Irreversible Esophageal Motor Dysfunction in Postvagotomy Dysphagia

Postvagotomy dysphagia is typically a temporary phenomenon but a small subgroup of patients appear to develop irreversible motility disorders of the esophagus. Two patients are reported with persistent symptomatic esophageal dysfunction demonstrated by modern hydraulic infusion technics. Both intially lost weight rapidly and then stabilized. The distal esophagus of both was greatly dilated but in one patient, lower esophageal sphincter pressure was normal. Aperistalsis with diminished motor activity was present throughout the body of the esophagus. Dysphagia and objective esophageal abnormalities were refractory to dilations with simple mercury bougies in one patient whose condition was improved by treatment with pneumatic dilation. The cause of this unusual complication is unknown but may involve a nonneoplastic form of secondary achalasia.     

High-Resolution Esophageal Manometry with ECG Monitoring for Management of Premature Ventricular Complexes-Associated Dysphagia

We report a novel technique for diagnosing a new cause of esophageal dysphagia in a patient without organic heart and esophageal disease. A coincidence between intermittent esophageal dysphagia and cardiac arrhythmia, frequent premature ventricular complexes (PVC) were confirmed by clinical observation, simultaneous ECG monitoring, and motility study. High-resolution esophageal manometry (HRM) revealed abnormal peristaltic waves only during frequent PVC. Abnormal peristaltic waves and PVC disappeared simultaneously and completely within 15 min after intravenous infusion of antiarrhythmic agent (140 mg propafenone). Oral treatment with antiarrhythmic drugs was not tolerated or ineffective. Complete remission of PVC and dysphagia was achieved immediately after radiofrequency catheter ablation of arrhythmogenic focus located in the right ventricular outflow tract. This case demonstrates a new technique for the management of a syndrome called “PVC-associated dysphagia” that can be mediated by cardioesophageal reflex. Interdisciplinary cooperation and simultaneous HRM with ECG monitoring may confirm the diagnosis and guide effective treatment.     

非梗阻性食管源性吞咽困难患者食管测压结果分析

背景:食管源性吞咽困难的病因可分为机械性梗阻和动力障碍两类。目前关于致吞咽困难的食管动力障碍类型的研究相对较少。目的:分析非梗阻性食管源性吞咽困难患者的食管测压结果,探讨引起吞咽困难症状的常见食管动力障碍类型。方法:纳入2007年1月～2012年6月西安交通大学医学院第二附属医院50例以吞咽困难为主诉而行食管测压者,对其测压结果进行分析。入组患者通过病史询问、内镜或食管钡透检查等除外非食管源性和梗阻性吞咽困难。结果:36例(72.0%)患者的食管动力障碍类型为非特异性食管动力障碍(NEMD),13例(26.0%)为贲门失弛缓症,1例(2.0%)食管测压结果正常。9例(18.0%)合并胃食管反流病者均为NEMD。NEMD和贲门失弛缓症患者的食管动力障碍均以食管体部运动功能紊乱和下食管括约肌功能异常为主。结论:本组非梗阻性食管源性吞咽困难患者的食管动力障碍类型多为NEMD,其次为贲门失弛缓症。非梗阻性食管源性吞咽困难患者的食管测压结果可能正常。     

Clinical Applications of Esophageal Impedance Monitoring and High-Resolution Manometry

Esophageal impedance monitoring and high-resolution manometry (HRM) are useful tools in the diagnostic work-up of patients with upper gastrointestinal complaints. Impedance monitoring increases the diagnostic yield for gastroesophageal reflux disease in adults and children and has become the gold standard in the diagnostic work-up of reflux symptoms. Its role in the work-up for belching disorders and rumination seems promising. HRM is superior to other diagnostic tools for the evaluation of achalasia and contributes to a more specific classification of esophageal disorders in patients with non-obstructive dysphagia. The role of HRM in patients with dysphagia after laparoscopic placement of an adjustable gastric band seems promising. Future studies will further determine the clinical implications of the new insights which have been acquired with these techniques. This review aims to describe the clinical applications of impedance monitoring and HRM.     

