High-resolution Manometry Findings Research Articles

BN O05 - Physiological Transit Assessment of the Oesophagus In Patients With Anti-Reflux Surgery

Abstract Background High-resolution manometry (HRM) is the gold-standard investigation for oesophageal motility in patients with dysphagia. The HRM findings may influence surgical decision for myotomy or anti-reflux surgery (ARS). However, HRM pitfall is the inability to measure oesophageal transit in parallel to the motility during physiology testing. Both transit and motility are complementary that offer insights in the pathophysiology and aetiology of the dysphagia symptoms. This research evaluates the multichannel intraoesophageal impedance transit (MIIT) concept [1] to assess the oesophageal transit in symptomatic patients who undertook the postoperative oesophageal physiology testing between January 2020 and June 2024. Method This cross-sectional retrospective study selected patients with intact Nissen fundoplication (NF) wrap on gastroscopy or with known LINX implant in-situ. HRM with Chicago Classification (version 4.0)[2] compared the ARS cases with augmented antireflux barrier [AARB] from the surgery to healthy treatment naïve controls. The multichannel impedance-pH studies assessed both reflux and the MIIT [1]. MIIT >0.76 minutes were considered positive and comparable to GOJ outflow obstruction [1]. This project was approved by the NHS institution and the local research ethics committee (REC 18/NW/0120)(IRAS 333800). Results 60 patients were found (NF 54, LINX implant 6)(females 30, mean age 51.3 years). 11 patients(18.3%) had pathological reflux despite ARS(DeMeester scores >14.72); 2 patients (18.2%) demonstrated hypotensive AARB. Conversely, 6 patients(10%) showed poor relaxation from the AARB and were compatible to outflow obstruction (5 patients [83.3%] showed conformation with MIIT >0.76 minutes). Patients with ineffective oesophagus (20%) and absent contractility(11.7%) showed MIIT >0.76 minutes in respectively two-thirds with ineffective oesophagus and in all patients with absent contractility. Normal HRM study was observed in 35 patients (58.3%) with 27 patients (77.1%) demonstrating MIIT >0.76 minutes. Conclusion MIIT was able to explain the post-surgical dysphagia in majority of patients from the equivalent transit to outflow obstruction (n=52 patients, 86.7%). Half of these cases had a normal HRM study and would have been perceived as having functional dysphagia. We would recommend performing MIIT adjunctive testing as part of postoperative oesophageal physiology assessment in symptomatic patients. Incidentally, we observed 16 patients (26.7%) having hypotensive AARB post ARS comparing to healthy treatment naïve controls with 2 patients (12.5%) having persistent pathological reflux who may still benefit from surgical revision.

280. MANOMETRIC FINDINGS IN PATIENTS WITH GIANT HIATAL HERNIA: OESOPHAGEAL PHYSIOLOGY APPEARS TO IMPROVE WITH SURGERY

Abstract Background High resolution manometry (HRM) is a gold standard test of oesophageal physiology. The use of HRM in patients with giant hiatus hernia (GHH) is limited by historical technical challenges as well as unclear clinical implications of the findings. The aim of this study is to demonstrate feasibility of HRM in patients with GHH and study effect of surgery on oesophageal physiology of patients undergoing GHH repair. Methods Data was extracted from a prospectively populated database of patients with giant (>30% stomach above diaphragm) hiatus hernias. All patients that underwent HRM before and after surgery were included. Manometric findings before and after surgery were analysed and compared. Patient symptoms were correlated with manometric findings. Results Inclusion criteria were met by 30 patients: 83% female, average age 74 (range 51-86), 93% had type III hernia containing on average 55% of stomach. All operations but one were performed laparoscopically. Pre-operatively average LOS length was 1.89cm which improved significantly to 2.19cm after surgery (p<0.05). Nine patients had ineffective oesophageal motility on index study which normalised post operatively in 4 patients. Lower oesophageal sphincter integrated relaxation pressure (IRP) increased post-operatively from 9.07mmHg to 11.52mmHg (p<0.05). Distal contractility improved post-operatively, however this was not significant. Most common presenting symptoms were dyspnoea, anaemia, retrosternal pain, and dysphagia. There was no association between dysphagia and manometric findings before or after surgery. Conclusion This study provides an insight into HRM findings in patients with GHH before and after surgery. Majority of the physiological parameters improved with surgery. There was no correlation of symptom of dysphagia with manometric findings.

