Reflux symptoms and oesophageal acidification in treated achalasia patients are often not reflux related

OBJECTIVE

After treatment, achalasia patients often develop reflux symptoms. Aim of this case-control study was to investigate mechanisms underlying reflux symptoms in treated achalasia patients by analysing oesophageal function, acidification patterns and symptom perception.

DESIGN

Forty treated achalasia patients (mean age 52.9 years; 27 (68%) men) were included, 20 patients with reflux symptoms (RS+; Gastro-Oesophageal Reflux Disease Questionnaire (GORDQ) ≥8) and 20 without reflux symptoms (RS-: GORDQ <8). Patients underwent measurements of oesophagogastric junction distensibility, high-resolution manometry, timed barium oesophagogram, 24 hours pH-impedance monitoring off acid-suppression and oesophageal perception for acid perfusion and distension. Presence of oesophagitis was assessed endoscopically.

RESULTS

Total acid exposure time during 24 hours pH-impedance was not significantly different between patients with (RS+) and without (RS-) reflux symptoms. In RS+ patients, acid fermentation was higher than in RS- patients (RS+: mean 6.6% (95% CI 2.96% to 10.2%) vs RS-: 1.8% (95% CI -0.45% to 4.1%, p=0.03) as well as acid reflux with delayed clearance (RS+: 6% (95% CI 0.94% to 11%) vs RS-: 3.4% (95% CI -0.34% to 7.18%), p=0.051). Reflux symptoms were not related to acid in both groups, reflected by a low Symptom Index. RS+ patients were highly hypersensitive to acid, with a much shorter time to heartburn perception (RS+: 4 (2-6) vs RS-:30 (14-30) min, p<0.001) and a much higher symptom intensity (RS+: 7 (4.8-9) vs RS-: 0.5 (0-4.5) Visual Analogue Scale, p<0.001) during acid perfusion. They also had a lower threshold for mechanical stimulation.

CONCLUSION

Reflux symptoms in treated achalasia are rarely caused by gastro-oesophageal reflux and most instances of oesophageal acidification are not reflux related. Instead, achalasia patients with post-treatment reflux symptoms demonstrate oesophageal hypersensitivity to chemical and mechanical stimuli, which may determine symptom generation.

Reflux and Belching after Laparoscopic 270 degree Posterior Versus 180 degree Anterior Partial Fundoplication

BACKGROUND

Laparoscopic 270 degree posterior, or Toupet (LTF), and 180 degree anterior partial fundoplication (LAF) ensure equal reflux control and reduce the risk of gas-related symptoms compared to 360 degree (Nissen) fundoplication. It is unclear which type of partial fundoplication is superior in preventing gas-related side-effects. The aim of this study was to determine differences in effect of LTF and LAF on reflux characteristics and belching patterns.

METHODS

Upper gastrointestinal endoscopy, esophageal manometry, and 24-h combined pH-impedance monitoring were performed before and 6 months after fundoplication (n = 10, LTF vs. n = 10, LAF). Observed changes after surgery (∆) were compared between the two procedures.

RESULTS

Symptomatic reflux control as well as the reduction in the mean number of acid (∆ - 58.5 vs. - 66.5; P = 0.912), liquid (∆ - 17.0 vs. - 43.5; P = 0.247), and mixed liquid gas reflux episodes (∆ - 38.0 vs. - 40.0; P = 0.579) were comparable following LTF and LAF. There were no differences in the mean number of weakly acidic reflux episodes after LTF and LAF (1.0 (0.8-4) vs. 1.0 (0-3), P = 0.436). The reduction in proximal (P = 1.000), mid-esophageal (P = 0.063), and distal reflux episodes (P = 0.315) was comparable. Both procedures equally reduced the number of gastric belches (P = 0.278) and supragastric belches (P = 0.123), with no significant reduction in the number of air swallows after either procedure (P = 0.278).

