Abnormal Bolus Transit Research Articles

Breaks in peristaltic integrity predict abnormal esophageal bolus clearance better than contraction vigor or residual pressure at the esophagogastric junction.

High-resolution impedance manometry (HRIM) evaluates esophageal peristalsis and bolus transit. We used esophageal impedance integral (EII), the ratio between bolus presence before and after an expected peristaltic wave, to evaluate predictors of bolus transit. From HRIM studies performed on 61 healthy volunteers (median age 27years, 48%F), standard metrics were extracted from each of 10 supine water swallows: distal contractile integral (DCI, mmHgcms), integrated relaxation pressure (IRP, mmHg), and breaks in peristaltic integrity (cm, using 20mmHg isobaric contour). Pressure and impedance coordinates for each swallow were exported into a dedicated, python-based program for EII calculation (EII ratio≥0.3=abnormal bolus clearance). Univariate and multivariate analyses were performed to assess predictors of abnormal bolus clearance. Of 591 swallows, 80.9% were intact, 10.5% were weak, and 8.6% failed. Visual analysis overestimated abnormal bolus clearance compared to EII ratio (p≤0.01). Bolus clearance was complete (median EII ratio 0.0, IQR 0-0.12) in 82.0% of intact swallows in contrast to 53.3% of weak swallows (EII ratio 0.29, IQR 0.0-0.57), and 19.6% of failed swallows (EII ratio 0.5, IQR 0.34-0.73, p<0.001). EII correlated best with break length (ρ=0.52, p<0.001), compared to IRP (ρ: -0.17) or DCI (ρ: -0.42). On ROC analysis, breaks predicted abnormal bolus transit better than DCI or IRP (AUC 0.79 vs. 0.25 vs. 0.44, p≤0.03 for each). On logistic regression, breaks remained independently predictive of abnormal bolus transit (p<0.001). Breaks in peristaltic integrity predict abnormal bolus clearance better than DCI or IRP in healthy asymptomatic subjects.

Updates on diagnostic modalities for esophageal dysphagia.

Esophageal dysphagia is a common symptom in adults. Fluoroscopic contrast studies, endoscopy, and esophageal manometry have been used in the diagnosis of esophageal dysphagia for many years. The diagnostic yield has been improved with new test protocols that highlight abnormal bolus transit in the esophagus and outflow obstruction, as well as new high-definition and high-resolution technical advances in equipment. Functional luminal impedance planimetry and the addition of impedance to high-resolution esophageal manometry have also allowed the assessment of new parameters to better understand esophageal structure and function. In this concise review, we describe the role and utility of various diagnostic modalities in the assessment of patients with esophageal dysphagia.

Etiologies and clinical characteristics of non-obstructive dysphagia in a Taiwanese population: A prospective study based on high-resolution impedance manometry

Esophageal motility disorders are the major cause of non-obstructive dysphagia (NOD), but may be underdiagnosed. In this high-resolution impedance manometry (HRIM)-based study, we aimed to clarify the etiologies and clinical characteristics of patients presenting with NOD in a Taiwanese population. From October 2014 to July 2017, consecutive patients with the chief complaint of dysphagia were prospectively enrolled in the study at a tertiary medical center. All subjects underwent a comprehensive diagnostic work-up, which included validated symptom questionnaires, esophagogastroduodenoscopy, timed barium esophagogram, and HRIM. Those with obstructive esophageal lesions were excluded. Esophageal motility disorders were diagnosed using the updated Chicago Classification v3.0. We categorized all patients based on the HRIM results, and compared the clinical characteristics and parameters between groups. A total of 120 patients (55 men; mean age [range], 52 [13-87] years) were analyzed. Achalasia was the most common diagnosis by HRIM (n=66, 55%), followed by ineffective esophageal motility (n=15, 12.5%), and absent contractility (n=6, 5%). Patients with achalasia experienced increased vomiting (62.1% vs. 31.5%, p=0.001), significant weight loss (22.7% vs. 7.4%, p=0.025), delayed esophageal emptying (90.9% vs. 12.9%, p<0.001), and abnormal bolus transit (100% vs. 25.9%, p<0.001) compared with non-achalasia patients. Based on HRIM and the updated Chicago Classification, achalasia was the most common diagnosis of NOD in a Taiwanese population. HRIM allows for a more detailed assessment and may assist in the tailoring of further treatment plans.

