High-resolution Manometry Parameters Research Articles

Clinical and high-resolution manometry of 801 patients with esophageal dysmotility, including achalasia, in relation to age.

Spectrum of esophageal motility disorders may differ according to age, but studies on this are scanty, contradictory, and included small number of patients. Accordingly, we retrospectively analyzed data of a large sample of patients to study the spectrum of esophageal motility disorders in relation to age, and to evaluate the clinical profile and high-resolution manometry parameters and achalasia subtypes according to Chicago IV criteria. Of 909 patients evaluated by high-resolution water perfusion or solid-state manometry during a 3-year period, data on 801 were finally analyzed. Achalasia cardia was the commonest motility disorder of esophagus in this large study and type II was the commonest subtype. There was no difference in clinical and manometry parameters among elderly patients as compared to younger patients with achalasia. Type I achalasia patients less often had chest pain and tended to have nocturnal coughing spells more often, and patients with achalasia experiencing chest pain tended to have higher distal contractile integral (DCI) than those not having pain irrespective of age. The clinical and high-resolution manometry parameters among young and elderly patients with esophageal motility disorders are quite comparable. However, these differed in relation to achalasia subtypes and symptoms. Type I achalasia patients less often had chest pain and those experiencing chest pain tended to have higher DCI values than those not having pain irrespective of age.

484. DELTA-IRP AS A NEW HIGH-RESOLUTION MANOMETRY METRIC TO PREDICT THE POSITIVE OUTCOME OF LAPAROSCOPIC HELLER-DOR IN PATIENTS WITH ACHALASIA

Abstract Background There is no consensus on the definition of failure after treatment in patients with esophageal achalasia. The Eckardt score (ES) is commonly used to define clinical outcome, but objective metrics based on high-resolution manometry (HRM) or other tools are lacking. Aim of this study was to identify any HRM objective parameters useful to predict a positive outcome after surgical treatment with laparoscopic Heller-Dor (LHD). Methods Patients who had undergone LHD between 2012 and 2022, with pre- and postoperative HRM at our Center, were enrolled. Patients were divided according to the outcome of treatment between success group (SG, symptom relief or resolution) and failure group (FG, ES>3 or the need for additional treatment). Further to the traditional HRM metrics commonly evaluated, we also measured the difference between median values of pre- and postoperative Integrated Relaxation Pressure (∆-IRP). A ROC curve analysis was applied to assess the accuracy of each HRM parameter identified. Data are reported in Table 1. Results We enrolled 358 patients (F:M=177:187): 331 in the SG and 27 in the FG. The ∆-IRP was higher in SG [22mmHg (IQR:15-31)] than in FG [14.3mmHg (IQR:9.9-18.3), p=0.04]. The univariate analysis is showed in Table 1. At multivariate analysis, the ∆-IRP was the only parameter independently related to clinical success (p<0.01). The ROC curve for the ∆-IRP showed an area under the curve of 0.71, with a threshold value set at 16.55 mmHg (sensibility 71%, specificity 70%). Conclusions Our data showed that the ∆-IRP with a threshold of 16.5 mmHg could represent a new objective tool to predict the positive outcome of LHD in patients with esophageal achalasia.

Esophageal motor disorders across ages: A retrospective multicentric analysis.

Age-related changes in the gastrointestinal system are common and may be influenced by physiological aging processes. To date, a comprehensive analysis of esophageal motor disorders in patients belonging to various age groups has not been adequately reported. We conducted a retrospective assessment of high-resolution manometry (HRM) studies in a multicenter setting. HRM parameters were evaluated according to the Chicago Classification version 4.0. Epidemiological, demographic, clinical data, and main manometric parameters, were collected at the time of the examination. Age groups were categorized as early adulthood (<35 years), early middle-age (35-49 years), late middle-age (50-64 years), and late adulthood (≥65 years). Overall, 1341 patients (632, 47.0% male) were included with a median age of 55 years. Late adulthood patients reported more frequently dysphagia (35.2%) than early adulthood patients (24.0%, p = 0.035), early middle-age patients (21.0%, p < 0.0001), and late middle-aged patients (22.7%, p < 0.0001). Esophagogastric junction outflow obstruction was more prevalent in late adulthood (16.7%) than in early adulthood (6.1%, p = 0.003), and in early middle-age (8.1%, p = 0.001). Patients with normal esophageal motility were significantly younger (52.0 years) than patients with hypercontractile esophagus (61.5 years), type III achalasia (59.6 years), esophagogastric junction outflow obstruction (59.4 years), absent contractility (57.2 years), and distal esophageal spasm (57.0 years), in multivariate model (p < 0.0001). The rate of esophageal motor disorders is higher in older patients, in particular esophagogastric junction outflow obstruction and hypercontractile esophagus. Future prospective studies are necessary to confirm our results and to find tailored strategies to improve clinical outcomes.

