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Pomenti S, Nathanson J, Phipps M, Aneke-Nash C, Katzka D, Freedberg D, Jodorkovsky D. Esophagogastroduodenoscopy findings that do no not explain dysphagia are associated with underutilization of high-resolution manometry. Dis Esophagus 2024; 37:doae028. [PMID: 38582609 DOI: 10.1093/dote/doae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 03/15/2024] [Accepted: 03/17/2024] [Indexed: 04/08/2024]
Abstract
In patients with dysphagia that is not explained by upper endoscopy, high-resolution esophageal manometry (HRM) is the next logical step in diagnostic testing. This study investigated predictors of failure to refer for HRM after an upper endoscopy that was performed for but did not explain dysphagia. This was a retrospective cohort study of patients >18 years of age who underwent esophagogastroduodenoscopy (EGD) for dysphagia from 2015 to 2021. Patients with EGD findings that explained dysphagia (e.g. esophageal mass, eosinophilic esophagitis, Schatzki ring, etc.) were excluded from the main analyses. The primary outcome was failure to refer for HRM within 1 year of the index non-diagnostic EGD. We also investigated delayed referral for HRM, defined as HRM performed after the median. Multivariable logistic regression modeling was used to identify risk factors that independently predicted failure to refer for HRM, conditioned on the providing endoscopist. Among 2132 patients who underwent EGD for dysphagia, 1240 (58.2%) did not have findings to explain dysphagia on the index EGD. Of these 1240 patients, 148 (11.9%) underwent HRM within 1 year of index EGD. Endoscopic findings (e.g. hiatal hernia, tortuous esophagus, Barrett's esophagus, surgically altered anatomy not involving the gastroesophageal junction, and esophageal varices) perceived to explain dysphagia were independently associated with failure to refer for HRM (adjusted odds ratio 0.45, 95% confidence interval 0.25-0.80). Of the 148 patients who underwent HRM within 1 year of index EGD, 29.7% were diagnosed with a disorder of esophagogastric junction outflow, 17.6% with a disorder of peristalsis, and 2.0% with both disorders of esophagogastric outflow and peristalsis. The diagnosis made by HRM was similar among those who had incidental EGD findings that were non-diagnostic for dysphagia compared with those who had completely normal EGD findings. Demographic factors including race/ethnicity, insurance type, and income were not associated with failure to refer for HRM or delayed HRM. Patients with dysphagia and endoscopic findings unrelated to dysphagia have a similar prevalence of esophageal motility disorders to those with normal endoscopic examinations, yet these patients are less likely to undergo HRM. Provider education is indicated to increase HRM referral in these patients.
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Affiliation(s)
- Sydney Pomenti
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - John Nathanson
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Meaghan Phipps
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Chino Aneke-Nash
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - David Katzka
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Daniel Freedberg
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Daniela Jodorkovsky
- Department of Medicine, Division of Digestive Diseases, Mount Sinai Doctors, New York, NY, USA
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Scharitzer M, Pokieser P, Ekberg O. Oesophageal fluoroscopy in adults-when and why? Br J Radiol 2024; 97:1222-1233. [PMID: 38547408 PMCID: PMC11186568 DOI: 10.1093/bjr/tqae062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/15/2024] [Accepted: 03/18/2024] [Indexed: 06/21/2024] Open
Abstract
Oesophageal fluoroscopy is a radiological procedure that uses dynamic recording of the swallowing process to evaluate morphology and function simultaneously, a characteristic not found in other clinical tests. It enables a comprehensive evaluation of the entire upper gastrointestinal tract, from the oropharynx to oesophagogastric bolus transport. The number of fluoroscopies of the oesophagus and the oropharynx has increased in recent decades, while the overall use of gastrointestinal fluoroscopic examinations has declined. Radiologists performing fluoroscopies need a good understanding of the appropriate clinical questions and the methodological advantages and limitations to adjust the examination to the patient's symptoms and clinical situation. This review provides an overview of the indications for oesophageal fluoroscopy and the various pathologies it can identify, ranging from motility disorders to structural abnormalities and assessment in the pre- and postoperative care. The strengths and weaknesses of this modality and its future role within different clinical scenarios in the adult population are discussed. We conclude that oesophageal fluoroscopy remains a valuable tool in diagnostic radiology for the evaluation of oesophageal disorders.
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Affiliation(s)
- Martina Scharitzer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Peter Pokieser
- Teaching Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Olle Ekberg
- Department of Translational Medicine, Diagnostic Radiology, Lund University, Skåne University Hospital, Inga Marie Nilssons gata 49, 205 02 Malmö, Sweden
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Reddy CA, Ellison A, Cipher DJ, Mendoza R, Souza RF, Spechler SJ, Konda VJA, Nguyen AD. Frequent discrepancies among diagnostic tests for detecting lower esophageal sphincter-related obstruction. Neurogastroenterol Motil 2024; 36:e14729. [PMID: 38129627 DOI: 10.1111/nmo.14729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/19/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND There are frequent discrepancies among high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and esophagram in identifying lower esophageal sphincter (LES)-related obstruction. We aimed to determine the frequency of those discrepancies and how they influenced clinical treatment/outcomes. METHODS We identified patients who had all three tests (HRM, FLIP, and esophagram) and endoscopy performed for evaluation of esophageal symptoms in our Center for Esophageal Diseases. Discrepancies among the tests for the presence of LES obstruction were noted, and the performance of individual tests was compared against a consensus opinion rendered by a panel of esophagologists. Binary logistical regression was performed, and ROC curves were generated for prediction of the consensus clinical diagnosis of LES obstruction. KEY RESULTS A total of 126 patients (mean age 57.9 ± 17.0 years; 67% female) met inclusion criteria. All three tests agreed on the presence or absence of LES obstruction in only 72 (57%) patients [no LES obstruction in 57 (45%), LES obstruction in 15 (12%)]. Thirteen patients (10%) had a change in management based on additional findings on FLIP +/- esophagram not seen on HRM with 69% having symptomatic improvement after LES-directed intervention. FLIP was the strongest predictor of a consensus diagnosis of LES obstruction by logistic regression and ROC (OR 23.36, AUC 0.796), followed by HRM (OR 15.41, AUC 0.764). CONCLUSIONS & INFERENCE High-resolution manometry, functional lumen imaging probe, and esophagram each have considerable limitations for identifying LES obstruction, and discrepancies among these tests occur frequently. Multimodal testing is often required for adequate evaluation of LES-related obstruction.
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Affiliation(s)
- Chanakyaram A Reddy
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Ashton Ellison
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Daisha J Cipher
- College of Nursing and Health Innovation, The University of Texas at Arlington, Arlington, Texas, USA
| | - Roseann Mendoza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Rhonda F Souza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Stuart J Spechler
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Vani J A Konda
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Anh D Nguyen
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
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Shah ED, Yadlapati R, Chan WW. Optimizing the Management Algorithm for Esophageal Dysphagia After Index Endoscopy: Cost-Effectiveness and Cost-Minimization Analysis. Am J Gastroenterol 2024; 119:97-106. [PMID: 37883488 PMCID: PMC10841887 DOI: 10.14309/ajg.0000000000002521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Guidelines advise esophageal motility testing for dysphagia when structural disorders are ruled out, but cost concerns impede adoption. We evaluated cost-effective positioning of esophageal motility testing in the algorithm to evaluate esophageal dysphagia. METHODS We developed a decision analytic model comparing 3 strategies: (i) esophageal manometry, (ii) screening impedance planimetry followed by esophageal manometry if needed, or (iii) nonalgorithmic usual care. Diagnostic test accuracy was adapted to expected rates of esophageal motility disorders in general gastroenterology populations. We modeled routine testing for all patients with nonstructural/mechanical dysphagia compared with selective testing with strong suspicion for achalasia. Cost outcomes were defined on national commercial and Medicare datasets stratified on age and sex. Health outcomes were modeled on populations with achalasia. The time horizon was 1 year. RESULTS Motility testing was preferred over nonalgorithmic usual care due to cost savings rather than health gains. To commercial insurers, routine esophageal manometry for nonstructural/mechanical dysphagia would be cost-saving below a reimbursed cost of $2,415. Screening impedance planimetry would be cost saving below a reimbursed cost of $1,130. The limit for reimbursed costs would be lower for patients older than 65 years to achieve cost savings mainly due to insurance. Sex did not significantly influence cost-effectiveness. Patients and insurers preferred routine screening impedance planimetry before manometry when the index of suspicion for achalasia was below 6%. DISCUSSION Aligning with practice guidelines, routine esophageal motility testing seems cost saving to patients and insurers compared with nonalgorithmic usual care to evaluate nonstructural/mechanical dysphagia. Choice of testing should be guided by index of suspicion.
