Esophageal Contraction Research Articles

Case Series of Patients with Brainstem Inflammation Causing Paroxysmal Movement Disorders (P4-5.016)

<h3>Objective:</h3> We describe five patients with various neuroinflammatory diseases who developed Paroxysmal Movement Disorders (PMD). <h3>Background:</h3> PMD are a rare phenomenon that has been described in patients with multiple sclerosis since the 1940s. PMD are typically responsive to carbamazepine. One subtype of PMD is paroxysmal dysarthria and ataxia syndrome (PDA), characterized by stereotyped episodes of dysarthria and ataxia, lasting seconds and recurring several times per day. This is thought to be due to transverse ephaptic transmission between demyelinated axons in the brainstem. Recently, cases of PDA in other neuroinflammatory diseases such as Behcet’s disease, MOG-antibody disease (MOGAD), Bickerstaff encephalitis, and anti-NMDA encephalitis have been described but the spectrum of PMD in neuroinflammatory diseases has not been sufficiently studied. <h3>Design/Methods:</h3> Case report series. <h3>Results:</h3> We describe in detail five patients with CNS inflammatory diseases who developed PMD. Underlying diseases were chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS), MS, MOGAD, and post-infectious encephalitis (COVID and LaCrosse virus). Four patients developed PDA, while one presented with paroxysmal esophageal contractions. Paroxysms were brief (less than 10 seconds) and frequent (up to hundreds of times a day). On MRI, four patients had lesions in the medial midbrain and one had a lesion in a cerebellar peduncle. In four cases paroxysms were treated successfully with carbamazepine. All patients had complete or near-complete remission of their PMD. <h3>Conclusions:</h3> This series highlights that different neuroinflammatory disorders can cause PMD. This is the first report of PDA in CLIPPERS or post-COVID encephalitis, and the second report in MOGAD. Most patients had lesions in the dorsal midbrain below the red nucleus, a site commonly reported to cause PDA. Treatment with carbamazepine was successful. PMD in neuroinflammatory disease is important to recognize as symptoms can be debilitating but successfully treated. This case series can help improve awareness of this rare condition. <b>Disclosure:</b> Dr. Luxenberg has nothing to disclose. The institution of Dr. Wang has received research support from Genentech. The institution of Dr. Wundes has received research support from Benaroya Research Institute . The institution of Dr. Von Geldern has received research support from Novartis. The institution of Dr. Von Geldern has received research support from National MS Society. Dr. Von Geldern has received personal compensation in the range of $0-$499 for serving as a DSMB member with NIH, NINDS. Dr. Von Geldern has a non-compensated relationship as a editorial board member with MS and Related Disorders Journal that is relevant to AAN interests or activities.

Advances in the Diagnosis and Management of Achalasia and Achalasia-Like Syndromes: Insights From HRM and FLIP.

High-resolution manometry, Chicago Classification v4.0, the functional lumen imaging probe, Panometry, and peroral endoscopic myotomy (POEM) are all now integral parts of the landscape for managing achalasia or, more precisely, achalasia-like syndromes. This narrative review examines the impact of these innovations on the management of achalasia-like syndromes. High-resolution manometry was the disruptive technology that prompted the paradigm shift to thinking of motility disorders as patterns of obstructive physiology involving the esophagogastric junction and/or the distal esophagus rather than as siloed entities. An early observation was that the cardinal feature of achalasia-impaired lower esophageal sphincter relaxation-can occur in several subtypes: without peristalsis, with pan-esophageal pressurization, with premature (spastic) distal esophageal contractions, or even with preserved peristalsis (esophagogastric junction outlet obstruction). Furthermore, there being no biomarker for achalasia, no manometric pattern is perfectly sensitive or specific for 'achalasia' and there is also no 'gold standard' for the diagnosis. Consequently, complimentary physiological testing with a timed barium esophagram or functional lumen imaging probe are employed both to improve the detection of patients likely to respond to treatments for 'achalasia' and to characterize other syndromes also likely to benefit from achalasia therapies. These findings have become particularly relevant with the development of a minimally invasive technique for performing a tailored esophageal myotomy, POEM. Now and in the future, optimal achalasia management is to render treatment in a phenotype-specific manner, that is, POEM calibrated in a patient-specific manner for obstructive physiology including the distal esophagus and more conservative strategies such as a short POEM or pneumatic dilation for obstructive physiology limited to the lower esophageal sphincter.

