Esophageal Function Testing Research Articles

RA06.07: PSYLLIUM SUPPLEMENTATION EFFECT ON ESOPHAGEAL FUNCTION TESTING AND SYMPTOMS IN PATIENTS WITH NON-EROSIVE GERD

Abstract Background Epidemiological data showed negative correlation between heartburn frequency and amount of dietary fiber consumed. However no interventional study was performed to prove clinically beneficial effect of dietary fibers in gastroesophageal reflux disease (GERD) patients. The aim of the study was to investigate the effect of dietary fiber on symptoms and esophageal function testing parameters in non-erosive GERD patients (NCT01882088) Methods Thirty six NERD patients were examined using food frequency questionnaire and in case of less than 20 g/day dietary fibre intake underwent high-resolution esophageal manometry and 24-hours esophageal pH-impedance. Language-specific GERD-Q questionnaire was used to assess symptoms. Repeated examinations were performed after 10 days of usual diet supplemented by psyllium 15.0 gram a day. Complete data of 30 NERD patients were available for the final analysis. Study design is shown in a figure 1. Wilcoxon matched pairs test was used to assess changes in the studied parameters Results The decrease in proportion of patients experiencing heartburn as well as GERD-Q score decrease were found. Minimal resting lower esophageal sphincter pressure increased from 5.41 ± 10.1 to 11.3 ± 9.4, P = 0.023. No change in residual LES pressure and mean resting pressure was found. Total number of gastroesophageal refluxes decreased from 67.9 ± 17.7 to 42.4 ± 13.5, P < 0.001 (Table 1). Conclusion Supplementation of diet with psyllium 5.0 gram TID in NERD patients led to significant increase of minimal esophageal resting pressure, decrease of number of gastroesophageal refluxes and frequency of heartburn per week. The work was supported by Federal Agency of Scientific Organizations of Russia (0529–2017-0057) Disclosure All authors have declared no conflicts of interest.

Outcome for Patients With Pathological Esophageal Acid Exposure After Laparoscopic Fundoplication.

The aim of the current study was to assess symptomatic outcome and need for surgical reintervention for patients identified with pathological esophageal acid exposure by routine postoperative 24-hour pH-monitoring. Although laparoscopic fundoplication is associated with excellent short- and midterm results, recurrent symptoms pose an important challenge. Postoperative pH-monitoring is considered the "gold standard" for diagnosing recurrent GERD and frequently used for routine postoperative follow up. Analysis of prospectively collected data from patients who underwent laparoscopic fundoplication between April 1994 and June 2015 and underwent routine postoperative 24-hour pH-monitoring was performed. Symptomatic outcome and need for surgical reintervention up to 5 years was compared between patients with pathological and physiological postoperative esophageal acid exposure. Primary endpoints were heartburn score and need for surgical reintervention for recurrent reflux. A total of 309 patients in whom routine postoperative 24-hour pH-monitoring was performed were included. Pathological acid exposure was present in 33 patients (11%) compared with 276 patients (89%) with physiological acid exposure. During 5-year follow up, there were no differences in heartburn, dysphagia, or satisfaction scores. Eighteen percent of all patients with abnormal postoperative pH-studies underwent redo fundoplication during 5-year follow up. Pathological acid exposure demonstrated by routine postoperative pH-monitoring was not associated with worse symptomatic outcome in terms of reflux control and satisfaction. A possible explanation for this finding is that laparoscopic fundoplication reduces the patients' ability to perceive reflux. This underlines the importance of assessing the association between symptomatic outcome and esophageal function tests in determining outcome of antireflux surgery.

