Distal Esophageal Contraction Research Articles

Esophageal motility characteristics in gastroesophageal reflux disease patients with or without dysphagia

Objective To investigate esophageal motility characteristics in gastroesophageal reflux disease (GERD) patients with or without dysphagia by high-resolution manometry and 24 h esophageal pH monitoring. Methods From August 2012 to November 2015, GERD patients with symptoms of acid reflux and heart burn who received 24 h esophageal pH monitoring were collected. The differences in esophageal motility were further analyzed between the GERD patients with dysphagia and without dysphagia. Student′s t test, χ2 test and Fisher′s exact test were performed for comparison analysis. Results A total of 194 patients received 24 h esophageal pH monitoring and diagnosed as GERD, and at the same period completed esophageal high-resolution manometry.Among them, there were 17 GERD patients (8.8%) with dysphagia and 177 patients (91.2%) without dysphagia. The main classification of esophageal motility disorder of GERD patients with dysphagia was severe esophageal motility disorders (5/17), but the motility type of GERD patients without dysphagia patients mainly was mild esophageal motility disorders (10.2%, 18/177). The integrated relaxation pressure, residual pressure of lower esophageal sphincter (LES), and contraction range at 3 cm and 11 cm above LES of GERD patients with dysphagia were all higher than those of patients without dysphagia ((9.70±0.98) mmHg (1 mmHg=0.133 kPa) vs (7.02±0.30) mmHg, (12.75±1.35) mmHg vs (9.18±0.42) mmHg, (106.80±11.97) mmHg vs (70.82±3.48) mmHg, (82.66±10.70) mmHg vs (56.93±3.11) mmHg), and the differences were statistically significant (t=2.601, 2.488, 2.887, 2.308, all P<0.05). Distal esophageal contraction integral score of GERD patients with dysphagia was significantly higher than that of GERD patients without dysphagia ((2 128.94±310.47) mmHg·cm·s vs (1 029.88±90.16) mmHg·cm·s), and the difference was statistically significant (t=3.400, P=0.001). However, residual pressure of upper esophageal sphincter was significantly lower than that of patients without dysphagia ((2.84±1.21) mmHg vs (6.18±0.38) mmHg, t=-2.650, P=0.009). Conclusions Esophageal motility disorder of GERD patients with dysphagia is severer than that of patients without dysphagia. High resolution esophageal manometry can provide objective evidence of esophageal dynamics of GERD patients, which can guide the diagnosis and treatment of GERD. Key words: GERD; High resolution esophageal manometry; Esophageal motility disorders

Effect of nasal noninvasive respiratory support methods on pharyngeal provocation-induced aerodigestive reflexes in infants.

The pharynx is a locus of provocation among infants with aerodigestive morbidities manifesting as dysphagia, life-threatening events, aspiration-pneumonia, atelectasis, and reflux, and such infants often receive nasal respiratory support. We determined the impact of different oxygen delivery methods on pharyngeal stimulation-induced aerodigestive reflexes [room air (RA), nasal cannula (NC), and nasal continuous positive airway pressure (nCPAP)] while hypothesizing that the sensory motor characteristics of putative reflexes are distinct. Thirty eight infants (28.0 ± 0.7 wk gestation) underwent pharyngoesophageal manometry and respiratory inductance plethysmography to determine the effects of graded pharyngeal stimuli (n = 271) on upper and lower esophageal sphincters (UES, LES), swallowing, and deglutition-apnea. Comparisons were made between NC (n = 19), nCPAP (n = 9), and RA (n = 10) groups. Importantly, NC or nCPAP (vs. RA) had: 1) delayed feeding milestones (P < 0.05), 2) increased pharyngeal waveform recruitment and duration, greater UES nadir pressure, decreased esophageal contraction duration, decreased distal esophageal contraction amplitude, and decreased completely propagated esophageal peristalsis (all P < 0.05), and 3) similarly developed UES contractile and LES relaxation reflexes (P > 0.05). We conclude that aerodigestive reflexes were similarly developed in infants using noninvasive respiratory support with adequate upper and lower aerodigestive protection. Increased concern for GERD is unfounded in this population. These infants may benefit from targeted oromotor feeding therapies and safe pharyngeal bolus transit to accelerate feeding milestones.