Combined Multichannel Intraluminal Impedance and High-resolution Manometry Improves Detection of Clinically Relevant Esophagogastric Junction Outflow Obstruction.

Background/AimsEsophagogastric junction outflow obstruction (EGJOO) is a diagnostically heterogeneous group with variable clinical relevance. We studied whether evaluation of bolus transit by multichannel intraluminal impedance (MII) is useful for discriminating clinically relevant EGJOO.MethodsA total 169 patients diagnosed as having EGJOO between June 2011 and February 2018 were analyzed. All the patients received a combined MII and high-resolution manometry (CMII-HRM). MII was reported as having abnormal liquid bolus transit (LBT) if < 80% of swallows had complete bolus transit. EGJOO was defined as a median integrated relaxation pressure of > 20 mmHg and when the criteria for achalasia were not met. Patients who progress to achalasia, show significant passage disturbance, or require pneumatic dilatation were defined as having a clinically relevant EGJOO.ResultsAmong the patients with EGJOO (n = 169), the clinically relevant group (n = 10) is more likely to have dysphagia (100% vs 25.2%, P < 0.001), compartmentalized pressurization (CP; 90.0% vs 22.0%, P < 0.001), and abnormal LBT (100% vs 66.7%, P = 0.032) compared to the non-relevant group (n = 159). The combination of dysphagia, CP, and abnormal LBT showed the best predictive power for clinically relevant EGJOO (sensitivity 90%, specificity 92.5%, positive predictive value 42.9%, negative predictive value 99.3%, positive likelihood ratio 11.9, and negative likelihood ratio 0.1). When CMII-HRM was used, an additional 8.3% of clinically relevant EGJOO cases were identified as compared with HRM alone.ConclusionClinically relevant EGJOO can be predicted using CMII-HRM.

A Quality Improvement Project: High Resolution Impedance Manometry (HRIM) Distilled Water (DW) Challenge: Quantifies Esophageal Wall Impedance and Clearance in Patients with Abnormal Bolus Transit: Presidential Poster Award

Introduction: Patients undergoing HRIM are given highly ionic low impedance (<500 Ohms) swallows to contrast with the higher impedance esophageal wall (2000-3000 Ohms) to assess bolus transit. Patients with Achalasia or weak peristalsis are unable to clear the esophagus. Patients with apparent retained fluid and normal motility defy explanation. Both Barrett’s Esophagus (BE) and Eosinophilic Esophagitis (EOE), have shown low impedance within the esophageal wall mimicking a fluid filled esophagus on HRIM. The impedance differential is diminished or lost when given low impedance swallows. High Impedance (DW) (>10000 Ohms) swallows restores the differential, frequently changing interpretation and increasing diagnostic yield. Methods: 100 consecutive patients referred for HRIM testing (Diversatek Health Inc.) with various symptoms. HRIM performed with 10-5cc salt water and 10-5cc viscous swallows. A variable number of 5cc DW swallows given to assess delayed clearance. Complete bolus transit defined >80% liquid and >70% viscous swallows. HRIM studies calculated using Chicago Classification v3 (liquid swallows only). Results: 100 studies analyzed Table 1; 29 Males, 71 Females, median age 58 years. 55 NM, 0/20 WP, 1/2 DES, 2/3 JH, 2/14 EGJOO, 0/6 ACH had normal bolus transit with liquids and viscous. 72 patients had incomplete bolus transit with liquids and viscous OR viscous alone. Table 2. 49/72(68%) patients demonstrated a change in interpretation with DW from no or poor clearance to delayed transit. DW Challenge contrasted with the lower impedance esophageal wall in two patients with known long segment BE thereby confirming the diagnosis. There were other impedance patterns noted in Figure 1.410_A Figure 1 No Caption available.Conclusion: HRIM should employ DW swallows to improve diagnostic yield, potentially changing interpretation and influencing therapeutic intervention. DW swallows identify delayed transit, regurgitation and the LES bathed in gastric ions. and can help identify conditions in the esophageal wall (ex: BE) where conventional highly ionic swallows currently fail to identify such abnormalities.410_B Figure 2 No Caption available.410_C Figure 3 No Caption available.