Factors predictive of gastroesophageal reflux disease and esophageal motility disorders in patients with non-cardiac chest pain

Background: Patients with non-cardiac chest pain (NCCP) are referred for esophageal motility testing and pH monitoring since gastroesophageal reflux disease (GERD) and esophageal motility disorders are frequently encountered in these patients. Our aim was to determine the prevalence and distribution of these disorders and to identify predictors of abnormal esophageal function testing.Methods: We performed a retrospective study of NCCP patients who presented after a negative cardiac evaluation and underwent esophageal manometry, esophageal pH monitoring and upper endoscopy from January 2010 to January 2017.Key results: In a total of 177 patients, esophageal motility disorders were diagnosed in 31% and GERD in 35% of the patients. The most common diagnoses were ineffective esophageal motility (IEM) in 14.1%, jackhammer esophagus in 6.8%, diffuse esophageal spasm in 5.1% and achalasia in 2.3% patients. Older age [for every 5-year increment, odds ratio (OR) 1.2 (95% confidence intervals (CI) 1.00–1.3) p = .047] and dysphagia [OR 3.8 (95% CI, 1.9–7.5) p < .001] were predictors of esophageal motility disorders. Older age [for every 5-year increment, OR 1.2 (95% CI, 1.01–1.3) p = .032] was predictive of GERD. Abnormal esophageal testing was associated with male gender [OR 2.2 (95% CI, 1.04–4.6) p = .039], older age [for every 5-year increment, OR 1.2 (95% CI, 1.03–1.3) p = .016] and Caucasian race [OR 3.1 (95% CI, 1.1–8.7) p < .029].Conclusions: Approximately two thirds of patients presenting with NCCP have GERD or esophageal motility disorders. Esophageal function testing in NCCP should be considered in older patients, men, Caucasians and those presenting with dysphagia.

Indications and interpretation of esophageal function testing.

Esophageal symptoms are common, and can arise from mucosal, motor, functional, and neoplastic processes, among others. Judicious use of diagnostic testing can help define the etiology of symptoms and can direct management. Endoscopy, esophageal high-resolution manometry (HRM), ambulatory pH or pH-impedance manometry, and barium radiography are commonly used for esophageal function testing; functional lumen imaging probe is an emerging option. Recent consensus guidelines have provided direction in using test findings toward defining mechanisms of esophageal symptoms. The Chicago Classification describes hierarchical steps in diagnosing esophageal motility disorders. The Lyon Consensus characterizes conclusive evidence on esophageal testing for a diagnosis of gastroesophageal reflux disease (GERD), and establishes a motor classification of GERD. Taking these recent advances into consideration, our discussion focuses primarily on the indications, technique, equipment, and interpretation of esophageal HRM and ambulatory reflux monitoring in the evaluation of esophageal symptoms, and describes indications for alternative esophageal tests.

Advances in the physiological assessment and diagnosis of GERD.

This corrects the article DOI: 10.1038/nrgastro.2017.130.

Thoracoabdominal pressure gradient and gastroesophageal reflux: insights from lung transplant candidates.