Effects of Microbeam Irradiation on Rodent Esophageal Smooth Muscle Contraction.

High-dose-rate radiotherapy has shown promising results with respect to normal tissue preservation. We developed an ex vivo model to study the physiological effects of experimental radiotherapy in the rodent esophageal smooth muscle. We assessed the physiological parameters of the esophageal function in ex vivo preparations of the proximal, middle, and distal segments in the organ bath. High-dose-rate synchrotron irradiation was conducted using both the microbeam irradiation (MBI) technique with peak doses greater than 200 Gy and broadbeam irradiation (BBI) with doses ranging between 3.5-4 Gy. Neither MBI nor BBI affected the function of the contractile apparatus. While peak latency and maximal force change were not affected in the BBI group, and no changes were seen in the proximal esophagus segments after MBI, a significant increase in peak latency and a decrease in maximal force change was observed in the middle and distal esophageal segments. No severe changes in physiological parameters of esophageal contraction were determined after high-dose-rate radiotherapy in our model, but our results indicate a delayed esophageal function. From the clinical perspective, the observed increase in peak latency and decreased maximal force change may indicate delayed esophageal transit.

Chronic opioid users with dysphagia are indistinguishable from symptomatic nonusers on functional lumen imaging probe evaluation.

Opioid-induced esophageal dysmotility (OIED) includes spastic esophageal motility disorders, increasingly recognized in the contemporary opioid epidemic. We assessed functional lumen imaging probe (FLIP) findings in diagnosing OIED. Symptomatic patients undergoing FLIP with no prior foregut surgery who completed validated questionnaires were identified and segregated into chronic opioid users and nonusers in this cohort study. Esophagogastric junction (EGJ) distensibility index (DI), EGJ diameter, and esophageal body contraction patterns were extracted. Symptom profiles were compared to FLIP findings between chronic opioid users and nonusers. Outcome was evaluated in a subset using the same validated questionnaires. Over the 18-months study period, of 116 patients (median age 62 years, 70.7% female), 33 (28.4%) were chronic opioid users, with median morphine milligram equivalent of 30 mg. While presenting symptoms were similar, chronic opioid users reported higher perceptive symptoms (p=0.008) and worse quality of life (p=0.01) compared to nonusers. Median DI trended lower in chronic opioid users (p=0.08), with more retrograde repetitive contractions (p < 0.001) and less absent contractility (p=0.007), but final FLIP diagnoses were similar compared to nonusers. There was no correlation between opioid dose and FLIP metrics. In the subset with follow-up, perceptive symptoms trended higher in chronic opioid users (p=0.08), but symptom improvement following therapy was similar in both groups. Symptomatic chronic opioid users have FLIP diagnoses that are similar to nonusers, despite higher perceptive symptoms and worse quality of life. Dominant symptoms improve both in chronic opioid users and nonusers following treatment directed by FLIP.

Evaluation of Therapeutic Effect of Buspirone in Improving Dysphagia in Patients with GERD and Ineffective Esophageal Motility: A Randomized Clinical Trial

Background: Ineffective esophageal motility (IEM) is the most common esophageal motility disorder associated with low-to-moderate amplitude contractions in the distal esophagus in manometric evaluations. Despite recent new conceptions regarding the pathophysiology of esophageal motility and IEM, there are still no effective therapeutic interventions for the treatment of this disorder. This study aimed to investigate the effect of buspirone in the treatment of concomitant IEM and GERD. Methods and Materials: The present study was a randomized clinical trial conducted at the Imam Khomeini Hospital, Tehran. Patients with a history of gastroesophageal reflux disease and dysphagia underwent upper endoscopy to rule out any mechanical obstruction and were diagnosed with an ineffective esophageal motility disorder based on high-resolution manometry. They were given a package containing the desired medication(s); half of the packets contained 10 mg (for 30 days) of buspirone and 40 mg (for 30 days) of pantoprazole, and the other half contained only 40 mg (for 30 days) of pantoprazole. Dysphagia was scored based on the Mayo score, as well as a table of dysphagia severity. Manometric variables were recorded before and after the treatment. Results: Thirty patients (15 pantoprazole and 15 pantoprazole plus buspirone) were included. Females comprised 63.3% of the population, with a mean age of 46.33 ± 11.15. The MAYO score and resting LES pressure significantly changed after treatment. The MAYO and Swallowing Disorder Questionnaire scores significantly decreased after treatment in both groups of patients. Our results revealed that the post-intervention values of manometric variables differed significantly between the two groups after controlling for the baseline values of the variables. This analysis did not demonstrate the superiority of buspirone. Conclusion: Buspirone seems to have no superiority over PPI. Treatment with concomitant IEM and GERD using proton pump inhibitors improves the patient’s clinical condition and quality of life. However, adding buspirone to the treatment regimen did not appear to make a significant difference in patient treatment.