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VanDruff VN, Amundson JR, Joseph S, Che S, Kuchta K, Zimmermann CJ, Ishii S, Hedberg HM, Ujiki MB. Impedance planimetry and panometry (EndoFLIP™) can replace manometry in preoperative anti-reflux surgery assessment. Surg Endosc 2024; 38:339-347. [PMID: 37770608 DOI: 10.1007/s00464-023-10419-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Endoluminal functional impedance planimetry and panometry assesses secondary peristalsis in response to volumetric distention under sedation. We hypothesize that impedance planimetry and panometry can replace high-resolution manometry in the preoperative assessment prior to anti-reflux surgery. METHODS Single institution prospective data were collected from patients undergoing anti-reflux surgery between 2021 and 2023. A 16-cm functional luminal imaging probe (FLIP) assessed planimetry and panometry prior to surgery under general anesthesia at the start of each case. Panometry was recorded and esophageal contractile response was classified as normal (NCR), diminished or disordered (DDCR), or absent (ACR) in real time by a single panometry rater, blinded to preoperative HRM results. FLIP results were then compared to preoperative HRM. RESULTS Data were collected from 120 patients, 70.8% female, with mean age of 63 ± 3 years. There were 105 patients with intraoperative panometry, and 15 with panometry collected during preoperative endoscopy. There were 60 patients (50%) who had peristaltic dysfunction on HRM, of whom 57 had FLIP dysmotility (55 DDCR, 2 ACR) resulting in 95.0% sensitivity. There were 3 patients with normal secondary peristalsis on FLIP with abnormal HRM, all ineffective esophageal motility (IEM). No major motility disorder was missed by FLIP. A negative predictive value of 91.9% was calculated from 34/37 patients with normal FLIP panometry and normal HRM. Patients with normal HRM but abnormal FLIP had larger hernias compared to patients with concordant studies (7.5 ± 2.8 cm vs. 5.4 ± 3.2 cm, p = 0.043) and higher preoperative dysphagia scores (1.5 ± 0.7 vs. 1.1 ± 0.3, p = 0.021). CONCLUSION Impedance planimetry and panometry can assess motility under general anesthesia or sedation and is highly sensitive to peristaltic dysfunction. Panometry is a novel tool that has potential to streamline and improve patient care and therefore should be considered as an alternative to HRM, especially in patients in which HRM would be inaccessible or poorly tolerated.
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Affiliation(s)
- Vanessa N VanDruff
- Department of Minimally Invasive Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA.
- Department of Surgery, University of Chicago, Chicago, IL, USA.
| | - Julia R Amundson
- Department of Minimally Invasive Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Stephanie Joseph
- Department of Minimally Invasive Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Simon Che
- Department of Minimally Invasive Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Kristine Kuchta
- Department of Minimally Invasive Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Christopher J Zimmermann
- Department of Minimally Invasive Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Shun Ishii
- Department of Minimally Invasive Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - H Mason Hedberg
- Department of Minimally Invasive Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Michael B Ujiki
- Department of Minimally Invasive Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
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Davis TA, Miller A, Hachem C, Velez C, Patel D. The current state of gastrointestinal motility evaluation in cystic fibrosis: a comprehensive literature review. Transl Gastroenterol Hepatol 2023; 9:10. [PMID: 38317748 PMCID: PMC10838618 DOI: 10.21037/tgh-23-59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/11/2023] [Indexed: 02/07/2024] Open
Abstract
Background and Objective As life expectancy in cystic fibrosis (CF) has increased over the years, a shift in focus toward extra-pulmonary comorbidities such as gastrointestinal (GI) disease has become a topic of particular importance. Although not well-defined in the current literature, GI dysmotility is thought to significantly contribute to GI symptomatology in the CF population. The objective of this article was to provide a comprehensive review of diagnostic modalities at the disposal of the clinician in the evaluation of patients with CF (pwCF) presenting with GI complaints. Furthermore, we aimed to highlight the available literature regarding utilization of these modalities in CF, in addition to their shortcomings, and emphasize areas within the motility literature where further research is essential. Methods A comprehensive review of all available literature in the English language through December 1, 2022 utilizing PubMed was conducted. Our search was limited to GI motility/transit and dysmotility in pwCF. Two researchers independently screened references for applicable articles and extracted pertinent data. Key Content and Findings Several diagnostic imaging and manometry options exist in the evaluation of dysmotility; however, the literature is lacking in high-quality, prospective studies to validate such testing in pwCF. Common symptoms experienced and diagnostic motility tools available based on segment of the GI tract as related to pwCF are explored in the current review. Shortcomings in the current literature are identified and future direction to enhance research efforts within the field of CF-related dysmotility is provided. Conclusions The influence of CF on GI integrity and motility is far-reaching. Despite improvements in longevity and advancement of pulmonary-specific treatment strategies, further high-quality research targeting the evaluation and management of GI dysmotility in pwCF is needed.
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Affiliation(s)
- Trevor A. Davis
- Division of Gastroenterology, Department of Pediatrics, Washington University School of Medicine, Saint Louis Children’s Hospital, St. Louis, MO, USA
| | - Abra Miller
- Division of Gastroenterology, Department of Pediatrics, Saint Louis University School of Medicine, SSM Cardinal Glennon Children’s Medical Center, St. Louis, MO, USA
| | - Christine Hachem
- Division of Gastroenterology, Department of Medicine, Saint Louis University School of Medicine, University Hospital, St. Louis, MO, USA
| | - Christopher Velez
- Division of Gastroenterology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Dhiren Patel
- Division of Gastroenterology, Department of Pediatrics, Saint Louis University School of Medicine, SSM Cardinal Glennon Children’s Medical Center, St. Louis, MO, USA
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Mascarenhas A, Mendo R, O'Neill C, Franco AR, Mendes R, Simão I, Rodrigues JP. Current Approach to Dysphagia: A Review Focusing on Esophageal Motility Disorders and Their Treatment. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2023; 30:403-413. [PMID: 38476159 PMCID: PMC10928869 DOI: 10.1159/000529428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 01/13/2023] [Indexed: 03/14/2024]
Abstract
Background Dysphagia is a prevalent condition which may severely impact the patient's quality of life. However, there are still lacking standardized therapeutic options for esophageal motility disorders. Summary Dysphagia is defined as a subjective sensation of difficulty swallowing which can result from oropharyngeal or esophageal etiologies. Regarding esophageal dysphagia, after excluding structural causes and esophageal mucosal lesions, high-resolution manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. HRM has not only improved the sensitivity for detecting achalasia but has also expanded our understanding of spastic and hypomotility disorders of the esophageal body. The Chicago Classification v4.0 uses a hierarchical approach and provides a standardized diagnosis of esophageal motility disorders, allowing a tailored therapeutic approach. Dysphagia is often a long-term health problem that broadly impacts health and well-being and leads to physical and psychosocial disability, namely, malnutrition and aspiration pneumonia, as well as social isolation, depression, and anxiety. Apart from achalasia, most esophageal motility disorders tend to have a benign long-term course with symptoms of dysphagia and noncardiac chest pain that can improve significantly over time. Patient-reported outcomes (PROs) are self-assessment tools that capture the patients' illness experience and help providers better understand symptoms from the patients' perspective. Therefore, PROs have a critical role in providing patient-centered care. Key Messages Motility disorders should be ruled out in the presence of nonobstructive esophageal dysphagia, and treatment options should be considered according to the severity of symptoms reported by the patient.
