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Pitisuttithum P, Goudie E, Araujo IK, Halder S, Carlson DA, Pandolfino JE, Kou W. Four-dimensional impedance manometry volume metrics for predicting abnormal bolus retention. Neurogastroenterol Motil 2024; 36:e14803. [PMID: 38676387 DOI: 10.1111/nmo.14803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND The objective measurement for esophageal bolus volume and bolus clearance could classify abnormal high-resolution manometry (HRM) beyond the current Chicago classification. We aimed to compare the novel four-dimensional impedance manometry (4D HRM) volume metrics with timed barium esophagram (TBE). METHODS Adults with esophageal symptoms undergoing HRM and TBE were included. A custom-built program for 4D HRM analysis measured esophageal luminal cross-sectional area (CSA) from impedance and subsequently derived esophageal bolus volume and clearance. 4D HRM volume metrics included pre-swallow residual volume, maximal volume, retention volume, and clearance ratio defined as 1.0-retention volume divided by the maximal volume. An abnormal TBE was defined as a column height >5 cm at 1 min or 5 min. KEY RESULTS A total of 95 patients (normal motility: 33%; ineffective esophageal motility: 12%; absent contractility: 10%; esophagogastric junction outflow obstruction: 30%; type I achalasia: 5%; type II achalasia: 12%) were categorized into normal TBE (58%), abnormal TBE at 1 min (17%), and abnormal TBE at 5 min (25%). The AUROC demonstrated that, among all 4D HRM volume metrics, the clearance ratio had the best performance in predicting abnormal TBE at 5 min (AUROC, 95% confidence interval: 0.89, 0.82-0.96), and exhibited a strong negative correlation with TBE at 5 min (r = -0.65; p < 0.001). CONCLUSIONS & INFERENCES Novel 4D HRM volume metrics provide objective measurement of esophageal bolus volume and bolus clearance. The clearance ratio has a strong correlation with TBE and could potentially serve as a substitute for TBE to measure esophageal retention.
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Affiliation(s)
- Panyavee Pitisuttithum
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Eric Goudie
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Thoracic Surgery, Department of Surgery, Université de Montréal, Montréal, Quebec, Canada
| | - Isis K Araujo
- Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Sourav Halder
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Wenjun Kou
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Elisha G, Halder S, Carlson DA, Kou W, Kahrilas PJ, Pandolfino JE, Patankar NA. A Mechanics-Based Perspective on the Function of Human Sphincters During Functional Luminal Imaging Probe Manometry. J Biomech Eng 2024; 146:021001. [PMID: 37994843 PMCID: PMC10750791 DOI: 10.1115/1.4064125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 11/24/2023]
Abstract
Functional luminal imaging probe (FLIP) is used to measure cross-sectional area (CSA) and pressure at sphincters. It consists of a catheter surrounded by a fluid filled cylindrical bag, closed on both ends. Plotting the pressure-CSA hysteresis of a sphincter during a contraction cycle, which is available through FLIP testing, offers information on its functionality, and can provide diagnostic insights. However, limited work has been done to explain the mechanics of these pressure-CSA loops. This work presents a consolidated picture of pressure-CSA loops of different sphincters. Clinical data reveal that although sphincters have a similar purpose (controlling the flow of liquids and solids by opening and closing), two different pressure-CSA loop patterns emerge: negative slope loop (NSL) and positive slope loop (PSL). We show that the loop type is the result of an interplay between (or lack thereof) two mechanical modes: (i) neurogenic mediated relaxation of the sphincter muscle or pulling applied by external forces, and (ii) muscle contraction proximal to the sphincter which causes mechanical distention. We conclude that sphincters which only function through mechanism (i) exhibition NSL whereas sphincters which open as a result of both (i) and (ii) display a PSL. This work provides a fundamental mechanical understanding of human sphincters. This can be used to identify normal and abnormal phenotypes for the different sphincters and help in creating physiomarkers based on work calculation.
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Affiliation(s)
- Guy Elisha
- Department of Mechanical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL 60201
| | - Sourav Halder
- Theoretical and Applied Mechanics Program, McCormick School of Engineering, Northwestern University, Evanston, IL 60201
| | - Dustin A. Carlson
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611
| | - Peter J. Kahrilas
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611
| | - Neelesh A. Patankar
- Department of Mechanical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL 60201; Theoretical and Applied Mechanics Program, McCormick School of Engineering, Northwestern University, Evanston, IL 60201
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Low EE, Yadlapati R. Utility of Functional Lumen Imaging Probe in the Evaluation of Esophageal Conditions. Am J Gastroenterol 2024; 119:15-20. [PMID: 37450632 PMCID: PMC10841715 DOI: 10.14309/ajg.0000000000002387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Eric E. Low
- Division of Gastroenterology and Hepatology, University of California, San Diego, San Diego, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology and Hepatology, University of California, San Diego, San Diego, California, USA
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Mittal RK, Zifan A. Why so Many Patients With Dysphagia Have Normal Esophageal Function Testing. GASTRO HEP ADVANCES 2023; 3:109-121. [PMID: 38420259 PMCID: PMC10899865 DOI: 10.1016/j.gastha.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/30/2023] [Indexed: 03/02/2024]
Abstract
Esophageal peristalsis involves a sequential process of initial inhibition (relaxation) and excitation (contraction), both occurring from the cranial to caudal direction. The bolus induces luminal distension during initial inhibition (receptive relaxation) that facilitates smooth propulsion by contraction travelling behind the bolus. Luminal distension during peristalsis in normal subjects exhibits unique characteristics that are influenced by bolus volume, bolus viscosity, and posture, suggesting a potential interaction between distension and contraction. Examining distension-contraction plots in dysphagia patients with normal bolus clearance, ie, high-amplitude esophageal peristaltic contractions, esophagogastric junction outflow obstruction, and functional dysphagia, reveal 2 important findings. Firstly, patients with type 3 achalasia and nonobstructive dysphagia show luminal occlusion distal to the bolus during peristalsis. Secondly, patients with high-amplitude esophageal peristaltic contractions, esophagogastric junction outflow obstruction, and functional dysphagia exhibit a narrow esophageal lumen through which the bolus travels during peristalsis. These findings indicate a relative dynamic obstruction to bolus flow and reduced distensibility of the esophageal wall in patients with several primary esophageal motility disorders. We speculate that the dysphagia sensation experienced by many patients may result from a normal or supernormal contraction wave pushing the bolus against resistance. Integrating representations of distension and contraction, along with objective assessments of flow timing and distensibility, complements the current classification of esophageal motility disorders that are based on the contraction characteristics only. A deeper understanding of the distensibility of the bolus-containing esophageal segment during peristalsis holds promise for the development of innovative medical and surgical therapies to effectively address dysphagia in a substantial number of patients.