Advanced lung disease is associated with gastroesophageal reflux disease (GERD). The thoracoabdominal pressure gradient (TAPG) facilitates gastroesophageal reflux, but the effects of TAPG on gastroesophageal reflux in patients with pulmonary disease have not been well defined. Patients diagnosed with end-stage lung disease are expected to have the most extreme derangement in respiratory mechanics. The aim of this study is to explore the relationship between TAPG and reflux in lung transplant (LTx) candidates. We reviewed LTx recipients who underwent pretransplant esophageal high-resolution manometry and a 24-hour pH study. Patients were excluded if they were undergoing redo LTx, had manometric hiatal hernia, or had previously undergone foregut surgery. TAPG was defined as the intra-abdominal pressure minus the intrathoracic pressure during inspiration. Adjusted TAPG was calculated by the TAPG minus the resting lower esophageal sphincter (LES) pressure (LESP). Twenty-two patients with normal esophageal function tests (i.e., normal esophageal motility with neither manometric hiatal hernia nor pathological reflux on 24-hour pH monitoring) were selected as the pulmonary disease-free control group. In total, 204 patients underwent LTx between January 2015 and December 2016. Of these, 77 patients met inclusion criteria. We compared patients with obstructive lung disease (OLD, n=33; 42.9%) and those with restrictive lung disease (RLD, n=42; 54.5%). 2/77 patients (2.6%) had pulmonary arterial hypertension. GERD was more common in the RLD group than in the OLD group (24.2% vs. 47.6%, P=0.038). TAPG was similar between the OLD group and the controls (14.2 vs. 15.3 mmHg, P=0.850); however, patients in the RLD group had significantly higher TAPG than the controls (24.4 vs. 15.3 mmHg, P=0.002). Although TAPG was not correlated with GERD, the adjusted TAPG correlated with reflux in all 77 patients with end-stage lung disease (DeMeester score, rs=0.256, P=0.024; total reflux time, rs=0.259, P=0.023; total number of reflux episodes, rs=0.268, P=0.018). Additionally, pathological reflux was seen in 59.1% of lung transplant candidates with adjusted TAPG greater than 0 mmHg (i.e., TAPG exceeding LESP); GERD was seen in 30.9% of patients who had an adjusted TAPG≤0 mmHg. In summary, TAPG varies based on the underlying cause of lung disease. Higher adjusted TAPG increases pathological reflux, even if patients have normal antireflux anatomy and physiology (i.e., no hiatal hernia and manometrically normal LES function). Adjusted TAPG may provide further insights into the pathophysiology of GERD.

Gastroesophageal reflux symptoms are not sufficient to guide esophageal function testing in lung transplant candidates.

Gastroesophageal reflux disease and esophageal dysmotility are prevalent in patients with advanced lung disease and are associated with graft dysfunction following lung transplantation. As a result, many transplant centers perform esophageal function testing as part of the wait-listing process but guidelines for testing in this population are lacking. The aim of this study is to describe whether symptoms of gastroesophageal reflux correlate with abnormal results on pH-metry and high-resolution manometry and can be used to identify those who require testing. We performed a retrospective cohort study of 226 lung transplant candidates referred for high-resolution manometry and pH-metry over a 12-month period in 2015. Demographic data, results of a standard symptom questionnaire and details of esophageal function testing were obtained. Associations between the presence of symptoms and test results were analyzed using Fisher's exact tests and multivariable logistic regression. The most common lung disease diagnosis was interstitial lung disease (N=131, 58%). Abnormal pH-metry was seen in 116 (51%) patients and the presence of symptoms was significantly associated with an abnormal study (p<0.01). Dysmotility was found in 98 (43%) patients, with major peristaltic or esophageal outflow disorders in 45 (20%) patients. Symptoms were not correlated with findings on esophageal high-resolution manometry. Fifteen of 25 (60%) asymptomatic patients had an abnormal manometry or pH-metry. These results demonstrate that in patients with advanced lung disease, symptoms of gastroesophageal reflux increase the likelihood of elevated acid exposure on pH-metry but were not associated with dysmotility. Given the proportion of asymptomatic patients with abnormal studies and associated post-transplant risks, a practice of universal high-resolution manometry and pH-metry testing in this population is justifiable.

Physiological Changes in Esophageal Function Testing After Paraesophageal Hernia Repair

Physiological Changes in Esophageal Function Testing After Paraesophageal Hernia Repair

Effect of Opiates on Esophageal Function Testing in Patients With Non-cardiac Chest Pain

Effect of Opiates on Esophageal Function Testing in Patients With Non-cardiac Chest Pain

Comparison Between Timed Barium Swallow and Esophageal Function Testing With High-Resolution Manometry In Patients With Esophagogastric Junction Outflow Obstruction (EGJOO)

Comparison Between Timed Barium Swallow and Esophageal Function Testing With High-Resolution Manometry In Patients With Esophagogastric Junction Outflow Obstruction (EGJOO)

An Analysis of Patients With Post-Nissen Fundoplication Symptoms Referred to a Tertiary Referral Center for Esophageal Function Testing

An Analysis of Patients With Post-Nissen Fundoplication Symptoms Referred to a Tertiary Referral Center for Esophageal Function Testing

The Rome IV versus Rome III criteria for heartburn diagnosis: A comparative study.