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Affiliation(s)
- André Mascarenhas
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Rui Mendo
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Catarina O'Neill
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Ana Rita Franco
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Raquel Mendes
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Inês Simão
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - José Pedro Rodrigues
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
- Pathophysiology Autonomous Disciplinary Area, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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Giulini L, Latorre-Rodriguez AR, Razia D, Mittal SK. Standardized Assessment of Esophageal Body Peristalsis on Barium Esophagram Correlates with Non-obstructive Dysphagia. J Gastrointest Surg 2023; 27:2601-2603. [PMID: 37558817 DOI: 10.1007/s11605-023-05792-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 07/21/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Luca Giulini
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
- Department of General, Gastrointestinal and Thoracic Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Andres R Latorre-Rodriguez
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
| | - Deepika Razia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA.
- Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, AZ, USA.
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Koop AH, Kahrilas PJ, Schauer J, Pandolfino JE, Carlson DA. The impact of primary peristalsis, contractile reserve, and secondary peristalsis on esophageal clearance measured by timed barium esophagogram. Neurogastroenterol Motil 2023; 35:e14638. [PMID: 37417394 DOI: 10.1111/nmo.14638] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Primary and secondary peristalsis facilitate esophageal bolus transport; however, their relative impact for bolus clearance remains unclear. We aimed to compare primary peristalsis and contractile reserve on high-resolution manometry (HRM) and secondary peristalsis on functional lumen imaging probe (FLIP) Panometry with emptying on timed barium esophagogram (TBE) and incorporate findings into a comprehensive model of esophageal function. METHODS Adult patients who completed HRM with multiple rapid swallows (MRS), FLIP, and TBE for esophageal motility evaluation and without abnormal esophagogastric junction outflow/opening or spasm were included. An abnormal TBE was defined as a 1-min column height >5 cm. Primary peristalsis and contractile reserve after MRS were combined into an HRM-MRS model. Secondary peristalsis was combined with primary peristalsis assessment to describe a complementary neuromyogenic model. KEY RESULTS Of 89 included patients, differences in rates of abnormal TBEs were observed with primary peristalsis classification (normal: 14.3%; ineffective esophageal motility: 20.0%; absent peristalsis: 54.5%; p = 0.009), contractile reserve (present: 12.5%; absent: 29.3%; p = 0.05), and secondary peristalsis (normal: 9.7%; borderline: 17.6%; impaired/disordered: 28.6%; absent contractile response: 50%; p = 0.039). Logistic regression analysis (akaike information criteria, area under the receiver operating curve) demonstrated that the neuromyogenic model (80.8, 0.83) had a stronger relationship predicting abnormal TBE compared to primary peristalsis (81.5, 0.82), contractile reserve (86.8, 0.75), or secondary peristalsis (89.0, 0.78). CONCLUSIONS AND INFERENCES Primary peristalsis, contractile reserve, and secondary peristalsis were associated with abnormal esophageal retention as measured by TBE. Added benefit was observed when applying comprehensive models to incorporate primary and secondary peristalsis supporting their complementary application.
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Affiliation(s)
- Andree H Koop
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jacob Schauer
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
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McCarthy K, Finch E, Miles A. The Introduction of a Protocol for Esophageal Screening in Videofluoroscopic Swallowing Studies: Exploring Clinical Impacts and Barriers. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:2267-2281. [PMID: 37668538 DOI: 10.1044/2023_ajslp-23-00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
PURPOSE Esophageal screening is a valuable inclusion in videofluoroscopic swallowing studies (VFSSs). However, routine standardized esophageal screening does not always occur in clinical practice. This study introduced and evaluated an esophageal screening protocol at one Australian hospital. METHOD Radiology, gastroenterology, and speech-language pathology endorsed an esophageal screening protocol, which followed a timed 20-ml International Dysphagia Diet Standardisation Initiative Level 0 bolus from mouth to stomach in an upright anterior-posterior position. Measures exploring clinical impacts and barriers were recorded. Participants were compared with 100 consecutive VFSS patients prior to the introduction of the esophageal screening protocol. RESULTS During the esophageal screening protocol trial, 163 VFSSs were conducted with recruited patients. Aspiration risk (29%, n = 47/163) and positioning limitation (3%, n = 5/163) were barriers to esophageal screening. Rates of esophageal screening significantly increased with the esophageal screening protocol (χ2 = 63.462, p < .001). There was no difference in radiation dose for patients who had esophageal screening and those who did not in the esophageal screening protocol group (U = 1689.000, p = .237). The VFSS team breached the esophageal screening protocol for some patients, when evaluating esophageal transit time (n = 28) and recommending gastroenterology referral (n = 6). There was no difference between groups for rates of gastroenterology consults (χ2 = 1.805, p = .188) or dysphagia procedures (χ2 = 1.951, p = .209). CONCLUSIONS This study confirms that routine esophageal screening provides additional clinical information to assist holistic dysphagia management without adverse operational impacts. Further research with the multidisciplinary dysphagia team has commenced to continue to optimize and refine esophageal screening practice.
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Affiliation(s)
- Kellie McCarthy
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Emma Finch
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Research and Innovation, West Moreton Health, Ipswich, Queensland, Australia
| | - Anna Miles
- Department of Speech Science, School of Psychology, The University of Auckland, New Zealand
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Hoshikawa Y, Iwakiri K. Esophageal Motility Disorders: Diagnosis and Treatment Strategies. Digestion 2023; 105:11-17. [PMID: 37634495 DOI: 10.1159/000533347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/25/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Esophageal motility disorders (EMDs) are caused by the impaired relaxation of the upper/lower esophageal sphincter and/or defective esophageal peristaltic contractions, resulting in dysphagia and noncardiac chest pain. High-resolution manometry (HRM) is essential for the diagnosis of primary EMD; however, the recognition of EMD and HRM by general practitioners in Japan is limited. This review summarizes the diagnosis of and treatment strategies for EMD. SUMMARY HRM is a specific test for the diagnosis of EMD, whereas endoscopy and barium swallow as screening tests provide characteristic findings (i.e., esophageal rosette and bird's beak sign) in some cases. It is important to note that manometric diagnoses apart from achalasia are often clinically irrelevant; therefore, the recently updated guidelines suggest additional manometric maneuvers, such as the rapid drink challenge, and further testing, including functional lumen imaging, for a more accurate diagnosis before invasive treatment. Endoscopic/surgical myotomy, pneumatic dilation, and botulinum toxin injections need to be considered for patients with achalasia and clinically relevant esophagogastric junction outflow obstruction. KEY MESSAGE Since the detailed pathophysiology of EMD remains unclear, their diagnosis needs to be cautiously established prior to the initiation of invasive treatment.
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Affiliation(s)
- Yoshimasa Hoshikawa
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
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Le KHN, Low EE, Yadlapati R. Evaluation of Esophageal Dysphagia in Elderly Patients. Curr Gastroenterol Rep 2023; 25:146-159. [PMID: 37312002 PMCID: PMC10726678 DOI: 10.1007/s11894-023-00876-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE OF REVIEW While guidelines exist for the evaluation and management of esophageal dysphagia in the general population, dysphagia disproportionately affects the elderly. In this article, we reviewed the literature on evaluating esophageal dysphagia in elderly patients and proposed a diagnostic algorithm based on this evidence. RECENT FINDINGS In older patients, dysphagia is often well compensated for by altered eating habits and physiologic changes, underreported by patients, and missed by healthcare providers. Once identified, dysphagia should be differentiated into oropharyngeal and esophageal dysphagia to guide diagnostic workup. For esophageal dysphagia, this review proposes starting with endoscopy with biopsies, given its relative safety even in older patients and potential for interventional therapy. If endoscopy shows a structural or mechanical cause, then further cross-sectional imaging should be considered to assess for extrinsic compression, and same session endoscopic dilation should be considered for strictures. If biopsies and endoscopy are normal, then esophageal dysmotility is more likely, and high-resolution manometry and additional workup should be performed following the updated Chicago Classification. Even after diagnosis of the root cause, complications including malnutrition and aspiration pneumonia should also be assessed and monitored, as they both result from and can further contribute to dysphagia. The successful evaluation of esophageal dysphagia in elderly patients requires a thorough, standardized approach to collecting a history, selection of appropriate diagnostic workup, and assessment of risk of potential complications, including malnutrition and aspiration.
