Contractile Integral Research Articles

Novel Diagnostic Criteria for Functional Esophageal Disorders

The diagnosis of functional esophageal disorders has evolved from conventional manometry in 1970s to high-resolution manometry in 2010s. The conventional manometry was based on linear plot, whereas newly developed high-resolution manometry is based on spatiotemporal plots. Additionally, novel parameters including integrated relaxation pressure, distal contractile integral, and distal latency have expanded our understanding of pathophysiology of functional esophageal disorders including esophageal achalasia. Following three rounds of revision, the fourth version of Chicago classification of esophageal motility disorders was developed, which is more closely related to clinical situations compared with the previous versions. Moreover, functional lumen imaging probe (FLIP), based on the distensibility of esophageal lumen and sphincter, has also strengthened our understanding of functional esophageal disorders.

Clinical presentation and therapeutic outcome of patients with jackhammer esophagus—a multicenter cohort study in Japan

BackgroundJackhammer esophagus (JE) is a hypercontractile esophageal motility disorder diagnosed using high-resolution manometry (HRM). We sought to determine the clinical presentation and therapeutic data of patients with JE in Japan.MethodsThe study included patients with JE, diagnosed through HRM performed for suspicious esophageal motility disorders. Demographics, esophagogastroduodenoscopy, radiology, and therapy data were collected from patient charts.ResultsAmong the 4,412 HRM tests performed, 89 patients (61.6 ± 13.4 years; 64 males, 25 females) were diagnosed with JE (2.0%). Dysphagia was the most frequent symptom (80%), followed by chest pain (40%) and heartburn (25%). Esophagogastroduodenoscopy showed abnormal findings in 32% of patients: corkscrew/rosary beads appearance in 26%, narrowing in 11%. Eosinophilic infiltration (> 15 eosinophils/high power field) was diagnosed in 21%. Esophagography showed abnormal findings in 9% of the patients. For the initial therapy, 47 patients received medical treatment followed by peroral endoscopic myotomy (21 patients) and laparoscopic myotomy (two patients). Thirteen patients did not receive any treatment and 10 of those (77%) reported spontaneous resolution of symptoms. Patients who required invasive treatment experienced severe disability in their quality of life and greater maximal distal contractile integral than those who did not.ConclusionsHRM showed that the prevalence of JE was very low (2%). Esophagogastroduodenoscopy revealed some characteristic features of JE in patients. Some patients showed improvement of symptoms without invasive treatments. Follow-up with/without medical treatment should be considered before performing invasive treatment in patients whose distal contractile integral is relatively low and the quality of life is not impaired.

Solid bolus swallows during high-resolution manometry complement multiple rapid swallows in predicting symptoms following antireflux surgery.

Solid bolus swallows (SBS) assess esophageal peristalsis on high-resolution manometry (HRM). It remains unknown if increase in contraction vigor (contraction reserve) following SBS (SBS-CR) provides information similar to that observed following multiple rapid swallows (MRS-CR). Clinical and HRM data from adult patients (n=96, age 58.2years, 61.5% female) undergoing esophageal testing prior to anti-reflux surgery (ARS) were analyzed if both MRS and SBS were available, and compared to similar data from healthy asymptomatic volunteers (n=18, age 27.5years, 55.6% female). Patients reported esophageal symptoms before and after ARS using 5-point Likert scales evaluating symptom frequency and severity; scores for each patient were averaged to determine global symptoms. Distal contractile integral (DCI) from single swallows was compared to MRS DCI and SBS DCI; the ratio of single swallow DCI to MRS DCI or SBS DCI ≥1 determined the presence of contraction reserve. Multiple rapid swallows CR was concordant with SBS CR in 55.6% of healthy volunteers, 100% of absent contractility, 100% of ineffective esophageal motility (IEM) and 56.9% without IEM. Correlation between MRS DCI and SBS DCI was highest when IEM criteria were met (Spearman's rho 0.998). While neither MRS CR nor SBS CR presence differed by presenting symptoms or global symptom score at baseline, post-ARS global symptom burden was highest in the absence of both MRS CR and SBS CR, especially in patients with esophageal hypomotility using Chicago Classification version 4.0 criteria (p=0.03). Multiple rapid swallows and SBS are complementary in predicting post-ARS symptom burden.

