anxiety and proton pump inhibitor use can reduce hypervigilance. CONCLUSIONS Hypervigilance and symptom-specific anxiety are important for our understanding of self-reported patient outcomes in EoE. These processes outweigh endoscopic and histologic markers of EoE disease activity across dysphagia, difficulty eating, and HRQoL. Clinicians should assess hypervigilance and anxiety, especially in patients with refractory symptoms and poor HRQoL.
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Carlson DA, Baumann AJ, Donnan EN, Krause A, Kou W, Pandolfino JE. Evaluating esophageal motility beyond primary peristalsis: Assessing esophagogastric junction opening mechanics and secondary peristalsis in patients with normal manometry. Neurogastroenterol Motil 2021; 33:e14116. [PMID: 33705590 PMCID: PMC8433263 DOI: 10.1111/nmo.14116] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/11/2021] [Accepted: 02/14/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Functional luminal imaging probe (FLIP) Panometry assesses the esophageal response to distention and may complement the assessment of primary peristalsis on high-resolution manometry (HRM). We aimed to investigate whether FLIP Panometry provides complementary information in patients with normal esophageal motility on HRM. METHODS Adult patients that completed FLIP and had an HRM classification of normal motility were retrospectively identified for inclusion. 16-cm FLIP studies performed during endoscopy were evaluated to assess EGJ distensibility, secondary peristalsis, and identify an abnormal response to distention involving sustained LES contraction (sLESC). Clinical characteristics and esophagram were assessed when available. KEY RESULTS Of 164 patients included (mean(SD) age 48(16) years, 75% female), 111 (68%) had normal Panometry with EGJ-distensibility index (DI) ≥2.0 mm2 /mmHg, maximum EGJ diameter ≥16mm and antegrade contractions. Abnormal EGJ distensibility was observed in 44/164 (27%), and 38/164 (23%) had an abnormal contractile response to distension. sLESC was observed in 11/164 (7%). Among 68 patients that completed esophagram, abnormal EGJ distensibility was more frequently observed with an abnormal esophagram than normal EGJ opening: 14/23 (61%) vs 10/45 (22%); P=0.003. Epiphrenic diverticula were present in 3/164 patients: 2/3 had sLESC. CONCLUSIONS & INFERENCES Symptomatic patients with normal esophageal motility on HRM predominantly have normal FLIP Panometry; however, abnormal FLIP findings can be observed. While abnormal Panometry findings appear clinically relevant via an association with abnormal bolus retention, complementary tests, such as provocative maneuvers with HRM and timed barium esophagram, are useful to determine clinical context.
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Affiliation(s)
| | | | - Erica N. Donnan
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Amanda Krause
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Wenjun Kou
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Cisternas D, Taft T, Carlson DA, Glasinovic E, Monrroy H, Rey P, Hani A, Ardila-Hani A, Leguizamo AM, Bilder C, Ditaranto A, Varela A, Agotegaray J, Remes-Troche JM, Ruiz de León A, Pérez de la Serna J, Marin I, Serra J. The Spanish version of the esophageal hypervigilance and anxiety score shows strong psychometric properties: Results of a large prospective multicenter study in Spain and Latin America. Neurogastroenterol Motil 2021; 33:e14102. [PMID: 33580617 DOI: 10.1111/nmo.14102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/16/2021] [Accepted: 01/29/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Anxiety is a significant modulator of sensitivity along the GI tract. The recently described Esophageal Hypervigilance and Anxiety Score (EHAS) evaluates esophageal-specific anxiety. The aims of this study were as follows: 1. translate and validate an international Spanish version of EHAS. 2. Evaluate its psychometric properties in a large Hispano-American sample of symptomatic individuals. METHODS A Spanish EHAS version was developed by a Delphi process and reverse translation. Patients referred for high-resolution manometry (HRM) were recruited prospectively from seven Spanish and Latin American centers. Several scores were used: EHAS, Hospital Anxiety and Depression Scale (HADS), Eckardt score (ES), Gastroesophageal Reflux Questionnaire (GERDQ), and the Brief Esophageal Dysphagia Questionnaire (BEDQ). Standardized psychometric analyses were performed. KEY RESULTS A total of 443 patients were recruited. Spanish EHAS showed excellent reliability (Cronbach´s alpha = 0.94). Factor analysis confirmed the presence of two factors, corresponding to the visceral anxiety and hypervigilance subscales. Sufficient convergent validity was shown by moderate significant correlations between EHAS and other symptomatic scores. Patients with high EHAS scores had significantly more dysphagia. There was no difference in EHAS scores when compared normal vs abnormal or major manometric diagnosis. CONCLUSIONS AND INFERENCES A widely usable Spanish EHAS version has been validated. We confirm its excellent psychometric properties in our patients, confirming the appropriateness of its use in different populations. Our findings support the appropriateness of evaluating esophageal anxiety across the whole manometric diagnosis spectrum.
