Conventional Manometry Research Articles

The Contribution of High-Resolution versus Conventional Esophageal Manometry to the Assessment of Esophageal Motor Disorders in Patients With Non-Cardiac Chest Pain (NCCP)

Introduction: NCCP is defined as recurring, angina-like, retrosternal chest pain of non-cardiac origin. It has been estimated that up to 30% of the non-GERD related NCCP patients demonstrate an esophageal motor disorder using conventional manometry (CM). Thus, the aim of the study was to determine if high resolution esophageal manometry (HREM), which has become the standard of care, improved the diagnosis of esophageal motor disorders, as compared with CM, in patients with NCCP. Methods: We evaluated 300 consecutive non-GERD related NCCP patients who underwent either HREM or CM. A total of 150 patients had CM and the other 150 patients HREM. The Chicago 3 classification and the Castell and Spechler classification were used to determine the esophageal motor disorder of patients undergoing HREM and CM, respectively. Results: In both HREM and CM groups, a normal esophageal motility study was the most frequent finding (47% vs. 36%, respectively). In patients who underwent CM, the most commonly demonstrated esophageal motility disorder was hypotensive lower esophageal sphincter. Hypotensive LES was a significantly more common finding in patients undergoing CM versus HREM (27.3% vs. 4.7%, p<0.001). Other less common motility disorders seen in the CM group were nonspecific esophageal motility disorders (NEMD) (12%), nutcracker esophagus (9.3%), ineffective esophageal motility (IEM) (6.7%), achalasia (2.7%), distal esophageal spasm (DES) (5.3%), and absent contractility (0.67%). In general, hypertensive motility disorders, like DES and nutcracker esophagus, were less common than hypotensive motility disorders (15% vs. 35%, p=0.9) in NCCP patients. There was no significant difference in the number of hypertensive or hypotensive motility disorders diagnosed with CM versus those diagnosed with HREM. In the HREM group, IEM was the most commonly diagnosed motility abnormality. The likelihood of finding an IEM was significantly more common in the HREM group as compared with the CM group (25% vs. 7%, p<0.001). Other motility abnormalities that were less commonly diagnosed with HREM included: achalasia (7.3%), esophagogastric junction outflow obstruction (4%), absent contractility (4%), jackhammer/nutcracker esophagus (3.3%), DES (2.7%) and NEMD (1.3%). Conclusion: HREM did not improve the percentage and type of esophageal motor disorders diagnosed in NCCP patients as compared with CM. This is likely due to limitations of Chicago 3 classification. Normal esophageal motility remains the most common finding.

The Pressure Inversion Point (PIP): Passeʼ or Paramount

PIP is produced by diaphragmatic moverment during respiration. In conventional manometry, it was used as a landmark to locate the approximate location of the LES. However, using this landmark in small hiatal hernia (HH) can give inaccurate LES location. The role of PIP in the era of high resolution manometry (HRM) has diminished. This is especially due to the easy recognition of HH using its colored pressure topography. HH is identified by 2 distal high pressure zones with the peristaltic sequence ending at the level of the LES, distinguishing it from the diaphragmatic pressure zone. Here we present a case of 72 year old female, referred to our motility laboratory by her primary care physician. Her main complain is recurrent episodes of epigastric pain, associated with nausea, dizziness and shortness of breath. Her past medical history includes hypertension and GERD. She denied dysphagia, weight loss and any atypical GERD symptoms. The patient states she had similar attacks throughout the last 8 years. Her work up included HRM and stress perfusion cardiac MRI. The HRM showed normal peristalsis with normal LES metrics (resting pressure and integrated relaxation pressure were 19 and 14 mm/Hg respectively). The only interesting finding was the absence of detectable PIP (figure 1). The stress perfusion MRI showed no cardiac perfusion and left ventricular function pararmeters. Incidentally, the MRI showed complete intrathoracic positioning of the stomach. CT abdomin was performed and it confirmed the finding (figure 2).Figure: HRM of the case. There was absence of detectable PIP with same respiratory cyclic color fluctuation above and below the LES.Figure: A: MRI showing the presence of intrathoracic stomach, B: CT abdomen confirming the same finding.Figure: An example of normal manometry with detectable PIP at the level of the LES. The respiratory cyclic color fluctuation is inverted in the region below the LES.Discussion: Locating the PIP is relatively easy using HRM. However, one must learn to recognize the color contour appearance of this phenomenon. In addition, its presence /absence can be roughly deetermined by observing the respiratory variations in the HRM color plot. The typical blue of the intraesophageal pressure darkens with inspiration and lightens with expiration. This finding assists in locating the diaphragm and so the PIP, since intraabdominal pressure changes inversely to the intrathoracic pressure with respiration (figure 3). In our case, these respiratory cyclic pressure fluctuations were the same above and below the LES. Lessons learned: Locating the PIP is important, despite not being used in the HRM algorithm of the Chicago classification. As shown in this case, the absence of detectable PIP reflects a significant structural pathology (complete intrathoracic stomach).

