High-resolution Manometry Testing Research Articles

Manometric esophagogastric junction barrier metrics as predictors of gastroesophageal reflux.

High-resolution manometry (HRM) tools, like esophagogastric junction contractile integral (EGJ-CI), assess EGJ barrier function. This study aimed to evaluate the relationships between manometric EGJ metrics with esophageal acid exposure. We conducted a retrospective review of 284 patients who underwent HRM and ambulatory reflux testing between 11/2017-1/2020. EGJ-CI and total-EGJ-CI were manually calculated. Pathologic acid exposure was defined as pH < 4 with esophageal acid exposure time (EAET) exceeding 6.0%. Pearson's correlation, univariable and multivariable regression models were utilized to assess the relationships between pathologic acid exposure and EGJ parameters. Sensitivity and specificity thresholds for EGJ-CI and total EGJ-CI were optimized with ROC analyses. On univariable analysis, patients with pathologic acid exposure had increased odds of having lower mean basal LES pressures, EGJ-CI, and total EGJ-CI than patients without pathologic acid exposure. On multivariable analysis, age, EGJ-CI and mean DCI were significant predictors of pathologic acid exposure. There were significant, though weak, correlations between EAET and EGJ-CI and total EGJ-CI (r = - 0.18, - 0.19, p < 0.01, respectively). An EGJ-CI cutoff of 44.16 as a predictor for pathologic acid exposure had a sensitivity of 46% and specificity of 42% (AUC 0.60). Total EGJ-CI cutoff of 11,461.3 for pathologic acid exposure had a sensitivity of 44% and a specificity of 43% (AUC 0.62). EGJ-CI can independently predict pathologic acid exposure. However, the poor correlation between EGJ-CI and acid exposure, as well as the low sensitivity and specificity of calculated thresholds, indicate that mechanisms other than EGJ barrier function may impact acid exposure.

Risk Factors Associated with Unsuccessful High-Resolution Manometry.

High-resolution manometry (HRM) is used to evaluate the esophageal motor function. Unfortunately, there are times when testing cannot be performed accurately. Our study aimed to quantify the occurrence of failed HRM and identify the associated risk factors.HRM tests were retrospectively collected between September 2021 and August 2022. HRM reports that could not be interpreted based on standard HRM protocol as per Chicago guidelines were classified as failed tests. Information reviewed included testing indications, patient demographics, previous medical/symptom history, and follow-up testing for failed HRM. We then compared patients with successful vs. unsuccessful HRM based on our pre-specified factors.152 HRM tests were performed, of which 28 tests (18%) were unsuccessful. Factors associated with failed manometry included a history of nausea/vomiting, dyspepsia, and achalasia. Patients who were unable to tolerate the probe during testing were more likely to have a history of dyspepsia (OR 20.3, p = < 0.001) and/or nausea/vomiting (OR 13.8, p = < 0.001). A history of achalasia was found to have an odds ratio of 13.2 when examining failure because of curling of the manometry catheter (p = 0.012). All seven patients who had repeat HRM with endoscopic placement were successful in obtaining diagnostic information.There are two groups that have risk factors for unsuccessful HRM testing. A history of nausea/vomiting and dyspepsia symptoms were associated with being unable to tolerate the manometry probe. The second group comprises patients with a history of achalasia in whom probe curling is more common. Future research targeting these risk factors may minimize diagnostic and treatment delays.

Comparing Pre- and Post-Operative Findings in Patients Who Underwent Laparoscopic Proximal Gastrectomy With a Double-Flap Technique: A Study on High-Resolution Manometry, Impedance pH Monitoring, and Esophagogastroduodenoscopy Findings.

