Conventional Manometry Research Articles

Esophageal Bezoar as a Rare Cause of Dysphagia in Achalasia

Dysphagia is a common presenting symptom in patients with achalasia. Recurrent dysphagia after successful endoscopic or surgical intervention is usually a sign of recurrent achalasia, reflux-induced strictures and esophagitis, or surgical complication. Our aim is to present a patient with worsening dysphagia due to an esophageal food bezoar who had a history of suspected achalasia. A 67 y/o woman presented with 3 weeks of acute dysphagia greater to solids than liquids, with ingestion of solids causing projectile vomiting, and minimal tolerance to clear liquids. She had a 40 year history of intermittent dysphagia to solids and liquids twice weekly, and post-prandial nausea and vomiting once to twice monthly, with stable weight. She had a suspected diagnosis of achalasia, and underwent 2 esophageal dilations 35 years ago. Endoscopy revealed pan-esophageal dilation with aperistalsis, a large distal esophageal food bezoar that was removed with a Roth net, and only mild resistance to passage of the endoscope through the lower esophageal sphincter (LES) (Figures 1 & 2). After removal of the bezoar, the patient's acute dysphagia symptoms resolved to her prior baseline. A barium esophagram showed esophageal dilation with narrowing at the LES and delayed transit into the stomach. High resolution esophageal manometry confirmed a diagnosis of achalasia type II, with normal LES pressure of 13.5mmHg, high IRP of 28.8mmHg, failed swallows, and isobaric pressure patterns throughout the esophagus. She declined further intervention as her symptoms had improved to her baseline.Figure 1Figure 2Esophageal food bezoars typically present with acute dysphagia, and are primarily found in the presence of an underlying structural abnormality, i.e. esophageal rings or strictures. Motility disorders, i.e. achalasia, may predispose to an esophageal bezoar as in our patient, who had confirmed achalasia via high resolution esophageal manometry. There are 4 patients previously reported with an esophageal bezoar associated with achalasia, 2 of which underwent conventional esophageal manometry [Mamel JJ 1984, Shah SW 1997, Kim KH 2010, Liang JJ 2013]. In evaluating patients with acute worsening of dysphagia and history of achalasia, endoscopic visualization should be performed initially to offer potential diagnosis and therapy. In summary, esophageal bezoars should be included in the differential diagnosis of dysphagia in patients with esophageal motility disorders such as known or suspected achalasia.

PWE-389 Anal acoustic reflectometry is a test of the internal anal sphincter?

Introduction Conventional anal manometry (ARM) suggested that the internal anal sphincter (IAS) contributes 60–85% of anal resting pressure, the remaining 15–40% being attributable to the tonic contraction of the external anal sphincter (EAS) and anal cushions. Anal acoustic reflectometry (AAR) is a more specific and sensitive indicator of sphincter function than ARM. Our aim was to determine the relative contributions of the IAS and EAS to anal resting pressure by isolating the IAS for interrogation using a bilateral pudendal nerve block (bPNB). Method Prospective cohort study of patients with pudendal neuralgia undergoing bPNB. Blocks were trans-vaginal (Women) and trans-gluteal (Men). EAS electromyography (EMG) was performed before and 5 mins after bPNB to establish its success. Patients received AAR and manometry (maximum resting pressure MRP, maximum squeeze pressure MSP and incremental squeeze pressure ISP) before and 30 mins after bPNB. Variables were compared using a paired t-test for parametric data and Wilcoxon signed rank test or Mann-Whitney U test* for non-parametric data. Results 15 patients, 10 (67%) women, median age 59 (25–89) and median reduction in EMG motor unit potential activity of 45% (Range -25–48%). There was no difference in reduction of EMG activity between trans-vaginal and trans-gluteal bPNB approach (30.3 v 38.5% p = 0.762*). There was no significant change in any AAR parameter at rest. AAR squeeze opening pressure showed a significant reduction post bPNB (121 v 104 cmH 2 O p = 0.039). MSP and ISP showed a significant reduction post bPNB; MRP 75 v 71 cmH 2 O p = 0.5, MSP 154 v 118 cmH 2 O p = 0.02, ISP 79 v 47 cmH 2 O p = 0.02. Conclusion We found a significant reduction in all measurements of EAS function after bPNB. No change was found after a 45% median reduction in EAS activity in measurements of IAS function, suggesting that AAR is primarily an investigation of the IAS. Disclosure of interest None Declared.

