High-resolution Manometry Recordings Research Articles

Accuracy of hiatal hernia detection with esophageal high-resolution manometry.

The diagnosis of a sliding hiatal hernia is classically made with endoscopy or barium esophagogram. Spatial separation of the lower esophageal sphincter (LES) and diaphragm, the hallmark of hiatal hernia, can also be observed on high-resolution manometry (HRM), but the diagnostic accuracy of this finding has not yet been investigated. To determine the diagnostic value of HRM in the detection of hiatal hernia. HRM recordings, endoscopy reports, and barium esophagograms of 90 patients were analyzed for the presence and size of a hiatal hernia. The diagnostic value of a hernia specific HRM pressure pattern was calculated, and the agreement of HRM with endoscopy and barium esophagogram for the assessment of hernia size. HRM was found to be highly sensitive and specific for hiatal hernia detection, with a sensitivity of 92% and specificity of 95%, exceeding the sensitivity of endoscopy or radiography alone (both 73%). Patients with a hiatal hernia on HRM were manometrically characterized by an esophagogastric junction (EGJ) with partial or complete separation of the LES and crural diaphragm (CD), the latter being associated with significantly lower EGJ pressure. A cutoff value of spatial LES-CD separation on HRM of 1.85cm yielded the optimal performance in identifying hiatal hernia. Agreement between HRM, endoscopy, and radiography for size of hiatal hernias was good (ICC [95% CI] 0.74 [0.65-0.82]). With HRM, the presence or absence and size of a hiatal hernia can be assessed with greater sensitivity than with endoscopy or radiography alone.

Inter- and intrarater reliability of the Chicago Classification in pediatric high-resolution esophageal manometry recordings.

The Chicago Classification (CC) facilitates interpretation of high-resolution manometry (HRM) recordings. Application of this adult based algorithm to the pediatric population is unknown. We therefore assessed intra and interrater reliability of software-based CC diagnosis in a pediatric cohort. Thirty pediatric solid state HRM recordings (13M; mean age 12.1 ± 5.1 years) assessing 10 liquid swallows per patient were analyzed twice by 11 raters (six experts, five non-experts). Software-placed anatomical landmarks required manual adjustment or removal. Integrated relaxation pressure (IRP4s), distal contractile integral (DCI), contractile front velocity (CFV), distal latency (DL) and break size (BS), and an overall CC diagnosis were software-generated. In addition, raters provided their subjective CC diagnosis. Reliability was calculated with Cohen's and Fleiss' kappa (κ) and intraclass correlation coefficient (ICC). Intra- and interrater reliability of software-generated CC diagnosis after manual adjustment of landmarks was substantial (mean κ = 0.69 and 0.77 respectively) and moderate-substantial for subjective CC diagnosis (mean κ = 0.70 and 0.58 respectively). Reliability of both software-generated and subjective diagnosis of normal motility was high (κ = 0.81 and κ = 0.79). Intra- and interrater reliability were excellent for IRP4s, DCI, and BS. Experts had higher interrater reliability than non-experts for DL (ICC = 0.65 vs ICC = 0.36 respectively) and the software-generated diagnosis diffuse esophageal spasm (DES, κ = 0.64 vs κ = 0.30). Among experts, the reliability for the subjective diagnosis of achalasia and esophageal gastric junction outflow obstruction was moderate-substantial (κ = 0.45-0.82). Inter- and intrarater reliability of software-based CC diagnosis of pediatric HRM recordings was high overall. However, experience was a factor influencing the diagnosis of some motility disorders, particularly DES and achalasia.

The Chicago Classification of esophageal motility disorders, v3.0.

