High-Resolution Manometry Diagnosis of Ineffective Esophageal Motility Is Associated With Higher Reflux Burden

Abstract

Introduction: Ineffective esophageal motility (IEM), defined as distal contractile integral (DCI) < 450 mmHg*s*cm on high resolution manometry (HRM) in ≥ 50% of swallows, is the most commonly diagnosed abnormality on HRM based on the Chicago Classification version 3.0. However, the clinical significance of IEM is unclear. We retrospectively analyzed symptom burden and physiologic reflux metrics in subjects having undergone HRM, aiming to clarify clinical implications of an IEM diagnosis. Methods: 239 consecutive subjects (51.8 ± 1.1 years, 32.6% male) with a diagnosis of IEM on HRM performed over a 3 year period beginning in January 2015 were retrospectively reviewed. Findings were compared with that of 100 subjects with normal HRM (50.6 ± 1.6 years, 28% male). Patient reported outcome (PRO) questionnaires including GERDQ and Brief Esophageal Dysphagia Questionnaire (BEDQ) along with pH testing parameters were compared. Subjects with prior foregut surgery were excluded. Results: Of the 239 IEM subjects, 146 underwent reflux monitoring (128 impedance-pH and 18 pHalone) and 155 had PRO data. IEM subjects were more likely to have elevated total reflux events > 73 compared to normal (27.3% vs. 14.0%, p = 0.02, Table 1). Within the IEM group, higher percentage of failed and weak swallows modestely correlated with acid exposure time (AET, rs=0.16, p=0.05) and total reflux events (rs = 0.22, p = 0.01, Figure 1). A modest inverse correlation was noted with increased GERDQ score (r = - 0.25, p = 0.05) and total reflux events (r = -0.28, p < 0.01) as the mean resting lower esophageal sphincter (LES) pressure decreased in IEM. Including only off-PPI reflux testing (N = 56 for IEM and N = 37 for normal), IEM subjects (Table 2) had significantly higher mean total AET (p = 0.02), DeMeester score (p = 0.01), total reflux events (p = 0.01), and bolus exposure time (p < 0.01). The percentage of weak and failed swallows correlated with AET (rs = 0.30, p = 0.03) in IEM subjects off of PPI. PRO scores were not significantly different between IEM and normal whether on or off of PPI.400_A Figure 1. IEM: Ineffective esophageal motility; AET: Acid exposure timeConclusion: Subjects with HRM diagnosis of IEM are more prone to acid reflux while off of PPI and nonacid reflux while on PPI. Reflux burden appears to be worse in those with higher percentage of weak and failed swallows or diminished LES pressure. Adjunctive medications such as transient-lower-esophageal-sphincter-relaxation inhibitors may be useful in IEM subjects incompletely responsive to PPI.400_B Figure 2 No Caption available.400_C Figure 3. IEM: Ineffective esophageal motility; AET: Acid exposure time