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Affiliation(s)
| | - Eric E Low
- Department of Gastroenterology and Hepatology, University of California, San Diego, CA, USA
| | - Rena Yadlapati
- Department of Gastroenterology and Hepatology, University of California, San Diego, CA, USA.
- , La Jolla, CA, USA.
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13
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Watts S, Gaziano J, Kumar A, Richter J. The Modified Barium Swallow Study and Esophageal Screening: A Survey of Clinical Practice Patterns. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:1065-1082. [PMID: 36917803 DOI: 10.1044/2022_ajslp-22-00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
PURPOSE Modified barium swallow study (MBSS) is a videofluoroscopic evaluation of oropharyngeal swallowing. Views of esophageal bolus flow during MBSS are permitted under speech-language pathology practice guidelines. However, controversy exists over its implementation. Poor consensus and limited practice guidance may lead to clinical practice variations. Aims of the investigation were to (a) describe current practice patterns of speech-language pathologist visualizing bolus flow through the esophagus during the MBSS, (b) understand areas of variation when incorporating esophageal visualization during the MBSS, and (c) determine clinicians' willingness to modify MBSS procedures to include esophageal imaging. METHOD A web-based survey (Qualtrics XM) consisting of 26 questions was distributed via web posting and e-mail to members of the American Speech-Language-Hearing Association Special Interest Group 13 and Dysphagia Café. The survey was open for 3 months. Descriptive and associative statistics were completed. Field-testing was performed prior to dissemination of the survey to address content validity. RESULTS A total of 321 individuals participated; 265 responses were used for analysis. Ninety-three percent of respondents viewed the esophagus during the MBSS. Twelve percent followed to the proximal esophagus, 15% to the mid esophagus, 66% to the lower esophagus, and 6% to varied levels. Variability was also reported in contrast type, volume administered, and nomenclature used. Interestingly, few people (3.61%) disagreed that esophageal visualization should be performed during MBSS. CONCLUSIONS Speech-language pathology respondents in this study visualize contrast flow through the esophagus and are enthusiastic about expanding the standard MBSS. However, results of the survey demonstrate a lack of uniformity in assessment practices. Unfortunately, this may impact the diagnostic accuracy and clinical utility when adding esophageal visualization to the MBSS. This study highlights the need for a standardized protocol and identifies current barriers and controversies that may prevent expanding the MBSS to more comprehensively evaluate individuals with dysphagia.
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Affiliation(s)
- Stephanie Watts
- Department of Internal Medicine, University of South Florida, Tampa
| | - Joy Gaziano
- Department of Internal Medicine, University of South Florida, Tampa
| | - Ambuj Kumar
- Department of Internal Medicine, University of South Florida, Tampa
| | - Joel Richter
- Department of Internal Medicine, University of South Florida, Tampa
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14
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Office-Based Evaluation and Management of Dysphagia in Otolaryngology. CURRENT OTORHINOLARYNGOLOGY REPORTS 2023. [DOI: 10.1007/s40136-023-00439-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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15
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Reedy EL, Simpson AN, O'Rourke AK, Bonilha HS. Abnormal Esophageal Clearance Identified During Modified Barium Swallow Study in an Acute Poststroke Cohort. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2022; 31:2643-2662. [PMID: 36179218 DOI: 10.1044/2022_ajslp-22-00029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
PURPOSE Dysphagia impacts many poststroke survivors with wide-ranging prevalence in the acute and chronic phases. One relatively unexplored manifestation of poststroke swallowing impairment is that of primary or co-occurring esophageal dysphagia. The incidence of esophageal dysphagia in this population is unknown despite the shared neuroanatomy and physiology with the oropharynx. We aimed to determine the presence of abnormal esophageal clearance in an acute poststroke sample using the Modified Barium Swallow Impairment Profile (MBSImP) Component 17 (esophageal clearance) as our outcome measure. METHOD We performed a retrospective, cross-sectional, cohort study of 57 poststroke patients with acute, first-ever, ischemic strokes. All participants received a modified barium swallow study (MBSS) using the MBSImP protocol and scoring metrics. Swallowing impairment was determined using a combination of MBSImP scores and Penetration-Aspiration Scale scores. Swallowing outcome measures were collected including Functional Oral Intake Scale and International Dysphagia Diet Standardization Initiative (IDDSI) scores. We performed tests of association and logistic regression analysis to determine if statistically significant associations exist between judgments of esophageal clearance and other swallowing impairments and/or swallowing outcome measures. RESULTS In our study of poststroke patients who received an MBSS as part of their care, 57.9% had abnormal esophageal clearance. Statistically significant associations were also identified in measures of pharyngeal physiology (MBSImP scores) and swallowing outcome measures (IDDSI scores and alternate means of nutrition). CONCLUSIONS Abnormal esophageal clearance was identified in greater than half of our poststroke patients. There is a dearth of scientific research regarding esophageal function poststroke. While esophageal visualization during the MBSS is not diagnostic of esophageal impairment, it may serve as an indicator for those poststroke patients who require dedicated esophageal testing to best determine the full nature of their swallowing pathophysiology and make the most effective treatment recommendations.
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Affiliation(s)
- Erin L Reedy
- Health Sciences and Research, Medical University of South Carolina, Charleston
| | - Annie N Simpson
- Health Sciences and Research, Medical University of South Carolina, Charleston
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Ashli K O'Rourke
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Heather Shaw Bonilha
- Health Sciences and Research, Medical University of South Carolina, Charleston
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
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16
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Improved esophagography screening for esophageal motility disorders using wave appearance and supra-junctional ballooning. J Gastroenterol 2022; 57:838-847. [PMID: 36001159 DOI: 10.1007/s00535-022-01913-4] [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: 12/28/2021] [Accepted: 08/07/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND High-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders (EMDs); however, it requires specialized equipment. The development of more accessible screening examinations is expected. We evaluated the utility of barium esophagography (BE) screening using two novel findings to diagnose EMDs. METHODS Between January 2013 and October 2020, 244 patients with suspected EMDs who underwent both HRM and BE were analyzed. The EMD diagnosis was based on HRM findings using Chicago Classification version 3.0. BE was performed using sequential esophagography with barium sulfate. Three conventional BE findings (air-fluid level, rosary-bead/corkscrew appearance, and absent/weak peristalsis) and two novel BE findings (wave appearance and supra-junctional ballooning) were used for diagnosis. RESULTS The sensitivity and specificity of BE screening using the two novel findings and conventional findings to diagnose EMDs were 79.4% and 88%, respectively [area under the receiver-operating characteristic curve (AUC) = 0.837]. Without these novel findings, they were 63.9% and 96%, respectively (AUC = 0.800), respectively. Achalasia was highly correlated with the air-fluid level (88.7%). Absent contractility was highly correlated with absent/weak peristalsis (85.7%). Relatively high correlations were observed between distal esophageal spasm and rosary-bead/corkscrew appearance (60%), and between achalasia and wave appearance (59.7%). The intra-observer reproducibility and inter-observer agreement for individual BE findings were 84.4% and 75%, respectively. Wave appearance was associated with higher integrated relaxation pressure (IRP) and shorter distal latency. Supra-junctional ballooning was associated with higher IRP. CONCLUSIONS BE screening using two additional novel findings to diagnose EMDs could be useful in general practice.
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Zaghloul MS, Elshaer YA, Ramadan ME, ElBatae HE. Different patterns of esophageal motility disorders among patients with dysphagia and normal endoscopy: A 2-center experience. Medicine (Baltimore) 2022; 101:e30573. [PMID: 36197212 PMCID: PMC9509117 DOI: 10.1097/md.0000000000030573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Esophageal motility disorders (EMDs) are the main etiology of nonobstructive dysphagia (NOD), but they are underestimated in Egypt. High-resolution manometry (HRM) with Chicago Classification version 3.0 (CC v3.0) is the current gold standard diagnostic modality to assess EMD in patients with NOD. In this HRM-based study, we aimed to classify EMD among Egyptian patients and explore the relationship between the severity of symptoms and the various groups of EMD. From January 2020 to January 2021, patients with dysphagia were subjected to diagnostic workup, which included symptom questionnaire for Eckardt score, esophagogastroduodenoscopy, barium esophagogram, and HRM. All patients were categorized based on the HRM results using CC version 3.0 after exclusion of those with obstructive esophageal lesions. Of 252 patients with dysphagia, 55 patients with NOD were analyzed according to CC version 3.0. Achalasia was diagnosed in 31 patients (56.4%) (type I: 18 [58.06%]; type II: 9 [29.03%], and type III: 4 [12.9%]), 3 patients (5.5%) with esophagogastric junction outflow obstruction, 2 patients (3.6%) with absent contractility, 4 patients (7.3%) with distal esophageal spasm, 7 patients (12.7%) with ineffective esophageal motility, and 8 patients (14.5%) with normal manometry. Patients with achalasia experienced significantly high regurgitation (96.8% vs 70.8%; P = .016) compared with those without achalasia. Achalasia was the most common EMD in Egyptian patients with NOD. Eckardt score was higher in patients with outflow obstruction and major motor disorder, but it could not differentiate different categories of CC of EMD. HRM is effective in characterization of EMD.
