Impaired motility in Barrett's esophagus: A study using high-resolution manometry with physiologic challenge.

Abstract

Esophageal dysmotility may predispose to Barrett's esophagus (BE). We hypothesized that high-resolution manometry (HRM) performed with additional physiologic challenge would better delineate dysmotility in BE. Included patients had typical reflux symptoms and underwent endoscopy, HRM with single water swallows and adjunctive testing with solids and rapid drink challenge (RDC) before ambulatory pH-impedance monitoring. BE and endoscopy-negative reflux disease (ENRD) subjects were compared against functional heartburn patient-controls (FHC). Primary outcome was incidence of HRM contractile abnormalities with standard and adjunctive swallows. Secondary outcomes included clearance measures and symptom association on pH-impedance. Seventy-eight patients (BE 25, ENRD 27, FHC 26) were included. Water swallow contractility was reduced in both BE (median DCI 87mmHg/cm/s) and ENRD (442mmHg/cm/s) compared to FHC (602mmHg/cm/s; P<.001 and .04, respectively). With the challenge of solid swallows and RDC, these parameters improved in ENRD (solids=1732mmHg/cm/s), becoming similar to FHC (1242mmHg/cm/s; P=.93), whereas abnormalities persisted in BE (818mmHg/cm/s; P<.01 c.f. FHC). In BE and ENRD, reflux events (67 vs 57 events/24hour) and symptom frequency were similar; yet symptom correlation was significantly better in ENRD compared to BE, which was comparable to FHC (symptom index 30% vs 4% vs 0%, respectively). Furthermore, bolus clearance and exposure times were more pronounced in BE (P<.01). Reduced contractile effectiveness persisted in BE with the more representative esophageal challenge of swallowing solids and free drinking; while in ENRD and FHC peristalsis usually improved, demonstrating peristaltic reserve. Furthermore, symptom association and refluxate clearance were reduced in BE. These factors may underlie BE pathogenesis.