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.

Beneficial effect of the 5-HT1A receptor agonist buspirone on esophageal dysfunction associated with systemic sclerosis: A pilot study.

Esophageal involvement in systemic sclerosis (SSc) carries significant morbidity and is empirically managed with domperidone, albeit with questionable efficacy. The oral 5-HT1A receptor agonist buspirone may enhance esophageal peristalsis and lower esophageal sphincter (LES) function in healthy volunteers. We aimed to test the hypothesis that buspirone may exert a beneficial acute effect on esophageal motor dysfunction in symptomatic patients with SSc. Twenty consecutive patients with SSc reporting esophageal symptoms underwent high-resolution manometry before and 30 minutes after administration of buspirone (10 mg). Ten other patients received domperidone (10 mg) and served as control group. Changes in LES resting and residual pressure, amplitude, duration, and velocity of distal esophageal body contractions were examined. Esophageal hypomotility and hypotensive LES was found in 63% and 67% of patients, respectively. Demographic and clinical characteristics, including baseline manometric parameters, were comparable between groups. Resting pressure of LES increased after buspirone from 9.42 ± 2.6 to 11.53 ± 3.4 mmHg (p = 0.0002 by paired t-test), but not after domperidone; a trend for increase of amplitude of contractions was also observed after buspirone (p = 0.09). Comparison of the individual changes revealed that buspirone was superior to domperidone in enhancing LES pressure ( + 2.11 ± 2.0 versus -0.45 ± 2.3 mmHg, p = 0.006). No significant effects of either drug were noted on other examined parameters of esophageal function. The beneficial acute effect of buspirone on impaired LES function associated with SSc suggests a role of 5-HT1A receptor-mediated interactions in these patients. Prospective studies to examine whether buspirone is of long-term therapeutic value for SSc-associated esophageal disease are warranted.

PWE-175 Prevalence of pathological gastroesophageal reflux in patients with severe oesophageal hypomotility who do not present with typical reflux symptoms

Introduction Oesophageal hypomotility (OH) disorders are characterised by a decrease in the vigour of distal oesophageal contractions. An estimated 21 to 49% of patients with pathological gastroesophageal reflux (GOR) also have associated OH. However, prevalence of pathological GOR in OH who do not present with reflux symptoms has not been characterised. Overlooked reflux in these patients may hamper the success in treatment and also increase the risk of long-term side effects from chronic reflux. The aim of this study was to investigate the prevalence of pathological GOR and clinical presentation of patients with severe OH who do not present typical gastroesophageal reflux disease (GORD) symptoms. Method All patients diagnosed with frequent failed peristalsis or absent peristalsis on oesophageal high resolution manometry during January 2013 – December 2014 were selected retrospectively. Exclusion criteria were having typical reflux symptoms (heartburn and/or regurgitation) and history of antireflux surgery. All patients underwent ambulatory 24 h reflux monitoring. pH cut off 4 was used and pathological GOR was defined as high acid exposure time (total >6.3%, supine >1.2%, upright >4.2%)1and/or high number of reflux events >73. Symptoms were reported by the patient during interview. P value Results In total, 78 patients (30 male, 48 female; mean age 55 [19–82]) were included. Pathological GOR was detected in 28/78 (36%) of the patients [abnormal acid exposure time: 12/78 (15%) upright, 11/78 (14%) supine, 12/78 (15%) total, abnormal number of reflux events 15/78 (19%)]. The most common symptoms in patients with pathological GOR: dysphagia 21/28 (75%), chest pain 11/28 (39%) and cough 9/28 (32%) and in patients without GOR: epigastric pain: 19/50 (38%), chest pain 18/50 (36%), dysphagia 16/50 (32%). Epigastric pain was more commonly reported in patients without pathological GOR (P Conclusion Pathological GOR is prevalent in one third of the patients with severe OH without typical GORD symptoms. Reflux monitoring maybe indicated in patients with severe OH regardless of their presenting symptoms. Disclosure of interest None Declared. Reference Johnson LF, DeMeester TR. Twenty-four-hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux. Am J Gastroenterol. 1974:62:325–332.

