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Albers D, Witt M, Pandolfino JE, Rösch T, Schachschal G, Beyna T, Neuhaus H, Gerges C, Kandler J, Allescher H, Martinek J, Repici A, Ebigbo A, Messmann H, Schumacher B, Werner YB. Peroral endoscopic myotomy for hypercontractile (Jackhammer) esophagus: A retrospective multicenter series with long-term follow-up. United European Gastroenterol J 2024; 12:930-940. [PMID: 38873948 PMCID: PMC11497736 DOI: 10.1002/ueg2.12586] [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: 05/19/2023] [Accepted: 03/22/2024] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION Long-term outcome data are limited for non-achalasia esophageal motility disorders treated by peroral endoscopy myotomy (POEM) as a separate group. We investigated a subset of symptomatic patients with hypercontractile esophagus (Jackhammer esophagus). METHODS Forty two patients (mean age 60.9 years; 57% female, mean Eckardt score 6.2 ± 2.1) treated by primary peroral myotomy for symptomatic Jackhammer esophagus 2012-2018 in seven European centers were retrospectively analyzed; myotomy included the lower esophageal sphincter but did not extend more than 1 cm into the cardia in contrast to POEM for achalasia. Manometry data were re-reviewed by an independent expert. The main outcome was the failure rate defined by retreatment or an Eckardt score >3 after at least two years following POEM. RESULTS Despite 100% technical success (mean intervention time 107 ± 48.9 min, mean myotomy length 16.2 ± 3.7 cm), the 2-year success rate was 64.3% in the entire group. In a subgroup analysis, POEM failure rates were significantly different between Jackhammer-patients without (n = 22), and with esophagogastric junction outflow obstruction (EGJOO, n = 20) (13.6% % vs. 60%, p = 0.003) at a follow-up of 46.5 ± 19.0 months. Adverse events occurred in nine cases (21.4%). 14 (33.3%) patients were retreated, two with surgical fundoplication due to reflux. Including retreatments, an improvement in symptom severity was found in 33 (78.6%) at the end of follow-up (Eckardt score ≤3, mean Eckardt change 4.34, p < 0.001). EGJOO (p = 0.01) and frequency of hypercontractile swallows (p = 0.02) were predictors of POEM failure. The development of a pseudodiverticulum was observed in four cases within the subgroup of EGJOO. CONCLUSIONS Patients with symptomatic Jackhammer without EGJOO benefit from POEM in long-term follow-up. Treatment of Jackhammer with EGJOO, however, remains challenging and probably requires full sphincter myotomy and future studies which should address the pathogenesis of this variant and alternative strategies.
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Affiliation(s)
- David Albers
- Department of Internal Medicine and GastroenterologyElisabeth‐Krankenhaus EssenEssenGermany
| | - Mana Witt
- Department of Interdisciplinary EndoscopyUniversity Hospital Hamburg‐EppendorfHamburgGermany
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Department of MedicineFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
| | - Thomas Rösch
- Department of Interdisciplinary EndoscopyUniversity Hospital Hamburg‐EppendorfHamburgGermany
| | - Guido Schachschal
- Department of Interdisciplinary EndoscopyUniversity Hospital Hamburg‐EppendorfHamburgGermany
| | - Torsten Beyna
- Department of Internal Medicine and GastroenterologyEvangelisches Krankenhaus DüsseldorfDüsseldorfGermany
| | - Horst Neuhaus
- Department of Internal Medicine and GastroenterologyEvangelisches Krankenhaus DüsseldorfDüsseldorfGermany
| | - Christian Gerges
- Department of Internal Medicine and GastroenterologyEvangelisches Krankenhaus DüsseldorfDüsseldorfGermany
- Present address:
University Hospital of EssenEssenGermany
| | - Jennis Kandler
- Department of Internal Medicine and GastroenterologyEvangelisches Krankenhaus DüsseldorfDüsseldorfGermany
- Present address:
University Hospital of DüsseldorfDüsseldorfGermany
| | - Hans‐Dieter Allescher
- Center for Esophageal and Gastrointestinal Motility DisordersCenter for Internal Medicine, Gastroenterology, Hepatology and MetabolismKlinikum Garmisch‐PartenkirchenGarmisch‐PartenkirchenGermany
| | - Jan Martinek
- Department of HepatogastroenterologyInstitute for Clinical and Experimental MedicinePragueCzech Republic
| | - Alessandro Repici
- Department of Biomedical SciencesPieve EmanueleHumanitas UniversityRozzanoItaly
- Department of GastroenterologyHumanitas Research Hospital ‐IRCCS‐RozzanoItaly
| | - Alanna Ebigbo
- Department of GastroenterologyUniversity Hospital AugsburgAugsburgGermany
| | - Helmut Messmann
- Department of GastroenterologyUniversity Hospital AugsburgAugsburgGermany
| | - Brigitte Schumacher
- Department of Internal Medicine and GastroenterologyElisabeth‐Krankenhaus EssenEssenGermany
- Present address:
University Hospital of EssenEssenGermany
| | - Yuki B. Werner
- Department of Interdisciplinary EndoscopyUniversity Hospital Hamburg‐EppendorfHamburgGermany
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Kandler J, Essing T, Schöler D, Flügen G, Knoefel WT, Roderburg C, Luedde T, Loosen SH. Surgical and per-oral endoscopic myotomy (POEM) for the treatment of primary esophageal motility disorders: A systematic analysis of current trends in Germany between 2011 and 2019. PLoS One 2024; 19:e0297265. [PMID: 38261581 PMCID: PMC10805300 DOI: 10.1371/journal.pone.0297265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/02/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND/AIMS While surgery remains a standard treatment for primary esophageal motility disorders (PEMDs), per-oral endoscopic myotomy (POEM) has recently evolved as an alternative. Systematic data on current trends of invasive procedures for PEMDs in Germany are missing. METHODS Hospital discharge data were used to evaluate trends and mortality of invasive treatment options for PEMDs in Germany between 2011 and 2019. RESULTS 4543 cases of PEMDs (achalasia: n = 4349, dyskinesia of the esophagus: n = 194) receiving open surgery (n = 200), minimal invasive surgery (n = 2366), or POEM (n = 1977) were identified. The relative proportion of POEM significantly increased from 10.9% (2011) to 65.7% (2019). Hospital mortality was 0.2%. The median duration of mechanical ventilation was significantly lower in POEM patients (29.4 hours) compared to open (274.0 hours) or minimal invasive (91.9 hours) surgery. The duration of hospitalization was lowest among POEM patients (5.7 days) compared to surgical procedures (13.7 and 7.7 days). CONCLUSION While the low in-hospital mortality of all procedures combined confirms the solid safety profile of invasive procedures in general, our findings show that POEM has the lowest duration of mechanical ventilation and hospitalization compared to invasive surgical options.
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Affiliation(s)
- Jennis Kandler
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Tobias Essing
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
- Department of Internal Medicine II, Marien Hospital, Wesel, Germany
| | - David Schöler
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Georg Flügen
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of General, Visceral and Pediatric Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Wolfram T. Knoefel
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of General, Visceral and Pediatric Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Christoph Roderburg
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Tom Luedde
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Sven H. Loosen
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
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Jadcherla AV, Litzenberg K, Balasubramanian G. Esophageal Dysfunction in Post-lung Transplant: An Enigma. Dysphagia 2022; 38:731-743. [PMID: 35960395 DOI: 10.1007/s00455-022-10508-3] [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: 11/09/2021] [Accepted: 08/01/2022] [Indexed: 11/30/2022]
Abstract
The prevalence of lung transplants has increased over the years, albeit with a low survival rate amongst all solid organ transplants, including liver and heart transplantation. Microaspiration is one of the primary mechanisms that has been implicated in the pathogenesis of lung injury following lung transplants. Of late, esophageal dysfunction such as gastroesophageal reflux and esophageal hypercontractility is often noted post-lung transplant. However, reflux is associated with chronic allograft lung injury such as bronchiolitis obliterans syndrome, which is one of the predictors for long-term survival in this specialized population. Its role in acute lung injury post-lung transplant is still being explored. This review critically examines the salient points which provide the current understanding of the characteristics, pathophysiology, and implications of esophageal dysfunction following lung transplant.
