Clinicomanometric factors associated with clinically relevant esophagogastric junction outflow obstruction from the Sandhill high-resolution manometry system

Integrated Relaxation Pressure and Its Diagnostic Ability May Vary According to the Conditions Used for HREM Recording

Integrated Residual Pressure (IRP) measured under conditions alternative to supine single swallows may provide clinically useful information regarding EGJ relaxation. This study aimed to compare IRP values obtained under different situations and explore their potential clinical utility. We analyzed and compared the values of IRP obtained from healthy volunteers and patients with suspected achalasia during supine single swallows (Ssup-IRP), sitting single swallows (Ssit-IRP), supine multiple rapid swallows (Msup-IRP), and sitting multiple rapid swallows (Msit-IRP). We analyzed the HREM recordings of 40 healthy volunteers and 53 patients with suspected achalasia. The four metrics were significantly different from each other in healthy volunteers (Ssup-IRP > Msup-IRP > Ssit-IRP > Msit-IRP) and their corresponding 95th percentiles were substantially distinct (Ssup-IRP: 25.3 mmHg, Ssit-IRP: 20.9 mmHg, Msup-IRP: 15.9 mmHg, and Msit-IRP: 11.9 mm Hg, respectively). Complete agreement among the four metrics in predicting abnormal IRP was found in 39 of the 47 patients with suspected achalasia who completed the protocol. Optimal cutoffs derived from ROC curve analysis demonstrated ≥ 0.95 specificities for detection of impaired EGJ relaxation among patients with suspected achalasia. Among the eight patients with suspected achalasia with normal Ssup-IRP, five demonstrated abnormal Msit-IRP and four abnormal Ssit-IRP. Significant differences of IRP exist depending on the measurement situation, indicating that correct interpretation of IRP values requires specific cutoffs for each situation.The sensitivities of Ssit-IRP and Msit-IRP in detecting defective EGJ relaxation appear to be slightly higher than that of Ssup-IRP.

Novel scale for evaluating the therapeutic efficacy of per-oral endoscopic myotomy in achalasia

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.

Malaysian joint societies' consensus recommendations on diagnosis and management of disorders of esophagogastric junction outflow

Disorders of esophagogastric junction (EGJ) outflow, including achalasia and EGJ outflow obstruction, are motility disorders characterized by inadequate relaxation of lower esophageal sphincter with or without impaired esophageal peristalsis. Current guidelines are technical and less practical in the Asia-Pacific region, and there are still massive challenges in timely diagnosis and managing these disorders effectively. Therefore, a Malaysian joint societies' task force has developed a consensus on disorders of EGJ outflow based on the latest evidence, while taking into consideration the practical relevance of local and regional context and resources. Twenty-one statements were established after a series of meetings and extensive review of literatures. The Delphi method was used in the consensus voting process. This consensus focuses on the definition, diagnostic investigations, the aims of treatment outcome, non-surgical or surgical treatment options, management of treatment failure or relapse, and the management of complications. This consensus advocates the use of high-resolution esophageal manometry for diagnosis of disorders of EGJ outflow. Myotomy, via either endoscopy or laparoscopy, is the preferred treatment option, while pneumatic dilatation can serve as a secondary option. Evaluation and management of complications including post-procedural reflux and cancer surveillance are recommended.

Compartmentalized pressurization is a novel prognostic factor for hypercontractile esophagus

BACKGROUND

Hypercontractile esophagus (HE) is a disorder of increased esophageal body contractile strength on high-resolution esophageal manometry (HREM). Compartmentalized pressurization (CP) is a pattern with an isobaric contour of >30 mmHg extending from the contractile front to the lower esophageal sphincter on HREM. The relevance of CP to HE has yet to be explored.

METHODS

A retrospective review was performed on 830 HREM studies of patients to identify HE. HE patients' CP status and symptoms by Eckardt score (ES) were reviewed. Diagnoses were made using Chicago Classification (CC) v4.0.

KEY RESULTS

Forty-seven patients (5.6%) were identified as having HE by CCv3, 30 (3.6%) of which had HE by CCv4. 11/30 HE patients had CP, and 19/30 did not. CP was associated with chronic opioid use (36.4% vs. 5.3% p = 0.047). Presenting ES was greater for HE patients with CP (7 vs. 4). Seven HE patients with CP and 11 without CP were managed medically. ES after medical therapy was higher in HE patients with CP compared to those without CP (9 vs. 0). No HE patients with CP responded to medical therapy. Kaplan-Meier analysis demonstrated significance of this association over time. 83% of all HE patients had all-cause symptom remission.

