High Resolution Esophageal Pressure Topography Research Articles

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

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)

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.

Heterogeneity of Esophageal Motor Abnormalities in Scleroderma Patients Assessed With High Resolution Esophageal Pressure Topography

Heterogeneity of Esophageal Motor Abnormalities in Scleroderma Patients Assessed With High Resolution Esophageal Pressure Topography

The Functional Lumen Imaging Probe Detects Esophageal Contractility Not Observed With Manometry in Patients With Achalasia

The functional lumen imaging probe (FLIP) could improve the characterization of achalasia subtypes by detecting nonocclusive esophageal contractions not observed with standard manometry. We aimed to evaluate esophageal contractions during volumetric distention in patients with achalasia using FLIP topography. Fifty-one treatment-naive patients with achalasia, defined and subclassified by high-resolution esophageal pressure topography, and 10 asymptomatic individuals (controls) were evaluated with the FLIP during endoscopy. During stepwise distension, simultaneous intrabag pressures and 16 channels of cross-sectional areas were measured; data were exported to software that generated FLIP topography plots. Esophageal contractility was identified by noting periods of reduced luminal diameter. Esophageal contractions were characterized further by propagation direction, repetitiveness, and based on whether they were occluding or nonoccluding. Esophageal contractility was detected in all 10 controls: 8 of 10 had repetitive antegrade contractions and 9 of 10 had occluding contractions. Contractility was detected in 27% (4 of 15) of patients with type I achalasia and in 65% (18 of 26, including 9 with occluding contractions) of patients with type II achalasia. Contractility was detected in all 10 patients with type III achalasia; 8 of these patients had a pattern of contractility that was not observed in controls (repetitive retrograde contractions). Esophageal contractility not observed with manometry can be detected in patients with achalasia using FLIP topography. The presence and patterns of contractility detected with FLIP topography may represent variations in pathophysiology, such as mechanisms of panesophageal pressurization in patients with type II achalasia. These findings could have implications for additional subclassification to supplement prediction of the achalasia disease course.

High Resolution Esophageal Pressure Topography (HREPT) in Asymptomatic Volunteers. A Comparative Study Between Solid-state and Water-perfused Systems

Background and Aim: a) HREPT is the most accurate technique for identifying esophageal motility disorders (EMD). Results: Twenty HV were included, 14 women, mean age 34 (24-55) years. The pressures in the UES and LES pressures, IRP are lower with the perfusion system (p 0.0064, 0.008 and 0.0061, respectively) and have a faster peristalsis registration with the solid system, (DL p 0.0002). With the CC 2012, the solid state system presented a higher frequency of volunteers with hypotensive peristalsis (p 0.0143).

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.

Association of Mayo Dysphagia Questionnaire 30-Day Scores to the Chicago Classification Diagnosis of Weak Peristalsis

Introduction: The Chicago classification of esophageal motility helps facilitate the interpretation of high resolution esophageal pressure topography studies. One unique feature of this classification is a hierarchical organization of motor disorders into those never encountered in normal individuals and those that lie outside of statistical norms. The latter group of disorders, including weak peristalsis, has less clear clinical significance and may even be present in normal subjects. The purpose of our study was to evaluate the association between weak peristalsis and the symptom of dysphagia via the Mayo Dysphagia Questionnaire-30 Day (MDQ-30) given the uncertain clinical significance of these peristaltic breaks. Methods: Consecutive patients presenting to our motility lab from May 2013 to March 2014 to receive high resolution esophageal manometry for any indication were asked to complete the MDQ-30, a tool used to reliably evaluate dysphagia symptoms over the last 30 days. A total of 100 patients completed both questionnaire and manometry. Each patient was assigned a dysphagia score based on their response to selected questions involving the symptom of dysphagia. Fisher’s exact test was used to evaluate statistical significance between the dysphagia score and the manometric diagnosis of weak peristalsis, with the level of statistical significance set at a P value of less than .05. Results: 38/100 patients met the Chicago classification definition of weak peristalsis with either large or small breaks. Out of these patients, 55% (21/38) had weak peristalsis with small breaks, 37% (14/38) had weak peristalsis with large breaks, and 8% (3/38) had both small and large peristaltic breaks. Using a cut off dysphagia score of 25 obtained from prior studies using this questionnaire, we found no statistically significant association between the symptom of dysphagia and the finding of weak peristalsis (small, large or mixed breaks) on esophageal manometry (Fisher’s exact test, p-value= 0.27). There was a slightly higher percentage of patients with normal esophageal motility compared to weak peristalsis (43% vs 39% respectively, p=0.79) who had “dysphagia” as the indication for undergoing manometry. Conclusion: Weak peristalsis is a common diagnosis encountered during the evaluation of patients receiving esophageal manometry. Our goal was to attempt to clarify the clinical significance of this diagnosis. When comparing MDQ-30 dysphagia scores to a diagnosis of weak peristalsis on high resolution esophageal pressure topography, we find no statistically significant association between weak peristalsis (large and/or small peristaltic breaks) and the symptom of dysphagia.

