Lower esophageal mucosal ring: correlation of referred symptoms with radiographic findings using a marshmallow bolus

Inter-rater reliability and clinical relevance of subjective and objective interpretation of videofluoroscopy findings

Background

Dysphagia is commonly evaluated using videofluoroscopy (VFS). As its ratings are usually subjective normal-abnormal ratings, objective measurements have been developed. We compared the inter-rater reliability of the usual VFS ratings to the objective measurement VFS ratings and evaluated their clinical relevance.

Methods

Two blinded raters analyzed the subjective normal-abnormal ratings of 77 patients' VFS. Two other blinded raters analyzed the objective measurements of pharyngeal aerated area with bolus held in the oral cavity (PAhold), the pharyngeal area of residual bolus during swallowing (PAmax), the pharyngeal constriction ratio (PCR), the maximum pharyngoesophageal segment opening (PESmax), pharyngoesophageal segment opening duration (POD), airway closure duration (ACD), and total pharyngeal transit time (TPT). We evaluated the inter-rater agreement in the subjective ratings and the objective measurements. Clinical utility analysis compared the measurements with the VFS findings of pharyngeal phase abnormality, penetration/aspiration, and cricopharyngeal relaxation.

Results

In the pharyngeal findings, the subjective analysis inter-rater agreement was mainly moderate to strong. The strongest agreements were on the pharyngeal residues and penetration/aspiration findings. The objective measurements had fair to good inter-rater agreement. Clinical utility analysis found statistically significant connections between TPT and pharyngeal phase abnormality, normal PCR and lack of penetration/aspiration, and normal PESmax and normal cricopharyngeal relaxation.

Conclusions

The subjective analysis had moderate to strong inter-rater agreement in the pharyngeal VFS findings, especially concerning pharyngeal residues and penetration/aspiration detection, reflecting the efficacy and safety of swallowing. The objective measurements had fair to good inter-observer reproducibility and could thus improve the reliability of VFS diagnostics.

Level of evidence

4.

South of the UES: Improving the ability of speech-language pathologists to detect oesophageal abnormalities during videofluoroscopy swallowing studies

PURPOSE

With two-thirds of adults presenting for a videofluoroscopy swallow study (VFSS) with oesophageal abnormalities, it seems prudent to include visualisation of the oesophagus, in the context of the entire swallow process, to provide further information to the diagnostic team. This study aims to evaluate the ability of speech-language pathologists (SLPs) to interpret oesophageal sweep on VFSS and the relative improvement in that ability with additional training.

METHOD

One hundred SLPs attended training in oesophageal visualisation during VFSS, based on a previous study. Ten oesophageal sweep videos (five normal, five abnormal) with one 20 ml thin fluid barium bolus (19% w/v) were presented at baseline and following training. Raters were blinded to patient information other than age. Binary ratings were collected for oesophageal transit time (OTT), presence of stasis, redirection, and referral to other specialists.

RESULT

Inter-rater reliability as measured by Fleiss' kappa improved for all parameters, reaching statistical significance for OTT (pre-test kappa = 0.34, post-test kappa = 0.73; p < 0.01) and redirection (pre-test kappa = 0.38, post-test kappa = 0.49; p < 0.05). Overall agreement improved significantly (p < 0.001) for all parameters except stasis, where improvement was only slight. Interaction between pre-post and type of video (normal/abnormal) was statistically significant (p < 0.001) for redirection, with a large pre-post increase in positive accuracy compared with a slight pre-post decrease in negative accuracy.

CONCLUSION

Findings indicate that SLPs require training to accurately interpret an oesophageal sweep on VFSS. This supports the inclusion of education and training on both normal and abnormal oesophageal sweep patterns, and the use of standardised protocols for clinicians using oesophageal visualisation as part of the VFSS protocol.

