Upper Esophageal Sphincter (UES) Abnormalities Are a Frequent Finding on High Resolution Manometry (HREM) and Associated With Esophageal Motility Disorders (EMD)

Abstract

Introduction: While there has been an increased frequency of UES abnormalities noted among patients with esophageal motility disorders (EMD), the Chicago Classification for manometric disorders does not comment on UES findings. Here, we assess the frequency and type of UES abnormalities among patients referred for HREM; the frequency of UES abnormalities among patients with EMD (achalasia and esophagogastric junction outflow obstruction (EGJOO)); bolus clearance, lower esophageal sphincter (LES) and UES residual pressures to determine the severity of disease in patients with both EMD and a UES abnormality and; if presence of UES abnormalities in patients with EMD is associated with poor treatment response. Methods: This retrospective study at 3 tertiary care hospitals identified 136 consecutive patients referred for HREM to assess for a suspected motility disorder from 10/2016-10/2017. UES pressures were measured before 10 wet swallows. HREM reports were analyzed for UES, LES and bolus transit abnormalities. Medical records were reviewed for demographic data. Results: UES abnormalities were present in 38% (n=51) of all patients referred for HREM (n=136) and in 43% of 54 patients with EMD. Of those with UES abnormalities present, 45% (n=23) had an EMD. Of these individuals, 61% (n=14) were diagnosed with EGJOO and 39% (n=9) with achalasia (predominantly Type II (n=7/9)). There was a significant correlation between impaired LES residual pressure and UES residual pressure (r=0.238, P=0.005) in patients with EMD. Incomplete bolus clearance was not significantly associated with UES pressure abnormalities (p=0.48, CI: 0.5699 to 3.3019). Data on treatment response was captured in 35 patients with EMD (57% had pharmacological treatment, 1 had fundoplication, and 46% had combined pharmacological and procedural treatment). There was a trend towards presence of UES abnormalities in EMD with poorer outcomes but was not statistically significant (p=0.37). Botox therapy was performed more commonly in the treatment of EMD with normal UES (62%) compared to those with abnormal UES (24%). Conclusion: There appears to be a significant correlation between impairment in UES and LES relaxation, suggesting a shared pathophysiological mechanism. A stratification scheme, based on pathophysiological defect, and inclusion of UES findings while evaluating EMD patients may help in understanding this increasingly common but undoubtedly heterogeneous syndrome and facilitate the development of targeted therapies.