Esophageal Pressure Topography Research Articles

Pre- and post-intervention oesophageal pressure topography metrics in the three subtypes of achalasia: A pilot study on Indian adults

BackgroundAchalasia is characterized by failure of relaxation of the lower oesophageal sphincter (LOS) and abnormal peristalsis during swallowing. The study aimed to observe the effects of intervention in three sub-types of achalasia and compare the intervention outcomes among the three sub-types. MethodsForty-one patients underwent Eckardt scoring for severity of achalasia, followed by high-resolution manometry (HRM). After three and six months of intervention (pneumatic dilatation or 'Heller's Cardiomyotomy), Eckardt scoring and HRM were repeated and compared with the initial results. ResultsOut of the 41 patients, 13 were diagnosed with type I achalasia (31.71%), 18 with type II (43.90%), and 10 with type III (24.39%). Significant differences between the pre- and post-intervention values of median integrated relaxation pressure (IRP) and Eckardt score were found in all three sub-types. Although the beneficial effect of intervention lasted up to six months postintervention, it was less than three months postintervention values. The intervention success rates were highest for both laparoscopic Heller's myotomy (LHM) and pneumatic dilatation (PD) in Type II Achalasia at three and six months postintervention, respectively. ConclusionOne-time intervention is effective in all three sub-types. This benefit tends to taper over time but remains significant after six months of intervention. Type II Achalasia shows the best intervention outcomes compared to the other two sub-types at three months and six months post-intervention. Type III Achalasia shows the least response compared to other sub-types and is the poorest responder to intervention. The benefit of one-time intervention also deteriorates most in type III achalasia at the end of six months.

Identification of Sliding Hiatus Hernia by High-Resolution Manometry and Upper Gastrointestinal Endoscopy in Patients with Gastro-Oesophageal Reflux Disease

The aim of this study was to compare high-resolution manometry (HRM) and upper gastrointestinal (GI) endoscopy as diagnostic utilities in detecting a sliding hiatus hernia in patients with gastro-oesophageal reflux disease (GORD) symptoms. For both diagnostic modalities, the data obtained from 31 patients (20 females; mean age 48.2) who qualified for Nissen fundoplication were analysed using oesophageal pressure topography in line with the Chicago Classification. Confirmation of hiatus hernia during the surgery was considered the gold standard. HRM protocol involved 10 consecutive boluses of 10 mL of water. Sliding hiatus hernia was confirmed intraoperatively in 29 out of 31 patients. In 14 patients, hiatus hernia was detected in HRM, while 19 patients were found to have hiatus hernia by upper GI endoscopy before surgery. No false positive results were obtained in HRM, while 15 false negative results were shown. In upper GI endoscopy, false positive data were observed in 1 patient, while false negative results were found in 10 patients. Thus, the sensitivity of HRM in detecting hiatus hernia was 48% (95%CIs: 29-67%), and sensitivity of upper GI endoscopy was 66% (95%CIs: 46-82%). It was not possible to assess the specificity of HRM or upper GI endoscopy because only 2 of 31 patients had no hiatus hernia during fundoplication (gold standard). False negative results (sensitivity) were not significantly different between compared diagnostic modalities HRM and upper GI endoscopy (52% vs. 34%, respectively, p = 0.29). Due to poor sensitivity, both modalities, i.e., HRM and upper GI endoscopy, are not reliable tools to diagnose sliding hiatus hernia in patients with GORD symptoms.

Esophageal Bolus Domain Pressure and Peristalsis Associated With Experimental Induction of Esophagogastric Junction Outflow Obstruction.

Background/AimsIntrabolus pressures are important for esophageal bolus transport and may detect obstructed bolus flow. This study measured the effect esophageal outflow obstruction experimentally induce by a leg-lift protocol.MethodsTwenty-five gastroesophageal reflux disease patients referred for esophageal manometry and a normal motility diagnosis were included. Supine liquid swallows were tested. Leg-lift protocol generated esophageal outflow obstruction by increasing abdominal pressure. Esophageal pressure topography and intrabolus pressure metrics were calculated. These included, (1) mid-domain bolus distension pressure during esophageal emptying (DPE, mmHg) and (2) ramp pressure (mmHg/sec), generated by compression of the bolus between the peristaltic contraction and esophagogastric junction (EGJ).ResultsEGJ relaxation pressure was increased by leg-lift from 13 (11-17) to 19 (14-30) mmHg (P < 0.005) and distal contractile integral also increased from 1077 (883-1349) to 1620 (1268-2072) mmHg∙cm∙sec (P < 0.001) as a physiological response to obstruction. All bolus pressures were increased by leg lift; DPE increased from 17 (15-20) to 27 (19-32) mmHg (P < 0.001), and ramp pressure increased from 3 (1-4) to 5 (2-9) mmHg/sec (P < 0.05).ConclusionMeasuring pressures within the intrabolus domain can quantify changes related to obstruction to outflow and may serve as adjunct measures for confirming a diagnosis EGJ outflow obstruction.