Implementation of Esophageal Screening in an Outpatient Hospital-Based Setting: A Quality Improvement Project

PURPOSE

Despite evidence supporting interconnectivity of oropharyngeal and esophageal swallowing, evaluation and treatment are dichotomized. When the videofluoroscopic swallowing study (VFSS) only considers oropharyngeal swallowing, the full scope of swallowing impairment may be missed. A lower rate of esophageal screening in an outpatient hospital setting may result from lack of speech-language pathologist (SLP) training and understanding of screening feasibility. This project was an internal quality improvement project (QIP) at Mayo Clinic in Arizona to (a) educate and train SLPs on conducting the Robust Esophageal Screening Test (REST) and (b) determine the feasibility of REST protocol implementation in a multidisciplinary swallow clinic.

METHOD

Fishbone analysis was used to identify potential causes of the gap in quality. Six Sigma methodology was used to outline the QIP. SLPs were trained in the REST protocol. To ensure adequate training, reliability ratings were assessed with the Cohen's kappa statistic. Esophageal screening via REST was implemented as an adjunct to the standard protocol during VFSS over a 3-month period for referred patients with dysphagia. Clinical findings were recorded.

RESULTS

All clinical rater SLPs reached the threshold of κ = .8 to ensure adequate rater reliability. Among 136 outpatients who underwent esophageal screening via REST, 100 patients completed the full REST screening and 36 completed a partial REST screening. Of the 100 full screenings, 80 patients had a failed screening, which indicated a potential esophageal swallowing impairment. Findings were discussed by members of the multidisciplinary dysphagia care team.

CONCLUSIONS

The results of this QIP show that focusing on assessment of dysfunction and interplay across the swallowing continuum can substantially improve patient care by expediting and specifying next steps of the multidisciplinary dysphagia care team.

The Introduction of a Protocol for Esophageal Screening in Videofluoroscopic Swallowing Studies: Exploring Clinical Impacts and Barriers

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.

Evaluation of Esophageal Dysphagia in Elderly Patients

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.

The Utility of the Marshmallow Barium Swallow Esophagogram for Investigation of Ineffective Esophageal Motility: A Systematic and Narrative Review

Objectives Current gold standard investigations to determine the pathology of ineffective esophageal motility (IEM) are invasive and resource-intensive. Marshmallow barium swallow esophagogram (MBSE) is emerging as a more feasible modality; however, our understanding of its role in the clinical setting is limited. Our aim was to appraise the current literature and describe the effectiveness and limitations of MBSE as a potential diagnostic tool when investigating the pathological cause of IEM.

Methods A search in PubMed was conducted on May 23, 2021. Search terms included “marshmallow” AND “barium.” We included all studies which examined MBSE in the context of esophageal disease. The primary outcome of interest was to characterize the use of MBSE in current literature.

Results A total of 12 studies were retrieved after initial search with 9 studies meeting final inclusion criteria. A total of 375 patients were included, with 296 patients (79%) having a relevant diagnosis or symptom prompting investigation with MBSE. The most common diagnoses included referral to a gastroenterology clinic for a barium swallow (44%), post-Angelchik insertion (23%), and dysphagia (13%). Esophageal disease was identified in both the MBSE and other screening tests in 63% participants, whereas in 27% participants abnormalities were only seen using the MBSE.

Conclusion There is currently limited high-quality evidence on the use of MBSE to diagnose IEM. Further large-scale studies comparing its use in patients with different pathologic causes of IEM and of older age are required to further delineate the optimal delivery of this emerging diagnostic modality.

[Approach of Dysphagia]

Dysphagia has been reported to be relatively common and seems to be increased in Korea. Dysphagia can be classified as oropharyngeal dysphagia or esophageal dysphagia. In patients with swallowing difficulties, it is important to determine whether the dysphagia is oropharyngeal or esophageal. Patients with orophayngeal dysphagia are likely to develop aspiration and aspiration pneumonia, so accurate diagnosis should be made in the early stages of complaining of swallowing difficulties. Patients with orophayngeal dysphagia complained difficulty initiating a swallow. Swallowing may be accompanied by coughing, choking, nasopharyngeal regurgitation, aspiration, and a sensation of residual food remaining in the pharynx. Patients with esophageal dysphagia complained difficulty swallowing several seconds after initiating a swallow and a sensation of food getting stuck in the esophagus. Esophageal dysphagia should be characterized by analyzing whether foods that cause swallowing difficulties are solid, liquids or both, whether symptoms are progressive or intermittent, how severe, and associated symptoms, such as weight loss, heartburn, or regurgitation. The approach to diagnostic testing to determine the cause of esophageal dysphagia is based upon the medical history. If esophageal motility disorder is suspected, barium esophagogram is performed first, and upper endoscopy is performed first if structural abnormalities are suspected. If an upper endoscopy shows normal findings, but the esophagus is still suspected of mechanical obstruction, a barium esophagogram is performed. Esophageal manometry should be performed in patients with swallowing difficulties who are suspected of esophageal motility disorder or have normal findings in upper endoscopy.