High-Resolution Manometry Thresholds and Motor Patterns Among Asymptomatic Individuals

ObjectiveHigh-resolution manometry (HRM) is the current standard for characterization of esophageal body and esophagogastric junction (EGJ) function. We aimed to examine the prevalence of abnormal esophageal motor patterns in health, and to determine optimal thresholds for software metrics across HRM systems.DesignManometry studies from asymptomatic adults were solicited from motility centers worldwide, and were manually analyzed using integrated relaxation pressure (IRP), distal latency (DL), and distal contractile integral (DCI) in standardized fashion. Normative thresholds were assessed using fifth and/or 95th percentile values. Chicago Classification v3.0 criteria were applied to determine motor patterns across HRM systems, study positions (upright vs supine), ages, and genders.ResultsOf 469 unique HRM studies (median age 28.0, range 18–79 years). 74.6% had a normal HRM pattern; none had achalasia. Ineffective esophageal motility (IEM) was the most frequent motor pattern identified (15.1% overall), followed by EGJ outflow obstruction (5.3%). Proportions with IEM were lower using stringent criteria (10.0%), especially in supine studies (7.1%–8.5%). Other motor patterns were rare (0.2%–4.1% overall) and did not vary by age or gender. DL thresholds were close to current norms across HRM systems, while IRP thresholds varied by HRM system and study position. Both fifth and 95th percentile DCI values were lower than current thresholds, both in upright and supine positions.ConclusionsMotor abnormalities are infrequent in healthy individuals and consist mainly of IEM, proportions of which are lower when using stringent criteria in the supine position. Thresholds for HRM metrics vary by HRM system and study position.     

Influence of Bolus Consistency and Position on Esophageal High-Resolution Manometry Findings

Background Conventional esophageal manometry evaluating liquid swallows in the recumbent position measures pressure changes at a limited number of sites and does not assess motility during solid swallows in the physiologic upright position. Aim To evaluate esophageal motility abnormalities during water and bread swallows in the upright and recumbent positions using high-resolution manometry (HRM). Methods Thirty-two-channel HRM testing was performed using water (10 ml each) and bread swallows in the upright and recumbent positions. The swallows were considered normal if the distal peristaltic segment >30 mmHg was >5 cm, ineffective if the 30-mmHg pressure band was <5 cm, and simultaneous if the onset velocity of the 30 mmHg pressure band was >8 cm/s. Abnormal esophageal manometry was defined as the presence of ≥30% ineffective and/or ≥20% simultaneous contractions. Results The data from 96 patients (48 F; mean age 51 years, range 17–79) evaluated for dysphagia (56%), chest pain (22%), and gastroesophageal reflux disease (GERD) symptoms (22%) were reviewed. During recumbent water swallows, patients with dysphagia, chest pain, and GERD had a similar prevalence of motility abnormalities. During upright bread swallows, motility abnormalities were more frequent (p = 0.01) in patients with chest pain (71%) and GERD (67%) compared to patients with dysphagia (37%). Conclusions Evaluating bread swallows in the upright position reveals differences in motility abnormalities overlooked by liquid swallows alone. This work was presented as an abstract at Digestive Disease Week (DDW) 2006, Los Angeles, CA, 20–25 May 2006.     

Rapid Drink Challenge During High-resolution Manometry for Evaluation of Esophageal Emptying in Treated Achalasia

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Healing of Severe Esophagitis Improves Esophageal Peristaltic Dysfunction

Reflux esophagitis is frequently associated withperistaltic dysfunction, which increases with theseverity of inflammatory lesions. In order to assessperistaltic dysfunction with more accuracy before and after healing, we used a 24-hr pH andpressure recording method. Nineteen patients (medianage: 65, range: 33-77) with stage II and III(Savary-Miller classification) esophagitis andperistaltic dysfunction were treated with 40 mg omeprazole for three tosix months until complete endoscopic healing wasachieved. Before treatment, median contraction amplitudewas significantly lower than median contraction amplitude of a control group of comparable age[31 (21-53) versus 42 (21-77) mm Hg, P < 0.01], aswell as median percentage of peristaltic contractions[27 (16-63) versus 44 (11-56), P < 0.01]. At the end of treatment, a statisticallysignificant improvement of esophageal motor functionswas observed for both median contraction amplitude [38(26-55), P = 0.001] and median percentage of peristaltic waves [45 (23-68), P = 0.0001]. Theposttreatment values, although still low, were notsignificantly different from control values. Inconclusion, complete healing of grade II and IIIesophagitis improves peristalsis. Inflammatory processes related tosevere esophagitis may be involved in failed peristalsisand low contraction amplitude.     

