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Tan Tanny SP, Senior ND, Comella A, McCall L, Hutson JM, Finch S, Safe M, Teague WJ, Omari TI, King SK. Esophago-gastric junction findings on high resolution impedance manometry in children with esophageal atresia. J Pediatr Gastroenterol Nutr 2024; 78:1225-1233. [PMID: 38623953 DOI: 10.1002/jpn3.12213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 02/11/2024] [Accepted: 03/06/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVES Using high resolution impedance manometry (HRIM), this study characterized the esophago-gastric junction (EGJ) dynamics in children with esophageal atresia (EA). METHOD Esophageal HRIM was performed in patients with EA aged less than 18 years. Objective motility patterns were analyzed, and EGJ data reported. Controls were pediatric patients without EA undergoing investigations for consideration of fundoplication surgery. RESULTS Seventy-five patients (M:F = 43:32, median age 1 year 3 months [3 months-17 years 4 months]) completed 133 HRIM studies. The majority (64/75, 85.3%) had EA with distal tracheo-esophageal fistula. Compared with controls, liquid swallows were poorer in patients with EA, as evident by significant differences in distension pressure emptying and bolus flow time (BFT). The integrated relaxation pressure for thin liquid swallows was significantly different between EA types, as well as when comparing patients with EA with and without previous esophageal dilatations. The BFT for solid swallows was significantly different when compared with EA types. CONCLUSIONS We have utilized HRIM in patients with EA to demonstrate abnormalities in their long-term EGJ function. These abnormalities correlate with poorer esophageal compliance and reduced esophageal peristalsis across the EGJ. Understanding the EGJ function in patients with EA will allow us to tailor long-term management to specific patients.
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Affiliation(s)
- Sharman P Tan Tanny
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
- F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Nicholas D Senior
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
- F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Assia Comella
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
- F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Monash Medical School, Monash University, Clayton, Victoria, Australia
| | - Lisa McCall
- Department of Human Physiology, Flinders University, Bedford Park, South Australia, Australia
| | - John M Hutson
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
- F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Sue Finch
- Melbourne Statistical Consulting Platform, The University of Melbourne, Parkville, Victoria, Australia
| | - Mark Safe
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Warwick J Teague
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
- F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Taher I Omari
- Department of Human Physiology, Flinders University, Bedford Park, South Australia, Australia
| | - Sebastian K King
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
- F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
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Kou W, Carlson DA, Kahrilas PJ, Patankar NA, Pandolfino JE. Normative values of intra-bolus pressure and esophageal compliance based on 4D high-resolution impedance manometry. Neurogastroenterol Motil 2022; 34:e14423. [PMID: 35661346 PMCID: PMC9529819 DOI: 10.1111/nmo.14423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 04/08/2022] [Accepted: 04/25/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND This study aimed to quantify normative values of phase-specific intra-bolus pressure (IBP) and esophageal distensibility using 4D analysis of high-resolution-impedance manometry (HRIM). METHODS HRIM studies of supine swallows from 34 normal controls were analyzed with respect to the four phases of bolus transit: (1) accommodation, (2) compartmentalization, (3) peristalsis/esophageal emptying, and (4) ampullary emptying. Phase-specific IBP, bolus volume, and distensibility index (DI) in the esophageal body and esophagogastric junction (EGJ) during phases 1-3 were extracted. RESULTS The median (5-95th/IQR) IBP values were as follows: phase 1: 4.0 (-2.0-10.4/1.9-5.8) mmHg, phase 2: 5.7 (0.2-14.1/3.6-8.9) mmHg, and phase 3: 11.2 (2.9-19.4/7.7-15.1) mmHg. The median bolus volume calculated by integrating impedance planimetry cross-sectional areas was 4.1 ml during the compartmentalization phase. The EGJ-DI at max EGJ diameter during phase 2 and 3 was 2.8 (1.1-9.5/1.8-3.7) mm2 /mmHg and 6.0 (3.2-20.3/5.1-7.8) mm2 /mmHg, respectively. The phase 3 EGJ-DI values (6.0 (3.2-20.3/5.1-7.8) mm2 /mmHg) were similar to those calculated using functional lumen imaging probe (FLIP) at the 60 ml volume on the same subjects (5.8 [3.5-7.2/5.0-6.4] mm2 /mmHg). CONCLUSIONS AND INFERENCES 4D-HRIM provides a standardized methodology to track the nadir impedance and provide measurements of IBP during maximal distention across phases 1-3 of bolus transit. Median IBP and delta IBP were different across the phases, supporting the need to define IBP by phase. Additionally, the EGJ-DI calculated during phase 3 was similar to the 60-ml EGJ-DI from FLIP in the same subjects suggesting that 4D-HRIM can quantify EGJ opening during primary peristalsis.
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Affiliation(s)
- Wenjun Kou
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dustin A. Carlson
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Peter J. Kahrilas
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Neelesh A. Patankar
- Department of Mechanical Engineering, Northwestern University, Evanston, Illinois
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Lei WY, Omari T, Liu TT, Wong MW, Hung JS, Yi CH, Liang SW, Cock C, Chen CL. Esophageal Bolus Domain Pressure and Peristalsis Associated With Experimental Induction of Esophagogastric Junction Outflow Obstruction. J Neurogastroenterol Motil 2022; 28:62-68. [PMID: 34980688 PMCID: PMC8748852 DOI: 10.5056/jnm20224] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/02/2021] [Indexed: 01/06/2023] Open
Abstract
Background/Aims Intrabolus pressures are important for esophageal bolus transport and may detect obstructed bolus flow. This study measured the effect esophageal outflow obstruction experimentally induce by a leg-lift protocol. Methods Twenty-five gastroesophageal reflux disease patients referred for esophageal manometry and a normal motility diagnosis were included. Supine liquid swallows were tested. Leg-lift protocol generated esophageal outflow obstruction by increasing abdominal pressure. Esophageal pressure topography and intrabolus pressure metrics were calculated. These included, (1) mid-domain bolus distension pressure during esophageal emptying (DPE, mmHg) and (2) ramp pressure (mmHg/sec), generated by compression of the bolus between the peristaltic contraction and esophagogastric junction (EGJ). Results EGJ relaxation pressure was increased by leg-lift from 13 (11-17) to 19 (14-30) mmHg (P < 0.005) and distal contractile integral also increased from 1077 (883-1349) to 1620 (1268-2072) mmHg∙cm∙sec (P < 0.001) as a physiological response to obstruction. All bolus pressures were increased by leg lift; DPE increased from 17 (15-20) to 27 (19-32) mmHg (P < 0.001), and ramp pressure increased from 3 (1-4) to 5 (2-9) mmHg/sec (P < 0.05). Conclusion Measuring pressures within the intrabolus domain can quantify changes related to obstruction to outflow and may serve as adjunct measures for confirming a diagnosis EGJ outflow obstruction.
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Affiliation(s)
- Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Taher Omari
- College of Medicine & Public Health Flinders University, Adelaide, SA, Australia
| | - Tso-Tsai Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Ming-Wun Wong
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Jui-Sheng Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Shu-Wei Liang
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Charles Cock
- College of Medicine & Public Health Flinders University, Adelaide, SA, Australia
| | - Chien-Lin Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
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Miller J, Khlevner J, Rodriguez L. Upper Gastrointestinal Functional and Motility Disorders in Children. Pediatr Clin North Am 2021; 68:1237-1253. [PMID: 34736587 DOI: 10.1016/j.pcl.2021.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Children with disorders affecting the sensory and motor functions of the esophagus will present primarily with swallowing dysfunction, dysphagia, and chest pain, and those with disorders affecting the normal function of the stomach will present with symptoms like abdominal pain, nausea, and vomiting. Recent advances in the mechanisms of disease and technology have increased our understanding of gastrointestinal physiology and that knowledge has been applied to develop new diagnostic studies and therapeutic interventions. We present an overview of the clinical presentation, diagnosis, and treatment of common primary and secondary functional and motility disorders affecting the upper gastrointestinal tract in children.
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Affiliation(s)
- Jonathan Miller
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Braodway CHN7, New York, NY 10032, USA
| | - Julie Khlevner
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Braodway CHN7, New York, NY 10032, USA
| | - Leonel Rodriguez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale New Haven Children's Hospital, Yale University School of Medicine, 333 Cedar Street, LMP 4093, New Haven, CT 06510, USA.
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Tack J, Pauwels A, Roman S, Savarino E, Smout A. European Society for Neurogastroenterology and Motility (ESNM) recommendations for the use of high-resolution manometry of the esophagus. Neurogastroenterol Motil 2021; 33:e14043. [PMID: 33274525 DOI: 10.1111/nmo.14043] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/30/2020] [Accepted: 11/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Several patients in gastroenterology practice present with esophageal symptoms, and in case of normal endoscopy with biopsies, high-resolution manometry (HRM) is often the next step. Our aim was to develop a European consensus on the clinical application of esophageal HRM, to offer the clinician guidance in selecting patients for HRM and using its results to optimize clinical outcome. METHODS A Delphi consensus was initiated with 38 multidisciplinary experts from 16 European countries who conducted a literature summary and voting process on 71 statements. Quality of evidence was evaluated using grading of recommendations assessment, development, and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 33 statements. RESULTS The process generated guidance on when to consider esophageal HRM, how to perform it, and how to generate the report. The Delphi process also identified several areas of uncertainty, such as the choice of catheters, the duration of fasting and the position in which HRM is performed, but recommended to perform at least 10 5-ml swallows in supine position for each study. Postprandial combined HRM impedance is considered useful for diagnosing rumination. There is a large lack of consensus on treatment implications of HRM findings, which is probably the single area requiring future targeted research. CONCLUSIONS AND INFERENCES A multinational and multidisciplinary group of European experts summarized the current state of consensus on technical aspects, indications, performance, analysis, diagnosis, and therapeutic implications of esophageal HRM.