Achalasia: a systematic review.

Achalasia significantly affects patients' quality of life and can be difficult to diagnose and treat. To review the diagnosis and management of achalasia, with a focus on phenotypic classification pertinent to therapeutic outcomes. Literature review and MEDLINE search of articles from January 2004 to February 2015. A total of 93 articles were included in the final literature review addressing facets of achalasia epidemiology, pathophysiology, diagnosis, treatment, and outcomes. Nine randomized controlled trials focusing on endoscopic or surgical therapy for achalasia were included (734 total patients). A diagnosis of achalasia should be considered when patients present with dysphagia, chest pain, and refractory reflux symptoms after an endoscopy does not reveal a mechanical obstruction or an inflammatory cause of esophageal symptoms. Manometry should be performed if achalasia is suspected. Randomized controlled trials support treatments focused on disrupting the lower esophageal sphincter with pneumatic dilation (70%-90% effective) or laparoscopic myotomy (88%-95% effective). Patients with achalasia have a variable prognosis after endoscopic or surgical myotomy based on subtypes, with type II (absent peristalsis with abnormal pan-esophageal high-pressure patterns) having a very favorable outcome (96%) and type I (absent peristalsis without abnormal pressure) having an intermediate prognosis (81%) that is inversely associated with the degree of esophageal dilatation. In contrast, type III (absent peristalsis with distal esophageal spastic contractions) is a spastic variant with less favorable outcomes (66%) after treatment of the lower esophageal sphincter. Achalasia should be considered when dysphagia is present and not explained by an obstruction or inflammatory process. Responses to treatment vary based on which achalasia subtype is present.

A Comparative Study on Comprehensive, Objective Outcomes of Laparoscopic Heller Myotomy With Per-Oral Endoscopic Myotomy (POEM) for Achalasia

To compare symptomatic and objective outcomes between HM and POEM. The surgical gold standard for achalasia is laparoscopic Heller myotomy (HM) and partial fundoplication. Per-oral endoscopic myotomy (POEM) is a less invasive flexible endoscopic alternative. We compare their safety and efficacy. Data on consecutive HMs and POEMs for achalasia from 2007 to 2012 were collected. swallowing function-1 and 6 months after surgery. operative time, complications, postoperative gastro-esophageal reflux disease (GERD). There were 101 patients: 64 HMs (42% Toupet and 58% Dor fundoplications) and 37 POEMs. Presenting symptoms were comparable. Median operative time (149 vs 120 min, P < 0.001) and mean hospitalization (2.2 vs 1.1 days, P < 0.0001) were significantly higher for HMs. Postoperative morbidity was comparable. One-month Eckardt scores were significantly better for POEMs (1.8 vs 0.8, P < 0.0001). At 6 months, both groups had sustained similar improvements in their Eckardt scores (1.7 vs 1.2, P = 0.1).Both groups had significant improvements in postmyotomy lower esophageal sphincter profiles. Postmyotomy resting pressures were higher for POEMs than for HMs (16 vs 7.1 mm Hg, P = 0.006). Postmyotomy relaxation pressures and distal esophageal contraction amplitudes were not significantly different between groups. Routine postoperative 24-hour pH testing was obtained in 48% Hellers and 76% POEMs. Postoperatively, 39% of POEMs and 32% of HM had abnormal acid exposure (P = 0.7). POEM is an endoscopic therapy for achalasia with a shorter hospitalization than HM. Patient symptoms and esophageal physiology are improved equally with both procedures. Postoperative esophageal acid exposure is the same for both. The POEM is comparable with laparoscopic HM for safe and effective treatment of achalasia.