S0430 The Effect of Hiatal Hernia on High-Resolution Esophageal Pressure Topography Measures in Patients With Esophagogastric Junction Outflow Obstruction

INTRODUCTION: High resolution esophageal pressure topography (HREPT) is used to diagnose esophagogastric junction outflow obstruction (EGJOO), a motility disorder with impairment of lower esophageal sphincter (LES) opening defined by an elevated integrated relaxation pressure (IRP) with preserved peristalsis. Many of these patients also have concomitant hiatal hernia (HH) that may independently affect LES relaxation pressures. This study aimed to evaluate the effect of HH on the diagnosis of EGJOO by comparing manometric outcomes at a single US tertiary care academic medical center. METHODS: This retrospective, observational, cohort study identified patients who had undergone HREPT between January 2017 and March 2018. Patients diagnosed with EGJOO were eligible for inclusion and further evaluated for HH via manometry. Those with obstructive dysphagia, pseudo-achalasia, or other neuromuscular disorders affecting esophageal motility were excluded. LES integrated relaxation pressures (IRP), basal pressure (BP), distal contractile integral (DCI), intrabolus pressure (IBP), and incomplete bolus transit (IBT) were collected. Student’s t- tests were used to compare groups and Chi-square analysis was used for independent variables. RESULTS: A total of 90 total patients were identified (n = 54 EGJOO without HH, n = 36 EGJOO with HH). In general, baseline characteristics were similar between groups with no significant differences in gender or age. Comparing patients with only EGJOO to those with both EGJOO and HH, there was a statistically significant difference in basal LES pressures (50.9 mmHg vs. 42.2 mmHg, P = 0.029) but no difference in IRP (22.5 mmHg vs. 20.3 mmHg, P = 0.173) between groups. Additionally there were no intergroup differences in DCI, IBP, or IBT. CONCLUSION: EGJOO is a heterogenous manometric diagnosis with many patients also experiencing anatomic defects including HH. Our study reports among the largest real-world comparisons of these groups. The observed higher basal LES pressures in patients with only EGJOO compared to those with both EGJOO and HH suggests a possible anatomic effect on LES pressures. However, this difference does not have affect other manometric measures including IRP which is currently the principal measure of outflow obstruction. Further work exploring the anatomic and physiologic components of LES pressure is needed to understand the development of EGJOO and guide therapeutic interventions.Table 1.: Outcomes

High-resolution manometry in the upright position could improve the manometric evaluation of morbidly obese patients with esophagogastric junction outflow obstruction.

Esophagogastric junction outflow obstruction (EGJOO) detected by manometry in the supine position is prevalent in patients with morbid obesity, but not all EGJOOs are clinically significant. We investigated whether including upright swallows during high-resolution manometry (HRM) could help identify non-clinically significant EGJOO in patients with morbid obesity. We performed a retrospective study of consecutive morbidly obese patients diagnosed with EGJOO by HRM from July 2012 through July 2018. The HRM protocol included 10 supine and five upright 5-mL water swallows. Endoscopy, esophagram, and computed tomography were performed to identify whether the patients should be diagnosed as having clinically significant EGJOO. A total of 230 patients with morbid obesity underwent HRM in the supine position during the study period. Fifty (21.7%) patients were diagnosed with EGJOO, among which 32 completed HRM both in the supine and upright positions. Only 8/32 patients were diagnosed with EGJOO in an upright position. Fewer artifacts were displayed in esophageal pressure topography in the upright position. None of the 32 patients could be diagnosed as clinically significant EGJOO based on all the examinations. Median esophageal gastric junction pressure, integrated relaxation pressure, and distal contractile integral were higher, and median distal latency was longer in the supine position compared with the upright position (all P<.05). Esophagus manometry in the upright position could reduce EGJOO overdiagnosis in patients with morbid obesity. Prolongation of the HRM study with some swallows in the upright position could be recommended in obese patients.