CONCLUSIONS & INFERENCES

HE patients with CP are associated with a higher presenting ES. HE patients with CP do not respond to medical therapy, while HE patients without CP frequently do respond. CP in HE may have prognostic value in determination of treatment strategy for patients with HE.

Major mixed motility disorders: An important subset of esophagogastric junction outflow obstruction

BACKGROUND

Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by a lack of relaxation of the esophagogastric junction (EGJ), with preserved esophageal body peristalsis. We propose new terminology for the coexistence of EGJOO with hypercontractile esophagus and distal esophageal spasm as a major mixed motility disorder (MMMD), and normal peristalsis or a minor disorder of peristalsis such as ineffective esophageal motility with EGJOO as isolated or ineffective EGJOO (IEGJOO).

METHODS

We reviewed prior diagnoses of EGJOO, stratified diagnoses as IEGJOO or MMMD, and compared their symptomatic presentations, high-resolution manometry (HRM) and endoluminal functional lumen imaging probe (EndoFLIP) metrics, and treatment responses at 2-6 months of follow-up.

RESULTS

Out of a total of 821 patients, 142 met CCv3 criteria for EGJOO. Twenty-two were confirmed by CCv4 and EndoFLIP as having EGJOO and were clinically managed. Thirteen had MMMD, and nine had IEGJOO. Groups had no difference in demographic data or presenting symptoms by Eckardt score (ES). HRM showed MMMD had greater distal contractile integral, frequency of hypercontractile swallows, and frequency of spastic swallows, and greater DI by EndoFLIP. Patients with MMMD showed greater reduction in symptoms after LES-directed intervention when measured by ES compared with IEGJOO (7.2 vs. 4.0).

CONCLUSION

Patients with MMMD and IEGJOO present similarly. Detectable differences in HRM portend different responses to endoscopic therapy. Because patients with MMMD have greater short-term prognosis, they should be considered a different diagnostic classification to guide therapy.

Risk scoring system for the preprocedural prediction of the clinical failure of peroral endoscopic myotomy: a multicenter case-control study

BACKGROUND

 Peroral endoscopic myotomy (POEM) is effective for the management of achalasia and its variants; however, it can be ineffective in some patients. We aimed to develop and validate a risk scoring system to predict the clinical failure of POEM preoperatively.

METHODS

 Consecutive patients who underwent POEM in 14 high volume centers between 2010 and 2020 were enrolled in this study. Clinical failure was defined as an Eckardt score of ≥ 4 or retreatment. A risk scoring system to predict the short-term clinical failure of POEM was developed using multivariable logistic regression and internally validated using bootstrapping and decision curve analysis.

RESULTS

 Of the 2740 study patients, 112 (4.1 %) experienced clinical failure 6 months after POEM. Risk scores were assigned for three preoperative factors as follows: preoperative Eckardt score (1 point), manometric diagnosis (-4 points for type II achalasia), and a history of prior treatments (1 point for pneumatic dilation or 12 points for surgical/endoscopic myotomy). The discriminative capacity (concordance statistics 0.68, 95 %CI 0.62-0.72) and calibration (slope 1.15, 95 %CI 0.87-1.40) were shown. Decision curve analysis demonstrated its clinical usefulness. Patients were categorized into low (0-8 points; estimated risk of clinical failure < 5 %) and high risk (9-22 points; ≥ 5 %) groups. The proportions of clinical failure for the categories were stratified according to the mid-term outcomes (log-rank test, P < 0.001).

CONCLUSIONS

 This risk scoring system can predict the clinical failure of POEM preoperatively and provide useful information when making treatment decisions.

Efficacy of peroral endoscopic myotomy for esophageal motility disorders after gastric surgery: Japan Achalasia Multicenter Study

OBJECTIVES

Patients with esophageal motility disorders (EMDs) including achalasia after gastric surgery have not been thoroughly characterized. Furthermore, the efficacy of peroral endoscopic myotomy (POEM) in this population should be clarified.

METHODS

In this retrospective multicenter study of 3707 patients with EMDs, 31 patients (0.8%) had a history of gastric surgery. Patient characteristics and POEM efficacy were compared between patients with and without previous gastric surgery.