Assessment of esophageal motor function using combined multichannel intraluminal impedance and manometry in patients with achalasia

Summary Background Achalasia is characterized by esophageal aperistalsis and a failure of lower esophageal sphincter (LES) relaxation. Combined multichannel intraluminal impedance and manometry (MII-EM) allows the simultaneous recording of esophageal peristalsis and bolus transport patterns. The aim of this study was to evaluate the feasibility of MII-EM for the assessment of esophageal motility and to characterize patterns of esophageal bolus transport in patients with achalasia with or without Heller myotomy. Materials and methods A total of nine patients (2 men and 7 women, age range 25–46 years) were enrolled in this study. Two of the patients had previously undergone Heller myotomy. All patients underwent combined MII-EM with a nine-channel esophageal function testing catheter containing four impedance measuring segments and five solid-state pressure transducers. Each patient received 10 liquid and 10 viscous swallows in a sitting position. All tracings were recorded and analyzed for esophageal contractions and bolus transit. Results None of the patients with achalasia, whether they had undergone a Heller myotomy or not, had manometrically normal esophageal peristalsis during saline or viscous swallowing. They had a normal LES resting pressure, incomplete LES relaxation, and lower distal esophageal contraction. The LES relaxation percentages in the patients who had undergone Heller myotomy (97% and 51%) were higher than those of the untreated patients (mean 47%). All patients demonstrated a low baseline impedance level in the distal esophagus. Air trapping in the proximal esophagus was also detected in nearly all of the patients. None of the patients in either group had complete bolus transit with either saline or viscous swallows. Conclusion Patients with achalasia are characterized by poor esophageal contraction and absent esophageal bolus clearance and such abnormalities are still noticeable after Heller myotomy. Although combined MII-EM can provide additional information regarding esophageal bolus transit, a low baseline impedance level and air trapping in the proximal esophagus may limit its utility in the diagnosis of esophageal dysmotility in patients with achalasia.

Mo1596 High Resolution Manometric Predictors of Post-Fundoplication Dysphagia

INTRODUCTION Post-fundoplication dysphagia is a well-described side effect of antireflux surgery. Esophageal manometry is a standard part of the preoperative evaluation prior to antireflux surgery. However, controversy exists regarding the value of traditional manometry to predict post-operative dysphagia after fundoplication. Today, high-resolution manometry (HRM) has replaced traditional water perfused systems for the analysis of esophageal physiology. The aim of this study was to evaluate the utility of HRM in predicting post-operative dysphagia in patients with an otherwise functioning Nissen fundoplication. METHODS Patients who underwent a laparoscopic Nissen fundoplication at a single institution were identified through a prospectively collected database. Patients were asked to undergo routine post-operative testing 6-12 months after surgery. Patients who had normal post-operative 24-hour pH test scores were eligible for the study. Of these patients, those without available raw data from preoperative HRM were excluded. Traditional ineffective motility (IEM) was defined as mean distal esophageal contraction amplitude of <30mmHg or 30% or less peristaltic waves. Post-operative dysphagia was graded using a standard scoring system (0= never, 1=1-2 times a month, 2=1-2 times per week, 3=daily). A symptom score of 2-3 was used to define post-operative dysphagia. Regression and association analysis of pre-operative manometric risk-factors were performed to determine predictors of post-operative dysphagia. P-values <0.05 were considered significant. RESULTS 95 patients (41 male; 54 female) were included in the analysis. Mean post-operative length of follow up was 14.9 months (range: 2-73). 70.2% patients had normal scores on all HRM parameters. Any dysphagia was reported by 50% of patients (17% grade-1, 23.4% grade-2, and 9.5% grade-3) Nineteen patients had traditional IEM. Of those with dysphagia, one also had traditional IEM. On univariate analysis only distal latency (DL) was found to be a significant predictor (p<0.001) of grade-3 but not grade-2 dysphagia. On multivariate analysis, no preoperative factors were found to be significant predictors of grade-3 dysphagia, but contraction front velocity predicted grade2 dysphagia. CONCLUSION Persistent daily dysphagia occurs in ~10% of patients following an otherwise successful Nissen fundoplication. Advancements in manometric technology provide additional data points in the preoperative analysis of these patients. This analysis reveals that elevated integrated relaxation pressure (IRP) is a useful new metric to predict post-operative dysphagia in addition to traditional identification of weak distal esophageal contraction amplitudes. Pre-operative factors as predictors of post-fundoplication dysphagia