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Affiliation(s)
- Daniel Cisternas
- Facultad de Medicina Clínica Alemana, Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - Tiffany Taft
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Dustin A Carlson
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Esteban Glasinovic
- Facultad de Medicina Clínica Alemana, Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - Hugo Monrroy
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Paula Rey
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Albis Hani
- San Ignacio Hospital, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Andres Ardila-Hani
- San Ignacio Hospital, Pontificia Universidad Javeriana, Bogota, Colombia
| | | | - Claudio Bilder
- Hospital Universitario, Escuela de Medicina, Fundación Favaloro, Buenos Aires, Argentina
| | - Andres Ditaranto
- Hospital Universitario, Escuela de Medicina, Fundación Favaloro, Buenos Aires, Argentina
| | - Amanda Varela
- Hospital Universitario, Escuela de Medicina, Fundación Favaloro, Buenos Aires, Argentina
| | - Joaquin Agotegaray
- Hospital Universitario, Escuela de Medicina, Fundación Favaloro, Buenos Aires, Argentina
| | | | | | | | - Ingrid Marin
- Motility and Functional Gut Disorders Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Hospital Germans Trias i Pujol, Universitat Autonoma de Barcelona, Badalona, Spain
| | - Jordi Serra
- Digestive System Research Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Hospital Vall d'Hebron, Barcelona, Spain
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Su H, Krause AJ, Masihi M, Prescott J, Decorrevont A, Germond E, Karasik D, Kou W, Pandolfino JE, Carlson DA. Normal Values of High-resolution Manometry Parameters With Provocative Maneuvers. J Neurogastroenterol Motil 2021; 27:354-362. [PMID: 34210900 PMCID: PMC8266507 DOI: 10.5056/jnm20118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 12/19/2020] [Indexed: 01/22/2023] Open
Abstract
Background/Aims Incorporation of complementary and provocative test swallows to the high-resolution manometry (HRM) protocol offers potential to address limitations posed by HRM protocols that involve only a single swallow type. The aim of this study is to describe normal findings of a comprehensive HRM testing protocol performed on healthy asymptomatic volunteers. Methods Thirty healthy asymptomatic volunteers completed HRM with 5-mL liquid swallows in the supine position. They also completed 5-mL liquid swallows in the upright position, viscous swallows, solid test swallows, multiple rapid swallows, and a rapid drink challenge. HRM studies were analyzed via Chicago classification version 3.0. Results The median (5th-95th percentiles) for integrated relaxation pressure (IRP) on supine swallows was 11 (4-16) mmHg; IRP was lower than supine on upright liquid 9 (0-17) mmHg, viscous 6 (0-15) mmHg, solid 9 (1-19) mmHg, multiple rapid swallows 3 (0-12) mmHg, and rapid drink challenge 5 (–3-12) mmHg; P < 0.005. While an “elevated” IRP value was observed on 1 to 2 test maneuvers in 8/30 (27%) subjects, all 30 subjects had an IRP value < 12 mmHg on at least one of the test maneuvers. Conclusions Normal values and findings from a comprehensive HRM testing protocol are reported based on evaluation of 30 healthy asymptomatic volunteers. Isolated “abnormalities” of IRP and contractile parameters were observed in the majority (80%) of these asymptomatic subjects, while all subjects also had normal features observed. Thus, the definition of “normal” should be recalibrated to focus on the entirety of the study and not individual metrics.