Comparison of Esophageal Dysmotility and Reflux Burden in Patients with Different Metabolic Obesity Phenotypes Based on High-Resolution Impedance Manometry and 24-h Impedance-pH

Introduction: The relationship between the metabolically healthy obesity (MHO) phenotype and the occurrence of gastroesophageal reflux disease (GERD) and inefficient esophageal motility (IEM) is still unclear. Thus, we assessed the association between different metabolic obesity phenotypes and GERD and IEM using empirical data. Methods: We collected clinical and test data of 712 patients, including 24-h multichannel intraluminal impedance-pH (24-h MII-pH) monitoring, high-resolution manometry (HRM), and endoscopy. We divided 567 individuals into four categories according to their metabolic obesity phenotype: metabolically unhealthy non-obesity (MUNO), metabolically unhealthy obesity (MUO), metabolically healthy non-obesity (MHNO), and MHO. We compared differences in the 24-h MII-pH monitoring, HRM, and endoscopy findings among the four metabolic obesity phenotypes. Results: Patients with the MUNO, MHO, or MUO phenotype showed a greater risk of IEM and GERD (pathologic acid exposure time [AET] >6%) compared with patients with the MHNO phenotype. Regarding the HRM results, patients with the MHNO or MUNO phenotype had a lower integrated relaxation pressure, esophageal sphincter pressure, and esophagogastric junction contractile integral, and more ineffective swallows than patients with the MHO or MUO phenotype (p < 0.05). In terms of 24-h MII-pH, patients with the MHO or MUO phenotype had a higher total, upright, and supine AET; a higher total number of reflux episodes (TRs); and a lower mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index compared with those with the MHNO or MUNO phenotype (all p < 0.05). Considering the odds ratio of 19.086 (95% confidence interval 6.170–59.044) for pathologic AET and 3.659 (95% confidence interval 1.647–8.130) for IEM, patients with the MUO phenotype had the greatest risk after adjusting for all confounding variables. Conclusion: Obesity and metabolic disorders increase the risk of GERD and IEM. Obesity has a greater impact on esophageal dysmotility and pathologic acid exposure than metabolic diseases.

Spectrum of esophageal manometry and 24-h pH impedance findings in non-erosive gastroesophageal reflux disease and response to phenotype-based treatment-A prospective observational study.

Gastroesophageal reflux disease (GERD) is classified into erosive reflux disease (ERD) and non-erosive reflux disease (NERD). NERD includes three phenotypes: true NERD, functional heartburn (FH) and reflux hypersensitivity (RH). The management of these NERD phenotypes differs. We aimed at studying the spectrum of high-resolution manometry (HRM) and 24-hour impedance-pH findings in Indian patients with NERD, classifying the phenotypes and assessing the response to phenotype-based treatment. We prospectively studied the clinical characteristics, endoscopy, HRM, 24-hour impedance-pH findings, symptom association and response to phenotype-specific treatment in patients with NERD. Of 53 patients with NERD, the following phenotypes were diagnosed namely: 35(66%) true NERD, 12(22.7%) RH and six(11.3%) FH. The esophagogastric junction-contractile integral (EGJ-CI) was low in 60.4% and ineffective esophageal motility (IEM) was present in 53% of patients. The respective median values for true NERD, RH and FH groups were as follows: proximal mean nocturnal baseline impedance (P-MNBI) 2250Ω, 2241Ω, 2550Ω, (p = 0.592), distal (D-MNBI) 1431Ω, 2887.5Ω, 2516Ω (p < 0.001), post-reflux swallow-induced peristaltic wave index (PSPWI) 11.1%, 16%, 18.7% (p = 0.127). Receiver operating characteristic (ROC) curve analyses showed that D-MNBI and PSPWI discriminated FH and RH from true NERD, respectively, with a cut-off of 2376.5Ω (area under curve [AUC]:0.919, p < 0.001), 22.6% (AUC:0.671, p = 0.184) and 2318Ω (AUC:0.919, p = < 0.001), 16.2%(AUC:0.671, p = 0.079). The median P-MNBI was lower in patients with GERD-associated cough than other symptoms 1325 (1250, -). Fifty (94.3%) patients showed significant improvement in symptom severity scores (p < 0.001) following phenotype-specific treatment. In NERD patients, EGJ-CI and IEM were low. D-MNBI and PSPWI could effectively discriminate true NERD from FH and RH, whereas P-MNBI could help diagnose GERD-associated cough. The phenotype-specific treatment provides better symptom relief for patients.