Predictive value of routine esophageal high-resolution manometry for gastro-esophageal reflux disease.

Using conventional manometry, gastro-esophageal reflux disease (GERD) was associated with a reduced lower esophageal sphincter (LES) pressure and impaired peristalsis. However, with a large overlap between GERD patients and controls, these findings are of limited clinical relevance. It is uncertain whether the more detailed information of high-resolution manometry (HRM) can discriminate GERD patients. Therefore, we aimed to determine to which extent HRM findings can predict GERD. HRM measurements in 69 patients with GERD and 40 healthy subjects were compared and the predictive value of HRM for the diagnosis of GERD was explored. GERD patients had a significantly lower contraction amplitude (55 vs 64 mmHg; p = 0.045) and basal LES pressure (10 vs 13.2 mmHg; p = 0.034) than healthy controls. GERD patients more often had a hiatal hernia than healthy subjects (30% vs 7%; p = 0.005). Patients with reflux esophagitis had a lower DCI than patients without reflux esophagitis (558 vs 782 mmHg cm s; p = 0.045). No significant difference was seen in contractile front velocity, distal latency, number of peristaltic breaks, residual LES pressure and LES length. On multivariate logistic regression analysis, both esophagogastric junction type I (OR 4.971; 95% CI 1.33-18.59; p = 0.017) and mean wave amplitude (OR 0.95; 95% CI 0.90-0.98; p = 0.013) were found to be independent predictors of GERD. However, the sensitivity and specificity of these findings were low. Hiatal hernia, low contraction amplitude and LES pressure are associated with GERD, but do not predict the disease with sufficient accuracy. Routine esophageal HRM can therefore not be used to distinguish GERD patients from healthy subjects.

Sa1364 Prospective Comparison of Test Performance Between Traditional and High-Resolution Anal Manometry (HRAM) in Female Healthy Volunteers and Patients With Fecal Incontinence

Introduction Conventional anal manometry (CAM) is widely used to measure sphincter function in patients with fecal incontinence (FI). However, results correlate poorly with symptom severity and may have limited impact on patient management. This study evaluated the discriminant utility of novel measures of anal resting and squeeze function using highresolution anorectal manometry (HRAM) compared to conventional measures. Methods Ninety-five healthy female volunteers (HV) (age 42 ± 13 years) and 95 females with FI (age 55 ± 16 years) underwent HRAM (solid state, 10 channels, 8 mm spacing). CAM data were subsampled from HRAM data. In each participant the CAM squeeze increment (CAM-SI) and CAM resting pressure (CAM-R) were compared with new derived HRAM ‘profile' measures (squeeze [HRAM-SP] and rest [HRAM-RP]). Results were compared between groups and metrics of diagnostic accuracy derived. Results Median St Marks Incontinence score was 11 (IQR=7) for FI vs. 1 (IQR=1) for HV, p <.001. In FI participants, abnormal squeeze function was demonstrated in 34/95 (36% sensitivity) using CAM-SI and 56/95 (59% sensitivity) using HRAM-SP (p <.001), resulting in superior receiver operator curve [ROC] characteristics for the novel measure (0.86 for HRAM-SP vs. 0.74 for CAM-SI). Regression demonstrated superiority of the HRAM-SP score (F = 17.91, adj R2 = 0.42) compared to CAM-SI scores (HRAM-SP: F = 12.52, adj R2 = 0.33; CAM-SI: F = 6.05, adj R2 = 0.18) in health status prediction. The difference between measures was less marked for analysis of anal resting pressure with abnormal function present in 24/95 (26% sensitivity) and 26/95 (27% sensitivity) when using CAM-R and HRAM-RP respectively. However slightly superior ROC characteristics were demonstrated for the novel measure (0.65 for HRAM-RP vs. 0.59 for CAM-R). Final cross tabulation of agreement between measures demonstrated that 25/ 61 patients who were classified as having normal function with the CAM measures displayed reduced function with wither the HRAM-R or HRAM-SP profile (26% of the cohort as a whole). Conclusions Novel HRAM measures appear superior in detecting impaired anal sphincter function in patients with FI over conventional measures and show enhanced correlation with symptom severity. In particular HRAM-SP has a 23% increase in sensitivity for detection of abnormal sphincter function in FI over conventional measures. The addition of this technique of analysis to manometric studies has a number of potential implications for clinical practice.