A132 ACHALASIA FOLLOWING A SARS-COV-2 INFECTION: A CASE REPORT

BackgroundSARS-CoV-2 is a novel virus currently causing a major pandemic. Recent studies have shown that SARS-CoV-2 has an affinity to ACE2 receptors which are present in the olfactory epithelium as well as the pulmonary and gastrointestinal (GI) systems. It is stipulated that these receptors are responsible for the entry of the virus into cells explaining the respiratory and GI symptoms of this infection. The anosmia related to COVID-19 is likely due to an aberrant immune response to the virus rather than direct damage to the olfactory epithelium. Similarly, achalasia is also believed to result from an aberrant immune response through which there is degeneration of inhibitory neurons in the myenteric plexus. In this case report, we present the first case of achalasia thought to be linked to a SARS-CoV-2 infection in contemporary literature.AimsWe hypothesize that SARS-CoV-2 caused an aberrant immune response in our patient, leading him to develop achalasia. We hope to expose clinicians to this potential complication of COVID-19, allowing them to consider it sooner in their differential.MethodsThe patient’s file was reviewed to extract the relevant information. A second gastroenterologist’s opinion was obtained on the manometry to confirm the diagnosis of type III achalasia.ResultsA 61-year-old man with a medical history of myasthenia gravis, chronic obstructive pulmonary disease, hypothyroidism, and chronic renal failure was treated in our establishment for a SARS-CoV-2 pneumonia. He experienced new severe dysphagic symptoms, regurgitations, and lost 10 pounds during his hospitalization. He also developed anosmia and diarrhea. A CT-scan of his neck and thorax showed no extrinsic compression of his esophagus. No neoplasm was found on his gastroscopy. A barium study was then conducted showing a stagnation of contrast in the distal third of his esophagus. No relaxation of the inferior gastroesophageal sphincter was noted. A manometry was then performed and confirmed a type III achalasia. The mean lower esophageal sphincter residual pressure was elevated at 43.7 mmHg. A calculated 69% of wet swallows were premature contractions with a distal latency value less than 4.5 seconds. The mean distal contractile integral was 13613 mmHg. This corroborates the spastic nature of type III achalasia.ConclusionsConsidering that our patient developed anosmia and knowing its pathogenesis in the context of COVID-19, an inappropriate immune response to SARS-CoV-2 could have equally taken place in the esophagus. This inflammatory response might have caused the degeneration of the inhibitory neurons in the myenteric plexus responsible for the achalasia. Furthermore, given the fact that our patient had diarrhea, this suggests that the virus has a GI tropism supporting our hypothesis. We therefore believe that achalasia may be a potential complication of COVID-19. High resolution esophageal motility study showing a type III achalasia pattern.Funding AgenciesNone

Accuracy of High-Resolution Pharyngeal Manometry Metrics for Predicting Aspiration and Residue in Oropharyngeal Dysphagia Patients with Poor Pharyngeal Contractility.

Several physiological metrics can be derived from pharyngeal high-resolution impedance manometry (HRPM), but their clinical relevance has not been well established. We investigated the diagnostic performance of these metrics in relation to videofluoroscopic (VFS) assessment of aspiration and residue in patients with oropharyngeal dysphagia. We analyzed 263 swallows from 72 adult patients (22-91 years) with diverse medical conditions. Metrics of contractility, upper esophageal sphincter (UES) opening and relaxation, flow timing, intrabolus distension pressure, and a global Swallow Risk Index (SRI) were derived from pressure-impedance recordings using pressure-flow analysis. VFS data were independently scored for airway invasion and pharyngeal residue using the Penetration-Aspiration Scale and the Normalized Residue Ratio Scale, respectively. We performed multivariate logistic regression analyses to determine the relationship of HRPM metrics with radiological outcomes and receiver-operating characteristic (ROC) analysis to evaluate their diagnostic accuracy. We identified aspiration in 25% and pharyngeal residue in 84% of the swallows. Aspiration was independently associated with hypopharyngeal peak pressure < 65mmHg (HypoPeakP) [adjusted odds ratio (OR) 5.27; 95% Confidence Interval (CI) (0.99-28.1); p = 0.051], SRI > 15 [OR 4.37; 95% CI (1.87-10.2); p < 0.001] and proximal esophageal contractile integral (PCI) < 55mmHg·cm·s [OR 2.30; 95% CI (1.07-4.96); p = 0.034]. Pyriform sinus residue was independently predicted by HypoPeakP < 65mmHg [OR 7.32; 95% CI (1.93-27.7); p = 0.003], UES integrated relaxation pressure (UES-IRP) > 3mmHg [OR 2.96; 95% CI (1.49-5.88); p = 0.002], and SRI > 15 [OR 2.17; 95% CI (1.04-4.51); p = 0.039]. Area under ROC curve (AUC) values for individual HRPM metrics ranged from 0.59 to 0.74. Optimal cut-off values were identified. This study demonstrates the diagnostic value of certain proposed and adjunct HRPM metrics for identifying signs of unsafe and inefficient bolus transport in patients with oropharyngeal dysphagia.