Manometric identikit of a functioning and effective fundoplication for gastroesophageal reflux disease in the high-resolution manometry ERA.

The pathophysiological and clinical value of performing High-Resolution Manometry (HRM) after laparoscopic fundoplication (LF) for gastroesophageal reflux disease (GERD) is still unclear and debated. We sought to establish the HRM parameters indicative of functioning fundoplications, and whether HRM could distinguish them from tight or defective ones. The study involved patients with GERD who underwent laparoscopic Nissen (LN) or Toupet (LT) fundoplication between 2010 and 2022. HRM and 24-h pH monitoring were performed before and 6months after surgery. The study population was divided into 5 groups: LN and LT patients with normal 24h-pH findings (LNpH- and LTpH-, respectively); LN and LT patients with pathological 24h-pH findings (LNpH+ and LTpH+groups, respectively); and patients with a postoperative dysphagia intensity score >2 (Dysphagia group). The novel Hiatal Morphology (HM) classification was applied, envisaging 3 different subtypes: HM1 (normal), HM2 (intrathoracic fundoplication), and HM3 (slipped fundoplication). Among the 132 patients recruited during the study period, 46 were in the LNpH- group, 51 in the LTpH- group, 15 in the LNpH+group, 7 in the LTpH+group, and 5 in the Dysphagia group. In multivariate analysis, postoperative abdominal lower esophageal sphincter length (p=0.001) and HM2 (p<0.001) were both independently associated with surgical failure. Integrated relaxation pressure was significantly higher in the Dysphagia group than in the LNpH- group. This study generated reference HRM values for an effective LF, and confirms that using HRM to assess the neo-sphincter and HM improves the clinical assessment in cases of symptom recurrence.

Esophageal Infusion of Menthol Does Not Affect Esophageal Motility in Patients with Gastroesophageal Reflux Disease.

Menthol is thought to trigger gastroesophageal reflux disease (GERD) symptoms by influencing esophageal peristalsis and lower esophageal sphincter (LES) function. We evaluated the effect of esophageal menthol infusion on esophageal motility and the LES in healthy volunteers and in patients with GERD. High resolution manometry (HRM) catheter with attached thin tube for menthol infusion was placed transnasally. Protocol which included baseline recording, 16 water swallows (5ml, 10ml, and 15ml) and the multiple rapid swallows was performed before and after esophageal infusion of menthol (3mM, 20min, 8ml/min). We evaluated the effect of this infusion on the HRM parameters of esophageal peristalsis (distal contractile integral, distal latency, contractile front velocity) and the lower esophageal sphincter (LES) barrier function (integrated relaxation pressure and the inspiratory augmentation of the LES). Simultaneously we evaluated the quality and intensity of the symptoms during the menthol infusion. Esophageal infusion of menthol did not appreciably affect HRM measurements characterizing esophageal peristalsis and LES pressure in healthy subjects (N = 13) or GERD patients (N = 11). The magnitude of the distal contractile integral (5ml) was changed neither in the healthy volunteers' group, (735 ± 127 vs. 814 ± 117mmHg, p = 0.5), nor in the GERD patients (295 ± 78 vs. 338 ± 96mmHg, p = 0.99). In healthy volunteers menthol did not change the inspiratory augmentation of the LES (8.67 ± 1.09 vs. 7.69 ± 0.96mmHg, p = 0.15) and neither did for GERD patients (8.8 ± 1.18 vs. 8.22 ± 0.91mmHg, p = 0.43). We observed no significant difference in any HRM parameter following menthol infusion, except for distal latency in 10ml swallows. By contrast, menthol infusion induced significantly more intense discomfort in GERD patient than in healthy volunteers. Our results suggest no significant temporal effect of menthol on the esophageal motility or LES function, neither in healthy volunteers, nor in GERD. Arguably, other mechanisms are responsible for menthol-related heartburn.