Rumination Syndrome: The Forgotten Offender

Rumination syndrome is an under-diagnosed and not well-understood condition. It's a repetitive and effortless habit that becomes a subconscious process, which affects children and adults that are developmentally challenged as well as healthy patients of all ages. It carries social stigmata and impacts one's health. We describe a case of a middle-aged woman suffering from this for majority of her life and once successfully diagnosed, she underwent biofeedback therapy and diaphragmatic breathing technique with remarkable improvement in her quality of life. A 68 year-old female with history of GERD presented with chronic regurgitations for > 48 years with re-mastication afterwards, negatively impacting her social life. Extensive work up was unremarkable including upper endoscopy, barium esophagram and gastric emptying study. Esophageal manometry showed normal contraction amplitude and LES profile. 24-hour pH-impedance reflux testing on acid suppression showed poor gastric acid control and slightly abnormal upright acid exposure (1.6%). One-hour high-resolution manometry-impedance study after consuming a provocative meal, with advancing the catheter distally into the proximal stomach, revealed total of 39 episodes of regurgitation (Figure 1). Episodes were preceded by increase in intra-gastric pressure (>30 mmHg), and were followed immediately by normal swallows to clear up the regurgitated food and were typical for rumination syndrome. Biofeedback was implemented, and diaphragmatic breathing technique was used as adjunctive modality for therapy. 6 months later, she had significant improvement in her social life with remarkable relief of symptoms. A Likert scale was used to quantify symptoms reduction (Figure 2). Rumination syndrome is often misdiagnosed for other upper gastrointestinal disorders (GERD, functional dyspepsia, eating disorders like bulimia, gastroparesis and chronic intestinal pseudo-obstruction). It involves involuntary increase in gastric pressure followed by opening of LES and increase in the intra-esophageal pressure to the same extent as gastric (common-cavity phenomenon). Rumination syndrome can be diagnosed with clinical symptomatology according to Rome IV criteria (Figure 3). Combined esophageal manometry-impedance testing is helpful in confirming the diagnosis. Biofeedback and behavioral modification therapy with diaphragmatic breathing proved to be useful in management of this chronic condition.Figure: High-resolution esophageal impedance-manometry showing sudden increase in intra-gastric and intra-esophageal pressure followed by a normal swallow to clear the regurgitated food (Left-hand side). Conventional manometry shows increase intra-gastric and esophageal pressure followed by normal swallow (Right-hand side).Figure: Patient's symptom improvement on Likert scale 1, 2 and 5 months through treatment. On a scale from 0-5, where 0 represents no symptoms and 5 represents severe symptoms, patient had 50% decrease in regurgitation, resolution of heartburn, 75% decrease in belching, 2/3 decrease in acid taste in mouth and resolution on bloating sensation with use of biofeedback and diaphragmatic breathing.Figure: Rome IV criteria for Rumination Syndrome

Use of Anal Acoustic Reflectometry in the Evaluation of Men With Passive Fecal Leakage.