RESULTS

In patients with EMD after gastric surgery, age at EMD diagnosis was higher (72.0 years), male sex was predominant (90.3%), and the American Society of Anesthesiologists physical status score was higher (≥II, 48.4%). High-resolution manometry (HRM) findings did not reveal significant differences. In patients who underwent gastric surgery, atrophic gastritis was common (80.6%), and gastric cancer was the primary surgical indication (32.3%). Distal gastrectomy was performed in 28 patients (90.3%). POEM was effective (3.3% adverse events; 100% treatment success). The incidence rates of reflux esophagitis (RE) and symptomatic gastroesophageal reflux disease (GERD) were 60.0% and 16.7%, respectively, without significant intergroup differences, and severe RE was not observed in the long-term follow-up. Extended gastric myotomy was a risk factor for RE.

CONCLUSION

Patients with gastric surgery often present severe disease manifestations; the surgical indication is mainly gastric cancer. HRM findings can be similarly used for diagnosis in patients with and without gastric surgery. POEM maintains safety and efficacy with acceptable RE and symptomatic GERD rates. To prevent RE, extended myotomy should be avoided.

Subtype of Achalasia and Integrated Relaxation Pressure Measured Using the Starlet High-resolution Manometry System: A Multicenter Study in Japan

Background/Aims

ManoScan and Sandhill high-resolution manometry (HRM) systems are used worldwide; however, the diagnosis of achalasia on the Starlet HRM system is not fully characterized. Furthermore, the impact of calcium channel blockers and nitrites in treating achalasia has not been investigated using HRM. Management of recurrent cases is a priority issue, although few studies have examined patient characteristics.

Methods

We conducted a multicenter, large-scale database analysis. First, the diagnosis of treatment-naive achalasia in each HRM system was investigated. Next, patient characteristics were compared between type I-III achalasia, and the impact of patient characteristics, including calcium channel blocker and nitrite use for integrated relaxation pressure (IRP) values, were analyzed. Finally, patient characteristics with recurrent achalasia were elucidated.

Results

The frequency of type I achalasia with Starlet was significantly higher than that with ManoScan and Sandhill HRM systems. In achalasia, multivariate analysis identified male sex, advanced age, long disease duration, obesity, type I achalasia, and sigmoid type as risk factors related to normal IRP values (< 26 mmHg). Calcium channel blockers and nitrites use had no significant impact on the IRP values, although achalasia symptoms were indicated to be alleviated. In recurrent cases, the IRP value was significantly lower, and advanced age, long disease duration, and sigmoid type were more common than in treatment-naive patients.

Conclusions

We should cautiously interpret the type of achalasia and IRP values in the Starlet HRM system. Symptoms of recurrent cases are related to disease progression rather than IRP values, which should be considered in decision making.

Risks of refractory chest pain after peroral endoscopic myotomy in achalasia-related esophageal motility disorders: short-term results from a multicenter study in Japan

BACKGROUND AND AIMS

The etiology of chest pain in achalasia-related esophageal motility disorders and the frequency and risk factors of persistent chest pain after peroral endoscopic myotomy (POEM) remain unclear.

METHODS

A multicenter cohort study including 14 hospitals was conducted to elucidate the characteristics of patients with chest pain and the efficacy of POEM.

RESULTS

Consecutive cases of achalasia-related esophageal motility disorders included 2294 (64.2%) and 1280 (35.8%) patients with and without chest pain, respectively. Among the 2107 patients with chest pain who underwent POEM, we observed complete remission in 1464 patients (69.5%) and nonremission in 643 patients (30.5%), including a partial response in 619 patients (29.4%) and resistance in 24 patients (1.1%). Multivariate analysis revealed that advanced age (odds ratio [OR], .28), male sex (OR, .70), prior treatment (OR, 1.39), and sigmoid type (OR, .65) were related to the prevalence of chest pain. Long disease duration (OR, .69) and esophageal dilation (OR, .79) were related to decreased severity. POEM improved patients' quality of life that was hindered by chest pain. Early onset (OR, 1.45), advanced age (OR, .58), male sex (OR, .79), prior treatment (OR, 1.37), and posterior myotomy (OR, 1.42) were associated with nonremission after POEM; high-resolution manometry (HRM) findings and myotomy length showed no statistical significance on pain etiology and persistence after POEM.