Quantitative assessment of multichannel intraluminal impedance pH and its clinical implications.

We sought to quantify the characteristics of acid reflux episodes in patients with extraesophageal GERD symptoms (EES), hiatal hernia (HH), and erosive esophagitis (EroE) using multichannel intraluminal impedance pH (MII‐pH) and investigate the correlation between impedance parameters and high resolution esophageal manometry (HREM). This was a retrospective analysis of esophageal manometric and impedance data inpatients with typical GERD symptoms who underwent both HREM and 24 h MII‐pH tests. Within the three patient subgroups, we evaluated impedance metrics such as average height of reflux, total duration of reflux, maximum duration of reflux, average pH, and average area of reflux. We also introduce a novel composite reflux index (CRI) metric, which is a measure of reflux height, duration, and acidity. Patients with EES exhibited a 29.3% increase in average height of reflux, compared to non‐EES patients (p < 0.01); the average height of reflux was found to be an independent predictor of EES (p < 0.01). Patients with HH showed a 190% longer total reflux duration (p < 0.01, vs. non‐HH patients). Total reflux duration was twice as long in EroE patients compared to those without (p = 0.02). Average CRI was significantly different within all three subgroup comparisons (p < 0.01). Impedance metrics shared weak negative correlations with lower esophageal sphincter (LES) rest pressure and distal contractile integral (DCI), and weak positive correlations with % absent peristalsis (p < 0.05 to p < 0.01 for various parameters). Quantitative impedance metrics provide useful insight into the pathophysiology of reflux in patients with EES, HH, and EroE.

Esophageal Bolus Domain Pressure and Peristalsis Associated With Experimental Induction of Esophagogastric Junction Outflow Obstruction.

Background/AimsIntrabolus pressures are important for esophageal bolus transport and may detect obstructed bolus flow. This study measured the effect esophageal outflow obstruction experimentally induce by a leg-lift protocol.MethodsTwenty-five gastroesophageal reflux disease patients referred for esophageal manometry and a normal motility diagnosis were included. Supine liquid swallows were tested. Leg-lift protocol generated esophageal outflow obstruction by increasing abdominal pressure. Esophageal pressure topography and intrabolus pressure metrics were calculated. These included, (1) mid-domain bolus distension pressure during esophageal emptying (DPE, mmHg) and (2) ramp pressure (mmHg/sec), generated by compression of the bolus between the peristaltic contraction and esophagogastric junction (EGJ).ResultsEGJ relaxation pressure was increased by leg-lift from 13 (11-17) to 19 (14-30) mmHg (P < 0.005) and distal contractile integral also increased from 1077 (883-1349) to 1620 (1268-2072) mmHg∙cm∙sec (P < 0.001) as a physiological response to obstruction. All bolus pressures were increased by leg lift; DPE increased from 17 (15-20) to 27 (19-32) mmHg (P < 0.001), and ramp pressure increased from 3 (1-4) to 5 (2-9) mmHg/sec (P < 0.05).ConclusionMeasuring pressures within the intrabolus domain can quantify changes related to obstruction to outflow and may serve as adjunct measures for confirming a diagnosis EGJ outflow obstruction.

Association of Bolus Transit Time on Barium Esophagram With Esophageal Peristalsis on High-resolution Manometry and Nonobstructive Dysphagia.