The Chicago Classification (CC) of esophageal motility disorders, utilizing an algorithmic scheme to analyze clinical high-resolution manometry (HRM) studies, has gained acceptance worldwide. This 2014 update, CC v3.0, developed by the International HRM Working Group, incorporated the extensive clinical experience and interval publications since the prior (2011) version. Chicago Classification v3.0 utilizes a hierarchical approach, sequentially prioritizing: (i) disorders of esophagogastric junction (EGJ) outflow (achalasia subtypes I-III and EGJ outflow obstruction), (ii) major disorders of peristalsis (absent contractility, distal esophageal spasm, hypercontractile esophagus), and (iii) minor disorders of peristalsis characterized by impaired bolus transit. EGJ morphology, characterized by the degree of overlap between the lower esophageal sphincter and the crural diaphragm and baseline EGJ contractility are also part of CC v3.0. Compared to the previous CC version, the key metrics of interpretation, the integrated relaxation pressure (IRP), the distal contractile integral (DCI), and the distal latency (DL) remain unchanged, albeit with much more emphasis on DCI for defining both hypo- and hypercontractility. New in CC v3.0 are: (i) the evaluation of the EGJ at rest defined in terms of morphology and contractility, (ii) 'fragmented' contractions (large breaks in the 20-mmHg isobaric contour), (iii) ineffective esophageal motility (IEM), and (iv) several minor adjustments in nomenclature and defining criteria. Absent in CC v3.0 are contractile front velocity and small breaks in the 20-mmHg isobaric contour as defining characteristics. Chicago Classification v3.0 is an updated analysis scheme for clinical esophageal HRM recordings developed by the International HRM Working Group.

Sa2008 Efficacy and Safety of Linaclotide in Chronic Idiopathic Constipation Patients With Abdominal Bloating: Phase 3b Trial Results

Colonic motor patterns, which might become biomarkers of colonic dysmotility in constipation, are still poorly defined in humans but have been clarified including the role of myogenic, neurogenic and interstitial cells of Cajal (ICC) control systems in the rat, mouse and guinea pig. The purpose of this study was to explore the characteristics of colonic motor patterns in 8 healthy volunteers and 22 patients with chronic constipation by high-resolutionmanometry (HRM). A 36-channel Unisensor solid-state probe, 1 cm spaced, was fixed at the transversedistal colon by colonoscopy for 6-8 hours manometry recording with Medkinetic acquisition software. After 60 min baseline recording, a yogurt meal (460 g, 1400 kJ) was given to observe the gastro-colonic reflex for 90 min, thereafter 2 mg prucalopride was given to evaluate short-term effects. Results: 1) Unique to HRM recordings were the clearly definable, distinguishable and quantifiable simultaneous and propulsive contractions which all had superimposed haustral contractions; distinct from any animal model. 2) In healthy volunteers, common motor patterns included simultaneous contractions (duration of 1-3 s, 40 100 mmHg, frequency 0.5-1.7 cpm), propulsive contractions including high amplitude propulsive contractions (HAPCs; 100-250 mmHg; figure), and stationary haustral contractions (30150 mmHg) that were often rhythmic at the ICC pacemaker frequency (3 cpm). The yogurt meal and 2 mg prucalopride promoted propulsive contractions, and decreased simultaneous contractions from 7 to 2 per 30 min recording. Eight HAPCs were observed in 3 cases, with propagating distances of 8-36 cm, amplitudes of 100-220 mmHg, velocity of 53 mm/s, several HAPCs were repetitive with intervals of 60-150 sec. HAPCs usually occurred without other patterns although it happened once in between 2 simultaneous contractions. 3) In patients with chronic constipation, simultaneous and retrograde-propagating contractions of low amplitude were the main patterns, no HAPCs were observed. Simultaneous contractions (duration 1-3 s, 30 mm Hg, frequency 0.4 -1.1 cpm) were significantly promoted by yogurt (from 5 to 16 episodes / 30 min). Retrograde contractions were increased after yogurt and prucalopride, with propagating distances of 8-21 cm, 10-60 mmHg, velocity of 61 mm/s and intervals of 60-150 sec. This did not occur in healthy volunteers. 4) Flatulence was associated with simultaneous contractions; yogurt increased the episodes of flatulence in both patients and healthy volunteers. In conclusion, rhythmic low amplitude simultaneous contractions and retrograde contractions, abundance of low amplitude rhythmic haustral contractions and failure to induce HAPCs characterized chronic constipation, suggestive of enhancement of local myogenic activity and dysfunctional neurogenic control systems of propulsion.