CONCLUSIONS

The prevalence and severity of chest pain were dependent on age, sex, disease duration, prior treatment, and esophageal morphology rather than HRM findings. The efficacy of POEM is satisfactory; however, residual pain was often observed. Excessively long myotomy can be avoided, and anterior myotomy may be recommended.

Risk factors and long-term course of gastroesophageal reflux disease after peroral endoscopic myotomy: A large-scale multicenter cohort study in Japan

BACKGROUND : Gastroesophageal reflux disease (GERD) and reflux esophagitis remain problems after peroral endoscopic myotomy (POEM). This study aimed to elucidate the risk factors and long-term course of reflux esophagitis and symptomatic GERD after POEM. METHODS : This multicenter cohort study involved 14 high volume centers. Overall, 2905 patients with achalasia-related esophageal motility disorders treated with POEM were analyzed for reflux esophagitis, severe reflux esophagitis (Los Angeles classification C or D), and symptomatic GERD. RESULTS : Reflux esophagitis was diagnosed in 1886 patients (64.9 %). Age ≥ 65 years (risk ratio [RR] 0.85), male sex (RR 1.11), posterior myotomy (RR 1.12), esophageal myotomy > 10 cm (RR 1.12), and gastric myotomy > 2 cm (RR 1.17) were independently associated with reflux esophagitis. Severe reflux esophagitis was diagnosed in 219 patients (7.5 %). Age ≥ 65 years (RR 1.72), previous treatments (RR 2.21), Eckardt score ≥ 7 (RR 0.68), sigmoid-type achalasia (RR 1.40), and esophageal myotomy > 10 cm (RR 1.59) were factors associated with severe reflux esophagitis. Proton pump inhibitors (PPIs) were more effective for reflux esophagitis at 5-year follow-up (P = 0.03) than after 1 year (P = 0.08). Symptomatic GERD was present in 458 patients (15.9 %). Symptom duration ≥ 10 years (RR 1.28), achalasia diagnosis (RR 0.68), integrated relaxation pressure ≥ 26 (RR 0.60), and posterior myotomy (RR 0.80) were associated with symptomatic GERD. The incidence of symptomatic GERD was lower at 5-year follow-up compared with that after 1 year (P = 0.04), particularly in PPI users (P < 0.001). CONCLUSIONS : The incidence of severe reflux esophagitis was low after POEM, but excessive myotomy for older patients with previous treatments should be avoided. Early phase symptomatic GERD is non-acid reflux dependent and the natural course is favorable, basically supporting conservative treatment.

Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics

Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.

Development of Dilated Esophagus, Sigmoid Esophagus, and Esophageal Diverticulum in Patients With Achalasia: Japan Achalasia Multicenter Study

Background/Aims

Patients with achalasia-related esophageal motility disorders (AEMDs) frequently present with dilated and sigmoid esophagus, and develop esophageal diverticulum (ED), although the prevalence and patients characteristics require further elucidation.

Methods

We conducted a multicenter cohort study of 3707 patients with AEMDs from 14 facilities in Japan. Esophagography on 3682 patients were analyzed.

Results

Straight (n = 2798), sigmoid (n = 684), and advanced sigmoid esophagus (n = 200) were diagnosed. Multivariate analysis revealed that long disease duration, advanced age, obesity, and type I achalasia correlate positively, whereas severe symptoms and integrated relaxation pressure correlate negatively with development of sigmoid esophagus. In contrast, Grade II dilation (3.5-6.0 cm) was the most common (52.9%), while grade III dilation (≥ 6 cm) was rare (5.0%). We found early onset, male, obesity, and type I achalasia correlated positively, while advanced age correlated negatively with esophageal dilation. Dilated and sigmoid esophagus were found mostly in types I and II achalasia, but typically not found in spastic disorders. The prevalence of ED was low (n = 63, 1.7%), and non-dilated esophagus and advanced age correlated with ED development. Patients with right-sided ED (n = 35) had a long disease duration (P = 0.005) with low integrated relaxation pressure values (P = 0.008) compared with patients with left-sided ED (n = 22). Patients with multiple EDs (n = 6) had lower symptom severity than patients with a single ED (P = 0.022).

Conclusions

The etiologies of dilated esophagus, sigmoid esophagus, and ED are considered multifactorial and different. Early diagnosis and optimal treatment of AEMDs are necessary to prevent these conditions.