Laparoscopic proximal gastrectomy (LPG) is a viable choice for treating proximal gastric lesions. However, the occurrence of severe reflux has limited its widespread adoption. To address this issue, the double flap technique (DFT), which incorporates artificial lower esophageal sphincteroplasty, has been developed to prevent reflux problems after proximal gastrectomy. In this study, we aimed to investigate the usefulness of this technique using high-resolution manometry (HRM), impedance pH monitoring, and esophagogastroduodenoscopy (EGD). The findings of pre- and postoperative 6-month HRM, pH monitoring, and EGD were compared for 9 patients who underwent LPG with DFT for various proximal gastric lesions at Incheon St. Mary's Hospital from January 2021 to December. A total of 9 patients underwent proximal gastrectomy. Approximately half of the patients had Hill's grade under II preoperatively, whereas all patients had Hill's grades I and II in EGD findings. In the HRM test, there was no significant difference between distal contractile integral (1,412.46±1,168.51 vs. 852.66±495.62 mmHg·cm·s, P=0.087) and integrated relaxation pressure (12.54±8.97 vs. 8.33±11.30 mmHg, P=0.27). The average lower esophageal sphincter (LES) pressure was 29.19±14.51 mmHg preoperatively, which did not differ from 19.97±18.03 mmHg after the surgery (P=0.17). DeMeester score (7.02±6.36 vs. 21.92±36.17, P=0.21) and total acid exposure time (1.49±1.48 vs. 5.61±10.17, P=0.24) were slightly higher, but the differences were not statistically significant. There is no significant functional difference in HRM and impedance pH monitoring tests after DFT. DFT appears to be useful in preserving LES function following proximal gastrectomy.

Esophageal Motility Abnormalities in Lung Transplant Recipients With Esophageal Acid Reflux Are Different From Matched Controls.

There is an increased incidence of gastroesophageal reflux disease (GERD) after lung transplantation (LT) that can be associated with graft dysfunction. It is unclear if the underlying esophageal motility changes in GERD are different following LT. This study aimed to use esophageal high-resolution manometry (HRM) to explore GERD mechanisms in LT recipients compared to matched controls. This was a retrospective study including patients with pathologic acid reflux who underwent HRM and pH testing at our healthcare facility July 2012 to October 2019. The study included 12 LT recipients and 36 controls. Controls were matched in a 1:3 ratio for age, gender, and acid exposure time (AET). LT recipients had less hypotensive esophagogastric junction (EGJ) (mean EGJ-contractile integral 89.2 mmHg/cm in LT vs 33.9 mmHg/cm in controls, P < 0.001). AET correlated with distal contractile integral and total EGJ-contractile integral only in LT group (r = -0.79, P = 0.002 and r = -0.57, P = 0.051, respectively). Following LT, acid reflux is characterized by a less hypotensive EGJ compared to controls with similar AET. The strongest correlation with AET after LT was found to be esophageal peristaltic vigor. These results add to the understanding of reflux after LT and may help tailor an individualized treatment plan.

Endoscopic impedance planimetry versus high-resolution manometry (HRM) for pre-operative motility evaluation in anti-reflux surgery.

Pre-operative evaluation of patients with gastroesophageal reflux disease (GERD) includes assessment of esophageal motility. High-resolution manometry (HRM) is the gold standard; endoscopic impedance planimetry (IP) with Endoflip 2.0 is increasingly utilized in esophageal disorders of motility. We hypothesized that normal IP motility would correlate with normal HRM motility and tested this in a prospective cohort study. Patients presenting for surgical evaluation of GERD between 9/2020 and 10/2021 were prospectively enrolled under an IRB-approved protocol. Patients with prior esophageal/gastric surgery, known motility disorders, or large paraesophageal hernias were excluded. All underwent HRM and IP, with normal motility defined by Chicago 3.0 classification for HRM and the presence of repetitive antegrade contractions for IP. Logistic regression and t test were used to analyze the data; p value < 0.05 was considered significant. Of 63 patients enrolled, 48 completed both IP and HRM testing. The cohort was 50% male with a median age of 52.5 [42.0, 66.0] years, mostly ASA class 1-2 (75.1%, n = 36) and had an average BMI of 31.4 ± 6.3kg/m2. Normal motility tracings were in 62.5% of IP and 75% of HRM tests. Using HRM as the gold standard, IP detected normal motility with a sensitivity of 65.8% and a specificity of 50% (positive predictive value 83.3%, negative predictive value 27.8%). Normal IP was not statistically significant in predicting normal HRM (OR 3.182, 95% CI 0.826-12.262, p = 0.0926). Tolerability of IP was significantly better than HRM with lower rates of discomfort (10.9% vs. 93.4%, p < 0.0001) and higher willingness to repeat testing (100% vs. 47.8%, p < 0.0001). Esophageal motility testing with Endoflip 2.0 is well tolerated by patients. The low specificity (50%), poor negative predictive value (27.8%), and lack of statistically significant concordance between IP and HRM raises concern for the reliability of this test as a stand-alone replacement for HRM in the pre-operative evaluation for 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.