CONCLUSION

LTF and LAF provide similar reflux control, with a comparable effect on acidic, liquid, and gas reflux. Both procedures equally reduced the number of belches and supragastric belches. This study provides the physiological evidence for the published randomized trials reporting similar symptomatic outcome after both types of partial fundoplication.

Rapid drinking challenge during high-resolution manometry is complementary to timed barium esophagogram for diagnosis and follow-up of achalasia

BACKGROUND

Esophageal stasis is a hallmark of achalasia. Timed barium esophagogram (TBE) is used to measure stasis but exposes patients to ionizing radiation. It is suggested that esophageal stasis can be objectified on high-resolution manometry (HRM) as well using a rapid drinking challenge test (RDC). We aimed to assess esophageal stasis in achalasia by a RDC during HRM and compare this to TBE.

METHODS

Thirty healthy subjects (15 male, age 40 [IQR 34-49]) and 90 achalasia patients (53 male, age 47 [36-59], 30 untreated/30 treated symptomatic/30 treated asymptomatic) were prospectively included to undergo HRM with RDC and TBE. RDC was performed by drinking 200 mL of water. Response to RDC was measured by basal and relaxation pressure in the esophagogastric junction (EGJ) and esophageal pressurization during the last 5 seconds.

KEY RESULTS

EGJ basal and relaxation pressure during RDC were higher in achalasia compared to healthy subjects (overall P < .01). Esophageal body pressurization was significantly higher in untreated (43 [33-35 mm Hg]) and symptomatic treated patients (25 [16-32] mm Hg) compared to healthy subjects (6 [3-7] mm Hg) and asymptomatic treated patients (11 [8-15] mm Hg, overall P < .01). A strong correlation was observed between esophageal pressurization during RDC and barium column height at 5 minutes on TBE (r = .75, P < .01), comparable to the standard predictor of esophageal stasis, IRP (r = .66, P < .01).

CONCLUSIONS & INFERENCES

The RDC can reliably predict esophageal stasis in achalasia and adequately measure treatment response to a degree comparable to TBE. We propose to add this simple test to each HRM study in achalasia patients.

Objectively diagnosing rumination syndrome in children using esophageal pH-impedance and manometry

BACKGROUND

Rumination syndrome is characterized by recurrent regurgitation of recently ingested food into the mouth. Differentiation with other diagnoses and gastroesophageal reflux disease (GERD) in particular, is difficult. Recently, objective pH-impedance (pH-MII) and manometry criteria were proposed for adults. The aim of this study was to determine diagnostic ambulatory pH-MII and manometry criteria for rumination syndrome in children.

METHODS

Clinical data and 24-hour pH-MII and manometry recordings of children with a clinical suspicion of rumination syndrome were reviewed. Recordings were analyzed for retrograde bolus flow extending into the proximal esophagus. Peak gastric and intraesophageal pressures closely related to these events were recorded and checked for a pattern compatible with rumination. Events were classified into primary, secondary, and supragastric belch-associated rumination.

KEY RESULTS

Twenty-five consecutive patients (11 males, median age 13.3 years [IQR 5.9-15.8]) were included; recordings of 18 patients were suitable for analysis. Rumination events were identified in 16/18 patients, with 50% of events occurring <30 minutes postprandially. Fifteen of 16 patients showed ≥1 gastric pressure peak >30 mmHg, while only 50% of all events was characterized by peaks >30 mmHg and an additional 20% by peaks >25 mmHg. Four patients had evidence of acid GERD, all showing secondary rumination.

CONCLUSIONS AND INFERENCES

Combined 24-hour pH-MII and manometry can be used to diagnose rumination syndrome in children and to distinguish it from GERD. Rumination patterns in children are similar compared with adults, albeit with lower gastric pressure increase. We propose a diagnostic cutoff for gastric pressure increase >25 mmHg associated with retrograde bolus flow into the proximal esophagus.