The inability to belch: a neglected disease in the era of high-resolution esophageal manometry.

Retrograde upper esophageal sphincter dysfunction (R-UESD) is characterized by the inability to belch. Evidence of using high-resolution manometry (HRM) in diagnosing R-UESD has emerged in recent years. We describe the clinical picture and HRM patterns of two patients with R-UESD. Case 1: A 23-year-old female presented with a two-year complaint of inability to belch. We performed HRM with a belch provocation test for which the patient drank 500 ml of carbonated water. The study revealed increased esophageal pressure, an absence of UES relaxation and secondary peristalsis once the patient mentioned the need to belch. Case 2: A 21-year-old male presented to our medical office with a history of an incapacity to belch during the last three years. We performed HRM with a belch provocation test. During the study, he reported an incapacity to belch and his symptoms coincided with increased esophageal pressure, an absence of UES relaxation, and secondary peristalsis. Retrograde upper esophageal sphincter dysfunction is a rare condition characterized by a lack of UES relaxation during esophageal distension. The incapacity to belch is the hallmark of the disease. We encourage the use of HRM, looking for an increase in esophageal pressure to the level of gastric pressure, failure of UES relaxation with consequently no venting of air across the UES, and secondary peristalsis. In conclusion, diverse R-UESD clinical presentations represent a diagnostic challenge for physicians. This case series highlights the need to actively search for typical HRM findings when encountering patients referring an incapacity to belch.

Midesophageal diverticulum with elevated intrabolus pressure: a case report

BackgroundEsophageal diverticulum is commonly associated with esophageal motility disorders, which can be diagnosed using high-resolution manometry (HRM) according to the Chicago classification. Although midesophageal diverticulum (M-ED) is associated with inflammatory processes, esophageal motility disorders have been recently identified as an etiology of M-ED.Case presentationWe present the case of a patient with M-ED and elevated intrabolus pressure (IBP), which did not meet the criteria for esophageal motility disorders according to the Chicago classification. A 71-year-old man presented with gradually worsening dysphagia for two years and was diagnosed as having an 8-cm-long M-ED and multiple small diverticula in lower esophagus. HRM revealed a median integrated relaxation pressure of 14.6 mmHg, a distal latency of 6.4 s, and an average maximum IBP of 35.7 mmHg. He underwent thoracoscopic resection of the M-ED and myotomy, which successfully alleviated the symptoms and reduced the intrabolus pressure to normal levels.ConclusionsIt is important to recognize the esophageal diverticulum pathology with HRM findings even in cases where the results may not meet the Chicago classification and to include myotomy based on the results.

The Role of High-Resolution Manometry Before and Following Antireflux Surgery: The Padova Consensus.

In the last 2 decades the development of high-resolution manometry (HRM) has changed and revolutionized the diagnostic assessment of patients complain foregut symptoms. The role of HRM before and after antireflux procedure remains unclear, especially in surgical practice, where a clear understanding of esophageal physiology and hiatus anatomy is essential for optimal outcome of antireflux surgery (ARS). Surgeons and gastroenterologists (GIs) agree that assessing patients following antireflux procedures can be challenging. Although endoscopy and barium-swallow can reveal anatomic abnormalities, physiological information on HRM allowing insight into the cause of eventually recurrent symptoms could be key to clinical decision-making. A multidisciplinary international working group (14 surgeons and 15 GIs) collaborated to develop consensus on the role of HRM pre-ARS and post-ARS, and to develop a postoperative classification to interpret HRM findings. The method utilized was detailed literature review to develop statements, and the RAND/University of California, Los Angeles Appropriateness Methodology (RAM) to assess agreement with the statements. Only statements with an approval rate >80% or a final ranking with a median score of 7 were accepted in the consensus. The working groups evaluated the role of HRM before ARS and the role of HRM following ARS. This international initiative developed by surgeons and GIs together, summarizes the state of our knowledge of the use of HRM pre-ARS and post-ARS. The Padova Classification was developed to facilitate the interpretation of HRM studies of patients underwent ARS.

Fifteen-year symptomatic outcome of patients with nonactionable motor findings on high-resolution manometry.