Dysphagia Evaluation: The Added Value of Concurrent MBS and Esophagram

OBJECTIVES/HYPOTHESIS

Dysphagia is associated with increased mortality and healthcare costs. The modified barium swallow study (MBS) is the gold standard in assessing oropharyngeal dysphagia, but does not evaluate the esophagus. A barium esophagram can visualize the esophagus but does not evaluate the oropharyngeal swallow, nor does it utilize the expertise of speech and language pathologists. Providers may order one or both studies yet still risk missing critical pathology.

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective chart review was conducted at an academic medical center between January 2016 and June 2019 focused on patients who had both MBS and esophagram as imaging for dysphagia evaluation. Analysis determined whether MBS and esophagram performed concomitantly improved diagnostic clarity.

RESULTS

A total of 5,183 patients underwent 6,066 swallow studies for dysphagia in the study period. Of which, 124 of these patients had concurrent MBS and esophagram. 10.5% of concurrent studies demonstrated a congruent negative evaluation. 59.7% of patients had an unremarkable MBS or esophagram paired with abnormal findings within the corresponding esophagram or MBS, respectively. 29.8% had both MBS and esophagrams that demonstrated an abnormality, but with unique pathologies identified by each study. In total, 85.1% of unremarkable MBS or esophagrams were paired with abnormal findings in the corresponding esophagram or MBS, respectively.

CONCLUSION

Selection of diagnostic testing is variable among providers and may be influenced by healthcare systems. This analysis revealed that MBS and esophagrams provide unique diagnoses. Concurrent MBS and esophagrams may improve diagnostic accuracy, yet minimize additional studies. National practices around dysphagia diagnostics are inconsistent and would benefit from standardization.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

ACR Appropriateness Criteria® Dysphagia

This review summarizes the relevant literature for the initial imaging of patients with symptoms of dysphagia. For patients with oropharyngeal dysphagia who have an underlying attributable cause, a modified barium swallow is usually appropriate for initial imaging but for those who have unexplained dysphagia a fluoroscopic biphasic esophagram is usually appropriate. Fluoroscopic biphasic esophagram is usually appropriate for initial imaging in both immunocompetent and immunocompromised patients who have retrosternal dysphagia. For postoperative patients with dysphagia, fluoroscopic single-contrast esophagram and CT neck and chest with intravenous (IV) contrast are usually appropriate for oropharyngeal or retrosternal dysphagia occurring in the early postoperative period where water-soluble contrast is usually preferred rather than barium sulfate. In the later postoperative period (greater than 1 month), CT neck and chest with IV contrast and fluoroscopic single-contrast esophagram are usually appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Aspects of the assessment and management of pharyngoesophageal dysphagia

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.

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

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.

Characteristics of Patients With Esophageal Dysphagia Assessed by Chest X-Ray Imaging After Videofluoroscopic Swallowing Study

Objective

To evaluate the prevalence rate, types, characteristics, and associated factors of esophageal dysphagia detected on chest X-ray images after videofluoroscopic swallowing study (VFSS).

Methods

The medical records of 535 adults were reviewed retrospectively. Chest X-ray images taken after barium swallow study were analyzed and presence of any residual barium in the esophagus was considered as esophageal dysphagia. Esophageal dysphagia was classified based on the largest width of barium deposit (mild, <2 cm; severe ≥2 cm) and the anatomic level at which it was located (upper and lower esophagus).