Men with passive fecal leakage represent a distinct clinical entity in which the pathophysiology remains unclear. Standard anorectal investigations fail to demonstrate consistent abnormalities in this group. Anal acoustic reflectometry is a new test of anal sphincter function with greater sensitivity and discriminatory ability than conventional anal manometry. The aim of this study was to determine whether men with fecal leakage have an abnormality in anal sphincter function that is detectable by anal acoustic reflectometry. This was an age-matched study of continent and incontinent men. The study was conducted at a university teaching hospital. Male patients with isolated symptoms of fecal leakage were recruited. Anal acoustic reflectometry, followed by conventional anal manometry, was performed. Results were then compared with those from an age-matched group of men with no symptoms of anal incontinence or anorectal pathology. Variables measured with anal acoustic reflectometry and anal manometry in the incontinent and continent men were compared. Thirty subjects were recruited, of whom 15 were men with fecal leakage and 15 were continent men. There was a significantly higher incidence of previous anorectal surgery in the men with leakage. The anal acoustic reflectometry variables of opening and closing pressure were significantly lower in leakers compared with continent subjects (p = 0.003 and p = 0.001). Hysteresis was significantly greater in the male leaker group (p = 0.026). No difference was seen in anal manometry. With a larger sample size, the effect of previous anorectal surgery and the presence of an anal sphincter defect could be clarified. Anal acoustic reflectometry is a sensitive test of anal sphincter function and, unlike anal manometry, can discriminate male leakers from continent subjects. An identifiable abnormality has been detected using anal acoustic reflectometry, which may further our understanding of the pathogenesis in this group.

Small Bowel Motility.

Small bowel motility disorders constitute a relatively small but important segment of clinical gastroenterology. Presenting features encompass a broad range of symptom manifestations and severity: from chronic functional-type complaints to life-threatening nutritional impairment. Diagnostic assessment of patients with suspected intestinal motility disorders is often hampered by the complexity of measuring intestinal contractile activity in humans. In this review, we describe and critically comment the main current and forthcoming methodologies. Beyond conventional small bowel manometry, radiological methods, and intestinal transit tests that have been available for several decades, now we focus on novel methodologies such as high-resolution manometry, magnetic resonance methodology, and endoluminal capsule image analysis. Gradual introduction of new approaches to diagnostic investigation of patients with suspected intestinal motility disorders should facilitate a less invasive and more accurate characterization of disturbed motor function. Enhanced understanding of the pathophysiological basis of clinical conditions should allow better application of therapeutic approaches that are also highlighted in this review.

A PICTORIAL PRESENTATION OF ESOPHAGEAL HIGH RESOLUTION MANOMETRY CURRENT PARAMETERS.

ABSTRACTIntroduction:High resolution manometry is the current technology used to the study of esophageal motility and is replacing conventional manometry in important centers for esophageal motility with parameters used on esophageal motility, following the Chicago Classification. This classification unifies high resolution manometry interpretation and classifies esophageal disorders. Objective:This review shows, in a pictorial presentation, the new parameters established by the Chicago Classification, version 3.0, aimed to allow an easy comprehension and interpretation of high resolution manometry. Methods:Esophageal manometries performed by the authors were reviewed to select illustrative tracings representing Chicago Classification parameters. Results:The parameters are: Esophagogastric Morphology, that classifies this junction according to its physiology and anatomy; Integrated Relaxation Pressure, that measures the lower esophageal sphincter relaxation; Distal Contractile Integral, that evaluates the contraction vigor of each wave; and, Distal Latency, that measures the peristalsis velocity from the beginning of the swallow to the epiphrenic ampulla. Conclusion:Clinical applications of these new concepts is still under evaluation.