High-resolution manometry (HRM) is performed for evaluation of esophageal symptoms, but patient outcome is unclear when no actionable motor disorder is identified. We evaluated long-term symptomatic outcome of patients with nonactionable HRM findings. Patients who underwent (HRM) studies in 2006-2008 were tracked. Patients with achalasia spectrum disorders, foregut surgery before or after HRM, and incomplete symptom documentation were excluded. Symptom questionnaires assessing dominant symptom intensity (DSI, product of symptom severity and frequency recorded on 5-point Likert scales) and global symptom severity (GSS, from 10 cm visual analog scale) were repeated. Change in symptom burden was compared against HRM motor findings using Chicago Classification 4.0 (CCv4.0), applied retroactively to 2006-2008 data. Overall, 134 patients (median age 68 years, 64.5% female) could be contacted. The majority (73.1%) had normal motility; others had ineffective esophageal motility (8.2%), esophagogastric junction outflow obstruction (13.4%), hypercontractile esophagus (3.0%), or absent contractility (2.2%), none managed invasively. Over 15 years of follow-up, DSI decreased from 8.0 (4.0-16.0) to 1.0 (0.0-6.0) (p < 0.001) and GSS improved from 5.5 (3.3-7.7) to 2.0 (0.0-4.0) (p < 0.001); improvement was consistent across CCv4.0 diagnoses and subgroups. The majority (82.8%) reported improvement over time, and antisecretory medication was the most effective intervention (83.0% improvement). There was no difference in medication efficacy (p = 0.75) or improvement in symptoms (p = 0.20) based on CCv4 diagnosis. Esophageal symptoms improve with conservative symptomatic management over long-term follow-up when no conclusive obstructive motor disorders or achalasia spectrum disorders are found on HRM.

Dysphagia associated with esophageal wall thickening in patients with nonspecific high-resolution manometry findings: Understanding motility beyond the Chicago classification version 4.0.

Previous studies have demonstrated that 50% of patients with normal high-resolution manometry (HRM) findings or ineffective esophageal motility (IEM) may have abnormal functional luminal imaging probe (FLIP) results. However, the specific HRM findings associated with abnormal FLIP results are unknown. Herein, we investigated the relationship between nonspecific manometry findings and abnormal FLIP results. We retrospectively analyzed 684 patients who underwent HRM at a tertiary care center in Seoul, Korea, based on the Chicago Classification version 4.0 protocol. Among the 684 patients, 398 had normal HRM findings or IEM. Of these 398 patients, eight showed esophageal wall thickening on endoscopic ultrasonography or computed tomography; however, no abnormalities were seen during esophagogastroduodenoscopy. Among these eight patients, seven showed repetitive simultaneous contractions (RSCs) in at least one of the two positions: 61% (±29%) in 10 swallows in the supine position and 51% (±30%) in five swallows in the upright position. Four patients who underwent FLIP had a significantly decreased esophagogastric junction distensibility index (1.0 ± 0.5 at 60 mL). Two of these patients underwent per-oral endoscopic myotomy (POEM) due to a lack of response to medication. Esophageal muscle biopsy revealed hypertrophic muscle with marginal eosinophil infiltration. A subset of patients (2%) with normal HRM findings or IEM and RSCs experienced dysphagia associated with poor distensibility of the thickened esophageal wall. FLIP assessment or combined HRM and impedance protocols may help better define these patients who may respond well to POEM.

Dysphagia Worsens With Increasing Ineffective Swallows Among Patients With Ineffective Esophageal Motility.

Ineffective esophageal motility (IEM) is the most common motility disorder identified on esophageal high-resolution manometry (HRM), but patients with this finding may be asymptomatic. Therefore, we aimed to identify specific HRM findings predictive of symptoms in IEM. Adult patients (≥18y) who underwent HRM between March 2016 and July 2019 were retrospectively evaluated and reclassified according to Chicago Classification 4.0 (CC4.0). Demographic information, HRM parameters, and gastroesophageal reflux disease Health-Related Quality of Life Questionnaire responses were captured among those with normal manometry or IEM. We evaluated the association between heartburn, regurgitation, and dysphagia, with respect to HRM findings including ineffective swallows. Of 379 patients, 243 (64.1%) had a normal manometry, 136 (35.9%) were on IEM spectrum, and 73 (19.3%) had conclusive IEM by CC4.0. Mean dysphagia scores were significantly higher in those with conclusive IEM compared with those with normal HRM (2.00 vs. 1.36, P=0.002), as was the percentage of individuals reporting dysphagia affecting daily activities (21.9% vs. 11.4%, P=0.02). Heartburn and regurgitation symptoms did not differ between groups. In a multivariable model of IEM patients, the percentage of ineffective swallows independently predicted a higher dysphagia burden (β regression coefficient: 0.032, P=0.04). Applying the CC4.0 definition for conclusive IEM identifies a group of patients with worse dysphagia symptoms. Within this group, the percentage of ineffective swallows was an independent predictor of dysphagia severity. These findings may help practitioners and patients contextualize the heterogeneous diagnosis of IEM.