The phenotypes of heartburn patients are heterogeneous. The objective of this study was to investigate the proportion of heartburn phenotypes in a Chinese population and to compare the Rome IV and III criteria for heartburn diagnosis. A retrospective study was performed among heartburn patients referred for upper endoscopy and esophageal function tests in a tertiary hospital. Their symptoms fulfilled Rome IV and III criteria. A total of 233 patients were included. Fifty-nine patients (25%) were diagnosed with esophagitis, 96 (41%) with non-erosive reflux disease (NERD) and 78 (34%) with functional heartburn (FH) based on Rome III criteria. Approximately 70% of the Rome III NERD patients were changed based on Rome IV criteria, with 36 patients (15%) diagnosed with reflux hypersensitivity (RH) and 32 patients (14%) who didn't fulfill the criteria considered unclassified. The FH and RH patients showed higher esophagogastric junction-contractile integral (EGJ-CI) and less hiatal hernia than did Rome IV NERD patients. The unclassified had more hiatal hernias than the FH and RH (p < 0.05). The EGJ-CI was similar between Rome III NERD and FH cases. The Rome IV criteria were stricter for heartburn diagnosis and superior in distinguishing NERD from functional disorders on motility patterns than Rome III.

Esophagogastric junction outflow obstruction is often associated with coexistent abnormal esophageal body motility and abnormal bolus transit.

Currently, the diagnosis of esophageal motility disorders is in part based upon a hierarchical algorithm in which abnormalities of the esophagogastric junction (EGJ) is prioritized. An important metric in evaluating the EGJ is the integrated relaxation pressure (IRP). Patients who do not have achalasia but are found to have an elevated IRP are diagnosed with EGJ outflow obstruction. It has been our observation that a subset of these patients also has a second named motility disorder and may also have abnormal bolus transit. The aim of this study is to determine the frequency of abnormal body motility and or abnormal bolus movement in patients with EGJ outflow obstruction. Further, in an effort to evaluate the potential clinical value in measuring bolus transit as a complement to esophageal manometry, specifically in patients with EGJ outflow obstruction, we analyzed the presenting symptoms of these patients. A total of 807 patients with a mean age of 53 years completed esophageal function testing with impedance monitoring and high-resolution manometry between January 2012 and October 2016. There were 74 patients with achalasia who were excluded from the study. Of the remaining 733 patients, 138 (19%) had an elevated IRP and were given a diagnosis of EGJ outflow obstruction. Among these patients, 56 (40%) were diagnosed with an abnormal motility pattern to liquids (ineffective esophageal motility =28, distal esophageal spasm =19, Jackhammer =6), of which 44 (76%) had abnormal bolus transit to liquids, viscous, or both. In contrast, there were 82 patients with EGJ outflow obstruction and normal esophageal motility, of which 33 (40%) had abnormal bolus transit. Patients with preserved esophageal motility and EGJ outflow obstruction were then evaluated. Of the 733 patients, 299 (40%) had intact esophageal motility. Of the 299 patients with normal esophageal motility, 56 patients had an elevated IRP, of which 16 (28%) had abnormal bolus transit. There were 243 (33%) patients with intact esophageal motility and normal IRP. Of these, 56 (23%) patients had abnormal bolus transit. Among patients with abnormal bolus transit, the two most commonly presenting symptoms were dysphagia and heartburn. A substantial percentage of patients with EGJ outflow obstruction have abnormal esophageal body motility and or abnormal bolus transit. The clinical implications of EGJ outflow obstruction need to be further elucidated as current criteria do not allow for the description of other abnormalities in esophageal motility and bolus transit among patients who are given the diagnosis of EGJ outflow obstruction.

