Assessment Of Esophageal Motility Research Articles

Ascona 2011: Proceedings of the HRM Working Group Conference–Introduction for the Proceedings of the Ascona Conference on Advances in Clinical Investigation of Esophageal Dysmotility and Reflux Disease

In April 2011, a conference ‘Advances in clinical investigation of esophageal dysmotility and reflux disease’ was held in Ascona, Switzerland. The conference was organized by members of the High-Resolution Manometry Working Group chaired by Associate Professor Dr. Mark Fox to bring together an international group of physicians and scientists with the aim to: Introduce the new ‘Chicago Classification Criteria of Esophageal Motility Disorders Defined in High Resolution Esophageal Pressure Topography’. To present guidelines that incorporate the current state of the art for investigation and management of esophageal motility disorders and gastro-esophageal reflux disease. To provide practical training to ensure best practice and maximum patient benefit wherever these technologies are applied. The Ascona meeting was supported by all the leading manufacturers of diagnostic instruments utilized in the assessment of esophageal motility and gastro-esophageal reflux. Industry representatives and engineers attended as observers because the clinical practice of esophagology is inseparable from developments in hardware and software. The key outcome of the Ascona meeting was the introduction of the ‘Chicago Classification of esophageal motility disorders’, the culmination of a series of meetings of the High-Resolution Manometry Working Group that began in San Diego at Digestive Disease Week 2008. The core content of the classification scheme was approved by the Working Group in Ascona and the lead authors were then charged with drafting the manuscript for publication in this supplement of Neurogastroenterology and Motility. This classification scheme is built on robust experimental data, and provides a clinically relevant hierarchy of diagnosis. It has been endorsed by both the European and American Neurogastroenterology and Motility Societies in addition to many other professional organizations. The authors hope that this unique consensus will not only promote better understanding of esophageal motility disorders amongst clinicians, but also provide a solid foundation for future research. Additionally this supplement provides a collection of focused topic reviews, highlights of the Ascona conference, on specific aspects of esophagology that reference the Chicago Classification and its use in clinical practice. Thus, on behalf of the members of the High-resolution Manometry Working Group, the Editorial Board of Neurogastroenterology and Motility and finally the professional organizations who have provided their endorsement of the Chicago Classification, we present the proceedings of the Ascona Conference.

Endoscopically Assisted Water Perfusion Esophageal Manometry With Minimal Sedation

To demonstrate feasibility and clinical utility of endoscopically assisted manometry (EAM). Esophageal manometry performed without sedation is the standard for assessment of esophageal motility. However, some patients cannot tolerate the procedure with intranasal intubation. We have accumulated experience performing EAM with minimal sedation on patients who cannot tolerate standard esophageal manometry. We report our single center experience of EAM in adult patients. Patient records were analyzed retrospectively. PROCEDURE PROTOCOL: Upper endoscopy is performed with minimal sedation to place a guide wire, over which a water perfusion manometry catheter is introduced and standard manometry protocol performed. From 2007 to 2009, 51 patients underwent EAM, 41 (80.4%) for failed transnasal esophageal manometry and 10 (19.6%) for Zencker diverticulum, achalasia, or neurologic disease. Five patients could not tolerate the procedure despite sedation. No early or late complications were recorded and 100% of the completed procedures were diagnostic: 15 (32.6%) patients had a normal study, 13 (28.3%) were diagnosed with achalasia, 12 (26.1%) patients had low lower esophageal sphincter pressure, 10 (21.7%) patients showed ineffective esophageal motility, 3 (6.5%) patients had hypertensive lower esophageal sphincter, and 1 (2.2%) patient had nutcracker esophagus. Completed procedures resulted in treatment for achalasia (33.3%), medication changes (33.3%), completion of preoperative assessment for antireflux surgery (27.7%), or no impact clinical management (11.1%). EAM had a direct clinical impact on 89% of patients. EAM is a safe, reliable, and feasible technique providing objective diagnostic information that directly impacted clinical management in many problematic patients where the standard procedure failed.

Comparison of High Resolution Manometry and Conventional Manometry in the Assessment of Esophageal Motility in Children

Comparison of High Resolution Manometry and Conventional Manometry in the Assessment of Esophageal Motility in Children

Elevated Nadir Impedance During Bolus Swallowing is a Marker of Dysphagia Due to Esophageal Obstruction