Characterising oesophageal motility disorders by high-resolution impedance manometry in dermatomyositis patients.

We studied high-resolution impedance manometry (HRiM) findings in dermatomyositis (DM) to detect oesophageal dysmotility, even in asymptomatic patients, and correlated the alterations to clinical and serological disease domains. We performed a cross-sectional study of DM patients, enrolled between December 2021 and December 2022. All patients underwent rheumatological, laboratory and HRiM assessment. HRiM findings were compared with different clinical and serological profiles. The study population consisted of 15 DM patients (13 women and 2 men, age 54±15.2 years). The mean disease duration was 6.6 years. According to HRiM findings, three different groups of oesophageal disease severity were identified (in order of severity G0, G1 and G>1, 5 patients per group). G>1 group was significantly associated with MDA5 antibodies (80% vs. 20%, p<0.05). Interstitial lung disease (ILD) did not show any significant association with HRiM findings. However, a diffusing lung capacity for carbon oxide (DLCO) < 80% was present in 100% of G>1 (p<0.05). No associations between dysphagia, creatine kinase (CK) level, muscle weakness, skin, articular involvement and treatment were found. Oesophageal involvement is frequent and should be evaluated in the comprehensive work-up of DM. We used for the first time HRiM in DM, which proved to be an accurate and objective technique in assessing oesophageal disease, even in the subclinical stage. Interestingly, the MDA5-positive group had a higher burden of HRiM pathological findings, suggesting a greater severity of oesophageal involvement, often asymptomatic.

Ethnic Differences in Clinical Presentations and Esophageal High-Resolution Manometry Findings in Patients with Achalasia.

Ethnic differences in achalasia presentations have scarcely been described. The association between achalasia and immunologic HLA haplotypes suggests that there may be a genetic predisposition. We aimed to evaluate differences in demographic, clinical, endoscopic, and manometric findings between two distinct ethnic groups with achalasia-Israeli Arabs (IA) and Israeli Jews (IJ). A retrospective study was performed at two medical centers. High-resolution manometry (HRM) reports were reviewed for newly-diagnosed achalasia patients. Demographic data, clinical presentations, endoscopy reports, and HRM metrics including the integrated relaxation pressure (IRP) were all reviewed. Overall, 94 achalasia patients were included (53.2% male; mean age 54.5 ± 18.0). 43 patients were IA (45.7%). Body mass index (BMI) was similar in both groups. Compared to IJ, the IA patients had more esophageal dysphagia (100% vs. 88.2%; P = 0.022), chest pain (46.5% vs. 25.5%; P = 0.033), and a tortuous esophagus on endoscopy (23.3% vs. 3.9%; p = 0.005). IA patients were also diagnosed at a younger age than IJ patients (50.9 ± 17.5 vs. 57.5 ± 18.0; p = 0.039). Furthermore, IRP values were higher among IA patients than IJ patients (32.2 ± 13.8 vs. 23.3 ± 8.4; p < 0.001). A regression model analysis found that ethnicity significantly predicted IRP (β = -10, p < .001). Ethnicity appears to affect achalasia clinical presentation and HRM findings. IA achalasia patients are diagnosed at a younger age, present with more severe esophageal symptoms, and have a higher IRP compared to IJ patients. Additional studies of diverse, multiethnic populations, especially with genetic evaluations, are required to further assess the role of ethnicity in achalasia.