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Affiliation(s)
- Jan Tack
- Division of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Ans Pauwels
- Universitaire Ziekenhuis Gasthuisberg, Leuven, Belgium
| | - Sabine Roman
- Department of Digestive Physiology, Hospices Civils de Lyon, Lyon University, Lyon, France
| | | | - André Smout
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
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Abstract
The esophagogastric junction (EGJ) is a complex barrier between the thoracic and abdominal luminal gut compartments, comprised primarily of the lower esophageal sphincter (LES) and crural diaphragm. Although closed at rest, the EGJ relaxes to allow antegrade bolus transit and retrograde venting of air. Abnormal relaxation is the hallmark of achalasia spectrum disorders, while increased frequency of transient lower esophageal sphincter relaxations and/or EGJ disruption are seen in gastroesophageal reflux disease. High resolution manometry (HRM) is the modern day gold standard for assessment of EGJ morphology and function, with better performance characteristics compared with endoscopy and barium esophagography. Conventional LES metrics defining EGJ function include resting LES pressure as well as postswallow residual pressures. Newer HRM-based metrics include EGJ contractile integral, which measures static barrier function at rest, and EGJ morphology, which characterizes the relationship between LES and crural diaphragm. Provocative maneuvers assess dynamic EGJ function during physiological or pharmacologic stress. The most useful of these maneuvers, the rapid drink challenge, assesses for latent obstruction, while multiple rapid swallows evaluate adequacy of deglutitive inhibition. Amyl nitrate and cholecystokinin administration can segregate motor from structural obstruction. Newer provocative tests (straight leg raise maneuver, abdominal compression) and novel diagnostic tools (functional lumen imaging probe) complement HRM evaluation of the EGJ. Although current HRM metrics and maneuvers show promise in identifying clinically relevant EGJ abnormalities, future investigations evaluating management outcomes will improve segregation of normal from abnormal EGJ morphology and function.
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Lai CJ, Chen JS, Ho SI, Lu ZY, Huang YJ, Cheng YJ. Detecting Oropharyngeal and Esophageal Emptying by Submental Ultrasonography and High-Resolution Impedance Manometry: Intubated vs. Non-Intubated Video-Assisted Thoracoscopic Surgery. Diagnostics (Basel) 2020; 10:diagnostics10121079. [PMID: 33322685 PMCID: PMC7763338 DOI: 10.3390/diagnostics10121079] [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] [Received: 10/23/2020] [Revised: 12/04/2020] [Accepted: 12/09/2020] [Indexed: 12/04/2022] Open
Abstract
Postoperative swallowing, affected by general anesthesia and intubation, plays an important part in airway and oral intake safety regarding effective oropharyngeal and esophageal emptying. However, objective evidence is limited. This study aimed to determine the time required from emergence to effective oropharyngeal and esophageal emptying in patients undergoing non-intubated (N) or tracheal-intubated (I) video-assisted thoracoscopic surgery (VATS). Hyoid bone displacement (HBD) by submental ultrasonography and high-resolution impedance manometry (HRIM) measurements were used to assess oropharyngeal and esophageal emptying. HRIM was performed every 10 min after emergence, up to 10 times. The primary outcome was to determine whether intubation affects the time required from effective oropharyngeal to esophageal emptying. The secondary outcome was to verify if HBD is comparable to preoperative data indicating effective oropharyngeal emptying. Thirty-two patients suitable for non-intubated VATS were recruited. Our results showed that comparable HBDs were achieved in all patients after emergence. Effective esophageal emptying was achieved at the first HRIM measurement in 11 N group patients and 2 I group patients (p = 0.002) and was achieved in all N (100%) and 13 I group patients (81%) within 100 min (p = 0.23). HBD and HRIM are warranted for detecting postoperative oropharyngeal and esophageal emptying.
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Affiliation(s)
- Chih-Jun Lai
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei 100025, Taiwan;
- Department of Anesthesiology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100225, Taiwan; (S.-IH.); (Z.-Y.L.); (Y.-J.H.)
| | - Jin-Shing Chen
- Department of Surgery, National Taiwan University Cancer Center, National Taiwan University College of Medicine, Taipei 106037, Taiwan;
| | - Shih-I Ho
- Department of Anesthesiology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100225, Taiwan; (S.-IH.); (Z.-Y.L.); (Y.-J.H.)
| | - Zhi-Yin Lu
- Department of Anesthesiology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100225, Taiwan; (S.-IH.); (Z.-Y.L.); (Y.-J.H.)
| | - Yi-Ju Huang
- Department of Anesthesiology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100225, Taiwan; (S.-IH.); (Z.-Y.L.); (Y.-J.H.)
| | - Ya-Jung Cheng
- Department of Anesthesiology, College of Medicine, National Taiwan University, Taipei 100233, Taiwan
- Department of Anesthesiology, National Taiwan University Cancer Center, Taipei 106037, Taiwan
- Correspondence: ; Tel.: +886-2-2312-3456 (ext. 65517)
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Rengarajan A, Argüero J, Yazaki E, Kadirkamanthan SS, Siriwardana HPP, Brunt LM, Sifrim D, Gyawali CP. High-resolution manometry features of paraesophageal hernia. Neurogastroenterol Motil 2020; 32:e13947. [PMID: 33118680 DOI: 10.1111/nmo.13947] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/22/2020] [Accepted: 06/25/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Paraesophageal hernias (PEH) can be associated with obstructive symptoms, but high-resolution manometry (HRM) characteristics have not been described in detail. METHODS HRM studies of confirmed PEH patients (n = 60, 66.3 ± 1.5 years, 76.7% F), axial hernias (n = 125, 56.1 ± 1.1 years, 58.4% F), and healthy controls (n = 20, 27.9 ± 0.7 years, 45% F) were analyzed. Axial hernias (type 1) were compared to PEH subtyped as isolated PEH (type 2), PEH with axial hernia (type 3), PEH with herniated abdominal organs (type 4), and unknown. Distal contractile integral (DCI), esophageal length, lower esophageal sphincter pressures (LESP), EGJ contractile integral (EGJ-CI), and integrated relaxation pressure (IRP) were extracted. Intra-luminal pressures were measured proximal (intrabolus pressure, IBP) and distal (intragastric pressure, IGP) to EGJ. Univariate and multivariate analyses were performed to characterize esophageal and EGJ motor physiology in PEH. KEY RESULTS PEH patients had LESP and EGJ-CI similar to controls; axial hernia patients had lower LESP. While IRP was within normal limits, PEH had elevated IBP and IGP, and shorter esophageal length compared to axial hernia and normal controls (P ≤ .0001 across groups). Short esophageal length was consistent across PEH subtypes (P = .06). On multivariate regression analysis, IBP remained an independent predictor of PEH (P < .0001). Within PEH subtypes, gastric pressure was higher when axial HH was also present, in contrast to isolated PEH (P = .03); other metrics did not differ. CONCLUSIONS & INFERENCES Luminal pressure increase both upstream and downstream of the EGJ on HRM likely represents obstructive phenomena in PEH, identification of which may support suspicion of PEH.
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Affiliation(s)
- Arvind Rengarajan
- Division of Gastroenterology, Washington University in St Louis, St Louis, MO, USA
| | - Julieta Argüero
- Barts and the London School of Medicine and Dentistry, Queen Mary Institute of London, London, UK
| | - Etsuro Yazaki
- Barts and the London School of Medicine and Dentistry, Queen Mary Institute of London, London, UK
| | | | | | - L Michael Brunt
- Section of Minimally Invasive Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Daniel Sifrim
- Barts and the London School of Medicine and Dentistry, Queen Mary Institute of London, London, UK
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University in St Louis, St Louis, MO, USA
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Kou W, Carlson DA, Patankar NA, Kahrilas PJ, Pandolfino JE. Four-dimensional impedance manometry derived from esophageal high-resolution impedance-manometry studies: a novel analysis paradigm. Therap Adv Gastroenterol 2020; 13:1756284820969050. [PMID: 33178334 PMCID: PMC7592175 DOI: 10.1177/1756284820969050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/24/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND This study aimed to introduce a novel analysis paradigm, referred to as 4-dimensional (4D) manometry based on biophysical analysis; 4D manometry enables the visualization of luminal geometry of the esophagus and esophagogastric junction (EGJ) using high-resolution-impedance-manometry (HRIM) data. METHODS HRIM studies from two asymptomatic controls and one type-I achalasia patient were analyzed. Concomitant fluoroscopy images from one control subject were used to validate the calculated temporal-spatial luminal radius and time-history of intraluminal bolus volume and movement. EGJ analysis computed diameter threshold for emptying, emptying time, flow rate, and distensibility index (DI), which were compared with bolus flow time (BFT) analysis. RESULTS For normal control, calculated volumes for 5 ml swallows were 4.1 ml-6.7 ml; for 30 ml swallows 21.3 ml-21.8 ml. With type-I achalasia, >4 ml of intraesophageal bolus residual was present both pre- and post-swallow. The four phases of bolus transit were clearly illustrated on the time-history of bolus movement, correlating well with the fluoroscopic images. In the control subjects, the EGJ diameter threshold for emptying was 8 mm for 5 ml swallows and 10 mm for 30 ml swallows; emptying time was 1.2-2.2 s for 5 ml swallows (BFT was 0.3-3 s) and 3.25-3.75 s for 30 ml swallows; DI was 2.4-3.4 mm2/mmHg for 5 ml swallows and 4.2-4.6 mm2/mmHg for 30 ml swallows. CONCLUSIONS The 4D manometry system facilitates a comprehensive characterization of dynamic esophageal bolus transit with concurrent luminal morphology and pressure from conventional HRIM measurements. Calculations of flow rate and wall distensibility provide novel measures of EGJ functionality.