Sa1365 Successful Implantation of a Tissue Engineered Gut (TEG) Using Human Smooth Muscle and Human Enteric Neural Progenitor Cell

Introduction Conventional anal manometry (CAM) is widely used to measure sphincter function in patients with fecal incontinence (FI). However, results correlate poorly with symptom severity and may have limited impact on patient management. This study evaluated the discriminant utility of novel measures of anal resting and squeeze function using highresolution anorectal manometry (HRAM) compared to conventional measures. Methods Ninety-five healthy female volunteers (HV) (age 42 ± 13 years) and 95 females with FI (age 55 ± 16 years) underwent HRAM (solid state, 10 channels, 8 mm spacing). CAM data were subsampled from HRAM data. In each participant the CAM squeeze increment (CAM-SI) and CAM resting pressure (CAM-R) were compared with new derived HRAM ‘profile' measures (squeeze [HRAM-SP] and rest [HRAM-RP]). Results were compared between groups and metrics of diagnostic accuracy derived. Results Median St Marks Incontinence score was 11 (IQR=7) for FI vs. 1 (IQR=1) for HV, p <.001. In FI participants, abnormal squeeze function was demonstrated in 34/95 (36% sensitivity) using CAM-SI and 56/95 (59% sensitivity) using HRAM-SP (p <.001), resulting in superior receiver operator curve [ROC] characteristics for the novel measure (0.86 for HRAM-SP vs. 0.74 for CAM-SI). Regression demonstrated superiority of the HRAM-SP score (F = 17.91, adj R2 = 0.42) compared to CAM-SI scores (HRAM-SP: F = 12.52, adj R2 = 0.33; CAM-SI: F = 6.05, adj R2 = 0.18) in health status prediction. The difference between measures was less marked for analysis of anal resting pressure with abnormal function present in 24/95 (26% sensitivity) and 26/95 (27% sensitivity) when using CAM-R and HRAM-RP respectively. However slightly superior ROC characteristics were demonstrated for the novel measure (0.65 for HRAM-RP vs. 0.59 for CAM-R). Final cross tabulation of agreement between measures demonstrated that 25/ 61 patients who were classified as having normal function with the CAM measures displayed reduced function with wither the HRAM-R or HRAM-SP profile (26% of the cohort as a whole). Conclusions Novel HRAM measures appear superior in detecting impaired anal sphincter function in patients with FI over conventional measures and show enhanced correlation with symptom severity. In particular HRAM-SP has a 23% increase in sensitivity for detection of abnormal sphincter function in FI over conventional measures. The addition of this technique of analysis to manometric studies has a number of potential implications for clinical practice.

Assessment of Obstructive Defecation by High-Resolution Anorectal Manometry Compared With Magnetic Resonance Defecography

Patients with obstructive defecation have abnormalities of anorectal function and/or structure. Conventional anorectal manometry (ARM) can identify abnormal function and behavior (dyssynergia); however, agreement between manometry and defecography is only fair. High-resolution (HR)-ARM may improve diagnostic agreement by differentiating pressure effects caused by dyssynergia and obstruction. We compared HR-ARM findings with magnetic resonance (MR) defecography in the clinical assessment of patients with symptoms of obstructive defecation defined by Rome III criteria. HR-ARM (Manoscan AR 360; Given Imaging, Yoqeam, Israel) assessed anal sphincter function and pressure during simulated defecation. Abnormal manometric findings were classified according to the Rao system and compared with MR defecography as the reference standard. A total of 188 consecutive patients (155 women; age, 19-93 y) with obstructive defecation underwent a full investigation. Compared with patients with dyssynergia on MR imaging (n = 66), patients with structural pathology (n = 87) had lower resting (P < .003) and squeeze pressures (P < .011), but a higher rectoanal pressure gradient (P < .0001) on HR-ARM. High intrarectal pressure with a steep, positive pressure gradient consistent with outlet obstruction on HR-ARM was present in 24 patients with intra-anal intussusception on MR imaging. This pattern was not observed in other patients. Interobserver agreement was substantial for HR-ARM diagnoses (κ = 0.67; 95% confidence interval, 0.559-0.779). Diagnostic accuracy for dyssynergia was 82% compared with MR imaging (sensitivity, 77% [51 of 66]; specificity, 85% [104 of 122]). The diagnostic agreement between anorectal HR-ARM and MR defecography is high and pressure measurements accurately identify recto-anal dyssynergia and intra-anal outlet obstruction by structural pathology as causes of obstructive defecation.