Esophageal wall compliance/stiffness during peristalsis in patients with functional dysphagia and high-amplitude esophageal contractions.

Recent studies that utilized distension/contraction plots to study peristalsis reveal poor distension of the esophagus in patients with functional dysphagia and high-amplitude contractions [high-amplitude esophageal contractions (HAECs)] even though the contraction phase of peristalsis is normal in these patients. Our goal was to determine biomechanical properties of the esophageal wall and bolus flow characteristics in patients with functional dysphagia and HAEC during primary peristalsis. Studies were performed on 30 healthy subjects, 30 patients with functional dysphagia, and 25 patients with HAEC. Subjects swallowed 10 mL, 0.5 N saline bolus in the Trendelenburg position to study primary peristalsis. A custom-built software (Dplots) determined peak distension from the impedance measurements, pressure at peak distension, wall tension (pressure × radius), wall distensibility [cross-sectional area (CSA)/pressure], and bolus flow (cm3/s) in four segments of esophagus (between upper and lower esophageal sphincter). Luminal CSA of distal esophagus was smaller, and average bolus flow rate was faster in patients with functional dysphagia and HAEC. Esophageal wall distensibility, a measure of esophageal wall compliance was lower and wall tension was higher in the distal esophagus of both patient groups compared with normal subjects. Ultrasound imaging confirmed poor distension of the esophagus. A trend toward greater wall thickness at the peak of distension was found in patients with functional dysphagia compared with normal subjects. A stiffer or noncompliant esophageal wall is the reason for poor distension of the esophagus during primary peristalsis in patients with functional dysphagia and HAEC.NEW & NOTEWORTHY We studied healthy asymptomatic subject, patients with functional dysphagia (FD), and patients with high-amplitude esophageal contractions (HAEC). Our data show that in patients with HAEC and functional dysphagia, luminal distension is smaller (low luminal CSA at peak distension), intraluminal pressure is higher, and liquid bolus travels faster through the esophagus as compared with normal subjects. We conclude that patients with functional dysphagia and HAEC have a stiffer distal esophageal wall during bolus transport related to primary peristalsis.

Abnormal response after multiple rapid swallow provocation is not predictive of post-operative dysphagia following a tailored fundoplication approach.

The aim was to evaluate the clinical significance of multiple rapid swallows (MRS) during high-resolution manometry (HRM) prior to fundoplication. Despite pre-operative HRM, up to 38% of patients report post-fundoplication dysphagia. Suggestion that MRS improves prediction of dysphagia after fundoplication has not been investigated when using a tailored approach. We hypothesize response to MRS is predictive of dysphagia after tailored fundoplication. A retrospective cohort study was performed on patients undergoing HRM with MRS provocation 5/2019-7/2021 at a single institution. Patients who underwent subsequent index laparoscopic fundoplication, without peptic stricture or achalasia, were included. After performing standard 10-swallow HRM, MRS provocation was performed. Patient-reported dysphagia frequency scores were collected at initial consultation and post-operative follow-up. At least weekly symptoms were considered clinically significant. Normal MRS response was defined as adequate deglutitive inhibition and MRS contractile response. Fundoplications were tailored based on standard HRM values. HRM was performed in 1201 patients, 220 met inclusion criteria. Clinically significant pre-operative dysphagia was reported by 85 (38.6%). Patients undergoing partial fundoplication (n = 123, 55.9%) had lower mean distal contractile integer, distal esophageal contraction amplitude, and percent peristalsis (p < 0.005). Post-operatively, 120 (54.5%) were without dysphagia, 59 (26.8%) had improved dysphagia, 26 (11.8%) had unchanged dysphagia, and 15 (6.8%) reported new dysphagia. There was no statistical difference in early or late dysphagia outcome between tailored fundoplication groups (p = 0.69). On univariate and multivariate analysis, neither MRS response, nor standard HRM metrics were significantly associated with post-operative dysphagia. Younger age (OR 0.96, 95% CI 0.94-0.986, p = 0.042) and the presence of pre-operative dysphagia (OR 2.54, 95% CI 1.17-5.65, p = 0.015) were significant predictors of post-operative dysphagia. The risk of clinically significant dysphagia post-fundoplication is low when using a tailored approach based on standard HRM metrics. Additional data provided by MRS does not add to surgical decision-making using the investigated approach.