Advances in Management of Esophageal Motility Disorders

Esophageal manometry is an important tool for evaluating esophageal function. It can be used for assessing the esophageal peristaltic pattern and also peristaltic intensity. Additionally, lower esophageal sphincter (LES) function can be studied simultaneously. This information allows clinicians to thoroughly investigate patients presenting with esophageal and/or respiratory symptoms without identifable structural cause. At present,&nbsp;high resolution manometry (HRM) is preferred over conventional manometry as it informs the result in pressure topography. These data correlate more precisely with the clinical presentation of patients with esophageal dysmotility. Consequently, the HRM working group has proposed the criteria known as Chicago classifcation to categorize and specify the esophageal motility abnormality based on the results from HRM. This article describes esophageal motility disorders according to the current diagnostic criteria and also how to manage them in brief.&nbsp;&nbsp

Downregulation of neuronal vasoactive intestinal polypeptide in Parkinson's disease and chronic constipation.

Chronic constipation (CC) is a common and severe gastrointestinal complaint in Parkinson's disease (PD), but its pathogenesis remains poorly understood. This study evaluated functionally distinct submucosal neurons in relation to colonic motility and anorectal function in PD patients with constipation (PD/CC) vs both CC and controls. Twenty-nine PD/CC and 10 Rome III-defined CC patients were enrolled. Twenty asymptomatic age-sex matched subjects served as controls. Colonic transit time measurement and conventional anorectal manometry were evaluated in PD/CC and CC patients. Colonoscopy was performed in all three groups. Colonic submucosal whole mounts from PD/CC, CC, and controls were processed for immunohistochemistry with antibodies for vasoactive intestinal polypeptide (VIP) and peripheral choline acetyltransferase, markers for functionally distinct submucosal neurons. The mRNA expression of VIP and its receptors were also assessed. Four subgroups of PD/CC patients were identified: delayed colonic transit plus altered anorectal manometry (65%); delayed colonic transit (13%); altered manometric pattern (13%); and no transit and manometric impairment (9%). There were no differences in the number of neurons/ganglion between PD/CC vs CC or vs controls. A reduced number of submucosal neurons containing VIP immunoreactivity was found in PD/CC vs controls (P<.05). VIP, VIPR1, and VIPR2 mRNA expression was significantly reduced in PD/CC vs CC and controls (P<.05). Colonic motor and rectal sensory functions are impaired in most PD/CC patients. These abnormalities are associated with a decreased VIP expression in submucosal neurons. Both sensory-motor abnormalities and neurally mediated motor and secretory mechanisms are likely to contribute to PD/CC pathophysiology.

High-resolution manometry versus conventional manometry in diagnosis of patients with nonobstructive dysphagia.

High-resolution manometry versus conventional manometry in diagnosis of patients with nonobstructive dysphagia.

Relationship Between Acid Suppression Therapy and Esophageal Motility in GERD Patients

Introduction: GERD is one of the well-known major risk factor for esophageal dysmotility. Two major classes of acid suppression therapy Proton Pump inhibitors and H2 blockers are widely used. Usefulness of the esophageal function test (EFT) to measure esophageal motility is well established. However whether the use of acid suppression therapy is associated with less severe esophageal dysmotiliy has not been well studied. Aim: The aim of this study is to examine whether uses of acid suppression therapy in patients with GERD is associated with presence and severity of esophageal dysmotility as measured by EFT.Figure 1Table 1Methods: Retrospective analysis was performed on 108 patients with GERD who had manometry study between 2009 and 2014.charecterstics of acid suppression therapy were collected. The group was divided based on their acid suppression therapy. group1: patients on combination therapy of PPI and H2blocker, group2: patients on PPI alone and group3: without therapy. EFT parameters were compared in all groups. Results: 66 % of patient were females with mean age of 50±19.02. EFT charecterstics are categorized based on the acid therapy in the following Table and figure. Conclusion: Acid suppression therapy doesn't appear to influence esophageal motility measured by Conventional Manometry in GERD patients.

Loss of Peristaltic Reserve, Determined by Multiple Rapid Swallows, Is the Most Frequent Esophageal Motility Abnormality in Patients With Systemic Sclerosis.