Management strategies for achalasia.

Treatment options for achalasia include oral pharmacologic therapy, endoscopic injection of botulinum toxin, pneumatic dilation, and myotomy (conventionally by laparoscopy, but more recently by an endoscopic approach). Oral pharmacologic agents have fallen out of use because of insufficient efficacy and frequent side effects. Endoscopic injection of botulinum toxin is safe and has good short-term effectiveness, but as the effect invariably wears off after a few months, this treatment is reserved for patients who are not candidates for more definitive treatments. Pneumatic dilation and surgical myotomy are currently considered the most effective treatments, with similar effectiveness in randomized controlled trials with follow-up of up to 2 years. The risk/benefit ratio and choice of therapy depend on patient characteristics (age, comorbidities, disease stage, prior treatments), patient's preference, and locally available expertise. Treatment of patients who fail or relapse after initial therapy is challenging and the success rate of pneumatic dilation or myotomy in this group is lower compared with previously untreated patients. The recently developed peroral endoscopic approach to myotomy has achieved excellent results in early uncontrolled studies, but high-quality randomized trials are needed to ensure widespread adoption is reasonable. Finally, retrospective data suggest that achalasia subtypes as defined by high-resolution esophageal pressure topography may guide treatment choice, but confirmation in prospective outcome studies is awaited.

Tu1986 Association of Mayo Dysphagia Questionnaire-30 Day Scores to the Chicago Classification Diagnosis of Esophagogastric Junction (EGJ) Outflow Obstruction

Background: The Chicago classification of esophageal motility was developed to facilitate the interpretation of high resolution esophageal pressure topography studies. A notable feature is the hierarchical organization of esophageal motor disorders into those never encountered in normal individuals (e.g. EGJ outflow obstruction) and those that lie outside of statistical norms. Given the frequency with which we detect EGJ outflow obstruction on high resolution manometry, we sought to evaluate the strength of association between manometrically defined EGJ outflow obstruction and the symptom of dysphagia via the Mayo Dysphagia Questionnaire-30 Day (MDQ-30). Methods: All patients presenting to our motility lab from May 2013 to November 2013 to receive high resolution esophageal manometry for any indication were asked to complete the MDQ-30. In total, 62 patients completed both the questionnaire and manometry. Each patient was assigned a dysphagia score based on their response to selected questions involving the symptom of dysphagia. Responses to questions assessing reflux symptoms were not included in the overall score. Given our small sample size, Fisher's exact test was used to evaluate statistical significance between the dysphagia score and the manometric diagnosis of EGJ outflow obstruction, with the level of statistical significance set at a P value of less than .05. Upper endoscopy and esophagram were reviewed in patients with a diagnosis of EJG obstruction to evaluate for underlying pathology. Results: 15 patients (24%) had EGJ outflow obstruction defined as impaired EGJ relaxation with intact peristalsis. This group had a mean MDQ-30 score of 13 whereas the mean score for those without EGJ obstruction (n=47) was 17. In both groups, 40% of patients had dysphagia as the indication for their manometry. Using a cut off dysphagia score of 25, we found no association between the symptom of dysphagia and the finding of EGJ outflow obstruction on manometry with Fisher's exact test (p-value= 1.0). The majority of patients (13/15) with EJG outflow obstruction on manometry received an EGD, EUS and/or esophagram. Of these 13 patients, only 38% were found to have pathology which was benign. These ranged from one peptic distal esophageal stricture, one esophageal ring and one fundoplication on EGD, one patient with a thickened muscularis propria on EUS, and one patient with a narrowed area in the distal esophagus not permitting passage of barium tablet on esophagram. Conclusion: Comparing MDQ-30 dysphagia scores to a diagnosis of EGJ outflow obstruction on high resolution esophageal pressure topography, we find that there is no association between the symptom of dysphagia and the finding of EGJ outflow obstruction. We also conclude that the minority of patients with EGJ outflow obstruction have evidence of pathology on endoscopy or esophagram.