Sa1321 VALUE OF ENDOSCOPY ULTRASONOGRAPHY IN THE TREATMENT OF DIFFUSE ESOPHAGEAL SPASM WITH PERORAL ENDOSCOPIC MYOTOMY

Diffuse esophageal spasm (DES) is a rare esophageal motility disorder of normal amplitude and accompanied by dysphagia. It is characterized by simultaneous, uncoordinated or rapidly propagated contractions. The etiology of DES is unknown. There are various theories proposed. Muscular hypertrophy or hyperplasia is present in the distal part of the esophagus comprising almost two-thirds of the esophagus in DES. High-resolution manometry (HRM) and esophageal pressure topography (EPT) is valuable for the diagnosis .These also be used to determine the length of myotomy preoperatively which is not very exact. Now, extended myotomy of the esophageal body or peroral endoscopic myotomy(POEM) is accepted to treat DES. How to determine the entire length of myotomy is important which needs including all the affected segment and extend several centimeters superior to the proximal border of the spastic region to prevent remnants of spasticity. Using high resolution 20 MHz small ultrasonic probe to detect the thickness of esophageal muscle layer from the upper and lower parts of the obvious spasm ring under endoscope. Recording the beginning position and region where the thickness of myometrium thickening. The thickness is obviously thicker than normal esophageal. The length of thickening region is different. The length of myotomy is determined preoperatively with ultrosound. Using a electric knife to cut the circular muscle from the begining of thickness to 2 centimeters below the cardia. The thickness of muscle layer is segmental thickening while common esopheal only 3 millimeters,The length of myotomy is different from 10 to 17centimeters. So,Using endoscopy ultrasonography to judge both the initial position and length of myotomy is valuable. And this can accelerate the accuracy of POEM procedure.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Maturation of Esophageal Motility and Esophagogastric Junction in Preterm Infants

Background: Preterm infants commonly present with oral feeding problems. The role of maturation of esophageal bolus transport mechanisms herein remains unclear. Objectives: To characterize esophageal motility and function of esophagogastric junction (EGJ) during deglutitive swallowing in healthy preterm infants and to describe maturational changes. Methods: Four consecutive high-resolution manometry studies with impedance studies were performed weekly to investigate esophageal motility and EGJ function. Esophageal pressure topography and pressure-impedance metrics were derived. Mixed models with repeated measures were used for statistical analysis. Results: We analyzed 137 nutritive swallows from 36 motility studies in 10 preterm infants. The mean gestational age was 30.17 ± 0.94 weeks; the mean postmenstrual age at time point 1 and 4 was 34.42 ± 0.86 and 37.45 ± 1.16 weeks, respectively. Esophageal peristaltic wave patterns in response to nutritive swallows were observed in all patients. At later time points, esophageal body peristalsis became more rapid, evidenced by a faster distal contractile velocity and shorter distal latency (p = 0.002 and p < 0.0001, respectively). In addition, 4-s integrated relaxation pressures increased and distal contractile integral decreased at later time points (p = 0.003 and p = 0.021, respectively). Bolus clearance also improved at later age (p = 0.008). Conclusions: Preterm infants demonstrate peristaltic esophageal motility following nutritive swallows. However, alterations in esophageal bolus transport in relation to peristalsis are demonstrated. Peristaltic progression becomes more rapid, while deglutitive relaxation pressures increase with increasing age. These maturational changes may suggest further development of the enteric nervous system after birth in former preterm neonates.

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.