We assessed peristaltic reserve using multiple rapid swallows (MRS) during esophageal high-resolution manometry (HRM) of 111 patients with systemic sclerosis (89 women; ages, 42-64 y). We performed a retrospective analysis of HRM studies that included MRS in patients with systemic sclerosis, performed at 2 tertiary referral centers, and compared data with those from 18 healthy volunteers (controls). HRM findings were analyzed according to the Chicago Classification to provide an esophageal motility diagnosis. Response to MRS was evaluated for the presence of contraction and for augmentation, defined as the distal contractile integral after MRS greater than the median distal contractile integral of 10 supine swallows. Esophageal motility diagnoses included 41% with absent contractility, 31% with normal motility, 23% with ineffective esophageal motility, and 5% that met the criteria for other esophageal motility disorders. Contraction (37%) and peristaltic augmentation (18%) after MRS were observed less frequently in patients with systemic sclerosis than in controls (83% and 100%, respectively). Impaired peristaltic reserve, as assessed with MRS during HRM, is therefore the most common esophageal motility finding among patients with systemic sclerosis.

High-Resolution Manometry Improves the Diagnosis of Esophageal Motility Disorders in Patients With Dysphagia: A Randomized Multicenter Study.

High-resolution manometry (HRM) might be superior to conventional manometry (CM) to diagnose esophageal motility disorders. We aimed to compare the diagnosis performed with HRM and CM and confirmed at 6 months in a multicenter randomized trial. Patients with unexplained dysphagia were randomized to undergo either CM or HRM. Motility disorders were diagnosed using the Castell and Spechler classification for CM and the Chicago classification for HRM. Diagnosis confirmation was based on clinical outcome and response to treatment after 6-month follow-up. The initial diagnosis and percentage of confirmed diagnoses were compared between the two arms (CM and HRM). In total, 247 patients were randomized and 245 analyzed: 122 in the CM arm and 123 in the HRM arm. A manometric diagnosis was more frequently initially achieved with HRM than with CM (97% vs. 84%; P<0.01). Achalasia was more frequent in the HRM arm (26% vs. 12% in the CM arm; P<0.01) while normal examinations were more frequent in the CM arm (52% vs. 28% in the HRM arm; P<0.05). After follow-up, the initial diagnosis was confirmed in 89% of patients in the HRM arm vs. 81% in the CM arm (P=0.07). Finally, overall procedure tolerance was better with CM than with HRM (P<0.01). This randomized trial demonstrated an improved diagnostic yield for achalasia with HRM compared with CM. Diagnoses tended to be more frequently confirmed in patients who underwent HRM, suggesting that esophageal motility disorders could be identified earlier with HRM than with CM (ClinicalTrial.gov, NCT01284894).

Colonic and anorectal motility testing in the high-resolution era.

The past few years have seen an increase in the number of research and clinical groups around the world using high-resolution manometry (HRM) to record contractile activity in the anorectum and colon. Yet despite the uptake and growing number of publications, the clinical utility and potential advantages over traditional manometry remain undetermined. Nearly all of the publications in the field of anorectal and colonic HRM have been published within the last 3 years. These studies have included some data on normal ranges in healthy adults, and abnormalities in patient groups with constipation or fecal incontinence, anal fissure, perineal descent, rectal cancer, and Hirschsprung's disease. Most of the studies have been conducted on adults, with only three published studies in pediatric populations. Very few studies have attempted to show advantages of HRM over traditional manometry High-resolution anorectal and colonic manometry provide a more comprehensive characterization of motility patterns and coordinated activity; this may help to improve our understanding of the normal physiology and pathophysiology in these regions. To date, however, no published study has conclusively demonstrated a clinical, diagnostic, or interventional advantage over conventional manometry.