Esophageal Pressure Topography, Body Position, and Hiatal Hernia

Whether body position affects lower esophageal sphincter (LES) function and detection of hiatal hernia is unknown. Moreover, the yield of high-resolution esophageal pressure topography (HREPT) when compared with endoscopy for detection of hiatal hernia is unclear. The aims of this study were to examine (a) the effects of body position (standing vs. supine) on LES function, and (b) to determine the diagnostic yield of HREPT and endoscopy for detection of hiatal hernia. A total of 50 subjects underwent both HREPT and endoscopy. The manometric/topographic changes of LES were examined in both supine and standing positions. Endoscopy assessed presence and length of hiatal hernia. Diagnostic agreement was compared between HREPT and endoscopy. The resting LES pressure was higher (P=0.0001), its mean length was longer (P=0.0003), and length of high-pressure zone was longer (P=0.0001) in the standing position compared with the supine position. HREPT detected twice as many subjects with hiatal hernia in standing (P=0.0001) compared with supine position or endoscopy with significant new diagnostic information (79%). Endoscopy detection rate (34%) was similar to supine manometry with good diagnostic agreement (77%) between HREPT and endoscopy. Hiatal hernia length was longer (P=0.0001) with HREPT in standing position compared with endoscopy. Body position significantly affects in the LES function and its measurements. HREPT when performed on standing position offers the best yield for detection of hiatal hernia and is superior to endoscopy or supine manometry.

Influence of everyday bolus consistencies in different body positions on high-resolution esophageal pressure topography (HREPT) parameters

The standard protocol for esophageal manometry involves placing the patient in the supine position with head turned to left (supine head left [SHL]) while evaluating liquid bolus swallows. Routinely, semisolid or solid boluses are not evaluated. Currently, the daily American diet includes up to 40% solid or semisolid texture. Thus far, the data on the effect of different bolus on high-resolution esophageal pressure topography (HREPT) parameters are scarce. This study aims to evaluate the effect of every day bolus consistencies in different body positions on HREPT variables. HREPT was performed on healthy volunteers with a modified protocol including liquid swallows in the SHL position followed by applesauce (semisolid), cracker (solid), and marshmallow (soft solid) in three different positions (SHL, sitting, and standing). A total of 38 healthy adult subjects (22 males and 16 females, median age = 27, and mean body mass index = 25) were evaluated. The resting upper esophageal sphincter pressure was significantly different while subjects swallowed crackers, applesauce, and marshmallows in most positions compared with liquid SHL (P < 0.05). The lower esophageal sphincter, contractile front velocity, and distal contractile integral pressures did not differ in all different consistencies compared with SHL. The integrated relaxation period was significantly higher with solid bolus compared with liquid bolus only in SHL position. The intrabolus pressure was significantly different with solid and soft solid boluses in all postures compared to liquid SHL. The American diet consistency affects upper esophageal sphincter pressure and partially integrated relaxation period and intrabolus pressure in various positions. Semisolid bolus swallows do not cause substantial pressure changes and are safe for evaluation and maintaining adequate caloric intake in patients with dysphagia who cannot tolerate solids.