Characterization of Esophageal Motility in Infants With Congenital Diaphragmatic Hernia Using High‐resolution Manometry

The aim of the study was to characterize esophageal motility and esophagogastric junction (EGJ) function in infants who underwent repair of an isolated congenital diaphragmatic hernia (iCDH). High-resolution manometry with impedance was used to investigate esophageal motility and EGJ function after diaphragmatic repair in 12 infants with iCDH (11 left-sided; 9 patch repair). They had esophageal motility studies during neonatal admission (n = 12), at 6 months (n = 10) and at 12 months of life (n = 7). Swallows were analyzed using conventional esophageal pressure topography and pressure flow analysis and were compared with 11 healthy preterm born infants at near-term age. Esophageal peristaltic motor patterns in patients with iCDH were comparable to controls. EGJ end-expiratory pressure was higher in patients with patch repair compared with controls (P = 0.050) and those without patch (P = 0.009). The difference between inspiratory and expiratory pressures at the EGJ was lower in patients with iCDH with patch (P = 0.045) compared to patients without. Patients with iCDH with patch showed increased Pressure Flow Index, resistance of bolus flow at the EGJ, compared with controls (P = 0.043). Normal esophageal wave patterns are present in the investigated patients with iCDH. EGJ end-expiratory pressure seems lower in patients with iCDH without patch suggesting a decreased EGJ barrier function hence increased vulnerability to gastroesophageal reflux. Patch repair appears to increase end-expiratory pressure at the EGJ above that of controls suggesting that patch surgery tightens the EGJ, thereby increasing flow resistance. This is in line with the increased Pressure Flow Index. In infants with a patch, the inspiration-expiration pressure difference is lower, reflecting diminished activity of the crural diaphragm.

DOZ047.17: Characterization of esophageal motility in children with operated esophageal atresia using high-resolution impedance manometry and pressure flow analysis

Abstract Background Esophageal dysmotility is common in patients with esophageal atresia (EA). High-resolution impedance manometry (HRIM) and pressure flow analysis (PFA) allow characterization of biomechanical bolus flow and swallow properties. The aim of this study was to characterize esophageal motility and bolus flow propulsion in children who underwent surgical EA repair. Patients and Methods HRIM was used in 14 children with EA (type C, n = 13; type A, n = 1). Study was performed at a median (range) age of 11 years (5–17). The HRIM recordings were analyzed using conventional esophageal pressure topography and PFA (AIMplot software deployed via the open access Swallow Gateway application) and were compared with 13 patient controls (median age 14 years, range 5.75–17; P = NS vs patients) who underwent HRIM considered as normal according to Chicago classification and for whom the manometry results did not lead to treatment changes. Medical charts were reviewed for medical/surgical history and symptoms were assessed by standardized questionnaires. Results Esophageal peristaltic motor patterns were abnormal in all EA patients and were subdivided in two groups: Group A with presence of distal contraction in ≥ 50% of the swallows (n = 6) and Group B with presence of distal contractions in &lt; 50% of the swallows (n = 8). IRP4s was similar in EA and controls. Bolus transport was impaired as shown by the higher impedance ratio (IR) in EA than in controls (0.47 vs 0.22, P &lt; 0.001). In Group A, proximal and distal contractile integrals were lower than in controls (P &lt; 0.001) and distal contractile velocity was shorter in EA (P &lt; 0.01). IR was lower in Group A than in Group B (P &lt; 0.01). In this sample, symptoms of dysphagia and presence of gastric metaplasia or esophagitis were not correlated with any of the measures determined. Conclusions Bolus transport as measured by impedance ratio is severely altered in EA patients but is not predictive of symptoms. The presence of residual distal contractions is associated with a more efficient bolus propulsion. Whether this is associated with a better outcome warrants further studies.

Detection of hiatal hernias: comparison of high-resolution manometry and physician reported in an obese-predominant population

BackgroundThe diagnosis of a hiatal hernia (HH) can be made by barium oesophagram or upper endoscopy. Data regarding the ability of high-resolution manometry (HRM) with oesophageal pressure topography (OPT) to...

High-Resolution Manometry Diagnosis of Ineffective Esophageal Motility Is Associated with Higher Reflux Burden.