474. MANOMETRIC IDENTIKIT OF A FUNCTIONING AND EFFECTIVE FUNDOPLICATION IN THE HIGH-RESOLUTION MANOMETRY ERA

Abstract Background Assessing patients following Laparoscopic Fundoplication (LF) can be challenging. Functional information provided by pathophysiological testing—which can shed light on the cause of recurrent symptoms—could be key to clinical decision making. The value of performing High-Resolution Manometry (HRM) after LF is still unclear and debated. We sought to establish the HRM parameters indicative of a functioning fundoplication, and whether HRM could distinguish it from a tight or defective one. Methods We studied patients with gastroesophageal reflux disease (GERD) who underwent laparoscopic Nissen (LN) or Toupet (LT) fundoplication between 2010–2022. HRM and pH monitoring were performed before and 6 months after surgery. LF failure was defined as GerdQ score ≥ 8 and abnormal 24 h-pH study or just abnormal 24 h-pH study. The study population was divided into 5 groups: LN and LT patients with normal pH monitoring (LNpH- and LTpH-, respectively); LN and LT patients with pathological pH monitoring (LNpH+ and LTpH+ groups, respectively); and patients with postoperative severe dysphagia (Dysphagia group). The novel Hiatal Morphology (HM) classification was applied, envisaging 3 subtypes: HM1 (normal morphology); HM2 (intrathoracic fundoplication); and HM3 (slipped fundoplication). Results We recruited 132 patients: 46 in the LNpH- group, 51 in the LTpH- group, 15 in the LNpH+ group, 7 in the LTpH+ group, and 5 in the Dysphagia group (Figure 1). Eight patients with GerdQ score ≥ 8 and normal 24 h-pH findings were excluded. At univariate analysis, postoperative lower esophageal sphincter (LES) basal pressure (p = 0.011), total and abdominal LES length (p = 0.014, p &amp;lt; 0.001) were correlated with LF failure. At multivariate analysis, postoperative abdominal LES length (p = 0.001) and HM2 (p &amp;lt; 0.001) were independently associated with surgical failure. Integrated relaxation pressure (IRP) was significantly higher in the Dysphagia group than in the LNpH- group. Conclusion This study generated reference HRM values for an effective LF and confirms that using HRM to assess the abdominal portion of the neo-sphincter and abnormal hiatal morphology (HM2) improves the clinical assessment of recurrent symptoms. HRM can distinguish patients with a well-functioning wrap from those developing recurrent GERD due to an ineffective wrap. Postoperative IRP also correlated significantly with the onset of dysphagia after surgery.

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.

Systematic Review With Meta-Analysis: Chronic Opioid Use Is Associated With Esophageal Dysmotility in Symptomatic Patients.

We aimed to conduct a systematic review and meta-analysis to assess the impact of chronic opioid exposure on esophageal motility in patients undergoing manometric evaluation. Multiple databases were searched through October 2022 for original studies comparing the manometric results of patients who have used chronic opioids (for >90 days) with those who do not. The primary outcomes were esophageal dysmotility disorders. Three high-resolution manometry parameters were conducted as secondary outcomes. A random-effects model was applied to calculate the odds ratio (OR) and means difference (MD) along with a 95% confidence interval (CI). Nine studies were included in this meta-analysis. Opioid use was associated with higher esophageal dysmotility disorders, including distal esophageal spasm (pooled OR 4.84, 95% CI 1.60-14.63, P = 0.005, I 2 = 96%), esophagogastric junction outflow obstruction (pooled OR 5.13, 95% CI 2.11-12.43, P = 0.0003, I 2 = 93%), and type III achalasia (pooled OR 4.15, 95% CI 2.15-8.03, P < 0.0001, I 2 = 64%). No significant differences were observed for hypercontractile esophagus, type I achalasia, or type II achalasia. The basal lower esophageal sphincter pressure (MD 3.02, 95% CI 1.55-4.50, P < 0.0001, I 2 = 90%), integrated relaxation pressure (MD 2.51, 95% CI 1.56-3.46, P < 0.00001, I 2 = 99%), and distal contractile integral (MD 640.29, 95% CI 469.56-811.03, P < 0.00001, I 2 = 91%) significantly differed between the opioid use and nonopioid use group. However, opioid use was associated with a lower risk of ineffective esophageal motility (pooled OR 0.68, 95% CI 0.49-0.95, P = 0.02, I 2 = 53%). Chronic opioid exposure is associated with an increased frequency esophageal dysmotility disorders. Our results revealed that opioid use is significantly associated with type III achalasia but not with type I and II achalasia. Therefore, opioid treatment should be taken into account as a potential underlying risk factor when diagnosing these major esophageal motor abnormalities.