The goal of this study was to correlate upright and prone bolus transit time (BTT) on barium esophagography (BE) with esophageal peristalsis on high-resolution manometry (HRM) and self-reported dysphagia in patients with normal lower esophageal sphincter parameters on HRM. BTT on BE could be the gold standard for assessing the effectiveness of esophageal peristalsis if it can be quantified. Patients with normal lower esophageal sphincter parameters and standard-protocol BE from 2017 to 2020 were included. Patients were divided, based on the number of normal swallows (distal contractile integral >450 mm Hg-s-cm), into 11 groups (10 normal swallows to 0 normal swallows). Liquid barium swallows in prone position were objectively evaluated for prone BTT. Patients reported difficulty in swallowing on a scale from 0 (none) to 4 (very severe). Fractional polynomial and logistic regression analysis were used to study the association (along with the rate of change) between BTT, peristalsis, and dysphagia. A total of 146 patients were included. Prone BTT increased as the number of normal swallows decreased ( P <0.001). Two deflection points were noted on the association between peristalsis and prone BTT at 50% normal swallows, 40 seconds and 30% normal swallows, 80 seconds, after which peristaltic function declined independently of prone BTT. Patients with prone BTT>40 seconds had nearly 6-fold higher odds of 0% normal swallows on HRM than patients with prone BTT<40 seconds ( P =0.002). Increasing prone BTT was associated with increasing dysphagia grades 1 and 2 ( P ≤0.036). Esophageal motility can be quantified by BE. Prone BTT correlates with the proportion of normal esophageal swallows and dysphagia.

Нарушение перистальтики пищевода и преобладание экспрессии CD206 у пациентов с гастроэзофагеальной рефлюксной болезнью

Objective. To study the immune response and esophageal motility in patients with non-erosive reflux disease (NERD), gastroesophageal reflux disease (GERD) complicated by intestinal-type cylindrical cell metaplasia (CCM), and Barrett’s esophagus (BE). Patients and methods. The study included 30 patients: 10 patients with NERD, 10 patients with GERD complicated by intestinaltype CCM, and 10 patients with BE. All patients underwent high-resolution esophageal manometry. The expression levels of surface receptors CD25, CD80 (Th1-type immune response) and CD163, CD206 (Th2-type immune response) were analyzed. Results. The analysis revealed high CD206 expression in patients with NERD and GERD complicated by intestinal-type CCM compared to BE (р = 0.011, р = 0.075, respectively). In patients with NERD, median distal contractile integral (DCI) was 920 [178; 2033] mmHg⋅s⋅cm; in patients with GERD complicated by intestinal-type CCM, it was 1046 [223; 3759] mmHg⋅s⋅cm; in patients with BE – 276 [1; 1870] mmHg⋅s⋅cm. Patients with BE had ineffective esophageal motility more often than patients with NERD and GERD complicated by intestinal-type CCM (р = 0.06, р = 0.052, respectively). Lower esophageal sphincter pressure was 22.5 [8; 40] mmHg in patients with NERD, 18.0 [7.0; 36.0] mmHg in patients with GERD complicated by intestinal-type CCM, and 14.5 [1.0; 30.0] mmHg in patients with BE. The positive correlation between high CD206 expression and DCI (r = 0.317, р = 0.077) was determined. Conclusion. The role of esophageal motility disorder and immune response in patients with GERD should be further studied to assess their impact on the course of the disease. Key words: gastroesophageal reflux disease, immune response, high-resolution esophageal manometry, metaplasia

Pharyngo-Esophageal Modulatory Swallow Responses to Bolus Volume and Viscosity Across Time.

Objectives/HypothesisModulation of the pharyngeal swallow to bolus volume and viscosity is important for safe swallowing and is commonly studied using high‐resolution pharyngeal manometry (HRPM). Use of unidirectional pressure sensor technology may, however, introduce variability in swallow measures and a fixed bolus administration protocol may induce time and order effects. We aimed to overcome these limitations and to investigate the effect of time by repeating randomized measurements using circumferential pressure sensor technology.Study DesignSub‐set analysis of data from the placebo arm of a randomized, repeated measures trial.MethodsHRPM with impedance was recorded using a solid‐state catheter with 36 circumferential pressure sensors and 18 impedance segments straddling from hypopharynx to stomach. Testing included triplicates of 5, 10, and 20 ml thin liquid and 10 ml thick liquid boluses, the order of the thin liquid boluses was randomized. The swallow challenges were repeated approximately 10 minutes after finishing the baseline measurement.ResultsWe included 19 healthy adults (10/9 male/female; age 24.5 ± 4.1 year). Intrabolus pressure, all upper esophageal sphincter (UES) opening and relaxation metrics, and flow timing metrics increased with larger volumes. A thicker viscosity decreased UES relaxation time, UES basal pressure, and flow timing metrics, whereas UES opening extent increased. Pre‐swallow UES basal pressure and post‐swallow UES contractile integral decreased over time.ConclusionUsing circumferential pressure sensor technology, the effects of volume and viscosity were largely consistent with previous reports. UES contractile pressures reduced over time. The growing body of literature offers a benchmark for recognizing aberrant pharyngo‐esophageal motor responses.Level of Evidence3 Laryngoscope, 132:1817–1824, 2022

