Dysphagia is associated with major esophageal motility disorders in the UAE: a retrospective cohort study from a tertiary care center in Abu Dhabi.

Introduction: NCCP is defined as recurring, angina-like, retrosternal chest pain of non-cardiac origin. It has been estimated that up to 30% of the non-GERD related NCCP patients demonstrate an esophageal motor disorder using conventional manometry (CM). Thus, the aim of the study was to determine if high resolution esophageal manometry (HREM), which has become the standard of care, improved the diagnosis of esophageal motor disorders, as compared with CM, in patients with NCCP. Methods: We evaluated 300 consecutive non-GERD related NCCP patients who underwent either HREM or CM. A total of 150 patients had CM and the other 150 patients HREM. The Chicago 3 classification and the Castell and Spechler classification were used to determine the esophageal motor disorder of patients undergoing HREM and CM, respectively. Results: In both HREM and CM groups, a normal esophageal motility study was the most frequent finding (47% vs. 36%, respectively). In patients who underwent CM, the most commonly demonstrated esophageal motility disorder was hypotensive lower esophageal sphincter. Hypotensive LES was a significantly more common finding in patients undergoing CM versus HREM (27.3% vs. 4.7%, p<0.001). Other less common motility disorders seen in the CM group were nonspecific esophageal motility disorders (NEMD) (12%), nutcracker esophagus (9.3%), ineffective esophageal motility (IEM) (6.7%), achalasia (2.7%), distal esophageal spasm (DES) (5.3%), and absent contractility (0.67%). In general, hypertensive motility disorders, like DES and nutcracker esophagus, were less common than hypotensive motility disorders (15% vs. 35%, p=0.9) in NCCP patients. There was no significant difference in the number of hypertensive or hypotensive motility disorders diagnosed with CM versus those diagnosed with HREM. In the HREM group, IEM was the most commonly diagnosed motility abnormality. The likelihood of finding an IEM was significantly more common in the HREM group as compared with the CM group (25% vs. 7%, p<0.001). Other motility abnormalities that were less commonly diagnosed with HREM included: achalasia (7.3%), esophagogastric junction outflow obstruction (4%), absent contractility (4%), jackhammer/nutcracker esophagus (3.3%), DES (2.7%) and NEMD (1.3%). Conclusion: HREM did not improve the percentage and type of esophageal motor disorders diagnosed in NCCP patients as compared with CM. This is likely due to limitations of Chicago 3 classification. Normal esophageal motility remains the most common finding.

Loss of Peristaltic Reserve, Determined by Multiple Rapid Swallows, Is the Most Frequent Esophageal Motility Abnormality in Patients With Systemic Sclerosis.

How to Effectively Use High-Resolution Esophageal Manometry

Introduction: The most recent Chicago Classification (CC) for esophageal motility disorders simplified the definition of minor motility disorders. Ineffective esophageal motility (IEM) is now defined as a distal contractile integral (DCI) <450 mmHg/s/cm in at least 50% of ten liquid swallows on high resolution esophageal manometry (HREM). It remains unclear whether this definition correlates with degree of dysphagia symptoms. Methods: Between 2013-2016, patients presenting for HREM prospectively rated their symptoms using the Eckardt score (Figure 1). Inclusion criteria were patients with non-obstructive dysphagia, and Eckardt dysphagia score of ≥1. Patients with major motility disorders were excluded. We retrospectively reviewed topography plots in order to classify patients according to CC version 3. Symptom scores between patients with IEM (group A) and patients with normal HREM (group B) were compared using two-tailed t-tests. Spearman's correlation coefficient was calculated to determine correlation between symptoms and % bolus clearance using impedance in both groups.Figure: Moderate inverse correlation between dysphagia score and % bolus clearance.Results: 241 patients were screened for inclusion; 33 patients (26 female) met criteria for Group A and 44 patients (36 female) for Group B. There was no difference between the two groups in mean symptom severity scores for dysphagia (1.63 vs. 1.61, P=0.89), chest pain (0.67 vs. 0.75, P=0.64), regurgitation (1.06 vs. 0.85, P=0.32), or weight loss (0.85 vs. 0.49, P=0.11). The % bolus clearance was significantly lower in group A (46.5% vs. 76.7%, P>0.01). There was a moderate inverse correlation between dysphagia score and % bolus clearance (R=-0.37) in group A, but no correlation between dysphagia score and % bolus clearance in group B (R=0.09), (Figure 2). Conclusion: The definition of IEM has evolved over the years, with the latest classification system simplifying its definition. Theoretically, patients with greater percentage of weak or failed swallows would have greater degrees of dysphagia compared to those with <50%, as the latter is considered a normal motor pattern. In our study, the classification of IEM did not discriminate from normal studies for symptom severity. However, patients with IEM did have a correlation between dysphagia score and bolus clearance whereas those without IEM did not. Therefore, adding impedance information to motor pattern classification increases the yield and should be considered in the assessment of dysphagia severity in minor motility disorders.Table: Eckardt Score.