Results

Esophageal residual barium on chest X-ray images was identified in 40 patients (7.5%, 40/535). Esophageal dysphagia was more frequent in individuals aged 65–79 years (odds ratio=4.78, p<0.05) than in those aged <65 years. Mild esophageal dysphagia was more frequent (n=32) than its severe form (n=8). Lower esophageal dysphagia was more frequent (n=31) than upper esophageal dysphagia (n=9). Esophageal residual barium in patients diagnosed with esophageal cancer or lung cancer was significantly associated with severe esophageal dysphagia (p<0.05) and at the upper esophagus level (p<0.01).

Conclusion

Esophageal residual barium was observed on chest X-ray imaging after VFSS. Esophageal barium in the upper esophagus with a diameter of ≥2 cm is an important indicator of malignancy, and chest X-ray image taken after VFSS is an important step to evaluate the presence of esophageal disorder.

Esophageal Transit Times Vary with Underlying Comorbid Disease

Objectives

Little is known about esophageal transit times (ETT) in relation to underlying comorbid disease or aspiration risk. Our study evaluated liquid ETT in patients relative to underlying comorbid disease and compared this with ETT in healthy adults. We examined whether prolonged ETT was associated with swallow risk.

Study Design

Prospective observational study.

Setting

Radiology department.

Subjects

Patients included those referred to speech pathology for a videofluoroscopic study of swallowing (VFSS) within a tertiary hospital.

Methods

A total of 617 patients (49% female; mean ± SD age, 77 ± 15 years) and 139 healthy adults (56% female; age, 59 ± 22 years) were included. All patients underwent a standardized VFSS with esophageal screening. Patients were categorized by chief underlying disorder: previous stroke (n = 207), other neurologic condition (n = 188), respiratory conditions (n = 91), or gastroenterology conditions (n = 131). All VFSSs were analyzed with objective measures. ETT and penetration-aspiration scores were compared between groups.

Results

Advancing age was significantly associated with increased ETT ( P < .05). When controlling for age, mean 20-mL ETT remained significantly different across groups: healthy adults, 11 seconds; stroke, 17 seconds; other neurologic condition, 15 seconds; gastroenterology, 14 seconds; and respiratory, 9 seconds ( P < .001). One-third of patients aspirated; no healthy adults aspirated. Increasing ETT was associated with aspiration events ( P < .001).

Conclusions

Liquid ETTs differ among patients with different underlying primary diagnoses. Patients following stroke show significantly prolonged ETT and increased risk of aspiration. Prolonged ETT may influence symptom complaint and warrants consideration.

Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia

BACKGROUND AND AIMS

Our aim is to review the literature and provide guidelines for the assessment of uninvestigated dysphagia.

METHODS

A systematic literature search identified studies on dysphagia. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Statements were discussed and revised via small group meetings, teleconferences, and a web-based platform until consensus was reached by the full group.

RESULTS

The consensus includes 13 statements focused on the role of strategies for the assessment of esophageal dysphagia. In patients presenting with dysphagia, oropharyngeal dysphagia should be identified promptly because of the risk of aspiration. For patients with esophageal dysphagia, history can be used to help differentiate structural from motility disorders and to elicit alarm features. An empiric trial of proton pump inhibitor therapy should be limited to four weeks in patients with esophageal dysphagia who have reflux symptoms and no additional alarm features. For patients with persistent dysphagia, endoscopy, including esophageal biopsy, was recommended over barium esophagram for the assessment of structural and mucosal esophageal disease. Barium esophagram may be useful when the availability of endoscopy is limited. Esophageal manometry was recommended for diagnosis of esophageal motility disorders, and high-resolution was recommended over conventional manometry.

CONCLUSIONS

Once oropharyngeal dysphagia is ruled out, patients with symptoms of esophageal dysphagia should be assessed by history and physical examination, followed by endoscopy to identify structural and inflammatory lesions. If these are ruled out, then manometry is recommended for the diagnosis of esophageal dysmotility.

Inter-rater reliability for speech-language therapists' judgement of oesophageal abnormality during oesophageal visualization

BACKGROUND

Oesophageal abnormalities are common findings in a speech-language therapy videofluoroscopy clinic. Fluoroscopic screening involving oropharynx alone fails to identify these patients. Oesophageal screening as an adjunct to videofluoroscopy is gaining popularity. Yet currently, little is known about the reliability of speech and language therapists' judgement of the oesophageal phase.