Introduction: Esophageal manometry and impedance measurement allows assessment of esophageal motility and associated bolus flow during swallowing in patients with esophageal dysphagia. This study examined differences in pressure-impedance derived functional measures between healthy subjects and patients with esophageal dysphagia due to bolus obstruction. Methods: Sixteen healthy adults (5 M, mean age 33yrs (range 20-48)) and 9 dysphagic patients were investigated with a combined impedance perfusion manometry catheter incorporating 7 impedance segments (2cm spaced) and 22 sidehole sensors (sensors adjacent impedance array at 2cm). The catheter was placed with the most distal impedance segment 2cm proximal to the EGJ junction. Subjects swallowed 5 x 5ml and 5 x 10ml liquid, viscous and solid boluses (total 30 swallows each). Patients swallowed 10-30 liquid, semisolid and/ or solid boluses (5-10ml). Pressure-impedance recordings were analysed for the following standard measures : total bolus transit time (TBTT), mean bolus presence time (BPT), distal contractile integral (DCI), size of the 30mmHg isocontour defect (cm<30ICP). In addition, a new automated impedance manometry (AIM) approach was used to automatically and objectively measure changes in the nadir impedance (NadImp) recorded in association with bolus flow along the esophageal body. Exported text files of swallows (30sec at 20Hz) were analysed. Impedance data were standardised to the median for each channel (presented as median standardised units, msu) and analysed objectively using a MATLAB-based algorithm. The average NadImp and the NadImp along the esophagus were assessed. Statistical analysis was done by Kruskal-Wallis One Way Analysis of Variance on Ranks (*p<0.05, **p<0.01, ***p<0.001). Results: 486 control and 185 patient bolus swallows were analysed. For all bolus consistencies, variables based on nadir impedance measurements and the DCI were significantly elevated in patients compared to controls. Standard variables were also altered however not consistently for all three bolus types; in patients, cm<30ICP was significantly less for viscous and solid, but not liquid boluses. TBTT and mean BPT were shorter for liquid and viscous boluses, but mean BPT was prolonged for solid boluses. Conclusion: NadImp variables can be derived through fully automated analysis. Of the range of functional markers assessed, NadImp was the only impedance variable that was consistently elevated in dysphagic patients for all three bolus consistencies. AIM derived NadImp variables may be useful general markers of dysphagia due to bolus obstruction.

The clinical usefulness of high-resolution manometry for the management of achalasia

Introduction: For many years, the assessment of esophageal motility relied on conventional manometry, typically performed through catheters with limited spatial resolution (pressure transducers spaced 5 cm apart). High-resolution manometry (HRM) uses a large number of closely spaced pressure sensors. This arrangement enables continuous monitoring of the entire pressure profi le from the pharynx to the stomach. Advances in computer processing have allowed this increased amount of data to be displayed as spatiotemporal plots rather than simple line graphs; these HRM pressure topography plots are considered more intuitive and may decrease interpretation time, and they provide a simpler and faster way to perform manometry because the “pull through” required to identify the lower esophageal sphincter and position the conventional manometry catheter is obviated [1]. Moreover, HRM provides accurate measurement of the esophageal sphincters in the presence of esophageal shortening or catheter displacement because the closely spaced sensors provide continuous monitoring of all pressure zones. Finally, HRM pressure topography can distinguish between luminal pressurization due to muscular contractions and that caused by retained bolus material [2]. Studies in healthy volunteers recently have defi ned normal fi ndings for esophageal peristalsis [3] and esophagogastric junction dynamics [4], and a classifi cation of esophageal motility disorders based on pressure topography has begun to take shape [5]. This classifi cation includes three achalasia subtypes based on HRM topography fi ndings in the esophageal body: negligible pressurization, pan-esophageal pressurization, and spastic contractions. Understandably, HRM has generated much enthusiasm. However, studies clearly documenting the advantages of this technique over conventional manometry in the clinical setting have been lacking. The study discussed here by Pandolfi no et al. addresses the usefulness of HRM in the management of achalasia.

New esophageal function testing (impedance, Bravo pH monitoring, and high-resolution manometry): Clinical relevance

Esophageal testing aims to quantify gastroesophageal reflux or characterize esophageal motility. Reflux monitoring traditionally has been based on the detection of acidic reflux by a transnasal catheter that measures esophageal pH. Recently there have been two major developments in this field: the wireless Bravo pH capsule (Medtronic, Inc., Minneapolis, MN), which allows catheter-free monitoring, and impedance-pH measurement, a catheter-based technique that enables detection of acidic and nonacidic reflux. The assessment of esophageal motility has relied on conventional manometry for many years. Two new procedures also recently became available to assess esophageal motility: high-resolution manometry, which uses many closely spaced pressure sensors and provides spatiotemporal plots of esophageal pressure changes, and impedance manometry, a test that directly measures bolus transit and provides conventional manometric data. The advantages, disadvantages, and clinical importance of these new esophageal tests are discussed in this review.