BackgroundUpper esophageal sphincter (UES) function may be evaluated manometrically using a solid-state high-resolution manometry (HRM) system, which allows for the measurement of manometric parameters specific to the UES. While many of these parameters have yet to be validated for use in clinical practice, there is some suggestion that there may be an association between esophageal motility and UES function.AimsWe aimed to identify the relationship between UES manometric variables and high-resolution esophageal manometry (HREM) diagnoses.MethodsA retrospective analysis of HREM studies was performed between 2019 and 2021. Extraction of esophageal and UES manometric variables were performed. UES manometric values of interest included: mean basal pressure (mmHg), mean residual pressure (mmHg), relaxation time-to-nadir (ms), relaxation duration (ms), and recovery time (ms). Relationships between manometric diagnosis (Chicago Classification version 3) and UES manometric variables were explored. All values are expressed a medians and group means were compared with the non-parametric Mann-Whitney U test.Results2119 symptomatic patients underwent HREM over the study period. Manometric diagnoses were achalasia (72 patients), esophagogastric junction outflow obstruction (286), absent contractility (108), distal esophageal spasm (53), jackhammer esophagus (32), and ineffective esophageal motility (694). 886 patients had no specific motility disorder; 643 of whom had ≤ 20% ineffective swallows and were considered symptomatic controls.Patients with achalasia had significantly higher mean basal pressures (63.2 vs. 54.4, p = .001), mean residual pressure (3.8 vs. -1.9, p < .001), relaxation-time-to-nadir (182.0 vs. 142.0, p = .005), relaxation duration (820.5 vs. 708.0, p < .001) and recovery time (623.0 vs. 562, p < .001) compared to control patients. Among patients with achalasia, the presence of panesophageal pressurization correlated weakly with recovery time (R2 .3, p = .03). Patients with ineffective esophageal motility had significantly higher mean basal pressures (61.7 vs. 54.0, p < .001).Among all patients, patients with incomplete bolus clearance (≥ 30%) had significantly higher UES mean basal pressure (58.9 vs. 54.6, p = .004), mean residual pressure (-.62 vs. -2, p < .001), relaxation duration (724.0 vs. 707.0, p = .014) and recovery time (580 vs. 558.0, p < .001).ConclusionsPatients with achalasia may have higher basal and residual UES pressures, and slower relaxation compared to patients with normal esophageal motility. This may reflect dynamic changes of the UES in response to obstruction at the esophagogastric junction. Elevated UES pressures are also seen in patients with ineffective esophageal motility, potentially reflecting a response to poor bolus clearance. More work needs to be done to validate these parameters in clinical practice.Funding AgenciesNone

Background/AimsHigh-resolution manometry with the Chicago classification scheme has been introduced in clinical practice as a gold standard for esophageal motility test. This study aims to evaluate the diagnostic yield of high-resolution manometry in Thai patients.MethodsAll available high-resolution esophageal manometry (HREM) studies performed during the study period were retrospectively reviewed and interpreted according to the Chicago classification version 3.0. The main esophageal symptoms and coexisting factors were correlated with the HREM findings.ResultsOf the 201 patients, nearly half (49.8%) were documented to have dysphagia. The second most common condition was refractory reflux symptoms (17.4%). More than 70.0% of dysphagia patients showed abnormal esophageal motility, contrary to globus patients who mostly had normal test findings (65.4%). Dysphagia still was the most often correlated condition with major esophageal motility disorders (88.7%), particularly the elderly patients who have coexisting weight loss. Endoscopic and/or surgical procedures were revealed for the highest rate among patients with dysphagia but no one in the globus group needed this intervention. The sensitivity and specificity of dysphagia for major esophageal motility disorders were 70.0% and 67.0%. A much lower sensitivity and higher specificity were found in other non-dysphagia symptoms, especially nausea/vomiting or belching (3.0% or 89.0%). The highest positive likelihood ratio (2.10) to detect major abnormalities was also observed in dysphagia.ConclusionEsophageal manometry provided the highest yield in dysphagia; it was not a strongly beneficial test in patients presenting with non-dysphagia to identify clinically relevant esophageal motor disorders.