AIM

To measure the inter-rater reliability of oesophageal abnormality judgement in speech and language therapists during upright videofluoroscopy.

METHODS & PROCEDURES

Seventy-four speech and language therapists were trained in oesophageal physiology and oesophageal visualization. Participants were asked to provide a rating of bolus transit (> or <15 s) for 10 segments of videofluoroscopy with oesophageal visualization showing ingestion of one 20 ml fluid barium bolus. Participants then provided a binary judgement of (1) the presence of stasis, (2) the presence of redirection and (3) the need for referral for further investigation. If stasis were present, they then rated the level of stasis as cervical, aortic or thoracic.

OUTCOMES & RESULTS

Participants achieved substantial agreement for bolus transit time, presence of stasis, presence of redirection and need for referral (K = 1.0.63.63 and .61 respectively). The level of stasis achieved only fair agreement (K = .22) with disagreement primarily between aortic, thoracic or aortic/thoracic across clinicians.

CONCLUSIONS & IMPLICATIONS

Speech and language therapists demonstrated substantial agreement in judging oesophageal abnormality during videofluoroscopy. Oesophageal screening as an adjunct to videofluoroscopy can be used reliably in trained clinicians.

Swallowing difficulties with medication intake assessed with a novel self-report questionnaire in patients with systemic sclerosis - a cross-sectional population study

OBJECTIVES

To assess subjective swallowing difficulties (SD) with medication intake and their practical consequences in patients suffering from systemic sclerosis (SSc) with a novel self-report questionnaire.

DESIGN AND SETTING

Based on a systematic literature review, we developed a self-report questionnaire and got it approved by an expert panel. Subsequently, we sent the questionnaire by post mail to SSc patients of the European Center for the Rehabilitation of Scleroderma Rheinfelden, Switzerland.

PARTICIPANTS

Patients were eligible if they were diagnosed with SSc, treated at the center, and were of age ≥18 years at the study start.

MAIN OUTCOME MEASURES

Prevalence and pattern of SD with oral medication intake, including localization and intensity of complaints.

RESULTS

The questionnaire consisted of 30 items divided into five sections Complaints, Intensity, Localization, Coping strategies, and Adherence. Of the 64 SSc patients eligible in 2014, 43 (67%) returned the questionnaire. Twenty patients reported SD with medication intake (prevalence 47%), either currently (11; 26%) or in the past that had been overcome (9; 21%). Self-reported SD were localized mostly in the larynx (43%) and esophagus (34%). They were of moderate (45%) or strong to unbearable intensity (25%). Modification of the dosage form was reported in 40% of cases with SD. Adherence was poor for 20 (47%) patients and was not associated with SD (p=0.148).

CONCLUSION

Our novel self-report questionnaire is able to assess the pattern of complaints linked to medication intake, that is, localization and intensity. It may serve as a guide for health care professionals in selecting the most suitable therapy option, enabling tailored counseling to reduce inappropriate medication modifications.

Comparison of videofluoroscopy and impedance planimetry for the evaluation of oesophageal stenosis: a retrospective study

Objectives

To compare videofluoroscopy that included a tablet test with impedance planimetry (EndoFLIP^®) for the evaluation of oesophageal stenosis in patients with dysphagia.

Methods

In 56 patients, videofluoroscopic examinations following the transit of a 14-mm tablet were retrospectively reviewed and correlated with impedance planimetry findings, a catheter-based method using impedance planimetry to display the oesophageal diameter estimates. Additional findings assessed were the occurrence of symptoms during tablet passage and evaluation of oesophageal motility.

Results

Impaction of the tablet occurred in 31/56 patients; nine showed a moderate delay (2–15 s), three a short delay (<2 s) and 13 no delay of tablet passage. Both methods showed a significant correlation between tablet impaction and oesophageal diameter <15.1 mm, as measured by impedance planimetry (p = 0.035). The feeling of the tablet getting stuck was reported by seven patients, six showing impaction of the tablet (four with an EndoFLIP-diameter < 13 mm, two with a diameter of 13–19 mm) and one showing delayed passage (EndoFLIP diameter of 17 mm).