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Affiliation(s)
- Hui Su
- Department of Gastroenterology, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Amanda J Krause
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Melina Masihi
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jacqueline Prescott
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alex Decorrevont
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Emma Germond
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Dave Karasik
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Araujo IK, Roman S, Napoléon M, Mion F. Diagnostic yield of adding solid food swallows during high-resolution manometry in esophageal motility disorders. Neurogastroenterol Motil 2021; 33:e14060. [PMID: 33314459 DOI: 10.1111/nmo.14060] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/26/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Isis K Araujo
- Endoscopy and Motility Unit, Gastroenterology Department, Hospital Clínic de Barcelona, Barcelona, Spain.,Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France
| | - Sabine Roman
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France.,Digestive Physiology, Lyon I University, Université de Lyon, Lyon, France.,LabTAU, Inserm U1032, Université de Lyon, Lyon, France
| | - Marie Napoléon
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France
| | - François Mion
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France.,Digestive Physiology, Lyon I University, Université de Lyon, Lyon, France.,LabTAU, Inserm U1032, Université de Lyon, Lyon, France
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Roman S, Guadagnoli LA, Hastier A, Becam E, Craven MRA, Pandolfino JE, Napoléon M, Carlson DA, Mion F, Taft T. Validation in French of the Brief Esophageal Dysphagia Questionnaire in Patients Referred For Esophageal Manometry. Dysphagia 2021; 37:392-398. [PMID: 33830347 DOI: 10.1007/s00455-021-10290-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/25/2021] [Indexed: 12/30/2022]
Abstract
A brief esophageal dysphagia questionnaire (BEDQ) was recently developed in English to evaluate frequency and intensity of dysphagia. Our aim was to validate this questionnaire in French in a cohort of patients referred for esophageal manometry. Patients referred for esophageal high resolution manometry were offered to fill out different questionnaires including Eckart score, GERDQ score and BEDQ. BEDQ was translated in French by two French native speakers and experts in esophageal motility. Patients were grouped according to the indications of esophageal high resolution manometry (dysphagia, GERD, others). The total BEDQ score was calculated and compared between groups. The validation method used the assessment of internal consistency with Cronbach's alpha and reliability with Guttman split-half reliability. BEDQ questionnaire was completed by 608 patients (44% males, mean age 54 years). The total score had an excellent internal consistency (Cronbach's alpha = 0.90) and reliability (Guttman statistic = 0.92). The correlation was good with Eckardt score (r = 0.65, p < 0.001) but poor with the GERDQ score (r = 0.21, p < 0.01). Patients referred for dysphagia (n = 197) had an Eckardt score and a BEDQ score significantly higher than those referred for GERD or other indications (5.48 vs 3.65 and 3.53 respectively for Eckardt score and 15.85 vs 4.64 and 5.78 for BEDQ, p < 0.001). BEDQ is a valid questionnaire in French to assess dysphagia in clinical practice. It remains to be determined if this score is sensitive to symptom variation and thus useful for the follow up of patients with dysphagia.
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Affiliation(s)
- Sabine Roman
- Hospices Civils de Lyon, Explorations Fonctionnelles Digestives, Hopital E Herriot, Digestive Physiology, 5, place d'Arsonval, 69437 cedex 03, Lyon, France.