Ineffective esophageal motility (IEM) is the most commonly diagnosed abnormality on high-resolution manometry (HRM). However, the clinical significance of IEM and associated reflux burden remains unclear. Our primary aim was to compare reflux patterns between IEM versus normal motility on HRM. HRM and reflux studies in patients with IEM and normal motility were retrospectively reviewed. Esophageal pressure topography parameters, reflux variables, and patient-reported outcome questionnaires were explored. A total of 239 patients with IEM were explored. Of these, 146 underwent reflux monitoring. Additionally, 100 patients with normal HRM all of whom had undergone reflux monitoring were included. IEM patients were more likely to have an abnormal number of reflux events compared to normal (22.7% vs. 9.0%, p < 0.01). Including only off-proton pump inhibitor (PPI) testing, IEM patients had higher mean total acid exposure time (AET) and total reflux events compared to normal motility (p = 0.02). Within IEM patients, higher AET modestly correlated with increased percentage of impaired swallows. Increased reflux events modestly correlated with higher impaired swallows and decreased lower esophageal sphincter (LES) resting pressure. Reflux burden increased with higher esophagogastric junction (EGJ) subtype, driven mostly by subtype III, although there was no difference in the distribution of EGJ subtypes between the IEM and normal HRM cohorts. Patients with HRM diagnosis of IEM may be more prone to acid reflux while off-PPI and non-acid reflux while on-PPI. Reflux burden appears to be worse in IEM patients who have lower resting LES pressure, higher EGJ subtype, or higher percentage of impaired swallows.

New Developments in Esophageal Motility Testing

The purpose of this review is to present the latest developments in esophageal motility testing and summarize the current paradigm of esophageal motility disorders. While high-resolution esophageal pressure topography interpreted according to the Chicago Classification represents the gold standard to evaluate esophageal motility, recent studies highlight the additional value of novel manometric applications. Novel applications include provocative measures to assess for obstructive physiology at the esophagogastric junction (EGJ), esophageal peristaltic reserve, and rumination and supragastric belching disorders. Furthermore, high-resolution impedance manometry provides assessment of bolus flow in relation to pressure changes. Distinct from manometry, the endolumenal functional lumen imaging probe examines esophageal motor response to distension to provide complementary and alternative data with regard to EGJ function and esophageal body motor function. Barium esophagram with timed swallow and barium tablet continues to be an important esophageal motility test. Furthermore, current use of multichannel intraluminal impedance-pH monitoring extends beyond reflux monitoring to measure reflux clearance and esophageal epithelial integrity. The diagnostic armamentarium for esophageal motility disorders has expanded tremendously to include a multitude of sophisticated tools. Advancements in diagnostic technology and understanding of esophageal physiology have shifted the field to more precisely characterize esophageal motility and guide phenotype-driven management.

In ineffective esophageal motility, failed swallows are more functionally relevant than weak swallows.

Esophageal pressure topography (EPT) diagnosis of ineffective esophageal motility (IEM) can be non-specific with unclear clinical significance. To determine whether peristaltic vigor or lower esophageal sphincter (LES) integrity is associated with poor clearance and acid reflux in IEM. Bolus clearance on high-resolution impedance manometry (HRIM) and available reflux studies in patients with IEM were retrospectively reviewed. Bolus clearance was assessed using both line tracing and colored contour methods on HRIM. EPT parameters, bolus clearance, and acid reflux variables were explored. Eighty-eight patients with IEM were included. Bolus clearance occurred in 71% of all swallows, and 55.7% of patients had complete bolus transit (CBT, bolus clearance in ≥80% of swallows). Bolus clearance was impaired in swallows with distal contractile integral (DCI) <100mmHg•cm•s compared to DCI 100-450 (0.43 vs 0.79, P<.0001). A cutoff at DCI 100mmHg•cm•s was associated with clearance with an accuracy of 76% compared to 49% at DCI 450 (P=.0001 for both). A median DCI <100 was associated with a higher Eckardt score (9 vs 3, P=.03), and on reflux testing available in 47 patients, with abnormal acid exposure time (P=.002). Peristaltic reserve (PR) defined as (DCI of multiple rapid swallow/median DCI of wet swallows), integrated relaxation pressure, and resting lower esophageal sphincter pressure were not associated with clearance or acid exposure. Failed peristalsis, as defined by DCI <100mmHg•cm•s, is associated with impaired bolus clearance and more severe dysphagia in IEM, and likely abnormal acid exposure.

