Conventional Manometry Research Articles

Effects of capsaicin on esophageal peristalsis in humans using high resolution manometry.

Capsaicin-containing red pepper sauce suspension augments esophageal contraction amplitude on conventional manometry. This study used high-resolution manometry (HRM) to investigate if capsaicin infusion modulates segmental esophageal smooth muscle peristalsis in healthy adults. Sixteen healthy volunteers (mean age 37 years, 14 male) underwent HRM for the evaluation of primary peristalsis and secondary peristalsis using slow and rapid air distensions. Both primary and secondary peristalsis were assessed following infusions of capsaicin-containing red pepper sauce and saline. Capsaicin infusion significantly increased heartburn symptoms compared to saline infusion (p < 0.001), and significantly decreased threshold volumes of secondary peristalsis during rapid air distensions (p = 0.02). The frequency of secondary peristalsis during rapid air distensions was significantly increased by capsaicin infusion (p = 0.03). Neither capsaicin infusion (p = 0.06) nor saline infusion (p = 0.27) altered threshold volume during slow air distensions. Capsaicin infusion significantly increased distal contractile integral (DCI) of primary peristalsis (p = 0.04), particularly in the proximal smooth muscle segment (p = 0.048). It enhanced secondary peristalsis during rapid air distensions (p = 0.003) but not during slow air distension (p = 0.23). Saline infusion significantly increased DCI of secondary peristalsis during rapid air distension (p = 0.01). Augmentation of distension-induced secondary peristalsis can be modulated by activation of capsaicin-sensitive afferents similar to mechanosensitive afferents. Capsaicin-induced augmentation of primary peristalsis isolates to the cholinergic-mediated proximal smooth muscle segment, which warrants study in ineffective esophageal motility to determine therapeutic potential.

Anal sphincter function in rectal intussusception and high and low "take-off" external rectal prolapse-A prospective observational study.

Rectal intussusception (RI) and external rectal prolapse (ERP) are associated with anal sphincter dysfunction. The aim of this study was to examine sphincter function with anal acoustic reflectometry (AAR) in RI and two distinct phenotypes of ERP termed high and low "take-off". A prospective study of patients with RI and ERP attending a tertiary pelvic floor unit. Clinical data, AAR, and conventional anal manometry were analysed according to the Oxford prolapse grade. A total of 108 (102 [94%] female, median age 62 years [range: 26-95]) patients were recruited into three groups according to prolapse grade: Oxford grades I and II (intrarectal RI, n = 34), Oxford grades III and IV (intra-anal RI, n = 35) and Oxford grade V (ERP, n = 39). As the grade of prolapse increased, resting AAR measurements of opening pressure, opening elastance, closing pressure, and closing elastance decreased (p < 0.001). Maximum resting pressure with manometry was reduced in ERP and intra-anal RI compared to intrarectal RI (p < 0.001). However, incremental squeeze function was not different between the three groups with either AAR or manometry (p > 0.05). There were no differences in AAR or manometry variables between grade IV RI (n = 18) and high take-off ERP (n = 20) (p > 0.05). By contrast, opening pressure (p = 0.010), closing pressure (p = 0.019) and elastance (p = 0.022) were reduced in low take-off ERP (n = 19). Increasing rectal prolapse grade is associated with reduced anal sphincter function at rest indicating internal anal sphincter dysfunction. Physiological differences exist between high and low take-off ERP with sphincter function in the former similar to that seen in grade IV RI.

High-resolution versus conventional manometry for the diagnosis of small bowel motor dysfunction.