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Affiliation(s)
- Ravinder K. Mittal
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California
| | - Ali Zifan
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California
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5
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Mittal RK, Ledgerwood M, Caplin M, Xu P, Marquez-Lavenant W, Zifan A. Impaired sliding between the lower esophageal sphincter and crural diaphragm (esophageal hiatus) in patients with achalasia esophagus. Am J Physiol Gastrointest Liver Physiol 2023; 325:G368-G378. [PMID: 37581423 PMCID: PMC10642994 DOI: 10.1152/ajpgi.00117.2023] [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: 06/09/2023] [Revised: 07/14/2023] [Accepted: 07/31/2023] [Indexed: 08/16/2023]
Abstract
Swallow-related axial shortening of the esophagus results in the formation of phrenic ampulla in normal subjects; whether it is the case in achalasia esophagus is not known. The goal is to study axial shortening of the esophagus and relative movement between the lower esophageal sphincter (LES) and crural diaphragm (CD) in normal subjects and patients with achalasia. A novel method, isoimpedance contour excursion at the lower edger of LES, as a marker of axial esophageal shortening was validated using X-ray fluoroscopy (n = 5) and used to study axial shortening and separation between the LES and CD during peristalsis in normal subjects (n = 15) and patients with achalasia type 2 esophagus (n = 15). Abdominal CT scan images were used to determine the nature of tissue in the esophageal hiatus of control (n = 15) and achalasia patients (n = 15). Swallow-induced peristalsis resulted in an axial excursion of isoimpedance contours, which was quantitatively similar to the metal clip anchored to the LES on X-ray fluoroscopy (2.3 ± 1.4 vs. 2.1 ± 1.4 cm with deep inspiration and 2.7 ± 0.6 cm vs. 2.7 ± 0.6 cm with swallow-induced peristalsis). Esophageal axial shortening with swallows in patients with achalasia was significantly smaller than normal (1.64 ± 0.5 cm vs. 3.59 ± 0.4 cm, P < 0.001). Gray-level matrix analysis of CT images suggests more "fibrous" and less fat in the hiatus of patients with achalasia. Lack of sliding between the LES and CD explains the low prevalence of hiatus hernia, and low compliance of the LES in achalasia esophagus, which likely plays a role in the pathogenesis of achalasia.NEW & NOTEWORTHY Swallow-related axial shortening of the esophagus is reduced, and there is no separation between the lower esophageal sphincter and crural diaphragm (CD) with swallowing in patients with achalasia esophagus. Fat in the hiatal opening of the esophagus appears to be replaced with fibrous tissue in patients with achalasia, resulting in tight anchoring between the LES and CD. The above findings explain low prevalence of hiatus hernia and the low compliance of the LES in achalasia esophagus.
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Affiliation(s)
- Ravinder K Mittal
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California, United States
| | - Melissa Ledgerwood
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California, United States
| | - Michelle Caplin
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California, United States
| | - Pudan Xu
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California, United States
| | - Walter Marquez-Lavenant
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California, United States
| | - Ali Zifan
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California, United States
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Hernández Mondragón OV, Solórzano Pineda OM. Peroral esophageal myotomy for esophageal motility disorders. Minerva Gastroenterol (Torino) 2023; 69:193-208. [PMID: 37191670 DOI: 10.23736/s2724-5985.22.02987-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
The concept of third space endoscopy first described in 2007, was adapted and performed in humans in 2010 by Inoue et al. in a group of patients with esophageal achalasia (EA). Since then, esophageal endoscopic myotomy (E-POEM), has been performed in more than 10,000 patients worldwide up to now. Safety and efficacy have been confirmed at early, mid and long-term evaluations, in different gastrointestinal diseases including achalasia, refractory gastroparesis, and other esophageal motility disorders (EMD). Nowadays, this treatment has shown to be not only an excellent option, but also with its excellent outcomes, the first option in certain clinical scenarios such as type III achalasia. Thus, the minimal invasive nature of POEM gives us multiple advantages compared with the classical treatments that includes pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM), including not only clinical aspects but also economical. High resolution manometry (HRM) has substantially redefined the actual approach of esophageal motility disorders with the major changes in instrumental use, diagnostic algorithms, and therapeutics. The previous Chicago's classification V 3.0 clearly improved our knowledge about pathophysiology of spastic esophageal motor disorders, however, with its recent update (Chicago V 4.0), multiple changes in diagnosis and treatment are expected. In the present article, we aimed to review and analyze the most important aspects about the results of E-POEM in the management of EMD according to the view of the new Chicago's classification V 4.0.
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Affiliation(s)
| | - Omar M Solórzano Pineda
- Department of Gastrointestinal Endoscopy, XXI Century National Medical Center, Mexico City, Mexico
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Zifan A, Gandu V, Mittal RK. Esophageal wall compliance/stiffness during peristalsis in patients with functional dysphagia and high-amplitude esophageal contractions. Am J Physiol Gastrointest Liver Physiol 2022; 323:G586-G593. [PMID: 36283085 PMCID: PMC9678403 DOI: 10.1152/ajpgi.00075.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 10/14/2022] [Accepted: 10/18/2022] [Indexed: 01/31/2023]
Abstract
Recent studies that utilized distension/contraction plots to study peristalsis reveal poor distension of the esophagus in patients with functional dysphagia and high-amplitude contractions [high-amplitude esophageal contractions (HAECs)] even though the contraction phase of peristalsis is normal in these patients. Our goal was to determine biomechanical properties of the esophageal wall and bolus flow characteristics in patients with functional dysphagia and HAEC during primary peristalsis. Studies were performed on 30 healthy subjects, 30 patients with functional dysphagia, and 25 patients with HAEC. Subjects swallowed 10 mL, 0.5 N saline bolus in the Trendelenburg position to study primary peristalsis. A custom-built software (Dplots) determined peak distension from the impedance measurements, pressure at peak distension, wall tension (pressure × radius), wall distensibility [cross-sectional area (CSA)/pressure], and bolus flow (cm3/s) in four segments of esophagus (between upper and lower esophageal sphincter). Luminal CSA of distal esophagus was smaller, and average bolus flow rate was faster in patients with functional dysphagia and HAEC. Esophageal wall distensibility, a measure of esophageal wall compliance was lower and wall tension was higher in the distal esophagus of both patient groups compared with normal subjects. Ultrasound imaging confirmed poor distension of the esophagus. A trend toward greater wall thickness at the peak of distension was found in patients with functional dysphagia compared with normal subjects. A stiffer or noncompliant esophageal wall is the reason for poor distension of the esophagus during primary peristalsis in patients with functional dysphagia and HAEC.NEW & NOTEWORTHY We studied healthy asymptomatic subject, patients with functional dysphagia (FD), and patients with high-amplitude esophageal contractions (HAEC). Our data show that in patients with HAEC and functional dysphagia, luminal distension is smaller (low luminal CSA at peak distension), intraluminal pressure is higher, and liquid bolus travels faster through the esophagus as compared with normal subjects. We conclude that patients with functional dysphagia and HAEC have a stiffer distal esophageal wall during bolus transport related to primary peristalsis.
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Affiliation(s)
- Ali Zifan
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California
| | - Vignesh Gandu
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California
| | - Ravinder K Mittal
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California
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8
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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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Omari TI, Zifan A, Cock C, Mittal RK. Distension contraction plots of pharyngeal/esophageal peristalsis: next frontier in the assessment of esophageal motor function. Am J Physiol Gastrointest Liver Physiol 2022; 323:G145-G156. [PMID: 35788152 PMCID: PMC9377784 DOI: 10.1152/ajpgi.00124.2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/16/2022] [Accepted: 06/27/2022] [Indexed: 01/31/2023]
Abstract
Esophageal peristalsis consists of initial inhibition (relaxation) followed by excitation (contraction), both of which move sequentially in the aboral direction. Initial inhibition results in receptive relaxation and bolus-induced luminal distension, which allows propulsion by the contraction with minimal resistance to flow. Similar to the contraction wave, luminal distension has unique waveform characteristics in normal subjects; both are modulated by bolus volume, bolus viscosity, and posture, suggesting a possible cause-and-effect relationship between the two. Distension contraction plots in patients with dysphagia with normal bolus clearance [high-amplitude esophageal contractions (HAECs), esophagogastric junction outflow obstruction (EGJOO), and functional dysphagia (FD)] reveal two major findings: 1) unlike normal subjects, there is luminal occlusion distal to bolus during peristalsis in certain patients, i.e., with type 3 achalasia and nonobstructive dysphagia; and 2) bolus travels through a narrow lumen esophagus during peristalsis in patients with HAECs, EGJOO, and FD. Aforementioned findings indicate a relative dynamic obstruction to the bolus flow during peristalsis and reduced distensibility of esophageal wall in the bolus segment of the esophagus. We speculate that a normal or supernormal contraction wave pushing bolus against resistance is the mechanism of dysphagia sensation in significant number of patients. Representations of distension and contraction, combined with objective measures of flow timing and distensibility are complementary to the current scheme of classifying esophageal motility disorders based solely on the characteristics of contraction phase of peristalsis. Better understanding of the distensibility of the bolus-containing segment of the esophagus during peristalsis will lead to the development of novel medical and surgical therapies in the treatment of dysphagia in significant number of patients.