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Affiliation(s)
| | - Dustin A. Carlson
- Feinberg School of Medicine, Northwestern
University, Chicago, IL, USA
| | - Neelesh A. Patankar
- Department of Mechanical Engineering,
Northwestern University, Evanston, IL, USA
| | - Peter J. Kahrilas
- Feinberg School of Medicine, Northwestern
University, Chicago, IL, USA
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10
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Lazarescu A, Chan WW, Gyawali CP, Lee YY, Xiao Y, Wu P. Updates on diagnostic modalities for esophageal dysphagia. Ann N Y Acad Sci 2020; 1481:108-116. [PMID: 32875574 DOI: 10.1111/nyas.14453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/26/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
Esophageal dysphagia is a common symptom in adults. Fluoroscopic contrast studies, endoscopy, and esophageal manometry have been used in the diagnosis of esophageal dysphagia for many years. The diagnostic yield has been improved with new test protocols that highlight abnormal bolus transit in the esophagus and outflow obstruction, as well as new high-definition and high-resolution technical advances in equipment. Functional luminal impedance planimetry and the addition of impedance to high-resolution esophageal manometry have also allowed the assessment of new parameters to better understand esophageal structure and function. In this concise review, we describe the role and utility of various diagnostic modalities in the assessment of patients with esophageal dysphagia.
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Affiliation(s)
- Adriana Lazarescu
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Yinglian Xiao
- Department of Gastroenterology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, PR China
| | - Peter Wu
- Department of Gastroenterology and Hepatology, St. George Hospital, Kogarah, New South Wales, Australia
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Rogers BD, Gyawali CP. Enhancing High-Resolution Esophageal Manometry: Use of Ancillary Techniques and Maneuvers. Gastroenterol Clin North Am 2020; 49:411-426. [PMID: 32718561 DOI: 10.1016/j.gtc.2020.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
High-resolution manometry evaluates esophageal motor function using 10 supine water swallows. Superimposing impedance over high-resolution manometry pressure topography assesses the relationship between contraction and bolus propulsion and identifies inadequate clearance. Ancillary techniques and maneuvers augment the standard supine high-resolution manometry evaluation by challenging peristaltic function. Increasing bolus volume (rapid drink challenge) and altering bolus consistency (standardized test meal, solid swallows) enhance identification of esophageal outflow obstruction syndromes. Physiologic maneuvers (multiple rapid swallows, abdominal compression) address the ability of the esophageal smooth muscle to augment contraction vigor. Pharmacologic challenge is less commonly used clinically, and elucidates pathophysiology of esophageal motor disorders.
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Affiliation(s)
- Benjamin D Rogers
- Division of Gastroenterology, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO 63110, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO 63110, USA.
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12
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Gong EJ, Choi K, Jung KW, Pandolfino JE, Kim DY, Yoon IJ, Seo SY, Koo HS, Na HK, Ahn JY, Lee JH, Choi KD, Kim DH, Song HJ, Lee GH, Jung HY, Myung SJ, Kim N, Joo S. New parameter for quantifying bolus transit with high-resolution impedance manometry: A comparison with simultaneous esophagogram. Neurogastroenterol Motil 2020; 32:e13847. [PMID: 32299145 DOI: 10.1111/nmo.13847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/19/2020] [Accepted: 03/18/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Esophageal bolus transit can be assessed using esophagogram or high-resolution impedance manometry (HRIM). The three-dimensional volume of inverted impedance (VII) has been developed to quantify the residual bolus between each swallow through spatiotemporal analysis. However, this novel metric has not been validated against simultaneous esophagogram. METHODS A total of nine healthy volunteers (Seven males, aged 19-45 years) were prospectively evaluated with HRIM and barium esophagogram. In addition, 21 symptomatic patients (12 males, aged 20-85 years) without major motility disorder were also included. The VII was estimated from HRIM data using MATLAB program and was compared with residual bolus volume in the esophagus estimated from simultaneous esophagogram. KEY RESULTS A total of 80 swallows (24 in controls and 56 in patients) were analyzed. Results from the VII method were concordant with the bolus transit pattern estimated from the esophagogram in 91.3% (73/80) of swallows. The correlation between quantitative data from VII and the volume of residual bolus estimated from esophagogram was strong in both groups with a Pearson's correlation coefficient of 0.805 for healthy volunteers and 0.730 for symptomatic patients. The intraclass correlation coefficient of VII between the three swallows within a subject was 0.901 in healthy subjects and 0.705 in patients, indicating a modest reliability of this method. CONCLUSIONS AND INFERENCES The newly developed VII method is a reliable method in assessing residual bolus volume in the esophagus based on comparison with bolus volume estimated from simultaneous esophagogram.
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Affiliation(s)
- Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Kyungmin Choi
- Department of Biomedical Engineering, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - John E Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Do Yeon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Yoon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - So Young Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Sook Koo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Nayoung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea
| | - Segyeong Joo
- Department of Biomedical Engineering, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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13
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Singendonk M, Kritas S, Omari T, Feinle-Bisset C, Page AJ, Frisby CL, Kentish SJ, Ferris L, McCall L, Kow L, Chisholm J, Khurana S. Upper Gastrointestinal Function in Morbidly Obese Adolescents Before and 6 Months After Gastric Banding. Obes Surg 2019; 28:1277-1288. [PMID: 29103072 DOI: 10.1007/s11695-017-3000-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The effects of laparoscopic adjustable gastric band (LAGB) placement on upper gastrointestinal tract function in obese adolescents are unknown. Therefore, our aim was to determine the short-term effects of LAGB on esophageal motility, gastroesophageal reflux, gastric emptying, appetite-regulatory hormones, and perceptions of post-prandial hunger and fullness. METHODS This study was part of a prospective cohort study (March 2009-December 2015) in one tertiary referral hospital. The study included obese adolescents (14-18 years) with a body mass index (BMI) > 40 (or ≥ 35 with comorbidities). Gastric emptying was assessed by 13C-octanoic acid breath test, pharyngeal, and esophageal motor function by high-resolution manometry with impedance (HRIM), and appetite and other perceptions using 100-mm visual analogue scales. Dysphagia symptoms were scored using a Dakkak questionnaire. Data were compared pre- and post-LAGB placement and at a 6-month follow-up. RESULTS Based upon analysis of 15 adolescents, at the 6-month follow-up, LAGB placement: (i) led to a significant reduction in weight and BMI; (ii) increased fullness and decreased hunger post-meal; (iii) increased symptoms of dysphagia after solid food; and, despite these effects, (iv) caused little or no changes to appetite hormones, while (v) effects on gastric emptying, esophageal motility, esophageal bolus transport, and esophageal emptying were not significant. CONCLUSION In adolescents, LAGB improved BMI and altered the sensitivity to nutrients without significant effects on upper gastrointestinal tract physiology at the 6-month follow-up.
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Affiliation(s)
- M Singendonk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/AMC, Amsterdam, The Netherlands
| | - S Kritas
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia
| | - T Omari
- Human Physiology, Medical Science and Technology, School of Medicine, Flinders University, Adelaide, South Australia, Australia.
| | - C Feinle-Bisset
- Centre for Nutrition and Gastrointestinal Diseases, Adelaide Medical School, University of Adelaide, Adelaide, Australia.,NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - A J Page
- South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
| | - C L Frisby
- Centre for Nutrition and Gastrointestinal Diseases, Adelaide Medical School, University of Adelaide, Adelaide, Australia.,South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
| | - S J Kentish
- Centre for Nutrition and Gastrointestinal Diseases, Adelaide Medical School, University of Adelaide, Adelaide, Australia.,South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
| | - L Ferris
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia.,Human Physiology, Medical Science and Technology, School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - L McCall
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia
| | - L Kow
- Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - J Chisholm
- Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - S Khurana
- Paediatric Surgery & Urology, Women's & Children's Hospital, Adelaide, Australia.,Department of Surgery, Flinders Medical Centre, Adelaide, Australia
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14
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Abstract
The literal definition of dysphagia is "disturbed eating". However, it is more accurately described in clinical practice as a sensation of food or liquid being stuck in the esophagus or chest. If this sensation is associated with pain, it is labeled odynophagia, and if it is associated with persistent obstruction and bolus retention, it is categorized as a food impaction. Through research and technological advances, we continue to expand our understanding of the etiologies and underlying pathophysiology relating to this complaint. However, for now, our clinical algorithms focus on endoscopy and manometry to break down dysphagia into three categories: obstructive dysphagia, esophageal motility disorders, and functional dysphagia. Here, we review some critical pitfalls in our current clinical diagnoses, new proposed underlying mechanisms of esophageal motor disorders, and developing technologies to aid in diagnosis and treatment.
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Affiliation(s)
- Joseph Triggs
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern Medicine, Northwestern University, Feinberg School of Medicine, 676 St Clair Street, Suite 14-009, Chicago, IL, 60611-2951, USA
| | - John Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern Medicine, Northwestern University, Feinberg School of Medicine, 676 St Clair Street, Suite 14-009, Chicago, IL, 60611-2951, USA
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15
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Savarino E, Marabotto E, Bodini G, Furnari M, Della Coletta M, Ghisa M, Barberio B, Frazzoni M, De Bortoli N, Zentilin P, Pellegatta G, Tolone S, Ottonello A, Savarino V. Advancements in the use of manometry and impedance testing for esophageal functional disorders. Expert Rev Gastroenterol Hepatol 2019; 13:425-435. [PMID: 30896306 DOI: 10.1080/17474124.2019.1595587] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The utilization of high-resolution manometry (HRM) has enhanced our understanding and assessment of esophageal motor disorders. Moreover, the combination of impedance technology with HRM (HRIM) has further improved our knowledge of esophageal physiology and the clinical evaluation of dysmotility, thanks to the addition of accurate measurement of bolus transit. Areas covered. This paper provides an overview of current knowledge in the use of HRIM for the study of esophageal functional disorders by reporting mainly the results of many publications and several systematic reviews in this field. Expert opinion. HRIM has represented a relevant improvement in the assessment of esophageal motility and has required the development of new metrics, such as the esophageal impedance integral ratio, the bolus flow time, the nadir impedance pressure and the impedance bolus height, which increase the evaluation of esophageal bolus transit. An extension of impedance is represented by functional lumen imaging probe (FLIP), which determines the biophysical properties and the distensibility of the esophagus and permits to detect contractility patterns not seen on HRM alone. We eagerly wait for a new and fruitful iteration of the Chicago Classification, now in version 3.0, which can cover the ongoing clinical experience of HRIM.