CME Exam 2: Opioid Exposure Differentially Impacts Esophageal Body Contraction Over the Lower Esophageal Sphincter

CME Exam 2: Opioid Exposure Differentially Impacts Esophageal Body Contraction Over the Lower Esophageal Sphincter

Distension contraction plots of pharyngeal/esophageal peristalsis: next frontier in the assessment of esophageal motor function.

Esophageal peristalsis consists of initial inhibition (relaxation) followed by excitation (contraction), both of which move sequentially in the aboral direction. Initial inhibition results in receptive relaxation and bolus-induced luminal distension, which allows propulsion by the contraction with minimal resistance to flow. Similar to the contraction wave, luminal distension has unique waveform characteristics in normal subjects; both are modulated by bolus volume, bolus viscosity, and posture, suggesting a possible cause-and-effect relationship between the two. Distension contraction plots in patients with dysphagia with normal bolus clearance [high-amplitude esophageal contractions (HAECs), esophagogastric junction outflow obstruction (EGJOO), and functional dysphagia (FD)] reveal two major findings: 1) unlike normal subjects, there is luminal occlusion distal to bolus during peristalsis in certain patients, i.e., with type 3 achalasia and nonobstructive dysphagia; and 2) bolus travels through a narrow lumen esophagus during peristalsis in patients with HAECs, EGJOO, and FD. Aforementioned findings indicate a relative dynamic obstruction to the bolus flow during peristalsis and reduced distensibility of esophageal wall in the bolus segment of the esophagus. We speculate that a normal or supernormal contraction wave pushing bolus against resistance is the mechanism of dysphagia sensation in significant number of patients. Representations of distension and contraction, combined with objective measures of flow timing and distensibility are complementary to the current scheme of classifying esophageal motility disorders based solely on the characteristics of contraction phase of peristalsis. Better understanding of the distensibility of the bolus-containing segment of the esophagus during peristalsis will lead to the development of novel medical and surgical therapies in the treatment of dysphagia in significant number of patients.

Phonation-induced Upper Esophageal Sphincter Contraction Caused by Different Phonation Types

The upper esophageal sphincter (UES) has been reported to show activity during phonation. As it is still unknown whether the phonation-induced UES contraction represents a reflex or a simultaneous activation phenomenon, i.e. co-innervation, this study aims to investigate and characterize the phonation-induced contraction of the UES in healthy individuals by analyzing the influence of various phonation tasks on pressure parameters of the UES. Twenty-five healthy volunteers produced the German neutral vowel [ə] in five different phonation tasks (modal voice, whispering, voiceless speech, creaky voice, and whispery voice). Simultaneously, they underwent high resolution manometry and electroglottography for measurement of pressure parameters in the region of the UES and latencies between larynx and UES activation. During all types of phonation, the maximum pressures of the UES increased significantly (maximum pressure increases of 72%-132%). With regard to mean pressures this was valid for modal voice and whispering (mean pressure increases of 20%-25%). Differences concerning total pressure changes reached statistical significance when comparing whispering and voiceless speech as well as whispery voice. However, differences concerning the total pressure change between modal voices on the one hand and voiceless speech and whispery voice on the other hand turned out to be small. The averaged time delay between larynx and UES activation ranged from approximately -15 ms (whispery voice) to +15 ms (whispering). A phonation induced pressure increase of the UES was confirmed in this study and did exist for different types of phonation. The extent of total pressure changes in the UES increases in relation with laryngeal muscle activity necessary for the phonation type. Next to varying effects of different types of phonation on UES activation, very short latencies indicate that a phonation induced contraction of the UES exists most likely due to co-innervation of UES and laryngeal muscles by the vagus nerve.