Role of Preoperative High-Resolution Manometry in the Identification of Patients at High Risk of Postoperative GERD Symptoms 1 Year After Sleeve Gastrectomy.

Sleeve gastrectomy (SG) has become the most common bariatric procedure, but it is often characterized by the onset of postoperative gastroesophageal reflux disease (GERD). High-resolution manometry (HRM) is a useful tool to detect risk factors for GERD. The aim of this study was to evaluate preoperative manometric parameters as possible predictors of postoperative GERD. This was a monocentric retrospective study. We analyzed 164 patients, with preoperative esophagitis/GERD symptoms who underwent preoperative HRM and were submitted to SG (July 2020-February 2022). Postoperative GERD was observed in 60 patients (36.6%): 41 of them (68%) already had preoperative GERD symptoms, whereas the remaining 19 patients (32%) developed postoperative symptoms. Female patients developed postoperative GERD in a significantly higher fraction of cases as compared to male patients (82% versus 18%; p < 0.001). DCI (distal contractile integral) was identified as the only HRM parameter correlating with the presence of GERD. Patients with DCI ≤ 1623 mmHg*cm*s developed postoperative GERD in 46% of cases (n = 43/94), as compared to 24% of cases (n = 17/70) among patients with DCI > 1623 mmHg*cm*s (p = 0.005). At multivariable analysis, female sex (OR 3.402, p = 0.002), preoperative GERD symptoms (OR 2.489, p = 0.013), and DCI ≤ 1623 mmHg*s*cm (OR 0.335, p = 0.003) were identified as independent determinants of postoperative GERD. All the patients with preoperative risk factors for reflux, such as GERD symptoms or esophagitis on EGDS (esophagogastroduodenoscopy), should be considered for an HRM. Moreover, when a DCI ≤ 1623 mmHg*s*cm is found, a bariatric procedure different from SG might be considered.

Esophagogastric Junction Outflow Obstruction Is Likely to Be a Local Manifestation of Other Primary Diseases: Analysis of Single-Center 4-Year Follow-Up Data.

Whether esophagogastric junction outflow obstruction (EGJOO) is a variant of achalasia cardia (AC) or an esophageal motility state of certain organic or systemic diseases remains controversial. We aimed to investigate the differences between EGJOO and AC in clinical characteristics and outcomes through a 4-year follow-up. Patients diagnosed with primary EGJOO or AC were included. Based on the presence of concomitant disease, EGJOO patients were divided into a functional and an anatomical EGJOO group; similarly, patients with AC were divided into an AC with organic disease group and a true AC group. Disease characteristics and high-resolution manometry (HRM) parameters were retrospectively compared between the groups, and the development of organic diseases that could affect esophageal motility disorders and responses to treatment were examined during the follow-up. Symptom relief was defined as an Eckardt score of ≤3 after the treatment. The study included 79 AC patients and 70 EGJOO patients. Compared with patients with AC, EGJOO patients were older, had shorter disease duration, a lower Eckardt score, and were more likely to have concurrent adenocarcinoma of the esophagogastric junction (AEG) and autoimmune disease (p < 0.05 for all). The severity of dysphagia and Eckardt scores were higher in the anatomical EGJOO group than in the functional EGJOO group. Significant differences were seen in HRM parameters (UES residual pressure, LES basal pressure, and LES residual pressure) between AC and EGJOO patients. However, no significant differences in HRM parameters were observed between the functional EGJOO and anatomical EGJOO groups. Sixty-seven (95.71%) patients with EGJOO and sixty-nine (87.34%) patients with AC experienced symptom relief (p = 0.071). Among patients achieving symptom relief, a relatively large proportion of patients with EGJOO had symptom relief after medications (37/67, 55.22%), the resolution of potential reasons (7/67, 10.45%), and spontaneous relief (15/67, 22.39%), while more patients with AC had symptom relief after POEM (66/69, 95.65%). Among EGJOO patients achieving symptom relief, more patients (7/20, 35%) with anatomical EGJOO had symptom relief after the resolution of potential reasons for EGJOO, while more patients (32/47, 68.09%) with functional EGJOO had symptom relief with medications. Concurrent AEG and autoimmune diseases are more likely in EGJOO than in AC. A considerable part of EGJOO may be the early manifestation of an organic disease. Anatomical EGJOO patients experience symptom improvement with the resolution of primary diseases, while most functional EGJOO patients experience symptom relief with pharmacotherapy alone or even without any treatment.