The Brief Esophageal Dysphagia Questionnaire shows better discriminative capacity for clinical and manometric findings than the Eckardt score: Results from a multicenter study

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.

Nonachalasic esophageal motor disorders, from diagnosis to therapy

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.

Can FLIP guide therapy in idiopathic esophagogastric junction outflow obstruction?

BACKGROUND

Esophagogastric junction outflow obstruction (EGJOO) has a variable disease course. Currently, barium swallow (BaS) and manometric parameters are used to characterize clinically significant EGJOO. The esophagogastric junction distensibility index (EGJ-DI) measured via functional lumen imaging probe (FLIP) can provide complementary information. Our aim was to assess symptom response in patients with EGJOO and an abnormal EGJ-DI after botulinum toxin (BT) treatment.

METHODS

A prospective cohort study of adults with idiopathic EGJOO was performed from September 2019 to March 2021. Patients with dysphagia underwent upper endoscopy with FLIP. If the EGJ-DI was abnormally low, BT was injected. Data examined included demographics, medical history, endoscopic and FLIP findings, BaS, manometry, and Eckardt score (ES). ES improvement was assessed via paired samples t-test. Pearson's chi-square tests were used to assess for associations.

RESULTS

Of the 20 patients, 75% had an abnormal EGJ-DI and underwent BT injections. Mean ES for patients with abnormal EGJ-DIs significantly improved from baseline to 1, 3, and 6 month follow-up (P-values: 0.01, 0.05, and 0.02, respectively). There was a significant association between an abnormal EGJ-DI with delayed bolus transit and presence of rapid drink challenge panesophageal pressurization on manometry: P = 0.03 and P = 0.03.

CONCLUSION

This prospective study revealed that an abnormal EGJ-DI can guide BT as assessed via symptomatic response. Additionally, abnormal EGJ-DI measurements were significantly associated with other parameters used previously to determine clinically relevant EGJOO. Larger follow-up studies are warranted to further elucidate guidance for therapy in EGJOO.

Esophagogastric junction outflow obstruction

In the Chicago Classification version 4.0 (CCv4), esophagogastric junction outflow obstruction (EGJOO) is manometrically defined as an elevated median integrated relaxation pressure (IRP) and elevated intrabolus pressure (IBP) during supine wet swallows, and persistently elevated median IRP in the upright position. A clinically relevant conclusive diagnosis of EGJOO requires a manometric diagnosis of EGJOO and associated symptoms such as dysphagia and/or chest pain with at least one of the following supportive investigations (pharmacologic provocation, timed barium esophagogram, and/or endoflip). The Chicago Classification is intended for diagnosis of primary esophageal motor disorders, and thus history and endoscopic evaluation are important to exclude conditions (eg, previous surgery, strictures, or masses) that can secondarily generate the EGJOO pattern on HRM. While a manometric finding of EGJOO is often made and can be an early sign of achalasia, more often it is a manometric finding without clinical implications. The proposed changes in CC4.0 have attempted to make the diagnosis more specific, in order to reduce the number of clinically irrelevant diagnoses and avoid confusion by patients and physicians alike.

Esophagogastric junction outflow obstruction in the differential diagnosis of post-fundoplication dysphagia in children

INTRODUCTION AND AIMS

Post-fundoplication dysphagia is resolved with no therapeutic intervention in the majority of cases but it can persist in 5.3% of children that undergo the procedure. Among the differential diagnoses, esophagogastric junction outflow obstruction (EGJOO) is a disorder that should be suspected if there is a persistence of dysphagia. The aim of our study was to describe the clinical characteristics, treatment, and follow-up in a case series of patients diagnosed with post-fundoplication EGJOO.

MATERIALS AND METHODS

The clinical records of patients diagnosed with EGJOO at a tertiary care hospital within the time frame of September 2015 to September 2019 were reviewed, with respect to manometry, etiology, treatment, and clinical course of the disease.

RESULTS

Of the 213 high-resolution esophageal manometries performed, 4 patients met the criteria for post-fundoplication EGJOO. The primary symptom was dysphagia, presenting 15 days after the procedure. Esophageal dilations were carried out on all the patients but with no improvement. Symptoms related to the condition resolved spontaneously in three of the four patients.

CONCLUSION

The management of children with post-fundoplication EGJOO continues to be a challenge. Even though more than half of the cases resolve with no intervention, optimum management of the motility disorder is still limited, given the scant experience with the condition in the pediatric population.