Hypercontractile esophagus responsive to potassium-competitive acid blockers: a case report

BackgroundHypercontractile esophagus is a rare hypercontractile esophageal motility disorder. The etiology of hypercontractile esophagus is unknown but an association between acid reflux and hypercontractile esophagus has been suggested. We present the first report on the use of potassium-competitive acid blockers in the treatment of hypercontractile esophagus.Case presentationA 43-year-old man presented with dysphagia, chest pain and regurgitation for a period of 1 year. Initial workup showed a twisted lumen with abnormal contractions in the distal esophagus during upper gastrointestinal endoscopy and abnormal acid exposure under 24-h esophageal pH monitoring. The use of standard-dose proton pump inhibitors didn’t relieve his symptoms. Subsequent high-resolution esophageal manometry made a diagnosis of hypercontractile esophagus. Treatment with vonoprazan resulted in symptomatic resolution and abnormal contractions were no longer detected on follow-up high-resolution manometry.ConclusionsPotassium-competitive acid blockers like vonoprazan offer an alternative therapeutic method for patients with hypercontractile esophagus who are refractory to proton pump inhibitor therapy. The use of potassium-competitive acid blockers in hypercontractile esophagus warrants further research and may provide evidence for an acid-related etiology of hypercontractile esophagus.

EndoFLIP Topography: Motor Patterns in an Obstructed Esophagus

EndoFLIP Topography: Motor Patterns in an Obstructed Esophagus

Opioid Exposure Differentially Impacts Esophageal Body Contraction Over the Lower Esophageal Sphincter

Background & AimsStudies with limited sample sizes have investigated association of chronic opioid use with motility disorders of esophagogastric junction and esophageal body peristalsis. Our aims were to use a large cohort of patients to assess (1) the impact of opioid exposure on clinical and manometric characteristics, and (2) the association of opioid exposure with higher long-term symptom burden. MethodsPatients recruited from a tertiary medical center who underwent high-resolution manometry (HRM) between 2007 and 2018 were included. Demographics, opiate exposure, clinical symptoms, and HRM parameters were compared. Patient-Reported Outcomes Measurement Information System–Gastrointestinal swallowing domain (PROMIS-GI swallowing domain) and Eckardt score were administered via phone interviews in patients with hypercontractile esophagus (HE) or distal esophageal spasm (DES) to determine long-term symptom burden between opioid and nonopioid users. ResultsOur cohort included 4075 patients (869 with opiate exposure with median morphine milligram equivalent [interquartile range] of 30 [10–45]). Patients in the opioid group were significantly more likely to have dysphagia (65% vs 51%, P < .01) and diagnosis of DES (11% vs 5%, P < .01) and HE (9% vs 3%, P < .01). Partial opioid agonists were not associated with motility abnormalities. Patients on opioids had significantly higher symptom burden on median (interquartile range) follow-up of 8.9 years (5.8–10.4) post manometric diagnosis with median PROMIS-GI swallowing domain score of 21.5 (17–25) compared with the nonopioid group at 15 (9.8–21, P = .03). ConclusionsNearly 2 of 3 patients with opioid exposure undergoing HRM have dysphagia and more than 25% of them with dysphagia as the primary symptom have a diagnosis of either DES or HE. Opioid users with spastic disorders have higher symptom burden long-term compared with nonopioid users.

Effects of standardized [6]-gingerol extracts and [6]-gingerol on isolated ileum and lower esophageal sphincter contractions in mice

Standardized [6]-gingerol extracts were prepared by microwave-assisted extraction using 20% v/v glycerin in ethanol and 20% v/v eutectic mixture of sucrose and citric acid in ethanol as alternative green solvents. The extracts obtained from 20% v/v glycerin in ethanol (GEE) and 20% v/v eutectic mixture of sucrose and citric acid in ethanol (EMSCEE) were standardized by HPLC to contain 17.0 mg/g of [6]-gingerol. The effects of the extracts on mouse ileal contractions via M3 and 5-HT3 receptors as well as lower esophageal sphincter (LES) contraction were determined in vitro relative to the marker compound, [6]-gingerol. [6]-Gingerol, GEE and EMSCEE demonstrated significant and concentration-dependent inhibitory effects on ileal contraction in mice via M3 and 5-HT3 receptors in a noncompetitive manner. In addition, [6]-gingerol and EMSCEE tend to increase the LES tone. These results indicated the potential of GEE and EMSCEE to attenuate nausea and vomiting and might be used as nutraceuticals.