Esophageal function testing: Billing and coding update

Esophageal function testing is being increasingly utilized in diagnosis and management of esophageal disorders. There have been several recent technological advances in the field to allow practitioners the ability to more accurately assess and treat such conditions, but there has been a relative lack of education in the literature regarding the associated Common Procedural Terminology (CPT) codes and methods of reimbursement. This review, commissioned and supported by the American Neurogastroenterology and Motility Society Council, aims to summarize each of the CPT codes for esophageal function testing and show the trends of associated reimbursement, as well as recommend coding methods in a practical context. We also aim to encourage many of these codes to be reviewed on a gastrointestinal (GI) societal level, by providing evidence of both discrepancies in coding definitions and inadequate reimbursement in this new era of esophageal function testing.

Comparison of oesophageal function tests between Chinese non-erosive reflux disease and reflux hypersensitivity patients

BackgroundBy means of 24 h multi-channel intraluminal impedance and pH recording (MII/pH), patients with heartburn and normal upper gastrointestinal endoscopy findings can be classified into those with non-erosive reflux disease (NERD) and those with reflux hypersensitivity (RH). Therefore, in this study, we investigated the difference in oesophageal function tests in Chinese patients with NERD and RH.MethodsNERD patients were selected from the digestive department, Beijing Anzhen Hospital and Beijing Chao-Yang Hospital, Capital Medical University, after upper gastrointestinal endoscope, high-resolution manometry and impedance (HRiM), and MII/pH examinations between 2014 and 2016.ResultsIn total, 111 NERD patients with abnormal acid exposure, and 92 RH patients were enrolled. Values for NERD and RH were as follows: lower oesophageal sphincter pressure, 15.3 ± 8.9 and 19.3 ± 23.3 mmHg (P = 0.122); integrated relaxation pressure, 7.5 ± 4.8 and 7.9 ± 5.2 mmHg (P = 0.485); distal contractile integral, 751.9 ± 856.2 and 661.9 ± 961.7 mmHg∙s∙cm (P = 0.482); ineffective oesophageal motility rate, 49.5% and 41.3% (P = 0.241); fragmented peristalsis rate, 5.4% and 9.8% (P = 0.235); hiatal hernia rate, 9.0% and 8.6% (P = 0.938); total bolus transit time, 6.3 ± 1.3 and 6.5 ± 1.3 s (P = 0.119); complete bolus transit rate, 76.1 ± 33.0% and 73.1 ± 32.0% (P = 0.224); total acid exposure time, 6.1 ± 3.7% and 0.8 ± 0.8% (P < 0.001); total bolus exposure time, 2.5 ± 2.1% and 1.5 ± 1.1% (P < 0.001); proximal acid reflux events, 13.2 ± 10.5 and 9.7 ± 8.9 (P = 0.011); distal acid reflux events, 25.3 ± 15.8 and 13.4 ± 11.2 (P < 0.001); post-reflux swallow-induced peristaltic wave index, 25.1 ± 9.5% and 32.6 ± 15.2% (P < 0.001); and mean nocturnal baseline impedance, 1,450.2 ± 750.8 and 2,503.6 ± 964.1 ohms (P < 0.001), respectively.ConclusionsNERD and RH patients showed similar values on HRiM. NERD patients had greater acid exposure time, bolus exposure time, proximal and distal acid reflux events, and increased impairment of chemical clearance and mucosal integrity than RH patients. NERD and RH should be classified correctly by MII/pH to provide adequate relief from related symptoms.