The diagnosis of small bowel motility disorders is performed by manometric evaluation of the contractile patterns of the small intestine. Conventional intestinal manometry systems include few pressure sensors at relatively long intervals. We have recently shown that high-resolution jejunal manometry, with multiple closely spaced recording sites, allows the analysis of propagation patterns of intestinal motility in healthy subjects that cannot be detected with conventional manometry. The objective of this pilot study was to explore the feasibility and diagnostic value of high-resolution intestinal manometry in patients with suspected small bowel dysmotility. Prospective pilot study evaluating intestinal motility patterns in 16 consecutive patients (16-61 years; 11 women) with severe, chronic digestive symptoms referred for the evaluation of intestinal motility and in 18 healthy controls (21-38 years; 8 women). A 36-channel high-resolution manometry catheter was orally placed under radiological guidance in the jejunum. Intestinal motility was continuously recorded for 3 h fasting and 2 h after a 450 kcal meal. The manometric recordings were analyzed in two formats: (a) with the high-resolution data from 34 channels and (b) showing only the recordings from 5 channels separated by 7 cm intervals, mimicking a conventional manometry recording. In the analysis mimicking conventional manometry, abnormal motility criteria were detected in six patients and in no healthy subject [bursts (n = 3), postprandial minute rhythm (n = 1) and myopathic pattern (n = 2)]. These classical dysmotility criteria were also detected by high-resolution manometry. High-resolution analysis detected one or more abnormal findings in seven additional patients that were not observed in any healthy subject, specifically: (a) abnormal propagation of Phase III (n = 3); (b) reduced propagated activity during Fasting Phase II (n = 4); (c) increased propagated activity during Fasting Phase II and postprandial phase (n = 1). This pilot study suggests that high-resolution intestinal manometry may improve the sensitivity of conventional manometry in the detection of intestinal motor dysfunction.

Laparoscopic heller myotomy versus peroral endoscopic myotomy for the treatment of achalasia.

To compare different therapeutic modalities and determine their role in the treatment of esophageal achalasia. The last 3 decades have seen a significant improvement in the diagnosis and treatment of esophageal achalasia. Conventional manometry has been replaced by high-resolution manometry, which has determined a more precise classification of achalasia in three subtypes, with important treatment implications. Therapy, while still palliative, has evolved tremendously. While pneumatic dilatation was for a long time the main choice of treatment, this approach slowly changed at the beginning of the nineties when minimally invasive surgery was adopted, initially thoracoscopically and then laparoscopically with the addition of partial fundoplication. And in 2010, the first report of a new endoscopic technique - peroral endoscopic myotomy (POEM) - was published, revamping the interest in the endoscopic treatment of achalasia. This review focuses particularly on the comparison of POEM and laparoscopic Heller myotomy (LHM) with partial fundoplication as primary treatment modality for esophageal achalasia. Based on the available data, we believe that LHM with partial fundoplication should be the primary treatment modality in most patients. POEM should be selected when surgical expertise is not available, for type III achalasia, for the treatment of recurrent symptoms, and for patients who had prior abdominal operations that would make LHM challenging and unsafe.

The Impact of Chronic Cannabis Use on Esophageal Motility in Patients Referred for Esophageal Manometry.

Tetrahydrocannabinol, the main psychoactive compound in cannabis, binds with high affinity to the cannabinoid 1 receptor. Small randomized controlled studies using conventional manometry have shown that the cannabinoid 1 receptor can modulate esophageal function, namely transient lower esophageal sphincter relaxation frequency and lower esophageal sphincter tone. The effect of cannabinoids on esophageal motility in patients referred for esophageal manometry has not been fully elucidated using high-resolution esophageal manometry (HREM). We aimed to characterize the clinical effect of chronic cannabis use on esophageal motility utilizing HREM. Patients who underwent HREM from 2009 to 2019 were identified at 4 academic medical centers. The study group consisted of patients with a noted history of chronic cannabis use, a diagnosis of cannabis-related disorder, or a positive urine toxicology screen. Age and gender-matched patients with no history of cannabis use were selected to form the control group. Data on HREM metrics based on the Chicago classification V3, and the prevalence of esophageal motility disorders were compared. Confounding effects of BMI and medications on esophageal motility were adjusted for. Chronic cannabis use was found to be an independent negative predictor of weak swallows (β=-8.02, P =0.0109), but not a predictor of failed swallows ( P =0.6890). The prevalence of ineffective esophageal motility was significantly lower in chronic cannabis users compared with nonusers (OR=0.44, 95% CI 0.19-0.93, P =0.0384). There was no significant difference in the prevalence of other esophageal motility disorders between the 2 cohorts. In patients with dysphagia as their primary indication for HREM, chronic cannabis use was found to be independently associated with increased median integrated relaxation pressure (β=6.638, P =0.0153) and increased mean lower esophageal sphincter resting pressure (β=10.38, P =0.0084). Chronic cannabis use is associated with decreased weak swallows and reduced prevalence of ineffective esophageal motility in patients referred for esophageal manometry. In patients referred for dysphagia, chronic cannabis use is associated with increased integrated relaxation pressure and lower esophageal sphincter resting pressure, though not to levels above the normal range.