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Affiliation(s)
- Mariam S. Zaghloul
- Department of Hepatology, Gastroenterology and Infectious Diseases, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
| | - Yasmine A. Elshaer
- Department of Hepatology, Gastroenterology and Infectious Diseases, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
- *Correspondence: Yasmine A. Elshaer, Department of Hepatology, Gastroenterology and Infectious Diseases, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt (e-mail: )
| | - Mohamed E. Ramadan
- Department of General Surgery, Faculty of Medicine, Benha University, Egypt
| | - Hassan E. ElBatae
- Department of Hepatology, Gastroenterology and Infectious Diseases, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
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Patel DA, Yadlapati R, Vaezi MF. Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics. Gastroenterology 2022; 162:1617-1634. [PMID: 35227779 PMCID: PMC9405585 DOI: 10.1053/j.gastro.2021.12.289] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/03/2021] [Accepted: 12/12/2021] [Indexed: 12/13/2022]
Abstract
Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.
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Affiliation(s)
- Dhyanesh A. Patel
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Diego
| | - Rena Yadlapati
- Vanderbilt University Medical Center and Division of Gastroenterology, University of California San Diego
| | - Michael F. Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Diego
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19
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Madigan KE, Smith JS, Evans JK, Clayton SB. Elevated average maximum intrabolus pressure on high-resolution manometry is associated with esophageal dysmotility and delayed esophageal emptying on timed barium esophagram. BMC Gastroenterol 2022; 22:74. [PMID: 35189822 PMCID: PMC8859877 DOI: 10.1186/s12876-022-02165-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intrabolus pressure (IBP) recorded by high-resolution manometry (HRM) portrays the compartmentalized force on a bolus during esophageal peristalsis. HRM may be a reliable screening tool for esophageal dysmotility in patients with elevated average maximum IBP (AM-IBP). Timed barium esophagram (TBE) is a validated measure of esophageal emptying disorders, such as esophagogastric junction outflow obstruction and achalasia. This study aimed to determine if an elevated AM-IBP correlates with esophageal dysmotility on HRM and/or delayed esophageal emptying on TBE. METHODS A retrospective analysis of all HRM (unweighted sample n = 155) performed at a tertiary referral center from 09/2015-03/2017 yielded a case group (n = 114) with abnormal AM-IBP and a control group (n = 41) with a normal AM-IBP (pressure < 17 mmHg) as consistent with Chicago Classification 3. All patients received a standardized TBE, with abnormalities classified as greater than 1 cm of retained residual liquid barium in the esophagus at 1 and 5 min or as tablet retention after 5 min. RESULTS AM-IBP was significantly related to liquid barium retention (p = 0.003) and tablet arrest on timed barium esophagram (p = 0.011). A logistic regression model correctly predicted tablet arrest in 63% of cases. Tablet arrest on AM-IBP correlated with an optimal prediction point at 20.1 mmHg on HRM. Patients with elevated AM-IBP were more likely to have underlying esophageal dysmotility (95.6% vs. 70.7% respectively; p < 0.001), particularly esophagogastric junction outflow obstruction disorders. Elevated AM-IBP was associated with incomplete liquid bolus transit on impedance analysis (p = 0.002). CONCLUSIONS Our findings demonstrate that an elevated AM-IBP is associated with abnormal TBE findings of esophageal tablet retention and/or bolus stasis. An abnormal AM-IBP (greater than 20.1 mm Hg) was associated with a higher probability of retaining liquid bolus or barium tablet arrest on TBE and esophageal dysmotility on HRM. This finding supports the recent incorporation of IBP in Chicago Classification v4.0.
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Affiliation(s)
- Katelyn E Madigan
- Department of Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - J Shawn Smith
- Department of Medicine, Prisma Health, Greenville School of Medicine, Greenville, USA
| | - Joni K Evans
- Department of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, USA
| | - Steven B Clayton
- Department of Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
- Department of Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston-Salem, USA
- Department of Medicine, Section on Gastroenterology, Greenville School of Medicine, Greenville, USA
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20
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Ong AML, Soh AYS, Wang YT, Wong RK, Chia CTW, Siah K, Ang D. Guidance on performance and reporting of high-resolution oesophageal manometry and ambulatory pH monitoring in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:629-637. [PMID: 34472558 DOI: 10.47102/annals-acadmedsg.2020623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION We aimed to provide a practical and evidence-based guide on the indications, performance and reporting of high-resolution oesophageal manometry (HRM) and ambulatory pH monitoring (PHM) in adult patients in Singapore. METHODS The guideline committee comprised local gastroenterologists from public and private sectors with particular expertise in aspects of HRM and PHM, and it was tasked to produce evidence-based statements on the indications, performance and reporting of these tests. Each committee member performed literature searches to retrieve relevant articles within the context of domains to which they were assigned. RESULTS Twelve recommendation statements were created and summarised. CONCLUSION Standardising key aspects of HRM and PHM is imperative to ensure the delivery of high-quality care. We reported the development of recommendations for the performance and interpretation of HRM and ambulatory reflux monitoring in Singapore.
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Affiliation(s)
- Andrew Ming Liang Ong
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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21
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Hamada S, Ihara E, Muta K, Wada M, Hata Y, Ikeda H, Tanaka Y, Ogino H, Chinen T, Ogawa Y. Onigiri esophagography as a screening test for esophageal motility disorders. J Neurogastroenterol Motil 2021; 28:43-52. [PMID: 34312324 PMCID: PMC8748848 DOI: 10.5056/jnm20138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/13/2020] [Accepted: 11/10/2020] [Indexed: 11/24/2022] Open
Abstract
Background/Aims No screening test for esophageal motility disorder (EMD) has been established, the objective of this study is to examine the potential usefulness of our newly developed “Onigiri esophagography” combined with an obstruction level (OL) classification system in screening for EMD. Methods A total of 102 patients with suspected EMDs who underwent both high-resolution manometry (HRM) and Onigiri esophagography between April 2017 and January 2019 were examined. The EMD diagnosis was performed based on the Chicago classification version 3.0 by HRM. Onigiri esophagography was performed using a liquid medium (barium sulfate) followed by a solid medium, which consisted of an Onigiri (a Japanese rice ball) with barium powder. The extent of medium obstruction was assessed by the OL classification, which was defined in a stepwise fashion from OL0 (no obstruction) to OL4 (severe obstruction). Results The patients with OL0 (32.3%), OL1 (50.0%), OL2 (88.0%), OL3 (100.0%), and OL4 (100.0%) were diagnosed EMDs by HRM. The area under the curve, as determined by a receiver operating characteristic analysis, for the OL classification was 0.86. Using the cutoff value of OL1, the sensitivity and specificity were 87.3% and 61.3%, respectively, while using a cutoff value of OL2, the sensitivity and specificity were 73.2% and 90.3%, respectively. Conclusion In conclusion, Onigiri esophagography combined with the OL classification system can be used as a screening test for EMDs with a cutoff value of OL1.