Sa2007 Colonic Motor Patterns in Patients With Chronic Constipation Assessed by High Resolution Manometry

Colonic motor patterns, which might become biomarkers of colonic dysmotility in constipation, are still poorly defined in humans but have been clarified including the role of myogenic, neurogenic and interstitial cells of Cajal (ICC) control systems in the rat, mouse and guinea pig. The purpose of this study was to explore the characteristics of colonic motor patterns in 8 healthy volunteers and 22 patients with chronic constipation by high-resolutionmanometry (HRM). A 36-channel Unisensor solid-state probe, 1 cm spaced, was fixed at the transversedistal colon by colonoscopy for 6-8 hours manometry recording with Medkinetic acquisition software. After 60 min baseline recording, a yogurt meal (460 g, 1400 kJ) was given to observe the gastro-colonic reflex for 90 min, thereafter 2 mg prucalopride was given to evaluate short-term effects. Results: 1) Unique to HRM recordings were the clearly definable, distinguishable and quantifiable simultaneous and propulsive contractions which all had superimposed haustral contractions; distinct from any animal model. 2) In healthy volunteers, common motor patterns included simultaneous contractions (duration of 1-3 s, 40 100 mmHg, frequency 0.5-1.7 cpm), propulsive contractions including high amplitude propulsive contractions (HAPCs; 100-250 mmHg; figure), and stationary haustral contractions (30150 mmHg) that were often rhythmic at the ICC pacemaker frequency (3 cpm). The yogurt meal and 2 mg prucalopride promoted propulsive contractions, and decreased simultaneous contractions from 7 to 2 per 30 min recording. Eight HAPCs were observed in 3 cases, with propagating distances of 8-36 cm, amplitudes of 100-220 mmHg, velocity of 53 mm/s, several HAPCs were repetitive with intervals of 60-150 sec. HAPCs usually occurred without other patterns although it happened once in between 2 simultaneous contractions. 3) In patients with chronic constipation, simultaneous and retrograde-propagating contractions of low amplitude were the main patterns, no HAPCs were observed. Simultaneous contractions (duration 1-3 s, 30 mm Hg, frequency 0.4 -1.1 cpm) were significantly promoted by yogurt (from 5 to 16 episodes / 30 min). Retrograde contractions were increased after yogurt and prucalopride, with propagating distances of 8-21 cm, 10-60 mmHg, velocity of 61 mm/s and intervals of 60-150 sec. This did not occur in healthy volunteers. 4) Flatulence was associated with simultaneous contractions; yogurt increased the episodes of flatulence in both patients and healthy volunteers. In conclusion, rhythmic low amplitude simultaneous contractions and retrograde contractions, abundance of low amplitude rhythmic haustral contractions and failure to induce HAPCs characterized chronic constipation, suggestive of enhancement of local myogenic activity and dysfunctional neurogenic control systems of propulsion.

Interobserver Agreement in the Assessment of High-resolution Manometry Recordings in Patients with Non-Achalasic Motility Disorders

Interobserver Agreement in the Assessment of High-resolution Manometry Recordings in Patients with Non-Achalasic Motility Disorders

Ambulatory high‐resolution manometry, lower esophageal sphincter lift and transient lower esophageal sphincter relaxation

Lower esophageal sphincter (LES) lift seen on high-resolution manometry (HRM) is a possible surrogate marker of the longitudinal muscle contraction of the esophagus. Recent studies suggest that longitudinal muscle contraction of the esophagus induces LES relaxation. Our goal was to determine: (i) the feasibility of prolonged ambulatory HRM and (ii) to detect LES lift with LES relaxation using ambulatory HRM color isobaric contour plots. In vitro validation studies were performed to determine the accuracy of HRM technique in detecting axial movement of the LES. Eight healthy normal volunteers were studied using a custom designed HRM catheter and a 16 channel data recorder, in the ambulatory setting of subject's home environment. Color HRM plots were analyzed to determine the LES lift during swallow-induced LES relaxation as well as during complete and incomplete transient LES relaxations (TLESR). Satisfactory recordings were obtained for 16 h in all subjects. LES lift was small (2 mm) in association with swallow-induced LES relaxation. LES lift could not be measured during complete TLESR as the LES is not identified on the HRM color isobaric contour plot once it is fully relaxed. On the other hand, LES lift, mean 8.4 ± 0.6 mm, range: 4-18 mm was seen with incomplete TLESRs (n = 80). Our study demonstrates the feasibility of prolonged ambulatory HRM recordings. Similar to a complete TLESR, longitudinal muscle contraction of the distal esophagus occurs during incomplete TLESRs, which can be detected by the HRM. Using prolonged ambulatory HRM, future studies may investigate the temporal correlation between abnormal longitudinal muscle contraction and esophageal symptoms.