Comparison of 180° anti-reflux mucosectomy versus 270° anti-reflux mucosectomy for treatment of refractory gastroesophageal reflux disease: a retrospective study

BackgroundAnti-reflux mucosectomy (ARMS) is a novel endoscopic treatment for refractory gastroesophageal reflux disease (rGERD). Several studies have validated its safety and effectiveness, but postoperative dysphagia remains in concern. Since the influence of different resection ranges on efficacy and complications of ARMS has rarely been studied, this study aimed to compare outcomes of 180°ARMS and 270°ARMS in treatment of rGERD.MethodsThis study was conducted from August 2017 to September 2020. 39 eligible patients underwent either 180° ARMS or 270° ARMS and followed up at 6 months postoperation. Primary outcome measure was assessed by Gastroesophageal Reflux Disease Questionnaire (GERD-Q). Secondary outcomes included quality of life, PPI use, gastroesophageal flap valve grade, presence of reflux esophagitis, acid exposure time (AET), distal contractile integral (DCI), and integrated relaxation pressure (IRP) measured by high-resolution manometry (HRM) and complication rate. Per-protocol analysis was performed.ResultsAmong 39 patients, 18 underwent 180° ARMS, while 21 underwent 270° ARMS. At postoperative 6 months follow-up period, primary outcome showed no significant difference between two groups (p = 0.34). Similarly, no significant difference was demonstrated between groups regarding most secondary outcomes except for fewer complaints of newly dysphagia in 180° ARMS group. No other serious complications were observed in both groups.ConclusionAlthough 180° ARMS and 270° ARMS could be equally effective for treatment of rGERD, 180° ARMS might be more recommended due to lower incidence of newly post-procedural dysphagia.

Comparative Analysis of Relaxation Time Interval and Integrated Relaxation Pressure as Risk Factors for Aspiration in Patients With Oropharyngeal Dysphagia.

Background/AimsIntegrated relaxation pressure (IRP) is an important metric for functional evaluation of the lower esophageal sphincter. However, the effectiveness of IRP for evaluation of upper esophageal sphincter (UES) function has not yet been clarified.MethodsHigh-resolution manometry (HRM) was performed in 180 patients with dysphagia. For comparison, 26 asymptomatic subjects were also recruited. IRP of the UES was defined as means of 0.2, 0.25, or 0.3 seconds (sIRPs) of maximal deglutitive relaxation in a 0.4-second window (a new equation for IRP calculation was developed using MATLAB). Also, the relaxation time interval of the UES, and mesopharyngeal and hypopharyngeal contractility (as a contractile integral) were evaluated using HRM.ResultsIn normal subjects, mean values of 0.2, 0.25, and 0.3 sIRPs differed significantly from each other (P < 0.05). They were not associated with the relaxation time interval of the UES. In contrast, in patients with dysphagia, mean values of 0.2, 0.25, and 0.3 sIRPs were strongly related to relaxation time intervals of the UES (P < 0.05), and mean values of 0.2, 0.25, and 0.3 sIRPs in patients with aspiration were significantly higher than those of patients without aspiration (P < 0.01). However, in multivariate regression analyses, the main risk factor for aspiration was only a shorter relaxation time interval.ConclusionsIRP values were significantly higher in patients with dysphagia and aspiration. However, its usefulness as a predictive factor for aspiration was less than the relaxation time interval of the UES.

Patients With Definite and Inconclusive Evidence of Reflux According to Lyon Consensus Display Similar Motility and Esophagogastric Junction Characteristics.