Diagnostic evaluation of achalasia: from the whalebone to the Chicago classification.

From the earliest description of dysphagia relieved by dilatation with a whalebone in 1674 we have witnessed the evolution of esophageal function testing from the conventional manometry to the high-resolution manometry (HRM) and esophageal topography pressure plotting that have led to the revised Chicago classification for esophageal motility disorders in 2014. The goals of this paper are, therefore, (1) to highlight the historical milestones that have led to the diagnostic definition of achalasia, as we know it today; (2) to describe the evaluation process of patients with suspected achalasia; (3) to describe the diagnostic value of the HRM and the usefulness of the Chicago classification in predicting treatment outcomes. The value of Chicago classification is linked to the ability of the clinician to perform a thorough clinical evaluation to identify and correlate specific clinical phenotypes to specific manometric subtypes and predict treatment outcomes. Chicago classification, however, cannot predict which treatment, pneumatic dilatation, or Heller myotomy, should be selected for those with a specific subtype of achalasia.

Can high resolution manometry parameters for achalasia be obtained by conventional manometry?

High resolution manometry (HRM) is a new technology that made important contributions to the field of gastrointestinal physiology. HRM showed clear advantages over conventional manometry and it allowed the creation of different manometric parameters. On the other side, conventional manometry is still wild available. It must be better studied if the new technology made possible the creation and study of these parameters or if they were always there but the colorful intuitive panoramic view of the peristalsis from the pharynx to the stomach HRM allowed the human eyes to distinguish subtle parameters unknown or uncomprehend so far and if HRM parameters can be reliably obtained by conventional manometry and data from conventional manometry still can be accepted in achalasia studies. Conventional manometry relied solely on the residual pressure to evaluate lower esophageal sphincter (LES) relaxation while HRM can obtain the Integrated Relaxation Pressure. Esophageal body HRM parameters defines achalasia subtypes, the Chicago classification, based on esophageal pressurization after swallows. The characterization of each subtype is very intuitive by HRM but also easy by conventional manometry since only wave amplitudes need to be measured. In conclusion, conventional manometry is still valuable to classify achalasia according to the Chicago classification. HRM permits a better study of the LES.

Comparison of High-resolution Anorectal Manometry With Water-perfused Anorectal Manometry.

Background/AimsTo date, high-resolution manometry has been used mainly in the study of esophageal motility disorders and has been shown to provide more physiological information than conventional manometry, and is easier to interpret. This study aimed to evaluate the usefulness of high-resolution anorectal manometry (HRARM) compared to water-perfused anorectal manometry.MethodsPatients who complained of chronic constipation with/without fecal incontinence underwent both water-perfused anorectal manometry and HRARM in a random order on the same day. Resting and squeezing pressures of the anal sphincter, attempted defecation, rectoanal inhibitory reflex, rectoanal contractile reflex, Rao’s type of dyssynergia during attempted defecation, anal canal length, defecation dynamic parameters and measurement times for each method were analyzed.ResultsOf 14 patients, 7 were female, and the median age was 59 years (range 35–77). Indications for manometry were constipation (n = 8) and constipation with fecal incontinence (n = 6). Resting and squeezing pressures showed that the 2 methods were strongly correlated (resting pressure: r = 0.746, P = 0.002; squeezing pressure: r = 0.921, P < 0.001). In attempted defection, one equivocal case with water-perfused anorectal manometry was diagnosed type I pelvic floor dyssynergia with HRARM providing detailed pressure changes in internal and external anal spincters, and puborectalis muscle which improved assessment of anorectal disorders. The measurement time for HRARM was significantly shorter than that for water-perfused anorectal manometry (11.3 vs 23.0 minutes, P < 0.001).ConclusionsBoth water-perfused anorectal manometry and HRARM are well tolerated and reliable methods of evaluating defecation disorders of pelvic floor dysfunction. HRARM is likely to provide better physiological information and to require a shorter measurement time compared to water-perfused anorectal manometry.

"Chicago classification" should be challenged in the diagnosis of achalasia: heterogeneity of achalasia.