Impact of peroral endoscopic myotomy on high-resolution manometry findings and their association with the procedure’s outcomes

Peroral endoscopic myotomy (POEM) is conducted for patients with esophageal motility disorders based on high-resolution manometry (HRM) findings. However, the impact of POEM on HRM findings and the associations between post-POEM HRM and outcomes have not been clarified. In a multicenter, observational, cohort study, patients with achalasia treated by POEM received follow-up HRM. Associations between patient characteristics, POEM procedures, and post-POEM HRM findings, including integrated relaxation pressure (IRP) and distal contractile integral (DCI), were investigated. Furthermore, POEM procedure outcomes were compared with post-POEM HRM findings. Of 2171 patients, 151 (7.0%) showed residual high post-POEM IRP (≥26mm Hg; Starlet [Starmedical Ltd, Tokyo, Japan]). In a multivariate analysis, high pre-POEM IRPs (odds ratio [OR], 24.3) and gastric myotomy >2 cm (OR, .22) were found to be positive and negative predictive factors of high post-POEM IRPs, respectively. Peristalsis recovery (DCI≥500mm Hg/cm/s, at least 1 swallow; Starlet) was visible in 121 of 618 patients (19.6%) who had type II to III achalasia. High pre-POEM IRP (OR, 2.65) and DCI≥500 (OR, 2.98) predicted peristalsis recovery, whereas esophageal dilation (OR, .42) predicted a risk of no recovery. Extended myotomy did not reveal a significant impact on peristalsis recovery. High or low post-POEM IRP and DCI did not increase the incidence of clinical failure, reflux esophagitis, or symptomatic GERD. Extended gastric myotomy decreased IRP values, whereas peristalsis recovery depended on the characteristics of achalasia. A residual high post-POEM IRP does not necessarily mean clinical failure. Routine HRM follow-up is not recommended after POEM.

S423 Association Between Defective Secondary Peristalsis Detected by Functional Lumen Imaging Probe Topography (FLIP) and GERD

Introduction: Esophageal secondary peristalsis is a defense mechanism against GERD by clearance of refluxate. When absent or defective, it may lead to increased esophageal acid exposure time (AET). Functional lumen imaging probe topography (FLIP) allows assessment of secondary peristalsis induced by volumetric distension. Aim: evaluate the association between secondary peristalsis and GERD. Methods: We included patients with esophageal symptoms who underwent FLIP topography and reflux monitoring (wireless pH or catheter-based pH-impedance) while off PPI ≥7 days, high-resolution esophageal manometry (HRM) findings (LES pressure, ineffective esophageal motility , absent contractility) were added for secondary analysis when available. Exclusion criteria: achalasia, prior gastroesophageal surgery, Botox injection within 6 months of FLIP and reflux study. Abnormal AET on reflux monitoring was defined as % time pH< 4 greater than 4%. FLIP was performed with a 16 cm balloon during propofol-sedated endoscopy; peristaltic response was assessed at 30-40-50-60 ml and classified as repetitive antegrade contractions (RACs), borderline contractile response, repetitive retrograde contractions (RRCs), impaired, absent, and spastic reactive. EGJ distensibility index (DI) was calculated at 60ml. Secondary peristalsis was considered intact if RACs seen at any volume, impaired otherwise. Those with borderline contractility but no RACs were excluded from analysis.. We assessed the association between FLIP and HRM findings and GERD by t test and chi square. Results: 37 patients included (23, 62% female), mean age 58.45 years, mean BMI 25.7. GERD present in 15 (40.5%). Mean esophageal AET was lower in patients with versus without intact peristalsis but significance not reached (5.8% vs 3.0%, p=0.058). The proportion of patients with GERD was lower in patients with peristalsis versus without intact peristalsis but significance not reached (25% vs 40%, p=0.18). There was no association between GERD and DI or any HRM measures. Conclusion: Our data suggests that defective secondary peristalsis is more frequent in GERD patients and is thus and important contributing factor to reflux. Lack of significance may be due to small sample size and type II error, but a larger number of patients is needed to clarify this and data collection is ongoing.

Improved esophagography screening for esophageal motility disorders using wave appearance and supra-junctional ballooning.