Distal Esophageal Spasm: An Update

Distal esophageal spasm (DES) is an esophageal motility disorder that presents clinically with chest pain and/or dysphagia and is defined manometrically as simultaneous contractions in the distal (smooth muscle) esophagus in ≥20% of wet swallows (and amplitude contraction of ≥30 mmHg) alternating with normal peristalsis. With the introduction of high resolution esophageal pressure topography (EPT) in 2000, the definition of DES was modified. The Chicago classification proposed that the defining criteria for DES using EPT should be the presence of at least two premature contractions (distal latency<4.5 s) in a context of normal EGJ relaxation. The etiology of DES remains insufficiently understood, but evidence links nitric oxide (NO) deficiency as a culprit resulting in a disordered neural inhibition. GERD frequently coexists in DES, and its role in the pathogenesis of symptoms needs further evaluation. There is some evidence from small series that DES can progress to achalasia. Treatment remains challenging due in part to lack of randomized placebo-controlled trials. Current treatment agents include nitrates (both short and long acting), calcium-channel blockers, anticholinergic agents, 5-phosphodiesterase inhibitors, visceral analgesics (tricyclic agents or SSRI), and esophageal dilation. Acid suppression therapy is frequently used, but clinical outcome trials to support this approach are not available. Injection of botulinum toxin in the distal esophagus may be effective, but further data regarding the development of post-injection gastroesophageal reflux need to be assessed. Heller myotomy combined with fundoplication remains an alternative for the rare refractory patient. Preliminary studies suggest that the newly developed endoscopic technique of per oral endoscopic myotomy (POEM) may also be an alternative treatment modality.

Esophageal Disorders Not Yet Addressed by High-resolution Manometry

TO THE EDITOR: We greatly appreciate the insight provided by Wang et al1 regarding their recent review of the esophageal disorders not assessed by the Chicago classification of motility disorders of the esophagus. This is an important issue as many people still fail to understand that the Chicago classification was designed to describe and categorize distal esophageal motor disorders focused on dysphagia and was not meant to be a global classification across the entire spectrum of esophageal disorders. All patients undergoing manometry will have a Chicago classification diagnosis, however, there may be other motor abnormalities of the upper esophageal sphincter, proximal esophagus or esophagogastric junction and proximal stomach that may be important in the patients presenting complaints and these need to be described separately from the Chicago classification diagnosis. To utilize the Chicago classification, one has to follow specific rules and calculate specific metrics in a predefined order and the analysis is confined to an assessment during 10 supine 5 mL water swallows.2 We experienced that changing position elicited a change in diagnosis in about 10% of studies, and that provocative bolus challenges modified the diagnoses by increasing the number of patients classified with an esophagogastric junction outflow obstruction.3 However, this did require utilization of different standard values and thresholds to allow for a refined characterization and represents one aspect where the Chicago classification diagnosis can be complemented. Similarly, the Chicago classification is also restricted to assessing patients before definitive treatment and although the Chicago classification can be modified to assess patients after antireflux procedures, bariatric surgery or treatments focused on disrupting the lower esophageal sphincter in achalasia; there are no reference ranges to define what is normal in the post-operative state. Nevertheless, the Chicago classification metrics, such as the integrated relaxation pressure and intrabolus pressure pattern, can help one discern whether there is an outflow obstruction after intervention and continued abnormal peristalsis.4,5 Thus, it is likely that the metrics described in the Chicago classification can be utilized, or modified, to help define disorders outside of those that are focused on distal esophageal motor function. Moving forward, the next steps in the evolution of high resolution manometry and esophageal pressure topography should focus on describing specific disease related processes highlighted in the review published by Wang et al,1 such as disorders related to gastroesophageal reflux, upper esophageal sphincter and proximal esophageal dysfunction in dysphagia, post-prandial complaints of regurgitation/possible rumination syndrome and postoperative assessment of symptomatic patients. This will require rigorous evaluation with careful description of normal thresholds and will require outcome data. This is no easy task as the evolution of the Chicago classification to its final version took almost 5 years and it is still being refined. Initial steps in the process of categorizing esophageal motor dysfunction as it relates to gastroesophageal reflux, are currently underway. Hoshino et al6 have described new metrics of defining esophagogastric junction function as an antireflux barrier using modifications of the Chicago classification metrics and correlates of ineffective motility have been defined for esophageal pressure topography.7 Additionally, more emphasis on post-prandial assessments and provocative meals are also being studied to help elucidate mechanism of reflux that may be contributing to the patients underlying symptoms and there are new definitions for the assessment of transient lower esophageal sphincter relaxation using high resolution manometry.8,9 These are promising advances, however, we are only in the preliminary stages and although many have described motor abnormalities in the upper sphincter and post-prandial state, there is a paucity of reference data and consensus regarding terminology and definitions to help define new classifications for these disorders. Thus, the Chicago classification should be utilized as it was intended and designed with the idea that it can be complemented by an assessment of motor function that extends beyond the distal esophagus and 10 supine water swallows. We look forward to future work that may lead to a parallel classification scheme for other disorders not covered by the Chicago classification and we look forward to another great city taking over where Chicago left off.