Evaluation of conventional anorectal manometry and biofeedback therapy in adolescents with functional constipation.

The aim was to evaluate the outcomes of conventional anorectal manometry (ARMM) testing and biofeedback therapy in adolescents with functional constipation. A retrospective analysis of ARMM findings in patients aged 10-18 years with intractable constipation over a 4-year period was conducted. Of the 41 patients (mean age, 13.5±2.44 years) included, 20 (48.7%) were male. Rectoanal inhibitory reflex (RAIR) was positive in all patients. Group 1 had 31 patients with dyssynergic defecation (DD) and Group 2 had 10 patients without DD. Anal canal resting pressure, squeeze test pressure, rectal defecation pressure, and first and urge sensation volumes were similar between the groups. Maximum tolerated volume and the relaxation percentage of RAIR were higher in Group 1 than in Group 2 (p<0.05). Among 31 patients referred for biofeedback therapy, 8 (25.6%) completed the program with complete resolution of their symptoms. The mean follow-up period for these patients was 21±14.7 months. DD is relatively common in patients with psychosocial adjustment disorders, and it can be diagnosed via ARMM. Despite the low rate of adherence to the therapy in the presented series, biofeedback therapy was highly effective in resolving the symptoms including soiling.

OGBN O06 Enhancing Surgical Decision-Making with High-Resolution Manometry and Distal Contractile Integral in Preoperative Assessment for Magnetic Sphincter Augmentation (LINX)

Abstract Background Preoperative assessment for magnetic sphincter augmentation (MSA) (LINX) involves evaluating the Mean Distal Amplitude (MDA) on conventional manometry to assess the patient suitability and risk of post-operative dysphagia. In the last decade high-resolution manometry (HRM) has superseded conventional manometry owing to obtaining more clinical information on the oesophageal motility, including the Distal Contractile Integral (DCI) that incorporates contractile amplitude, duration and contractility propagation length within the oesophageal body. The purpose of this study is to translate the MDA to modern DCI as preoperative marker to MSA. Methods This retrospective study includes patients referred to oesophageal laboratory at Guy’s Hospital between March and May 2023. Patients underwent HRM with ten 5ml water swallows that provided manometric information to compute mean DCI and MDA (MDA waveforms at 11cm, 7cm and 3cm above the GOJ were used). Statistical analysis investigated the relationship between MDA and mean DCI using Pearson correlation, Student t-test, ROC curve analysis and relevant metrics assess the cut-off threshold accuracy and reliability in classifying normal MDA. Results 270 patients were included in the study (female:male=190:80 males, mean age 52.1 years). There was strong direct correlation between MDA and mean DCI (r=0.71, p&amp;lt;0.0001) (Figure 1). Patients with normal MDA had a significantly higher mean DCI compared with weak MDA at 11cm (601mmHgscm vs 167.15mmHgscm, p&amp;lt;0.0001) 7cm (286.4mmHgscm vs 741mmHgscm, p&amp;lt;0.001), 3cm (592mmHgscm vs 192.6mmHgscm, p&amp;lt;0.0001) and overall MDA (714.2mmHgscm vs 259mmHgscm, p&amp;lt;0.001) (Figure 2). ROC curve analysis revealed the mean DCI thresholds for normal MDA to be 615mmHgscm at 11cm, 419mmHgscm at 7cm, 318mmHgscm at 3cm and 453mmHgscm for the overall MDA (Table 1). Conclusions The findings of this study show HRM and the clinical measurement DCI may be a suitable preoperative assessment for MSA. This translation of MDA to modernisation in manometry may assist surgeons adopt DCI which is regarded as more robust assessment that offers more detailed clinical information of the oesophageal motility health and disorder.

True peristaltic recovery is uncommon following treatment, particularly endoscopic dilation for achalasia cardia, though pseudo-recovery often occurs.