Esophagogastric junction outflow obstruction is often associated with coexistent abnormal esophageal body motility and abnormal bolus transit.

Currently, the diagnosis of esophageal motility disorders is in part based upon a hierarchical algorithm in which abnormalities of the esophagogastric junction (EGJ) is prioritized. An important metric in evaluating the EGJ is the integrated relaxation pressure (IRP). Patients who do not have achalasia but are found to have an elevated IRP are diagnosed with EGJ outflow obstruction. It has been our observation that a subset of these patients also has a second named motility disorder and may also have abnormal bolus transit. The aim of this study is to determine the frequency of abnormal body motility and or abnormal bolus movement in patients with EGJ outflow obstruction. Further, in an effort to evaluate the potential clinical value in measuring bolus transit as a complement to esophageal manometry, specifically in patients with EGJ outflow obstruction, we analyzed the presenting symptoms of these patients. A total of 807 patients with a mean age of 53 years completed esophageal function testing with impedance monitoring and high-resolution manometry between January 2012 and October 2016. There were 74 patients with achalasia who were excluded from the study. Of the remaining 733 patients, 138 (19%) had an elevated IRP and were given a diagnosis of EGJ outflow obstruction. Among these patients, 56 (40%) were diagnosed with an abnormal motility pattern to liquids (ineffective esophageal motility =28, distal esophageal spasm =19, Jackhammer =6), of which 44 (76%) had abnormal bolus transit to liquids, viscous, or both. In contrast, there were 82 patients with EGJ outflow obstruction and normal esophageal motility, of which 33 (40%) had abnormal bolus transit. Patients with preserved esophageal motility and EGJ outflow obstruction were then evaluated. Of the 733 patients, 299 (40%) had intact esophageal motility. Of the 299 patients with normal esophageal motility, 56 patients had an elevated IRP, of which 16 (28%) had abnormal bolus transit. There were 243 (33%) patients with intact esophageal motility and normal IRP. Of these, 56 (23%) patients had abnormal bolus transit. Among patients with abnormal bolus transit, the two most commonly presenting symptoms were dysphagia and heartburn. A substantial percentage of patients with EGJ outflow obstruction have abnormal esophageal body motility and or abnormal bolus transit. The clinical implications of EGJ outflow obstruction need to be further elucidated as current criteria do not allow for the description of other abnormalities in esophageal motility and bolus transit among patients who are given the diagnosis of EGJ outflow obstruction.

Sa1667 - EGJ Outflow Obstruction is Often Associated with Coexistent Abnormal Esophageal Body Motility and Abnormal Bolus Transit

Sa1667 - EGJ Outflow Obstruction is Often Associated with Coexistent Abnormal Esophageal Body Motility and Abnormal Bolus Transit

Manometry and radiology

The relationship between radiological and manometric findings in esophageal motility disorders is poorly understood. Therefore, 20 subjects (4 normal; 13 diffuse spasm; 3 other motility disorders) were studied using synchronous manometry and videofluoroscopy with alternate 5-ml and 10-ml barium swallows. A total of 181 swallows were analyzed. Concordance between manometry and fluoroscopy was excellent for individual swallows (98%), groups of 5 swallows (97%), and final diagnoses (90%). Contraction onset intervals less than 0.8 s apart over 5 cm (velocity greater than 6.25 cm/s) were critical in determining abnormal bolus transit (98% sensitivity and positive predictive value). Radiologically, segmental tertiary activity (complete luminal obliteration) was always associated with disrupted primary peristalsis, but nonsegmental tertiary activity was often seen with normal bolus transit and did not have a specific manometric correlate. Four patterns of interrupted peristalsis radiologically were found--segmental tertiary contractions, a generalized esophageal contraction, absence of motor activity, or discoordinated "to-and-fro" movement. Surprisingly, nearly complete barium clearance occurred by the first two mechanisms in two thirds of swallows. Thus, the authors believe radiology and manometry are both excellent studies for identifying abnormal esophageal peristalsis. In difficult cases, these tests give complementary information because radiology assesses bolus movement while manometry provides quantitative pressure data.