Reproducible determination of transpulmonary pressures

Oesophageal pressures, as measured in an oesophageal balloon catheter, are a validated substitute for pleural pressures.Transpulmonary pressures, indispensable to improve our understanding of ventilatory physiology, are therefore typically calculated as the difference between airway and oesophageal pressures.The oesophageal pressure signal, however, features a superimposed oscillation due to cardiac motion, not representative for pleural pressure. Additionally, oesophageal contractions or surgical manipulation can alter the signal. In practice, transpulmonary pressures are therefore manually determined from the pressure-time graphic by visual inspection of the waves and averaging a limited number of samples.We suggest an approach to extract the end-expiratory transpulmonary pressure from the raw monitoring data.•Our approach reproducibly determines end-expiratory transpulmonary pressures at a given level of set positive end-expiratory pressure at the ventilator.•Our approach ignores surgical disturbance and cardiac oscillations in the oesophageal pressure signal.

Bridge Swallowing Exercise for Gastroesophageal Reflux Disease Symptoms: A Pilot Study.

ABSTRACTObjectives:We previously reported that swallowing in the bridge position (bridge swallowing) increased distal esophageal contractions and lower esophageal sphincter pressure against gravity. Moreover, bridge swallowing had the potential to strengthen esophageal peristalsis. In this study, we sought to evaluate whether the bridge swallowing exercise could improve gastroesophageal reflux disease (GERD) symptoms and gastroscopy findings.Methods:Seventeen subjects with scores of 8 points or higher on the Frequency Scale for Symptoms of GERD (FSSG) questionnaire participated in the study. The exercise of dry swallowing in the bridge posture lasted 4 weeks and was performed ten times per day. FSSG scores were compared before and after exercise. Three of the 17 participants underwent upper gastrointestinal endoscopy. The modified Los Angeles classification of reflux esophagitis was used for objective assessment before and after exercise.Results:No participants dropped out of this study. FSSG scores improved significantly after exercise (from median [range] 16 [13–21] points before exercise to 5 [4–10] points after exercise, P <0.001). Upper gastrointestinal endoscopy showed improvement in the modified Los Angeles classification grade in one participant.Conclusions:The bridge swallowing exercise significantly improves FSSG scores. This exercise can be performed easily and safely without adverse events. Further multicenter prospective studies are needed to validate that the bridge swallowing exercise is effective in improving GERD.

The Impact of Magnetic Sphincter Augmentation (MSA) on Esophagogastric Junction (EGJ) and Esophageal Body Physiology and Manometric Characteristics.

To evaluate the impact of MSA on lower esophageal sphincter (LES) and esophageal body using high resolution impedance manometry. MSA is an effective treatment in patients with gastroesophageal reflux disease, but there is limited data on its impact on esophageal functional physiology. Patients who underwent MSA were approached 1-year after surgery for objective foregut testing consists of upper endoscopy, esophagram, high resolution impedance manometry, and esophageal pH-monitoring. Postoperative data were then compared to the preoperative measurements. A total of 100 patients were included in this study. At a mean follow up of 14.9(10.1) months, 72% had normalization of esophageal acid exposure. MSA resulted in an increase in mean LES resting pressure [29.3(12.9) vs 25(12.3), P < 0.001]. This was also true for LES overall length [2.9(0.6) vs 2.6(0.6), P = 0.02] and intra-abdominal length [1.2(0.7) vs 0.8(0.8), P < 0.001]. Outflow resistance at the EGJ increased after MSA as demonstrated by elevation in intrabolus pressure (19.6 vs 13.5 mmHg, P < 0.001) and integrated relaxation pressure (13.5 vs 7.2, P < 0.001). MSA was also associated with an increase in distal esophageal body contraction amplitude [103.8(45.4) vs 94.1(39.1), P = 0.015] and distal contractile integral [2647.1(2064.4) vs 2099.7(1656.1), P < 0.001]. The percent peristalsis and incomplete bolus clearance remained unchanged ( P = 0.47 and 0.08, respectively). MSA results in improvement in the LES manometric characteristics. Although the device results in an increased outflow resistance at the EGJ, the compensatory increase in the force of esophageal contraction will result in unaltered esophageal peristaltic progression and bolus clearance.

Comparison of scope holding sign on endoscopy and lower esophageal sphincter contraction on high-resolution manometry: A pilot study.