- Université Claude Bernard Lyon I, Explorations Fonctionnelles Digestives, Lyon, France.
| | - Livia Anna Guadagnoli
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, USA
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Audrey Hastier
- Hospices Civils de Lyon, Explorations Fonctionnelles Digestives, Hopital E Herriot, Digestive Physiology, 5, place d'Arsonval, 69437 cedex 03, Lyon, France
| | - Estelle Becam
- Hospices Civils de Lyon, Explorations Fonctionnelles Digestives, Hopital E Herriot, Digestive Physiology, 5, place d'Arsonval, 69437 cedex 03, Lyon, France
| | - Meredith Ruth Ann Craven
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, USA
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Marie Napoléon
- Hospices Civils de Lyon, Explorations Fonctionnelles Digestives, Hopital E Herriot, Digestive Physiology, 5, place d'Arsonval, 69437 cedex 03, Lyon, France
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Francois Mion
- Hospices Civils de Lyon, Explorations Fonctionnelles Digestives, Hopital E Herriot, Digestive Physiology, 5, place d'Arsonval, 69437 cedex 03, Lyon, France
- Université Claude Bernard Lyon I, Explorations Fonctionnelles Digestives, Lyon, France
| | - Tiffany Taft
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, USA
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, USA
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Cisternas D, Taft T, Carlson DA, Glasinovic E, Monrroy H, Rey P, Hani A, Ardila-Hani A, Leguizamo AM, Bilder C, Ditaranto A, Varela A, Agotegaray J, Remes-Troche JM, Ruiz de León A, Pérez de la Serna J, Marin I, Serra J. Validation and psychometric evaluation of the Spanish version of Brief Esophageal Dysphagia Questionnaire (BEDQ): Results of a multicentric study. Neurogastroenterol Motil 2021; 33:e14025. [PMID: 33169488 DOI: 10.1111/nmo.14025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 10/07/2020] [Accepted: 10/13/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The recently developed Brief Esophageal Dysphagia Questionnaire (BEDQ) evaluates esophageal obstructive symptoms. Its initial evaluation showed strong psychometric properties. The aims of this study were to (a) translate and validate an international Spanish version of BEDQ and (b) evaluate its psychometric properties in a large Hispano-American sample of symptomatic individuals. METHODS A Spanish BEDQ version was performed by Hispano-American experts using a Delphi process and reverse translation. Patients were prospectively recruited from seven centers in Spain and Latin America among individuals referred for high-resolution manometry (HRM). Patients completed several scores: Hospital Anxiety & Depression Scale (HADS), Eckardt score (ES), Gastroesophageal Reflux Questionnaire (GERDQ), and the BEDQ. Standardized psychometric analyses were performed. KEY RESULTS A total of 426 patients were recruited. Spanish BEDQ showed excellent reliability (Cronbach's alpha = 0.91). Factor analysis confirmed its unidimensional character. Moderate significant correlations between BEDQ and other symptomatic scores were found, suggesting sufficient convergent validity. Patients with abnormal or obstructive HRM findings scored significantly higher when compared to normal or non-obstructive findings, respectively. Using a cutoff of 10, BEDQ showed a sensitivity of 65.38% and a specificity of 66.21% and an area under the curve of 0.71 for obstructive or major manometric diagnosis. CONCLUSIONS AND INFERENCES A widely usable Spanish BEDQ version has been validated. We confirm its excellent psychometric properties in our patients, confirming the appropriateness of its use in different populations.