A Non-Invasive Remote Pressure Sensor Design for Extreme Environments using Tunable Optics with Conventional Manometry

This paper presents the design of a non-invasive, non-contact remote pressure sensor using free-space optics, an electronically controlled variable focus lens (ECVFL), and a standard liquid manometer to monitor pressure inside high temperature and pressure chambers in harsh and hazardous environments. The proposed sensor does not require transparent manometers, and cameras in close proximity to determine pressure as the manometer liquid level are monitored remotely. This sensing mechanism is ideal for use in toxic environments, such as chemical plants as well as volatile and combustible units, such as oil refineries. Furthermore, the use of a low-power Gaussian laser beam for remote measurements mitigates the risk of destabilizing a semistable combustible system. Two experiments using manometers with identical and non-identical columns were performed as a proof-of-concept. Average measurement resolutions of 0.011 and 0.047 kPa corresponding to the relative resolutions of 0.109% and 0.085% are demonstrated in the two experiments. With the chosen ECVFL model, the sensor can deliver impressive 1700 measurements/min for stable pressure conditions and acceptable 60 measurements/min for drastically fluctuating pressure conditions in harsh environments.

Esophageal testing: What we have so far.

Gastroesophageal reflux disease (GERD) is a common disorder of the gastrointestinal tract. In the last few decades, new technologies have evolved and have been applied to the functional study of the esophagus, allowing for the improvement of our knowledge of the pathophysiology of GERD. High-resolution manometry (HRM) permits greater understanding of the function of the esophagogastric junction and the risks associated with hiatal hernia. Moreover, HRM has been found to be more reproducible and sensitive than conventional water-perfused manometry to detect the presence of transient lower esophageal sphincter relaxation. Esophageal 24-h pH-metry with or without combined impedance is usually performed in patients with negative endoscopy and reflux symptoms who have a poor response to anti-reflux medical therapy to assess esophageal acid exposure and symptom-reflux correlations. In particular, esophageal 24-h impedance and pH monitoring can detect acid and non-acid reflux events. EndoFLIP is a recent technique poorly applied in clinical practice, although it provides a large amount of information about the esophagogastric junction. In the coming years, laryngopharyngeal symptoms could be evaluated with up and coming non-invasive or minimally invasive techniques, such as pepsin detection in saliva or pharyngeal pH-metry. Future studies are required of these techniques to evaluate their diagnostic accuracy and usefulness, although the available data are promising.

Progression of Jackhammer Esophagus to Type II Achalasia.

It has been suggested that patients with certain motility disorders may progress overtime to develop achalasia. We describe a 66 year-old woman who presented with dysphagia for solids and liquids for a period of 18 months. Her initial workup showed normal endoscopy and non-specific esophageal motility disorder on conventional manometry. Six months later, due to persistence of symptoms, the patient underwent a high resolution esophageal manometry (HREM) demonstrating jackhammer esophagus. The patient was treated with a high dose proton pump inhibitor but without resolution of her symptoms. During the last year, the patient reported repeated episodes of food regurgitation and a significant weight loss. A repeat HREM revealed type II achalasia. Multiple case reports, and only a few prospective studies have demonstrated progression from certain esophageal motility disorders to achalasia. However, this report is the first to describe a case of jackhammer esophagus progressing to type II achalasia.

Clinical Application of Esophageal High-resolution Manometry in the Diagnosis of Esophageal Motility Disorders.

Esophageal high-resolution manometry (HRM) is replacing conventional manometry in the clinical evaluation of patients with esophageal symptoms, especially dysphagia. The introduction of HRM gave rise to new objective metrics and recognizable patterns of esophageal motor function, requiring a new classification scheme: the Chicago classification. HRM measurements are more detailed and more easily performed compared to conventional manometry. The visual presentation of acquired data improved the analysis and interpretation of esophageal motor function. This led to a more sensitive, accurate, and objective analysis of esophageal motility. In this review we discuss how HRM changed the way we define and categorize esophageal motility disorders. Moreover, we discuss the clinical applications of HRM for each esophageal motility disorder separately.

Gastric Tube Motility Patterns in Patients After Esophageal Resection with Gastric Pull-up.