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Affiliation(s)
- Edoardo Savarino
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Elisa Marabotto
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Giorgia Bodini
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Manuele Furnari
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Marco Della Coletta
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Matteo Ghisa
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Brigida Barberio
- a Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology , University of Padua , Padua , Italy
| | - Marzio Frazzoni
- c Digestiva Pathophysiology Unit , Baggiovara Hospital , Modena , Italy
| | - Nicola De Bortoli
- d Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery , University of Pisa , Pisa , Italy
| | - Patrizia Zentilin
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Gaia Pellegatta
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
| | - Salvatore Tolone
- e Surgery Unit, Department of Surgery , University of Campania Luigi Vanvitelli , Caserta , Italy
| | - Andrea Ottonello
- f Department of Surgical Science and Integrated Diagnostics , University of Genoa , Genoa , Italy
| | - Vincenzo Savarino
- b Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties , University of Genoa , Genoa , Italy
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16
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Yadlapati R, Furuta GT, Menard-Katcher P. New Developments in Esophageal Motility Testing. ACTA ACUST UNITED AC 2019; 17:76-88. [DOI: 10.1007/s11938-019-00218-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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17
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Singendonk MJ, Lin Z, Scheerens C, Tack J, Carlson DA, Omari TI, Pandolfino JE, Rommel N. High-resolution impedance manometry parameters in the evaluation of esophageal function of non-obstructive dysphagia patients. Neurogastroenterol Motil 2019; 31:e13505. [PMID: 30426609 PMCID: PMC9380031 DOI: 10.1111/nmo.13505] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/24/2018] [Accepted: 10/09/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND High-resolution impedance manometry (HRIM) allows evaluation of esophageal bolus retention, flow, and pressurization. We explored novel HRIM measures and assessed their temporal relationship to dysphagia symptoms for boluses of different volume and consistency in non-obstructive dysphagia (NOD) patients. METHODS Thirty-three NOD patients (n = 19 minor or no disorder of peristalsis ("Normal") and n = 14 esophagogastric junction outflow obstruction ("EGJOO")) were evaluated with HRIM. Patients were administered 5 and 10 mL liquid, semisolid, and 2 and 4 cm solid boluses and indicated bolus perception during individual swallows using a 5-point Likert scale. HRIM was analyzed to assess Chicago Classification and pressure flow metrics, esophageal impedance integral (EII) ratio, and bolus flow time (BFT). KEY RESULTS Overall, bolus perception increased with increasing bolus consistency (P < 0.001), but did not differ significantly between EGJOO and Normal patients. EGJOO patients had higher IRP4, higher levels of bolus residual (ie, EII ratio and IR), and restricted esophageal emptying. The results for linking semisolid bolus perception to semisolid-derived measures revealed more biomechanically plausible and consistent patterns when compared to those derived for liquid boluses. In Normal patients, perception of boluses of heavier viscosity was related to higher bolus flow resistance during transport, whilst in EGJOO, perception was related to restriction of esophageal emptying. CONCLUSION & INFERENCES These novel pressure-impedance measures may aid in the evaluation of NOD patients by revealing abnormal motor patterns, which may explain symptom generation. Future studies are needed to evaluate which of these measures are worthy of calculation and to establish protocol settings that allow for their meaningful interpretation.
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Affiliation(s)
- Maartje J. Singendonk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital/Amsterdam UMC, Amsterdam, The Netherlands
| | - Zhiyue Lin
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Charlotte Scheerens
- Department of Neurosciences, ExpORL, University of Leuven, Leuven, Belgium,Translational Research Center for Gastrointestinal Diseases, University of Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Diseases, University of Leuven, Leuven, Belgium
| | - Dustin A. Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Taher I. Omari
- Department of Neurosciences, ExpORL, University of Leuven, Leuven, Belgium,School of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - John E. Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Nathalie Rommel
- Department of Neurosciences, ExpORL, University of Leuven, Leuven, Belgium,Translational Research Center for Gastrointestinal Diseases, University of Leuven, Leuven, Belgium
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18
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Omari T, Connor F, McCall L, Ferris L, Ellison S, Hanson B, Abu-Assi R, Khurana S, Moore D. A study of dysphagia symptoms and esophageal body function in children undergoing anti-reflux surgery. United European Gastroenterol J 2018; 6:819-829. [PMID: 30023059 PMCID: PMC6047286 DOI: 10.1177/2050640618764936] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/22/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The role of high-resolution esophageal impedance manometry (HRIM) for establishing risk for dysphagia after anti-reflux surgery is unclear. We conducted a prospective study of children with primary gastroesophageal reflux (GER) disease, for whom symptoms of dysphagia were determined pre-operatively and then post-operatively and we examined for features that may predict post-operative dysphagia. METHODS Thirteen children (aged 6.8-15.5 years) undergoing work-up prior to 360o Nissen fundoplication were included in the study. A dysphagia score assessed symptoms at pre-operative study and post-operatively (mean 1.4 years). A HRIM procedure recorded 5-ml liquid, 5-ml viscous and 2-cm solid boluses. We assessed esophageal motility, esophago-gastric junction (EGJ) morphology, EGJ contractility and pressure-flow variables indicative of bolus distension pressures and bolus clearance pressures. A composite pressure-flow index score was also derived. RESULTS Pre-operative pressure-flow index was positively correlated with post-operative dysphagia score (viscous bolus r = 0.771, p < 0.005). Of three variables that comprise the pressure-flow index, the ramp pressure measured during bolus clearance was the main driver of the effect seen (viscous bolus r = 0.819, p < 0.005). CONCLUSIONS In order to mitigate symptoms in relation to anti-reflux surgery, dysphagia symptoms and esophageal function need to be pre-operatively assessed. In patients with normal motility, an elevated pressure-flow index may predict post-operative dysphagia.
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Affiliation(s)
- T Omari
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Centre for Neuroscience, Flinders University, Adelaide, Australia
| | - F Connor
- Department of Gastroenterology, Royal Children's Hospital, Brisbane, Australia
| | - L McCall
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia
| | - L Ferris
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Centre for Neuroscience, Flinders University, Adelaide, Australia
| | - S Ellison
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia
| | - B Hanson
- UCL Mechanical Engineering, University College London, London, UK
| | - R Abu-Assi
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia
| | - S Khurana
- Paediatric Surgery & Urology, Women's & Children's Hospital, Adelaide, Australia
| | - D Moore
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia
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19
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Tseng PH, Wong RKM, Wu JF, Chen CC, Tu CH, Lee YC, Lee HC, Wang HP, Wu MS. Normative values and factors affecting water-perfused esophageal high-resolution impedance manometry for a Chinese population. Neurogastroenterol Motil 2018; 30:e13265. [PMID: 29230939 DOI: 10.1111/nmo.13265] [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: 07/24/2017] [Accepted: 11/20/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Combined esophageal high-resolution impedance manometry (HRIM) measures multiple pressures and bolus transit simultaneously, facilitating detailed assessment of esophageal motility. Currently, normative values for water-perfused HRIM systems for Chinese populations are lacking. METHODS Healthy volunteers were enrolled for comprehensive anthropometric measures, blood biochemistry tests, and an HRIM study using 22 water-perfused pressure sensors and 12 impedance channels. Ten 5-mL liquid swallows of saline at 30-second intervals were conducted. The following parameters were calculated: distal contractile integral (DCI), distal latency (DL), lower esophageal sphincter (LES) basal pressure, 4-second integrated relaxation pressure (IRP-4s), and complete bolus transit percentage. Normal values were established based on the 5th and 95th percentiles. KEY RESULTS All 66 participants (34 male, 32 female, aged 21-64 years) completed the study and tolerated the HRIM procedure well. The upper normal limit (95th percentile) of IRP-4 second was 20 mmHg. The 5th-95th percentile range for DCI, DL, and complete bolus transit was 99-2186 mmHg●s●cm, 6.2-11.3 second, and 50%-100%, respectively. Age was negatively correlated with DL. Females had significantly higher upper limits for IRP-4s and median DCI than males. Multivariate analyses confirmed that IRP-4s was higher in females, and that higher body mass index and waist circumference were associated with reduced DL and better bolus transit, respectively. CONCLUSIONS AND INFERENCES We established normative values for the water-perfused HRIM system for a Chinese population. Gender and anthropometric factors may affect various major HRIM parameters and should be taken into account when interpreting HRIM results in clinical practice.
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Affiliation(s)
- P-H Tseng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - R K M Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Medicine, University Medical Cluster, National University Health System, Singapore
| | - J-F Wu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - C-C Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - C-H Tu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Y-C Lee
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - H-C Lee
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - H-P Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - M-S Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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20
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Carlson DA, Lin Z, Kou W, Pandolfino JE. Inter-rater agreement of novel high-resolution impedance manometry metrics: Bolus flow time and esophageal impedance integral ratio. Neurogastroenterol Motil 2018; 30:e13289. [PMID: 29322591 PMCID: PMC5992008 DOI: 10.1111/nmo.13289] [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: 09/25/2017] [Accepted: 12/15/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Novel high-resolution impedance manometry (HRIM) metrics of bolus flow time (BFT) and esophageal impedance integral (EII) ratio have demonstrated clinical utility, though the reliability of their analysis has not been assessed. We aimed to evaluate the inter-rater agreement of the BFT and EII ratio. METHODS HRIM studies including five upright, liquid swallows from 40 adult patients were analyzed by two raters using a customized MATLAB program to generate the BFT and EII ratio. Inter-rater agreement was assessed using the intraclass correlation coefficient (ICC) for median values generated per patient and also for all 200 swallows. KEY RESULTS The ICC (95% confidence interval, CI) for BFT was 0.873 (0.759-0.933) for median values and 0.838 (0.778-0.881) for all swallows. The ICC (95% CI) for EII ratio was 0.983 (0.968-0.991) for median values and 0.905 (0.875-0.928) for all swallows. Median values for both BFT and EII ratio were similar between the two raters (P-values .05). CONCLUSIONS AND INFERENCES The BFT and EII ratio can be reliably calculated as supported by generally excellent inter-rater agreement. Thus, broader utilization of these measures appears feasible and would facilitate further evaluation of their clinical utility.