Su1079 Esophageal Motility Disorders, Response to Multiple Rapid Swallows, and Bolus Transit Abnormalities in Patients With Non-Obstructive Dysphagia

Su1079 Esophageal Motility Disorders, Response to Multiple Rapid Swallows, and Bolus Transit Abnormalities in Patients With Non-Obstructive Dysphagia

Mo1135 Trends in the Incidence of Esophageal Adenocarcinoma and Early Stage Esophageal Adenocarcinoma in the United States

G A A b st ra ct s difference with 139 (65%) females and 74 (35%) males having IEM-A versus 5 (33%) females and 10 (66%) males with IEM-P (p = 0.035). The mean age of IEM-P patients (61.7 years) was significantly higher (p < 0.05) than that of IEM-A (55.7 years). There was no significant difference in the race: 153 (72%) whites, 56 (26%) blacks in IEM-A versus 11 (73%) whites and 4 (27%) blacks in IEM-P. 147/228 patients had an ambulatory reflux study done. 88 (61%) were abnormal. Of those 84 were IEM-A (60%) and 4 IEM-P (80%) (p = 0.36). Finally, abnormal bolus transit for both liquid and viscous was present in 10/ 11 (91%) of IEM-P versus 128/182 (70% of 182) of IEM-A. Failure to find p < 0.05 for reflux and bolus transit likely due to type II statistical error. Conclusions: These results support the hypothesis that there are 2 distinct clinical subtypes of IEM. Furthermore, they suggest that IEM-P with an older male predominance and with a trend to more severe reflux and more abnormal bolus transit is a more severe manifestation than IEM-A. IEM subtypes: IEM-A and IEM-P

Mo1133 Anti-Viral Antibodies in Epstein-Barr Virus (EBV) Positive and Negative Gastric Cancer

G A A b st ra ct s difference with 139 (65%) females and 74 (35%) males having IEM-A versus 5 (33%) females and 10 (66%) males with IEM-P (p = 0.035). The mean age of IEM-P patients (61.7 years) was significantly higher (p < 0.05) than that of IEM-A (55.7 years). There was no significant difference in the race: 153 (72%) whites, 56 (26%) blacks in IEM-A versus 11 (73%) whites and 4 (27%) blacks in IEM-P. 147/228 patients had an ambulatory reflux study done. 88 (61%) were abnormal. Of those 84 were IEM-A (60%) and 4 IEM-P (80%) (p = 0.36). Finally, abnormal bolus transit for both liquid and viscous was present in 10/ 11 (91%) of IEM-P versus 128/182 (70% of 182) of IEM-A. Failure to find p < 0.05 for reflux and bolus transit likely due to type II statistical error. Conclusions: These results support the hypothesis that there are 2 distinct clinical subtypes of IEM. Furthermore, they suggest that IEM-P with an older male predominance and with a trend to more severe reflux and more abnormal bolus transit is a more severe manifestation than IEM-A. IEM subtypes: IEM-A and IEM-P

Dysmotility and reflux disease

In the last decade, with the advent of new oesophageal testing [i.e. 24-h impedance-pH monitoring, combined impedance-manometry, high-resolution manometry (HRM)], relevant progress in understanding the mechanisms contributing to the development of gastro-oesophageal reflux disease (GORD) has been made, allowing a better management of patients with this disorder. The aim of our review is to report the state-of-the-art about oesophageal motor disorders in patients with reflux disease and to stimulate new research in this field. Hypotensive lower oesophageal sphincter (LOS), transient LOS relaxations, impairment of oesophagogastric junction including hiatal hernia, oesophageal bolus transit abnormalities and presence of ineffective oesophageal motility have been strongly implicated in GORD development. In particular, the majority of recent studies carried out with HRM and impedance-pH testing reported that these motor abnormalities are increasingly prevalent with increasing severity of GORD, from nonerosive reflux disease and erosive oesophagitis to Barrett's oesophagus. Defining and characterizing oesophageal dysmotility in patients with reflux disease is of maximum importance in order to properly diagnose these patients and to treat them with the best management of care. New studies are needed in order to better understand the physiomechanic basis of oesophageal dysmotility in GORD patients.