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Affiliation(s)
| | - Kevin Litzenberg
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gokulakrishnan Balasubramanian
- Division of Gastroenterology, Hepatology and Nutrition, Gastrointestinal Motility Laboratory, Department of Internal Medicine, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd Floor, Columbus, OH, USA.
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Ribolsi M, Ghisa M, Savarino E. Nonachalasic esophageal motor disorders, from diagnosis to therapy. Expert Rev Gastroenterol Hepatol 2022; 16:205-216. [PMID: 35220870 DOI: 10.1080/17474124.2022.2047648] [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] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Investigations conducted using conventional manometry and, recently, using high-resolution manometry (HRM), allowed us to explore the field of esophageal motility and understand the potential link between motor features and gastroesophageal reflux disease (GERD) pathogenesis. The management of patients with nonachalasic esophageal motor disorders is often challenging, due to the clinical heterogeneous presentation and the multifactorial nature of the mechanisms underlying symptoms. AREAS COVERED Several studies, carried out using HRM, have better interpreted the esophageal motor function in patients with esophagogastric junction outflow obstruction (EGJOO), distal esophageal spasm (DES), hypertensive esophagus, and hypomotility disorders. Moreover, HRM studies have shown a direct correlation between reduced esophageal motility, disruption of the esophagogastric junction, and gastroesophageal reflux burden. EXPERT OPINION Pathogenesis, clinical presentation, diagnosis, and treatment of nonachalasic esophageal motor disorders still represent a challenging area, requiring future evaluation by multicenter outcome studies carried out in a large cohort of patients and asymptomatic subjects. However, we believe that an accurate clinical, endoscopic, and HRM evaluation is, nowadays, helpful in addressing patients with nonachalasic esophageal motor disorders to optimal treatment options.
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Affiliation(s)
- Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | - Matteo Ghisa
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
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Choi SI. [Chicago Classification ver. 4.0: Diagnosis of Peristaltic Disorder]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 79:66-71. [PMID: 35232921 DOI: 10.4166/kjg.2022.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 01/28/2022] [Accepted: 01/31/2022] [Indexed: 11/03/2022]
Abstract
The Chicago Classification is being revised continuously for the accurate diagnosis of esophageal peristaltic disorders in which the etiology is unclear, and the disease behavior is heterogeneous. The ver. 4.0 was recently updated. A representative change in the diagnosis of esophageal peristaltic disorders of the ver. 4.0 showed that the distinction between major and minor disorders was eliminated and was divided into the following four diagnoses: absent contractility, distal esophageal spasm (DES), hypercontractile esophagus (HE), and ineffective esophageal motility. Compared to the ver. 3.0, it recommended a more detailed protocol of high-resolution esophageal manometry and methods of interpreting manometric. In addition, it emphasized the clinically relevant symptoms in diagnosing DES and HE, and presented provocative tests (e.g., multiple rapid swallow and rapid drinking challenge), as well as additional testing, including impedance, timed barium esophagogram and functional lumen imaging probe, which may provide more standardized and rigorous criteria for peristaltic patterns and to minimize the ambiguity in diagnosis. Although it will take time and effort to apply this revised Chicago Classification in clinical practice, it may help diagnose and manage patients with esophageal peristalsis disorder in the future.
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Affiliation(s)
- Soo In Choi
- Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Clinical presentation and therapeutic outcome of patients with jackhammer esophagus-a multicenter cohort study in Japan. Esophagus 2022; 19:393-400. [PMID: 35249162 PMCID: PMC9166863 DOI: 10.1007/s10388-022-00916-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 02/21/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Jackhammer esophagus (JE) is a hypercontractile esophageal motility disorder diagnosed using high-resolution manometry (HRM). We sought to determine the clinical presentation and therapeutic data of patients with JE in Japan. METHODS The study included patients with JE, diagnosed through HRM performed for suspicious esophageal motility disorders. Demographics, esophagogastroduodenoscopy, radiology, and therapy data were collected from patient charts. RESULTS Among the 4,412 HRM tests performed, 89 patients (61.6 ± 13.4 years; 64 males, 25 females) were diagnosed with JE (2.0%). Dysphagia was the most frequent symptom (80%), followed by chest pain (40%) and heartburn (25%). Esophagogastroduodenoscopy showed abnormal findings in 32% of patients: corkscrew/rosary beads appearance in 26%, narrowing in 11%. Eosinophilic infiltration (> 15 eosinophils/high power field) was diagnosed in 21%. Esophagography showed abnormal findings in 9% of the patients. For the initial therapy, 47 patients received medical treatment followed by peroral endoscopic myotomy (21 patients) and laparoscopic myotomy (two patients). Thirteen patients did not receive any treatment and 10 of those (77%) reported spontaneous resolution of symptoms. Patients who required invasive treatment experienced severe disability in their quality of life and greater maximal distal contractile integral than those who did not. CONCLUSIONS HRM showed that the prevalence of JE was very low (2%). Esophagogastroduodenoscopy revealed some characteristic features of JE in patients. Some patients showed improvement of symptoms without invasive treatments. Follow-up with/without medical treatment should be considered before performing invasive treatment in patients whose distal contractile integral is relatively low and the quality of life is not impaired.
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Eftekharzadeh P, Ahmed S. Acute Coronary Syndrome or Right Atrial Cardiac Myxoma? An Atypical Presentation. Cureus 2021; 13:e19116. [PMID: 34858757 PMCID: PMC8614161 DOI: 10.7759/cureus.19116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 11/28/2022] Open
Abstract
The size and location of cardiac tumors determine how patients present with signs of heart failure due to diminished cardiac output within the circulatory system. Poor cardiac output presents with signs of heart failure, which include pulmonary edema, lower extremity edema, jugular venous distention, dyspnea, orthopnea and can be insidious in onset. Vital signs on presentation can often be abnormal and patients may present hemodynamically unstable. We present a case of a female who presented to the emergency room after experiencing a sudden onset of substernal, pressure-like chest pain while sleeping. Vital signs on presentation were stable with no evidence of heart failure symptoms as listed above. Cardiac catheterization showed patent coronary arteries but was found to have a 5.8 x 4.7 x 3.5 cm hypervascular cardiac myxoma located in the right atrium. Instead of a typical heart failure presentation, as any space-occupying mass would decrease the effective cardiac output, the patient presented with angina. During the procedure, the mass was noted to be perfused by the left circumflex artery, creating coronary steal phenomenon, shifting blood away from the coronary arteries and into the mass, causing ischemic anginal pain. The patient ultimately underwent surgical excision of the lesion and her anginal symptoms resolved.
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Rogers BD, Gyawali CP. Making Sense of Nonachalasia Esophageal Motor Disorders. Gastroenterol Clin North Am 2021; 50:885-903. [PMID: 34717877 DOI: 10.1016/j.gtc.2021.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Achalasia is the prototypical obstructive motor disorder diagnosed using HRM, but non-achalasia motor disorders are often identified in symptomatic patients. The clinical relevance of these disorders are assessed using ancillary HRM maneuvers (multiple rapid swallows, rapid drink challenge, solid swallows) that augment the standard supine HRM evaluation by challenging peristaltic function. Finding obstructive motor physiology in non-achalasia motor disorders may raise the option of invasive management akin to achalasia. Certain non-achalasia disorders, particularly hypermotility disorders, may manifest as epiphenomena seen with esophageal hypersensitivity. Symptomatic management is offered for superimposed reflux disease, psychological disorders, functional esophageal disorders, and behavioral disorders.