Background/AimsThe role of esophageal high-resolution manometry (HRM) within Lyon consensus phenotypes, especially patients with inconclusive gastroesophageal reflux disease (GERD) evidence, has not been fully investigated. In this multicenter, observational study we aim to compare HRM parameters in patients with GERD stratified according to the Lyon consensus.MethodsClinical and endoscopic data, HRM and multichannel intraluminal impedance-pH (MII-pH) studies performed off proton pump inhibitor therapy in patients with esophageal GERD symptoms were reviewed. Lyon consensus criteria identified pathological GERD, reflux hypersensitivity, functional heartburn, and inconclusive GERD. Patients, with inconclusive GERD were further subdivided into 2 groups based on total reflux numbers (≤ 80 or > 80 reflux episodes) during the MII-pH recording time.ResultsA total of 264 patients formed the study cohort. Pathological GERD and inconclusive GERD patients were associated with higher numbers of reflux episodes, lower mean nocturnal baseline impedance (MNBI) values, and a higher proportion of patients with pathologic MNBI compared to functional heartburn (P < 0.05 for each comparison). On multivariate analysis, pathological GERD and inconclusive GERD patients, both with ≤ 80 or > 80 reflux episodes, were significantly associated with pathologic esophagogastric junction contractile integral values and with presence of hiatus hernia (type 2/3 esophagogastric junction). Patients with inconclusive GERD and > 80 reflux episodes were significantly associated with fragmented peristalsis and ineffective esophageal motility whilst inconclusive GERD with ≤ 80 reflux episodes were significantly associated with fragmented peristalsis.ConclusionEsophageal motor parameters on HRM are similar between pathologic and inconclusive GERD according to the Lyon consensus.

Symptom Severity Related With Contraction Peaks in Patients With Jackhammer Esophagus.

Background/AimsJackhammer esophagus is an uncommon heterogeneous motility disorder associated with a distal contractile integral > 8000 mmHg∙sec∙cm. The spectrum of abnormality ranges from a relatively normal looking contraction to chaotic repetitive contractions akin to a jackhammer. Although previous studies have shown an uncertain correlation between peristaltic vigor and symptoms, we hypothesize that symptoms may be more severe with repetitive contractions as opposed to an elevated contractile measure. Thus, this study aims to investigate whether symptom severity is related to the contraction pattern in the patients with hypercontractile esophagus.MethodsPatients with hypercontractile esophagus were retrospectively identified, their demographic and high-resolution manometry characteristics were collected. Contraction pattern on high-resolution manometry was categorized into single-peak and multiple-peak. Comparison was performed between patients with single-peak and multiple-peak.ResultsAltogether 35 patients (age range, 45-70 years; femalemale, 2411) were included. Seven patients presented with single-peak hypercontractile swallows, while 28 patients presented with multiple-peak hypercontractile swallows. The patients with multiple-peak showed higher Brief Esophageal Dysphagia Questionnaire scores compared with patients with single-peak. The jackhammer swallows with multiple-peak were associated with higher distal contractile integral values, longer distal latency intervals, and a lower integrated relaxation pressure.ConclusionsRepetitive contractions akin to a jackhammer were common amongst patients with hypercontractile esophagus. Patients with the jackhammer pattern also presented with more severe symptoms. Further distinction of hypercontractile esophagus into a jackhammer dominant subtype may be warranted.

The Natural Swallow: Factors Affecting Subject Choice of Bolus Volume and Pharyngeal Swallow Parameters in a Self-selected Swallow.

Predetermined volumes are used extensively throughout clinical assessment of swallowing physiology, but bolus volumes selected by an individual in their natural swallow can vary greatly from those used in structured assessment. This study aims to identify factors influencing self-selected volume and how the mechanics of self-selected volume swallows differ from predetermined volume swallows. We used pharyngeal high-resolution manometry (HRM) with simultaneous videofluoroscopy to measure swallowing pressures in the velopharynx, hypopharynx, and upper esophageal sphincter (UES). Data were collected from 95 healthy adults during thin liquid swallows of 10mL and a self-selected comfortable volume. An intraclass correlation coefficient (ICC) was calculated to analyze within-subject self-selected volume reliability. Linear mixed effects regression models were used to examine the association of subject characteristics with self-selected swallow volume and of self-selected volumes on pharyngeal swallowing pressures and timing events. Mean self-selected volume was 16.66 ± 7.70mL. Increased age (p = 0.002), male sex (p = 0.021), and increased pharyngeal hold area (p = 0.007) were significantly associated with increase in self-selected bolus volume. There was good reliability between subjects' individual swallow volumes (ICC = 0.80). Velopharyngeal maximum pressure and pressure integral, tongue base duration and maximum pressure, UES pre- and post-swallow maximum pressure, and overall pharyngeal contractile integral decreased significantly with self-selected boluses. Understanding a patient's natural swallow volume, and how their natural swallow functions, will be important for designing clinical evaluations that place stress on the patient's natural swallowing mechanics in order to assess for areas of dysfunction.

Impaired Proximal Esophageal Contractility Predicts Pharyngeal Reflux in Patients With Laryngopharyngeal Reflux Symptoms.