High-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders (EMDs); however, it requires specialized equipment. The development of more accessible screening examinations is expected. We evaluated the utility of barium esophagography (BE) screening using two novel findings to diagnose EMDs. Between January 2013 and October 2020, 244 patients with suspected EMDs who underwent both HRM and BE were analyzed. The EMD diagnosis was based on HRM findings using Chicago Classification version 3.0. BE was performed using sequential esophagography with barium sulfate. Three conventional BE findings (air-fluid level, rosary-bead/corkscrew appearance, and absent/weak peristalsis) and two novel BE findings (wave appearance and supra-junctional ballooning) were used for diagnosis. The sensitivity and specificity of BE screening using the two novel findings and conventional findings to diagnose EMDs were 79.4% and 88%, respectively [area under the receiver-operating characteristic curve (AUC) = 0.837]. Without these novel findings, they were 63.9% and 96%, respectively (AUC = 0.800), respectively. Achalasia was highly correlated with the air-fluid level (88.7%). Absent contractility was highly correlated with absent/weak peristalsis (85.7%). Relatively high correlations were observed between distal esophageal spasm and rosary-bead/corkscrew appearance (60%), and between achalasia and wave appearance (59.7%). The intra-observer reproducibility and inter-observer agreement for individual BE findings were 84.4% and 75%, respectively. Wave appearance was associated with higher integrated relaxation pressure (IRP) and shorter distal latency. Supra-junctional ballooning was associated with higher IRP. BE screening using two additional novel findings to diagnose EMDs could be useful in general practice.

The Natural History of Esophageal "Absent Contractility" and Its Relationship with Rheumatologic Diseases: A Multi-Center Case-Control Study.

(1) Background: Absent contractility (AC) is an esophageal motility disorder defined as a normal integrated relaxation pressure with 100% failed peristalsis. We sought to clarify the natural history of this disorder and its relationship with rheumatologic diseases, such as systemic sclerosis (scleroderma). (2) Methods: We retrospectively identified patients with AC based on high-resolution manometry findings at three referral institutions and then matched them with controls with esophageal complaints who had normal manometries. (3) Results: Seventy-four patients with AC were included (mean age 56 years; 69% female). Sixteen patients (21.6%) had a rheumatologic disease. Compared to controls, patients with AC were significantly more likely to present with heartburn, dysphagia, vomiting, and weight loss. During follow-up, they were also more likely to be seen by a gastroenterologist, be diagnosed with gastroesophageal reflux disease, take a proton pump inhibitor, and undergo repeat upper endoscopies. No AC patients developed a new rheumatologic disease during follow-up. No significant differences were noted in the clinical presentation or course of AC patients with rheumatologic disease compared to those without. (4) Conclusions: Patients with AC have more esophageal symptoms and require more intense gastrointestinal follow-up than controls. Only a minority of patients with AC have underlying rheumatologic disease. Those without rheumatologic disease at baseline did not subsequently develop one, suggesting that a rheumatologic evaluation is likely unnecessary. The clinical course of AC in patients with rheumatologic disease and those without appears to be similar.

Risks of refractory chest pain after peroral endoscopic myotomy in achalasia-related esophageal motility disorders: short-term results from a multicenter study in Japan

The etiology of chest pain in achalasia-related esophageal motility disorders and the frequency and risk factors of persistent chest pain after peroral endoscopic myotomy (POEM) remain unclear. A multicenter cohort study including 14 hospitals was conducted to elucidate the characteristics of patients with chest pain and the efficacy of POEM. Consecutive cases of achalasia-related esophageal motility disorders included 2294 (64.2%) and 1280 (35.8%) patients with and without chest pain, respectively. Among the 2107 patients with chest pain who underwent POEM, we observed complete remission in 1464 patients (69.5%) and nonremission in 643 patients (30.5%), including a partial response in 619 patients (29.4%) and resistance in 24 patients (1.1%). Multivariate analysis revealed that advanced age (odds ratio [OR], .28), male sex (OR, .70), prior treatment (OR, 1.39), and sigmoid type (OR, .65) were related to the prevalence of chest pain. Long disease duration (OR, .69) and esophageal dilation (OR, .79) were related to decreased severity. POEM improved patients' quality of life that was hindered by chest pain. Early onset (OR, 1.45), advanced age (OR, .58), male sex (OR, .79), prior treatment (OR, 1.37), and posterior myotomy (OR, 1.42) were associated with nonremission after POEM; high-resolution manometry (HRM) findings and myotomy length showed no statistical significance on pain etiology and persistence after POEM. The prevalence and severity of chest pain were dependent on age, sex, disease duration, prior treatment, and esophageal morphology rather than HRM findings. The efficacy of POEM is satisfactory; however, residual pain was often observed. Excessively long myotomy can be avoided, and anterior myotomy may be recommended.

Relationship between esophageal achalasia subtypes and esophageal clearance.