Impaired Esophageal Bolus Transit in Patients with Gastroesophageal Reflux Disease and Abnormal Esophageal Acid Exposure

Background/AimsWe assessed the bolus transit and motility characteristics in gastroesophageal reflux disease (GERD) patients with abnormal esophageal pH monitoring.MethodsWe retrospectively reviewed the combined impedance-esophageal manometry data from consecutive patients who had abnormal acid exposure during 24-hour esophageal pH monitoring. We compared these data to the results from functional heartburn (FH) and asymptomatic volunteers.ResultsThe data from 33 GERD patients (mean age of 51 years, 18 males), 14 FH patients (mean age of 51 years, one male), and 20 asymptomatic volunteers (mean age of 27 years, nine males) were analyzed. Ineffective esophageal motility was diagnosed in 10% of the volunteers, 21% of the FH patients, and 15% of the GERD patients. Ineffective contraction was more frequent in GERD and FH patients than in volunteers (16% and 20% vs 6%, respectively; p<0.05). Additionally, 10% of the volunteers, 21% of the FH patients and 36% of the GERD patients had an abnormal bolus transit. Complete bolus transit was less frequent, and bolus transit was slower in GERD patients than in volunteers for liquid (70% vs 85%) and viscous swallows (57% vs 73%). A longer acid clearance time was associated with abnormal bolus transit in the GERD group.ConclusionsPatients with GERD have mild peristaltic dysfunction and incomplete and slower esophageal bolus transit. These conditions predispose them to prolonged acid contact with the esophagus.

Heterogeneity in oesophageal dysfunction among patients with different reflux symptoms

Ineffective oesophageal motility (IOM) often occurs in patients with gastro-oesophageal reflux disease. We aimed to examine the hypothesis of whether the presence of IOM differs between patients with gastro-oesophageal reflux disease with different symptom profiles. Eligible patients were subclassified according to their predominant symptom of heartburn (HB) or acid regurgitation (AR). All patients underwent combined multichannel intraluminal impedance and oesophageal manometry. IOM was further graded according to the presence of oesophageal transit abnormalities. Fourteen healthy individuals, 16 HB patients and 24 AR patients participated in this study. The percentage of swallows with complete bolus transit was lower in AR than in HB patients during liquid and viscous swallowing (P<0.05). Abnormal bolus transit occurred more frequently in AR patients than in HB patients with liquid swallows (P<0.001) and viscous swallows (P<0.05). IOM occurred more frequently in AR patients than in HB patients (42.7 vs. 12.5%, P=0.049). In patients with IOM, severe functional abnormality was more frequently found in AR patients than in HB patients (P<0.05). This study suggests a potential link between oesophageal body dysfunction and individual reflux symptom. Patients with a predominant symptom of AR are characterized by greater IOM and defective bolus clearance.

Functional aspects of distal oesophageal spasm: The role of onset velocity and contraction amplitude on bolus transit

BackgroundDistal oesophageal spasm is a rare and under-investigated motility abnormality. Recent studies indicate effective bolus transit in varying percentages of distal oesophageal spasm patients. AimExplore functional aspects including contraction onset velocity and contraction amplitude cut-off values for simultaneous contractions to predict complete bolus transit. MethodsWe re-examined data from 107 impedance-manometry recordings with a diagnosis of distal oesophageal spasm. Receiver operating characteristic analysis was conducted, regarding effects of onset velocity on bolus transit taking into account distal oesophageal amplitude and correcting for intra-individual repeated measures. ResultsMean area under the receiver operating characteristic curve for saline and viscous swallows were 0.84±0.05 and 0.84±0.04, respectively. Velocity criteria of >30cm/s when distal oesophageal amplitude>100mmHg and 8cm/s when distal oesophageal amplitude<100mmHg for saline and 32cm/s when distal oesophageal amplitude>100mmHg and >7cm/s when distal oesophageal amplitude<100mmHg for viscous had a sensitivity of 75% and specificity of 80% to identify complete bolus transit. Using these criteria, final diagnosis changed in 44.9% of patients. Abnormal bolus transit was observed in 50.9% of newly diagnosed distal oesophageal spasm patients versus 7.5% of patients classified as normal. Distal oesophageal spasm patients with distal oesophageal amplitude>100mmHg suffered twice as often from chest pain than those with distal oesophageal amplitude<100mmHg. ConclusionThe proposed velocity cut-offs for diagnosing distal oesophageal spasm improve the ability to identify patients with spasm and abnormal bolus transit.