Medical Therapy for Ineffective Esophageal Motility: A Systematic Review

Background: Ineffective esophageal motility (IEM) is a commonly identified disorder of peristalsis. Although often asymptomatic, IEM can be associated with dysphagia. Aside from treating co-existing gastroesophageal reflux disease and sources of mechanical obstruction, few options are available for management in this context. We therefore systematically reviewed the literature to identify randomized controlled trials (RCTs) for medical treatments of IEM. Methods: MEDLINE, Embase, Cochrane Library, and Web of Science were searched using controlled vocabulary and keywords to identify RCTs from inception through 9/22/2021. Prospective studies evaluating medical therapy to improve dysphagia in adults with IEM were included. The risk of bias was assessed using the revised Cochrane risk-of-bias tool. Results: Among 1046 studies identified, 6 (0.58%) met inclusion criteria with a total of 65 patients. Most studies evaluated serotonin receptor agonists (buspirone, mosapride, prucalopride, and sumatriptan), primarily assessing changes on esophageal high-resolution manometry parameters, and only 1 study evaluated patient reported outcomes. Overall, medical therapy improved these pooled outcomes in 5 (83%) studies. Although treatment endpoints varied, the risk of bias in study reporting was low for 4 studies and uncertain for 2 studies. Conclusions: There are currently few therapeutic options available for IEM patients with symptomatic non-obstructive dysphagia. Our systematic review identified 6 studies utilizing medical therapy in patients with IEM, and a majority demonstrated an improvement in HRM parameters. Medical therapy may therefore be considered in this context, but additional studies are warranted to assess for similar improvement in patient symptoms.

The Relationship Between Vocal Fold Mobility Disorders and Ineffective Esophageal Motility

Deglutition, speech production, and airway protection are extraordinarily complex, interrelated functions that are coordinated, in large part, by the motor and sensory innervation of CN X. Previous studies assessing the relationship between neurogenic voice disorders and dysphagia have focused on the risk of aspiration due to glottic insufficiency and the association of vocal fold hypomobility (VFH) with systemic neurologic disease. The purpose of this study was to investigate the relationship between VFH disorders and ineffective esophageal motility (IEM). Adult voice patients who underwent laryngeal electromyography (LEMG) and dual 24-hour pH impedance with high-resolution manometry (HRM) testing were included in the study. Subjects were assigned to one of two groups based on the presence or absence of moderate-to-severe RLN and/or SLN VFH (Mo-SLNH/RLNH) using results from six muscle LEMG tests. In subjects with Mo-SLNH/RLNH, there was 0-60% muscle recruitment on LEMG, whereas control subjects in the non-Mo-SLNH/RLNH group demonstrated 61-100% muscle recruitment. Analysis of mild-to-severe VFH (80% muscle recruitment or less) was also performed in a similar manner. The prevalence of IEM, defined using Chicago Classification Version 4.0 (CCv4.0), was compared between groups, as were HRM parameters. One hundred sixty-two subjects were included (37.7% male/62.3% female, mean age of 43.88 ± 17.285). No differences in IEM prevalence were found when stratifying for cases of mild-to-severe VFH. However, there was significantly higher percentage of IEM in those with Mo-SLNH/RLNH. Mo-SLNH/RLNH subjects demonstrated higher rates of weak swallows and inefficient swallows, as well as lower IBP and UES residual pressures on HRM. Patients with Mo-SLNH/RLNH demonstrated a significantly higher prevalence of IEM. Those with mild-to-severe VFH did not. Higher rates of ineffective and weak swallows, and lower IBP and UES residual pressures among Mo-SLNH/RLNH subjects suggest a possible connection between Mo-SLNH/RLNH and IEM disorders. These manometric differences were more prominent with sub-stratification of the Mo-SLNH/RLNH group by IEM. Additional research is advised.

Long-term outcomes of peroral endoscopic myotomy for Chicago classification type I vs type III achalasia in treatment-naive patients.