Conclusions

Videofluoroscopy and impedance planimetry correlate significantly regarding tablet impaction and residual oesophageal lumen. A standardized 14-mm tablet is helpful in demonstrating oesophageal strictures in dysphagic patients. Triggering of subjective symptoms provides valuable information during a videofluoroscopic study.

Key Points

• A 14-mm tablet can demonstrate oesophagogastric junction narrowing in patients with dysphagia.

• Type of passage of a tablet enables estimation of oesophageal luminal diameter.

• Videofluoroscopy and impedance planimetry correlate significantly regarding tablet impaction and residual oesophageal lumen.

Abdominal compression during endoscopy (the Bolster technique) demonstrates hidden Schatzki rings (with videos)

BACKGROUND AND AIMS

Schatzki rings are found in the distal esophagus, are associated with hiatal hernias, and present with intermittent dysphagia to solid foods. They can be identified by radiology (GI series or barium swallow studies) or endoscopy. Rings are not always visualized during endoscopy in patients in whom they are suspected clinically. The Bolster technique involves application of epigastric abdominal pressure, which offers the potential to reveal a Schatzki ring that is otherwise obscured within a reduced hiatal hernia. The aim of this study was to determine whether the Bolster technique improves endoscopic detection of Schatzki rings.

METHODS

We reviewed 30 symptomatic patients with a history of a Schatzki ring in a tertiary care center. The Bolster technique was applied to patients in whom the ring was not visible during standard endoscopy. The main outcome measurement was identification of the Schatzki ring after the Bolster technique.

RESULTS

A Schatzki ring was visible during standard endoscopy in 26 of the 30 patients. In the remaining 4, the ring was visible only after the application of the Bolster technique.

CONCLUSION

The Bolster technique is a simple maneuver that can increase detection rates of Schatzki rings during endoscopy.

Approach to the patient with dysphagia

Dysphagia is a fascinating symptom. It is ostensibly simple when defined by trouble swallowing, yet its subtleties in deciphering and its variations in pathophysiology almost mandate a thorough knowledge of medicine itself. With patience and careful questioning, a multitude of various disorders may be suggested before an objective test is performed. Indeed, the ability to diligently and comprehensively explore the symptom of dysphagia is not only rewarding but also a real test for a physician who prides himself or herself on good history taking.

Videofluoroscopic swallowing study: esophageal alterations in patients with dysphagia

CONTEXT

Videofluoroscopic swallowing study is a dynamic exam and allows the evaluation of the complete swallowing process. However, most published studies have only reported alterations in the oropharynx and pharyngoesophageal transition, leaving the analysis of the esophagus as a secondary goal.

OBJECTIVES

The goal of this study was to investigate the prevalence of alterations in the esophageal phase thorough videofluoroscopic swallowing study in patients with dysphagia.

METHODS

Consecutive patients with dysphagia who underwent videofluoroscopic swallowing study including esophageal analysis between May 2010 and May 2012 had their exams retrospectively reviewed. Patients were classified into two groups: Group I - without a pre-established etiological diagnosis and Group II - with neurological disease. During the exam, the patients ingested three different consistencies of food (liquid, pasty and solid) contrasted with barium sulfate and 19 items were analyzed according to a protocol. The esophageal phase was considered abnormal when one of the evaluated items was compromised.

RESULTS

Three hundred and thirty-three (n = 333) consecutive patients were studied - 213 (64%) in Group I and 120 (36%) in Group II. Esophageal alterations were found in 104 (31%) patients, with a higher prevalence in Group I (36.2%), especially on the items esophageal clearance (16.9%) and tertiary contractions (16.4%). It was observed that 12% of individuals in Group I only presented alterations on the esophageal phase.

CONCLUSION

Evaluation of the esophageal phase of swallowing during videofluoroscopic swallowing study detects abnormalities in patients with cervical dysphagia, especially in the group without pre-established etiological diagnosis.