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Affiliation(s)
- Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA; Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, 550 South Preston Street, Louisville, KY 40202, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA.
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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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Manometrically jackhammer esophagus with fluoroscopically/endoscopically distal esophageal spasm: a case report. BMC Gastroenterol 2021; 21:222. [PMID: 34001027 PMCID: PMC8130342 DOI: 10.1186/s12876-021-01808-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/09/2021] [Indexed: 12/19/2022] Open
Abstract
Background Jackhammer esophagus is a rare esophageal motility disorder that can result in dysphagia, chest pain, and gastro-esophageal reflux symptoms. High-resolution manometry is the gold standard for diagnosis, while corkscrew esophagus on upper gastrointestinal endoscopy is an uncommon manifestation. Case presentation 72-year-old man who presented with progressive dysphagia for three months without symptoms of chest pain or heartburn. Initial workup showed a corkscrew esophagus on upper gastrointestinal endoscopy; subsequently, high-resolution manometry revealed an esophago-gastric junction outflow obstruction with hypercontractile (jackhammer) esophagus. Treatment with calcium channel blockers and proton pump inhibitors was successful and relieved his symptoms near completion. Conclusions Even though the corkscrew esophagus is typically for distal esophageal spasm, the hypercontractile (jackhammer) esophagus can appear. The high-resolution manometry can help to distinguish each specific motility disorder.
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Achem SR, Vazquez-Elizondo G, Fass R. Jackhammer Esophagus: Current Concepts and Dilemmas. J Clin Gastroenterol 2021; 55:369-379. [PMID: 33337637 DOI: 10.1097/mcg.0000000000001472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/23/2020] [Indexed: 12/27/2022]
Abstract
Jackhammer esophagus (JE) is a recently recognized esophageal motility disorder that is characterized by hypercontractile peristalsis. More than 500 cases have been reported in the literature. Among patients referred for esophageal motility disorders, the prevalence of JE ranges from 0.42% to 9%, with most series describing a prevalence of 2% to 4%. Most cases are women (60.5%). The mean reported age of patients with JE is 65.2 years, and patients commonly have dysphagia (62.8%). Reflux symptoms occur in ∼40% of patients, and chest pain affects more than one-third of patients (36.4%). JE is a heterogenous disorder that is associated with several conditions, including obesity, opioid use, lung transplantation, eosinophilic infiltration of the esophagus, neoplasia, and systemic diseases. The cause and pathogenesis remain unknown, but several observations suggest that it is the result of multiple conditions that likely precipitate increased excitation and abnormal inhibition of neuromuscular function. The natural course of JE also is unknown, but progression to achalasia has been observed in a few patients. Treatment is challenging, in part because of the insufficient understanding of the disorder's underlying mechanisms. Various therapeutic modalities have been used, ranging from observation only to pharmacologic and endoscopic interventions (eg, botulinum toxin injection) to peroral endoscopic myotomy. Treatment efficacy remains largely anecdotal and insufficiently studied.
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Affiliation(s)
- Sami R Achem
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL
| | | | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Metro Health Medical Center, Cleveland, OH
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Hypercontractile Esophagus From Pathophysiology to Management: Proceedings of the Pisa Symposium. Am J Gastroenterol 2021; 116:263-273. [PMID: 33273259 DOI: 10.14309/ajg.0000000000001061] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022]
Abstract
Hypercontractile esophagus (HE) is a heterogeneous major motility disorder diagnosed when ≥20% hypercontractile peristaltic sequences (distal contractile integral >8,000 mm Hg*s*cm) are present within the context of normal lower esophageal sphincter (LES) relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). HE can manifest with dysphagia and chest pain, with unclear mechanisms of symptom generation. The pathophysiology of HE may entail an excessive cholinergic drive with temporal asynchrony of circular and longitudinal muscle contractions; provocative testing during HRM has also demonstrated abnormal inhibition. Hypercontractility can be limited to the esophageal body or can include the LES; rarely, the process is limited to the LES. Hypercontractility can sometimes be associated with esophagogastric junction (EGJ) outflow obstruction and increased muscle thickness. Provocative tests during HRM can increase detection of HE, reproduce symptoms, and predict delayed esophageal emptying. Regarding therapy, an empiric trial of a proton pump inhibitor, should be first considered, given the overlap with gastroesophageal reflux disease. Calcium channel blockers, nitrates, and phosphodiesterase inhibitors have been used to reduce contraction vigor but with suboptimal symptomatic response. Endoscopic treatment with botulinum toxin injection or pneumatic dilation is associated with variable response. Per-oral endoscopic myotomy may be superior to laparoscopic Heller myotomy in relieving dysphagia, but available data are scant. The presence of EGJ outflow obstruction in HE discriminates a subset of patients who may benefit from endoscopic treatment targeting the EGJ.
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Yadlapati R, Kahrilas PJ, Fox MR, Bredenoord AJ, Prakash Gyawali C, Roman S, Babaei A, Mittal RK, Rommel N, Savarino E, Sifrim D, Smout A, Vaezi MF, Zerbib F, Akiyama J, Bhatia S, Bor S, Carlson DA, Chen JW, Cisternas D, Cock C, Coss-Adame E, de Bortoli N, Defilippi C, Fass R, Ghoshal UC, Gonlachanvit S, Hani A, Hebbard GS, Wook Jung K, Katz P, Katzka DA, Khan A, Kohn GP, Lazarescu A, Lengliner J, Mittal SK, Omari T, Park MI, Penagini R, Pohl D, Richter JE, Serra J, Sweis R, Tack J, Tatum RP, Tutuian R, Vela MF, Wong RK, Wu JC, Xiao Y, Pandolfino JE. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0 ©. Neurogastroenterol Motil 2021; 33:e14058. [PMID: 33373111 PMCID: PMC8034247 DOI: 10.1111/nmo.14058] [Citation(s) in RCA: 460] [Impact Index Per Article: 153.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/21/2020] [Accepted: 11/24/2020] [Indexed: 12/12/2022]
Abstract
Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diagnostic criteria for ineffective esophageal motility and description of baseline EGJ metrics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for patterns of disorders of peristalsis and obstruction at the EGJ.
