A Quality Improvement Project: High Resolution Impedance Manometry (HRIM) Distilled Water (DW) Challenge: Quantifies Esophageal Wall Impedance and Clearance in Patients with Abnormal Bolus Transit: Presidential Poster Award

Abstract

Introduction: Patients undergoing HRIM are given highly ionic low impedance (<500 Ohms) swallows to contrast with the higher impedance esophageal wall (2000-3000 Ohms) to assess bolus transit. Patients with Achalasia or weak peristalsis are unable to clear the esophagus. Patients with apparent retained fluid and normal motility defy explanation. Both Barrett’s Esophagus (BE) and Eosinophilic Esophagitis (EOE), have shown low impedance within the esophageal wall mimicking a fluid filled esophagus on HRIM. The impedance differential is diminished or lost when given low impedance swallows. High Impedance (DW) (>10000 Ohms) swallows restores the differential, frequently changing interpretation and increasing diagnostic yield. Methods: 100 consecutive patients referred for HRIM testing (Diversatek Health Inc.) with various symptoms. HRIM performed with 10-5cc salt water and 10-5cc viscous swallows. A variable number of 5cc DW swallows given to assess delayed clearance. Complete bolus transit defined >80% liquid and >70% viscous swallows. HRIM studies calculated using Chicago Classification v3 (liquid swallows only). Results: 100 studies analyzed Table 1; 29 Males, 71 Females, median age 58 years. 55 NM, 0/20 WP, 1/2 DES, 2/3 JH, 2/14 EGJOO, 0/6 ACH had normal bolus transit with liquids and viscous. 72 patients had incomplete bolus transit with liquids and viscous OR viscous alone. Table 2. 49/72(68%) patients demonstrated a change in interpretation with DW from no or poor clearance to delayed transit. DW Challenge contrasted with the lower impedance esophageal wall in two patients with known long segment BE thereby confirming the diagnosis. There were other impedance patterns noted in Figure 1.410_A Figure 1 No Caption available.Conclusion: HRIM should employ DW swallows to improve diagnostic yield, potentially changing interpretation and influencing therapeutic intervention. DW swallows identify delayed transit, regurgitation and the LES bathed in gastric ions. and can help identify conditions in the esophageal wall (ex: BE) where conventional highly ionic swallows currently fail to identify such abnormalities.410_B Figure 2 No Caption available.410_C Figure 3 No Caption available.