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Affiliation(s)
- Shohei Hamada
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan.,Department of Gastroenterology and Metabolism Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Kazumasa Muta
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Masafumi Wada
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Hiroko Ikeda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Yoshimasa Tanaka
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Haruei Ogino
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Takatoshi Chinen
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Maidashi, Higashi-ku, Fukuoka, Japan
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22
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Oude Nijhuis RAB, Zaninotto G, Roman S, Boeckxstaens GE, Fockens P, Langendam MW, Plumb AA, Smout A, Targarona EM, Trukhmanov AS, Weusten B, Bredenoord AJ. European guidelines on achalasia: United European Gastroenterology and European Society of Neurogastroenterology and Motility recommendations. United European Gastroenterol J 2021; 8:13-33. [PMID: 32213062 PMCID: PMC7005998 DOI: 10.1177/2050640620903213] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Achalasia is a primary motor disorder of the oesophagus characterised by absence of peristalsis and insufficient lower oesophageal sphincter relaxation. With new advances and developments in achalasia management, there is an increasing demand for comprehensive evidence-based guidelines to assist clinicians in achalasia patient care. METHODS Guidelines were established by a working group of representatives from United European Gastroenterology, European Society of Neurogastroenterology and Motility, European Society of Gastrointestinal and Abdominal Radiology and the European Association of Endoscopic Surgery in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument. A systematic review of the literature was performed, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Recommendations were voted upon using a nominal group technique. RESULTS These guidelines focus on the definition of achalasia, treatment aims, diagnostic tests, medical, endoscopic and surgical therapy, management of treatment failure, follow-up and oesophageal cancer risk. CONCLUSION These multidisciplinary guidelines provide a comprehensive evidence-based framework with recommendations on the diagnosis, treatment and follow-up of adult achalasia patients.
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Affiliation(s)
- R A B Oude Nijhuis
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - S Roman
- Digestive Physiology, Hôpital Edouard Herriot, Lyon, France
| | - G E Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Centre for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - P Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - M W Langendam
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - A A Plumb
- Centre for Medical Imaging, University College London, London, UK
| | - Ajpm Smout
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - E M Targarona
- Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - A S Trukhmanov
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Blam Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
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Factors associated with esophageal motility improvement after bilateral lung transplant in patients with an aperistaltic esophagus. J Thorac Cardiovasc Surg 2021; 163:1979-1986. [PMID: 33568319 DOI: 10.1016/j.jtcvs.2020.12.130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/03/2020] [Accepted: 12/27/2020] [Indexed: 01/18/2023]
Abstract
OBJECTIVES We reported that esophageal peristalsis can improve after lung transplant (LTx), even in patients with pretransplant esophageal aperistalsis. This improvement was associated with better outcomes. We analyzed preoperative factors and sought to predict persistent aperistalsis or motility improvement in patients with pre-LTx esophageal aperistalsis. METHODS Patients with esophageal aperistalsis who underwent LTx between January 2013 and December 2016 were included. Preoperative barium esophagrams were blinded and re-examined; subjective scores were assigned to motility and dilation patterns. Postoperative high-resolution manometry was used to divide patients into 2 groups: persistent esophageal aperistalsis (PEA) or improved esophageal peristalsis (IEP). RESULTS We identified 29 patients: 20 with restrictive lung disease, 7 with obstructive lung disease, and 2 with pulmonary arterial hypertension. Post-LTx, 10 patients had PEA and 19 had IEP (mean age, 53.3 ± 6.6 years and 61.2 ± 10.6 years, respectively; P = .04). All 9 patients (100%) with obstructive lung disease or pulmonary arterial hypertension but only 10 of 20 patients (50%) with restrictive lung disease had IEP post-LTx (P = .01). All 4 patients with scleroderma had PEA. Nearly absent contractility on preoperative esophagrams was more prevalent in the PEA group than in the IEP group (100% vs 58.8%; P = .06). No further differences were observed between the groups. CONCLUSIONS Patients with esophageal aperistalsis and obstructive lung disease or pulmonary arterial hypertension, but not patients with restrictive lung disease and scleroderma, are likely to have IEP post-LTx. Additional studies may determine whether subjective esophagram assessment can help predict IEP post-LTx in patients with restrictive lung disease without scleroderma.
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Rehman H, Abid A, Awan S, Hashmi FL, Abid S. Spectrum and Clinical Outcome of Motility Disorders on High-Resolution Esophageal Manometry: A Study From a Tertiary Center on Patients With Dysphagia in Pakistan. Cureus 2020; 12:e12088. [PMID: 33489506 PMCID: PMC7805506 DOI: 10.7759/cureus.12088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2020] [Indexed: 12/20/2022] Open
Abstract
Objective This study aimed to evaluate the outcome of high-resolution esophageal manometry (HRM) in the diagnosis of esophageal motility disorders in a Pakistani population. It also evaluates the outcomes of management of patients with esophageal dysphagia and no structural abnormality on endoscopy. Methods This is a cross-sectional study. Patients with symptoms of dysphagia with normal endoscopy were subjected to esophageal manometry and to barium swallow as a part of routine workup. Esophageal motility disorders diagnosed by HRM were compared to barium swallow findings. A follow-up of these patients was done after a one-year interval to evaluate improvement in their symptoms. Results A total of 202 patients underwent HRM. There were abnormal findings in 160 patients (79.2%) with achalasia being the most common diagnosis in 35.6% of the total patients. Out of 72 patients diagnosed to have achalasia on HRM, only 46 (32.6%) had similar findings on barium esophagram and this difference is statistically significant, p < 0.001). Among achalasia patients, laparoscopic surgery was performed in 22 (30.5%) patients with 59% patients reporting a good to excellent improvement (>50%) in their symptoms, balloon dilatations were done in 47 (65.27%) patients with a good to excellent improvement in symptoms in 55% patients. Only three patients (5.5%) were given botulinum toxin injections, and two of them had an improvement of >50% in their symptoms. Patients with motility disorders other than achalasia were treated with a combination of proton pump inhibitors (PPIs), calcium channel blockers and selective serotonin reuptake inhibitors (SSRIs). Conclusion Achalasia was the most common esophageal motility disorder in our population. HRM can diagnose significantly more patients with achalasia compared to barium swallow. Likewise, HRM was helpful in detecting other esophageal motility disorders and planning their management.
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Affiliation(s)
| | - Adeel Abid
- Medicine, Aga Khan Health Service, Karachi, PAK
| | - Safia Awan
- Internal Medicine, Aga Khan Health Service, Karachi, PAK
| | | | - Shahab Abid
- Gastroenterology, Aga Khan University, Karachi, PAK
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Zambito G, Roether R, Kern B, Conway R, Scheeres D, Banks-Venegoni A. Is barium esophagram enough? Comparison of esophageal motility found on barium esophagram to high resolution manometry. Am J Surg 2020; 221:575-577. [PMID: 33228948 DOI: 10.1016/j.amjsurg.2020.11.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/20/2020] [Accepted: 11/12/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of the study is to determine if barium esophagram (BE) alone is sufficient to diagnose esophageal dysmotility when compared to the gold standard, high-resolution manometry (HRM). METHODS This is a retrospective review of patients that underwent laparoscopic fundoplication by two surgeons at a single institution from 10/1/2015-6/29/2019. Patients with large paraesophageal hernias and patients without both BE and HRM were excluded. RESULTS Forty-six patients met the inclusion criteria. BE was found to be concordant with HRM for esophageal motility in only 21 patients (46%). Setting HRM as the gold standard, BE had a sensitivity of 14% (95% CI: 5%-35%), specificity of 72% (95% CI: 52%-86%), PPV of 30% (95% CI: 11%-60%), and NPV of 50% (95% CI: 35%-66%). The accuracy was 46%, while a McNemar test showed p = 0.028. CONCLUSION Traditional BE should not be used in place of HRM for assessing pre-operative motility in patients undergoing anti-reflux surgery.