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Affiliation(s)
- Rena Yadlapati
- Center for Esophageal Diseases, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, CA, USA
| | - Peter J Kahrilas
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark R Fox
- Division of Gastroenterology and Hepatology, University Hospital, Zurich, Switzerland
- Department of Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - C Prakash Gyawali
- Division of Gastroenterology & Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon, Université Lyon I, Univ Lyon, Lyon, France
- Hospices Civils de Lyon, INSERM, LabTAU, Université Lyon I, Univ Lyon, Lyon, France
| | | | - Ravinder K Mittal
- Center for Esophageal Diseases, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, CA, USA
- Veteran Affairs San Diego Healthcare System, La Jolla, CA, USA
| | - Nathalie Rommel
- Department of Gastroenterology, Neurosciences, Experimental ORL, Neurogastroenterology & Motility, Deglutology - University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Daniel Sifrim
- Wingate institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | - André Smout
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | | | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, INSERM CIC 1401, Université de Bordeaux, Bordeaux, France
| | - Junichi Akiyama
- National Center for Global Health and Medicine, Tokyo, Japan
| | | | - Serhat Bor
- Div. Gastroenterology, Ege University School of Medicine, Izmir, Turkey
| | - Dustin A Carlson
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Daniel Cisternas
- Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo. Santiago, Chile
| | | | - Enrique Coss-Adame
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición, Ciudad de México, CDMX, Mexico
| | - Nicola de Bortoli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | - Ronnie Fass
- MetroHealth System and case Western Reserve University, Cleveland, OH, USA
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sutep Gonlachanvit
- Excellence Center on Neurogastroenterology and Motility, Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Albis Hani
- Pontificia Universidad Javeriana-Hospital San Ignacio, Bogota, Colombia
| | - Geoffrey S Hebbard
- Royal Melbourne Hospital, University of Melbourne, Parkville, Vic, Australia
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | | | - Abraham Khan
- Langone Health, New York University, New York, NY, USA
| | | | | | | | | | - Taher Omari
- College of Medicine & Public Health, Flinders University, Adelaide, SA, Australia
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Roberto Penagini
- Gastroenterology Unit, Fondazione IRCCS Ca, Granda Ospedale Maggiore Policlinico and Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Joel E Richter
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Jordi Serra
- CIBERehd, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Rami Sweis
- University College London Hospital, London, UK
| | - Jan Tack
- TARGID, University of Leuven, Leuven, Belgium
| | - Roger P Tatum
- Department of Surgery/VA Puget Sound HCS, University of Washington, Seattle, WA, USA
| | - Radu Tutuian
- Bürgerspital Solothurn, University of Bern, Bern, Switzerland
- Bürgerspital Solothurn, University of Zurich, Zurich, Switzerland
| | | | - Reuben K Wong
- Yong Loo Lin of Medicine, National University of Singapore, Singapore, Singapore
| | - Justin C Wu
- The Chinese University of Hong Kong, Hong Kong SAR
| | - Yinglian Xiao
- Department of Gastroenterology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - John E Pandolfino
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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14
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Philonenko S, Roman S, Zerbib F, Gourcerol G, Gault N, Ropert A, Bruley des Varannes S, Barret M, Vitton V, Bouchoucha M, Billard N, Gorbatchef C, Duboc H, Coffin B. Jackhammer esophagus: Clinical presentation, manometric diagnosis, and therapeutic results-Results from a multicenter French cohort. Neurogastroenterol Motil 2020; 32:e13918. [PMID: 32510747 DOI: 10.1111/nmo.13918] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/07/2020] [Accepted: 05/19/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND/AIMS Jackhammer esophagus (JE) is a hypercontractile esophageal motor disorder defined by at least two swallows with a distal contractile integral (DCI) >8000 mm Hg.s.cm during high-resolution manometry (HRM). The relationship between symptoms and hypercontractility and the response to therapies have been poorly evaluated. The aim of this study was to determine the clinical presentation, manometric diagnosis, and therapeutic results in a large cohort of JE patients. METHODS Patients with JE diagnosed among the HRM tests performed in nine academic French centers from 01/01/2010 to 08/31/2016 were included. Patient charts were reviewed to collect clinical and therapeutic data. RESULTS Among the 16 264 HRM tests performed during this period, 227 patients (60.8 ± 13.8 years, 151 male) had JE (1.7%). Dysphagia was the most frequent symptom (74.6%), followed by regurgitation (37.1%) and chest pain (36.6%); 4.7% of the patients were asymptomatic. The diagnostic workup was heterogeneous, and only a minority of patients had esophageal biopsies. None of the individual symptoms were significantly associated with any of the manometric parameters defined, except for dysphagia, which was significantly associated with the mean of all DCIs >8000 mm Hg.s.cm (P = .04). Additionally, the number of symptoms was not associated with any manometric parameter. Medical treatment and endoscopic treatments had poor efficacy and a high relapse rate. CONCLUSION Jackhammer esophagus is a rare motility disorder. Diagnostic workup is heterogeneous and should be standardized. Symptoms are poorly associated with manometric parameters. The medical treatments and endoscopic therapies currently used are inefficient.
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Affiliation(s)
- Sara Philonenko
- Gastroenterology Unit, AP-HP Hôpital Louis Mourier, Université de Paris, Paris, France
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon, Lyon I University, Lyon, France
| | - Frank Zerbib
- Gastroenterology Department, CHU de Bordeaux, INSERM CIC 1401, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Université de Bordeaux, Bordeaux, France
| | | | - Nathalie Gault
- Epidemiology, Biostatistic and Clinical Research Department, INSERM CIC-EC 1425, AP-HP Hôpital Bichat, Paris, France
| | - Alain Ropert
- Gastroenterology Unit, Hôpital Pontchaillou, Rennes, France
| | | | | | | | | | - Nicolas Billard
- Epidemiology, Biostatistic and Clinical Research Department, INSERM CIC-EC 1425, AP-HP Hôpital Bichat, Paris, France
| | - Caroline Gorbatchef
- Gastroenterology Unit, AP-HP Hôpital Louis Mourier, Université de Paris, Paris, France
| | - Henri Duboc
- Gastroenterology Unit, AP-HP Hôpital Louis Mourier, Université de Paris, Paris, France
| | - Benoit Coffin
- Gastroenterology Unit, AP-HP Hôpital Louis Mourier, Université de Paris, Paris, France
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15
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Savarino E, Smout AJPM. The hypercontractile esophagus: Still a tough nut to crack. Neurogastroenterol Motil 2020; 32:e14010. [PMID: 33043556 PMCID: PMC7685127 DOI: 10.1111/nmo.14010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 09/21/2020] [Accepted: 09/21/2020] [Indexed: 12/26/2022]
Abstract
Hypercontractile esophagus (HE), also known as jackhammer esophagus, is an esophageal motility disorder. Nowadays, high-resolution manometry (HRM) is used to diagnose the disorder. According to the latest iteration of the Chicago classification, HE is present when at least 2 out 10 liquid swallow-induced peristaltic waves have an abnormally high Distal Contractile Integral. In the era of conventional manometry, a similar condition, referred to as nutcracker esophagus, was diagnosed when the peristaltic contractions had an abnormally high mean amplitude. Although the HRM diagnosis of HE is relatively straight-forward, effective management of the disorder is challenging as the correlation with symptoms is variable and treatment effects are dubious. In this mini-review, we discuss the most troublesome uncertainties that still surround HE, in the light of new data on etiology and epidemiology published in this issue of Neurogastroenterology and Motility.
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Affiliation(s)
- Edoardo Savarino
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly
| | - André J. P. M. Smout
- Department of Gastroenterology and HepatologyAmsterdam University Medical CentersAmsterdamThe Netherlands
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16
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Anon B, Aubourg A, Moussata D, Babuty D, Picon L. Hypercontractile esophagus resolved after radiofrequency catheter ablation for atrial fibrillation: About a case. Neurogastroenterol Motil 2020; 32:e13886. [PMID: 32483908 DOI: 10.1111/nmo.13886] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 01/01/2023]
Abstract
The pathophysiology of jackhammer esophagus is complex and remains unclear. Radiofrequency catheter ablation is indicated for highly symptomatic and drug-refractory atrial fibrillation. This technique can induce esophageal and nerve lesions, due to thermal injury. In this report, we describe a case of hypercontractile esophagus diagnosed by HRM (high-resolution manometry). Esophageal symptoms and HRM normalized immediately after RFCA, and we discuss the pathophysiology of hypercontractile esophagus.
