Esophageal Pressure Topography Metrics Research Articles

High-resolution esophageal manometry in pediatrics: Effect of esophageal length on diagnostic measures.

BackgroundHigh‐resolution esophageal manometry (HREM), derived esophageal pressure topography metrics (EPT), integrated relaxation pressure (IRP), and distal latency (DL) are influenced by age and size. Combined pressure and intraluminal impedance also allow derivation of metrics that define distension pressure and bolus flow timing. We prospectively investigated the effects of esophageal length on these metrics to determine whether adjustment strategies are required for children.MethodsFifty‐five children (12.3 ± 4.5 years) referred for HREM, and 30 healthy adult volunteers (46.9 ± 3.8 years) were included. Studies were performed using the MMS system and a standardized protocol including 10 × 5 mL thin liquid bolus swallows (SBM kit, Trisco Foods) and analyzed via Swallow Gateway (http://www.swallowgateway.com). Esophageal distension pressures and swallow latencies were determined in addition to EGJ resting pressure and standard EPT metrics. Effects of esophageal length were examined using partial correlation, correcting for age. Adult‐derived upper limits were adjusted for length using the slopes of the identified linear equations.Key ResultsMean esophageal length in children was 16.8 ± 2.8 cm and correlated significantly with age (r = 0.787, P = .000). Shorter length correlated with higher EGJ resting pressure and 4‐s integrated relaxation pressures (IRP), distension pressures, and shorter contraction latencies. Ten patients had an IRP above the adult upper limit. Adjustment for esophageal length reduced the number of patients with elevated IRP to three.Conclusions & InferencesWe prospectively confirmed that certain EPT metrics, as well as potential useful adjunct pressure‐impedance measures such as distension pressure, are substantially influenced by esophageal length and require adjusted diagnostic thresholds specifically for children.

Trends in Diagnoses After Implementation of the Chicago Classification for Esophageal Motility Disorders (V3.0) for High-Resolution Manometry Studies at a Large Academic Medical Center

Introduction: High resolution esophageal manometry (HRM) is considered the gold standard diagnostic test for esophageal motility disorders. The Chicago Classification (CC V3.0) is a hierarchical approach to interpret HRM studies and defines metrics for the diagnosis of esophageal motility disorders. The real world clinical practice impact of using CC V3.0 is unknown. The objective of this study was to determine the diagnostic distribution of esophageal motility disorders before and after implementation of CC V3.0 for HRM interpretation.Table 2: Rate Ratios for Diagnoses associated with Implementation of Chicago Classification V3.0 (09/01/2014)Methods: This was a retrospective analysis of patients with a HRM study conducted at a single center from January 1, 2013 through September 30, 2015. The implementation of CC V3.0 occurred in September 2014 and was fully adopted by December 2014. Patient charts were reviewed to extract demographics (age, sex), clinical variables (symptoms, indications), and HRM variables (esophageal pressure topography metrics, diagnoses and interpretation). If a diagnosis was not clearly stated, it was categorized as indeterminate. Rate ratios (RR) for CC V3.0 diagnostic categories (normal, indeterminate, achalasia and EGJ outflow obstruction (EGJOO), and major and minor motility disorders) were calculated by Poisson regression associated with the period after CC V 3.0 implementation. All models were adjusted for age and sex, and the reference time period was quarter 1 (Jan-Mar 2013). Results: There were 796 HRM studies included in the study. The mean ± standard deviation patient age was 53.4 ±15.5 years, with 59% being female (Table 1). The graphical trends in diagnoses over time are shown in Figure 1. The percentage of indeterminate and major motility disorder diagnoses was significantly lower in the time period after CC V 3.0 implementation. The percentage of normal, EGJOO, and minor motility disorder diagnoses were significantly higher post implementation. There was no change in the % of achalasia diagnoses.Figure 1Table 1: Characteristics of the study population overall, and by time periods before and after Chicago Classification V3.0 policy implementation on 09/01/2014Conclusion: This is one of the first studies showing the impact of CC V3.0 on HRM interpretation in clinical practice. The increase in the number of normal studies and decrease in the number of indeterminate studies suggests that CC V3.0 clarifies the criteria for a normal study. The increase in studies with a diagnosis of EGJ outflow obstruction may reflect the heterogeneity of disorders with clinically relevant outflow obstruction. Further study is needed to determine if these results translate to changes in therapeutic decision making and treatment outcomes.