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Affiliation(s)
- Taher I Omari
- Flinders Health and Medical Research Institute and College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Ali Zifan
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, California
| | - Charles Cock
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Ravinder K Mittal
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, California
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Zifan A, Gandu V, Ledgerwood M, Mittal R. Bolus flow and biomechanical properties of the esophageal wall during primary esophageal peristalsis: Effects of bolus viscosity and posture. Neurogastroenterol Motil 2022; 34:e14281. [PMID: 34636107 DOI: 10.1111/nmo.14281] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Studies show that intraluminal impedance recordings of the esophagus allow one to measure the luminal distension during peristalsis, an important parameter for calculation of the biomechanical properties of esophageal wall. The goal was to determine the effect of subject posture and bolus viscosity on the biomechanical properties of esophageal wall, and the rate of bolus flow along the length of the esophagus during primary peristalsis. METHODS High-resolution manometry impedance recordings were obtained in 14 normal healthy subjects. Swallows of 10 ml saline and viscous bolus were recorded in the supine and Trendelenburg positions. User identified the region of interest, and a custom-designed software extracted parameters of interest such as bolus flow rate, esophageal wall tension, and esophageal wall distensibility in four equal segments of the esophagus. KEY RESULTS Bolus flow rate decreases along the length of the esophagus, being slowest in the distal esophagus. Bolus flow rate is smaller in the Trendelenburg position and with viscous bolus as compared with supine position and saline bolus. Esophageal wall tension is greater in the Trendelenburg position and with viscous bolus as compared with the supine position and saline bolus. The esophageal wall distensibility is larger in the distal as compared with proximal esophagus, which is true for both the saline and viscous bolus. CONCLUSIONS & INFERENCES We report, for the first time, bolus flow rate and biomechanical properties of the esophageal wall during swallow-induced primary peristalsis. Future studies may investigate biomechanical basis of esophageal motility disorders using the methodology described.
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Affiliation(s)
- Ali Zifan
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Vignesh Gandu
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Melissa Ledgerwood
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Ravinder Mittal
- Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California, USA
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11
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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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12
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Bredenoord AJ, Babaei A, Carlson D, Omari T, Akiyama J, Yadlapati R, Pandolfino JE, Richter J, Fass R. Esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2021; 33:e14193. [PMID: 34120375 DOI: 10.1111/nmo.14193] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 12/13/2022]
Abstract
In the Chicago Classification version 4.0 (CCv4), esophagogastric junction outflow obstruction (EGJOO) is manometrically defined as an elevated median integrated relaxation pressure (IRP) and elevated intrabolus pressure (IBP) during supine wet swallows, and persistently elevated median IRP in the upright position. A clinically relevant conclusive diagnosis of EGJOO requires a manometric diagnosis of EGJOO and associated symptoms such as dysphagia and/or chest pain with at least one of the following supportive investigations (pharmacologic provocation, timed barium esophagogram, and/or endoflip). The Chicago Classification is intended for diagnosis of primary esophageal motor disorders, and thus history and endoscopic evaluation are important to exclude conditions (eg, previous surgery, strictures, or masses) that can secondarily generate the EGJOO pattern on HRM. While a manometric finding of EGJOO is often made and can be an early sign of achalasia, more often it is a manometric finding without clinical implications. The proposed changes in CC4.0 have attempted to make the diagnosis more specific, in order to reduce the number of clinically irrelevant diagnoses and avoid confusion by patients and physicians alike.
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Affiliation(s)
- Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Arash Babaei
- Division of Gastroenterology, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Dustin Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Taher Omari
- College or Medicine & Public Health, Flinders University, Adelaide, SA, Australia
| | - Jun Akiyama
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Rena Yadlapati
- Division of Gastroenterology & Hepatology, Center for Esophageal Diseases, University of California San Diego, La Jolla, CA, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joel Richter
- Joy McCann Culverhouse Center for Esophageal Diseases, University of South Florida College of Medicine, Tampa, FL, USA
| | - Ronnie Fass
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Metrohealth Medical System, Case Western Reserve University, Cleveland, OH, USA
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13
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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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14
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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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15
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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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16
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Ayazi S, Grubic AD, Zheng P, Zaidi AH, Schwameis K, Alleyne AC, Myers BM, Omstead AN, Jobe BA. Measurement of outflow resistance imposed by magnetic sphincter augmentation: defining normal values and clinical implication. Surg Endosc 2020; 35:5787-5795. [PMID: 33051761 PMCID: PMC8437925 DOI: 10.1007/s00464-020-08068-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/29/2020] [Indexed: 12/15/2022]
Abstract
Introduction No manometric criteria have been defined to select patients for magnetic sphincter augmentation (MSA). The first step to establish such criteria is to measure the outflow resistance at esophagogastric junction (EGJ) imposed by MSA. This resistance needs to be overcome by the esophageal contraction in order for the esophagus to empty and to avoid postoperative dysphagia. This study was designed to measure the outflow resistance caused by MSA in patients free of postoperative dysphagia. Methods Records of the patients who underwent MSA in our institution were reviewed. A group of MSA patients with excellent functional outcome, who were free of clinically significant postoperative dysphagia, were selected. These patients then underwent high-resolution impedance manometry (HRIM) at a target date of 1 year after surgery. The outflow resistance was measured by the esophageal intrabolus pressure (iBP) recorded 2 cm proximal to the lower esophageal sphincter (LES). Results The study population consisted of 43 patients. HRIM was performed at mean of 20.4 (10.4) months after surgery. The mean (SD) amplitude of the iBP was 13.5 (4.3) before surgery and increased to 19.1 (5.6) after MSA (p < 0.0001). Patients with a smaller size LINX device (≤ 14 beads) had a similar iBP when compared to those with a larger device (> 15 beads) [19.7 (4.5) vs. 18.4 (5.9), p = 0.35]. There was a significant correlation between the iBP and % incomplete bolus clearance [Spearman R: 0.44 (95% CI 0.15–0.66), p = 0.0032]. The 95th percentile value for iBP after MSA was 30.4 mmHg. Conclusion The EGJ outflow resistance measured by iBP is increased after MSA. The upper limit of normal for iBP is 30 mmHg in this cohort of patients who were free of dysphagia after MSA. This degree of resistance needs to be overcome by distal esophageal contraction and will likely be requisite to prevent persistent postoperative dysphagia.