Impedance nadir values correlate with barium bolus amount

We examined the value of impedance monitoring in measuring bolus volume compared with videoesophagram. Eighty consecutive subjects were studied with simultaneous impedance-manometry-videoesophagram. A catheter with both an impedance electrode pair and a pressure transducer at four sites (5, 10, 15, 20 cm above lower esophageal sphincter) was passed per nares. Six 10-cc boluses of 45% barium mixed with 0.9% NaCl were swallowed at 20- to 30-second intervals. When impedance fell to below 1000 ohms, other than that occurring during administered swallows, the videofluoroscopic image corresponding to the time of impedance nadir was reviewed. If barium was present at the impedance site, barium area was calculated. The video was reviewed for the cause of abnormal barium transit causing barium presence. We found 38/80 subjects had a total of 169 impedance falls to below 1000 ohms. Ninety-seven percent (164/169) of impedance falls had barium present at the impedance site, and there was good correlation (r = 0.83, P < 0.001) between impedance nadir value and barium area. The impedance nadir value : barium area relationship was similar for the three causes of barium presence identified by video: failed bolus clearing; gastroesophageal reflux; and esophageal escape. Impedance nadir values 700-999 ohms usually had a small barium area. In contrast, nadir values <400 ohms had a large barium area covering all or most of the catheter and filling the esophagus at the impedance site. Impedance falls from >1000 ohms to a low nadir value from all forms of abnormal esophageal bolus transit imply a large bolus amount.

Oesophageal motility and bolus transit abnormalities increase in parallel with the severity of gastro-oesophageal reflux disease

Limited data are available regarding the frequency of oesophageal motility and bolus transit abnormalities in subgroups of patients with gastro-oesophageal reflux disease (GERD). To assess oesophageal motility and bolus transit in endoscopically defined GERD subgroups. Patients (N=755) with typical reflux symptoms underwent upper endoscopy, conventional or impedance oesophageal manometry and/or impedance-pH testing. They were divided into: erosive oesophagitis (EO; N=340), Barrett Oesophagus (BO; N=106), non-erosive reflux disease (NERD; endoscopy-, abnormal pH and/or SAP/SI+; N=239) and functional heartburn (FH; endoscopy-, normal pH and SAP/SI-; N=70). Manometric patterns and bolus transit were defined according to previously published criteria. Increasing GERD severity was associated with decreased lower oesophageal sphincter resting pressure (P< 0.05) and distal oesophageal amplitude (P<0.01), higher prevalence of hiatal hernia (P<0.01) and increased prevalence of ineffective oesophageal motility (P<0.01). Patients with EO and BO had a significantly lower percentage of complete bolus transit compared with NERD and FH (P<0.01). Overall, abnormal bolus transit (ABT) for liquid swallows was found in 12% of FH, 20% of NERD, 54% of EO and 56% of BO (P<0.01). Combined impedance-manometry showed abnormal oesophageal function in 4% of FH, 4% of NERD, 22% of EO and 21% of BO patients with normal oesophageal manometry. Oesophageal motility abnormalities increase in parallel with the severity of GERD from NERD to EO and BO. Bolus transit abnormalities in severe reflux disease underscore the importance of impaired oesophageal function in the development of mucosal injury.