Relieving esophagogastric junction (EGJ) obstruction has been the focus of treatment for achalasia cardia. The recovery of peristalsis has been an elusive goal. Studies analyzing post-intervention peristaltic recovery have several limitations such as theuse of conventional manometry or lack of standard definitions of peristalsis. Accordingly, we undertook this study to analyze frequency and pattern of peristaltic recovery following treatment for achalasia cardia on high-resolution manometry (HRM) and standard Chicago definition of peristalsis. Pre and post-intervention HRM records of 71 treatment-naive patients diagnosed as achalasia cardia were retrospectively analyzed. Records with pre and post-intervention HRM on different systems (e.g. solid state and water perfusion) and those with inadequate information were excluded. All HRMs were interpreted as per Chicago classification version 3.0. After pneumatic dilation (PD) or laparoscopic Heller's myotomy (LHM), pseudorecovery of peristalsis was defined as any contraction at least 3cm in length along 20mmHg isobaric contour with a distal latency of less than 4.5seconds. True recovery and premature contractions were defined by standard Chicago classification v3.0 criteria. Change in diagnosis was observed in 38 of 71 (53.5%) patients after intervention. While pseudo-peristaltic recovery occurred in 11 of 71 (15.5%) patients, only three (4.2%) had a true recovery. Another nine (12.7%) patients showed new premature contractions. True peristaltic recovery is uncommon in achalasia cardia following intervention, particularly PD. Pseudo-peristaltic recovery is more common. Further research is warranted on this issue.

Effects of Aging and Gender on the Anorectal Function of Healthy Subjects Assessed with Conventional Anorectal Manometry.

Anorectal functions are influenced by gender and age. This study sought to define the normal anorectal pressure values measured with conventional anorectal manometry (ARM) and to evaluate the effects of age and gender on anorectal function in asymptomatic subjects. Conventional ARM was used to measure the anorectal pressures of 164 asymptomatic healthy subjects, including 86 males and 76 females. The resting anal pressures of males and females aged >60 years were significantly lower than those ≤60 years (males, 44.09±14.22 vs. 57.45±17.69, p<0.001; females, 44.09±14.22 vs. 57.45±17.69, p<0.001). The anal high-pressure zone was significantly lower in older males than in younger males (2.42±0.93 vs. 2.82±0.739, p=0.048). In both age groups (<60 and ≥60 years), the anal squeezing pressures of males were significantly higher than those of females (<60 years old, 168.40±75.94 vs. 119.15±57.53, p=0.001; ≥60 years, 149.61±64.68 vs. 101.3±54.92, p=0.006). The normal anorectal pressure values measured with ARM in males and females were different. Older males and females had lower anal resting pressures than those of the younger subjects, but squeezing pressure was not affected by age.

Role of 3D high resolution anorectal manometry compared to conventional technique in management of constipation and fecal incontinence in children

BackgroundAnorectal manometry is a valuable tool for objective assessment of motility motor and sensory function of the anorectum. The aim of this study was to investigate role of water-perfused (WP) three dimensional high-resolution anorectal manometry (3D-HRARM) compared to WP conventional manometry (CM) in the management of chronic idiopathic constipation (CIC) and faecal incontinence (FI) in children. MethodsThis was a retrospective review of 122 consecutive children, who had WP 8-channel CM or 24 channel 3D-HRARM and endosonography under ketamine anaesthesia from September 2012 to February 2019. All patients had a validated symptom severity score questionnaire ranging from 0 (best) to 65 (worst). Mann-Whitney-U test and Spearman rank test were used and p<0.05 was considered significant. ResultsSubjects were divided according to investigation: CM group (n = 75) and 3D-HRAM (n = 47), who were otherwise comparable. Median anal resting pressure was 50 mmHg and rectoanal inhibitory reflex (RAIR) threshold volume was 10mls across the entire cohort. There were no significant differences in resting pressure or RAIR threshold when using conventional or 3D-HRARM. Rectal capacity was significantly higher in the CM group (p = 0.002). Rectal capacity and internal anal sphincter (IAS) thickness positively correlated with symptom severity, duration and patient age. 3D-HRARM provided a more detailed depiction of the anorectal pressure profile. Botulinum toxin was injected into the external anal sphincter (EAS) muscle (n = 75, 61%) and an anterograde colonic enema (ACE) stoma was needed subsequently in 19 (16%) to treat recurrent constipation and soiling symptoms. Rectal biopsy was done in 43(35%) patients, if RAIR was absent or inconclusive. ConclusionCM and 3D-HRARM are comparable in terms of resting pressure and RAIR threshold. 3D-HRAM is safe and provides detailed functional morphology of anal sphincters and it is useful to understand underlying pathophysiology of constipation and faecal incontinence in children and plan further treatment. Level of EvidenceLevel I