ObjectivesLower esophageal sphincter (LES) plays a key role in gastroesophageal reflux disease (GERD) pathogenesis. In retroflexion and under sufficient insufflation, it can be seen how the lower esophagus grasps the endoscope, which we named scope holding sign (SHS). This study aimed to compare the SHS and LES pressure on high‐resolution manometry (HRM), to elucidate whether the sphincter can be visualized endoscopically.MethodsThis was a single‐center, prospective pilot study. Patients with symptoms of GERD, who underwent endoscopy and HRM between February 2021 and April 2021, were included. A manometry catheter and an ultra‐slim endoscope were inserted, and the resting LES pressure was measured. The lower esophagus holding (SHS‐positive) and releasing (SHS‐negative) the endoscope and catheter were observed. The LES pressures during SHS‐positive and SHS‐negative were compared.ResultsEleven patients (median age: 57 years; eight men) with normal esophageal motility were analyzed. The median LES pressure in SHS‐positive was significantly higher than the resting LES pressure (40.4 [22.9–74.0] vs. 25.9 [2.0–66.7] mm Hg; p = 0.001) and the LES pressure in SHS‐negative (4.6 [1.5–9.3]; p = 0.001). Furthermore, the LES pressure in SHS‐negative was significantly lower than the resting LES pressure (4.6 [1.5–9.3] vs. 25.9 [2.0–66.7] mm Hg; p = 0.005).ConclusionsThis study demonstrated that the SHS parallels LES pressure, indicating that the sphincter can be observed endoscopically. This may enable us to evaluate LES function during endoscopy in patients with GERD, thus, deserving further evaluation in future studies.

Esophageal mucosal sensory nerves and potential mechanoreceptors in patients with ineffective esophageal motility.

Ineffective esophageal motility (IEM) is the most common motility disorder. However, little is known about its pathophysiology. Vagal afferent nerves convey esophageal intraluminal bolus information to solitary nucleus, which is likely to be involved with esophageal primary and secondary peristalsis (SP). We hypothesized that altered mucosal sensory afferents underlie the pathogenesis of IEM. We prospectively collected esophageal biopsies from 38 patients with proton pump inhibitor-refractory reflux symptoms from January to December 2019. All patients underwent high-resolution manometry for the evaluation of primary and secondary peristalsis, and off-PPI 24-h impedance-pH studies. Biopsies were analyzed using immunohistochemistry for identification of calcitonin gene-related peptide-immunoreactive (CGRP-IR) nerves and qPCR for mRNA expression of potential mechanoreceptors. Overall 32 patients were finally analyzed which consisted of 11 patients with normal motility and 21 patients with IEM. The position of mucosal CGRP-IR nerves from the esophageal lumen did not differ between the two groups (the proximal esophagus (p=0.52), the mid-esophagus (p=0.92), the distal esophagus (p=0.29)) with the similar reflux profile. No difference was seen in the position of CGRP-IR nerves between patients with successful triggering of SP and those unable to trigger SP. There was also no difference in mRNA expression of each potential mechanoreceptors (TRPA1, TRPV1, TRPV4, ASIC1, ASIC3) between the two groups. Our study showed that mucosal sensory afferents nerve position and mRNA expression of potential mechanoreceptors did not correlate to weak esophageal contraction.

Attention graph convolutional nets for esophageal contraction pattern recognition in high-resolution manometries

Diagnosis of the esophageal motility disorders is ongoing in clinical evaluations, which is based on traditional method called High-resolution manometry (HRM). However, the huge raw swallow data sets from the HRM are not allowed the doctors to interpret and classify the patients with esophageal symptoms. To this end, modeling propagation between vigor is useful for recognizing esophageal contraction patterns in large-scale high-resolution manometries. In this paper, we learned a discriminative propagation between vigor using deep learning methods. Furthermore, we designed an efficient graph to incorporate contractile vigor propagation (CVP) that considers the contraction and pressure propagation between vigor in HRM images. Using an attention graph convolutional network (GAT), the edges in CVP can automatically learn the contraction patterns (i.e., local temporal information) trends in time series and propagation (i.e., global information) through the attention units. The attention mechanism layer leverages the short-term trend to improve the prediction accuracy. The quantitative experiments showed that the proposed method achieves high accuracy in esophageal contraction pattern recognition and demonstrates its effectiveness compared to existing traditional methods. We also visualized the learned vigor-specific propagation patterns in the contractile features, which show that the proposed CVP-GAT is able to develop interpretable propagation information for esophageal contraction pattern recognition.