Esophageal Visualization as an Adjunct to the Videofluoroscopic Study of Swallowing

Objective

Complaints of dysphagia for solids lead to speech-language pathology (SLP) referral. Yet many of these patients are later diagnosed with esophageal rather than oropharyngeal dysphagia. Fluoroscopic screening involving the oropharynx alone fails to identify these patients. The aim of this study was to investigate the prevalence of esophageal abnormalities in an SLP-led videofluoroscopic study of swallowing (VFSS) clinic.

Study Design

Prospective, observational study.

Setting

Radiology suite, public hospital.

Subjects and Methods

In total, 111 consecutive mixed-etiology patients referred to the clinic by otorhinolaryngology (ORL) (59) or by a speech-language pathologist (52) were recruited. A VFSS was performed according to protocol, and at completion, esophageal visualization (in anterior-posterior plane) was performed by administration of a large liquid barium bolus and a barium capsule. All VFSS recordings were analyzed using objective digital measures of timing and displacement.

Results

Sixty-eight percent of patients had an abnormal esophageal transit. One-third of those referred presented exclusively with esophageal abnormalities, while one-third had both oropharyngeal and esophageal abnormalities. Oral abnormalities, reduced pharyngoesophageal segment maximum opening (PESmax), and increasing age were significantly associated with esophageal abnormalities.

Conclusion

Fluoroscopic evaluation of the pharynx alone, without esophageal review, risks incomplete diagnosis of patients with esophageal disorders. Using esophageal visualization allows timely referral for further investigation by appropriate medical specialties, avoiding incomplete management of patients with dysphagia.

Barium esophagram: does it have a role in gastroesophageal reflux disease?

The barium esophagram is an integral part of the assessment and management of patients with gastroesophageal reflux disease (GERD) before, and especially after, antireflux procedures. While many of the findings on the examination can be identified with endosocopy, a gastric emptying study and an esophageal motility examination, the barium esophagram is better at demonstrating the anatomic findings after anti-reflux surgery, especially in symptomatic patients. These complementary examinations, when taken as a whole, fully evaluate a patient with suspected GERD as well as symptomatic patients after antireflux procedures.

Neurogenic [corrected] and oropharyngeal dysphagia

Oropharyngeal dysphagia (OD) is a swallowing disorder caused by congenital abnormalities and structural damage and disease-associated damage of the oral cavity, pharynx, and upper esophageal sphincter. Patients with OD lack the protective mechanisms necessary for effective swallowing, exhibiting difficulty controlling food in the mouth and initiating a swallow, leading to choking, coughing, and nasal regurgitation. OD is a major risk factor for malnutrition, dehydration, and aspiration pneumonia. The following on OD includes commentaries on the application of simulation of oropharyngeal transient receptor potential vanilloid 1 (TRPV1) and maneuvers like the Shaker exercise to improve the safety and efficacy of swallow in OD patients; the prevalence of esophageal pathologies in OD patients and the need to evaluate the esophagus, esophagogastric junction, and stomach; and strategies for clinical screening to detect OD and aspiration among high-risk patients and to improve oral health care, maintain nutrition and hydration, and prevent aspiration pneumonia.

Schatzki ring in pediatric and young adult patients

BACKGROUND

A Schatzki ring (SR) is an uncommon finding in children. Entities previously associated with an SR include gastroesophageal reflux (GER), hiatal hernia (HH) and eosinophilic esophagitis (EE).

OBJECTIVE

The purpose of this study was to evaluate the overall incidence of SR and the frequency of the different entities associated with SR in the pediatric population.

MATERIALS AND METHODS

All radiology reports finalized between January 2000 and December 2009 were queried to identify patients with an SR. Each study identified through the search was reviewed to confirm the presence of a SR. The patient's electronic medical record was then searched to identify all associated findings.

RESULTS

A total of 18,668 upper gastrointestinal (GI) examinations or esophagrams were performed in 15,410 children and young adults during the study period. After reviewing the reports and images, 25 patients (0.2% of all patients) were confirmed to have a SR. Of these 24 patients (96%) had HH; 10/25 (40%) had EE, and 10/25 (40%) had GER.