Achalasia

Achalasia is characterized by peristaltic failure and incomplete relaxation of the lower esophageal sphincter. The incidence and prevalence of achalasia increase with age, although achalasia can affect all age groups. The pathophysiology of achalasia involves the loss of inhibitory ganglion cells in the myenteric plexus of the esophagus. Its main symptoms include dysphagia, chest pain, regurgitation, and weight loss. The method of diagnosing achalasia has evolved from conventional manometry in the 1970s to high-resolution manometry in the 2010s. High-resolution manometry based on spatiotemporal plots can diagnose achalasia more precisely than conventional manometry. Moreover, novel parameters such as integrated relaxation pressure (IRP) (according to the Chicago classification) have increased diagnostic accuracy. However, cases of achalasia presenting with normal IRP have been reported. Therefore, the novel Chicago classification version 4.0 has adopted additional tests. These tests include the stress test for esophageal motor disorders, timed barium esophagography, and test using a functional lumen imaging probe that measures the distensibility of the esophagogastric junction. Achalasia was previously treated using surgical myotomy, balloon dilation, and botulinum toxin injection. However, peroral endoscopic myotomy (POEM) has recently become the mainstay treatment. POEM has a higher clinical success rate and a lower complication rate than surgical myotomy. Esophageal cancer and pulmonary conditions such as aspiration pneumonia are possible complications of achalasia. In this review, the current knowledge regarding achalasia together with novel diagnostic and therapeutic strategies are discussed.

Anorectal Function with High-Resolution Anorectal Manometry in Active Ulcerative Colitis and after Remission: A Pilot Study.

Ulcerative colitis may impair anorectal function, causing disabling symptoms such as incontinence and/or increase in the stool frequency, urgency and tenesmus. Data on anorectal function in these patients evaluated by conventional anorectal manometry are conflicting. The aim of this prospective study was to assess by means of high resolution anorectal manometry the anorectal function in patients with mild-to-moderate ulcerative colitis at presentation and after remission. Anorectal function of ulcerative colitis patients was compared to that observed in healthy volunteers. 20 patients with mild to moderate left-sided ulcerative colitis or proctitis and 20 healthy volunteers were prospectively enrolled. All ulcerative colitis patients underwent high resolution anorectal manometry before treatment and after clinical remission. Ulcerative colitis patients showed similar values for anal sphincter function as healthy volunteers, whereas rectal threshold volume for the first sensation, desire to defecate, urgency to defecate and maximum discomfort were significantly lower than in healthy volunteers (p<0.05). Rectal compliance was significantly lower in ulcerative colitis than in healthy volunteers (p<0.05). After remission, rectal threshold volumes, as well as rectal compliance, significantly increased. An inverse linear correlation was found between regression of urgency and stool frequency and rectal compliance (r=0.811; p<0.05). Ulcerative colitis patients show altered rectal function, with increased rectal sensitivity and lower compliance, compared to controls. This altered function is restored after successful treatment of the underlying inflammatory process. Finally high resolution anorectal manometry provides useful information on anorectal functionality and, in our opinion, should be preferred over conventional manometry.

Relationship Between Esophageal Motility Disorders and Autonomic Nervous System in Diabetic Patients: Pilot North African Study.

Little attention has been given to esophageal disorders in diabetes mellitus. Pathophysiology of esophageal motility disorders (EMD) in patients with diabetes mellitus is multifactorial. The aims of the present study were: (a) to evaluate the prevalence of EMD in patients with Type 2 diabetes mellitus and (b) to determine the relationship between EMD and autonomic neuropathy as assessed by heart rate variability (HRV). All the patients completed a questionnaire about diabetes characteristics and gastrointestinal symptoms. Conventional esophageal manometry was performed in all patients. HRV was measured in three different situations (Lying Position 1, standing position, and Lying Position 2). The temporal and frequency domain parameters were considered for analysis. The prevalence of EMD in our patients was 60.5% (n = 23). Low score physical activity was significantly more frequent in patients with EMD (p = .03). There was an increase in sympathetic activity represented by the low frequency (LF) parameter (p = .027) in the presence of EMD. Whereas parasympathetic modulation of heart rate represented by the high frequency (HF) parameter (p = .027) was declined in patients with EMD compared to those without. The LF/HF ratio was significantly higher (p = .002) in patients with EMD. EMD were prevalent in diabetes mellitus and were associated to autonomic nervous system dysfunction predominantly at the parasympathetic component.