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Affiliation(s)
- Benjamin Anon
- Department of Gastroenterology, Hôpital Trousseau, CHRU de Tours, Tours, France
| | - Alexandre Aubourg
- Department of Gastroenterology, Hôpital Trousseau, CHRU de Tours, Tours, France
| | - Driffa Moussata
- Department of Gastroenterology, Hôpital Trousseau, CHRU de Tours, Tours, France
| | - Dominique Babuty
- Department of Cardiology, Hôpital Trousseau, CHRU de Tours, Tours, France
| | - Laurence Picon
- Department of Gastroenterology, Hôpital Trousseau, CHRU de Tours, Tours, France
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17
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Woo M, Liu A, Wilsack L, Li D, Gupta M, Nasser Y, Buresi M, Curley M, Andrews CN. Gastroesophageal Reflux Disease Is Not Associated With Jackhammer Esophagus: A Case-control Study. J Neurogastroenterol Motil 2020; 26:224-231. [PMID: 32235029 PMCID: PMC7176498 DOI: 10.5056/jnm19096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/27/2019] [Accepted: 09/20/2019] [Indexed: 01/01/2023] Open
Abstract
Background/Aims The pathophysiology of jackhammer esophagus (JE) remains unknown but may be related to gastroesophageal reflux disease or medication use. We aim to determine if pathologic acid exposure or the use of specific classes of medications (based on the mechanism of action) is associated with JE. Methods High-resolution manometry (HRM) studies from November 2013 to March 2019 with a diagnosis of JE were identified and compared to symptomatic control patients with normal HRM. Esophageal acid exposure and medication use were compared between groups. Multivariate regression analysis was performed to look for predictors of mean distal contractile integral. Results Forty-two JE and 127 control patients were included in the study. Twenty-two (52%) JE and 82 (65%) control patients underwent both HRM and ambulatory pH monitoring. Two (9%) JE patients and 14 (17%) of controls had evidence of abnormal acid exposure (DeMeester score > 14.7); this difference was not significant (P = 0.290). Thirty-six (86%) JE and 127 (100%) control patients had complete medication lists. Significantly more JE patients were on long-acting beta agonists (LABA) (JE = 5, control = 4; P = 0.026) and calcium channel blockers (CCB) (JE = 5, control = 3; P = 0.014). Regular opioids (β = 0.298, P = 0.042), CCB (β = 0.308, P = 0.035), and inhaled anticholinergics (β = 0.361, P = 0.049) predicted mean distal contractile integral (R2 = 0.082, F = 4.8; P = 0.003). Conclusions Pathologic acid exposure does not appear to be associated with JE. JE patients had increased CCB and LABA use. The unexpected finding of increased LABA use warrants more investigation and may provide support for a cholinergic etiology of JE.
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Affiliation(s)
- Matthew Woo
- Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Andy Liu
- Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Lynn Wilsack
- Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Dorothy Li
- Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Milli Gupta
- Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Yasmin Nasser
- Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Michelle Buresi
- Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Michael Curley
- Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Christopher N Andrews
- Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Canada
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18
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Nabi Z, Reddy DN. Non-achalasia esophageal motility disorders: Role of per-oral endoscopic myotomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Nikaki K, Sawada A, Ustaoglu A, Sifrim D. Neuronal Control of Esophageal Peristalsis and Its Role in Esophageal Disease. Curr Gastroenterol Rep 2019; 21:59. [PMID: 31760496 DOI: 10.1007/s11894-019-0728-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Esophageal peristalsis is a highly sophisticated function that involves the coordinated contraction and relaxation of striated and smooth muscles in a cephalocaudal fashion, under the control of central and peripheral neuronal mechanisms and a number of neurotransmitters. Esophageal peristalsis is determined by the balance of the intrinsic excitatory cholinergic, inhibitory nitrergic and post-inhibitory rebound excitatory output to the esophageal musculature. RECENT FINDINGS Dissociation of the longitudinal and circular muscle contractions characterizes different major esophageal disorders and leads to esophageal symptoms. Provocative testing during esophageal high-resolution manometry is commonly employed to assess esophageal body peristaltic reserve and underpin clinical diagnosis. Herein, we summarize the main factors that determine esophageal peristalsis and examine their role in major and minor esophageal motility disorders and eosinophilic esophagitis.
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Affiliation(s)
- K Nikaki
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK
| | - A Sawada
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK
| | - A Ustaoglu
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK
| | - D Sifrim
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London, E1 2AJ, UK.
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20
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Choi YI, Kim KO, Park DK, Chung JW, Kim YJ, Kwon KA. Clinical outcomes and safety of high-resolution manometry guided superficial partial circular muscle myotomy in per-oral endoscopic myotomy for Jackhammer esophagus: Two cases report. World J Clin Cases 2019; 7:2322-2329. [PMID: 31531326 PMCID: PMC6718798 DOI: 10.12998/wjcc.v7.i16.2322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 07/01/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Jack hammer esophagus is a relatively rare disease and to date, there is no dramatic treatment option. Recently, conventional per-oral endoscopic myotomy (POEM) have expanded their area into Jackhammer esophagus. However, several complications such as post procedure motility disorders (e.g., passage disturbance) are issues after POEM. To overcome these issues, we here introduced high-resolution manometry (HRM)-guided superficial partial circular muscle myotomy, which involves cutting only the superficial layer of the esophageal circular muscle.
CASE SUMMARY We report two cases of patients with Jackhammer esophagus who were treated with HRM-guided extremely superficial partial circular muscle myotomy during POEM. Case 1 was a 53-year-old female with medication-refractory odynophagia and case 2 was a 47-year-old man who presented with chest pain. They were diagnosed with Jackhammer esophagus using HRM, and the hypercontractile segments of the esophagus were identified. HRM-guided extremely superficial partial circular muscle myotomy was performed while preserving the lower esophageal sphincter. Therefore, the circular and longitudinal muscle layers are preserved but hypercontractile movements are reduced, even after POEM. Patients’ clinical symptoms dramatically improved right after POEM, and 6-mo follow-up HRM revealed completely resolved status. During a 1-year follow-up period, patients were still in good health and remained symptom free.
CONCLUSION HRM-guided superficial partial circular muscle myotomy may be a promising alternative to conventional POEM for treating Jackhammer esophagus with improved efficacy.
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Affiliation(s)
- Youn I Choi
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Kyoung Oh Kim
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Dong Kyun Park
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Jun-Won Chung
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Yoon Jae Kim
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Kwang An Kwon
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
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21
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Gómez-Escudero O, Coss-Adame E, Amieva-Balmori M, Carmona-Sánchez R, Remes-Troche J, Abreu-Abreu A, Cerda-Contreras E, Gómez-Castaños P, González-Martínez M, Huerta-Iga F, Ibarra-Palomino J, Icaza-Chávez M, López-Colombo A, Márquez-Murillo M, Mejía-Rivas M, Morales-Arámbula M, Rodríguez-Chávez J, Torres-Barrera G, Valdovinos-García L, Valdovinos-Díaz M, Vázquez-Elizondo G, Villar-Chávez A, Zavala-Solares M, Achem S. The Mexican consensus on non-cardiac chest pain. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2019.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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22
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Gómez-Escudero O, Coss-Adame E, Amieva-Balmori M, Carmona-Sánchez RI, Remes-Troche JM, Abreu Y Abreu AT, Cerda-Contreras E, Gómez-Castaños PC, González-Martínez MA, Huerta-Iga FM, Ibarra-Palomino J, Icaza-Chávez ME, López-Colombo A, Márquez-Murillo MF, Mejía-Rivas M, Morales-Arámbula M, Rodríguez-Chávez JL, Torres-Barrera G, Valdovinos-García LR, Valdovinos-Díaz MA, Vázquez-Elizondo G, Villar-Chávez AS, Zavala-Solares M, Achem SR. The Mexican consensus on non-cardiac chest pain. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2019; 84:372-397. [PMID: 31213326 DOI: 10.1016/j.rgmx.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/22/2019] [Accepted: 05/16/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases. AIM To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients. METHODS Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system. RESULTS AND CONCLUSIONS The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.