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Affiliation(s)
- Shahin Ayazi
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA.
| | - Andrew D Grubic
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ping Zheng
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ali H Zaidi
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Katrin Schwameis
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Adam C Alleyne
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Brittney M Myers
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ashten N Omstead
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Blair A Jobe
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
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Jehangir A, Tanner S, Malik Z, Parkman HP. Characterizing the proximal esophageal segment in patients with symptoms of esophageal dysmotility. Neurogastroenterol Motil 2020; 32:e13888. [PMID: 32485784 DOI: 10.1111/nmo.13888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/25/2020] [Accepted: 04/29/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Proximal esophageal striated muscle contractility may be abnormal in patients with esophageal symptoms, but is not assessed in the Chicago Classification (CC) v3.0. We aimed to (a) determine the prevalence of abnormal proximal esophageal contractility in patients with esophageal symptoms; (b) compare proximal esophageal contractility in patients with different esophageal motility disorders; (c) assess the association of abnormal proximal esophageal contractility with esophageal symptoms. METHODS Patients undergoing high-resolution esophageal manometry (HREM) from 7/2019 to 11/2019 and healthy volunteers (HVs) were studied. Measurements of the proximal esophageal segment included the vigor of contractility of the proximal esophagus (proximal contractile integral/PCI). Patients rated gastrointestinal symptoms' severity. KEY RESULTS HREM was performed on 221 patients (63.8% females, mean age 57.1 ± 1.1 years) and 19 HVs. Mean PCI in HVs was 299.5 ± 30.6 (95% CI 32.3-566.7 mm Hg. s. cm). Of all patients, 61 (27.6%) had abnormal PCI. HVs and patients with different esophageal motility disorders had significantly different PCI (P < .01). Type 1 achalasia patients had weaker PCI than patients with absent contractility (P = .02). Patients with abnormal PCI had more severe dysphagia (P = .02), nausea (P = .03), vomiting (P = .03), and lower bolus clearance (P < .01) than patients with normal PCI. CONCLUSIONS AND INFERENCES Abnormal PCI was found in a fourth of patients with esophageal symptoms. PCI may be useful to distinguish some esophageal motility disorders. Patients with abnormal PCI had a higher severity of some upper gastrointestinal symptoms than patients with normal PCI. Assessing the proximal esophageal segment on HREM may be useful in characterizing patients with esophageal symptoms.
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Affiliation(s)
- Asad Jehangir
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Samuel Tanner
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Zubair Malik
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Henry P Parkman
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
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18
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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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Ivashkin VT, Mayev IV, Trukhmanov AS, Storonova OA, Abdulkhakov SA, Andreev DN, Bordin DS, Valitova ER, Klyaritskaya IL, Krivoy VV, Kucheryavyi YA, Lapina TL, Morozov SV, Sablin OA, Semenikhina EV, Uspenskiy YP, Sheptulin AA. Recommendations of the Russian Gastroenterological Association on Clinical Use of High-Resolution Manometry in Diagnosis of Esophageal Disorders. RUSSIAN JOURNAL OF GASTROENTEROLOGY, HEPATOLOGY, COLOPROCTOLOGY 2020. [DOI: 10.22416/1382-4376-2020-30-3-61-88] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Aim. Current recommendations of the Russian Gastroenterological Association on clinical use of high-resolution manometry in diagnosis of esophageal disorders are intended to assist in clinical decision making, terminology standardisation and interpretation of clinical data.Key points. In 2018, a joint meeting of the Russian Gastroenterological Association and Russian Neurogastroenterology and Motility Group approved unified terminology and classification of esophageal motor function disorders for high-resolution manometry diagnosis.Gastrointestinal patient complaints typically concern esophageal disorders such as dysphagia, regurgitation, heart-burn, chest pain or belching. To exclude erosive and ulcerative lesions, eosinophilic esophagitis and organic changes, esophagogastroduodenoscopy and biopsy are recommended in pre-treatment. Upon excluding mucosal lesions and esophageal lumen obstruction as causal for symptoms, use of high-resolution manometry is recommended. This method of esophageal examination has become the “gold standard” in diagnosis of motor disorders.High-resolution manometry enables detailed investigation of integral quantitative and qualitative characteristics of esophagus motor function and specific related disorders, analysis of esophageal contractile propagation and strictly coordinated synchronous peristalsis of upper esophageal sphincter, esophagus and lower esophageal sphincter, which malfunction may provoke development of achalasia, esophagospasm, hiatal hernia, ineffective eso pha geal motility and other motor disorders.Conclusion. High-resolution manometry is a relatively new method for study of esophagus motor function gaining increasingly wide application in clinical practice. It enables a medical professional to obtain evidence that may critically affect the choice of optimal patient care strategy and effective treatment. Current recommendations are based on an extensive review of up-to-date information and will be updated with new corpus of clinical data and assessment emerging in evidential medicine to provide gastroenterologists country-wide with latest scientific and practical guidelines.
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Affiliation(s)
- V. T. Ivashkin
- Sechenov First Moscow State Medical University (Sechenov University)
| | - I. V. Mayev
- Moscow State University of Medicine and Dentistry
| | - A. S. Trukhmanov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - O. A. Storonova
- Sechenov First Moscow State Medical University (Sechenov University)
| | | | | | - D. S. Bordin
- Moscow State University of Medicine and Dentistry; Loginov Moscow Clinical Scientific Center; Tver State Medical University
| | | | | | | | | | - T. L. Lapina
- Sechenov First Moscow State Medical University (Sechenov University)
| | - S. V. Morozov
- Federal Research Center for Nutrition, Biotechnology and Food Safety
| | - O. A. Sablin
- Nikiforov All-Russian Center for Emergency and Radiation Medicine
| | | | - Yu. P. Uspenskiy
- Saint-Petersburg State Pediatric Medical University; Pavlov First Saint-Petersburg State Medical University
| | - A. A. Sheptulin
- Sechenov First Moscow State Medical University (Sechenov University)
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20
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Wu PI, Sloan JA, Kuribayashi S, Gregersen H. Impedance in the evaluation of the esophagus. Ann N Y Acad Sci 2020; 1481:139-153. [PMID: 32557676 DOI: 10.1111/nyas.14408] [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: 03/24/2020] [Revised: 05/09/2020] [Accepted: 05/14/2020] [Indexed: 12/16/2022]
Abstract
The aim of this paper is to review esophageal electrical impedance technologies and to discuss the use of these technologies for physiological measurements, diagnostics, and therapy of esophageal disease. In order to develop a better understanding of the pathophysiology of and improve the diagnosis of esophageal disorders, such as gastroesophageal reflux disease (GERD) and achalasia, several new diagnostic tests, including intraluminal impedance, esophageal mucosal impedance, and the functional luminal imaging probe, have been developed. These technologies have proven valuable for assessment of the esophagus in recent years. They provide information on esophageal flow properties, mucosal integrity, lumen shape, and distensibility in esophageal disorders, in particular for GERD and achalasia. Despite their promise and novel clinical studies, the potential of these technologies has been far from realized. New multidisciplinary approaches will contribute to our understanding and interpretation of esophageal impedance data and disease mechanisms.