Impaired bolus clearance in asymptomatic older adults during high-resolution impedance manometry.

Dysphagia becomes more common in old age. We performed high-resolution impedance manometry (HRIM) in asymptomatic healthy adults (including an older cohort >80years) to assess HRIM findings in relation to bolus clearance. Esophageal HRIM was performed in a sitting posture in 45 healthy volunteers (n=30 young control, mean age 37±11years and n=15 older subjects aged 85±4years) using a 3.2-mm solid-state catheter (Solar GI system; MMS, Enschede, The Netherlands) with 25 pressure (1-cm spacing) and 12 impedance segments (2-cm intervals). Five swallows each of 5- and 10-mL liquid and viscous bolus were performed and analyzed using esophageal pressure topography metrics and Chicago classification criteria as well as pressure-flow parameters. Bolus transit was determined using standard impedance criteria. A p-value <0.05 was considered significant. Impaired bolus clearance occurred more frequently in asymptomatic older subjects compared with young controls (YC) during liquid (40 vs 18%, χ2 =4.935; p<0.05) and viscous (60 vs 17%; χ2 =39.08; p<0.001) swallowing. Longer peristaltic breaks (p<0.05) and more rapid peristalsis (L: p<0.004, V: p=0.003) occurred in the older cohort, with reduced impedance-based clearance for both bolus consistencies (L: p<0.05, V: p<0.001). Decreased peristaltic vigor (distal contractile integral <450mmHg/s/cm) was associated with reduced liquid clearance in both age groups (p<0.001) and of viscous swallows in the older group (p<0.001). Impedance ratio, a marker of bolus retention, was increased in older subjects during liquid (p=0.002) and viscous (p<0.001) swallowing. Impaired liquid and viscous bolus clearance, esophageal pressure topography, and pressure-flow changes were seen in asymptomatic older subjects.

Normal esophageal pressure topography metrics for data derived from the Sandhill‐Unisensor high‐resolution manometry assembly in supine and sitting positions

Normal values of the esophageal motor function parameters for high-resolution manometry (HRM-EPT) adopted by the Chicago classification were established using the proprietary system of Given Imaging. It is conceivable that normal values of a system do not apply to data from others. Most studies using HRM were based on supine swallows, whereas deglutition occurs mostly in the upright position. We wished to establish normal values for HRM-EPT parameters obtained with the Sandhill's HRM-EPT system and compare the results in supine and sitting positions. Sixty-nine healthy volunteers, 38 females, median age 27years, were included in this study. All underwent supine HRM, and 34 of them underwent sitting HRM, with at least 10 single 5-mL swallows for analysis obtained in each position. The normal range (5-95th percentiles) for the following parameters was calculated: distal contractile integral (DCI), 606-4998mmHg·s·cm; contractile front velocity (CFV), 2.0-6.5cm/s; distal latency (DL), 5.1-8.8s; intrabolus pressure (IBP), 1.9-17.6mmHg; upper esophageal sphincter (UES) pressure, 45.2-186.9mmHg; esophagogastric junction (EGJ) length, 1.8-4cm; EGJ resting pressure, 8.1-61.6mmHg, and integrated relaxation pressure (IRP) 2.5-23.5mmHg. Normal values of EGJ resting pressure, IRP, DCI, and IBP but not CFV, DL, and UES resting pressure were significantly lower in the sitting posture. Studies performed with Sandhill's HRM-EPT system should use its own specific normal data. Normal values should be established for different study.

Esophageal hypomotility and spastic motor disorders: current diagnosis and treatment.

Esophageal hypomotility (EH) is characterized by abnormal esophageal peristalsis, either from a reduction or absence of contractions, whereas spastic motor disorders (SMD) are characterized by an increase in the vigor and/or propagation velocity of esophageal body contractions. Their pathophysiology is not clearly known. The reduced excitation of the smooth muscle contraction mediated by cholinergic neurons and the impairment of inhibitory ganglion neuronal function mediated by nitric oxide are likely mechanisms of the peristaltic abnormalities seen in EH and SMD, respectively. Dysphagia and chest pain are the most frequent clinical manifestations for both of these dysfunctions, and gastroesophageal reflux disease (GERD) is commonly associated with these motor disorders. The introduction of high-resolution manometry (HRM) and esophageal pressure topography (EPT) has significantly enhanced the ability to diagnose EH and SMD. Novel EPT metrics in particular the development of the Chicago Classification of esophageal motor disorders has enabled improved characterization of these abnormalities. The first step in the management of EH and SMD is to treat GERD, especially when esophageal testing shows pathologic reflux. Smooth muscle relaxants (nitrates, calcium channel blockers, 5-phosphodiesterase inhibitors) and pain modulators may be useful in the management of dysphagia or pain in SMD. Endoscopic Botox injection and pneumatic dilation are the second-line therapies. Extended myotomy of the esophageal body or peroral endoscopic myotomy (POEM) may be considered in highly selected cases but lack evidence.