OBJECTIVES:The pathophysiology of laryngopharyngeal reflux (LPR) remains incompletely understood. Proximal esophageal motor dysfunction may impair bolus clearance, increasing the risk of pharyngeal refluxate exposure. We aimed to evaluate the association of proximal esophageal contractility with objective reflux metrics.METHODS:We evaluated adults with LPR symptoms undergoing high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing at a tertiary center between March 2018 and August 2019. Routine parameters per Chicago classification were obtained on HRM. Proximal esophageal contractility was evaluated using proximal contractile integral (PCI), which quantifies contractile pressure >20 mm Hg for the region spanning the distal margin of the upper esophageal sphincter and transition zone. Univariate (Kendall correlation and Student t test) and multivariable (general linear regression and logistic regression) analyses were performed.RESULTS:We enrolled 138 patients (66.7% women, mean age 57.1 years) in this study. Lower PCI was associated with an elevated risk of increased pharyngeal reflux (adjusted odds ratio 0.83 per 100 mm Hg-s-cm change in PCI, 95% confidence interval: 0.69–0.98), with a trend toward increased bolus exposure time and total reflux events, after multivariable adjustment. The relationship between PCI and pharyngeal reflux was strongest among participants without a primary motility disorder on HRM (adjusted odds ratio 0.63, 95% confidence interval: 0.42–0.85, P interaction = 0.04). Among continuously expressed reflux parameters, lower PCI was significantly associated with more distal acid reflux events (β = −0.0094, P = 0.03) and total reflux events (β = −0.0172, P = 0.05), after adjusting for confounders.DISCUSSION:Reduced proximal esophageal contractility as assessed by decreased PCI on HRM independently predicted increased pharyngeal reflux in patients with LPR symptoms, particularly among those without a coexisting motility disorder.

S3570 One and Done? Revisiting Need for Repeat Esophageal Manometry in Patients With Persistent Symptoms

Introduction: Achalasia is a motility disorder characterized by the absence of esophageal peristalsis and failure of the LES to relax in response to swallowing. High resolution manometry (HRM) has been established as the gold standard for diagnosis; however, the utility of repeat manometry has been investigated in only a limited number of reports. Whether repeat manometry provides new information or changes the diagnosis remains unclear Case Description/Methods: 70y/o female with GERD, PUD, cervical spondylosis, and rheumatoid arthritis, presented in 2015 with dysphagia to solids. Initial work-up included EGD which showed an esophageal web. She was started on acid suppression therapy without improvement. In 2017 she underwent HRM which showed an abnormal median integrated relaxation pressure of 39.6(n< 15mmHg) and an elevated upper esophageal sphincter relaxation pressure of 13.7(n< 12mmHg). 70% of swallows were failed with 30% of swallows peristaltic with normal distal contractile integral. There was incomplete bolus clearance in all swallows. Patient met Chicago Classification 3.0 criteria for esophagogastric junction outflow obstruction. However, given the large presence of non-peristaltic swallows, the possibility of an evolving achalasia was considered. Due to worsening symptoms, patient underwent barium esophagram (BE) ;in 2018 which did not suggest achalasia. There was however, small residual of contrast in the distal esophagus with delayed emptying suggesting a motility disorder. She then underwent video swallow study which was unrevealing. She again underwent BE; in 2019 revealing a prominent cricopharyngeus muscle causing narrowing of the esophageal lumen during the swallowing phase. She subsequently underwent repeat HRM which was consistent with Type II Achalasia per Chicago classification 3.0. LES pressure was elevated at 43.8 mmHg, UES pressure was normal (6.2 mmHg). 100% of all contractions had pan esophageal pressurization deeming them non-peristaltic. Patient had incomplete bolus clearance in all swallows. Of note, patient was not on any medications, including benzodiazepines or opioids, that would impact motility studies. Due to persistent symptoms, patient underwent peroral endoscopic myotomy with significant improvement of symptoms. Discussion: HRM is the gold standard for identifying causes of esophageal dysmotility. In patients whose symptoms progress over time, there is high utility in performing repeat manometry to evaluate the cause of their dynamic symptoms, as treatment options may change