Upper esophageal sphincter abnormalities and high-resolution esophageal manometry findings in patients with laryngopharyngeal reflux

Background: The association between laryngopharyngeal reflux (LPR) and abnormalities of upper esophageal sphincter (UES) and esophageal motility is not clearly known. High-resolution esophageal manometry (HREM) has allowed accurate measurement and evaluation of UES and esophageal function.Goals: To evaluate the UES function and esophageal motility using HREM in patients with LPR and compare them to patients with typical gastroesophageal reflux disease (GERD).Study: All patients evaluated for GERD or LPR symptoms with esophageal function testing including HREM, ambulatory distal pH monitoring and upper endoscopy between 2006 and 2014 were retrospectively studied (n = 220). The study group (group A, n = 57) consisted of patients diagnosed with LPR after comprehensive evaluation. They were compared to patients who had typical GERD symptoms only (group B, n = 98) and patients with both GERD and LPR symptoms (group C, n = 65).Results: Abnormalities in UES pressures and relaxation were found in about one-third of patients in all groups. There were no significant differences between the groups. Group B had higher prevalence of abnormal esophageal motility compared to others (group A vs. B vs. C = 20.8% vs. 28% vs. 12.5%, p = .029). Group B patients also had higher prevalence of Barrett’s esophagus compared to others (group A vs. B vs. C = 0% vs.12.2% vs. 4.6%, p = .01). Distal pH testing revealed no significant differences between the three groups.Conclusions: Abnormal UES function was noted in one-third of patients with LPR or GERD. However, there were no abnormalities on esophageal function testing specific for LPR.

Sa1171 - Differences in Motility and Reflux Profiles on Esophageal Function Testing Between Upper and Lower Airway Manifestations of Gastroesophageal Reflux Disease

Sa1171 - Differences in Motility and Reflux Profiles on Esophageal Function Testing Between Upper and Lower Airway Manifestations of Gastroesophageal Reflux Disease

Comparison of Esophageal Function Tests in Chinese Patients with Functional Heartburn and Reflux Hypersensitivity.

Objective To investigate the differences in the results of esophageal function tests for functional heartburn (FH) and reflux hypersensitivity (RH). Methods Patients with FH and RH and healthy volunteers (HVs) from the Department of Gastroenterology, Beijing Anzhen Hospital and Beijing Chao-Yang hospital, who underwent high-resolution manometry and impedance (HRIM), and 24-hour multichannel intraluminal impedance and pH recording (MII/pH) between 2014 and 2016, were enrolled in this study. Results 36 HV, 147 FH patients, and 91 RH patients were enrolled. The postreflux swallow-induced peristaltic wave index (PSPW index) and mean nocturnal baseline impedance (MNBI) values were significantly lower in RH than in FH and HV. The ineffective esophageal motility (IEM), fragmented peristalsis rates, total bolus exposure, proximal total reflux events, and distal total reflux events were significantly greater in RH than in FH and HV. Conclusions Compared to HV and FH patients, RH patients exhibited greater IEM and fragmented peristalsis rates, a greater total bolus exposure, more proximal total and distal total reflux events, and reduced chemical clearance and mucosal integrity. By using the above described parameters, HRIM and MII/pH assays could be used to correctly classify RH and FH and hence allow physicians to provide adequate relief from associated symptoms.

How to Optimally Apply Impedance in the Evaluation of Esophageal Dysmotility.

The utilization of impedance technology has enhanced our understanding and assessment of esophageal dysmotility. Esophageal high-resolution manometry (HRM) catheters incorporated with multiple impedance electrodes help assess esophageal bolus transit, and the combination is termed high-resolution impedance manometry (HRIM). Novel metrics have been developed with HRIM-including esophageal impedance integral ratio, bolus flow time, nadir impedance pressure, and impedance bolus height-that augments the assessment of esophageal bolus transit. Automated impedance-manometry (AIM) analysis has enhanced understanding of the relationship between bolus transit and pressure phenomena. Impedance-based metrics have improved understanding of the dynamics of esophageal bolus transit into four distinct phases, may correlate with symptomatic burden, and can assess the adequacy of therapy for achalasia. An extension of the use of impedance involves impedance planimetry and the functional lumen imaging probe (FLIP), which assesses esophageal biophysical properties and distensibility, and could detect patterns of esophageal contractility not seen on HRM. Impedance technology, therefore, has a significant impact on esophageal function testing in the present day.

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.