Breaks in peristaltic integrity predict abnormal esophageal bolus clearance better than contraction vigor or residual pressure at the esophagogastric junction.

Abstract

High-resolution impedance manometry (HRIM) evaluates esophageal peristalsis and bolus transit. We used esophageal impedance integral (EII), the ratio between bolus presence before and after an expected peristaltic wave, to evaluate predictors of bolus transit. From HRIM studies performed on 61 healthy volunteers (median age 27years, 48%F), standard metrics were extracted from each of 10 supine water swallows: distal contractile integral (DCI, mmHgcms), integrated relaxation pressure (IRP, mmHg), and breaks in peristaltic integrity (cm, using 20mmHg isobaric contour). Pressure and impedance coordinates for each swallow were exported into a dedicated, python-based program for EII calculation (EII ratio≥0.3=abnormal bolus clearance). Univariate and multivariate analyses were performed to assess predictors of abnormal bolus clearance. Of 591 swallows, 80.9% were intact, 10.5% were weak, and 8.6% failed. Visual analysis overestimated abnormal bolus clearance compared to EII ratio (p≤0.01). Bolus clearance was complete (median EII ratio 0.0, IQR 0-0.12) in 82.0% of intact swallows in contrast to 53.3% of weak swallows (EII ratio 0.29, IQR 0.0-0.57), and 19.6% of failed swallows (EII ratio 0.5, IQR 0.34-0.73, p<0.001). EII correlated best with break length (ρ=0.52, p<0.001), compared to IRP (ρ: -0.17) or DCI (ρ: -0.42). On ROC analysis, breaks predicted abnormal bolus transit better than DCI or IRP (AUC 0.79 vs. 0.25 vs. 0.44, p≤0.03 for each). On logistic regression, breaks remained independently predictive of abnormal bolus transit (p<0.001). Breaks in peristaltic integrity predict abnormal bolus clearance better than DCI or IRP in healthy asymptomatic subjects.