The rhythm and rate of distension‐induced esophageal contractility: A physiomarker of esophageal function

Abstract

Distention of the esophagus elicits a unique pattern of repetitive contractions in healthy controls. We aimed to assess the rhythm and rate of distension-induced contractile patterns between achalasia and controls and identify factors that distinguish the normal contractile response to distension. Twenty asymptomatic controls and 140 adult patients with treatment-naïve achalasia defined by HRM (29 type I, 81 type II, 30 type III) were prospectively evaluated with functional luminal imaging probe (FLIP) during sedated endoscopy. 16-cm FLIP balloons were positioned within the distal esophagus during stepwise balloon distension. Functional luminal imaging probe panometry studies were retrospectively analyzed using a customized program. All controls had contractility in a repetitive antegrade contraction (RAC) pattern with a rate of mean (10-90th) 6 (4-8) contractions per minute. 19/20 controls had>6 consecutive antegrade contractions (ACs), that is, duration>6 ACs, >6cm in length, at a rate of 6±3 contractions per minute (met the "Rule-of-6s"). 50 achalasia patients had repetitive contractions that occurred at a rates of 11 (7 - 15) ACs per minute; P<.001 compared with controls, or 12 (8-15) repetitive retrograde contractions per minute. Only 1/140 achalasia patients had a contractile response that met the "Rule-of-6s." The normal contractile response to sustained distention is associated with>6 RACs with a consistent rate of 6±3 per minute, which was exceptionally rare in achalasia. These findings support that the RAC pattern is disrupted in achalasia and the faster rate may be a manifestation of abnormal inhibition and/or a reduced refractory period.