Preoperative physiological esophageal assessment for anti-reflux surgery: A guide for surgeons on high-resolution manometry and pH testing.

Gastroesophageal reflux disease (GERD) is one of the most commonly encountered digestive diseases in the world, with the prevalence continuing to increase. Many patients are successfully treated with lifestyle modifications and proton pump inhibitor therapy, but a subset of patients require more aggressive intervention for control of their symptoms. Surgical treatment with fundoplication is a viable option for patients with GERD, as it attempts to improve the integrity of the lower esophageal sphincter (LES). While surgery can be as effective as medical treatment, it can also be associated with side effects such as dysphagia, bloating, and abdominal pain. Therefore, a thorough pre-operative assessment is crucial to select appropriate surgical candidates. Newer technologies are becoming increasingly available to help clinicians identify patients with true LES dysfunction, such as pH-impedance studies and high-resolution manometry (HRM). Pre-operative evaluation should be aimed at confirming the diagnosis of GERD, ruling out any major motility disorders, and selecting appropriate surgical candidates. HRM and pH testing are key tests to consider for patients with GERD like symptoms, and the addition of provocative measures such as straight leg raises and multiple rapid swallows to HRM protocol can assess the presence of underlying hiatal hernias and to test a patient’s peristaltic reserve prior to surgery.

Optimal cutoff value of integrated relaxation pressure on the esophagogastric junction to detect outflow obstruction using starlet high-resolution manometry system.

Achalasia and esophagogastric junction outflow obstruction (EGJOO) are idiopathic esophageal motility disorders characterized by impaired deglutitive relaxation of the lower esophageal sphincter (LES). High-resolution manometry (HRM) provides integrated relaxation pressure (IRP) which represents adequacy of LES relaxation. The Starlet HRM system is widely used in Japan; however, IRP values in achalasia/EGJOO patients assessed with the Starlet system have not been well studied. We propose the optimal cutoff of IRP for detecting achalasia/EGJOO using the Starlet system. Patients undergone HRM test using the Starlet system at our institution between July 2018 and September 2020 were included. Of these, we included patients with either achalasia or EGJOO and those who had normal esophageal motility without hiatal hernia. Abnormally impaired LES relaxation (i.e., achalasia and EGJOO) was diagnosed if prolonged esophageal emptying was evident based on timed barium esophagogram (TBE). A total of 111 patients met study criteria. Of these, 48 patients were diagnosed with achalasia (n = 45 [type I, n = 20; type II, n = 22; type III, n = 3]) or EGJOO (n = 3). In the 48 patients who had a prolonged esophageal clearance based on TBE, IRP values distributed along a wide-range of minimal 14.1 to a maximal of 72.2mmHg. The optimal cutoff value of IRP was 24.7mmHg with sensitivity of 89.6% and specificity of 84.1% (AUC 0.94). The optimal cutoff value of IRP to distinguish achalasia/EGJOO was ≥ 25mmHg using the Starlet HRM system in our cohort. This indicates that the current proposed cutoff of 26mmHg appears to be relevant.