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Affiliation(s)
- O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopia Digestiva y Motilidad Gastrointestinal «Endoneurogastro», Hospital Ángeles Puebla, Puebla, Puebla, México
| | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México.
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - R I Carmona-Sánchez
- Unidad de Medicina Ambulatoria Christus Muguerza, San Luis Potosí, S.L.P., México
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - A T Abreu Y Abreu
- Gastroenterología y Fisiología Digestiva, Hospital Ángeles del Pedregal, Ciudad de México, México
| | - E Cerda-Contreras
- Medicina Interna, Gastroenterología y Motilidad Gastrointestinal, Hospital Médica Sur, Profesor de Medicina ITESM, Ciudad de México, México
| | | | - M A González-Martínez
- Departamento de Endoscopia, Laboratorio de Motilidad Gastrointestinal, Hospital de Especialidades CMN Siglo XXI IMSS, Ciudad de México, México
| | - F M Huerta-Iga
- Jefe de Endoscopia y Fisiología Digestiva, Hospital Ángeles Torreón, Torreón, Coahuila, México
| | - J Ibarra-Palomino
- Laboratorio de Motilidad Gastrointestinal, Área de Gastroenterología, Hospital Ángeles del Carmen, Guadalajara, Jalisco, México
| | - M E Icaza-Chávez
- Hospital Star Médica de Mérida, Profesora de Gastroenterología de la UNIMAYAB, Mérida, Yucatán, México
| | - A López-Colombo
- Dirección de Educación e Investigación en Salud, UMAE Hospital de Especialidades del Centro Médico Nacional «Manuel Ávila Camacho», Instituto Mexicano del Seguro Social, Puebla, Puebla, México
| | - M F Márquez-Murillo
- Cardiólogo Electrofisiólogo, Departamento de Electrocardiología, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - M Mejía-Rivas
- Gastroenterología, Endoscopia, Neurogastroenterología, Hospital «Vivien Pellas», Managua, Nicaragua
| | | | - J L Rodríguez-Chávez
- Gastroenterología y Neurogastroenterología, Hospital Puerta de Hierro, Guadalajara, Jalisco, México
| | - G Torres-Barrera
- Departamento de Gastroenterología, Hospital Universitario, Universidad Autónoma de Nuevo León, Profesor de cátedra, ITESM, Monterrey, Nuevo León, México
| | - L R Valdovinos-García
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - M A Valdovinos-Díaz
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - G Vázquez-Elizondo
- Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, OnCare Group, Monterrey, Nuevo León, México
| | - A S Villar-Chávez
- Gastroenterología y Motilidad Gastrointestinal, Hospital Ángeles Acoxpa, Ciudad de México, México
| | - M Zavala-Solares
- Unidad de Motilidad Gastrointestinal, Servicio de Gastroenterología, Hospital General de México «Dr. Eduardo Liceaga», Ciudad de México, México
| | - S R Achem
- Profesor de Medicina Interna y Gastroenterología, Facultad de Medicina, Mayo College of Medicine, Mayo Clinic, Jacksonville, Florida, Estados Unidos de América
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23
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Jackhammer Esophagus: Symptom Presentation, Associated Distal Contractile Integral, and Assessment of Bolus Transit. J Clin Gastroenterol 2019. [PMID: 29521727 DOI: 10.1097/mcg.0000000000001021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
GOALS The aim of our study was to characterize jackhammer esophagus symptoms and their relationship with the distal contractile integral (DCI) and bolus transit. BACKGROUND Jackhammer esophagus is defined by the Chicago Classification version 3.0. This diagnosis is relatively new, with the most current definition being established in 2014. The forerunners of this diagnosis, nutcracker (or hypercontractile) esophagus, have been associated with noncardiac chest pain (NCCP). STUDY A retrospective chart review was performed of motility studies from 2011 to 2016. Studies with a diagnosis of jackhammer esophagus, hypercontractile esophagus, nutcracker, esophagogastric junction outflow obstruction, or hypertensive lower esophageal sphincter were reread using Chicago Classification version 3.0, and were included if they met criteria for jackhammer esophagus. Unpaired t-tests were used for analysis (P≤0.05). RESULTS In total, 142 studies were identified with the above diagnoses. After excluding 84 studies, 58 remained for analysis and 17 were found to have jackhammer esophagus (29%). The mean age was 54 (28 to 75), 5 (29%) were males and 12 (71%) were females. The primary indications were NCCP (5), dysphagia (8), and other causes (4) (cough, heartburn, or regurgitation). The mean DCIs were 17,245 mm Hg×s×cm (NCCP), 14,669 mm Hg×s×cm (dysphagia), and 11,264 mm Hg×s×cm (other causes). The mean DCIs were compared: NCCP versus dysphagia (P=0.41), and NCCP versus other causes (P=0.05). Fifteen (88%) had normal bolus transit for both liquid and viscous swallows. CONCLUSIONS In our small sample size, dysphagia was frequently the presenting symptom followed by NCCP. Those with NCCP have a trend toward a higher DCI. Bolus transit appeared to be normal in this patient population. More data are needed to further elucidate the genesis of symptoms and how they relate to the degree of contractility.
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Woo M, Andrews CN, Buresi M. Reversible Jackhammer esophagus in a patient with a gastric band. Neurogastroenterol Motil 2019; 31:e13572. [PMID: 30843357 DOI: 10.1111/nmo.13572] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We wish to report a case of Jackhammer esophagus in a patient with laparoscopic gastric band, with confirmed resolution of hypertensive peristalsis on deflation of the band. This finding adds to the growing body of evidence that outlet obstruction plays an important role in the pathophysiology of Jackhammer esophagus, which remains incompletely defined.
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Affiliation(s)
- Matthew Woo
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher N Andrews
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michelle Buresi
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Jackhammer Esophagus: From Manometric Diagnosis to Clinical Presentation. Can J Gastroenterol Hepatol 2019; 2019:5036160. [PMID: 30941328 PMCID: PMC6421016 DOI: 10.1155/2019/5036160] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/18/2019] [Accepted: 02/04/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Jackhammer esophagus is a hypercontractile esophageal disorder recently brought to light with the advent of high resolution manometry (HRM). As little is known about its clinical presentation, the aim of this study was to identify the clinical characteristics associated with this new gastrointestinal motility disorder. METHODS A retrospective study was conducted on patients visiting the CHUM's Gastro-Intestinal Motility Center from January 2015 to December 2017. The HRM diagnoses were collated in a database along with age and sex of every individual. The latest Chicago classification (version 3.0) was used. Among all the patients subjected to HRM, those diagnosed with Jackhammer esophagus were included in the study. Patient charts were reviewed to collect relevant demographic and clinical data. KEY RESULTS A total of 36 patients with Jackhammer esophagus were included (62 ± 13 years age, 89% females). Their main symptoms were dysphagia (72%), pyrosis (42%), retrosternal chest pain (36%), and epigastralgia (33%). Other manometric findings were hypertonia (22%) and/or inadequate relaxation (19%) of the lower esophageal sphincter. Among the 26 patients who had esogastroduodenoscopy, hiatal hernia was seen in 3 patients. Pathological gastroesophageal reflux was found in 4 of the 10 patients investigated by pH-monitoring. CONCLUSIONS AND INFERENCES Jackhammer esophagus represents 3% of the HRM diagnoses in this study, with a significant female preponderance. In more than two-thirds of cases, the clinical presentation of Jackhammer esophagus is dysphagia.