High resolution manometry to detect transient lower oesophageal sphincter relaxations: diagnostic accuracy compared with perfused‐sleeve manometry, and the definition of new detection criteria

Inhibition of transient lower oesophageal sphincter relaxations (tLESRs) has become one of the most relevant therapeutic objectives in patients with reflux symptoms resistant to proton pump inhibitors. tLESRs are currently detected by oesophageal perfused-sleeve manometry (PSM), but oesophageal high resolution manometry (HRM), which combines closely spaced pressure sensors and oesophageal pressure topography plots, may prove to be a better tool. To evaluate the efficacy, reproducibility and interobserver agreement of HRM for the detection of tLESRs, in comparison with PSM. Twenty-four healthy volunteers underwent HRM alone and on a separate occasion with PSM simultaneously. LES pressure was monitored for 1 h during fasting and 2 h postprandial. Criteria for tLESRs were defined by characterising spontaneous LES relaxation associated with common cavity and then applied to all spontaneous LES relaxations. Interobserver agreement and the rates of tLESRs detected by HRM and PSM were compared. New HRM criteria for the detection of tLESRs have been established. A similar number of tLESRs were identified during the two HRM recordings (median per subject 15 and 13 (P = 0.07) and less with PSM (median per subject 11, P < 0.01). The overall concordance rate between the two procedures was substantial (kappa = 0.61). The interobserver agreement was almost perfect (kappa = 0.83) with HRM and only fair (kappa = 0.38) with PSM. High resolution manometry is reproducible and more sensitive than PSM to detect tLESRs. HRM provides a better interobserver agreement. These results confirm that HRM is the gold standard for detecting tLESRs (NTC00931593).

Hyperdynamic Upper Esophageal Sphincter Pressure: A Manometric Observation in Patients Reporting Globus Sensation

Although globus sensation is a common symptom, its pathogenesis is poorly defined. The aim of this study was to quantify the timing and magnitude of respiratory variation in upper esophageal sphincter (UES) pressure with high-resolution manometry (HRM) in patients with globus sensation, normal controls, and gastroesophageal reflux disease (GERD) patients without globus sensation. HRM recordings spanning from the hypopharynx to the stomach were analyzed in 131 consecutive globus patients with normal (64) and abnormal (67) distal esophageal motility. Resting UES pressure was analyzed up to 5 min before 10 5-ml water swallows. Change in UES pressure, its average magnitude between inspiration and expiration, and nadir UES relaxation pressure in globus patients were compared with those in 68 controls and 46 GERD patients without globus. UES pressure typically increased during inspiration in both controls and patients. Respiration-related change in resting UES pressure was significantly amplified in globus patients (37.3 mm Hg) compared with controls (10.6 mm Hg) and GERD patients (13.0 mm Hg) (P<0.0001). A respiratory change in UES pressure>27 mm Hg was found in >60% of globus patients and <15% of controls and GERD patients without globus. This hyperdynamic UES was not associated with other abnormalities of esophageal motor function. Hyperdynamic respiratory UES pressure changes were prevalent in patients reporting globus sensation irrespective of their deglutitive UES and distal esophageal motility. Although the etiology of this hyperdynamic UES is unclear, it does appear to be a frequent manometric observation in this patient group and may provide a new focus for further studies into pathogenesis and therapy.

Oesophageal high-resolution manometry: moving from research into clinical practice

Manometry measures pressure within the oesophageal lumen and sphincters, and provides an assessment of the neuromuscular activity that dictates function in health and disease. It is performed to investigate the...