The efficacy of peroral endoscopic myotomy (POEM) for achalasia has potential associations with Chicago classification by high-resolution manometry (HRM). Type II achalasia demonstrates the best response to POEM of all subtypes, while there remain controversies between type I and type III. Moreover, previous treatment history might cause discrepancy in direct comparison. We aimed to compare the clinical outcome of POEM for type I vs type III in treatment-naive patients. In total, 82 patients with type I or type III achalasia (45 type I, 37 type III) from February 2015 to December 2018 were enrolled and POEM was carried out as the initial treatment. Clinical success, change of Eckardt scores and HRM parameters were analyzed and compared between type I and type III group. About, 43 (95.6%) patients and 34 (91.9%) patients in type I and type III group acquired the clinical success (P = 0.821). Eckardt score and HRM results after POEM treatment decreased significantly in either group (P<0.01). Compared to type III group, higher reduction rates of Eckardt score (type I vs type III, 78.6 vs 66.9%, P = 0.034) and basal LES pressure (type I vs type III, 58.9 vs 40.4%, P = 0.040) were observed in type I group. Type I achalasia patients showed better response to POEM with more favorable clinical remission in Eckardt score and HRM outcomes than type III.

Opioid Exposure Differentially Impacts Esophageal Body Contraction Over the Lower Esophageal Sphincter

Background & AimsStudies with limited sample sizes have investigated association of chronic opioid use with motility disorders of esophagogastric junction and esophageal body peristalsis. Our aims were to use a large cohort of patients to assess (1) the impact of opioid exposure on clinical and manometric characteristics, and (2) the association of opioid exposure with higher long-term symptom burden. MethodsPatients recruited from a tertiary medical center who underwent high-resolution manometry (HRM) between 2007 and 2018 were included. Demographics, opiate exposure, clinical symptoms, and HRM parameters were compared. Patient-Reported Outcomes Measurement Information System–Gastrointestinal swallowing domain (PROMIS-GI swallowing domain) and Eckardt score were administered via phone interviews in patients with hypercontractile esophagus (HE) or distal esophageal spasm (DES) to determine long-term symptom burden between opioid and nonopioid users. ResultsOur cohort included 4075 patients (869 with opiate exposure with median morphine milligram equivalent [interquartile range] of 30 [10–45]). Patients in the opioid group were significantly more likely to have dysphagia (65% vs 51%, P < .01) and diagnosis of DES (11% vs 5%, P < .01) and HE (9% vs 3%, P < .01). Partial opioid agonists were not associated with motility abnormalities. Patients on opioids had significantly higher symptom burden on median (interquartile range) follow-up of 8.9 years (5.8–10.4) post manometric diagnosis with median PROMIS-GI swallowing domain score of 21.5 (17–25) compared with the nonopioid group at 15 (9.8–21, P = .03). ConclusionsNearly 2 of 3 patients with opioid exposure undergoing HRM have dysphagia and more than 25% of them with dysphagia as the primary symptom have a diagnosis of either DES or HE. Opioid users with spastic disorders have higher symptom burden long-term compared with nonopioid users.

Patients With Definite and Inconclusive Evidence of Reflux According to Lyon Consensus Display Similar Motility and Esophagogastric Junction Characteristics.

Background/AimsThe role of esophageal high-resolution manometry (HRM) within Lyon consensus phenotypes, especially patients with inconclusive gastroesophageal reflux disease (GERD) evidence, has not been fully investigated. In this multicenter, observational study we aim to compare HRM parameters in patients with GERD stratified according to the Lyon consensus.MethodsClinical and endoscopic data, HRM and multichannel intraluminal impedance-pH (MII-pH) studies performed off proton pump inhibitor therapy in patients with esophageal GERD symptoms were reviewed. Lyon consensus criteria identified pathological GERD, reflux hypersensitivity, functional heartburn, and inconclusive GERD. Patients, with inconclusive GERD were further subdivided into 2 groups based on total reflux numbers (≤ 80 or > 80 reflux episodes) during the MII-pH recording time.ResultsA total of 264 patients formed the study cohort. Pathological GERD and inconclusive GERD patients were associated with higher numbers of reflux episodes, lower mean nocturnal baseline impedance (MNBI) values, and a higher proportion of patients with pathologic MNBI compared to functional heartburn (P < 0.05 for each comparison). On multivariate analysis, pathological GERD and inconclusive GERD patients, both with ≤ 80 or > 80 reflux episodes, were significantly associated with pathologic esophagogastric junction contractile integral values and with presence of hiatus hernia (type 2/3 esophagogastric junction). Patients with inconclusive GERD and > 80 reflux episodes were significantly associated with fragmented peristalsis and ineffective esophageal motility whilst inconclusive GERD with ≤ 80 reflux episodes were significantly associated with fragmented peristalsis.ConclusionEsophageal motor parameters on HRM are similar between pathologic and inconclusive GERD according to the Lyon consensus.