TO THE EDITOR: We read with interest the review article by Lee et al1 regarding “Clinical characteristics and treatment outcomes of 3 subtypes of achalasia according to the Chicago classification in a tertiary institute in Korea.” The study showed that type II achalasia (n = 28 [50.9%]) is the most common subtype followed by type I (n = 21 [38.2%]) and type III (n = 6 [10.9%]). Interestingly, all type III patients responded to calcium channel blocker in the study. The authors suggested that type III should be a different entity from those of type I and II. We strongly agree with their opinion. We have been evaluating patients with suspected achalasia using high-resolution manometry (HRM) with special interest for 5 years. To our experience, the definition of achalasia according to “Chicago classification of HRM” is not perfect. We have experienced achalasia patients with normal integrated relaxation pressure (IRP). As one example, a 12-year-old female who began to experience dysphagia for solid food approximately 2 months before presentation. Physical examination did not reveal signs of scleroderma. Upper endoscopy revealed esophageal dilatation with retained secretion and food material (Fig. 1A and ​and1B).1B). A barium esophagogram showed severe disturbance in emptying into the stomach (Fig. 1C). HRM at sitting position showed aperistalsis with normal 4 second-IRP (normal range < 15 mmHg) (Fig. 1D). Eckardt score at that time was 5. Based on this constellation of data, the patient was diagnosed with achalasia, and underwent peroral endoscopic myotomy. On follow-up at 6 months, she was free of dysphagia, and upper endoscopy revealed unremarkable findings except for scar changes at the site of the mucosal entrance (Fig. 2A and ​and2B).2B). Barium esophagography showed free flow of contrast from the esophagus to the stomach (Fig. 2C). HRM showed weak peristalsis with large peristaltic defects (Fig. 2D). Figure 1. Clinical findings of a 12-year-old female with solid dysphagia. (A) Upper endoscopy shows dilated esophagus and retained food material. (B) Lower esophageal sphincter is not opened with air inflation. (C) Esophageal dilatation with bird-beak narrowing ... Figure 2. The clinical findings of follow-up at 6 months after peroral endoscopic myotomy. (A) Upper endoscopy shows opened lower esophageal sphincter. (B) A scar is visible at the site of the mucosal entrance. (C) Barium esophagogram shows free flow of contrast ... The Chicago classification is challenged by this case of achalasia with normal IRP. In fact, we have experienced 4 patients with achalasia, who were similar to this case. These findings suggested that normal IRP does not preclude a diagnosis of achalasia. Refining the IRP should be needed especially in patients with low lower esophageal sphincter (LES) pressure, although the sitting position might contribute to these atypical findings. Earlier studies of conventional manometry demonstrated that a subset of achalasia patients had apparently normal LES relaxation.2–5 In the past, one plausible explanation for the reason is that it represents an artifact from the movement of manometry catheter. In the era of HRM, the achalasia cases with normal LES relaxation (ie normal IRP) can not be explained by the artifact associated with catheter movement. The findings of achalasia with normal IRP also raise a number of issues regarding the etiopathogenesis of achalasia. The findings might be a representative of an early phase of the achalasia. The relatively short period follow-up (2 months) may support this possible explanation. Interestingly, this case showed transition from achalasia to weak peristalsis after treatment. In conclusion, we should know the significance in the heterogeneity of achalasia, that is not addressed by current “Chicago classification of HRM.”

High-resolution manometry in diagnosis and treatment of achalasia: help or hype.

High-resolution manometry (HRM) with 36 pressure transducers spanning the esophagus has revolutionized the diagnosis and treatment of esophageal motility disorders, especially with respect to achalasia. The three major contributions of HRM are as follows: (a) Integrated relaxation pressure (IRP) at the esophagus gastric junction (EGJ) >15 mmHg has a sensitivity of 97 % for the diagnosis of achalasia; (b) there are three distinct subtypes of achalasia - type 1 (no distal pressurization), type II (panesophageal pressurization), and type III (spastic contractions); and (c) subtypes predict the success of treatment with type II patients doing the best and type III being the most difficult to treat. Recent studies also suggest that HRM is superior to conventional manometry for diagnosis of achalasia. Other useful observation from HRM is the recognition of EGJ outflow obstruction (type IV achalasia) with normal peristalsis which may be due to mechanical or functional impairment at the EGJ. Finally, after successful treatment of achalasia, the IRP falls to less than 15 mmHg and the achalasia pressurization pattern resolves sometimes with the return of weak peristalsis. This complements well with the information obtained by the timed barium esophagram.

