Clinical and Manometric Characteristics of LES-dependent and Independent Jackhammer Esophagus

Abstract

Introduction: Jackhammer esophagus (JHE) is a disorder of esophageal peristalsis characterized by increased contractile vigor, as measured by the distal contractile integral (DCI) on high-resolution esophageal manometry (HRM). The Chicago classification of esophageal motility disorders version 3.0 (CCv3.0) expanded the definition of JHE to include hypercontractility that may involve or even be localized to the lower esophageal sphincter (LES). Whether patients whose diagnosis of JHE depends on inclusion of the LES differ clinically from those that meet criteria without LES inclusion is unknown. Aim: Describe and compare demographics, manometric features, clinical characteristics, and management in patients with LES-dependent and independent JHE. Methods: Retrospective analysis of patients with HRM diagnosis of JHE based on CCv3.0 from January 2012 to April 2016. HRM performed with a solid state catheter with 36 circumferential pressure sensors 1-cm apart; ten 5-ml liquid swallows given and analyzed with Manoview software (version 3.0.1, Given Imaging, Inc.).EGJ integrated relaxation pressure, DCI, and distal latency were calculated, and CCv3.0 algorithm applied to diagnose JHE, defined by ≥2 swallows with DCI ≥ 8,000 mmHg-cm-s. Measurements were taken with and without inclusion of the LES. Therapies were chosen at the discretion of the treating esophagologists. Response was defined as none/partial/complete based upon chart review. Statistical analysisincluded Fisher exact test and Student's t-test for categorical and continuous variables, respectively. Results: 46 patients met criteria for inclusion, with median follow up of 42.5 months. The DCI fell below diagnostic criteria for JHE in 10 patients (21.7%) after LES exclusion(LES-dependent JHE). Demographics, manometric features, and clinicalcharacteristics for LES-dependent and independent JHE are shown in Table 1. LES-dependent JHE was associated with a significantly decreased DCI, both before and after LES exclusion. LES-dependent patients were equally likely to be treated, but more likely to undergo dilation as their treatment modality. No differences in treatment outcome were observed. Conclusion: Patients with LES-dependent JHE are quantitatively (i.e. mean DCI), but not clinically, distinct from their LES-independent counterparts. Given the lack of any substantial clinical difference between groups, particularly with regards to treatment response, our data support the continued inclusion of the LES in JHE diagnosis.Figure 1