Diagnostic yield of 24-hour esophageal manometry in non-cardiac chest pain

BACKGROUND

In the past, ambulatory 24-h manometry has been shown useful for the evaluation of patients with non-cardiac chest pain (NCCP). With the diagnostic improvements brought by pH-impedance monitoring and high-resolution manometry (HRM), the contribution of ambulatory 24-h manometry to the diagnosis of esophageal hypertensive disorders has become uncertain. Our aim was to assess the additional diagnostic yield of ambulatory manometry to HRM and ambulatory pH-impedance monitoring in this patient population.

METHODS

All patients underwent 24-h ambulatory pressure-pH-impedance monitoring and HRM. Patients had retrosternal pain as a predominant symptom and no explanation after cardiologic and digestive endoscopic evaluations. Diagnostic measurements were analyzed by two independent physicians.

KEY RESULTS

Fifty-nine patients met the inclusion criteria; 37.3% of the patients had their symptoms explained by abnormalities on pH-impedance monitoring and 6.8% by ambulatory manometry. Functional chest pain was diagnosed in 52.5% of the patients. High-resolution manometry, using the Chicago Classification v3.0 criteria alone, did not identify any of the four patients with esophageal spasm on ambulatory manometry. However, taking into account other abnormalities, such as simultaneous (rapid) or repetitive contractions, HRM had a sensitivity of 75% and a specificity of 98.2% for the diagnosis of esophageal spasm.

CONCLUSIONS & INFERENCES

In the work-up of NCCP, ambulatory 24-h manometry has a low additional diagnostic yield. However, it remains the best technique to identify esophageal spasm as the cause of symptoms. This is particularly useful when an unequivocal diagnosis is needed before treatment.

Effect of Running on Gastroesophageal Reflux and Reflux Mechanisms

OBJECTIVES

Reflux symptoms are common among athletes and can have a negative impact on athletic performance. At present, the mechanisms underlying excess reflux during exercise are still poorly understood. The aim of this study was to investigate the effect of exercise on reflux severity and examine the underlying reflux mechanisms.

METHODS

Healthy sporty volunteers were studied using both high-resolution manometry and pH-impedance monitoring. After a meal and a rest period, subjects ran on a treadmill for 30 min at 60% of maximum heart rate, followed by a short rest period and another 20-min period of running at 85% of maximum heart rate.

RESULTS

Ten healthy volunteers were included. Exercise led to a significantly higher percentage of time with an esophageal pH<4 and a higher frequency and duration of reflux episodes. Moreover, exercise resulted in a decrease in contractility and duration of peristaltic contractions. The minimal lower esophageal sphincter resting pressure decreased during exercise, whereas the average and maximum abdominal pressure both increased. Importantly, the percentage of transient lower esophageal sphincter relaxations (TLESRs) that resulted in reflux significantly increased during exercise and all but one reflux episode occurred during TLESRs. In six subjects a hiatus hernia was detected during the exercise period but not during rest.

CONCLUSIONS

Running induces gastroesophageal reflux almost exclusively through TLESRs. These are not more frequent during exercise but are more often associated with a reflux episode, possibly due to increased abdominal pressure, body movement, a change in esophagogastric junction morphology, and a decreased esophageal clearance during exercise.

Distal esophageal spasm and the Chicago classification: is timing everything?

BACKGROUND

According to the Chicago classification of esophageal motility disorders, distal esophageal spasm (DES) is defined as premature esophageal contractions (distal latency [DL] <4.5 s) for ≥20% of swallows, in the presence of a normal mean integral relaxation pressure (IRP). However, some patients with symptoms of DES have rapid contractions with a normal DL. The aim of this study was to characterize these patients and compare their clinical characteristics to those of patients classified as DES.

METHODS

We retrospectively compared clinical characteristics and high-resolution manometry findings of patients with rapid contractions with normal latency to those meeting the Chicago classification criteria for DES.