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Affiliation(s)
- Giuseppe Zambito
- Spectrum Health Medical Group Department of Surgery, Michigan State University School of Medicine, United States.
| | - Robert Roether
- Spectrum Health Medical Group Department of Surgery, Michigan State University School of Medicine, United States
| | - Brittany Kern
- Spectrum Health Medical Group Department of Surgery, Michigan State University School of Medicine, United States
| | - Ryan Conway
- Spectrum Health Medical Group Department of Surgery, Michigan State University School of Medicine, United States
| | - David Scheeres
- Spectrum Health Medical Group Department of Surgery, Michigan State University School of Medicine, United States
| | - Amy Banks-Venegoni
- Spectrum Health Medical Group Department of Surgery, Michigan State University School of Medicine, United States
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Biggemann L, Uhlig J, Gliem N, Al-Bourini O, Wedi E, Ellenrieder V, Ghadimi M, Uecker M, Frahm J, Lotz J, Hosseini ASA, Streit U. Assessment of esophageal motility disorders by real-time MRI. Eur J Radiol 2020; 132:109265. [PMID: 33010683 DOI: 10.1016/j.ejrad.2020.109265] [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] [Received: 04/22/2020] [Revised: 07/08/2020] [Accepted: 08/10/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE To investigate imaging findings of esophageal motility disorders on dynamic real-time. MATERIAL AND METHODS 102 patients with GERD-like symptoms were included in this retrospective study between 2015-2018. Dynamic real-time MRI visualized the transit of a 10 mL pineapple juice bolus through the esophagus and EGJ with a temporal resolution of 40 ms. Dynamic and anatomic parameters were measured by consensus reading. Imaging findings were compared to HRM utilizing the Chicago classification of esophageal motility disorders, v3.0. RESULTS All 102 patients completed real-time MRI in a median examination time of 15 min. On HRM, 14 patients presented with disorders with EGJ outlet obstruction (EGJOO) (13.7 %), 7 patients with major disorders of peristalsis (6.9 %), and 32 patients with minor disorders of peristalsis (31.4 %). HRM was normal in 49 patients (48.0 %). Incomplete bolus clearance was significantly more frequent in patients with esophageal motility disorders on HRM than in patients with normal HRM (p = 0.0002). In patients with motility disorders with EGJOO and major disorders of peristalsis, the esophageal diameter tended to be wider (23.6 ± 8.0 vs. 21.2 ± 3.5 mm, p = 0.089) and the sphincter length longer (19.7 ± 7.3 vs. 16.7 ± 3.0 mm, p = 0.091) compared to patients with normal HRM. 3/7 patients with achalasia type II were correctly identified by real-time MRI and one further achalasia type II patient was diagnosed with a motility disorder on MRI films. The other 3/7 patients presented no specific imaging features. CONCLUSION Real-time MRI is an auxiliary diagnostic tool for the assessment of swallowing events. Imaging parameters may assist in the detection of esophageal motility disorders.
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Affiliation(s)
- Lorenz Biggemann
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany.
| | - Johannes Uhlig
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany
| | - Nina Gliem
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Göttingen, Germany
| | - Omar Al-Bourini
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany
| | - Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Göttingen, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Göttingen, Germany
| | - Michael Ghadimi
- Department of General, Visceral, and Paediatric Surgery, University Medical Center, Göttingen, Germany
| | - Martin Uecker
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany
| | - Jens Frahm
- Biomedical NMR, Max-Planck-Institute for Biophysical Chemistry, Göttingen, Germany
| | - Joachim Lotz
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany
| | - Ali Seif Amir Hosseini
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany
| | - Ulrike Streit
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany
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Abstract
Esophageal symptoms are common and may indicate the presence of gastroesophageal reflux disease (GERD), structural processes, motor dysfunction, behavioral conditions, or functional disorders. Esophageal physiologic tests are often performed when initial endoscopic evaluation is unrevealing, especially when symptoms persist despite empiric management. Commonly used esophageal physiologic tests include esophageal manometry, ambulatory reflux monitoring, and barium esophagram. Functional lumen imaging probe (FLIP) has recently been approved for the evaluation of esophageal pressure and dimensions using volumetric distension of a catheter-mounted balloon and as an adjunctive test for the evaluation of symptoms suggestive of motor dysfunction. Targeted utilization of esophageal physiologic tests can lead to definitive diagnosis of esophageal disorders but can also help rule out organic disorders while making a diagnosis of functional esophageal disorders. Esophageal physiologic tests can evaluate obstructive symptoms (dysphagia and regurgitation), typical and atypical GERD symptoms, and behavioral symptoms (belching and rumination). Certain parameters from esophageal physiologic tests can help guide the management of GERD and predict outcomes. In this ACG clinical guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to describe performance characteristics and clinical value of esophageal physiologic tests and provide recommendations for their utilization in routine clinical practice.
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Allen J, Dewan K, Herbert H, Randall DR, Starmer H, Stein E. Aspects of the assessment and management of pharyngoesophageal dysphagia. Ann N Y Acad Sci 2020; 1482:5-15. [PMID: 32794195 DOI: 10.1111/nyas.14456] [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: 03/18/2020] [Revised: 05/26/2020] [Accepted: 07/08/2020] [Indexed: 02/06/2023]
Abstract
Swallowing complaints are common and may have significant consequences for nutrition and pulmonary health. Etiology varies and different aspects of the deglutitive system may be affected. A thorough assessment from the oral cavity to the stomach will provide physiologic information that enables specific targeted management plans to be devised. Although the swallow trajectory bridges anatomic areas, there has previously been a tendency to compartmentalize assessment and treatment by arbitrary anatomic boundaries. It is now clear that this approach fails to appreciate the complexity of swallow mechanics and that systems (oral, pharyngeal, esophageal, and pulmonary) are intertwined and codependent. Swallowing specialists from different backgrounds and with complementary skill sets form a multidisciplinary team that can provide insight and address multiple areas of management. With the advent of new tools for instrumental evaluation, such as manometry, targeted rehabilitative strategies can be informed by physiology, increased in precision and breadth, and assessed quantitatively. Surgical approaches have evolved toward endoscopic techniques, and food technology is expanding options in dietary management. The multidisciplinary team is core to managing this varied and often neglected patient population. This review is for clinicians treating swallowing disorders and will explore the selected aspects of the assessment and management of pharyngoesophageal swallowing disorders.
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Affiliation(s)
- Jacqueline Allen
- Department of Surgery, the University of Auckland, Auckland, New Zealand
| | - Karuna Dewan
- Division of Otolaryngology, Stanford University, Stanford, California
| | - Hayley Herbert
- Department of Otolaryngology, University of Western Australia, Perth, Western Australia, Australia
| | - Derrick R Randall
- Division of Otolaryngology, the University of Calgary, Calgary, Alberta, Canada
| | - Heather Starmer
- Division of Otolaryngology, Stanford University, Stanford, California
| | - Ellen Stein
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical School, Baltimore, Maryland
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Zhuo ZG, Li G, Deng HY, Luo J, Alai GH, Wang YC, Lin YD. Preoperative dilated esophagus is associated with a high risk of intrathoracic anastomotic leakage for patients with esophageal cancer. J Thorac Dis 2020; 12:2325-2332. [PMID: 32642137 PMCID: PMC7330295 DOI: 10.21037/jtd.2020.03.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background The association between the preoperative condition of the esophagus and anastomotic leakage has seldom been studied. We observed a dominant dilation of the esophagus under barium esophagography in some esophageal cancer patients. In consideration of the larger circular stapler are applied in colorectal surgery, we wonder if larger circular stapler should be applied in these patients to fit the larger esophagus. The larger size of the circular stapler also could decrease the incidence of anastomosis stricture. Thus, we made this study to explore if patients with a dilated esophagus were facing a higher risk of anastomotic leakage when applying the 25 mm circular stapler. Methods A retrospective review of patients undergoing gastroesophageal intrathoracic anastomosis using a 25 mm circular stapler was performed. Patients with endoscopy or barium esophagography confirmed anastomotic leakage was assigned to leakage group (LG) while the left was enrolled in no leakage group (NLG). The measurement of the diameter of the esophagus was carried out at the level of 5 centimeters away from the upper margin of the tumor on esophagography. Results LG had a greater intraluminal mucosal phase diameter (IMPD) than NLG (P=0.010). The ROC curve indicated 1.79 cm as the cutoff value for IMPD. Patients with IMPD greater than 1.79 cm had a statistically significant higher rate of leakage. In the multivariate logistic regression analysis, dilated IMPD was proven to be a risk factor of 25 mm-circular-stapler anastomotic leakage. Conclusions Patients with an IMPD over 1.79 mm are facing a higher risk of intrathoracic anastomosis leakage when applying the 25 mm circular stapler. Larger circular stapler or hand-sewn would be the better choice for these patients.