S367 Adherence to Major Society Recommendations in Patients Diagnosed with Esophagogastric Outflow Obstruction in a Large Tertiary Academic Center: A Retrospective Analysis

Introduction: Patients diagnosed with esophagogastric junction outflow obstruction (EGJOO) with high resolution manometry (HRM) are recommended to be evaluated with additional imaging modalities such as barium swallow (BaSw), CT, or endoscopic ultrasound (EUS) to exclude secondary etiologies of the elevated integrated relaxation pressure central to the diagnosis of EGJOO. We retrospectively evaluated adherence and yield with these recommendations at a large tertiary referral center. Methods: Patients undergoing HRM and diagnosed with EGJOO from January 2016 to December 2019 were included in this analysis. Demographics and HRM parameters were collected and, using a central electronic medical record (EMR), patient records were examined over 1 year from the time of diagnosis of EGJOO to determine if subsequent imaging modalities were obtained and if so, whether an explanation for EGJOO was identified. Results: A total of 117/1800 (6.5%) patients were diagnosed with EGJOO. Ninety patients (76.9%) were female, 9 (7.7%) had undergone antireflux surgery prior to HRM, and 2 (1.7%) had undergone bariatric surgery prior to HRM. Narcotic use was present in 7 (6.0%) at the time of HRM. A total of 116 follow up imaging studies were ordered within 1 year of the EGJOO diagnosis and 75 patients (64.1%) completed additional imaging within 1 year, with 34 (45%) undergoing multiple studies (Table 1). 26 patients (22.2%) underwent EUS and 11 (42.3%) of these examinations explained the EGJOO. 48 patients (41.0%) underwent CT and an explanation for EGJOO was found in 8 of these patients (16.6%). Finally, 42 patients underwent BaSw with 25 (59%) of these tests demonstrating an explanation for EGJOO (Figure 1). Conclusion: Additional imaging with BaSw, CT, or EUS is recommended in patients diagnosed with EGJOO. Among 117 patients diagnosed with EGJOO at a tertiary medical center, one-third did not undergo additional imaging within 1 year of their EGJOO diagnosis. Among patients who did undergo additional imaging, CT and BaSw were the most commonly used modalities. When obtained, additional imaging was felt to explain EGJOO in 58.7% of patients diagnosed with EGJOO on HRM. Prospective studies evaluating the compliance and yield of additional imaging after EGJOO diagnosis are needed.Table 1.: Demographic and Clinical Characteristics of GERD Cohort During Study.Figure 1.: APT-1011 3 mg HS vs Placebo: Response Defined by >=50% reduction in dysphagia frequency with 14-day period Kaplan Meier display utilizes mid-step.

Esophagogastric junction contractile integral abnormalities in patients with proton pump inhibitor-refractory symptoms.

Esophagogastric junction contractile integral (EGJ-CI) is a novel indicator to evaluate quantitatively the esophagogastric junction (EGJ) barrier function. We aimed to assess the role of EGJ-CI in patients with refractory gastroesophageal reflux disease (GERD) symptoms and the correlation between EGJ-CI and impedance-pH monitoring characteristics. In total 82 patients with proton pump inhibitors (PPIs)-refractory gastroesophageal reflux symptoms (heartburn or regurgitation) were enrolled. These patients were further divided into two groups based on their EGJ-CI value (39 mmHg·cm). The mean nocturnal baseline impedance (MNBI) was measured to explore its association with EGJ-CI. The median EGJ-CI in patients with PPI-refractory symptoms was 30.8 mmHg·cm. EGJ-CI was inversely correlated with acid exposure time and reflux episodes; while it was positively correlated with MNBI, distal contractile integral, lower esophageal sphincter basal pressure and integrated relaxation pressure. Patients were further divided into the high (n=27) and low (n=55) EGJ-CI groups using a cut-off value of 39.0 mmHg·cm. Patients with a low EGJ-CI had a lower MNBI level than those with a high EGJ-CI (2703 Ω vs 3545 Ω, P = 0.034). In patients with PPIs-refractory symptoms, EGJ-CI is associated with acid exposure and conventional high-resolution manometry parameters. EGJ-CI may play an important role in the diagnosis and treatment of patients with refractory GERD.