The Effect of Race in Patients with Achalasia Diagnosed With High-Resolution Esophageal Manometry

Background

The advent of the Chicago Classification for esophageal motility disorders allowed for clinically reproducible subgrouping of patients with achalasia based on manometric phenotype. However, there are limited data with regards to racial variation using high-resolution esophageal manometry (HREM). The aim of our study was to evaluate the racial differences in patients with achalasia diagnosed with HREM using the Chicago Classification. We evaluated the clinical presentation, treatment decisions and outcomes between blacks and non-blacks with achalasia to identify potential racial disparities.

Utility of Esophageal High-Resolution Manometry in Clinical Practice: First,Do HRM

Esophageal high-resolution manometry (HRM) has advanced the understanding of esophageal motor function and the ability to diagnose and manage disorders of esophageal motility. In this review, we describe the indications for and the technical performance of HRM. The Chicago classification of esophageal motor function, now in its third iteration, streamlines and standardizes the nomenclature and basic interpretation of HRM data depicted as Clouse topographic plots. In clinical practice, HRM is an important diagnostic test for patients with dysphagia as well as patients with suspected gastroesophageal reflux disease (GERD), particularly in those patients with a suboptimal symptomatic response to antisecretory therapy. HRM can support diagnoses such as achalasia, as well as provide evidence for behavioral disorders such as rumination syndrome or supragastric belching with the assistance of postprandial HRM with impedance. Further, the GERD classification of motor function introduces a three-part hierarchical evaluation of esophageal motor function in GERD, highlighting the value of assessment of esophageal contractile reserve through provocative maneuvers during HRM such as multiple rapid swallows.     

Evaluation of the Upper Esophageal Sphincter (UES) Using Simultaneous High-Resolution Endoluminal Sonography (HRES) and Manometry

The aim of this study was to characterize the motion, morphology, and pressure of the upper esophageal sphincter (UES). The UES and its surrounding structures were evaluated in seven normal subjects and four human cadavers, using simultaneous high-resolution endoluminal sonography and manometry. The UES musculature on ultrasound is a C-shaped structure with an angle of 107 +/- 19 degrees. The mean peak resting UES pressure was 74 mm Hg, with a total cross-sectional area (CSA) of 0.87 +/- 0.33 cm2. During swallowing, the UES moved in an orad direction. Localizing the UES sonographically, the peak UES pressure in the cadavers was 19.7 +/- 10.0 mm Hg. The UES has a greater muscular CSA and resting pressure than the upper esophageal body. In the cadaver studies, the UES was imaged in conjunction with a significant increase in pressure, indicating that the pressure is due to passive mechanical conformational changes.     

Regional Esophageal Dysfunction in Scleroderma and Achalasia using Multichannel Intraluminal Impedance and Manometry

Background Achalasia and scleroderma are esophageal motility abnormalities characterized by severely impaired bolus transit. Combined multichannel intraluminal impedance and manometry (MII-EM) enables the simultaneous measurement of intraesophageal pressures and bolus transit at various levels within the esophagus. Aim The aim of the study was to evaluate and characterize regional pressure and transit profile differences in scleroderma and achalasia patients. Methods A retrospective analysis was carried out of MII-EM studies of patients with scleroderma (15), achalasia (20), and poorly relaxing lower esophageal sphincter (LES) with normal esophageal body function (20) as a control group. Bolus presence and segmental transit were evaluated by MII. Results In patients with achalasia, bolus transit was impaired across all four sites compared with scleroderma (P < 0.0125) even though distal esophageal pressures were higher (P < 0.05) in patients with achalasia. Pressures in patients with achalasia were similar across all four sites (ANOVA; saline, P = 0.373; viscous, P = 0.615). Bolus clearance rates and contraction amplitudes in patients with scleroderma decreased from proximal to distal. In the control group, bolus clearance was complete during ≥83% of all swallows and esophageal pressure amplitudes increased distally. Conclusion While the overall bolus transit is impaired in both patients with achalasia and scleroderma regional pressure and bolus transit differences exist. Bolus transit abnormalities result from abnormal esophageal body contraction and not abnormal LES relaxation.     

