393 7 Patterns of Esophageal Motility Disorders Detected by Multiple Rapid Swallows

Abstract

INTRODUCTION: High resolution manometry (HRM) has improved the ability to detect esophageal motility abnormalities. In conjunction with HRM, the Chicago Classification has been widely used to classify these disorders. Provocative tests, such as multiple rapid swallows, are used as a preoperative assessment for GERD and hiatal hernia. Our study assesses the utility of MRS beyond its use as a preoperative assessment. METHODS: After completion of the standard protocol, patients perform multiple rapid swallows under the instruction and supervision of a trained RN. MRS consists of a series of rapid 2-mL swallows at 2-3 second intervals. Patient repeats MRS with the goal of 3-4 MRS. RESULTS: In this cohort, we had a total of 90 patient: 3 patients were excluded from MRS due to high suspicion of achalasia. 5 patients did not complete MRS protocol. 2 cases only tolerated 1 MRS. MRS aided in the diagnosis of 16 patients, with a diagnostic utility of 20%. We identified the following 7 patterns: 1) loss of peristaltic reserve, 2) presence of good reserve, 3) repetitive spasm pattern, 4) unmasking hypercontractility, 5) paradoxical LES contractions, 6) loss of deglutition inhibition, 7) distal esophageal pressurization. CONCLUSION: Currently, HRM studies involve a series of single swallows, which do not represent normal swallowing physiology. In contrast, MRS comprises series of wet swallows, which may better represent deglutition pathophysiology as it inhibits esophageal smooth muscles contraction and relaxes the lower esophageal sphincter (LES). Thus, MRS is hypothesized to serve as a non-invasive substitute to evaluate esophagus integrity. In our study, MRS had a high diagnostic yield in assessing peristaltic reserve, unmasking underlying hypercontractility and esophageal spasm, and confirming true outflow obstruction with pressurization pattern. Pathophysiology was also detected such as paradoxical LES contraction and loss of deglutition inhibition, which helped with diagnosing cases of achalasia variant and esophageal spasm. MRS is an effective, simple, and inexpensive technique to identify esophageal disorders. It was very well tolerated by majority of patients and did not add cost to the procedure. We recommend standardizing MRS in HRM protocol as it provides a better understanding of esophageal disorders. Stoikes, Nathaniel et al. “The value of multiple rapid swallows during preoperative esophageal manometry before laparoscopic antireflux surgery.” 2012: 3401-7.