KEY RESULTS

Over a 3-year period, nine patients were diagnosed with DES and 14 showed rapid contractions in the distal esophagus with normal latency. The latter were younger than DES patients (60 ± 4 vs 72 ± 3 years, p < 0.05). Dysphagia and retrosternal pain occurred to a similar degree in both groups. Weight loss and abnormal barium esophagogram tended to be more frequent in DES patients. There was no difference in contractile front velocity (CFV) and in distal contractile integral (DCI) between patients with DES and rapid contractions with normal latency. Lower esophageal sphincter pressures were not different between groups. However, IRP was significantly higher in DES compared to rapid contractions with normal latency (11.7 ± 0.6 mmHg vs 7.6 ± 1.2 mmHg, p < 0.05), albeit still within the normal range.

CONCLUSIONS & INFERENCES

These data suggest that patients with simultaneous contractions with normal latency represent a group of patients with many features similar to DES.

Normal values of esophageal motility after antireflux surgery; a study using high-resolution manometry

BACKGROUND

Fundoplication is an effective therapy for gastroesophageal reflux disease (GERD), but can be complicated by postoperative dysphagia. High-resolution manometry (HRM) can assess esophageal function, but normal values after fundoplication are lacking. Our aim was to obtain normal values for HRM after successful Toupet and Nissen fundoplication.

METHODS

Esophageal HRM was performed 3 months after Toupet or Nissen fundoplication in 40 GERD patients without postoperative dysphagia and with a normal barium esophagogram. Normal values for all measures of the Chicago classification were calculated as 5th and 95th percentile ranges.

KEY RESULTS

The normal values (5th-95th percentiles) for integrated relaxation pressure (IRP) were higher after Nissen (5.1-24.4 mmHg) than after Toupet fundoplication (3.1-15.0 mmHg), and upper limit of normal was significantly higher after Nissen fundoplication than observed in the asymptomatic subjects that were described in the Chicago Classification. Distal contractile integral was significantly higher after Nissen (357-4947 mmHg*s*cm) than after Toupet (68-2177 mmHg*s*cm), and transition zone length was significantly shorter after Nissen (0-4.8 cm) than after Toupet fundoplication (0-12.8 cm).

CONCLUSIONS & INFERENCES

HRM metrics for subjects after a Toupet fundoplication are similar to the normal values derived from healthy subjects used for the Chicago classification. However, after Nissen fundoplication a higher esophagogastric junction resting pressure and higher IRP are observed in asymptomatic subjects and this can be considered normal in the postoperative state. In addition, more vigorous contractions and less and smaller peristaltic breaks are normal after Nissen fundoplication.

Prucalopride decreases esophageal acid exposure and accelerates gastric emptying in healthy subjects

BACKGROUND

The 5-HT4 receptor agonist prucalopride is a prokinetic drug which improves colonic motility. Animal data and in vitro studies suggest that prucalopride also affects gastric and esophageal motor function. We aimed to assess the effect of prucalopride on gastric emptying, esophageal motility, and gastro-esophageal reflux in man.

METHODS

In this double-blind, placebo-controlled, randomized, crossover study, we included 21 healthy volunteers who received 4 mg prucalopride or placebo per day for 6 days. We performed high-resolution manometry (HRM) followed by 120-min HRM-pH-impedance monitoring after a standardized meal, ambulatory 24-h pH-impedance monitoring, and gastric emptying for solids.

KEY RESULTS

Prucalopride decreased (median [IQR]) total acid exposure time (3.4 [2.5-5.6] vs 1.7 [0.8-3.5] %, p < 0.05). The total number of reflux events was unaffected by prucalopride, however, the number of reflux events extending to the proximal esophagus was reduced by prucalopride (15.5 [9.8-25.5] vs 10.5 [5.3-17.5], p < 0.05). Furthermore, prucalopride improved acid clearance time (77.5 [47.8-108.8] vs 44.0 [30.0-67.8] s, p < 0.05). Prucalopride did not affect the number of transient lower esophageal sphincter (LES) relaxations or their association with reflux events. Esophageal motility and basal pressure of the LES were not affected by prucalopride. Prucalopride increased gastric emptying (T1/2 ; 32.7 [27.9-44.6] vs 49.8 [37.7-55.0] min, p < 0.05) and decreased residue after 120 min (8.8 [4.4-14.8] vs 2.7 [1.3-5.4] %, p < 0.05).