Gastroesophageal flap valve reflected EGJ morphology and correlated to acid reflux

ObjectiveThe anatomy of esophagogastric junction (EGJ) serves as the anti-reflux barrier. The gastroesophageal flap valve (GEFV) is a component of EGJ. The aim of the current study was to assess its correlation with the esophageal acid exposure and the impact on anti-reflux barrier function by using the metrics of EGJ contraction.MethodsEighty three patients with typical GERD symptoms were included in the study. Upper endoscopy, high-resolution manometry (HRM) and 24 h multichannel intraluminal impedance-pH (MII-pH) monitoring were performed in all patients. GEFV was determined as four grades during endoscopic examination based on the Hill classification. The esophageal pressure topography (EPT) metrics defined in the updated Chicago Classification were measured by HRM, including integrated relaxation pressure (IRP), EGJ contractile index (EGJ-CI),expiratory EGJ pressure(EGJP-exp) and inspiratory EGJ pressure (EGJP-insp).ResultsThe GEFV grade III and IV was more commonly found in patients with esophagitits (p < 0.05). The acid exposure time (AET%) and supine AET% were lower in patients with GEFV grade I (p < 0.01). There was weak correlation between AET% and GEFV grades (r = 0.27, p = 0.013). There were more EGJ morphology type III in patients with GEFV grade IV (p < 0.05).There were no significant differences on the values of four HRM metrics among the patients with different GEFV grades (p > 0.05).ConclusionThe GEFV grades were associated with acid reflux positively and could be a good reflection of EGJ morphology in HRM. But it had no impact on the four HRM metrics. Our research revealed that GEFV may play an assistant role in the anti-reflux barrier.

Physiological augmentation of esophageal distension pressure and peristalsis during conditions of increased esophageal emptying resistance.

Abdominal compression has been implemented as a provocative maneuver in high-resolution impedance manometry (HRIM) to "challenge" normal esophageal physiology with the aim of revealing abnormal motor patterns which may explain symptoms. In this study, we measured the effects of abdominal compression on esophageal functioning utilizing novel pressure-impedance parameters and attempted to identify differences between healthy controls and globus patients. Twenty-two healthy volunteers (aged 23-32years, 41% female) and 22 globus patients (aged 23-72years, 68% female) were evaluated with HRIM using a 3.2-mm water perfused manometric and impedance catheter. All participants received 10×5mL liquid swallows; healthy controls also received 10×5mL liquid swallows with abdominal compression created using an inflatable cuff. All swallows were analyzed to assess esophageal pressure topography (EPT) and pressure-flow metrics, indicative of distension pressure, flow timing and bolus clearance were derived. The effect of abdominal compression was shown as a greater contractile vigor of the distal esophagus by EPT and higher distension pressure based on pressure-flow metrics. Age and body mass index also increased contractile vigor and distension pressure. Globus patients were similar to controls. Intrabolus pressure and contractile vigor are indicative of the physiological modulation of bolus transport mechanisms. Provocative testing by abdominal compression induces changes in these esophageal bolus dynamics.

Effects of remifentanil on esophageal and esophagogastric junction (EGJ) bolus transit in healthy volunteers using novel pressure-flow analysis.

Remifentanil is associated with subjective dysphagia and an objective increase in aspiration risk. Studies of opioid effects have shown decreased lower esophageal sphincter relaxation. We assessed bolus transit through the esophagus and esophagogastric junction (EGJ) during remifentanil administration using objective pressure-flow analysis. Data from 11 healthy young participants (23±3years, 7M) were assessed for bolus flow through the esophagus and EGJ using high-resolution impedance manometry (Manoscan™, Sierra Scientific Instruments, Inc., LES Angeles, CA, USA) with 36 pressure and 18 impedance segments. Data were analyzed for esophageal pressure topography and pressure-flow analysis using custom Matlab analyses (Mathworks, Natick, USA). Paired t tests were performed with a P-value of <.05 regarded as significant. Duration of bolus flow through (remifentanil/R 3.0±0.3 vs baseline/B 5.0±0.4seconds; P<.001) and presence at the EGJ (R 5.1±0.5 vs B 7.1±0.5seconds; P=.001) both decreased during remifentanil administration. Distal latency (R 5.2±0.4 vs B 7.5±0.2seconds; P<.001) and distal esophageal distension-contraction latency (R 3.5±0.1 vs B 4.7±0.2seconds; P<.001) were both reduced. Intrabolus pressures were increased in both the proximal (R 5.3±0.9 vs B 2.6±1.3mmHg; P=.01) and distal esophagus (R 8.6±1.7 vs B 3.1±0.8mmHg; P=.001). There was no evidence of increased esophageal bolus residue. Remifentanil-induced effects were different for proximal and distal esophagus, with a reduced time for trans-sphincteric bolus flow at the EGJ, suggestive of central and peripheral μ-opioid agonism. There were no functional consequences in healthy subjects.

High-resolution esophageal manometry: interpretation in clinical practice.