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Affiliation(s)
- D. A. Carlson
- Department of Medicine; Division of Gastroenterology and Hepatology; Feinberg School of Medicine; Northwestern University; Chicago IL USA
| | - Z. Lin
- Department of Medicine; Division of Gastroenterology and Hepatology; Feinberg School of Medicine; Northwestern University; Chicago IL USA
| | - W. Kou
- Department of Medicine; Division of Gastroenterology and Hepatology; Feinberg School of Medicine; Northwestern University; Chicago IL USA
| | - J. E. Pandolfino
- Department of Medicine; Division of Gastroenterology and Hepatology; Feinberg School of Medicine; Northwestern University; Chicago IL USA
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21
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van Lennep M, van Wijk MP, Omari TIM, Benninga MA, Singendonk MMJ. Clinical management of pediatric achalasia. Expert Rev Gastroenterol Hepatol 2018; 12:391-404. [PMID: 29439587 DOI: 10.1080/17474124.2018.1441023] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Achalasia is a rare esophageal motility disorder. Much of the literature is based on the adult population. In adults, guidance of therapeutic approach by manometric findings has led to improvement in patient outcome. Promising results have been achieved with novel therapies such as PerOral Endoscopic Myotomy (POEM). Areas covered: In this review, we provide an overview of the novel diagnostic and therapeutic tools for achalasia management and in what way they will relate to the future management of pediatric achalasia. We performed a PubMed and EMBASE search of English literature on achalasia using the keywords 'children', 'achalasia', 'pneumatic dilation', 'myotomy' and 'POEM'. Cohort studies < 10 cases and studies describing patients ≥ 20 years were excluded. Data regarding patient characteristics, treatment outcome and adverse events were extracted and presented descriptively, or pooled when possible. Expert commentary: Available data report that pneumatic dilation and laparoscopic Heller's myotomy are effective in children, with certain studies suggesting lower success rates in pneumatic dilation. POEM is increasingly used in the pediatric setting with promising short-term results. Gastro-esophageal reflux disease (GERD) may occur post-achalasia intervention due to disruption of the LES and therefore requires diligent follow-up, especially in children treated with POEM.
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Affiliation(s)
- Marinde van Lennep
- a Department of Pediatric Gastroenterology and Nutrition , Emma Children's Hospital/Academic Medical Center , Amsterdam , The Netherlands
| | - Michiel P van Wijk
- b Department of Pediatric Gastroenterology , VU University Medical Center , Amsterdam , The Netherlands
| | - Taher I M Omari
- c College of Medicine and Public Health , Flinders University , Adelaide , Australia.,d Center for Neuroscience , Flinders University , Adelaide , Australia
| | - Marc A Benninga
- a Department of Pediatric Gastroenterology and Nutrition , Emma Children's Hospital/Academic Medical Center , Amsterdam , The Netherlands
| | - Maartje M J Singendonk
- a Department of Pediatric Gastroenterology and Nutrition , Emma Children's Hospital/Academic Medical Center , Amsterdam , The Netherlands
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22
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Brink GJ, Lei WY, Omari TI, Singendonk MMJ, Hung JS, Liu TT, Yi CH, Chen CL. Physiological augmentation of esophageal distension pressure and peristalsis during conditions of increased esophageal emptying resistance. Neurogastroenterol Motil 2018; 30:e13225. [PMID: 29063658 DOI: 10.1111/nmo.13225] [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: 08/21/2017] [Accepted: 09/14/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Abdominal compression has been implemented as a provocative maneuver in high-resolution impedance manometry (HRIM) to "challenge" normal esophageal physiology with the aim of revealing abnormal motor patterns which may explain symptoms. In this study, we measured the effects of abdominal compression on esophageal functioning utilizing novel pressure-impedance parameters and attempted to identify differences between healthy controls and globus patients. METHODS Twenty-two healthy volunteers (aged 23-32 years, 41% female) and 22 globus patients (aged 23-72 years, 68% female) were evaluated with HRIM using a 3.2-mm water perfused manometric and impedance catheter. All participants received 10 × 5 mL liquid swallows; healthy controls also received 10 × 5 mL liquid swallows with abdominal compression created using an inflatable cuff. All swallows were analyzed to assess esophageal pressure topography (EPT) and pressure-flow metrics, indicative of distension pressure, flow timing and bolus clearance were derived. KEY RESULTS The effect of abdominal compression was shown as a greater contractile vigor of the distal esophagus by EPT and higher distension pressure based on pressure-flow metrics. Age and body mass index also increased contractile vigor and distension pressure. Globus patients were similar to controls. CONCLUSIONS AND INTERFERENCES Intrabolus pressure and contractile vigor are indicative of the physiological modulation of bolus transport mechanisms. Provocative testing by abdominal compression induces changes in these esophageal bolus dynamics.
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Affiliation(s)
- G J Brink
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, AMC, Amsterdam, The Netherlands
| | - W Y Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - T I Omari
- School of Medicine, Flinders University, South Australia
| | - M M J Singendonk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, AMC, Amsterdam, The Netherlands
| | - J S Hung
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - T T Liu
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - C H Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - C L Chen
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
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Rosen R, Garza JM, Tipnis N, Nurko S. An ANMS-NASPGHAN consensus document on esophageal and antroduodenal manometry in children. Neurogastroenterol Motil 2018; 30:10.1111/nmo.13239. [PMID: 29178261 PMCID: PMC5823717 DOI: 10.1111/nmo.13239] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/27/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Upper gastrointestinal symptoms in children are common and motility disorders are considered in the differential diagnosis. High resolution esophageal manometry (HRM) has revolutionized the study of esophageal physiology, and the addition of impedance has provided new insights into esophageal function. Antroduodenal motility has provided insight into gastric and small bowel function. PURPOSE This review highlights some of the recent advances in pediatric esophageal and antroduodenal motility testing including indications, preparation, performance, and interpretation of the tests. This update is the second part of a two part series on manometry studies in children (first part was on anorectal and colonic manometry [Neurogastroenterol Motil. 2016;29:e12944]), and has been endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the American Neurogastroenterology and Motility Society (ANMS).
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Affiliation(s)
- Rachel Rosen
- Aerodigestive Center, Boston Children’s Hospital
| | - Jose M. Garza
- Children’s Center for Digestive Health Care, and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Neelesh Tipnis
- Department of Pediatrics University of Mississippi Medical Center
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children’s Hospital
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Novel Pressure-Impedance Parameters for Evaluating Esophageal Function in Pediatric Achalasia. J Pediatr Gastroenterol Nutr 2018; 66:37-42. [PMID: 28604515 DOI: 10.1097/mpg.0000000000001647] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE In achalasia, absent peristalsis and reduced esophagogastric junction (EGJ) relaxation and compliance underlie dysphagia symptoms. Novel high-resolution impedance manometry variables, that is, bolus presence time (BPT) and trans-EGJ-bolus flow time (BFT) have been developed to estimate the duration of EGJ opening and trans-EGJ bolus flow. The aim of this study was to evaluate esophageal motor function and bolus flow in children diagnosed with achalasia using these variables. METHODS High-resolution impedance manometry recordings from 20 children who fulfilled the Chicago Classification (V3) criteria for achalasia were compared with recordings of 15 children with normal esophageal high-resolution manometry findings and no other evidence suggestive of achalasia. Matlab-based analysis software was used to calculate BPT and BFT. RESULTS Both BPT and BFT were significantly reduced in achalasia patients compared with children with normal esophageal motility (BPT 3.3 s vs 5.1 s P < 0.01; BFT 1.4 s vs 4.3 s P < 0.001). BFT was significantly lower than BPT (achalasia difference 1.9 s ± 1.3 s, P = 0.001 and normal difference 0.9 ± 0.3 s, P = 0.001). Overall, there was a significant correlation between BPT and BFT (r = 0.825, P < 0.001). We observed a 2-way differentiation of achalasia patients; those in whom the BPT and BFT were proportional, but significantly lower than in patients with normal peristalsis, and those in whom BFT was disproportionately lower than BPT. CONCLUSIONS Calculation of BPT and BFT may help determine whether esophageal bolus transport to the EGJ and/or esophageal emptying through the EGJ are aberrant. For achalasia, this may detect flow resistance at the EGJ, potentially improving both diagnosis and objective assessment of therapeutic effects.