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Kahn A, Al-Qaisi MT, Obeid RA, Katzka DA, Ravi KM, Ramirez FC, Crowell MD, Vela MF. Clinical features and long-term outcomes of lower esophageal sphincter-dependent and lower esophageal sphincter-independent jackhammer esophagus. Neurogastroenterol Motil 2019; 31:e13507. [PMID: 30443964 DOI: 10.1111/nmo.13507] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/09/2018] [Accepted: 10/15/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND The most recent Chicago Classification expanded the criteria for diagnosis of jackhammer esophagus (JHE) to include the distal contractile integral (DCI) of the lower esophageal sphincter (LES). The clinical impact of the manometric inclusion of LES hypercontractility remains unclear. We aimed to analyze the clinical features and long-term outcomes of measured LES-dependent (LD-JHE) and LES-independent (LI-JHE) jackhammer esophagus. METHODS Patients meeting diagnostic criteria for JHE were identified at two academic medical centers. High-resolution esophageal manometry data were re-analyzed with inclusion and exclusion of the LES DCI. LD-JHE was defined by falling outside JHE diagnostic criteria with exclusion of the LES. A telephone survey was conducted for follow-up utilizing the impact dysphagia (IDQ-10) questionnaire. KEY RESULTS Eighty-one patients met study inclusion criteria, with 12 (14.8%) classified as LD-JHE. LD-JHE patients had a significantly lower mean DCI and fewer swallows with DCI >8000 mm Hg-s-cm. Basal LES pressure was higher in patients with dysphagia to solids than those with dysphagia to solids and liquids. Clinical and manometric parameters were otherwise similar between groups. Sixty-six patients had clinical or phone follow-up at a median of 46.6 months. Forty-one patients (62.1%) received therapies directed at JHE. There was no difference in symptom improvement for treated vs untreated patients or for JHE subtype. CONCLUSIONS AND INFERENCES Our findings suggest that LD-JHE and LI-JHE are clinically indistinguishable and thus support existing diagnostic criteria. Furthermore, our long-term follow-up data suggest that JHE, irrespective of LES involvement, may improve without treatment. Further study is needed to clarify which patients merit therapeutic intervention.
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Affiliation(s)
- Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Mohanad T Al-Qaisi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Robert A Obeid
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Karthik M Ravi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Francisco C Ramirez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Michael D Crowell
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
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Heinrich H, Sweis R. The role of oesophageal physiological testing in the assessment of noncardiac chest pain. Ther Adv Chronic Dis 2018; 9:257-267. [PMID: 30719270 PMCID: PMC6348533 DOI: 10.1177/2040622318791392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 05/14/2018] [Indexed: 12/15/2022] Open
Abstract
Oesophageal physiology testing plays an important role in the diagnosis of noncardiac chest pain (NCCP) after cardiac, structural and mucosal abnormalities have been ruled out. Endoscopy can establish the presence of structural causes of chest pain such as cancer, oesophageal webs and diverticula. Even if macroscopically normal, eosinophilic oesophagitis is a common cause of chest pain and needs to be ruled out with an adequate biopsy regimen. In the remaining cases, diagnosis is focused on the identification of often subtle mechanisms that lead to NCCP. The most common oesophageal aetiologies for NCCP are gastro-oesophageal reflux disease (GORD), oesophageal dysmotility and functional chest pain. Ambulatory pH studies (with or without impedance or wireless measurements) can establish the presence of GORD, nonerosive reflux as well any association with symptoms of chest pain. High-resolution manometry, particularly with the inclusion of adjunctive testing, can rule out major motility disorders such as spasm, hypercontraction or achalasia. The EndoFLIP device can help define disorders with reduced distensibility, not easily appreciated with endoscopy or manometry. When all tests remain negative, a diagnosis of oesophageal hypersensitivity is normally made and therapy is shifted from targeting a disease to treating symptoms and patient affect.
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Affiliation(s)
- Henriette Heinrich
- University Hospital Zuerich, Department for Gastroenterology and Hepatology, Zuerich, Switzerland St Claraspital, Bauchzentrum, Basel, Switzerland
| | - Rami Sweis
- GI Services, University College London Hospital, Ground floor west, 250 Euston Road, London, NW1 2 PG, London, UK
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Phenotypes of Jackhammer esophagus in patients with typical symptoms of gastroesophageal reflux disease responsive to proton pump inhibitors. Sci Rep 2018; 8:9949. [PMID: 29967357 PMCID: PMC6028385 DOI: 10.1038/s41598-018-27756-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 06/05/2018] [Indexed: 12/30/2022] Open
Abstract
This trial was designed to assess the prevalence and characteristics of Jackhammer esophagus (JE), a novel hypercontractile disorder associated with progression to achalasia and limited outcomes following anti-reflux surgery in patients with typical symptoms of GERD and responsiveness to proton pump inhibitor (PPI) therapy. Consecutive patients, who were referred for surgical therapy because of PPI responsive typical symptoms of GERD, were prospectively assessed between January 2014 and May 2017. Patients diagnosed with JE subsequently underwent rigorous clinical screening including esophagogastroduodenoscopy (EGD), ambulatory pH impedance monitoring off PPI and a PPI trial. Out of 2443 evaluated patients, 37 (1.5%) subjects with a median age of 56.3 (51.6; 65) years were diagnosed with JE and left for final analysis. Extensive testing resulted in 16 (43.2%) GERD positive patients and 5 (13.9%) participants were observed to have an acid hypersensitive esophagus. There were no clinical parameters that differentiated phenotypes of JE. The prevalence of JE in patients with typical symptoms of GERD and response to PPI therapy is low. True GERD was diagnosed in less than half of this selected cohort, indicating the need for objective testing to stratify phenotypes of JE. (NCT03347903).
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Vazquez-Elizondo G, Hernández-González LE, Achem SR. High-resolution esophageal manometry in a Mexican population: diagnostic outcome. Dis Esophagus 2018; 31:4850453. [PMID: 29444254 DOI: 10.1093/dote/dox159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Indexed: 12/11/2022]
Abstract
High-resolution esophageal manometry (HREM) has become the method of choice for evaluation of esophageal motility disorders. There is a paucity of data with this technique from Hispanic countries. This study aims to characterize the diagnostic outcome of HREM in a large cohort of consecutive patients in Mexico.This study was conducted in Monterrey, Mexico from March 1, 2013 to March 31, 2015. Our diverse study population included patients from a major academic institution and the community. HREM was done applying the Chicago Classification 3. Diagnostic outcome was grouped as weak peristaltic disorders, gastroesophageal junction disorders, and hypertensive/uncoordinated peristalsis.We studied 670 consecutive patients, 57% were women, mean age was 43.8 years. The majority (465 [69%]) were referred for preoperative evaluation of gastroesophageal reflux disease (GERD), 365 (78%) of whom had a normal study. Overall, 193 (29%) patients had abnormal motility, the most common disorder being weak peristalsis (104 [54%]). In patients with dysphagia, the most frequent finding was achalasia (23/46 [50%]).To our knowledge, this is the first study to characterize the diagnostic outcome of HREM in a large cohort of Hispanic patients in Latin America. At our open access center, 69% of patients were referred for preoperative evaluation of GERD, reflecting the popularity of antireflux surgery. This study confirms the high prevalence of weak peristalsis and highlights the importance of addressing its pathophysiology and management. The finding of achalasia in 50% of our patients with dysphagia is consistent with recent reports regarding the rising incidence of this disorder and underscores the need of prompt motility testing in this population.