Oral intake after esophagectomy is decreased in about a quarter of the patients, even in the absence of anastomotic or pyloric stenosis and in early-stage disease.1 Dysmotility of the vagotomized gastric tube may be a putative factor for dysphagia. The manometric motor activity of the gastric tube has been scarcely studied in the era of conventional manometry. Some studies showed that the fasting migrating motor complexes may occur late in follow-up in no more than half of the patients,2,3 but the gastric tube was virtually inert after swallowing.4,5 High-resolution manometry gives a detailed view that allows proper study of organs not conventionally studied by standard manometry in identifying the pressure impression of non-contractile anatomy structures, subtle peristalsis and flow obstructions. This technology is probably the most adequate to study the gastric tube after esophagectomy even though no previous studies focused on the topic. Our figure illustrates high-resolution manometry findings in patients eating an unrestricted diet, and without anastomotic stenosis detected at upper endoscopy, that underwent trans-hiatal esophagectomy, gastric pull-up, and pyloroplasty for esophageal cancer. Absence of peristalsis was noticed in all patients, including the cervical esophageal stump. Pressurization of the esophagus proximal to the anastomosis and flow resistance at the level of the anastomosis as well as the thoracic inlet were secondary findings. Figure High-resolution manometric findings of patients who underwent trans-hiatal esophagectomy for esophageal cancer showing: (A) aperistalsis, seen in 100% of the patients, (B) pressurization of the esophagus proximal to the anastomosis (arrow), (C) flow resistance ...

Ineffective Esophageal Motility (IEM): the Old-New Frontier in Esophagology.

Ineffective esophageal motility (IEM) is characterized by distal esophageal contraction amplitude of <30 mmHg on conventional manometry (Blonski et al. Am J Gastroenterol. 103(3):699-704, 2008), or a distal contractile integral (DCI) < 450 mmHg*s*cm on high-resolution manometry (HRM) (Kahrilas et al. Neurogastroenterol Motil. 27(2):160-74, 2015) in≥50 % of test swallows. IEM is the most common abnormality on esophageal manometry, with an estimated prevalence of 20-30 % (Tutuian and Castell Am J Gastroenterol. 99(6):1011-9, 2004; Conchillo et al. Am J Gastroenterol. 100(12):2624-32, 2005). Non-obstructive dysphagia has been considered to be frequently associated with severe esophageal peristaltic dysfunction. Defective bolus transit (DBT) on multichannel intraluminal impedance testing was found in more than half of IEM patients who presented with dysphagia (Tutuian and Castell Am J Gastroenterol. 99(6):1011-9, 2004), highlighting the functional defect of this manometric finding. Treatment of IEM has been challenging because of lack of promotility agents that have a definite effect on esophageal function.

Histopathologic patterns among achalasia subtypes.

Achalasia has three distinct manometric phenotypes. This study aimed to determine if there were corresponding histopathologic patterns. We retrospectively examined surgical muscularis propria biopsies obtained from 46 patients during laparoscopic esophagomyotomy. Pre-operative (conventional) manometry tracings were reviewed by two expert gastroenterologists who categorized patients into Chicago Classification subtypes. Pathology specimens were graded on degree of neuronal loss, inflammation, fibrosis, and muscle changes. Manometry studies were categorized as follows: type I (n = 20), type II (n = 20), type III (n = 3), and esophagogastric junction outflow obstruction (EGJOO) (n = 3). On histopathology, complete ganglion cell loss occurred in 74% of specimens, inflammation in 17%, fibrosis in 11%, and muscle atrophy in 2%. Comparing type I and type II specimens, there was a statistically significant greater proportion of type I specimens with aganglionosis (19/20 vs 13/20, p = 0.044) and a statistically significant greater degree of ganglion cell loss in type I specimens (Wilcoxon Rank-Sum, p = 0.016). CD3(+) /CD8(+) cytotoxic T cells represented the predominant inflammatory infiltrate on immunohistochemistry. Three patients had completely normal appearing tissue (1 each in type II, type III, EGJOO). The greater degree, but similar pattern, of ganglion cell loss observed in type I compared to type II achalasia specimens suggests that type I achalasia represents a progression from type II achalasia. The spectrum of histopathologic findings - from complete neuronal loss to lymphocytic inflammation to apparently normal histopathology - emphasizes that 'achalasia' represents a pathogenically heterogeneous patient group with the commonality being EGJ outflow obstruction.