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.

Nonachalasic esophageal motor disorders, from diagnosis to therapy

ABSTRACT Introduction Investigations conducted using conventional manometry and, recently, using high-resolution manometry (HRM), allowed us to explore the field of esophageal motility and understand the potential link between motor features and gastroesophageal reflux disease (GERD) pathogenesis. The management of patients with nonachalasic esophageal motor disorders is often challenging, due to the clinical heterogeneous presentation and the multifactorial nature of the mechanisms underlying symptoms. Areas covered Several studies, carried out using HRM, have better interpreted the esophageal motor function in patients with esophagogastric junction outflow obstruction (EGJOO), distal esophageal spasm (DES), hypertensive esophagus, and hypomotility disorders. Moreover, HRM studies have shown a direct correlation between reduced esophageal motility, disruption of the esophagogastric junction, and gastroesophageal reflux burden. Expert opinion Pathogenesis, clinical presentation, diagnosis, and treatment of nonachalasic esophageal motor disorders still represent a challenging area, requiring future evaluation by multicenter outcome studies carried out in a large cohort of patients and asymptomatic subjects. However, we believe that an accurate clinical, endoscopic, and HRM evaluation is, nowadays, helpful in addressing patients with nonachalasic esophageal motor disorders to optimal treatment options.

The value of conventional manometry in the identification of normal esophageal manometry.

In the last decade, high-resolution esophageal manometry (HREM) is the main device for the management of dysphagia replacing conventional manometry (CM). Conventional manometry still seems to have some space to diagnose major motility disorders and differentiate normal from abnormal esophageal motility. The long term outcomes of patients with normal CM were analyzed in our study.Participants (patients with dysphagia and normal CM) took a questionnaire via a phone call in February 2021. Impact Dysphagia Questionnaire (IDQ) was used as an assessment tool.Only 55% (83/151) the individuals with previous normal manometric findings were reached via telephone. The group who have completed the survey was representative of the cohort. 66.2% of the participants were female (P = .40). The mean age was 57.21, mean weight was 70.69 kg, mean height was 163.74 cm and mean body mass index was 26.41. More than 40% of patients were completely asymptomatic at follow up, reflected by an IDQ score of 0. Only 28 out of 83 (33.7%) patients reported significant symptoms as reflected by an IDQ score greater than or equal to 7. The rest of responders admitted as having moderate to mild symptoms.HREM is a valid technique with comparable precision to CM. HREM measurements differ considerably to CM. The identification of normal motor function in CM is not likely a positive prognostic indicator and must be interpreted precautiously.

The Role of High Resolution Manometry in Non-Cardiac Chest Pain

The most common cause of noncardiogenic chest pain is gastroesophageal reflux disease, and other esophageal motility disorders are also frequent. Esophageal manometry is important for diagnosing esophageal motility disease. Recently, high resolution manometry (HRM) has emerged and is reported to be more useful than conventional esophageal manometry in evaluating primary esophageal motility disease. In this study, the role and usefulness of HRM in noncardiac chest pain were investigated. From August 2018 to April 2021, 136 patients with chest pain were enrolled. Classification was carried out according to Chicago classification version 3.0, and 95 out of 136 patients showed normal findings, and 23 patients showed ineffective esophageal motility. When gastroesophageal reflux disease was classified according to Los Angeles (LA) classification, LA-M was 20% (6/30), LA-A was 63.3% (19/30), LA-B was 16.6% (5/30), and LA-C was, there were no patients with LA-D. Through this study, it was confirmed that about 22% of patients with noncardiogenic chest pain had reflux esophagitis, and about 30% of patients had esophageal motility disease. High-resolution esophageal manometry appears to be useful for the differentiation of noncardiogenic chest pain caused by esophageal motility disorders other than reflux esophagitis. After diagnosis of esophageal motor disease, follow-up studies on whether non-cardiac chest pain improves after drug treatment is required. Keywords: Chest pain, Esophageal motility disorder, Esophagitis, Gastroesophageal reflux, High resolution manometry

A Short History of High-Resolution Esophageal Manometry.