Esophageal high-resolution manometry (HRM) is the current state-of-the-art diagnostic tool to evaluate esophageal motility patterns and, as such, is widely adopted in clinical practice. This article will review the interpretation of esophageal HRM in clinical practice. HRM uses a high-resolution catheter to transmit intraluminal pressure data that are subsequently converted into dynamic esophageal pressure topography (EPT) plots. Metric data from EPT plots are synthesized to yield an esophageal motility diagnosis according to the Chicago Classification, a formal analytic scheme for esophageal motility disorders, which is currently in version 3.0. The standard HRM protocol consists of a baseline phase and a series of 10 wet swallows in the supine or reclined position. In addition, data from swallows in the seated position and provocative HRM maneuvers provide useful information about motility properties. Combined high-resolution impedance technology is also clinically available and enables concurrent assessment of bolus transit and postprandial responses. Finally, there is ongoing interest to optimize the training and competency assessment for interpretation of HRM in clinical practice. Esophageal HRM is a valuable and sophisticated clinical tool to evaluate esophageal motility patterns. Emerging clinical applications of esophageal HRM include combined impedance technology, provocative maneuvers, and postprandial evaluation.

Assessing the pre- and postpeak phases in a swallow using esophageal pressure topography.

The current paradigm of measuring esophageal contractile vigor assesses the entirety of a pressure wave using a single measurement, the distal contractile integral (DCI). We hypothesize that an assessment identifying separate phases of the contractile pressure wave before and after the pressure peak may help distinguish abnormalities in patients presenting with chest pain and dysphagia. The aim of the present study was to develop a technique to assess the individual phases and report on the values in healthy controls. Seventy-one healthy controls were enrolled. High-resolution manometry studies of five intact liquid swallows in both supine and upright positions were analyzed using a customized MATLAB program to divide swallows into a prepeak phase and postpeak phase, and compute the contractile integral of both phases. The contractile integrals were also controlled by duration over each phase. The composite DCI measurement in healthy controls appears to be weighted toward slightly higher contractile activity during postpeak phase based on postpeak to prepeak ratios in both the supine and upright position (1.50 and 1.49, respectively). The contribution of postpeak phase on the composite DCI was weakened when controlled by time (0.92 and 0.96 in both supine and upright position, respectively). We developed a novel measurement focused on separating the prepeak and postpeak components of the peristaltic contractile activity during swallowing. Using this technique, it appears that overall contractile activity is higher during postpeak phase and this is related to the longer time component during this phase.

Sa1662 - In Ineffective Esophageal Motility, Failed Swallows are More Functionally Relevant than Weak Swallows

BACKGROUND Esophageal pressure topography (EPT) diagnosis of ineffective esophageal motility (IEM) can be non-specific with unclear clinical significance. AIMS To determine whether peristaltic vigor or lower esophageal sphincter (LES) integrity is associated with poor clearance and acid reflux in IEM. METHODS Bolus clearance on high-resolution impedance manometry (HRIM) and available reflux studies in patients with IEM were retrospectively reviewed. Bolus clearance was assessed using both line tracing and colored contour methods on HRIM. EPT parameters, bolus clearance, and acid reflux variables were explored. KEY RESULTS Eighty-eight patients with IEM were included. Bolus clearance occurred in 71% of all swallows, and 55.7% of patients had complete bolus transit (CBT, bolus clearance in ≥80% of swallows). Bolus clearance was impaired in swallows with distal contractile integral (DCI) <100 mmHg•cm•s compared to DCI 100-450 (0.43 vs 0.79, P < .0001). A cutoff at DCI 100 mmHg•cm•s was associated with clearance with an accuracy of 76% compared to 49% at DCI 450 (P = .0001 for both). A median DCI <100 was associated with a higher Eckardt score (9 vs 3, P = .03), and on reflux testing available in 47 patients, with abnormal acid exposure time (P = .002). Peristaltic reserve (PR) defined as (DCI of multiple rapid swallow/median DCI of wet swallows), integrated relaxation pressure, and resting lower esophageal sphincter pressure were not associated with clearance or acid exposure. CONCLUSIONS & INFERENCES Failed peristalsis, as defined by DCI <100 mmHg•cm•s, is associated with impaired bolus clearance and more severe dysphagia in IEM, and likely abnormal acid exposure.