Mo1597 Impedance Planimetry as a Diagnostic Tool to Evaluate the Degree of Clinical Lower Esophageal Sphincter Dysfunction

INTRODUCTION Post-fundoplication dysphagia is a well-described side effect of antireflux surgery. Esophageal manometry is a standard part of the preoperative evaluation prior to antireflux surgery. However, controversy exists regarding the value of traditional manometry to predict post-operative dysphagia after fundoplication. Today, high-resolution manometry (HRM) has replaced traditional water perfused systems for the analysis of esophageal physiology. The aim of this study was to evaluate the utility of HRM in predicting post-operative dysphagia in patients with an otherwise functioning Nissen fundoplication. METHODS Patients who underwent a laparoscopic Nissen fundoplication at a single institution were identified through a prospectively collected database. Patients were asked to undergo routine post-operative testing 6-12 months after surgery. Patients who had normal post-operative 24-hour pH test scores were eligible for the study. Of these patients, those without available raw data from preoperative HRM were excluded. Traditional ineffective motility (IEM) was defined as mean distal esophageal contraction amplitude of <30mmHg or 30% or less peristaltic waves. Post-operative dysphagia was graded using a standard scoring system (0= never, 1=1-2 times a month, 2=1-2 times per week, 3=daily). A symptom score of 2-3 was used to define post-operative dysphagia. Regression and association analysis of pre-operative manometric risk-factors were performed to determine predictors of post-operative dysphagia. P-values <0.05 were considered significant. RESULTS 95 patients (41 male; 54 female) were included in the analysis. Mean post-operative length of follow up was 14.9 months (range: 2-73). 70.2% patients had normal scores on all HRM parameters. Any dysphagia was reported by 50% of patients (17% grade-1, 23.4% grade-2, and 9.5% grade-3) Nineteen patients had traditional IEM. Of those with dysphagia, one also had traditional IEM. On univariate analysis only distal latency (DL) was found to be a significant predictor (p<0.001) of grade-3 but not grade-2 dysphagia. On multivariate analysis, no preoperative factors were found to be significant predictors of grade-3 dysphagia, but contraction front velocity predicted grade2 dysphagia. CONCLUSION Persistent daily dysphagia occurs in ~10% of patients following an otherwise successful Nissen fundoplication. Advancements in manometric technology provide additional data points in the preoperative analysis of these patients. This analysis reveals that elevated integrated relaxation pressure (IRP) is a useful new metric to predict post-operative dysphagia in addition to traditional identification of weak distal esophageal contraction amplitudes. Pre-operative factors as predictors of post-fundoplication dysphagia

Esophageal mucosal mast cell infiltration and changes in segmental smooth muscle contraction in noncardiac chest pain.

Mast cells release potent mediators that alter enteric nerve and smooth muscle functions and may contribute to the pathogenesis of functional gastrointestinal disorders. The goal of this study was to determine if mucosal mast cell infiltration was associated with smooth muscle segmental changes in esophageal contraction. All patients with noncardiac chest pain (NCCP) were divided into two groups consisting of patients with non-erosive reflux disease or functional chest pain (FCP) according to the results of ambulatory 24 hours esophageal pH monitoring and high-resolution manometry. Pressure-volume (PV) was calculated by multiplying the length of the esophageal segment, duration of the contraction, and mean pressure over the entire space-time box (P mean). Quantification of mast cells was performed in five consecutive nonoverlapping immunostained sections. Spearman correlation analysis showed that the distal segment PV correlated with the mast cell count in all of the patients combined and in patients with FCP with correlation coefficients of 0.509 and 0.436, respectively (P = 0.004 and P = 0.042). Similar findings were observed for the segmental ratio of distal to proximal smooth muscle PV in all patients and in patients with FCP (correlation coefficients 0.566; P = 0.001 and correlation coefficients 0.525; P = 0.012, respectively). Mucosal mast cell infiltration was associated with distal esophageal contraction as a key pathophysiologic factor of NCCP.