CONCLUSIONS & INFERENCES

Prucalopride reduces esophageal acid exposure and accelerates gastric emptying in healthy male volunteers. These findings suggest that the drug could be effective for treatment of patients with reflux disease and functional dyspepsia.

Impact of spatial resolution on results of esophageal high-resolution manometry

BACKGROUND

The Chicago classification for esophageal motility disorders was designed for a 36-channel manometry system with sensors spaced at 1 cm. However, many motility laboratories outside the USA use catheters with a lower resolution in the segments outside the esophagogastric junction. Our aim was to investigate the effect of spatial resolution on the Chicago metrics and diagnosis.

METHODS

In 20 healthy volunteers and 47 patients with upper gastrointestinal symptoms, high-resolution manometric studies of the esophagus were retrospectively reanalyzed using the original 1-cm spacing in the segments outside the 7-cm esophagogastric junction segment, and again after manually increasing the spacing between sensors to 2, 3, and 4 cm (above the lower esophageal sphincter region). Measurements were analyzed in random order and the investigator was blinded to the outcome of the analyses performed in another resolution of the same patient. Intra-class correlation coefficients (ICC) and Kappa values were determined.

KEY RESULTS

There was a very strong correlation between the 1-cm and 2-cm analysis for all Chicago metrics studied in healthy volunteers (ICCs: distal contractile integral 0.998; contractile front velocity (CFV) 0.964; distal latency 0.919; peristaltic break size 0.941). The 2-cm spacing analysis also correlated very well with the 1-cm analysis for the different Chicago diagnoses obtained in the patients (Kappa values ranging from 0.665 to 1.000). When the sensor spacing was increased to 3 and 4 cm, the correlation was reduced to moderate for the Chicago metrics, especially for break size and CFV of peristalsis.

CONCLUSIONS & INFERENCES

The Chicago classification for esophageal motility disorders is still valid and the same normal values can be used when catheters with a slightly lower resolution are used (i.e., 2-cm vs 1-cm spacing). For larger sensor intervals, the classification and the normal values will need to be adjusted.

The effect of endoscopic mucosal resection and transanal endoscopic microsurgery on anorectal function

AIM

The study assessed the impact on anorectal function of endoscopic mucosal resection (EMR) and transanal endoscopic microsurgery (TEM) of large rectal adenomas.

METHOD

Patients with a large (≥ 3 cm) rectal adenoma undergoing EMR or TEM were included. Self-reported faecal incontinence was assessed using the Colorectal Functional Outcome (COREFO) questionnaire and the Wexner Incontinence Grading Scale. Anorectal manometry was performed before and at 6 months after treatment to measure anal resting (ARP) and squeeze pressure (SP), squeeze endurance (SE), the rectoanal inhibitory reflex (RAIR), rectal volumetry of first sensation (FS), first urge (FU), maximum tolerable volume (MTV) and rectal compliance (RC).

RESULTS

Twenty-four patients were included in the study, of whom 11 underwent EMR and 13 underwent TEM. The mean adenoma size was 51 ± 19 mm and the median distance from the anal verge was 3 cm (interquartile range 1-10 cm). Follow-up data were available from 20 patients; one patient had died and three had undergone total mesorectal excision. Incontinence for liquid stool and Wexner score decreased significantly after treatment. In contrast, none of the measured parameters of anorectal motility (ARP, SP, SE, RAIR, RC) and perception (FS, FU, MTV) was affected by adenoma resection. No differences were found in baseline and follow-up incontinence and functional parameters between intervention groups, except for postprocedural ARP, which was lower after TEM than after EMR.

CONCLUSION

Continence in patients with a large rectal adenoma improved after EMR or TEM, probably due to decreased rectal mucus production. Anal sphincter pressure, rectoanal reflexes, rectal sensation and compliance were not affected by adenoma resection.