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25
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Wang D, Xu H, Tang T, Wang J, Yu Y, Gyawali CP. Assessment of the esophagogastric junction (EGJ) using the EGJ contractile integral (EGJ-CI) following per-oral endoscopic myotomy (POEM) in achalasia. REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS 2018; 110. [DOI: 10.17235/reed.2018.5560/2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
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26
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High-resolution Impedance Manometry after Sleeve Gastrectomy: Increased Intragastric Pressure and Reflux are Frequent Events. Obes Surg 2017; 26:2449-56. [PMID: 26956879 DOI: 10.1007/s11695-016-2127-y] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION AND PURPOSE Sleeve gastrectomy (SG) is gaining ground in the field of bariatric surgery. Data are scarce on its impact on esophagogastric physiology. Our aim was to evaluate the impact of SG on esophagogastric motility with high-resolution impedance manometry (HRIM) and to assess the usefulness of HRIM in patients with upper gastrointestinal (GI) symptoms after SG. METHODS A retrospective analysis of 53 cases of HRIM performed after SG was conducted. Upper GI symptoms at the time of HRIM were scored. HRIM was analyzed according to the Chicago classification v3.0. A special attention was devoted to the occurrence of increased intragastric pressure (IIGP) after water swallows and reflux episodes as detected with impedance. A measurement of sleeve volume and diameter was performed with CT scan in a subgroup of patients. RESULTS IIGP occurred very frequently in patients after SG (77 %) and was not associated with any upper GI symptoms, specific esophageal manometric profile, or impedance reflux. Impedance reflux episodes were also frequently observed after SG (52 %): they were significantly associated with gastroesophageal reflux (GER) symptoms and ineffective esophageal motility. The sleeve volume and diameters were also significantly smaller in patients with impedance reflux episodes (p < 0.01). CONCLUSION SG significantly modified esophagogastric motility. IIGP is frequent, not correlated to symptoms, and should be regarded as a HRIM marker of SG. Impedance reflux episodes were also frequent, associated with GER symptoms and esophageal dysmotility. HRIM may thus have a clinical impact on the management of patients with upper GI symptoms after SG.
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27
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Expert consensus document: Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes. Nat Rev Gastroenterol Hepatol 2017; 14:677-688. [PMID: 28951579 DOI: 10.1038/nrgastro.2017.132] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
High-resolution manometry (HRM) and new analysis algorithms, summarized in the Chicago Classification, have led to a restructured classification of oesophageal motility disorders. This advance has led to increased detection of clinically relevant disorders, in particular achalasia. It has become apparent that the cardinal feature of achalasia - impaired lower oesophageal sphincter (LES) relaxation - can occur in several disease phenotypes: without peristalsis (type I), with pan-oesophageal pressurization (type II), with premature (spastic) distal oesophageal contractions (type III), or with preserved peristalsis (outlet obstruction). Furthermore, no manometric pattern is perfectly sensitive or specific for achalasia caused by a myenteric plexopathy, and there is no biomarker for this pathology. Consequently, physiological testing reveals other syndromes not meeting achalasia criteria that also benefit from therapies formerly reserved for achalasia. These findings have become particularly relevant with the development of a minimally invasive technique for performing a long oesophageal myotomy, the per-oral endoscopic myotomy (POEM). Optimal management is to render treatment in a phenotype-specific manner; that is, POEM calibrated to patient-specific physiology for spastic achalasia and the spastic disorders, and more conservative strategies such as pneumatic dilation for the disorders limited to the LES. This Consensus Statement examines the effect of HRM on our understanding of oesophageal motility disorders, with a focus on the diagnosis, epidemiology and management of achalasia and achalasia-like syndromes.
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Singendonk MMJ, Rosen R, Oors J, Rommel N, van Wijk MP, Benninga MA, Nurko S, Omari TI. Intra- and interrater reliability of the Chicago Classification of achalasia subtypes in pediatric high-resolution esophageal manometry (HRM) recordings. Neurogastroenterol Motil 2017; 29. [PMID: 28585270 DOI: 10.1111/nmo.13113] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Subtyping achalasia by high-resolution manometry (HRM) is clinically relevant as response to therapy and prognosis have shown to vary accordingly. The aim of this study was to assess inter- and intrarater reliability of diagnosing achalasia and achalasia subtyping in children using the Chicago Classification (CC) V3.0. METHODS Six observers analyzed 40 pediatric HRM recordings (22 achalasia and 18 non-achalasia) twice by using dedicated analysis software (ManoView 3.0, Given Imaging, Los Angeles, CA, USA). Integrated relaxation pressure (IRP4s), distal contractile integral (DCI), intrabolus pressurization pattern (IBP), and distal latency (DL) were extracted and analyzed hierarchically. Cohen's κ (2 raters) and Fleiss' κ (>2 raters) and the intraclass correlation coefficient (ICC) were used for categorical and ordinal data, respectively. RESULTS Based on the results of dedicated analysis software only, intra- and interrater reliability was excellent and moderate (κ=0.89 and κ=0.52, respectively) for differentiating achalasia from non-achalasia. For subtyping achalasia, reliability decreased to substantial and fair (κ=0.72 and κ=0.28, respectively). When observers were allowed to change the software-driven diagnosis according to their own interpretation of the manometric patterns, intra- and interrater reliability increased for diagnosing achalasia (κ=0.98 and κ=0.92, respectively) and for subtyping achalasia (κ=0.79 and κ=0.58, respectively). CONCLUSIONS Intra- and interrater agreement for diagnosing achalasia when using HRM and the CC was very good to excellent when results of automated analysis software were interpreted by experienced observers. More variability was seen when relying solely on the software-driven diagnosis and for subtyping achalasia. Therefore, diagnosing and subtyping achalasia should be performed in pediatric motility centers with significant expertise.
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Affiliation(s)
- M M J Singendonk
- Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/AMC, Amsterdam, The Netherlands
| | - R Rosen
- Division of Gastroenterology, Center for Motility and Functional Gastrointestinal Disorders, Boston, MA, USA
| | - J Oors
- Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/AMC, Amsterdam, The Netherlands
| | - N Rommel
- Translational Research Center for Gastrointestinal Diseases, University of Leuven, Leuven, Belgium.,Department of Neurosciences, ExpORL, University of Leuven, Leuven, Belgium
| | - M P van Wijk
- Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/AMC, Amsterdam, The Netherlands.,Department of Pediatric Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
| | - M A Benninga
- Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/AMC, Amsterdam, The Netherlands
| | - S Nurko
- Division of Gastroenterology, Center for Motility and Functional Gastrointestinal Disorders, Boston, MA, USA
| | - T I Omari
- Department of Neurosciences, ExpORL, University of Leuven, Leuven, Belgium.,Gastroenterology Unit, Women's and Children's Health Network, Adelaide, SA, Australia.,School of Medicine, Flinders University, Bedford Park, SA, Australia
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Abstract
PURPOSE OF REVIEW To review recent advances in achalasia diagnostics and therapeutics. RECENT FINDINGS The cardinal feature of achalasia, impaired lower esophageal sphincter (LES) relaxation, can occur in association with varied patterns of esophageal contractility. The Chicago Classification distinguishes among these as follows: without contractility (type I), with panesophageal pressurization (type II), with premature (spastic) distal esophageal contractions (type III), or even with preserved peristalsis [esophagogastric junction (EGJ) outlet obstruction]. Physiological testing also reveals achalasia-like syndromes that also benefit from achalasia therapies. Coincident with this has been the development of peroral endoscopic myotomy (POEM), an endoscopic technique for performing an esophageal myotomy. Hence, the option now exists to either selectively ablate the LES (pneumatic dilation, laparoscopic Heller myotomy, or POEM) or to ablate the sphincter and create a myotomy along some or the entire adjacent smooth muscle esophagus (POEM). Each achalasia syndrome has unique treatment considerations; type II achalasia responds well to all therapies, whereas type III responds best to POEM. SUMMARY Emerging data support the concept that optimal management of achalasia is phenotype-specific, guided by high-resolution manometry, and, in some instance, functional luminal imaging probe studies. This opinion article reviews the varied characteristic and treatment considerations of achalasia syndromes as currently understood.
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30
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Abstract
PURPOSE OF REVIEW Esophageal high-resolution manometry (HRM) is the current state-of-the-art diagnostic tool to evaluate esophageal motility patterns and, as such, is widely adopted in clinical practice. This article will review the interpretation of esophageal HRM in clinical practice. RECENT FINDINGS HRM uses a high-resolution catheter to transmit intraluminal pressure data that are subsequently converted into dynamic esophageal pressure topography (EPT) plots. Metric data from EPT plots are synthesized to yield an esophageal motility diagnosis according to the Chicago Classification, a formal analytic scheme for esophageal motility disorders, which is currently in version 3.0. The standard HRM protocol consists of a baseline phase and a series of 10 wet swallows in the supine or reclined position. In addition, data from swallows in the seated position and provocative HRM maneuvers provide useful information about motility properties. Combined high-resolution impedance technology is also clinically available and enables concurrent assessment of bolus transit and postprandial responses. Finally, there is ongoing interest to optimize the training and competency assessment for interpretation of HRM in clinical practice. SUMMARY Esophageal HRM is a valuable and sophisticated clinical tool to evaluate esophageal motility patterns. Emerging clinical applications of esophageal HRM include combined impedance technology, provocative maneuvers, and postprandial evaluation.
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Cock C, Besanko LK, Burgstad CM, Thompson A, Kritas S, Heddle R, Fraser RJL, Omari TI. Age-related impairment of esophagogastric junction relaxation and bolus flow time. World J Gastroenterol 2017; 23:2785-2794. [PMID: 28487616 PMCID: PMC5403758 DOI: 10.3748/wjg.v23.i15.2785] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 01/27/2017] [Accepted: 03/20/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the functional effects of abnormal esophagogastric (EGJ) measurements in asymptomatic healthy volunteers over eighty years of age.
METHODS Data from 30 young controls (11 M, mean age 37 ± 11 years) and 15 aged subjects (9 M, 85 ± 4 years) were compared for novel metrics of EGJ-function: EGJ-contractile integral (EGJ-CI), “total” EGJ-CI and bolus flow time (BFT). Data were acquired using a 3.2 mm, 25 pressure (1 cm spacing) and 12 impedance segment (2 cm) solid-state catheter (Unisensor and MMS Solar GI system) across the EGJ. Five swallows each of 5 mL liquid (L) and viscous (V) bolus were analyzed. Mean values were compared using Student’s t test for normally distributed data or Mann Whitney U-test when non-normally distributed. A P value < 0.05 was considered significant.
