Abstract
BackgroundMotility disorders of upper gastrointestinal tract are common in critical illness and associated with significant clinical consequences. However, detailed quantitative and qualitative analyses of esophageal motor functions are lacking. Therefore, we aimed to characterize the key features of esophageal motility functions using high-resolution impedance manometry (HRIM) and to evaluate an objective link between esophageal motor patterns, gastric emptying, and gastroesophageal reflux. We also studied the prokinetic effects of metoclopramide.MethodsWe prospectively performed HRIM for 16 critically ill hemodynamically stable patients. Patients were included if they had low gastric volume (LGV; < 100 mL/24 h, n = 8) or high gastric volume (HGV; > 500 mL/24 h, n = 8). The HRIM data were collected for 5 h with intravenous metoclopramide administration (10 mg) after the first 2 h.ResultsThe findings were grossly abnormal for all critically ill patients. The esophageal contraction vigor was markedly increased, indicating prevailing hypercontractile esophagus. Ineffective propulsive force was observed for 73% of esophageal activities. Panesophageal pressurization was the most common pressurization pattern (64%). Gastroesophageal reflux predominantly occurred with transient lower esophageal sphincter relaxation. The common features of the LGV group were a hyperreactive pattern, esophagogastric outflow obstruction, and frequent reflux. Ineffective motility with reduced lower esophageal sphincter tone, and paradoxically fewer reflux episodes, was common in the HGV group. Metoclopramide administration reduced the number of esophageal activities but did not affect the number of reflux episodes in either group.ConclusionAll critically ill patients had major esophageal motility abnormalities, and motility patterns varied according to gastric emptying status. Well-preserved gastric emptying and maintained esophagogastric barrier functions did not eliminate reflux. Metoclopramide failed to reduce the number of reflux episodes regardless of gastric emptying status.Trial registration ISRCTN, ISRCTN14399966. Registered 3.9.2020, retrospectively registered. https://www.isrctn.com/ISRCTN14399966.
Highlights
Dysfunction of the upper gastrointestinal tract (UGIT) leads to deterioration in the patient’s nutritional status, bacterial colonization, and increased risks of reflux esophagitis, and aspiration [1]
Esophageal contraction vigor The distal contractile integral (DCI) values, which reflect contraction vigor, were significantly higher in the patients than normally seen in healthy volunteers [8], which suggested that hypercontractile esophagus was common
Gastroesophageal reflux predominantly occurred due to transient lower esophageal sphincter relaxation (TLESR) that was often preceded by panesophageal secondary peristalsis, and reflux was only associated with the absence of lower esophageal sphincter (LES) tone and episodes of straining in a minority of patients
Summary
Dysfunction of the upper gastrointestinal tract (UGIT) leads to deterioration in the patient’s nutritional status, bacterial colonization, and increased risks of reflux esophagitis, and aspiration [1]. Nind et al evaluated 15 mechanically ventilated patients and reported that gastroesophageal reflux was predominantly related to low or absent lower esophageal sphincter (LES) pressure, which often coexisted with cough or straining [3]. Those studies evaluated esophageal motility using conventional manometry, where the sensors are spaced at 3–5-cm intervals. High-resolution impedance manometry (HRIM) measures esophageal pressures with 423 sensors distributed longitudinally and radially in the esophagus, along with esophageal impedance monitoring (18 sensors), allowing for a very detailed evaluations of esophageal pressures, peristalsis, sphincter functions, and reflux [4].
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