M1152 Integrity of Esophageal Emptying in Spasm Patients: A High-Resolution Impedance Manometry Study

Abstract

Chest pain and dysphagia are the most common symptoms reported by patients diagnosed with esophageal spasm. The role of esophageal emptying in the etiology of symptoms in these patients is unclear. Our AIM was to determine the integrity of esophageal emptying in patients with manometrically defined esophageal spasm using high-resolution impedance manometry (HRIM). METHODS: Esophageal HRIM data were retrospectively reviewed from 12 patients (7 male) classified as esophageal spasm (Pandolfino et al, AJG, 2008). Data were collected using a solid state HRIM system with 36 manometry and 8 impedance sensors (MMS Inc, Dover, NH). All patients underwent 10 5-ml water swallows and 10 5-ml viscous swallows. Patients were classified based on symptoms as either chest pain dominant (n=5) or dysphagia dominant (n=7). Esophageal motility and lower sphincter relaxation were quantified using the distal contractile integral (DCI), propagation front velocity (PFV) and the 4-second integrated relaxation pressure (IRP). Manometric parameters reflecting bolus transit, i.e. flow permissive time (FPT) and bolus domain pressure (BDP) were quantified using MATLAB programs (The Mathworks Inc, Natick, MA). Complete esophageal emptying was defined as a recovery back to 50% of baseline impedance on all intraesophageal sensors. All results are average ± std dev. RESULTS: Two manometric patterns were noted in spasm patients, (i) spastic contractions with DCI >5000 mmHg.cm.s and contractions restricted to the mid-esophagus (Type I), and (ii) spastic contractions with DCI > 7000 mmHg.cm.s and contractions spanning the mid and distal esophagus (Type II). 1/5 chest pain dominant patients was classified in type I and the remaining 4 chest pain patients were classified in Type II. Of the 7 dysphagia dominant patients, 3 were type I and 4 type II. Type I patients had complete bolus transit in all 4 patients, while 5 of the 8 type II patients had incomplete bolus emptying on at least two consecutive impedance sensors. FPT was longer in type I vs type II patients (3.2 ± 2.7 s vs. 1.9 ± 1.0 s; p 0.05). All patients had complete LES relaxation, 4-s IRP = 12.8±4.1 mmHg). Viscous swallows showed higher frequency of bolus retention compared to water swallows. CONCLUSIONS: Two manometric variations are seen in spasm patients. Type II patients have a stronger association with incomplete bolus transit and are more likely to have symptoms of dysphagia than chest pain. This suggests that impaired bolus transit is likely an important factor in the etiology of dysphagia but not of chest pain in the symptomatology of spasm patients.