High-resolution esophageal manometry (HRM) utilizes sufficient pressure sensors such that intraluminal pressure is monitored as a continuum along luminal length, similar to time viewed as a continuum on polygraph tracings in 'conventional' manometry. When HRM is coupled with pressure topography plotting, and pressure amplitude is transformed into spectral colors with isobaric areas indicated by same-colored regions, "Clouse plots" are generated. HRM has several advantages compared to the technology that it replaced: (1) the contractility of the entire esophagus can be viewed simultaneously in a uniform standardized format, (2) standardized objective metrics of peristaltic and sphincter function can be systematically applied for interpretation, and (3) topographic patterns of contractility are more easily recognized with greater reproducibility. Leveraging these advantages led to the current standard for the interpretation of clinical esophageal HRM studies, the Chicago Classification (CC), now in its fourth iteration. Compared to conventional manometry, HRM has vastly improved the sensitivity for detecting achalasia, largely due to the objectivity and accuracy of identification of impaired esophagogastric junction (EGJ) relaxation. Additionally, it has led to the subcategorization of achalasia into three clinically relevant subtypes, differentiated by the contractile function of the esophageal body, and identified an additional disorder of EGJ outflow obstruction wherein esophageal peristalsis is preserved. Headway has also been made in understanding hypocontractile and hypercontractile conditions. In summary, HRM and the CC process have revolutionized our understanding of esophageal motility and motility disorders. Moving forward, there will always be remaining challenges, but we now have the tools to meet them.

MOTILITY OF THE UNPREPARED INTESTINAL TRACT IN HEALTHY HUMANS AND PATIENTS WITH SLOW TRANSIT CONSTIPATION REVEALED BY USING MICRO-ELECTRONIC CAPSULE

Slow transit constipation (STC) is usually accompanied by intestinal motility abnormalities. Although conventional anorectal manometry could record the pressure in the colon, most patients need preparation of intestinal tract. The intervention of catheter for monitoring the intestinal pressure also affects the clinical measurement. The pressure data collected by the conventional anorectal manometry cannot fully characterize the dynamic characteristics of the intestine. Thus, we aimed to obtain colonic pressure data under normal physiological conditions. Utilizing these data, we analyze the difference of colonic motility parameters between healthy control and patients with STC. A micro-electronic capsule made by ourselves was used to gather the subjects’ intestinal pressure in their daily life. Several intestinal motility parameters were calculated from the pressure profile. The average energy of colonic pressure data in the STC group is higher than the healthy control group (HC: 259.95 vs. STC: 821.28). But the STC group has a lower average complexity of colonic motility (HC: 0.80 vs. STC: 0.64). About 81.25% of the colonic data from patients with STC could be identified by using slow transit constipation (SVM) classifier. Compared with health control, most colonic parameters of patients with STC are higher under the normal physiological conditions, but the complexity of colonic motility is lower in the STC group. The correct rate of colonic pressure recognition in the STC group is more than 80% by using SVM classifier.

Esophagogastric junction contractile integral abnormalities in patients with proton pump inhibitor-refractory symptoms.

Esophagogastric junction contractile integral (EGJ-CI) is a novel indicator to evaluate quantitatively the esophagogastric junction (EGJ) barrier function. We aimed to assess the role of EGJ-CI in patients with refractory gastroesophageal reflux disease (GERD) symptoms and the correlation between EGJ-CI and impedance-pH monitoring characteristics. In total 82 patients with proton pump inhibitors (PPIs)-refractory gastroesophageal reflux symptoms (heartburn or regurgitation) were enrolled. These patients were further divided into two groups based on their EGJ-CI value (39 mmHg·cm). The mean nocturnal baseline impedance (MNBI) was measured to explore its association with EGJ-CI. The median EGJ-CI in patients with PPI-refractory symptoms was 30.8 mmHg·cm. EGJ-CI was inversely correlated with acid exposure time and reflux episodes; while it was positively correlated with MNBI, distal contractile integral, lower esophageal sphincter basal pressure and integrated relaxation pressure. Patients were further divided into the high (n=27) and low (n=55) EGJ-CI groups using a cut-off value of 39.0 mmHg·cm. Patients with a low EGJ-CI had a lower MNBI level than those with a high EGJ-CI (2703 Ω vs 3545 Ω, P = 0.034). In patients with PPIs-refractory symptoms, EGJ-CI is associated with acid exposure and conventional high-resolution manometry parameters. EGJ-CI may play an important role in the diagnosis and treatment of patients with refractory GERD.