BackgroundHigh-resolution esophageal manometry (HREM) is the diagnostic test of choice for evaluation of non-obstructive dysphagia. Studies regarding the predictors of esophageal dysmotility are limited. Therefore, our aim was to study the prevalence of and factors associated with esophageal motility disorders in patients with non-obstructive dysphagia.MethodsWe performed a retrospective review of all patients with non-obstructive dysphagia who underwent HREM in a tertiary center between 1 January 2014 and 31 December 2015. After obtaining IRB approval (16–051), clinical records were scrutinized for demographic data, symptoms, medication use, upper endoscopic findings and esophageal pH findings. HREM plots were classified per Chicago Classification version 3.0. Primary outcome was prevalence of esophageal motility disorders; secondary outcomes assessed predictive factors.ResultsIn total, 155 patients with non-obstructive dysphagia (55 ± 16 years old, 72% female) were identified. HREM diagnosis was normal in 49% followed by ineffective esophageal motility in 20%, absent contractility in 7.1%, achalasia type II in 5.8%, outflow obstruction in 5.2%, jackhammer esophagus in 4.5%, distal esophageal spasm in 3.9%, fragment peristalsis in 1.9%, achalasia type I in 1.9%, and achalasia type III in 0.6%. Men were five times more likely to have achalasia than women [odds ratio (OR) 5.3, 95% confidence interval (CI): 2.0–14.2; P = 0.001]. Patients with erosive esophagitis (OR 2.9, 95% CI: 1.1–7.7; P = 0.027) or using calcium channel blockers (OR 3.0, 95% CI: 1.2–7.4; P = 0.015) were three times more likely to have hypomotility disorders.ConclusionFrom this study, we concluded that HREM diagnosis per Chicago Classification version 3.0 was normal in 49% of patients with non-obstructive dysphagia. Male gender, erosive esophagitis and use of calcium channel blockers were predictive of esophageal motility disorders.

Since publication of Chicago Classification version 3.0 in 2015, the clinical and research applications of high-resolution manometry (HRM) have expanded. In order to update the Chicago Classification, an International HRM Working Group consisting of 52 diverse experts worked for two years and utilized formally validated methodologies. Compared with the prior iteration, there are four key modifications in Chicago Classification version 4.0 (CCv4.0). First, further manometric and non-manometric evaluation is required to arrive at a conclusive, actionable diagnosis of esophagogastric junction (EGJ) outflow obstruction (EGJOO). Second, EGJOO, distal esophageal spasm, and hypercontractile esophagus are three manometric patterns that must be accompanied by obstructive esophageal symptoms of dysphagia and/or non-cardiac chest pain to be considered clinically relevant. Third, the standardized manometric protocol should ideally include supine and upright positions as well as additional manometric maneuvers such as the multiple rapid swallows and rapid drink challenge. Solid test swallows, postprandial testing, and pharmacologic provocation can also be considered for particular conditions. Finally, the definition of ineffective esophageal motility is more stringent and now encompasses fragmented peristalsis. Hence, CCv4.0 no longer distinguishes between major versus minor motility disorders but simply separates disorders of EGJ outflow from disorders of peristalsis.

IntroductionOesophagogastric outflow obstruction (OGJOO) may coexist with minor and major oesophageal motility disorders. It is unknown whether there is a severity in the OGJOO that may influence the oesophageal body...

Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by a lack of relaxation of the esophagogastric junction (EGJ), with preserved esophageal body peristalsis. We propose new terminology for the coexistence of EGJOO with hypercontractile esophagus and distal esophageal spasm as a major mixed motility disorder (MMMD), and normal peristalsis or a minor disorder of peristalsis such as ineffective esophageal motility with EGJOO as isolated or ineffective EGJOO (IEGJOO). We reviewed prior diagnoses of EGJOO, stratified diagnoses as IEGJOO or MMMD, and compared their symptomatic presentations, high-resolution manometry (HRM) and endoluminal functional lumen imaging probe (EndoFLIP) metrics, and treatment responses at 2-6months of follow-up. Out of a total of 821 patients, 142 met CCv3 criteria for EGJOO. Twenty-two were confirmed by CCv4 and EndoFLIP as having EGJOO and were clinically managed. Thirteen had MMMD, and nine had IEGJOO. Groups had no difference in demographic data or presenting symptoms by Eckardt score (ES). HRM showed MMMD had greater distal contractile integral, frequency of hypercontractile swallows, and frequency of spastic swallows, and greater DI by EndoFLIP. Patients with MMMD showed greater reduction in symptoms after LES-directed intervention when measured by ES compared with IEGJOO (7.2 vs. 4.0). Patients with MMMD and IEGJOO present similarly. Detectable differences in HRM portend different responses to endoscopic therapy. Because patients with MMMD have greater short-term prognosis, they should be considered a different diagnostic classification to guide therapy.