Validation and psychometric evaluation of the Spanish version of Brief Esophageal Dysphagia Questionnaire (BEDQ): Results of a multicentric study

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.

[Endoscopic Management of Dysphagia]

Dysphagia is difficulty in swallowing that can be caused by a number of disorders that involve either the oropharynx or the esophagus. Specific endoscopic treatment for dysphagia depends on its etiology, whether the dysphagia is caused by mechanical narrowing or a motor disorder. Variable endoscopic treatment strategies can be used to manage dysphagia. Patient with dysfunction of the upper esophageal sphincter may benefit from esophageal dilationor injection of botulinum toxin. Pneumatic balloon dilation, injection of botulinum toxin, peroral endoscopic myotomy can be considered as treatment options for esophageal motility disorders. Endoscopic dilation is the treatment choice of esophageal stricture, while intraluminal steroid injection and temporary stent can be considered in refractory benign esophageal stricture. Self-expandable metal stent insertion can be considered for dysphagia with malignant cause.

Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0©

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.

Esophageal peroral endoscopic myotomy (POEM) for treatment of esophagogastric junction outflow obstruction: results from the first prospective trial

Background and study aims  Esophagogastric junction outflow obstruction (EGJOO) is a rare esophageal dysmotility disease that is characterized by elevated integrated relaxation pressuse (IRP) with evidence of preserved peristalsis. The role of peroral endoscopic myotomy (POEM) in management of EGJOO is currently unknown. Patients and methods  This is a prospective trial conducted in a single US tertiary care center from June 2015 to June 2019. Symptomatic patients, diagnosed with EGJOO on both HRM and endoluminal functional lumen imaging probe (EndoFLIP), who were eligible for POEM were recruited. Primary outcome was clinical success, defined as Eckardt score (ES) ≤ 3, at 6 months post-POEM. Other outcomes included dysphagia score, quality of life as measured by 36-item Short Form health survey scales (SF-36), post-POEM HRM, EndoFLIP, and pH measurements, and adverse events. Results  A total of 15 patients (51.8 yr. 9 F) with EGJOO underwent POEM. Pre-POEM mean IRP on HRM and Distensibility index (DI) on EndoFLIP were 24.3 ± 2.2 mmHg and 1.1 ± 0.6 mm ² /mmHg, respectively. Clinical success was achieved in 93 % at 6 months post-POEM. There was significant decrease in IRP (-17.6 mmHg) post-POEM. There was significant improvement at 6 months in two of the SF-36 subscales. Ten patients underwent post-POEM pH testing, seven of whom had abnormal DeMeester score. Seven patients underwent EGD evaluation revealing esophagitis in five (2 Los Angeles grade A and 3 grade B). Conclusions  POEM offers a high clinical success rate for patients with EGJOO confirmed by impedance planimetry.

Fair reliability of eckardt scores in achalasia and non-achalasia patients: Psychometric properties of the eckardt spanish version in a multicentric study

BACKGROUND

Eckardt symptom score (ESS) is the most used tool for the evaluation of esophageal symptoms. Recent data suggest that it might have suboptimal reliability and validity. The aims of this study were as follows: (a) Develop and validate an international Spanish ESS version. (b) Perform psychometric ESS evaluation in patients with achalasia and non-achalasia patients.

METHODS

Eckardt symptom score translation was performed by Delphi process. ESS psychometric evaluation was done in two different samples of patients referred for manometry. First sample: 430 dysphagia non-achalasia patients. Second sample: 161 achalasia patients. Internal consistency was evaluated using Cronbach's α and Guttman coefficient (<0.5 = unacceptable. 0.5-0.7 = fair. >0.7 = acceptable).

KEY RESULTS

Our data show that in patients without and with achalasia, ESS behaves similarly. Both show a fair reliability with Cronbach's α of 0.57 and 0.65, respectively. Based on our results, we recommend interpretation of the Spanish ESS be done with caution. The psychometric quality of the ESS could not be improved by removal of any items based on the single-factor structure of the scale and no items meeting criteria for elimination.

CONCLUSIONS AND INFERENCES

Eckardt symptom score Spanish translation was developed. ESS showed a fair reliability for the evaluation of patients with any causes of dysphagia. Our results highlight the need for development and psychometric validation of new dysphagia scoring tools.