High Resolution Manometry Has Low Sensitivity and High Specificity for Detecting Hiatal Hernia

Introduction: Hiatal hernias (HH) are frequently diagnosed during upper endoscopy or barium radiography. With the introduction of high resolution manometry (HRM), hiatal hernias can be identified based on finding 2 separate high pressure zones on high resolution topography. The aim of this study is to compare HRM and endoscopic identification of HH. An earlier study done in our institution in 2005 by Agrawal et.al comparing conventional manometry (CM) to endoscopy to identify HH showed that CM had low sensitivity (20%), but high specificity (99%) in identifying HH compared to endoscopy. Methods: A retrospective review was performed of 600 patients who had HRM performed in our laboratory between January 2013 and February 2014. We identified 160 patients (107 females, mean age 54.5 years) who had both HRM and upper endoscopy. The manometric studies were reviewed looking for characteristic double high-pressure zone on high resolution topography separated by 1 cm or more. The endoscopic reports were reviewed for independent identification of HH. Results: Of the 160 patients who had both HRM and EGD, 31 (19%) had HH identified by HRM compared to 29 (18%) by EGD. 12/31 of the manometrically identified HH were also seen on endoscopy. Compared to endoscopy (gold standard), HRM had a sensitivity of 41.4% and a specificity of 87.2% for detecting HH. Conclusion: HRM has low sensitivity and relatively high specificity in identifying HH. Further studies analyzing HRM using better objective criteria need to be identified to more accurately detect HH. Related to our earlier study of CM and EGD, HRM showed higher sensitivity, but lower specificity compared to CM to identify HH. Disclosure - Dr. Donald Castell is a consultant for Sandhill Scientific.

High-resolution manometry for the evaluation of gastric motility.

This review focus on the utility of HRM for the evaluation of gastric motility. The evaluation of gastric motility has clinical implications for the study of a myriad of diseases. Disordered motility represents a spectrum of dysfunction ranging from delayed gastric emptying to abnormally rapid gastric transit. Gastric motility may be measured by a variety of methods with different efficacy and different variables that may be obtained. High-resolution manometry was created and added to the diagnostic armamentarium. The methods and outcomes for the study of proximal motility that may be useful to assess the thoracoabdominal pressure gradient, gastric filling and accommodation are described. Also, studies on antroduodenal manometry are reviewed. High-resolution manometry allows gastric manometry without technical limitations found on conventional manometry; however, studies are still on the phase of understanding the normal findings.

Esophagus motility in overt hypothyroidism

Gastrointestinal tract is one of the most affected systems in hypothyroidism. Despite decreased esophageal emptying, prolonged esophageal and gastric transit time have been indicated in previous reports, the mechanism of thyroid hormones activity and antibodies on the esophagus motility is not yet fully understood. This study was conducted to evaluate the esophagus motility by manometry in hypothyroid patients. The study enrolled with 28 overt, newly diagnosed hypothyroid patients and 29 age- and sex-matched healthy controls. Twenty-one females and 7 males with overt hypothyroidism and 22 females and 7 males with healthy control subjects were recruited to study. Esophageal manometry was performed using MMS (Medical Measurement Systems bv. The Netherlands) Solar GI-Air-Charged Intelligent Gastrointestinal Conventional Manometry. The lower esophageal sphincter pressure (LESP) was 19.5 ± 6.5 mmHg in hypothyroid patients and 17.48 ± 4.65 mmHg in controls, and there was no significant difference (p = 0.18). Percentage of relaxation was 61.5 and 80.9 %, and it was significantly lower in hypothyroid patients than controls (p < 0.001). Additionally, duration of relaxation was found 3.85 ± 2.3 and 5.5 ± 2.28 s in patients and controls, respectively (p = 0.009). In patient group, LESP was positively correlated with fT3 (p = 0.033), and the duration of the contraction was negatively correlated with fT4 (p = 0.044). In this study, we observed that hypothyroid state can affect esophagus motility via shortened duration of relaxation and reduced percentage of relaxation even if in patients without any gastrointestinal symptoms. Further studies are needed to clarify the effect of thyroid hormones on esophagus motility.

Mo1598 Do Outcomes of Surgical Treatment for Achalasia Depend on the Manometric Subtype?