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Affiliation(s)
- Peter I Wu
- Department of Gastroenterology and Hepatology, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Joshua A Sloan
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology, Gunma University Hospital, Maebashi, Japan
| | - Hans Gregersen
- GIOME, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
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21
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Lang IM, Medda BK, Shaker R. Characterization and mechanism of the esophago-esophageal contractile reflex of the striated muscle esophagus. Am J Physiol Gastrointest Liver Physiol 2019; 317:G304-G313. [PMID: 31268772 PMCID: PMC6774085 DOI: 10.1152/ajpgi.00138.2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
An esophago-esophageal contractile reflex (EECR) of the cervical esophagus has been identified in humans. The aim of this study was to characterize and determine the mechanisms of the EECR. Cats (n = 35) were decerebrated, electrodes were placed on pharynx and cervical esophagus, and esophageal motility was recorded using manometry. All areas of esophagus were distended to locate and quantify the EECR. The effects of esophageal perfusion of NaCl or HCl, vagus nerve or pharyngoesophageal nerve (PEN) transection, or hexamethonium administration (5 mg/kg iv) were determined. We found that distension of the esophagus at all locations activated EECR rostral to stimulus only. EECR response was greatest when the esophagus 2.5-11.5 cm from cricopharyngeus (CP) was distended. HCl perfusion activated repetitively an EECR-like response of the proximal esophagus only within 2 min, and after ~20 min EECR was inhibited. Transection of PEN blocked or inhibited EECR 1-7 cm from CP, and vagotomy blocked EECR at all locations. Hexamethonium blocked EECR at 13 and 16 cm from CP but sensitized its activation at 1-7 cm from CP. EECR of the entire esophagus exists, which is directed in the orad direction only. EECR of striated muscle esophagus is mediated by vagus nerve and PEN and inhibited by mechanoreceptors of smooth muscle esophagus. EECR of smooth muscle esophagus is mediated by enteric nervous system and vagus nerve. Activation of EECR of the striated muscle esophagus is initially sensitized by HCl exposure, which may have a role in prevention of supraesophageal reflux.NEW & NOTEWORTHY An esophago-esophageal contractile reflex (EECR) exists, which is directed in the orad direction only. EECR of the proximal esophagus can appear similar to and be mistaken for secondary peristalsis. The EECR of the striated muscle is mediated by the vagus nerve and pharyngoesophageal nerve and inhibited by mechanoreceptor input from the smooth muscle esophagus. HCl perfusion initially sensitizes activation of the EECR of the striated muscle esophagus, which may participate in prevention of supraesophageal reflux.
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Affiliation(s)
- Ivan M. Lang
- Dysphagia Research Laboratory, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Bidyut K. Medda
- Dysphagia Research Laboratory, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Reza Shaker
- Dysphagia Research Laboratory, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
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22
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Oetzmann von Sochaczewski C, Lindner A, Heimann A, Balus A, Patel VH, Harrison MR, Muensterer OJ. Beyond Magnamosis: A Method to Test Sutureless Esophageal Anastomotic Devices in Living Swine by Creating an Esophageal Bypass Loop for Natural Oral Nutrition. J Laparoendosc Adv Surg Tech A 2019; 29:852-855. [PMID: 30882275 DOI: 10.1089/lap.2018.0778] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction: Thoracoscopic esophageal atresia repair has become increasingly popular, but is still limited to a few expert centers and has some challenges and shortcomings. One of them has a longer operation time compared with conventional thoracotomy. Magnetic compression anastomosis may contribute toward shorter operation times by avoiding the time-consuming anastomotic suturing. We aimed to establish a method of testing sutureless anastomoses in parallel to having swine eating the natural way. Materials and Methods: We used four juvenile Pietrain swine-aged 8 weeks, weighing 15 kg-to establish a living animal model after preceding cadaver tests. Esophagi were fully mobilized through right-sided thoracotomy to gain sufficient length to create an esophageal loop that served as a bypass for food after magnet deployment. Six hours later, patency of the bypass esophageal loop was assessed by passing an orogastric tube and by allowing swine to drink methylene blue-stained water. We also tested the device stability using the classical burst pressure test. Results: The esophageal lumen was patent for feeding tube. Swine were able to drink and methylene blue colored fluid reached the stomach. Clinical signs of obstruction such as regurgitation or coughing were absent. Magnets sustained burst pressures up to 200,000 Pascal until they became disrupted. At 6 hours after magnet placing, we already saw subtle esophageal mucosa erosions indicating the beginning of anastomotic formation. Conclusion: This animal model is useful to test different magnet designs for sutureless esophageal anastomosis or even future devices for in vivo tissue engineering.
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Affiliation(s)
| | - Andreas Lindner
- 1 Department of Paediatric Surgery, and Universitätsmedizin Mainz der Johannes-Gutenberg-Universität, Mainz, Germany
| | - Axel Heimann
- 2 Department of Neurosurgical Pathophysiology, Universitätsmedizin Mainz der Johannes-Gutenberg-Universität, Mainz, Germany
| | - Alexandru Balus
- 3 Division of Pediatric Surgery, University of California, San Francisco, California
| | - Veeshal H Patel
- 3 Division of Pediatric Surgery, University of California, San Francisco, California
| | - Michael R Harrison
- 3 Division of Pediatric Surgery, University of California, San Francisco, California
| | - Oliver J Muensterer
- 1 Department of Paediatric Surgery, and Universitätsmedizin Mainz der Johannes-Gutenberg-Universität, Mainz, Germany
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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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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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Kahrilas PJ, Bredenoord AJ, Carlson DA, Pandolfino JE. Advances in Management of Esophageal Motility Disorders. Clin Gastroenterol Hepatol 2018; 16:1692-1700. [PMID: 29702296 PMCID: PMC6317712 DOI: 10.1016/j.cgh.2018.04.026] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/26/2018] [Accepted: 04/13/2018] [Indexed: 02/07/2023]
Abstract
The widespread adoption of high-resolution manometry (HRM) has led to a restructuring in the classification of esophageal motility disorder classification summarized in the Chicago Classification, currently in version 3.0. It has become apparent that the cardinal feature of achalasia, impaired lower esophageal sphincter relaxation, can occur in several disease phenotypes: without peristalsis, with premature (spastic) distal esophageal contractions, with panesophageal pressurization, or even with preserved peristalsis. Furthermore, despite these advances in diagnostics, no single manometric pattern is perfectly sensitive or specific for idiopathic achalasia and complimentary assessments with provocative maneuvers during HRM or interrogating the esophagogastric junction with the functional luminal imaging probe during endoscopy can be useful in clarifying equivocal or inexplicable HRM findings. Using these tools, we have come to conceptualize esophageal motility disorders as characterized by obstructive physiology at the esophagogastric junction, smooth muscle esophagus, or both. Recognizing obstructive physiology as a primary target of therapy has become particularly relevant with the development of a minimally invasive technique for performing a calibrated myotomy of the esophageal circular muscle, the POEM procedure. Now and going forward, optimal management is to render treatment in a phenotype-specific manner: e.g. POEM calibrated to patient-specific physiology for spastic achalasia and spastic disorders of the smooth muscle esophagus, more conservative strategies (pneumatic dilation) for the disorders limited to the sphincter.