Management of Functional Esophagogastric Junction Outflow Obstruction: A Systematic Review

GOALS

Awareness of functional esophagogastric junction outflow obstruction (fEGJOO) has increased, but because there is no consensus on its management, we performed a systematic review of the literature to explore treatment strategies and outcomes.

BACKGROUND

EGJOO is a heterogenous disorder defined by high-resolution manometry parameters of elevated integrated relaxation pressure with preserved esophageal peristalsis. The etiology may be mechanical obstruction or idiopathic, the latter being fEGJOO.

STUDY

The PubMed/MEDLINE, Embase, and the Cochrane library electronic databases were searched through June 2018 for all studies of adult patients describing a treatment strategy for fEGJOO or incomplete lower esophageal sphincter relaxation. The search strategy yielded 1792 studies and 8 (0.4%) met inclusion criteria.

RESULTS

All but one included studies were retrospective (n=184 patients). There were 5 interventions described, with botulinum toxin (Botox) injection (n=69) and expectant management (n=82) the most frequently reported, with success rates of 58% and 54%, respectively. There was substantial heterogeneity among patients and treatments were not directly compared, though reported symptom resolution was similar among all strategies with a mean follow-up time of 15 months.

CONCLUSIONS

There are a variety of management strategies available for fEGJOO and some patients may not require any intervention. However, among 4 potential approaches aimed at disrupting lower esophageal sphincter hypertonicity, the largest existing evidence base supports either a therapeutic challenge of Botox injection or watchful waiting. Ultimately, these data indicate the need for further study with controlled trials to identify a definitive approach.

Jackhammer Esophagus: From Manometric Diagnosis to Clinical Presentation

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.

Combined Multichannel Intraluminal Impedance and High-resolution Manometry Improves Detection of Clinically Relevant Esophagogastric Junction Outflow Obstruction

BACKGROUND/AIMS

Esophagogastric junction outflow obstruction (EGJOO) is a diagnostically heterogeneous group with variable clinical relevance. We studied whether evaluation of bolus transit by multichannel intraluminal impedance (MII) is useful for discriminating clinically relevant EGJOO.

METHODS

A total 169 patients diagnosed as having EGJOO between June 2011 and February 2018 were analyzed. All the patients received a combined MII and high-resolution manometry (CMII-HRM). MII was reported as having abnormal liquid bolus transit (LBT) if ＜ 80% of swallows had complete bolus transit. EGJOO was defined as a median integrated relaxation pressure of ＞ 20 mmHg and when the criteria for achalasia were not met. Patients who progress to achalasia, show significant passage disturbance, or require pneumatic dilatation were defined as having a clinically relevant EGJOO.

RESULTS

Among the patients with EGJOO (n = 169), the clinically relevant group (n = 10) is more likely to have dysphagia (100% vs 25.2%, P ＜ 0.001), compartmentalized pressurization (CP; 90.0% vs 22.0%, P ＜ 0.001), and abnormal LBT (100% vs 66.7%, P = 0.032) compared to the non-relevant group (n = 159). The combination of dysphagia, CP, and abnormal LBT showed the best predictive power for clinically relevant EGJOO (sensitivity 90%, specificity 92.5%, positive predictive value 42.9%, negative predictive value 99.3%, positive likelihood ratio 11.9, and negative likelihood ratio 0.1). When CMII-HRM was used, an additional 8.3% of clinically relevant EGJOO cases were identified as compared with HRM alone.

CONCLUSION

Clinically relevant EGJOO can be predicted using CMII-HRM.

Esophagogastric junction outflow obstruction: Where are we now in diagnosis and management?

Esophagogastric junction outflow obstruction (EGJOO) is a major motility disorder based on the Chicago Classification of esophageal motility disorders. This entity involves a heterogenous group of underlying etiologies. The diagnosis is reached by performing high-resolution manometry. This reveals evidence of obstruction at the esophagogastric junction, manifested by an elevated integrated relaxation pressure (IRP) above a cutoff value (IRP threshold varies by the manometric technology and catheter used), with preserved peristalsis. Further tests like endoscopy, timed barium esophagram, and cross-sectional imaging can help further elucidate the underlying etiology and rule out mechanical causes. Treatment is tailored to the underlying cause. Similar to achalasia, treatment targeting lower esophageal sphincter disruption like pneumatic dilation, peroral endoscopic myotomy, and botulinum injection are used in patients with functional EGJOO and persistent symptoms.