High-Resolution Esophageal Manometry: A Time Motion Study

High-resolution manometry (HRM) of the esophagus is a new technique that provides a more precise assessment of esophageal motility than conventional techniques. Because HRM measures pressure events along the entire length of the esophagus simultaneously, clinical procedure time should be shorter because less catheter manipulation is required. According to manufacturer advertising, the new HRM system is more accurate and up to 50% faster than conventional methods. To test the hypothesis that clinical testing with HRM requires less procedural time than a standard water perfusion (WP) method. Forty-one consecutive patients were studied (20 underwent WP and 21 underwent HRM). Using time-motion analysis, the start and end times for each task associated with performing the study were recorded. Patient discomfort and study quality were also assessed by using five- and four-point qualitative scales, respectively. Total procedure time was reduced on average by 25.6% in the HRM group (from 41.8 minutes with WP to 30.7 minutes with HRM, P<0.05). There was no significant difference in the discomfort scores reported by the study subjects and no difference in study quality. HRM requires less time to complete than conventional manometry and should therefore shorten the wait-times of patients scheduled for esophageal manometry and have a significant impact on the cost of performing this commonly used clinical investigation.

The effect of laparoscopic Nissen fundoplication on laryngeal findings and voice quality

This study aimed to report the need for an ear, nose, and throat (ENT) specialist to evaluate the laryngeal findings and the voice quality of patients with gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) symptoms before and after surgery. For this study, 38 GERD patients who had a Reflux Symptom Index (RSI) score higher than 14 underwent complete assessment in the ENT department. Standard 24-h pH monitoring, esophageal motility assessment, a detailed ENT examination including the RSI, the Reflux Finding Score (RFS), and objective voice analysis were performed for all the patients before reflux surgery, then 6 to 8 months afterward. The subject's mean RSI scores were 25.45 +/- 7.5 before and 16.52 +/- 5.06 after surgery (p < 0.05), and the mean RFS scores were, respectively, 10.37 +/- 2.7 and 5.5 +/- 1.45 (p < 0.05). The pre- and postoperative differences in the RSI and RFS scores and the voice parameters were statistically significant. Objective voice analysis, RSI, and RFS can be used to evaluate the postoperative results for GERD patients with LPR symptoms. Examination of these patients by an ENT specialist is necessary before and after the operation.

Esophageal Ultrasonography: A New View on Esophageal Motility

Esophageal manometry has long been the gold standard for assessment of esophageal motility. Recently, high-frequency intraluminal ultrasonography (HFIUS) has been introduced to measure esophageal contractility and the thickness of esophageal muscle. Greater esophageal muscle thickness has been reported in patients with achalasia, diffuse spasm, and hypertensive peristalsis. In this issue of the Journal, Mittal and colleagues report additional observations in patients with esophageal symptoms referred for esophageal manometry. Their findings confirm earlier observations in patients with spastic motor disorders and report new findings of greater muscle thickness in patients with nonspecific motor disorders as well as normal manometry. Greater muscle thickness was associated with a greater prevalence of dysphagia suggesting the possibility that symptoms may be related, at least in part, to alterations in the biomechanics of the esophagus. The place of HFIUS in the assessment of esophageal function remains to be determined, but it offers the possibility of greater insights into esophageal physiology as well as clinical esophageal motor disorders.

Derived M-mode Ultrasonography: A Valuable Imaging Modality for the Visual Assessment of Esophageal Motility

Background: Imaging of esophagus (ES) using catheter-based high frequency US (HFUS) allows measurement of longitudinal muscle activity of the ES. Visual inspection of 2-D HFUS image does not provide insight into changes in the muscle thickness (MT) over time and quantitation of the HFUS image is time consuming and laborious. Aim: To improve our understanding of the changes in MT over time, we derived m-mode images from the 2-D HFUS image during swallow-induced bolus transport in ES. Method: We acquired 2-D HFUS image from normal subjects at 30 fps using an HP Sonos 100 platform interfaced to a 3.5 F, 30 MHz transducer. A manometry and an US probe were positioned through the nose in the ES 5 cm above the LES. Data were acquired during a 5 ml bolus swallow. Data Analysis: HFUS images were digitized to a PC. On one of the 2-D HFUS images, an m-mode image plane to be analyzed was selected as a line passing through the center of the catheter. By sectioning the 2-D stacked images (30 fps) for the entire duration we created 8 m-mode images that were spatially separated 45o relative to the selected plane. For the same interval 2-D HFUS images were also quantitated for MT every 4th frame. Resultant MT information was time-aligned and superimposed over the m-mode image. Results: The figure shows an m-mode image of a normal swallow from a healthy volunteer with time-aligned manometric pressures (PR), calculated cross-sectional area (CSA) and MT. Segments A, B and C are resting, distension and contraction phases of the swallow. Longitudinal (C1) and circular (C2) contraction period are also identified. Conclusion: M-mode display of 2-D HFUS image is an effective method for visual inspection of changes in MT with changes in pressure over time, and may provide better understanding of the physiology and pathophysiology of the esophagus.

Manometric assessment of esophageal motility in patients with primary Sjögren's syndrome.