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Affiliation(s)
- Peter J Kahrilas
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Albert J Bredenoord
- Academic Medical Centre, Department of Gastroenterology and Hepatology, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Dustin A Carlson
- Northwestern University, Feinberg School of Medicine, Department of Medicine, 676 St Clair Street, 14 floor, Chicago, Illinois 60611-2951, USA
| | - John E Pandolfino
- Northwestern University, Feinberg School of Medicine, Department of Medicine, 676 St Clair Street, 14 floor, Chicago, Illinois 60611-2951, USA
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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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Kou W, Pandolfino JE, Kahrilas PJ, Patankar NA. Studies of abnormalities of the lower esophageal sphincter during esophageal emptying based on a fully coupled bolus-esophageal-gastric model. Biomech Model Mechanobiol 2018; 17:1069-1082. [PMID: 29644483 DOI: 10.1007/s10237-018-1014-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/20/2018] [Indexed: 01/27/2023]
Abstract
The aim of this work was to develop a fully coupled bolus-esophageal-gastric model based on the immersed boundary-finite element method to study the process of esophageal emptying across the esophagogastric junction (EGJ). The model included an esophageal segment, an ellipsoid-shaped stomach, a bolus, and a simple model of the passive and active sphincteric functions of the lower esophageal sphincter (LES). We conducted three sets of case studies: (1) the effect of a non-relaxing LES; (2) the influence of the tissue anisotropy in the form of asymmetrical right- and left-sided compliance of the LES segment; and (3) the influence of LES and gastric wall stiffness on bulge formation of the distal esophageal wall. We found that a non-relaxing LES caused sustained high wall stress along the LES segment and obstruction of bolus emptying. From the simulations of tissue anisotropy, we found that the weaker side (i.e., more compliant) of the LES segment sustained greater deformation, greater wall shear stress, and a greater high-pressure load during bolus transit. In the third set of studies, we found that a right-sided bulge in the esophageal wall tends to develop during esophageal emptying when LES stiffness was decreased or gastric wall stiffness was increased. Hence, the bulge may be partly due to the asymmetric configuration of the gastric wall with respect to the esophageal tube. Together, the observations from these simulations provide insight into the genesis of epiphrenic diverticula, a complication observed with esophageal motility disorders. Future work, with additional layers of complexity to the model, will delve into the mechanics of gastroesophageal reflux and the effects of hiatus hernia on EGJ function.
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Affiliation(s)
- Wenjun Kou
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, 14th Floor, Chicago, IL, 60611, USA
| | - John E Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, 14th Floor, Chicago, IL, 60611, USA
| | - Peter J Kahrilas
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, 14th Floor, Chicago, IL, 60611, USA
| | - Neelesh A Patankar
- Department of Mechanical Engineering, Northwestern University, 2145 Sheridan Road, Evanston, IL, 60208, USA.
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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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Philpott H, Garg M, Tomic D, Balasubramanian S, Sweis R. Dysphagia: Thinking outside the box. World J Gastroenterol 2017; 23:6942-6951. [PMID: 29097867 PMCID: PMC5658312 DOI: 10.3748/wjg.v23.i38.6942] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 08/29/2017] [Accepted: 09/26/2017] [Indexed: 02/07/2023] Open
Abstract
Dysphagia is a common symptom that is important to recognise and appropriately manage, given that causes include life threatening oesophageal neoplasia, oropharyngeal dysfunction, the risk of aspiration, as well as chronic disabling gastroesophageal reflux (GORD). The predominant causes of dysphagia varies between cohorts depending on the interplay between genetic predisposition and environmental risk factors, and is changing with time. Currently in white Caucasian societies adopting a western lifestyle, obesity is common and thus associated gastroesophageal reflux disease is increasingly diagnosed. Similarly, food allergies are increasing in the west, and eosinophilic oesophagitis is increasingly found as a cause. Other regions where cigarette smoking is still prevalent, or where access to medical care and antisecretory agents such as proton pump inhibitors are less available, benign oesophageal peptic strictures, Barrett's oesophagus, adeno- as well as squamous cell carcinoma are endemic. The evaluation should consider the severity of symptoms, as well as the pre-test probability of a given condition. In young white Caucasian males who are atopic or describe heartburn, eosinophilic esophagitis and gastroesophageal reflux disease will predominate and a proton pump inhibitor could be commenced prior to further investigation. Upper gastrointestinal endoscopy remains a valid first line investigation for patients with suspected oesophageal dysphagia. Barium swallow is particularly useful for oropharyngeal dysphagia, and oesophageal manometry mandatory to diagnose motility disorders.
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Affiliation(s)
- Hamish Philpott
- Department of Gastroenterology, Eastern Health Clinical School Monash University, Melbourne 3128, Australia
| | - Mayur Garg
- Department of Gastroenterology, Eastern Health Clinical School Monash University, Melbourne 3128, Australia
| | - Dunya Tomic
- Department of Gastroenterology, Eastern Health Clinical School Monash University, Melbourne 3128, Australia
| | - Smrithya Balasubramanian
- Department of Gastroenterology, Eastern Health Clinical School Monash University, Melbourne 3128, Australia
| | - Rami Sweis
- University College London, London NW1 2BU, United Kingdom
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Quader F, Reddy C, Patel A, Gyawali CP. Elevated intrabolus pressure identifies obstructive processes when integrated relaxation pressure is normal on esophageal high-resolution manometry. Am J Physiol Gastrointest Liver Physiol 2017; 313:G73-G79. [PMID: 28408642 PMCID: PMC5538833 DOI: 10.1152/ajpgi.00091.2017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 04/05/2017] [Accepted: 04/10/2017] [Indexed: 01/31/2023]
Abstract
Elevated integrated relaxation pressure (IRP) on esophageal high-resolution manometry (HRM) identifies obstructive processes at the esophagogastric junction (EGJ). Our aim was to determine whether intrabolus pressure (IBP) can identify structural EGJ processes when IRP is normal. In this observational cohort study, adult patients with dysphagia and undergoing HRM were evaluated for endoscopic evidence of structural EGJ processes (strictures, rings, hiatus hernia) in the setting of normal IRP. HRM metrics [IRP, distal contractile integral (DCI), distal latency (DL), IBP, and EGJ contractile integral (EGJ-CI)] were compared among 74 patients with structural EGJ findings (62.8 ± 1.6 yr, 67.6% women), 27 patients with normal EGD (52.9 ± 3.2 yr, 70.3% women), and 21 healthy controls (27.6 ± 0.6 yr, 52.4% women). Findings were validated in 85 consecutive symptomatic patients to address clinical utility. In the primary cohort, mean IBP (18.4 ± 0.9 mmHg) was higher with structural EGJ findings compared with dysphagia with normal EGD (13.5 ± 1.1 mmHg, P = 0.002) and healthy controls (10.9 ± 0.9 mmHg, P < 0.001). However, mean IRP, DCI, DL, and EGJ-CI were similar across groups (P > 0.05 for each comparison). During multiple rapid swallows, IBP remained higher in the structural findings group compared with controls (P = 0.02). Similar analysis of the prospective validation cohort confirmed IBP elevation in structural EGJ processes, but correlation with dysphagia could not be demonstrated. We conclude that elevated IBP predicts the presence of structural EGJ processes even when IRP is normal, but correlation with dysphagia is suboptimal.NEW & NOTEWORTHY Integrated relaxation pressure (IRP) above the upper limit of normal defines esophageal outflow obstruction using high-resolution manometry. In patients with normal IRP, elevated intrabolus pressure (IBP) can be a surrogate marker for a structural restrictive or obstructive process at the esophagogastric junction (EGJ). This has the potential to augment the clinical value of esophageal HRM by raising suspicion for a structural EGJ process when IBP is elevated.