An audit of combined multichannel intraluminal impedance manometry in the assessment of dysphagia

Multichannel Intraluminal Impedance (MII) Monitoring is a method of examining oesophageal bolus transit without the need for radiation. In combination with oesophageal manometry it allows correlation of bolus transit with peristaltic activity. The clinical application of impedance manometry is still being refined. This audit looked to examine whether impedance manometry had advantages over standard manometry in assessment of patients with dysphagia. 41 patients with the presenting symptom of dysphagia were assessed by combined MII and oesophageal manometry at a Wellington Hospital between February 2008 and December 2009. Each underwent manometry and MII using standardised techniques. Achalasia was diagnosed in 23 patients (56.1%), Ineffective oesophageal motility (IEM) in 5 patients (12.2%), Diffuse oesophageal Spasm (DES) in 7 patients (17.1%), and Nutcracker oesophagus in 2 patients (4.9%). 4 patients had normal manometry studies (9.8%). All patients with achalasia, IEM, and DES had abnormal bolus transit. All patients with normal manometry had abnormal bolus transit. Both patients with nutcracker oesophagus had normal bolus transit. 4 patients with achalasia had undergone previous Hellers myotomy. Two of these patients (50.0%) now had normal LES relaxation pressures, but all four still had abnormal oesophageal peristalsis and abnormal bolus transit. Multichannel Intraluminal Impedance manometry has advantages over standard manometry in characterising the physiological abnormalities associated with dysphagia. Patients in this study had severe defects including achalasia where bolus transit was invariably poor meaning little further information was gained. Extension of this study to include a wider group of patients with dysphagia may yield different results.

Impedance detected abnormal bolus transit in patients with normal esophageal manometry. Sensitive indicator of esophageal functional abnormality?

When used in combination with manometry, multichannel intraluminal impedance better characterizes the established manometric abnormalities into those with and without associated transit defects. However, the significance of the finding of normal manometry and abnormal impedance is not known. The objective of this study is to evaluate the clinical relevance of abnormal impedance associated with normal manometry during esophageal function testing in patients with a variety of esophageal symptoms. All patients referred for esophageal function testing during a 27-month period underwent combined multichannel intraluminal impedance and esophageal manometry studies including 10 liquid and 10 viscous swallows in supine position. From 576 patients with normal esophageal body manometry we identified 158 patients (27%) with abnormal impedance. The primary symptom in these 158 patients was compared to that in 146 consecutive patients with normal manometry and normal impedance selected from the original 576 patients. Abnormal bolus transit was found with viscous, liquid and both type swallows in 60%, 19% and 21% of the patients respectively. Of patients with abnormal bolus transit, 23% presented with dysphagia compared to 10% of normal transit patients (p = 0.0035). In conclusion, abnormal impedance even in patients with normal manometry may be a sensitive indicator of esophageal functional abnormality as represented by the symptom of dysphagia in these patients. Abnormal transit was more frequently identified with viscous than liquid swallows. Prospective studies to further clarify impedance detected transit defects in patients with normal manometry and the role of viscous swallows in diagnostic testing are warranted.

Utility of esophageal impedance in identifying dysmotility in patients with erosive esophagitis

This study was intended to assess the utility of combined multiple intraluminal impedance and esophageal manometry (MII-EM) in evaluating reflux patients and in identifying those with esophageal dysmotility. Thirteen controls and 20 patients with gastroesophageal reflux disease (GERD) underwent combined MII-EM with a catheter containing four impedance-measuring segments and four solid-state pressure transducers. Each subject received 10 liquid and 10 viscous boluses to be swallowed. Distal esophageal contraction amplitude was significantly lower in GERD patients than in controls for viscous swallows (58.3 +/- 7.3 mmHg versus 82.4 +/- 4.1 mmHg, P = 0.005). Total bolus transit time was significantly slower in GERD patients than in controls for liquid swallows (P = 0.035). The percentages of complete bolus transit were significantly lower in GERD patients compared with controls (all P = 0.005). Half of GERD patients with normal EM still had abnormal bolus transit while three-quarters of those with abnormal EM had abnormal bolus transit. MII helps identify bolus transit abnormalities not detected by conventional manometry. Combined MII-EM is clinically useful for detecting esophageal dysmotility in patients with erosive esophagitis.