Manometric assessment of esophageal motor function in patients with primary biliary cirrhosis

Introduction/aimPrimary biliary cirrhosis is associated with other autoimmune diseases including Sjögren's syndrome, and scleroderma. Esophageal dysmotility is well known in scleroderma, and Sjögren's syndrome. The aim of this study is to investigate whether any esophageal motor dysfunction exists in patients with primary biliary cirrhosis. MethodThe study was performed in 37 patients (36 women, mean age: 56.29±10.01years) who met diagnostic criteria for primary biliary cirrhosis. Thirty-seven functional dyspepsia patients, were also included as a control group. Patients entering the study were asked to complete a symptom questionnaire. Distal esophageal contraction amplitude, and lower esophageal sphincter resting pressure were assessed. ResultsManometric findings in primary biliary cirrhosis patients vs. controls were as follows: Median lower esophageal sphincter resting pressure (mmHg): (24 vs 20, p=0.033); median esophageal contraction amplitude (mmHg): (71 vs 56, p=0.050); mean lower esophageal sphincter relaxation duration (sc, x±SD): (6.10±1.18 vs 8.29±1.92, p<0.001); and median lower esophageal sphincter relaxation (%) (96 vs 98, p=0.019); respectively. No significant differences were evident in median peak velocity (sc) (3.20 vs 3.02, p=0.778) between patients with primary biliary cirrhosis and the functional dyspepsia patients. Esophageal dysmotility was found in 17 (45.9%) primary biliary cirrhosis patients (non-specific esophageal motor disorder in ten patients, hypomotility of esophagus in five patients, nutcracker esophagus in one patient and hypertensive lower esophageal sphincter in one patient). ConclusionEsophageal dysmotility was detected in 45.9% of patients. The study suggests that subclinic esophageal dysmotility is frequent in patients with primary biliary cirrhosis.

Bolus retention in hiatal hernia identified by high-resolution esophageal manometry with impedance

Esophageal acid retention in a hiatal hernia (HH) may play a role in gastro-esophageal reflux. The aims of this study were to determine the prevalence of bolus retention (BR) in HH and to compare pressure profiles in patients with HH with BR in the hernia to those with bolus clearance (BC) through the hernia using high-resolution esophageal manometry with impedance (HREMI). Clinical HREMI studies with HH ≥1.5cm were analyzed for lower esophageal sphincter (LES) and crural diaphragm (CD) pressures and pressure profiles during 12 saline swallows. Impedance was analyzed for swallow retention in the HH. Bolus retention in a HH was present in 35 of 53 (66%) patients with a HH. Patients with BR had overall lower pressure profiles including a lower basal LES pressure (14.8±10.6 vs 28.9±16.8mmHg; p=0.0001), LES-CD gradient (6.8±17.9 vs 20.6±12.2mmHg; p=0.002), residual LES pressure (2.5±4.6 vs 6.1±12.2mmHg; p=0.017), amplitude of distal esophageal contractions (83.2±38.8 vs 111.2±42.8mmHg; p=0.020), and distal contractile integral (1487±1016 vs 2608±1221mmHg-cm-sec; p=0.001) compared to the BC group. Patients with BR were more likely to have a larger sized HH compared to the BC group (3.1±1.6 vs 2.1±0.6cm; p=0.016); similar pressure changes were found when the groups were divided up by HH sizes. Bolus retention was seen in 66% of patients with HH. Bolus retention in the HH was associated with larger HH size, lower LES pressure, and lower esophageal contractile pressures compared to those with BC.