Effects of Bolus Consistencies on Different Esophageal Variables Using High Resolution Esophageal Pressure Topography (HREPT)

Purpose: Esophageal manometry is used in evaluating patients with esophageal motility disorders. The standard protocol involves placing the patient in the supine position with head turned to left (SHL) while evaluating liquid bolus swallows. There is scarce data evaluating the effect different kind of bolus consistencies on the measured variables. We hypothesized that different bolus consistencies could affect esophageal variables measured by HREPT compared to the standard liquid bolus. Aim: To compare esophageal pressure morphologies and function during swallowing different bolus consistencies in three different positions compared to water in traditional SHL position. Methods: Healthy adult volunteers were screened using a GERD symptom assessment scale (GSAS) questionnaire. Those eligible underwent an HREPT. The probe (36 sensors, 2.75 mm in diameter, 1 cm apart) was positioned from the nasopharynx to stomach. The volunteers were placed in the following positions: supine head left (SHL), seated at a 90° angle with head facing forward, and standing with head facing forward. Each patient was given 10 standard liquid boluses in the SHL position (traditional way), 3 boluses each of applesauce (AS), crackers (CR), and marshmallow (MM). All boluses were given in the aforementioned positions. We evaluated resting upper and lower esophageal sphincter (UES and LES) pressures, integrated relaxation pressure (IRP), contractile front velocity (CFV), distal contractile integral (DCI), intrabolus pressure (IBP), and IBP-LES. Data was compared using repeated test ANOVA corrected for multiple comparison using Tukey. Results: 44 healthy volunteers (M/F: 25/19, mean age=27 years, mean BMI= 25) were evaluated. The UES pressure was significantly different while subjects swallowed solids in most positions compared to liquid SHL (p<0.05). The IRP and IBP-LES were significantly different while subjects swallowed CR compared to liquid (p<0.05). The LES, CFV, DCI, and IBP were not significantly different while the subjects swallowed solids compared to liquids in all positions (Table 1).Table: [19] Table 1. Comparison between water and solid bolus on esophageal variablesConclusion: The resting UES pressure was significantly different while subjects swallowed solid bolus in most positions compared to standard liquid SHL. The IRP was significantly different while subjects swallowed CR compared to liquid SHL, but IBP-LES was only different in the SHL compared to liquid. The LES resting pressure, CFV, DCI, and IBP were not significantly different while the subjects were swallowing solids, compared to standard liquid SHL. Different bolus consistencies and different positions can affect HRM parameters, and could have a diagnostic implication on HREPT protocols, and treatment in patients suffering from GERD and dysphagia.

A Study of Interobserver Agreement with High Resolution Esophageal Pressure Topography and Impedance Manometry