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Affiliation(s)
- Daniel Cisternas
- Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile
| | - Tiffany Taft
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Dustin A Carlson
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Esteban Glasinovic
- Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Clínica Alemana de Santiago, Santiago, Chile
| | - Hugo Monrroy
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Paula Rey
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Albis Hani
- San Ignacio Hospital, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Andres Ardila-Hani
- San Ignacio Hospital, Pontificia Universidad Javeriana, Bogota, Colombia
| | | | - Claudio Bilder
- Escuela de Medicina, Fundación Favaloro, Hospital Universitario, Buenos Aires, Argentina
| | - Andres Ditaranto
- Escuela de Medicina, Fundación Favaloro, Hospital Universitario, Buenos Aires, Argentina
| | - Amanda Varela
- Escuela de Medicina, Fundación Favaloro, Hospital Universitario, Buenos Aires, Argentina
| | - Joaquin Agotegaray
- Escuela de Medicina, Fundación Favaloro, Hospital Universitario, Buenos Aires, Argentina
| | | | | | | | - Ingrid Marin
- Motility and Functional Gut Disorders Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Hospital Germans Trias i Pujol, Badalona, Spain.,Universitat Autonoma de Barcelona, Badalona, Spain
| | - Jordi Serra
- Motility and Functional Gut Disorders Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Hospital Germans Trias i Pujol, Badalona, Spain.,Universitat Autonoma de Barcelona, Badalona, Spain
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Abstract
INTRODUCTION This study aimed to assess the diagnostic yield of routine esophageal biopsies in patients with refractory reflux symptoms. METHODS We prospectively enrolled consecutive patients referred for upper endoscopy and collected histological, clinical, and endoscopic data. RESULTS Of the 301 included patients, 14 (4.7%) patients met the clinicopathological diagnostic definition of eosinophilic esophagitis. Presence of dysphagia, food bolus impaction, atopic background, and typical endoscopic features were the factors with the strongest association and diagnostic accuracy for eosinophilic esophagitis. The diagnostic yield in patients lacking symptoms of dysphagia or endoscopic features was negligible (0% and 1.9%, respectively). DISCUSSION Routine esophageal biopsy sampling in patients with refractory reflux symptoms has a low diagnostic yield. Esophageal biopsies should only be obtained in patients with refractory reflux symptoms who also present with dysphagia (see Visual abstract, Supplementary Digital Content 2, http://links.lww.com/AJG/B792).
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Krause AJ, Su H, Triggs JR, Beveridge C, Baumann AJ, Donnan E, Pandolfino JE, Carlson DA. Multiple rapid swallows and rapid drink challenge in patients with esophagogastric junction outflow obstruction on high-resolution manometry. Neurogastroenterol Motil 2021; 33:e14000. [PMID: 33043557 PMCID: PMC7902305 DOI: 10.1111/nmo.14000] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/23/2020] [Accepted: 09/06/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Esophagogastric junction outflow obstruction (EGJOO) as defined by Chicago Classification of esophageal motility disorders (CCv3.0) encompasses a broad range of diagnoses, thus posing clinical challenges. Our aims were to evaluate multiple rapid swallow (MRS) and rapid drink challenge (RDC) during high-resolution manometry (HRM) to aid identifying clinically relevant EGJOO. METHODS Patients with a HRM diagnosis of EGJOO based on CCv3.0 that also completed MRS and RDC during HRM and barium esophagram were retrospectively identified. Radiographic EGJOO (RAD-EGJOO) was defined by either liquid barium retention or delayed passage of a barium tablet on barium esophagram. Thirty healthy asymptomatic controls that completed HRM were also included. MRS involved drinking 2 mL for 5 successive swallows. RDC involved rapid drinking of 200 mL liquid. Integrated relaxation pressure (IRP) and presence of panesophageal pressurization (PEP) during MRS and RDC were assessed. KEY RESULTS One hundred one patients, mean (SD) age 56 (16) years, were included; 32% had RAD-EGJOO, 68% did not. RAD-EGJOO patients more frequently had elevated (>12 mmHg) upright IRP (100%), MRS-IRP (56%), RDC-IRP (53%), and PEP during RDC (66%) than both controls [17%; 0%; 7%; 3%] and patients without RAD-EGJOO [83%; 35%; 39%; 41%] Having IRP >12 mmHg during both MRS and RDC was twice as likely to be associated with RAD-EGJOO (19%) than those without RAD-EGJOO (9%) among patients with upright IRP >12 mmHg. CONCLUSIONS AND INFERENCES Adjunctive HRM maneuvers MRS and RDC appear to help identify clinically significant EGJOO. While future outcome studies are needed, comprehensive multimodal evaluation helps clarify relevance of EGJOO on HRM.