Presentation, Diagnosis, and Management of Achalasia

Presentation, Diagnosis, and Management of Achalasia

Symptoms and esophageal motility based on phenotypic findings of scleroderma

Scleroderma esophagus is characterized by ineffective peristalsis and reduced esophageal sphincter pressure. Esophageal disease in scleroderma can precede cutaneous manifestations and has been associated with Raynaud's phenomenon (RP) and pulmonary fibrosis (PF). The objective of the study is to evaluate the impact of cutaneous findings, RP, and PF on demographics, symptoms, and esophageal motility in patients with scleroderma. Scleroderma patients with esophageal involvement were included after review of esophageal manometries and charts over a 6-year period. High-resolution esophageal manometry was performed. Patients completed a symptom questionnaire. The study enrolled 28 patients (22 females; mean age 50.3 ± 12.8 years) with scleroderma esophagus. Patients without skin involvement (n= 12) reported more severe heartburn (P= 0.02), while those with cutaneous findings (n= 16) had more frequent dysphagia with solids (P= 0.02). Patients with RP (n= 22) had lower amplitude of distal esophageal contractions (P= 0.01) than those without RP (n= 6). Patients with PF (n= 11) reported more severe coughing and wheezing (both P= 0.03) than those without lung disease (n= 17). This study highlights subgroups of patients with scleroderma esophagus according to phenotypic findings of dermatologic changes, RP, and PF. Heartburn and dysphagia are important symptoms that may be associated with different stages of disease progression based on skin changes in scleroderma. RP was associated with greater esophageal dysmotility. Coughing and wheezing were more severe in patients with PF.

Automated calculation of the distal contractile integral in esophageal pressure topography with a region‐growing algorithm

The distal contractile integral (DCI) is an index of contractile vigor in high-resolution esophageal pressure topography (EPT) calculated as the product of amplitude, duration, and span of the distal esophageal contraction. The aim of this study was to develop an automated algorithm calculating DCI. The DCI was calculated conventionally using ManoView™ (Given Imaging, Los Angeles, CA, USA) software in EPT studies from 72 controls and 20 patients and compared to the calculation using a MATLAB™ (Version 7.9.0, R2009b; The MathWorks Inc., Natick, MA, USA) 'region-growing' algorithm. This algorithm first established the spatial limits of the distal contraction (the proximal pressure trough to either the distal pressure trough or to the superior margin of the lower esophageal sphincter at rest). Pixel-by-pixel horizontal line segments were then analyzed within this span starting at the pressure maximum and extending outward from that point. The limits of 'region-growing' were defined either by the spatial DCI limits or by encountering a pressure <20 mmHg. The DCI was then calculated as the total units of mmHg s cm greater than 20 mmHg within this domain. Excellent correlation existed between the two methods (r = 0.98, P < 0.001). The DCI values obtained with the conventional calculation were slightly but significantly greater than with the region-growing algorithm. Differences were attributed to the inclusion of vascular pressures in the conventional calculation or to differences in localization of the distal limit of the DCI. The proposed region-growing algorithm provides an automated method to calculate DCI that limits inclusion of vascular pressure artifacts and minimizes the need for user input in data analysis.

Dysphagia and Gastroesophageal Junction Resistance to Flow Following Partial and Total Fundoplication

BackgroundEsophageal peristalsis and basal gastroesophageal junction (GEJ) pressure correlate poorly with dysphagia. AimTo determine intraluminal pressures that reflect GEJ function and to determine manometric correlates for dysphagia before and after fundoplication. MethodsThe relationships between maximal intrabolus pressure, residual GEJ relaxation pressure and peak peristaltic pressure for water swallows were determined in normal volunteers and patients with reflux disease before and after fundoplication. GEJ anatomy was assessed by radiological, endoscopic and surgical criteria, whilst dysphagia was measured with a validated composite dysphagia score. ResultsDysphagia was significantly associated with lower peak peristaltic pressure in the distal esophagus and the presence of a hiatus hernia preoperatively, as well as higher residual pressure on GEJ relaxation postoperatively. Peak distal peristaltic pressure and residual GEJ relaxation pressure were predictors of intrabolus pressure after total fundoplication (p < 0.002). Residual GEJ relaxation pressure was four times higher after 360° fundoplication (N = 19) compared to 90° fundoplication (N = 14, p < 0.0001). Similarly, intrabolus pressure was elevated 2.5 times after 360° fundoplication and nearly doubled after 90° fundoplication and both were significantly different from controls (N = 22) and reflux disease patients (N = 53, p < 0.0001). ConclusionsGastroesophageal junction impedance to flow imposed by fundoplication is associated with dysphagia when there is suboptimal distal esophageal contraction strength and relatively high residual GEJ relaxation pressure.