The diagnosis and pathological evaluation of esophageal achalasia have been improved dramatically by the development of high-resolution manometry. It is currently known to be divided into three subtypes. However, the differences between subtypes in terms of esophageal clearance remain unclear. To compare the pathology of subtypes in patients with esophageal achalasia from the perspective of esophageal clearance. We classified the patients diagnosed with esophageal achalasia into three subtypes based on the high-resolution manometry findings and compared the patient background, esophagography findings, esophageal manometry findings, timed barium esophagogram (TBE) findings, and their symptoms. We also calculated the esophageal clearance rate from TBE to investigate the relationship with the subtypes. There were 71 cases of Type I, 140 cases of Type II, and 10 cases of Type III. No differences by subtype were found in patient background or symptoms. Regarding the esophageal manometry findings, the integrated relaxation pressure was high in Type II (p = 0.0006). The esophagography revealed a mild degree of esophageal flexion in Type III (p = 0.0022) and a high degree of esophageal dilation in Type I and II (p = 0.0227). The esophageal clearance rate in descending order was: Type III, II, and I (height: p = 0.0302, width: p = 0.0008). The subtypes by high-resolution manometry diagnosis had an association with the esophagography findings and best reflected the esophageal clearance, with no correlation to the patient backgrounds and symptoms.

Spastic secondary contractile patterns identified by FLIP panometry in symptomatic patients with unremarkable high-resolution manometry.

Functional lumen imaging probe (FLIP) panometry can show spastic secondary contractile patterns of unclear significance in symptomatic patients who have no esophageal obstructive disorders, and no motility disorders on high-resolution manometry (HRM). We retrospectively analyzed non-obstructed, symptomatic patients with HRM findings of no motility disorder or ineffective esophageal motility (IEM) for whom spastic secondary contractile patterns identified by FLIP panometry were used to guide treatment. Symptoms were scored using the Brief Esophageal Dysphagia Questionnaire (BEDQ). We identified ten symptomatic patients treated at our medical center who met inclusion criteria (seven women; mean age 56years; eight no motility disorder, two IEM). On FLIP panometry, seven had spastic secondary contractions at 60ml, two at 40ml, and one at both 40ml and 60ml balloon volumes. Eight patients (80%) had improvement in BEDQ scores with therapies that targeted the spastic secondary contractile patterns identified by FLIP (five botulinum toxin injection, two Esoflip dilation, and one Heller myotomy). Interestingly, review of HRM tracings revealed that all patients had a novel HRM finding of mid-vertical pressurization in at least 20% swallows, with seven exhibiting this finding in >50% of swallows. This case series demonstrates that treatments targeting spastic secondary contractions identified by FLIP panometry can result in symptomatic improvement in patients with no obstructive disorder and no diagnostic motility disorder on HRM. In such patients, we have identified the novel HRM finding of mid-vertical pressurization, which might be the manometric manifestation of spasm limited to the mid-esophagus.

Novel description on esophageal timed barium swallow: a correlation between advanced parametrization and esophageal X-ray images.

The TBS-derived image processing method, based on the observer's diagnosis, has been developed in the current investigation. Image parametrization is proposed for both novel description and convergent shreds of evidence. Condensed X-ray images of the esophageal timed barium swallow (TBS) provide substantial implications for elucidating the pathophysiological dimensions of esophageal motility disorders. Through the simultaneous study on TBS and high-resolution manometry (HRM) findings, we performed a retrospective cohort study on 252 patients from March 2018 to October 2019. Interventions, irrelevant information, and insufficient patient data were excluded. Only subjects with adequate data and acceptable test accuracy were considered for participation. We reviewed 117 Dicom (digital imaging and communications in medicine) X-ray images from patients with confirmed diagnoses of achalasia type II, esophagogastric junction outflow obstruction (EGJOO), or non-achalasia. The results suggested a cut-off level of 47% in DDi (dilated diameter index) as a sign of the dilated body. In achalasia type II patients (n=66 images), the mean DDi was 55.6%. Our method presented a sensitivity of 95% and a specificity of 93% compared to images of the non-achalasia findings. The mean DDi in EGJOO patients was 50.4%, according to the 27 images. Moreover, results from EGJOO patients provided a sensitivity of 85% and specificity of 87%. TBS is an efficacious method and a prominent component in the process of achalasia diagnosis. Standard parametrization might develop radiological exports proposed by DDi. Our method could assist in obtaining a non-invasive medical diagnosis and help advance diagnostic reports to identify achalasia subtypes somewhat earlier. To the best of our knowledge, this interface is an innovative parametrization for TBS image review.