Background: High Resolution Manometry (HRM) yields better understanding of esophageal motility than does conventional manometry, and a new classification system which describes three distinct HRM subtypes of achalasia based on esophageal body contraction patterns appears to be a promising tool in predicting results of treatment with standard Heller Myotomy. The aim of this study is to analyze the outcomes of surgical treatment with extended Heller myotomy) for each subtype and to identify additional parameters that may predict success of therapy. Methods: From 2008 to 2013 at a single institution 72 patients underwent laparoscopic extended Heller myotomy for first time. In addition to manometric parameters, clinical records were reviewed for symptom duration, patient age at the time of referral, and preoperative esophageal dilation (stage I-III) as assessed by radiography. We defined treatment failure as no improvement in symptoms and/or need for a second therapy within one year after the operation. Long term follow up data (15 to 46 months) was available for a subset of 25 patients in the form of a survey evaluating overall satisfaction with the operation. Results: The 72myotomy patients included 11 with type I (no contractions), 56 with type II (pan-esophageal pressurizations), and 5 with type III (high-amplitude distal spasm). Failure was found in 1 patient with manometric type I and radiologic stage III esophageal dilation, 1 patient with manometric type II and radiologic stage II esophageal dilation, and none with manometric type III. All of the type I patients had at least some degree of esophageal dilation on radiography, whereas no dilation was found in the type III group. Treatment failure was not observed in any of the patients under 50 years old (n= 35) nor in any patients with stage I esophageal dilation. Only one of the 25 patients with long term follow up reported dissatisfaction with the treatment result; this patient had type II achalasia on HRM and esophageal dilation was stage I. Conclusions: Overall, laparoscopic extended Heller myotomy is a highly successful treatment for patients with achalasia, and outcomes do not appear to vary significantly according to HRM subtypes. Stage I esophageal dilation and age below 50 may be better indicators of consistent symptom relief after surgical therapy for this disease.

Esophagus motility in overt hypothyroidism

Gastrointestinal tract is one of the most affected systems in hypothyroidism. Despite decreased esophageal emptying, prolonged esophageal and gastric transit time have been indicated in previous reports, the mechanism of thyroid hormones activity and antibodies on the esophagus motility is not yet fully understood. This study was conducted to evaluate the esophagus motility by manometry in hypothyroid patients. The study enrolled with 28 overt, newly diagnosed hypothyroid patients and 29 age- and sex-matched healthy controls. Twenty-one females and 7 males with overt hypothyroidism and 22 females and 7 males with healthy control subjects were recruited to study. Esophageal manometry was performed using MMS (Medical Measurement Systems bv. The Netherlands) Solar GI—Air-Charged Intelligent Gastrointestinal Conventional Manometry. The lower esophageal sphincter pressure (LESP) was 19.5 ± 6.5 mmHg in hypothyroid patients and 17.48 ± 4.65 mmHg in controls, and there was no significant difference (p = 0.18). Percentage of relaxation was 61.5 and 80.9 %, and it was significantly lower in hypothyroid patients than controls (p < 0.001). Additionally, duration of relaxation was found 3.85 ± 2.3 and 5.5 ± 2.28 s in patients and controls, respectively (p = 0.009). In patient group, LESP was positively correlated with fT3 (p = 0.033), and the duration of the contraction was negatively correlated with fT4 (p = 0.044). In this study, we observed that hypothyroid state can affect esophagus motility via shortened duration of relaxation and reduced percentage of relaxation even if in patients without any gastrointestinal symptoms. Further studies are needed to clarify the effect of thyroid hormones on esophagus motility.

Water‐perfused manometry vs three‐dimensional high‐resolution manometry: a comparative study on a large patient population with anorectal disorders

Our aim was to compare for the first time measurements obtained with water-perfused catheter anorectal manometry and three-dimensional (3D) high-resolution manometry in patients with anorectal disorders. Consecutive patients referred to our centre for anorectal manometry (ARM) were recruited to undergo the two procedures successively. Conventional manometry was carried out using a water-perfused catheter (WPAM) and high-resolution manometry was achieved with a 3D probe (3DHRAM). For each procedure, parameters recorded included the following: anal canal length, resting pressure, squeeze pressure and rectal sensitivity. Two hundred and one patients were included in this study. The mean values for resting and squeeze pressures were correlated and found to be significantly higher when measured with 3DHRAM than with WPAM. However, the length of the anal canal was not significantly different when measured by the two techniques without correlation between the two mean values obtained. The presence of the rectoanal inhibitory reflex was systematically assessed by both WPAM and 3DHRAM and anismus was also systematically diagnosed by both WPAM and 3DHRAM. The pressure values obtained with 3DHRAM are correlated with those measured with conventional manometry but are systematically higher. 3DHRAM has the advantage of providing a pressure recording over the entire length and circumference of the anal canal, allowing a more useful physiological assessment of anorectal function.