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Affiliation(s)
- Farhan Quader
- 1Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri;
| | - Chanakyaram Reddy
- 1Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri; ,2Division of Gastroenterology University of Michigan School of Medicine, Ann Arbor, Michigan; and
| | - Amit Patel
- 1Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri; ,3Division of Gastroenterology, Duke University School of Medicine and Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - C. Prakash Gyawali
- 1Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri;
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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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Carlson DA, Hirano I. Application of the Functional Lumen Imaging Probe to Esophageal Disorders. ACTA ACUST UNITED AC 2017; 15:10-25. [PMID: 28265971 DOI: 10.1007/s11938-017-0116-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT The functional luminal imaging probe (FLIP) provides a novel method to evaluate esophageal physiology and function in both health and disease. FLIP enables assessment of a previously underexplored component of esophageal function, distensibility, by utilizing high-resolution impedance planimetry to evaluate the relationship of the esophageal luminal geometry with pressure during controlled volumetric distension. Recent studies have described the potential utility of FLIP to evaluate the severity and effectiveness of therapy for esophageal diseases including achalasia, gastroesophageal reflux disease, and eosinophilic esophagitis. This review summarizes these emerging clinical applications of FLIP in the evaluation and management of esophageal diseases.
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Affiliation(s)
- Dustin A Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 St Clair St, Suite 1400, Chicago, IL, 60611-2951, USA.
| | - Ikuo Hirano
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 St Clair St, Suite 1400, Chicago, IL, 60611-2951, 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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Kou W, Pandolfino JE, Kahrilas PJ, Patankar NA. Simulation studies of the role of esophageal mucosa in bolus transport. Biomech Model Mechanobiol 2017; 16:1001-1009. [PMID: 28050744 DOI: 10.1007/s10237-016-0867-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 12/19/2016] [Indexed: 10/20/2022]
Abstract
Based on a fully coupled computational model for esophageal transport, we analyzed the role of the mucosa (including the submucosa) in esophageal bolus transport and how bolus transport is affected by mucosal stiffness. Two groups of studies were conducted using a computational model. In the first group, a base case that represents normal esophageal transport and two hypothetical cases were simulated: (1) esophageal mucosa replaced by muscle and (2) esophagus without mucosa. For the base case, the geometric configuration of the esophageal wall was examined and the mechanical role of mucosa was analyzed. For the hypothetical cases, the pressure field and transport features were examined. In the second group of studies, cases with mucosa of varying stiffness were simulated. Overall transport characteristics were examined, and both pressure and geometry were analyzed. Results show that a compliant mucosa helped accommodate the incoming bolus and lubricate the moving bolus. Bolus transport was marginally achieved without mucosa or with mucosa replaced by muscle. A stiff mucosa greatly impaired bolus transport due to the lowered esophageal distensibility and increased luminal pressure. We conclude that mucosa is essential for normal esophageal transport function. Mechanically stiffened mucosa reduces the distensibility of the esophagus by obstructing luminal opening and bolus transport. Mucosal stiffening may be relevant in diseases characterized by reduced esophageal distensibility, elevated intrabolus pressure, and/or hypertensive muscle contraction such as eosinophilic esophagitis and jackhammer esophagus.
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Affiliation(s)
- Wenjun Kou
- Theoretical and Applied Mechanics, Northwestern University, 2145 Sheridan Road, Evanston, IL, 60208, USA
| | - John E Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, 14th Floor, Chicago, IL, 60611, USA
| | - Peter J Kahrilas
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, 14th Floor, Chicago, IL, 60611, USA
| | - Neelesh A Patankar
- Department of Mechanical Engineering, Northwestern University, 2145 Sheridan Road, Evanston, IL, 60208, USA.
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Abstract
Ineffective esophageal motility (IEM) is characterized by low to very low amplitude propulsive contractions in the distal esophagus, hence primarily affecting the smooth muscle part of the esophagus. IEM is often found in patients with dysphagia or heartburn and is commonly associated with gastroesophageal reflux disease. IEM is assumed to be associated with ineffective bolus transport; however, this can be verified using impedance measurements or evaluation of a barium coated marshmallow swallow. Furthermore, water swallows may not assess accurately the motor capabilities of the esophagus, since contraction amplitude is strongly determined by the size and consistency of the bolus. The “peristaltic reserve” of the esophagus can be evaluated by multiple rapid swallows that, after a period of diglutative inhibition, normally give a powerful peristaltic contraction suggestive of the integrity of neural orchestration and smooth muscle action. The amplitude of contraction is determined by a balance between intrinsic excitatory cholinergic, inhibitory nitrergic, as well as postinhibition rebound excitatory output to the musculature. This is strongly influenced by vagal efferent motor neurons and this in turn is influenced by vagal afferent neurons that send bolus information to the solitary nucleus where programmed activation of the vagal motor neurons to the smooth muscle esophagus is initiated. Solitary nucleus activity is influenced by sensory activity from a large number of organs and various areas of the brain, including the hypothalamus and the cerebral cortex. This allows interaction between swallowing activities and respiratory and cardiac activities and allows the influence of acute and chronic emotional states on swallowing behavior. Interstitial cells of Cajal are part of the sensory units of vagal afferents, the intramuscular arrays, and they provide pacemaker activity to the musculature that can generate peristalsis in the absence of innervation. This indicates that a low-amplitude esophageal contraction, observed as IEM, can be caused by a multitude of factors, and therefore many pathways can be potentially explored to restore normal esophageal peristalsis.
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Affiliation(s)
- Ji-Hong Chen
- Department of Gastroenterology, Renmin Hospital, Wuhan University, Wuhan, People's Republic of China; Division of Gastroenterology, Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
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Colizzo JM, Clayton SB, Richter JE. Intrabolus pressure on high-resolution manometry distinguishes fibrostenotic and inflammatory phenotypes of eosinophilic esophagitis. Dis Esophagus 2016; 29:551-7. [PMID: 25913144 DOI: 10.1111/dote.12360] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of this investigation was to determine the motility patterns of inflammatory and fibrostenotic phenotypes of eosinophilic esophagitis (EoE) utilizing high-resolution manometry (HRM). Twenty-nine patients with a confirmed diagnosis of EoE according to clinicopathological criteria currently being managed at the Joy McCann Culverhouse Swallowing Center at the University of South Florida were included in the retrospective analysis. Only patients who completed HRM studies were included in the analysis. Patients were classified into inflammatory or fibrostenotic subtypes based on baseline endoscopic evidence. Their baseline HRM studies prior to therapy were analyzed. Manometric data including distal contractile integral, integrated relaxation pressure, and intrabolus pressure (IBP) values were recorded. HRM results were interpreted according to the Chicago Classification system. Statistical analysis was performed with SPSS software (Version 22, IBM Co., Armonk, NY, USA). Data were compared utilizing Student's t-test, χ(2) test, Pearson correlation, and Spearman correlation tests. Statistical significance was set at P < 0.05. A total of 29 patients with EoE were included into the retrospective analysis. The overall average age among patients was 40 years. Male patients comprised 62% of the overall population. Both groups were similar in age, gender, and overall clinical presentation. Seventeen patients (58%) had fibrostenotic disease, and 12 (42%) displayed inflammatory disease. The average IBP for the fibrostenotic and inflammatory groups were 18.6 ± 6.0 mmHg and 12.6 ± 3.5 mmHg, respectively (P < 0.05). Strictures were only seen in the fibrostenotic group. Of the fibrostenotic group, 6 (35%) demonstrated proximal esophageal strictures, 7 (41%) had distal strictures, 3 (18%) had mid-esophageal strictures, and 1 (6%) patient had pan-esophageal strictures. There was no statistically significant correlation between the level of esophageal stricture and degree of IBP. Integrated relaxation pressure, distal contractile integral, and other HRM metrics did not demonstrate statistical significance between the two subtypes. There also appeared no statistically significant correlation between patient demographics and esophageal metrics. Patients with the fibrostenotic phenotype of EoE demonstrated an IBP that was significantly higher than that of the inflammatory group.