Postoperative Impedance–pH Testing is Unreliable After Nissen Fundoplication With or Without Giant Hiatal Hernia Repair

IntroductionCombined 24-h multichannel intralumenal impedance–pH monitoring (MII-pH) is gaining popularity as a diagnostic tool for gastroesophageal reflux. Since the surgical reduction of hiatal hernias and creation of a fundoplication anatomically restores the gastroesophageal reflux barrier, one would assume that it effectively stops all reflux regardless of composition. Our aim is to evaluate the results of routine MII-pH testing in successful Nissen fundoplication patients. Material and MethodsSixty-two patients with normal acid exposure, confirmed by 24-h pH testing, after Nissen fundoplication were evaluated with symptomatic questionnaire, esophageal manometry and MII-pH testing more than 6 months after surgery. Patients were grouped into normal and abnormal based on postoperative impedance results. Patients with Nissen alone were separately compared to patients with Nissen + giant hiatal hernia (GHH). ResultsTwenty-nine (47%) patients exhibited abnormal impedance after successful Nissen fundoplication. Abnormal impedance was associated with GHH repair, lower bolus pressures, and lower distal esophageal contraction amplitudes. ConclusionPostoperative testing with the standard MII-pH catheters using published normative values seems to be clinically irrelevant. Clinicians should analyze the results of routine MII-pH testing in the setting of a fundoplication critically as the current technology is associated with a high false positive rate.

Pharyngeal and Oesophageal Dysmotility and Dysfunction in Patients With Chronic Cough: Assessment by High-Resolution Manometry

Introduction Laryngopharyngeal reflux (LPR) of gastric contents is a cause of chronic cough; however the pathophysiology of this disease remains unclear. Conventional manometry has insufficient spatial resolution for the functional assessment of the pharynx, upper oesophageal sphincter (UOS) and coordination between the proximal and distal oesophageal contractions that clear refluxate from the laryngopharynx and proximal oesophagus. This study applied high resolution manometry (HRM) in patients with chronic cough with and without association to reflux events. Methods Consecutive patients referred for investigation of chronic cough in 2009 were reviewed. Patients with hiatus hernia, severe co-morbidity and previous oeosphageal surgery were excluded. Of 66 patients referred, 34 (52%) (21 F:13 M) were eligible. HRM (ManoScan 360, Sierra) with detailed analysis (ManoView 2.0, Sierra) of 10 water swallows was performed followed by 24-h ambulatory pH-monitoring. Of this group 21 patients had negative reflux-cough symptom association probability (SAP; group A) and 13 had positive SAP (group B). Results from 23 healthy controls were available for comparison. A secondary analysis to assess the association of gastro-oeosphageal reflux (GOR) disease and motility was performed. Results Mean patient age was 55±15 (19–77). Mean acid exposure time was similar in group A and B (4.9±6.5 vs 3.7±4.0; p=0.34) and a similar proportion had pathologic reflux >4.2% acid exposure/24 h (7/21, 4/13; p=0.198). Moreover there was no significant interaction between the presence of GOR on pH-monitoring and any measurement of pharyngeal or oesophageal motility in this population. There was no significant differences for baseline UOS pressure; however residual UOS intrabolus pressure on 5 ml water swallows was higher in group A and B than controls (−0.34±0.69 and 1.09±0.64 mm Hg vs −4.4±5.8 mm Hg; p The percentage of primary peristaltic contractions was lower in group B with reflux associated cough than groups A and C (56% vs 79% and 87%; p=0.03 and p Conclusion Detailed analysis of swallowing and oesophageal motility by HRM revealed changes to UOS and oesophageal function that impair clearance from the pharynx and oesophagus in patients with cough compared to healthy controls. These changes were most marked in patients in whom cough was associated to reflux events. These findings suggest that not only GOR but also impaired clearance of luminal contents from the pharynx and proximal oesophagus contribute to chronic cough.

Pharyngeal and oesophageal dysmotility and dysfunction in patients with chronic cough: assessment by high-resolution manometry

IntroductionLaryngopharyngeal reflux (LPR) of gastric contents is a cause of chronic cough; however the pathophysiology of this disease remains unclear. Conventional manometry has insufficient spatial resolution for the functional assessment...