810 REPRODUCIBILITY OF REPEATED MEASUREMENTS OF OESOPHAGEAL MOTILITY METRICS WITHIN A STUDY

Abstract To compare reproducibility of repeated measurements of oesophageal motility metrics after 5 wet swallows within a study. Methods Patients referred for high-resolution esophageal manometry (HREM) to assess oesophageal motor function were enrolled. Solid-state 36-channel 10 Fr catheter (Unisensor AG) and Solar (MMS) software were used. Minimum 10 water swallows by 5 mL each were obtained. Two operators independently assessed the results of examination. Records of swallows were divided into 2 series by 5 measurements each. These series were compared by key metrics: integrated relaxation pressure (IRP), distal contractile integral (DCI), distal latency (DL), and contractile front velocity (CFV). Non-parametric statistics was used to compare the results. Results We enrolled 46 men and 68 women, age (mean ± SD) 48.8 ± 11.5 y.o. Of them, 52 patients had GERD, 25-different types of achalasia and 37 had no oesophageal disorders. The inter-observer agreement between 2 series of measurements reached 98%. No significant difference was found between the mean results of IRP, DCI, DL and CFV in 2 series of measurements (table 1). Conclusion No significant differences between studied HREM metrics in two series of measurements were found. The results of two series by 5 measurements within a study are reproducible. This may indicate the possibility of reducing the standard number of measurements. Reduction of time necessary for standard examination may allow additional time for functional tests (solid food swallows, RDC or MRS).

Age-Related Functional Reserve Decline Is Not Seen in Pharyngeal Swallowing Pressures.

Purpose Functional reserve represents the difference between an individual's ability to produce a maximum output function and the ability to perform a functional task. Several studies have documented an age-related decrease in functional reserve with oral tongue pressure generation. Whether this pattern is seen in pharyngeal swallowing pressures is unknown. The aim of this study was to investigate pharyngeal functional reserve using high-resolution manometry during normal-effort and effortful swallows. Method Pharyngeal high-resolution manometry was performed on 38 younger healthy individuals (≤ 40 years) and 18 older healthy individuals (≥ 60 years) during normal-effort and effortful water swallows. Pressure metrics included maximum pressure in the velopharynx, tongue base, and hypopharynx, as well as pharyngeal contractile integral and minimum pressure in the upper esophageal sphincter (UES). Repeated-measures analysis of variance was used to determine the effects of swallow task, age, and pharyngeal region on pressure generation. Results Maximum pharyngeal pressures and pharyngeal contractile integral were significantly increased during the effortful swallows compared to normal-effort swallows (p < .001), but there were no interactions between task and age in pharyngeal pressures. In the UES, minimum pressures were significantly elevated in older individuals during effortful swallows compared to normal-effort swallows (p = .007) but did not follow a pattern consistent with reduced functional reserve. Conclusions Healthy individuals increase pharyngeal driving pressures during effortful swallows, without an age-related reduction in the magnitude of pressure increase. Thus, this study did not find evidence for an age-related reduction in pharyngeal functional reserve. The preserved ability to increase pharyngeal pressures during effortful swallowing in aging may support the use of behavioral swallowing interventions in older individuals without neuromuscular conditions. Supplemental Material https://doi.org/10.23641/asha.16606709.

Effects of menthol on esophageal motility in humans: Studies using high-resolution manometry.

The cold receptor, transient receptor potential melastatin 8 (TRPM8), has been reported to be expressed in esophageal vagal afferents. Esophageal infusion of menthol modulates esophageal perception in reflux patients via TRPM8, but the effects of menthol on esophageal motility are not well investigated. This study aimed to test the hypothesis whether the infusion of menthol into the esophagus could affect esophageal peristaltic characteristics. Eighteen healthy adults (men 13, mean age 27) underwent high-resolution manometry (HRM) using a catheter with the injection port located in mid-esophagus. Primary peristalsis was performed with ten wet swallows, while secondary peristalsis was generated by 10 rapid air injections. Two different sessions were randomly performed including acute administration of menthol (3mM) and the placebo. Menthol significantly decreased upper esophageal (UES) pressure of primary peristalsis than the placebo (p=0.019). There was no difference in distal contractile integral (p=0.33), distal latency (p=0.86), basal lower esophageal sphincter pressure (p=0.19), or 4-second integrated relaxation pressure (p=0.75) between menthol and placebo. Menthol significantly decreased the frequency of secondary peristalsis subsequent to the administration of menthol during rapid injections with 20mL air (p=0.04). Intraluminal infusion of menthol reduces UES basal pressure and inhibits peristaltic frequency of secondary peristalsis. The data suggest that the triggering of secondary peristalsis is probably modulated by TRPM8-sensitive mechanoreceptors; however, the activation of TRPM8 from menthol does not alter esophageal motility following deglutition or distension-induced secondary peristalsis.