RESULTS EGJ-CI at rest was similar for older subjects compared to controls. “Total” EGJ-CI, measured during liquid swallowing, was increased in older individuals when compared to young controls (O 39 ± 7 mmHg.cm vs C 18 ± 3 mmHg.cm; P = 0.006). For both liquid and viscous bolus consistencies, IRP4 was increased (L: 11.9 ± 2.3 mmHg vs 5.9 ± 1.0 mmHg, P = 0.019 and V: 14.3 ± 2.4 mmHg vs 7.3 ± 0.8 mmHg; P = 0.02) and BFT was reduced (L: 1.7 ± 0.3 s vs 3.8 ± 0.2 s and V: 1.9 ± 0.3 s vs 3.8 ± 0.2 s; P < 0.001 for both) in older subjects, when compared to young. A matrix of bolus flow and presence above the EGJ indicated reductions in bolus flow at the EGJ occurred due to both impaired bolus transport through the esophageal body (i.e., the bolus never reached the EGJ) and increased flow resistance at the EGJ (i.e., the bolus retained just above the EGJ).
CONCLUSION Bolus flow through the EGJ is reduced in asymptomatic older individuals. Both ineffective esophageal bolus transport and increased EGJ resistance contribute to impaired bolus flow.
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Carlson DA, Omari T, Lin Z, Rommel N, Starkey K, Kahrilas PJ, Tack J, Pandolfino JE. High-resolution impedance manometry parameters enhance the esophageal motility evaluation in non-obstructive dysphagia patients without a major Chicago Classification motility disorder. Neurogastroenterol Motil 2017; 29:10.1111/nmo.12941. [PMID: 27647522 PMCID: PMC5328837 DOI: 10.1111/nmo.12941] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 08/18/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND High-resolution impedance manometry (HRIM) allows evaluation of esophageal bolus retention, flow, and pressurization. We aimed to perform a collaborative analysis of HRIM metrics to evaluate patients with non-obstructive dysphagia. METHODS Fourteen asymptomatic controls (58% female; ages 20-50) and 41 patients (63% female; ages 24-82), 18 evaluated for dysphagia and 23 for reflux (non-dysphagia patients), with esophageal motility diagnoses of normal motility or ineffective esophageal motility, were evaluated with HRIM and a global dysphagia symptom score (Brief Esophageal Dysphagia Questionnaire). HRIM was analyzed to assess Chicago Classification metrics, automated pressure-flow metrics, the esophageal impedance integral (EII) ratio, and the bolus flow time (BFT). KEY RESULTS Significant symptom-metric correlations were detected only with basal EGJ pressure, EII ratio, and BFT. The EII ratio, BFT, and impedance ratio differed between controls and dysphagia patients, while the EII ratio in the upright position was the only measure that differentiated dysphagia from non-dysphagia patients. CONCLUSIONS & INFERENCES The EII ratio and BFT appear to offer an improved diagnostic evaluation in patients with non-obstructive dysphagia without a major esophageal motility disorder. Bolus retention as measured with the EII ratio appears to carry the strongest association with dysphagia, and thus may aid in the characterization of symptomatic patients with otherwise normal manometry.
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Affiliation(s)
- DA Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - T Omari
- Department of Human Physiology, School of Medicine, Flinders University, Bedford Park, SA, Australia
| | - Z Lin
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - N Rommel
- Department of Neurosciences, Experimental Otorhinolaryngology, Deglutology, University of Leuven, Leuven, Belgium,Translational Research Center for Gastrointestinal Diseases (TARGID), University of Leuven, Leuven, Belgium
| | - K Starkey
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - PJ Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - J Tack
- Translational Research Center for Gastrointestinal Diseases (TARGID), University of Leuven, Leuven, Belgium
| | - JE Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Abstract
The utilization of impedance technology has enhanced our understanding and assessment of esophageal dysmotility. Esophageal high-resolution manometry (HRM) catheters incorporated with multiple impedance electrodes help assess esophageal bolus transit, and the combination is termed high-resolution impedance manometry (HRIM). Novel metrics have been developed with HRIM-including esophageal impedance integral ratio, bolus flow time, nadir impedance pressure, and impedance bolus height-that augments the assessment of esophageal bolus transit. Automated impedance-manometry (AIM) analysis has enhanced understanding of the relationship between bolus transit and pressure phenomena. Impedance-based metrics have improved understanding of the dynamics of esophageal bolus transit into four distinct phases, may correlate with symptomatic burden, and can assess the adequacy of therapy for achalasia. An extension of the use of impedance involves impedance planimetry and the functional lumen imaging probe (FLIP), which assesses esophageal biophysical properties and distensibility, and could detect patterns of esophageal contractility not seen on HRM. Impedance technology, therefore, has a significant impact on esophageal function testing in the present day.
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Affiliation(s)
- Amit Patel
- Division of Gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, 704 15th Street no. 221, Durham, NC, 27705, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8124, Saint Louis, MO, 63110, USA.
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Rommel N, Rayyan M, Scheerens C, Omari T. The Potential Benefits of Applying Recent Advances in Esophageal Motility Testing in Patients with Esophageal Atresia. Front Pediatr 2017; 5:137. [PMID: 28680874 PMCID: PMC5478877 DOI: 10.3389/fped.2017.00137] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 05/30/2017] [Indexed: 12/12/2022] Open
Abstract
Infants and children with esophageal atresia commonly present with swallowing dysfunction or dysphagia. Dysphagia can lead to a range of significant consequences such as aspiration pneumonia, malnutrition, dehydration, and food impaction. To improve oral intake, the clinical diagnosis of dysphagia in patients with esophageal atresia should focus on both the pharynx and the esophagus. To characterize the complex interactions of bolus flow and motor function between mouth, pharynx, and esophagus, a detailed understanding of normal and abnormal deglutition is required through the use of adequate and objective assessment techniques. As clinical symptoms do not correlate well with conventional assessment methods of motor function such as radiology or manometry but do correlate with bolus flow, the current state-of-the-art diagnosis involves high-resolution manometry combined with impedance measurements to characterize the interplay between esophageal motor function and bolus clearance. Using a novel pressure flow analysis (PFA) method as an integrated analysis method of manometric and impedance measurements, differentiation of patients with impaired esophago-gastric junction relaxation from patients with bolus outflow disorders is clinically relevant. In this, pressure flow matrix categorizing the quantitative PFA measures may be used to make rational therapeutic decisions in patients with esophageal atresia. Through more advanced diagnostics, improved understanding of pathophysiology may improve our patient care by directly targeting the failed biomechanics of both the pharynx and the esophagus.
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Affiliation(s)
- Nathalie Rommel
- Neurogastroenterology and Motility, Gastroenterology, University Hospitals Leuven, Leuven, Belgium.,Experimental Otorhinolaryngology, Department of Neurosciences, Deglutology, University of Leuven, Leuven, Belgium
| | - Maissa Rayyan
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, University of Leuven, Leuven, Belgium
| | - Charlotte Scheerens
- Neurogastroenterology and Motility, Gastroenterology, University Hospitals Leuven, Leuven, Belgium.,Experimental Otorhinolaryngology, Department of Neurosciences, Deglutology, University of Leuven, Leuven, Belgium
| | - Taher Omari
- School of Medicine, Flinders University, Adelaide, SA, Australia
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35
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Carlson DA, Lin Z, Kahrilas PJ, Sternbach J, Hungness ES, Soper NJ, Balla M, Listernick Z, Tye M, Ritter K, Craft J, Ciolino JD, Pandolfino JE. High-Resolution Impedance Manometry Metrics of the Esophagogastric Junction for the Assessment of Treatment Response in Achalasia. Am J Gastroenterol 2016; 111:1702-1710. [PMID: 27698386 PMCID: PMC5224522 DOI: 10.1038/ajg.2016.442] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 08/22/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We aimed to evaluate the value of novel high-resolution impedance manometry (HRIM) metrics, bolus flow time (BFT), and esophagogastric junction (EGJ) contractile integral (CI), as well as EGJ pressure (EGJP) and the integrated relaxation pressure (IRP), as indicators of treatment response in achalasia. METHODS We prospectively evaluated 75 patients (ages 19-81, 32 female) with achalasia during follow-up after pneumatic dilation or myotomy with Eckardt score (ES), timed-barium esophagram (TBE), and HRIM. Receiver-operating characteristic (ROC) curves for good symptomatic outcome (ES≤3) and good radiographic outcome (TBE column height at 5 min<5 cm) were generated for each potential predictor of treatment response (EGJP, IRP, BFT, and EGJ-CI). RESULTS Follow-up occurred at a median (range) 12 (3-291) months following treatment. A total of 49 patients had good symptomatic outcome and 46 had good radiographic outcome. The area-under-the-curves (AUCs) on the ROC curve for symptomatic outcome were 0.55 (EGJP), 0.62 (IRP), 0.77 (BFT) and 0.56 (EGJ-CI). The AUCs for radiographic outcome were 0.64 (EGJP), 0.48 (IRP), 0.73 (BFT), and 0.65 (EGJ-CI). Optimal cut-points were determined as 11 mm Hg (EGJP), 12 mm Hg (IRP), 0 s (BFT), and 30 mm Hg•cm (EGJ-CI) that provided sensitivities/specificities of 57%/46% (EGJP), 65%/58% (IRP), 78%/77% (BFT), and 53%/62% (EGJ-CI) to predict symptomatic outcome and 57%/66% (EGJP), 57%/41% (IRP), 76%/69% (BFT), and 57%/66% (EGJ-CI) to predict radiographic outcome. CONCLUSIONS BFT, a novel HRIM metric, provided an improved functional assessment over manometric measures of EGJP, IRP, and EGJ-CI at follow-up after achalasia treatment and may help direct clinical management.
