“Ineffective Esophageal Motility” Is Associated With Impaired Bolus Clearance but Does Not Correlate With Severity of Dysphagia

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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.