Comparison of Air-Coupled Balloon Esophageal and Anorectal Manometry Catheters with Solid-State Esophageal Manometry and Water-Perfused Anorectal Manometry Catheters

Clinical gastrointestinal manometry studies are currently performed with multilumen water-perfused polyvinyl or strain gauge sensor solid-state catheters. A disposable catheter incorporating air-filled balloons has been developed with performance characteristics suitable for esophageal and anorectal manometry studies. Our aim was to compare esophageal and anorectal pressure measurements using this newly developed catheter with measurements obtained using standard solid-state or water-perfused catheters. Measurements of resting LES pressure, esophageal contraction amplitudes, and anorectal rest and squeeze pressures were obtained in 10 healthy volunteers using a solid-state esophageal catheter, a water-perfused anorectal catheter, and air-filled balloon esophageal and anorectal catheters. Correlation coefficient analysis demonstrated that LES pressures, esophageal contraction amplitudes, and anorectal resting and squeeze pressures were not significantly among between the different catheters. We conclude that recently developed air-filled balloon esophageal and anorectal manometry catheters provide very similar measurements of LES, esophageal body, and anorectal sphincter pressures compared to presently used manometry catheters.     

Reinterpretation of Follow-Up,High-Resolution Manometry for Esophageal Motility Disorders Based on the Updated Chicago Classification

The aim of this study was to assess changes between primary classification of esophageal motility disease and follow-up classification by high resolution manometry (HRM) and to determine whether previously classified diseases could be recategorized according to the updated Chicago Classification published in 2011. We reviewed individual medical records and HRM findings twice for each of 13 subjects. We analyzed primary and follow-up HRM findings based on the original Chicago Classification. We then reclassified the same HRM findings according to the updated Chicago Classification. This case series revealed the variable course of esophageal motility disorders; some patients experienced improvement, whereas others experienced worsening symptoms. Four cases were reclassified from variant achalasia to peristaltic abnormality, one case from diffuse esophageal spasm to type II achalasia and one case from peristaltic abnormality to variant achalasia. Four unclassified findings were recategorized as variant achalasia. In conclusion, esophageal motility disorders are variable and may not be best conceptualized as an independent group. Original classifications can be recategorized according to the updated Chicago Classification system. More research is needed on this topic.     

Esophageal High-Resolution Manometry for Diagnosing the Severity of the Chronic Intestinal Pseudo-Obstruction: A Case Series

Digestive Diseases and Sciences - Chronic intestinal pseudo-obstruction (CIPO) is a severe and refractory intestinal motility disorder. However, due to its rarity and difficult histological...     

Multiple Rapid Swallow Maneuver Enhances the Clinical Utility of High-Resolution Manometry in Patients Showing Ineffective Esophageal Motility

The clinical significance of ineffective esophageal motility (IEM) together with multiple rapid swallow (MRS) has not been yet evaluated in the Chicago Classification v3.0. This study evaluated the adjunctive role of MRS in IEM and determined the criteria of abnormal MRS to maximize the utility of IEM. We analyzed 186 patients showing IEM or normal esophageal motility (NEM), who underwent esophageal high-resolution impedance–manometry for esophageal symptoms. Two different criteria for abnormal MRS were applied to IEM subjects, resulting in 2 corresponding subgroups: IEM-A when distal contractile integral (DCI) ratio between an average wet swallows and MRS contraction was <1 and IEM-B when MRS contraction DCI was <450 mm Hg-s-cm. One IEM subject inadequately performed MRS. Among the remaining 52 IEM subjects, 18 (34.6%) were classified into IEM-A and 23 (44.2%) into IEM-B. IEM subjects showed less complete bolus transit (median 0.0%, interquartile range 0.0–20.0% vs 60.0%, 30.0–80.0; P < 0.001) resulting in higher impaired bolus transit than NEM subjects (98.1% vs 66.9%, P = 0.001). IEM-B subjects showed additionally higher pathologic bolus exposure than NEM subjects (55.6% vs 29.3%, P = 0.001), whereas IEM-A subjects could not. Although IEM-B subjects had the highest prevalence of gastroesophageal reflux disease among the subjects groups, it did not reach statistical significance. In conclusion, IEM patients with abnormal MRS contraction have an increased risk of prolonged bolus clearance, poor bolus transit, and pathologic bolus exposure. IEM patients need to be assessed concerning whether MRS contraction DCI is <450 mm Hg-s-cm to segregate clinically relevant patients.