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Affiliation(s)
- Ze-Guo Zhuo
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Gang Li
- Department of Thoracic Surgery, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, Chengdu 610000, China
| | - Han-Yu Deng
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jun Luo
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Gu-Ha Alai
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yun-Cang Wang
- Department of Thoracic Surgery, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, Chengdu 610000, China
| | - Yi-Dan Lin
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
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Davidson K, O'Rourke A, Fortunato JE, Jadcherla S. The Emerging Importance of High-Resolution Manometry in the Evaluation and Treatment of Deglutition in Infants, Children, and Adults: New Opportunities for Speech-Language Pathologists. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2020; 29:945-955. [PMID: 32650654 DOI: 10.1044/2019_ajslp-19-00067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Purpose Diagnostic precision and prolonged testing before, during, and after deglutition is lacking across the age spectrum. Conventional clinical evaluation and radiologic methods are widely used but are reliant on human perception, carrying the risk of subjectivity. High-resolution manometry (HRM) is an emerging clinical and research tool and has the capability to objectively measure the dynamics, kinetics, regulatory, and correlation aspects of deglutition. Method We review the basics of manometry and the methods, metrics, and applications of this technology across the age spectrum. The goal is to aid in the translation of HRM from research tool to clinical use by the speech-language pathologist in the development of better global plans to understand normal and abnormal deglutition. Results HRM is an easily adaptable precise diagnostic tool that can be used to examine deglutition phases and abnormalities across the age spectrum from neonates to nonagenarians and can be a valuable adjunct to specialty evaluation of persistent deglutition disorders. Conclusion New opportunities will emerge upon further research for larger-scale translation once normative data and recognition of biomarkers of abnormality are ascertained.
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Affiliation(s)
- Kate Davidson
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Ashli O'Rourke
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - John E Fortunato
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, NC
- Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, IL
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Sudarshan Jadcherla
- Innovative Infant Feeding Disorders Research Program, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
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Kunen L, Fontes L, Moraes-Filho J, Assirati F, Navarro-Rodriguez T. Esophageal motility patterns are altered in older adult patients. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2020. [DOI: 10.1016/j.rgmxen.2019.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Kunen LCB, Fontes LHS, Moraes-Filho JP, Assirati FS, Navarro-Rodriguez T. Esophageal motility patterns are altered in older adult patients. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2020; 85:264-274. [PMID: 31902552 DOI: 10.1016/j.rgmx.2019.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 07/06/2019] [Accepted: 07/26/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION AND AIMS Since the 1960s, several studies have shown the effect of aging on esophageal motility, with inconsistent results. The aim of the present study was to evaluate the manometric results in older adult patients (=60 years of age) with an esophageal disorder and compare them with adults under 60 years of age. MATERIALS AND METHODS A cross-sectional, retrospective study was conducted that included a sample of 1,175 patients (936 older adults and 239 non-older adults). The patients were evaluated and compared with respect to (i) sex, (ii) main complaint for which esophageal manometry was indicated, (iii) comorbidities, (iv) current medications, (v) smoking, and (vi) manometry results. RESULTS Patient age ranged from 19 to 92 years (women made up 76.5% of the older adults and 72.8% of the non-older adults). Normal lower esophageal sphincter relaxation and normal peristalsis were more frequent in the non-older patient group (91.1% vs. 84.8% and 87.4% vs. 76%, respectively). The manometry results for the non-older adults vs. the older adults, respectively, were: achalasia (2.9% vs. 5.9%); hypercontractile disorder (9.2% vs. 10.4%); hypocontractile disorder (38.5% vs. 47.6%); and normal values (49.4% vs. 36.1%). After excluding the variables that could change esophageal motility, the results revealed significant differences between the two study groups. CONCLUSIONS Esophageal manometry demonstrated statistically significant differences between the older adult and non-older adult study population evaluated.
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Affiliation(s)
- L C B Kunen
- Departamento de Gastroenterología, Escuela de Medicina de la Universidad de Sao Paulo, São Paulo, Brasil; Hospital Estatal de Servidores Públicos, São Paulo, Brasil
| | - L H S Fontes
- Departamento de Gastroenterología, Escuela de Medicina de la Universidad de Sao Paulo, São Paulo, Brasil; Hospital Estatal de Servidores Públicos, São Paulo, Brasil
| | - J P Moraes-Filho
- Departamento de Gastroenterología, Escuela de Medicina de la Universidad de Sao Paulo, São Paulo, Brasil
| | - F S Assirati
- Departamento de Gastroenterología, Escuela de Medicina de la Universidad de Sao Paulo, São Paulo, Brasil; Hospital Estatal de Servidores Públicos, São Paulo, Brasil
| | - T Navarro-Rodriguez
- Departamento de Gastroenterología, Escuela de Medicina de la Universidad de Sao Paulo, São Paulo, Brasil.
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Posner S, Mehta K, Parish A, Niedzwiecki D, Gupta RT, Fisher DA, Leiman DA. Esophageal Function Tests are Not Associated with Barium Swallow Findings in Advanced Lung Disease. Dysphagia 2020; 35:864-870. [PMID: 32277290 DOI: 10.1007/s00455-020-10113-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 04/03/2020] [Indexed: 11/29/2022]
Abstract
Gastroesophageal reflux disease and esophageal dysmotility are common in patients with advanced lung disease (ALD) and are associated with worse outcomes. Assessing esophageal function in these patients is relevant for determining pulmonary transplant eligibility and prognosticating post-transplant outcomes. Barium Swallow (BaS) is a non-invasive testing modality often performed as a complement to formal esophageal function tests (EFTs), but its role and clinical utility in this context is unknown. Therefore, we aimed to determine the relationship between BaS and EFTs with high-resolution manometry (HRM) and 24-h ambulatory pH-metry in patients with ALD. We performed a retrospective study of 226 consecutive patients undergoing evaluation for lung transplantation at a single center. All patients underwent EFTs and BaS independent of clinical history or symptoms per institutional protocol. Appropriate statistical tests were performed to evaluate the relationship between EFTs and BaS. Mucosal, reflux and motility findings were categorized. Abnormal motility was reported in 133 (59%) patients by BaS and 99 (44%) by HRM, with a significant difference in the proportions of patients with abnormal studies (p < 0.01). There were 7 (26%) patients with abnormal barium tablet passage who had normal HRM. The sensitivity (35%) and specificity (77%) for detecting pathologic reflux with BaS was poor. Inducibility of reflux and barium column height were not associated with pH-metry results. No clinically significant luminal irregularities were identified. In conclusion, while BaS can non-invasively assess esophageal mucosa, its findings are not associated with EFTs in patients with ALD.
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Affiliation(s)
- Shai Posner
- Division of Gastroenterology, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27705, USA
| | - Kurren Mehta
- Duke University School of Medicine, Duke University, Durham, NC, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Rajan T Gupta
- Department of Radiology, Duke University, Durham, NC, USA
| | - Deborah A Fisher
- Division of Gastroenterology, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27705, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - David A Leiman
- Division of Gastroenterology, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27705, USA. .,Duke Clinical Research Institute, Durham, NC, USA.
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Abstract
Prevalence, clinical manifestations and of modern classifications of achalasia are reviewed in the article. Diagnosis and treatment of this pathology were analyzed by using of 58 references.
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Affiliation(s)
- A M Gasanov
- Sklifosovsky Research Institute for Emergency Medicine of Moscow Healthcare Department, Moscow, Russia
| | - N A Aliev
- Sklifosovsky Research Institute for Emergency Medicine of Moscow Healthcare Department, Moscow, Russia
| | - Sh N Danielyan
- Sklifosovsky Research Institute for Emergency Medicine of Moscow Healthcare Department, Moscow, Russia
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Alicuben ET, Bildzukewicz N, Samakar K, Katkhouda N, Dobrowolsky A, Sandhu K, Lipham JC. Routine esophageal manometry is not useful in patients with normal videoesophagram. Surg Endosc 2018; 33:1650-1653. [DOI: 10.1007/s00464-018-6456-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 09/18/2018] [Indexed: 10/28/2022]
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Esophageal motility disorders. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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