Tu1207 Normative Esophageal Pressure Topography Metrics for Data Derived From the Sandhill High Resolution Manometry Assembly

Tu1207 Normative Esophageal Pressure Topography Metrics for Data Derived From the Sandhill High Resolution Manometry Assembly

Presentation, Diagnosis, and Management of Achalasia

Presentation, Diagnosis, and Management of Achalasia

Exam 2: A Comparison of Symptom Severity and Bolus Retention With Chicago Classification Esophageal Pressure Topography Metrics in Patients With Achalasia

Exam 2: A Comparison of Symptom Severity and Bolus Retention With Chicago Classification Esophageal Pressure Topography Metrics in Patients With Achalasia

A Comparison of Symptom Severity and Bolus Retention With Chicago Classification Esophageal Pressure Topography Metrics in Patients With Achalasia

We compared findings from timed barium esophagrams (TBEs) and esophageal pressure topography studies among achalasia subtypes and in relation to symptom severity. We analyzed data from 50 patients with achalasia (31 men; age, 20-79 y) who underwent high-resolution manometry (HRM), had TBE after a 200-mL barium swallow, and completed questionnaires that determined Eckardt Scores. Twenty-five patients were not treated, and 25 patients were treated (11 by pneumatic dilation, 14 by myotomy). Nonparametric testing was used to assess differences among groups of treated patients (10 had type 1 achalasia and 15 had type 2 achalasia), and the Pearson correlation was used to assess their relationship. There were no significant differences in TBE measurements between patient groups. Of the 25 patients who received treatment, 10 had a manometric pattern consistent with persistent achalasia after treatment (6 patients with type 1 and 4 patients with type 2 achalasia), whereas 15 appeared to have resolved the achalasia pattern (peristalsis was absent in 8 patients and weak in 7 patients). The height of the barium column at 5 minutes and Eckardt Scores were reduced significantly in patients who had resolved their achalasia pattern, based on HRM. The integrated relaxation pressure and the TBE column height correlated at 5 minutes (r = 0.422; P < .05). Patients who resolved their achalasia pattern, based on HRM, showed improved emptying based on TBE measurements and improved symptom scores. There was no significant difference between patients with type 1 or type 2 achalasia in TBEs. These findings indicate that normalization of the integrated relaxation pressure on HRM is a clinically relevant objective of treatment for achalasia.

The effect of a sitting vs supine posture on normative esophageal pressure topography metrics and Chicago Classification diagnosis of esophageal motility disorders

Although, the current protocol for high resolution manometry (HRM) using the Chicago Classification is based on the supine posture, some practitioners prefer a sitting posture. Our aims were to establish normative esophageal pressure topography data for the sitting position and to determine the effect of applying those norms to Chicago Classification diagnoses. Esophageal pressure topography studies including test swallows in both a supine and sitting position of 75 healthy volunteers and 120 patients were reviewed. Integrated relaxation pressure (IRP), distal contractile integral (DCI), contractile front velocity (CFV), and distal latency were measured and compared between postures. Normative ranges were established from the healthy volunteers and the effect of applying sitting normative values to the patients was analyzed. Normative values of IRP, DCI, and CFV all decreased significantly in the sitting posture. Applying normative sitting metrics to patient studies [27% reduction in IRP (15 to 11 mmHg), 69% reduction in DCI (8000-2500 mmHg-s-cm)] reclassified 13/120 (11%) patients as having abnormal esophagogastric junction relaxation and 26/120 (22%) as hypercontractile. Three patients with an abnormal supine IRP normalized when sitting with elimination of a vascular artifact. Clinical HRM studies should include both a supine and sitting position to minimize misdiagnoses attributable to anatomical factors. However, until outcome studies demonstrating the significance of isolated abnormalities of IRP or DCI in the sitting position are available, the Chicago Classification of esophageal motility disorders should continue to be based on supine swallows using normative data from the supine posture.