The Chicago Classification of Motility Disorders: An Update

Esophageal Motility Disorders: A Concise Review on Classification, Diagnosis, and Management.

Introduction: High resolution esophageal manometry (HRM) is considered the gold standard diagnostic test for esophageal motility disorders. The Chicago Classification (CC V3.0) is a hierarchical approach to interpret HRM studies and defines metrics for the diagnosis of esophageal motility disorders. The real world clinical practice impact of using CC V3.0 is unknown. The objective of this study was to determine the diagnostic distribution of esophageal motility disorders before and after implementation of CC V3.0 for HRM interpretation.Table 2: Rate Ratios for Diagnoses associated with Implementation of Chicago Classification V3.0 (09/01/2014)Methods: This was a retrospective analysis of patients with a HRM study conducted at a single center from January 1, 2013 through September 30, 2015. The implementation of CC V3.0 occurred in September 2014 and was fully adopted by December 2014. Patient charts were reviewed to extract demographics (age, sex), clinical variables (symptoms, indications), and HRM variables (esophageal pressure topography metrics, diagnoses and interpretation). If a diagnosis was not clearly stated, it was categorized as indeterminate. Rate ratios (RR) for CC V3.0 diagnostic categories (normal, indeterminate, achalasia and EGJ outflow obstruction (EGJOO), and major and minor motility disorders) were calculated by Poisson regression associated with the period after CC V 3.0 implementation. All models were adjusted for age and sex, and the reference time period was quarter 1 (Jan-Mar 2013). Results: There were 796 HRM studies included in the study. The mean ± standard deviation patient age was 53.4 ±15.5 years, with 59% being female (Table 1). The graphical trends in diagnoses over time are shown in Figure 1. The percentage of indeterminate and major motility disorder diagnoses was significantly lower in the time period after CC V 3.0 implementation. The percentage of normal, EGJOO, and minor motility disorder diagnoses were significantly higher post implementation. There was no change in the % of achalasia diagnoses.Figure 1Table 1: Characteristics of the study population overall, and by time periods before and after Chicago Classification V3.0 policy implementation on 09/01/2014Conclusion: This is one of the first studies showing the impact of CC V3.0 on HRM interpretation in clinical practice. The increase in the number of normal studies and decrease in the number of indeterminate studies suggests that CC V3.0 clarifies the criteria for a normal study. The increase in studies with a diagnosis of EGJ outflow obstruction may reflect the heterogeneity of disorders with clinically relevant outflow obstruction. Further study is needed to determine if these results translate to changes in therapeutic decision making and treatment outcomes.

Chapter 2 - Esophageal Body in Health and Disease

To investigate esophageal motility disorders in patients with esophageal residual barium on chest x-rays after videofluoroscopic swallowing studies (VFSS) through high-resolution esophageal manometry (HREM). We reviewed the records of 432 patients who underwent VFSS from September 2019 to May 2021, and 85 patients (19.7%) with large residual barium (diameter ≥1 cm) were included. As a result of HREM, motility disorders were classified as major or minor motility disorders according. Esophagogastroduodenoscopy and chest computed tomography results available were also reviewed. Among 85 patients with large residual barium in the esophagus, 16 patients (18.8%) underwent HREM. Abnormal esophageal motilities were identified in 68.8% patient: three patients (18.8%) had major motility disorders-achalasia (n=1), esophagogastric junction (EGJ) outflow obstruction (n=2)-and eight patients (50%) had minor motility disorders-ineffective esophageal motility (n=7), fragmented peristalsis (n=1). In those with normal esophageal motility, three patients of esophageal structure disorders (18.8%)-esophageal cancer (n=1), cardiogenic dysphagia (n=1), slight narrowing without obstruction of EGJ (n=1)-and two patients (12.5%) with chronic atrophic gastritis (n=2) were confirmed. Esophageal motility disorders were identified in 68.8% of 16 patients with large esophageal residual barium with three patients in the major and eight patients in the minor categories. Residual barium in the esophagus was not rare and can be a sign of significant esophageal motility disorders.