High-Resolution Manometry Classifications for Idiopathic Achalasia in Patients with Chagas' Disease Esophagopathy

BackgroundIdiopathic achalasia (IA) and Chagas' disease esophagopathy (CDE) share several similarities. The comparison between IA and CDE is important to evaluate whether treatment options and their results can be accepted universally. High-resolution manometry (HRM) has proved a better diagnostic tool compared to conventional manometry. This study aims to evaluate HRM classifications for idiopathic achalasia in patients with CDE. MethodsWe studied 98 patients: 52 patients with CDE (52 % females, mean age, 57 ± 14 years) and 46 patients with IA (54 % females; mean age 48 ± 19 years). All patients underwent a HRM and barium esophagogram. ResultsThe Chicago classification was distributed in IA as Chicago I, 35 %; Chicago II, 63 %; and Chicago III, 2 %, and in CDE as Chicago I, 52 %; Chicago II, 48 %; and Chicago III, 0 % (p = 0.1, 0.1, and 0.5, respectively). All patients had the classic Rochester type. CDE patients had more pronounced degrees of esophageal dilatation (p < 0.002). The degree of esophageal dilatation did not correlate with Chicago classification (p = 0.08). In nine (9 %) patients, the HRM pattern changed during the test from Chicago I to II. ConclusionOur results show that (a) HRM classifications for IA can be applied in patients with CDE and (b) HRM classifications did not correlate with the degree of esophageal dilatation. HRM classifications may reflect esophageal repletion and pressurization instead of muscular contraction. The correlation between manometric findings and treatment outcomes for CDE needs to be answered in the near future.

Clinical Characteristics and Treatment Outcomes of 3 Subtypes of Achalasia According to the Chicago Classification in a Tertiary Institute in Korea

Background/AimsAchalasia is classified into 3 types according to the Chicago classification. The aim of this study was to investigate characteristics and treatment outcomes of 3 achalasia subtypes in Korean patients.MethodsFifty-five patients diagnosed with achalasia based on conventional or high-resolution esophageal manometry were consecutively enrolled. Their clinical characteristics, manometric, endoscopic and esophagographic findings and treatment responses were analyzed among the 3 subtypes of achalasia.ResultsOf 55 patients, 21 (38.2%) patients had type I, 28 (50.9%) patients had type II and 6 (10.9%) patients had type III. The median follow-up period was 22.4 (interquartile range, 3.6-67.4) months. Type III patients were older than type I and II patients (70.0 vs. 46.2 and 47.6 years, P = 0.023). The width of the esophagus in type I patients was wider with more frequent bird's beak appearance on esophagogram than the other 2 types (P = 0.010 and 0.006, respectively). Of the 50 patients who received the evaluation for treatment response at 3 months, 7 patients (36.8% vs. 26.9%) were treated with pneumatic dilatation and 4 patients (21.1% vs. 15.4%) with laparoscopic Heller's myotomy in type I and II groups, respectively. The treatment responses of pneumatic dilatation and Heller's myotomy in type I group were 71.4 and 50.0% and in type II were 85.7 and 75.0%, respectively, and all 5 patients in type III group showed good response to medical therapy.ConclusionsClinical characteristics of 3 achalasia subtypes in Korean patients are consistent with other studies. Treatment outcomes are variable among 3 subtypes.

New Insights in Gastroesophageal Reflux, Esophageal Function and Gastric Emptying in Relation to Dysphagia Before and After Anti-Reflux Surgery in Children

In children with gastroesophageal reflux (GER) disease refractory to pharmacological therapies, anti-reflux surgery (fundoplication) may be a treatment of last resort. The applicability of fundoplication has been hampered by the inability to predict which patient may benefit from surgery and which patient is likely to develop post-operative dysphagia. pH impedance measurement and conventional manometry are unable to predict dysphagia, while the role of gastric emptying remains poorly understood. Recent data suggest that the selection of patients who will benefit from surgery might be enhanced by automated impedance manometry pressure-flow analysis (AIM) analysis, which relates bolus movement and pressure generation within the esophageal lumen.