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Affiliation(s)
- G Vazquez-Elizondo
- Escuela Nacional de Medicina, Tecnológico de Monterrey, Monterrey, Nuevo León, Mexico
| | | | - S R Achem
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Xiao Y, Carlson DA, Lin Z, Alhalel N, Pandolfino JE. Jackhammer esophagus: Assessing the balance between prepeak and postpeak contractile integral. Neurogastroenterol Motil 2018; 30:e13262. [PMID: 29193439 PMCID: PMC6317707 DOI: 10.1111/nmo.13262] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 11/09/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND We hypothesized that symptoms in Jackhammer esophagus (JH) are associated with an imbalance between the prepeak and postpeak phases of contraction. Thus, we developed a method to distinguish the contractile integral components of prepeak and postpeak phase contractile activity to determine the contribution of each phase and their association with dysphagia. METHODS Patients diagnosed with JH were enrolled and compared to controls. The first five intact swallows during manometry were analyzed. A single swallow was divided into a prepeak and postpeak phase. The contractile integral of each phase and its corresponding time-controlled integral were computed. All metrics were compared between controls and JH patients subcategorized by the impaction dysphagia question (IDQ) score with cut-off of 6. KEY RESULTS Thirty eight JH patients and 71 controls were included. Twelve JH patients had IDQ ≤ 6 and 26 with IDQ > 6. JH patients had higher contractile integral in both phases, and a higher ratio between postpeak to prepeak contractile integral independent of duration. Similarly, JH patients with an IDQ > 6 had higher contractile metrics than those with IDQ ≤ 6. There was a correlation between the IDQ score and the ratio within the postpeak to prepeak contractile integral (r = .375). CONCLUSIONS Abnormalities in contractile integral of the postpeak phase are more significant in JH with higher dysphagia scores Although the total postpeak contractile integral was higher in symptomatic patients, this was associated with longer duration of postpeak activity suggesting that dysphagia patients with JH have a defect in the postpeak phase of peristalsis.
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Affiliation(s)
- Yinglian Xiao
- Department of Gastroenterology and Hepatology, 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
| | - Zhiyue Lin
- Department of Medicine, the Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Nathan Alhalel
- 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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Kristo I, Schwameis K, Paireder M, Jomrich G, Kainz A, Schoppmann SF. Dysphagia severity is related to the amplitude of distal contractile integral in patients with Jackhammer esophagus. Neurogastroenterol Motil 2018; 30:e13276. [PMID: 29266608 DOI: 10.1111/nmo.13276] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 12/04/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Dysphagia and non-cardiac chest pain are common symptoms associated with a novel hypercontractile disorder, namely Jackhammer esophagus (JE). The aim of this study was to explore these symptoms in patients with JE and to elucidate associations with disease defining metrics, crucial for subsequent therapies. METHODS All consecutive patients, who were referred between January 2014 and December 2016 and fulfilled the criteria for JE were included in this study. Exclusion criteria were opioid intake, previous gastrointestinal surgery, mechanical esophageal obstruction and diseases explaining their symptoms. KEY RESULTS Of 2205 examined subjects, thirty patients (females: n = 17, 56.7%) with a median age of 58 (51.6-64.9) years were finally enrolled. Dysphagia was noted in 53.3% (n = 16), whereas non-cardiac chest pain was specified within 40% (n = 12) with symptom duration of up to 10 years. Perception of dysphagia (P = .03) and presence of both symptoms (P = .008) increased to the end of the study period. Dysphagia was significantly associated with distal contractile integral (DCI) scores of all (P = .023), hypercontractile (P = .011) and maximum DCI swallows (P = .008). Symptoms duration influenced hypercontractile DCI scores (P = .015, r = .438) and significantly correlated with the intensity of perceived dysphagia (P = .01, r = .585). Presence of non-cardiac chest pain was not associated with any of these metrics. CONCLUSIONS & INTERFERENCES The DCI mediates dysphagia in patients with JE. Duration of symptoms affected hypercontractile DCI scores and aggravated perception of dysphagia indicating a progressive character of disease.
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Affiliation(s)
- I Kristo
- Department of Surgery, Upper GI Research & Service, Medical University of Vienna, Vienna, Austria
| | - K Schwameis
- Department of Surgery, Upper GI Research & Service, Medical University of Vienna, Vienna, Austria
| | - M Paireder
- Department of Surgery, Upper GI Research & Service, Medical University of Vienna, Vienna, Austria
| | - G Jomrich
- Department of Surgery, Upper GI Research & Service, Medical University of Vienna, Vienna, Austria
| | - A Kainz
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - S F Schoppmann
- Department of Surgery, Upper GI Research & Service, Medical University of Vienna, Vienna, Austria
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Carlson DA, Kahrilas PJ, Tye M, Listernick Z, Ritter K, Wong I, Xiao Y, Bul V, Pandolfino JE. High-resolution manometry assessment of the lower esophageal sphincter after-contraction: Normative values and clinical correlation. Neurogastroenterol Motil 2018; 30:10.1111/nmo.13156. [PMID: 28730686 PMCID: PMC5739993 DOI: 10.1111/nmo.13156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 06/13/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Chicago Classification v3.0 proposed extending the distal contractile integral (DCI) measurement domain to include the lower esophageal sphincter (LES) to enhance the detection of esophageal hypercontractility. However, normative and clinical data for this approach are unreported. We aimed to describe the application of an extended DCI measurement in asymptomatic controls and patients. METHODS High-resolution manometry (HRM) of 65 asymptomatic controls and 72 patients with normal motility were evaluated retrospectively. Dysphagia and chest pain symptoms were assessed using the brief esophageal dysphagia questionnaire (BEDQ); ≥10 was considered abnormal. HRM studies of 10 supine swallows were evaluated via the standard DCI and an extended DCI measurement domain (DCI+) to include the lower esophageal sphincter (LES) during and after the peristaltic wave. The DCI-increment was calculated as the DCI+ minus DCI. KEY RESULTS Among controls, the median (5-95th percentile) DCI+ was 1915 (1359-6921) mm Hg/cm/s and DCI-increment was 534 (126-1488) mm Hg/cm/s. Two patients (3%) had ≥2 swallows with DCI+ >8000 mm Hg/cm/s and seven (10%) patients had at least one swallow with DCI+ >8000 mm Hg/cm/s, ie, had potential motility reclassification by application of DCI+. Seven of these nine patients (78%) were evaluated for dysphagia or chest pain, but only 3/9 (33%) had an abnormal BEDQ. CONCLUSIONS AND INFERENCES Extension of the DCI measurement domain may aid quantifying hypercontractility that involves the LES. However, adjusting management strategies based on reclassification of patients with otherwise normal motility should be cautiously considered.
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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
| | - Peter J. Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael Tye
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Zoe Listernick
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Katherine Ritter
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ian Wong
- Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Ying Xiao
- Department of Gastroenterology and Hepatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Vadim Bul
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Department of Medicine, University of Illinois College of Medicine, 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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Abstract
PURPOSE OF REVIEW High-resolution manometry (HRM) is increasingly performed worldwide, to study esophageal motility. The Chicago classification is subsequently applied to interpret the manometric findings and facilitate a diagnosis of esophageal motility disorders. This review will discuss new insights regarding the diagnosis and management using the Chicago classification. RECENT FINDINGS Recent studies have demonstrated that high-resolution manometry is superior to conventional manometry, and has a higher sensitivity to diagnose achalasia. Furthermore, the subclassification of achalasia as used in the Chicago classification has prognostic value and can be used to direct treatment. Diagnosis of esophageal spasm has been improved by using the distal latency as diagnostic criterion. Recently, criteria for minor disorders of peristalsis have been sharpened, leading to a lower rate of patients with abnormal results, thereby increasing the relevance of a diagnosis. High-resolution manometry is now considered the gold standard for diagnosis of esophageal motility disorders. The Chicago classification provides a standardized approach for analysis and categorization of abnormalities that has led to a significant increase in our knowledge regarding the diagnosis and management of motility disorders. Further refinement of the classification will be required.
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