CONCLUSION

SR is a rare diagnosis in children. Three entities are commonly associated with a ring: HH, EE and GER. Because of the relatively high incidence of EE, endoscopy and biopsy should be considered whenever a SR is identified in a child.

Oropharyngeal and Esophageal Swallowing Impairments: Their Association and the Predictive Value of the Modified Barium Swallow Impairment Profile and Combined Multichannel Intraluminal Impedance—Esophageal Manometry

Objectives:

Deglutition is a highly integrated process of neural signaling and coordinated muscular contraction that begins with bolus preparation in the oral cavity and ends with closure of the lower esophageal sphincter after bolus passage. The goal of this study was to examine the relationship between measures of oropharyngeal and esophageal swallow function.

Methods:

A retrospective review was performed of patients who underwent modified barium swallow study (MBSS) and multichannel intraluminal impedance–esophageal manometry (MII-EM) over 7 years at an academic institution. The MBSS was scored with the Modified Barium Swallow Impairment Profile (MBSImP). Associations between impairments as measured by the MBSImP and MII-EM were assessed with a 2-sided Fisher's exact test.

Results:

One hundred sixty-four patients met the inclusion criteria for the study. Comparison of MBSImPcomponent and oral and pharyngeal total regional scores to MII-EM scores revealed a significant association between abnormal esophageal clearance on MBSS (MBSImP component 17) and abnormal findings on MII-EM (p < 0.001). Delay in initiation of pharyngeal swallow (MBSImPcomponent 6) was significantly associated with abnormal esophageal clearance on MBSS (p = 0.023).

Conclusions:

Abnormal esophageal clearance on MBSS (MBSImP component 17) indicates a need for further esophageal testing. A functional interrelationship between abnormalities of oropharyngeal and esophageal swallowing does exist, illuminating the importance of thorough pharyngoesophageal examination for dysphagia symptoms.

Gastroesophageal reflux disease: integrating the barium esophagram before and after antireflux surgery

Gastroesophageal reflux disease (GERD) is a common medical problem in the United States. As a result, laparoscopic antireflux surgery is a common surgical procedure. At the authors' institution, the barium esophagram before and after antireflux surgery is a critical examination in patients with GERD. This article summarizes the authors' examination protocol and describes how the findings are integrated in the care of these patients.

Schatzki's ring: a benign cause of dysphagia in adults

The lower esophageal mucosal ring, or Schatzki's ring, was first described by Templeton. Anatomically, it represents the lower end of the esophagus. Patients classically present with intermittent dysphagia to solids. Diagnosis is made by endoscopy or a barium esophagram. Gastroesophageal reflux disease has been suggested as an etiology. It can usually be treated by passing a large dilator. Further controlled studies are needed to study its cause.

Radiologic evaluation of the esophagus: methods and value in motility disorders and GERD

The barium esophagram is an essential component in the workup of a patient with dysphagia and gastroesophageal reflux disease, especially when considering antireflux surgery or after such surgery. The examination requires a flexible approach with an emphasis on the motility portion of the examination. When properly performed, the examination should identify the following: normal or impaired esophageal emptying; normal or abnormal motility; the presence and type of hiatal hernia; the presence of a distal stricture or mucosal ring; and in many instances, the presence of gastroesophageal reflux. In patients after antireflux surgery, the examination should identify the following: normal of impaired esophageal emptying; normal or abnormal motility; the location, tightness, and length of the fundoplication; the presence of a recurrent hernia; and the presence of gastroesophageal reflux.

Peptic strictures of the esophagus

Peptic esophageal strictures occur in the context of inadequately treated gastroesophageal reflux, especially in elderly patients. Studies show more pronounced abnormalities of esophageal function resulting in an increased number of prolonged reflux episodes. The diagnosis is best made by a combination of barium esophagram and endoscopy. Patients usually require esophageal dilation to relieve dysphagia followed by adequate medical therapy. Proton pump inhibitors are effective for preventing the recurrence of strictures after dilation. In young patients and patients with strictures that are difficult to dilate or need frequent dilations, surgery may be required; however, results can be disappointing.

AGA technical review on treatment of patients with dysphagia caused by benign disorders of the distal esophagus

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the committee on September 27, 1998.