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Affiliation(s)
- Amanda J. Krause
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Hui Su
- Department of Gastroenterology, Capital Medical University Affiliated Beijing Shijitan Hospital. No.10, Tieyilu, Yangfangdian Street, Haidian District, Beijing, China, 1000383
| | - Joseph R. Triggs
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Claire Beveridge
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Alexandra J. Baumann
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Erica Donnan
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dustin A. Carlson
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Baumann AJ, Donnan EN, Triggs JR, Kou W, Prescott J, Decorrevont A, Dorian E, Kahrilas PJ, Pandolfino JE, Carlson DA. Normal Functional Luminal Imaging Probe Panometry Findings Associate With Lack of Major Esophageal Motility Disorder on High-Resolution Manometry. Clin Gastroenterol Hepatol 2021; 19:259-268.e1. [PMID: 32205217 PMCID: PMC7502471 DOI: 10.1016/j.cgh.2020.03.040] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/19/2020] [Accepted: 03/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS A normal esophageal response to distension on functional luminal imaging probe (FLIP) panometry during endoscopy might indicate normal esophageal motor function. We aimed to investigate the correlation of normal FLIP panometry findings with esophageal high-resolution manometry (HRM) and outcomes of discrepant patients. METHODS We performed a retrospective study using data from a registry of patients who completed FLIP during sedated endoscopy. We identified 111 patients with normal FLIP panometry findings (mean age, 42 y; 69% female) and corresponding HRM data. A normal FLIP panometry was defined as an esophagogastric junction (EGJ) distensibility index greater than 3.0 mm2/mm Hg, an absence of repetitive retrograde contractions, and a repetitive antegrade contraction pattern that met the Rule-of-6s: ≥6 consecutive antegrade contractions of ≥6-cm in length, at a rate of 6 ± 3 contractions per minute. HRM findings were classified by the Chicago classification system version 3.0. RESULTS HRM results were classified as normal motility in 78 patients (70%), ineffective esophageal motility in 10 patients (9%), EGJ outflow obstruction in 20 patients (18%), and 3 patients (3%) as other. In patients with EGJ outflow obstruction based on HRM, the integrated relaxation pressure normalized on adjunctive swallows in 16 of 20 patients (80%), and in 8 of 9 patients (88%) who completed a barium esophagram and had normal barium clearance. Thus, although 23 of 111 patients (21%) with normal FLIP panometry had abnormal HRM findings, these HRMs often were considered to be false-positive or equivocal results. All patients with an abnormal result from HRM were treated conservatively. CONCLUSIONS In a retrospective cohort study, we found that patients with normal FLIP panometry results did not have a clinical impression of a major esophageal motor disorder. Normal FLIP panometry results can exclude esophageal motility disorders at the time of endoscopy, possibly negating the need for HRM in select patients.