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Affiliation(s)
- J M Colizzo
- Department of Internal Medicine, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, Florida, USA
| | - S B Clayton
- Department of Internal Medicine, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, Florida, USA
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, Florida, USA
| | - J E Richter
- Department of Internal Medicine, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, Florida, USA
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, Florida, USA
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Abstract
PURPOSE OF REVIEW The aim of this review is to summarize use of the functional lumen imaging probe (FLIP) for the evaluation and management of esophageal diseases. RECENT FINDINGS The FLIP utilizes high-resolution impedance planimetry to evaluate the functional geometry and cross-sectional area/pressure relationship (i.e. distensibility) of the esophageal sphincters and body. Recent studies have reported the potential utility of FLIP to evaluate esophageal diseases, such as achalasia, gastroesophageal reflux disease, and eosinophilic esophagitis. SUMMARY Esophageal distensibility measures provided by the FLIP will add to our understanding of the contribution of esophageal mechanical properties to esophageal symptoms and function. Application of the FLIP in clinical practice complements the diagnostic evaluation of esophageal function and may also be a valuable tool to help direct and target clinical management of esophageal diseases.
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Carlson DA, Gluskin AB, Mogni B, Koo J, Sood R, Lin Z, Pandolfino JE. Esophageal diverticula are associated with propagating peristalsis: a study utilizing high-resolution manometry. Neurogastroenterol Motil 2016; 28:392-8. [PMID: 26646704 PMCID: PMC4760883 DOI: 10.1111/nmo.12739] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 10/30/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Esophageal diverticula have been associated with esophageal motility disorders, most commonly achalasia. We aimed to evaluate high-resolution manometry (HRM) motility diagnoses and pressurization patterns in patients with esophageal diverticula. METHODS Patients were retrospectively identified for distal esophageal diverticula and previously completed HRM. High-resolution manometries were analyzed according to the Chicago Classification, and the pressure slope of the compartmentalization phase (time between upper esophageal sphincter closure and the transition zone) of esophageal bolus transit was measured. Pressure slopes were also measured in 10 asymptomatic volunteers (controls) for comparison. KEY RESULTS Nineteen patients (ages 31-83) were included. Eight (42%) patients had normal motility, five (26%) had esophagogastric junction outflow obstruction, and two (11%) had jackhammer esophagus; four patients had other motility diagnoses including only one patient with achalasia. A total of six patients (32%) had at least one hypercontractile swallow. Greater compartmentalization phase pressure slopes were observed in patients at the mid-esophageal body in both supine (median [interquartile range]: 1.9 mmHg/s [0.9, 3.6]) and upright (1.1 [0.1, 3.1]) positions than in controls (supine: -1.3 [-2.4, -0.11], p = 0.001; upright; -0.71 [-2.1, -0.02], p = 0.005). CONCLUSIONS & INFERENCES Propagating peristalsis, often with hypercontractility, was commonly seen in our cohort of patients with esophageal diverticula. Abnormal compartmentalization phase pressurization may indicate a relationship of abnormal esophageal wall mechanics and/or compliance with diverticula; however whether these findings are causal or reactionary remains unclear.
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Affiliation(s)
- D. A. Carlson
- Division of Gastroenterology and Hepatology; Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - A. B. Gluskin
- Division of Gastroenterology and Hepatology; Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - B. Mogni
- Division of Gastroenterology and Hepatology; Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - J. Koo
- Division of Gastroenterology and Hepatology; Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - R. Sood
- Division of Gastroenterology and Hepatology; Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - Z. Lin
- Division of Gastroenterology and Hepatology; Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - J. E. Pandolfino
- Division of Gastroenterology and Hepatology; Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
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Leibbrandt RE, Dinning PG, Costa M, Cock C, Wiklendt L, Wang G, Tack J, van Beckevoort D, Rommel N, Omari TI. Characterization of Esophageal Physiology Using Mechanical State Analysis. Front Syst Neurosci 2016; 10:10. [PMID: 26924967 PMCID: PMC4756108 DOI: 10.3389/fnsys.2016.00010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 02/01/2016] [Indexed: 01/29/2023] Open
Abstract
The esophagus functions to transport swallowed fluids and food from the pharynx to the stomach. The esophageal muscles governing bolus transport comprise circular striated muscle of the proximal esophagus and circular smooth muscle of the distal esophagus. Longitudinal smooth muscle contraction provides a mechanical advantage to bolus transit during circular smooth muscle contraction. Esophageal striated muscle is directly controlled by neural circuits originating in the central nervous system, resulting in coordinated contractions. In contrast, the esophageal smooth muscle is controlled by enteric circuits modulated by extrinsic central neural connections resulting in neural relaxation and contraction. The esophageal muscles are modulated by sensory information arising from within the lumen. Contraction or relaxation, which changes the diameter of the lumen, alters the intraluminal pressure and ultimately inhibits or promotes flow of content. This relationship that exists between the changes in diameter and concurrent changes in intraluminal pressure has been used previously to identify the “mechanical states” of the circular muscle; that is when the muscles are passively or actively, relaxing or contracting. Detecting these changes in the mechanical state of the muscle has been difficult and as the current interpretation of esophageal motility is based largely upon pressure measurement (manometry), subtle changes in the muscle function during peristalsis can be missed. We hypothesized that quantification of mechanical states of the esophageal circular muscles and the pressure-diameter properties that define them, would allow objective characterization of the mechanisms that govern esophageal peristalsis. To achieve this we analyzed barium swallows captured by simultaneous videofluoroscopy and pressure with impedance recording. From these data we demonstrated that intraluminal impedance measurements could be used to determine changes in the internal diameter of the lumen comparable with measurements from videofluoroscopy. Our data indicated that identification of mechanical state of esophageal muscle was simple to apply and revealed patterns consistent with the known neural inputs activating the different muscles during swallowing.
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Affiliation(s)
- Richard E Leibbrandt
- Department of Human Physiology, School of Medicine, Flinders University Bedford Park, SA, Australia
| | - Phil G Dinning
- Department of Human Physiology, School of Medicine, Flinders UniversityBedford Park, SA, Australia; Department of Gastroenterology and Hepatology, School of Medicine, Flinders UniversityBedford Park, SA, Australia; Department of Surgery, School of Medicine, Flinders UniversityBedford Park, SA, Australia
| | - Marcello Costa
- Department of Human Physiology, School of Medicine, Flinders University Bedford Park, SA, Australia
| | - Charles Cock
- Department of Gastroenterology and Hepatology, School of Medicine, Flinders University Bedford Park, SA, Australia
| | - Lukasz Wiklendt
- Department of Human Physiology, School of Medicine, Flinders University Bedford Park, SA, Australia
| | - Guangsong Wang
- Department of Human Physiology, School of Medicine, Flinders University Bedford Park, SA, Australia
| | - Jan Tack
- Gastroenterology, Neurogastroenterology and Motility, University Hospitals LeuvenLeuven, Belgium; Translational Research Center for Gastrointestinal Diseases (TARGID), University of LeuvenLeuven, Belgium
| | | | - Nathalie Rommel
- Gastroenterology, Neurogastroenterology and Motility, University Hospitals LeuvenLeuven, Belgium; Translational Research Center for Gastrointestinal Diseases (TARGID), University of LeuvenLeuven, Belgium; Neurosciences, ExpORL, University of LeuvenLeuven, Belgium
| | - Taher I Omari
- Department of Human Physiology, School of Medicine, Flinders UniversityBedford Park, SA, Australia; Department of Gastroenterology and Hepatology, School of Medicine, Flinders UniversityBedford Park, SA, Australia
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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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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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