Normal Values of High-resolution Manometry Parameters With Provocative Maneuvers.

Background/AimsIncorporation of complementary and provocative test swallows to the high-resolution manometry (HRM) protocol offers potential to address limitations posed by HRM protocols that involve only a single swallow type. The aim of this study is to describe normal findings of a comprehensive HRM testing protocol performed on healthy asymptomatic volunteers.MethodsThirty healthy asymptomatic volunteers completed HRM with 5-mL liquid swallows in the supine position. They also completed 5-mL liquid swallows in the upright position, viscous swallows, solid test swallows, multiple rapid swallows, and a rapid drink challenge. HRM studies were analyzed via Chicago classification version 3.0.ResultsThe median (5th-95th percentiles) for integrated relaxation pressure (IRP) on supine swallows was 11 (4-16) mmHg; IRP was lower than supine on upright liquid 9 (0-17) mmHg, viscous 6 (0-15) mmHg, solid 9 (1-19) mmHg, multiple rapid swallows 3 (0-12) mmHg, and rapid drink challenge 5 (–3-12) mmHg; P < 0.005. While an “elevated” IRP value was observed on 1 to 2 test maneuvers in 8/30 (27%) subjects, all 30 subjects had an IRP value < 12 mmHg on at least one of the test maneuvers.ConclusionsNormal values and findings from a comprehensive HRM testing protocol are reported based on evaluation of 30 healthy asymptomatic volunteers. Isolated “abnormalities” of IRP and contractile parameters were observed in the majority (80%) of these asymptomatic subjects, while all subjects also had normal features observed. Thus, the definition of “normal” should be recalibrated to focus on the entirety of the study and not individual metrics.

Effects of Pyridostigmine on Esophageal and Pharyngeal Motility in Dysphagic Patients Undergoing High-Resolution Manometry.

Weak or absent peristalsis of the esophageal musculature is a common finding in ambulatory patients suffering from dysphagia and frequently associated with gastroesophageal reflux. There is currently no pharmacologic intervention that reliably improves esophageal contractility in patients suffering from various esophageal motility disorders. Our objective was to evaluate the acute effects of pyridostigmine on high-resolution manometry parameters in patients suffering from dysphagia with evidence of esophageal dysmotility. Pyridostigmine is an acetylcholinesterase inhibitor which increases effective concentrations of acetylcholine at the neuromuscular junction of both striated and smooth muscle cells. We conducted a prospective crossover study of five patients with dysphagia and proven esophageal dysmotility. Three patients had baseline ineffective esophageal motility and two had achalasia. Patients underwent pharyngeal and esophageal manometry before and after pyridostigmine administration. The median distal contractile integral (DCI), a marker of esophageal contractile vigor, was significantly higher post pyridostigmine administration 3001 (1950.3-3703.2) mmHg × s × cm compared to pre-pyridostigmine DCI of 1229.9 (956.2-2100) mmHg × s × cm; P < 0.001. Pre-pyridostigmine 18/25 (72%) of the patient's swallows was peristaltic compared to 25/25 (100%) post-pyridostigmine; P < 0.005. No other pharyngeal or esophageal high-resolution manometry parameter differed significantly after pyridostigmine administration. The results of this pilot study demonstrate that pyridostigmine acutely improves esophageal contractile vigor in patients suffering from dysphagia with esophageal dysmotility. Further investigation with larger sample size, longer follow-up, side effect profile, and patient-reported outcome measures is still needed to determine the clinical usefulness of pyridostigmine in specific disorders of esophageal motility.

Pneumatic dilation for persistent dysphagia after antireflux surgery, a multicentre single-blind randomised sham-controlled clinical trial

ObjectiveThere is no evidence-based treatment for persistent dysphagia after laparoscopic fundoplication. The aim of this study was to evaluate the effect of pneumatic dilation on persistent dysphagia after laparoscopic fundoplication.DesignWe...