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Affiliation(s)
- Alexandra J Baumann
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Erica N Donnan
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Joseph R Triggs
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jacqueline Prescott
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alex Decorrevont
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Emily Dorian
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
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Carlson DA, Kou W, Masihi M, Acharya S, Baumann AJ, Donnan EN, Kahrilas PJ, Pandolfino JE. Repetitive Antegrade Contractions: A novel response to sustained esophageal distension is modulated by cholinergic influence. Am J Physiol Gastrointest Liver Physiol 2020; 319:G696-G702. [PMID: 33026823 DOI: 10.1152/ajpgi.00305.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND & AIMS A unique motor response to sustained esophageal distension, repetitive antegrade contractions (RACs), is observed using functional luminal imaging probe (FLIP) panometry. However, physiologic mechanisms related to this response are unexplored. This study aimed to evaluate the impact of cholinergic inhibition with atropine on the esophageal contractile response to sustained distention, including RACs, among healthy volunteers. METHODS 8 asymptomatic volunteers (ages 22-45) were evaluated in a crossover study design with 16-cm FLIP positioned across the esophagogastric junction and distal esophagus during sedated upper endoscopy. The FLIP study involving stepwise volumetric distension was performed twice in each subject, at baseline and again after atropine (15 mcg/kg) was administered intravenously. FLIP panometry was analyzed to assess the contractile response to distension. RESULTS Antegrade contractions, lumen-occluding contractions, and a RAC pattern were observed in 8/8, 8/8, and 7/8(88%) subjects, respectively, at baseline and in 5/8 (63%), 2/8 (25%) and 2/8 (25%) subjects after atropine. The rate of contractions in the RAC pattern was similar (6-7 contractions per minute) before and after atropine. Compared with the baseline study, distension-induced contractility was triggered at higher fill volumes after atropine. FLIP pressures were lower in response to volumetric filling after atropine than at baseline. CONCLUSIONS The vigor and triggering of the esophageal contractile response to distension is reduced by cholinergic inhibition in asymptomatic controls. The observation that the rate of contractions did not change when patients developed repetitive contractile responses suggests that this rate is not modified by cholinergic inhibition once contractility is triggered.
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Affiliation(s)
| | - Wenjun Kou
- Medicine, Northwestern University, United States
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Postobesity Surgery Esophageal Dysfunction: A Combined Cross-Sectional Prevalence Study and Retrospective Analysis. Am J Gastroenterol 2020; 115:1669-1680. [PMID: 32558689 DOI: 10.14309/ajg.0000000000000733] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Esophageal dysmotility including features of achalasia may develop because of bariatric surgery. However, the prevalence of these complications is unknown. We sought to define the prevalence of dysphagia and major esophageal motility disorders including achalasia after bariatric surgery through a large retrospective database review. METHODS Patients with a history of laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass who underwent a diagnostic high-resolution impedance manometry (HRIM) either before or after bariatric surgery across 3 large tertiary referral sites from June 2012 through February 2019 were identified from a procedural database. HRIM studies were interpreted per the Chicago classification v3.0 by a blinded investigator (K.R.). Demographic/clinical features were collected. In addition, patients who underwent bariatric surgery from January 2014 to April 2015 were contacted and administered a validated symptom assessment survey to gauge the overall prevalence of dysphagia in a postbariatric population. RESULTS A total of 137 patients were identified, including 97 who underwent HRIM after bariatric surgery (laparoscopic sleeve gastrectomy [n = 39, 40.1%]; Roux-en-Y gastric bypass [n = 58, 59.8%]) at a median of 5.84 years (interquartile range 2.1-12.5) postoperatively and 40 preoperative bariatric surgery candidates with medically complicated obesity. A manometric pattern consistent with achalasia was identified in 7 (7.2%) postsurgical patients compared with none in the preoperative group (P = 0.08). We further identified a separate achalasia-like pattern defined by aperistalsis and increased intragastric pressure (postobesity surgery esophageal dysfunction [POSED]) in 5 (5.2%) postsurgical patients vs none found preoperatively (P = 0.14). Achalasia or POSED was associated with postbariatric surgery (12.4% vs 0%, P = 0.02). Increasing time since surgery was independently associated with the development of achalasia (median 12.5 vs 5.8 years, P = 0.02), POSED (median 15.0 vs 5.8 years, P = 0.02) and major motility disorders (6.6 vs 4.9 years, P = 0.01). Furthermore, among 271 postbariatric surgery patients contacted for symptom assessment via survey, the prevalence of dysphagia was 13.7% at a mean 3.9 years after surgery. DISCUSSION Postoperative dysphagia is a common long-term complication of bariatric surgery. This is potentially the consequence of a time-dependent association with the development of postoperative esophageal dysmotility, particularly achalasia and POSED. Consequently, esophageal dysmotility may be an important under-recognized complication of bariatric surgery.
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