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Affiliation(s)
- Dustin A. Carlson
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Zhiyue Lin
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Peter J. Kahrilas
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joel Sternbach
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eric S. Hungness
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Nathaniel J. Soper
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michelle Balla
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Zoe Listernick
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael Tye
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Katherine Ritter
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jenna Craft
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jody D. Ciolino
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Lin Z, Carlson D, Dykstra K, Sternbach J, Hungness E, Kahrilas PJ, Ciolino JD, Pandolfino JE. High-resolution impedance manometry measurement of bolus flow time in achalasia and its correlation with dysphagia. Neurogastroenterol Motil 2015; 27:1232-8. [PMID: 26088614 PMCID: PMC4587662 DOI: 10.1111/nmo.12613] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 05/11/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND We assessed whether a high-resolution impedance manometry (HRIM) metric, bolus flow time (BFT) across the esophagogastric junction (EGJ), was abnormal in achalasia patients subtyped by the Chicago Classification and compared BFT to other HRM metrics. METHODS HRIM studies were performed in 60 achalasia patients (14 type I, 36 type II and 10 type III) and 15 healthy controls. Studies were analyzed with a MATLAB program to calculate BFT using a virtual HRIM sleeve. Integrated relaxation pressure (IRP) and basal end-expiratory EGJ pressure were also calculated. The relationship between BFT and dysphagia symptom scores was assessed using the impaction dysphagia questionnaire (IDQ). KEY RESULTS Median BFT was significantly lower in achalasia patients (0.5 s, range 0.0-3.5 s) compared to controls (3.5 s, range 2.0-5.0 s; p < 0.05). BFT was significantly lower in types I and II than in type III achalasia in both the supine and upright positions (p < 0.0001). BFT was the only HRIM metric significantly associated with IDQ score in both the supine (R(2) = 0.20, p = 0.0046) and upright positions (R(2) = 0.27, p = 0.0002). CONCLUSIONS & INFERENCES BFT was significantly reduced in all subtypes of achalasia and complementary to the IRP as a diagnostic discriminant in equivocal achalasia cases. Additionally, BFT had a more robust correlation with dysphagia severity compared to other metrics of EGJ function.
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Affiliation(s)
- Zhiyue Lin
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Dusty Carlson
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Kristina Dykstra
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joel Sternbach
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eric Hungness
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Peter J. Kahrilas
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jody D. Ciolino
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Advances in the evaluation and management of esophageal disease of systemic sclerosis. Curr Rheumatol Rep 2015; 17:475. [PMID: 25475597 DOI: 10.1007/s11926-014-0475-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Symptoms of heartburn and dysphagia as well as objective findings of abnormal esophageal acid exposure and esophageal dysmotility are common in patients with systemic sclerosis (SSc). Treatments for SSc esophageal disease are generally limited to gastroesophageal reflux disease (GERD) treatment with proton pump inhibitors. Progresses made in esophageal diagnostic testing offer the potential for improved clinical characterization of esophageal disease in SSc that may help direct management decisions. In addition to reviewing GERD management in patients with SSc, present and potential uses of endoscopy, reflux monitoring, manometry, impedance planimetry, and endoscopic ultrasound are discussed.
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Abstract
Oesophageal dysphagia is a common symptom, which might be related to severe oesophageal diseases such as carcinomas. Therefore, an organic process must be ruled out in the first instance by endoscopy in all patients presenting with dysphagia symptoms. The most prevalent obstructive aetiologies are oesophageal cancer, peptic strictures and eosinophilic oesophagitis. Eosinophilic oesophagitis is one of the most common causes of dysphagia in adults and children, thus justifying the need to obtain oesophageal biopsy samples from all patients presenting with unexplained dysphagia. With the advent of standardized high-resolution manometry and specific metrics to characterize oesophageal motility, the Chicago classification has become a gold-standard algorithm for manometric diagnosis of oesophageal motor disorders. In addition, sophisticated investigations and analysis methods that combine pressure and impedance measurement are currently in development. In the future, these techniques might be able to detect subtle pressure abnormalities during bolus transport, which could further explain pathophysiology and symptoms. The degree to which novel approaches will help distinguish dysphagia caused by motor abnormalities from functional dysphagia still needs to be determined.
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Carlson DA, Pandolfino JE. High-Resolution Manometry in Clinical Practice. Gastroenterol Hepatol (N Y) 2015; 11:374-384. [PMID: 27118931 PMCID: PMC4843031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
High-resolution manometry (HRM) is the primary method used to evaluate esophageal motor function. Displayed and interpreted by esophageal pressure topography (EPT), HRM/ EPT provides a detailed assessment of esophageal function that is useful in the evaluation of patients with nonobstructive dysphagia and before foregut surgery. Esophageal motility diagnoses are determined systematically by applying objective metrics of esophageal sphincter and peristaltic function to the Chicago Classification of esophageal motility disorders. This article discusses HRM study, EPT interpretation, and the translation of EPT findings into clinical practice. Examples are provided to illustrate several clinical challenges.
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Affiliation(s)
- Dustin A Carlson
- Dr Carlson is a fellow and Dr Pandolfino is a professor of medicine and chief of the Division of Gastroenterology and Hepatology at Northwestern University Feinberg School of Medicine in Chicago, Illinois
| | - John E Pandolfino
- Dr Carlson is a fellow and Dr Pandolfino is a professor of medicine and chief of the Division of Gastroenterology and Hepatology at Northwestern University Feinberg School of Medicine in Chicago, Illinois
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Kahrilas PJ, Bredenoord AJ, Fox M, Gyawali CP, Roman S, Smout AJPM, Pandolfino JE. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil 2015; 27:160-74. [PMID: 25469569 PMCID: PMC4308501 DOI: 10.1111/nmo.12477] [Citation(s) in RCA: 1352] [Impact Index Per Article: 150.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 10/30/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Chicago Classification (CC) of esophageal motility disorders, utilizing an algorithmic scheme to analyze clinical high-resolution manometry (HRM) studies, has gained acceptance worldwide. METHODS This 2014 update, CC v3.0, developed by the International HRM Working Group, incorporated the extensive clinical experience and interval publications since the prior (2011) version. KEY RESULTS Chicago Classification v3.0 utilizes a hierarchical approach, sequentially prioritizing: (i) disorders of esophagogastric junction (EGJ) outflow (achalasia subtypes I-III and EGJ outflow obstruction), (ii) major disorders of peristalsis (absent contractility, distal esophageal spasm, hypercontractile esophagus), and (iii) minor disorders of peristalsis characterized by impaired bolus transit. EGJ morphology, characterized by the degree of overlap between the lower esophageal sphincter and the crural diaphragm and baseline EGJ contractility are also part of CC v3.0. Compared to the previous CC version, the key metrics of interpretation, the integrated relaxation pressure (IRP), the distal contractile integral (DCI), and the distal latency (DL) remain unchanged, albeit with much more emphasis on DCI for defining both hypo- and hypercontractility. New in CC v3.0 are: (i) the evaluation of the EGJ at rest defined in terms of morphology and contractility, (ii) 'fragmented' contractions (large breaks in the 20-mmHg isobaric contour), (iii) ineffective esophageal motility (IEM), and (iv) several minor adjustments in nomenclature and defining criteria. Absent in CC v3.0 are contractile front velocity and small breaks in the 20-mmHg isobaric contour as defining characteristics. CONCLUSIONS & INFERENCES Chicago Classification v3.0 is an updated analysis scheme for clinical esophageal HRM recordings developed by the International HRM Working Group.
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Affiliation(s)
- P. J. Kahrilas
- Department of Medicine; Feinberg School of Medicine; Northwestern University; Chicago IL USA
| | - A. J. Bredenoord
- Department of Medicine; Feinberg School of Medicine; Northwestern University; Chicago IL USA
| | - M. Fox
- Department of Medicine; Feinberg School of Medicine; Northwestern University; Chicago IL USA
| | - C. P. Gyawali
- Department of Medicine; Feinberg School of Medicine; Northwestern University; Chicago IL USA
| | - S. Roman
- Department of Medicine; Feinberg School of Medicine; Northwestern University; Chicago IL USA
| | - A. J. P. M. Smout
- Department of Medicine; Feinberg School of Medicine; Northwestern University; Chicago IL USA
| | - J. E. Pandolfino
- Department of Medicine; Feinberg School of Medicine; Northwestern University; Chicago IL USA
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Omari T, Tack J, Rommel N. Impedance as an adjunct to manometric testing to investigate symptoms of dysphagia: What it has failed to do and what it may tell us in the future. United European Gastroenterol J 2014; 2:355-66. [PMID: 25360313 DOI: 10.1177/2050640614549096] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 07/31/2014] [Indexed: 12/17/2022] Open
Abstract
Dysphagia is a common reason for referral for investigations of oesophageal motility. Impedance measurement has now been incorporated into commercially available diagnostic manometry systems for more than a decade. This innovation, which offered the ability to record patterns of bolus transport without the need for simultaneous radiology, has for the most part failed to live up to expectations, offering few additional diagnostic insights. This review examines the potential pitfalls related to how impedance patterns are currently analysed and introduces and discusses the new concept of pressure-flow analysis integrating pressure and impedance measurements to derive new metrics linked to the pressures occurring within and around the bolus as it is being transported.
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Affiliation(s)
- T Omari
- School of Medicine, Flinders University, Bedford Park, Australia ; The Robinson Institute, University of Adelaide, Adelaide, Australia ; Translational Research Center for Gastrointestinal Diseases, University of Leuven, Belgium
| | - J Tack
- Translational Research Center for Gastrointestinal Diseases, University of Leuven, Belgium
| | - N Rommel
- Translational Research Center for Gastrointestinal Diseases, University of Leuven, Belgium ; Neurosciences, ExpORL, University of Leuven, Belgium
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Abstract
The Chicago Classification defines esophageal motility disorders in high resolution manometry. This is based on individual scoring of 10 swallows performed in supine position. Disorders of esophago-gastric junction (EGJ) outflow obstruction are defined by a median integrated relaxation pressure above the limit of normal and divided into 3 achalasia subtypes and EGJ outflow obstruction. Major motility disorders (aperistalsis, distal esophageal spasm, and hypercontractile esophagus) are patterns not encountered in controls in the context of normal EGJ relaxation. Finally with the latest version of the Chicago Classification, only two minor motor disorders are considered: ineffective esophageal motility and fragmented peristalsis.
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