The aim of this study was to assess the esophageal motility by manometry in patients with primary Sjögren's syndrome. Esophageal manometry was carried out in 40 patients with primary Sjögren's syndrome (SS), 15 with rheumatoid arthritis (RA), 15 with RA and secondary SS, and 21 healthy volunteers. We found that the mean lower esophageal sphincter (LES) pressures measured by station pull-through and rapid pull-through techniques were significantly higher in primary SS patients than with healthy controls and RA patients with or without SS (P<0.05). Our study did not show any major differences when comparing the three patient groups (P>0.05). However, peristaltic contraction velocity was lower and peristaltic contraction duration significantly higher at the middle and lower thirds of the esophagus in primary SS patients than in healthy controls (P<0.05). The results of our study support the view that various esophageal motility disorders can be found in patients with primary SS which could be related to an increase in LES pressure. We also found no correlation of the esophageal abnormalities with other factors studied, suggesting that the cause of dysphagia is multifactorial in nature.

Assessment of esophageal motility in achalasia using high frequency ultrasonographic (HFIUS) study

Assessment of esophageal motility in achalasia using high frequency ultrasonographic (HFIUS) study

Assessment of esophageal motility in achalasia using high frequency introluminal ultrasonography (HFIUS)

Assessment of esophageal motility in achalasia using high frequency introluminal ultrasonography (HFIUS)

Assessment of esophageal motility in achalasia using high frequency introluminal ultrasonography (HFIUS)

Assessment of esophageal motility in achalasia using high frequency introluminal ultrasonography (HFIUS)

Assessment of esophageal motility in achalasia using high frequency ultrasonographic (HFIUS) study

Assessment of esophageal motility in achalasia using high frequency ultrasonographic (HFIUS) study

Abnormal Esophageal Body Function: Radiographic-Manometric Correlation

Stationary manometry is the gold standard for the evaluation of patients with suspected esophageal motility disorders. Comparison of videoesophagram in the evaluation of esophageal motility disorders with stationary motility has not been objectively studied. Two hundred two patients with foregut symptoms underwent stationary motility and videoesophagram. Radiographic assessment of esophageal motility was done by video recording of five 10-cc swallows of barium. Abnormal esophageal body function was defined by stasis of barium in the middle third of the esophagus on at least four swallows or stasis on at least three swallows in the distal third. Stationary manometry was performed using a five-channel water perfused system. Contraction amplitudes <25 mm Hg in any of the last two channels or the presence of simultaneous or interrupted waves in 10 per cent or more were considered to be abnormal. Sixty-two patients had abnormal manometry. Thirty-four patients also demonstrated abnormal videoesophagrams for an overall sensitivity of 55 per cent. The positive predictive value was 53 per cent; specificity was 79 per cent; and negative predictive value was 80 per cent. Sensitivity was greatest in patients with achalasia (94%) and scleroderma (100%) and in patients presenting with dysphagia (89%). Sensitivity was poor for nonspecific esophageal motility disorders. A videoesophagram is relatively insensitive in detecting motility disorders. It seems most useful in the detection of patients with esophageal dysfunction, for which surgical treatment is beneficial, and in those patients presenting with dysphagia.

Factors Determining Pressure Measurement Accuracy by Intraluminal Esophageal Manometry

Measurement accuracy represents an important prob­ lem for all physicians using esophageal pressure determi­ nations for clinical or investigative assessment of esoph­ ageal motor function. Although intraluminal manometry is generally regarded as providing sophisticated quanti­ tative assessment of esophageal motility, the examina­ tion, as currently performed, often yields only semiquan­ titative information. Inaccurate esophageal pressure measurement causes two major problems: (1) measurement artifact, and (2) measurement insensitivity. In some circumstances, ap­ parent differences in esophageal pressure values between subject groups may represent measurement artifact rather than real physiological or pathological differ­ ences. In contrast, measurement insensitivity may ob­ scure real differences in esophageal pressures existing between subject populations, causing such differences to go unrecognized. Clearly, reduction or elimination of measurement inaccuracy is desirable. We believe that the instrumentation and methodology are now available to achieve accurate quantitation of esophageal pressure activity. Esophageal pressure values obtained by manometry are determined by several different factors, including: recording system perform­ ance fidelity, recording technique, scoring method, and conditions existent during manometry. All these factors must be dealt with satisfactorily in order to achieve precise esophageal pressure measurements. Instrumentation In the late nineteenth centrury esophageal pressure studies were first performed by Kronecker and Meltzer 1 using intraluminal balloons. The balloon method under­ went modification,2, a but remained the major technique for recording esophageal motor activity until the early 1950's. Because this cumbersome method featured am­ plitude lag at high frequencies, and sphincter pressure varied with different balloon diameters,4-6 investigators sought other recording methods. In the 1950's Ingelfinger's group in Boston,7, 8 Code