Purpose: High Resolution Esophageal Pressure Topography (HREPT) has been heralded as a advance in the study of esophageal motility. Recently, high resolution impedance and manometry (HRIM) has become available. The interobserver agreement of HRIM using waveform versus topographic impedance or the additive benefit of their combined utility is not clearly known. This study compares interobserver agreement of HRIM analysis and bolus transit assessment by conventional impedance versus analogous plots.Figure: [72] Figure. Interobserver linear correlation of hr manometric parameters.Methods: 108 swallows were randomly selected from 18 subjects (M:F= 6:12; median age=43 years) who underwent esophageal HRIM testing using a catheter equipped with 36 pressure and 18 impedance channels (Given Imaging, Yoqneam, Israel). Swallows were independently analyzed by two investigators. Distal esophageal analysis for each swallow included the following HREPT parameters: distal contractile integrals (DCI), contractile frontal velocity (CFV), integral residual pressure (IRP), and intrabolus pressure (IBP). Complete or incomplete bolus transit was assessed using waveform tracings. Contraction pattern identification via Chicago Classification and assessment of complete/incomplete bolus transit were analyzed using HRIM topographic plots. All measurements were performed separately by observers. Linear correlation of DCI, IRP, IBP, and CFV measurements were assessed using linear regression. Interobserver agreement (Kappa) was assessed for impedance via waveform and HRIM methods, as well as HRIM contraction patterns. Results: Correlation of DCI and IRP measures between observers were strong (r=0.99, r=0.95) while IBP and CFV measures revealed good correlation (r=0.63, 0.50). HRIM bolus transit, HRIM contraction pattern, and waveform bolus transit results are shown (Table).Table: [72] Table. Interobserver agreement of HR contraction patterns and bolus transitConclusion: There was good to excellent correlation between for HREPT parameters (DCI, IRP, IBP and CFV) and good correlations for HRIM contraction pattern recognition. Impedance agreement is better using topographic plots as identification of complete bolus transit is higher when interpreting topographic studies to waveform impedance. Our results suggest an incremental benefit via addition of HR impedance to HR manometry for diagnosis of esophageal dysfunction.

The Chicago criteria for esophageal motility disorders

The Chicago Classification for esophageal motility disorders was developed to complement the enhanced characterization of esophageal motility provided by high-resolution esophageal pressure topography (HREPT) as this new technology has emerged within clinical practice. This review aims to summarize the evidence supporting the evolution of the classification scheme since its inception. Studies examining the specific esophageal motility disorders in regards to HREPT metrics, clinical characteristics, and responses to treatments have facilitated updates of the diagnostic scheme and criteria. These studies have demonstrated variation in treatment responses associated with subclassification of achalasia, the use of distal latency in the diagnosis of distal esophageal spasm, and the development of diagnoses including esophagogastric junction outflow obstruction and hypercontractile esophagus. The diagnostic criteria described in the Chicago Classification have evolved to demonstrate a greater focus on distinct clinical phenotypes. Future evaluation of the natural history and treatment outcomes will assist in further refinement of this diagnostic scheme and management of esophageal motility disorders.

Sa1191 High-Resolution Esophageal Pressure Topography (HREPT) in Asymptomatic Volunteers. a Comparative Study Between Solid-State and Water-Perfused Systems

Sa1191 High-Resolution Esophageal Pressure Topography (HREPT) in Asymptomatic Volunteers. a Comparative Study Between Solid-State and Water-Perfused Systems

Sa1195 Conventional Manometry is Superior to High-Resolution Esophageal Pressure Topography in Evaluation of Weak Esophageal Peristalsis

Sa1195 Conventional Manometry is Superior to High-Resolution Esophageal Pressure Topography in Evaluation of Weak Esophageal Peristalsis

Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography1

The Chicago Classification of esophageal motility was developed to facilitate the interpretation of clinical high resolution esophageal pressure topography (EPT) studies, concurrent with the widespread adoption of this technology into clinical practice. The Chicago Classification has been an evolutionary process, molded first by published evidence pertinent to the clinical interpretation of high resolution manometry (HRM) studies and secondarily by group experience when suitable evidence is lacking. This publication summarizes the state of our knowledge as of the most recent meeting of the International High Resolution Manometry Working Group in Ascona, Switzerland in April 2011. The prior iteration of the Chicago Classification was updated through a process of literature analysis and discussion. The major changes in this document from the prior iteration are largely attributable to research studies published since the prior iteration, in many cases research conducted in response to prior deliberations of the International High Resolution Manometry Working Group. The classification now includes criteria for subtyping achalasia, EGJ outflow obstruction, motility disorders not observed in normal subjects (Distal esophageal spasm, Hypercontractile esophagus, and Absent peristalsis), and statistically defined peristaltic abnormalities (Weak peristalsis, Frequent failed peristalsis, Rapid contractions with normal latency, and Hypertensive peristalsis). The Chicago Classification is an algorithmic scheme for diagnosis of esophageal motility disorders from clinical EPT studies. Moving forward, we anticipate continuing this process with increased emphasis placed on natural history studies and outcome data based on the classification.