339 OPTIMAL CUTOFF VALUE OF INTEGRATED LOWER ESOPHAGEAL SPHINCTER RELAXATION PRESSURE FOR ACHALASIA USING STARLET HIGH-RESOLUTION MANOMETRY SYSTEM

Abstract The Starlet high-resolution manometry (HRM) system is currently used in Japan. HRM provides integrated relaxation pressure (IRP) of which value represents adequacy of lower esophageal sphincter (LES) relaxation. The upper limit of normal IRP for the Starlet was proposed as 26 mmHg using healthy subjects. However, few studies have addressed whether this cutoff may well-distinguish patients diagnosed with/without achalasia. We propose the optimal cutoff of IRP for detecting achalasia using the Starlet. Methods Patients who underwent HRM test using the Starlet system at our institution between July 2018 and December 2019 were included. Of these, we excluded patients who had a history of achalasia surgery and/or endoscopic intervention, or whose HRM testing of poor quality. Achalasia was diagnosed if impaired esophageal emptying was evident based on timed barium esophagogram, upper endoscopy, and/or computed tomography. The optimal cutoff value of IRP was estimated using the receiver operating characteristic curve analysis. We further investigate difference in IRP values between achalasia subtypes to identify characteristics of patients who are more likely to be misdiagnosed. Results In total, 145 patients met study criteria. The mean age in our cohort was 52.5 ± 15.5 years, 89 patients (61.4%) were men. Of these, 42 patients (29.0%) were diagnosed with achalasia. In achalasia patients, IRP values extended to a wide-range from minimal 18.7 to maximal 63.9 mmHg. The optimal cutoff value of IRP was 24.7 mmHg with sensitivity 90.5% and specificity 90.3% (AUC 0.96 [95% CI; 0.92¬ to 0.99]). Patients with achalasia type I based on Chicago classification were most likely to have IRP value below the threshold of 25 mmHg (4/19 patients [21.1%]). Conclusion The optimal cutoff value of IRP to distinguish achalasia was ≥25 mmHg using the Starlet HRM system. This value was nearly close to the upper limit of normal IRP value of 26 mmHg in healthy volunteers. Achalasia type I was more likely to have normal IRP value indicating that comprehensive foregut assessment (eg, timed barium esophagogram, upper endoscopy, and computed tomography) is still valuable for management of achalasia.

Esophageal Manometry, pH Testing, Endoscopy, and Videofluoroscopy in Patients With Globus Sensation

Combine techniques commonly employed in the clinical workup of patients with isolated globus sensation to identify the most common pharyngoesophageal abnormality. The primary aim was to retrospectively review high-resolution manometry, pH probe testing, contrast videofluoroscopy, and endoscopy studies in patients with a primary complaint of globus sensation. The specific hypothesis was esophageal high-resolution manometry identifies the most significant proportion of abnormalities compared to all other modalities. Retrospective cohort study. An inclusive retrospective chart review was performed for patients evaluated between 2009 and 2016 with the primary complaint of globus sensation. Age at testing, self-identified gender, associated diagnoses, and results from each modality were collected. Descriptive statistics and pairwise comparisons were performed as well as sensitivity and specificity calculations. One hundred seventy-two patients met inclusion criteria. The cohort had an age range of 22.7 to 88.5 years and was predominantly female. Esophageal manometry identified abnormalities in 62.8% of patients, and pH testing identified abnormal acidification in approximately 20%. The esophagram identified abnormalities in 24% of patients, and esophagogastroduodenoscopy identified abnormalities in 22%. Modified barium swallows were normal in 93% of patients. Measures of sensitivity and specificity of other modalities were poor compared to esophageal manometry and pH testing. Patients with isolated globus sensation have evidence of esophageal dysmotility and laryngopharyngeal and gastroesophageal reflux disease in high proportions. Esophageal high-resolution manometry testing identifies the greatest proportion of abnormalities of the investigated modalities. 4 Laryngoscope, 130:2120-2125, 2020.

Elevation of Lower Esophageal Sphincter Pressure With Acute Transcutaneous Electrical Acustimulation Synchronized With Inspiration

Gastroesophageal reflux disease (GERD) is a common esophageal disorder. Transcutaneous electrical acustimulation (TEA), as a needleless method of electroacupuncture (EA) has been reported to improve hypotensive lower esophageal sphincters pressure (LESP) in GERD. Synchronized TEA (STEA) with inspiration has been revealed to be more effective than TEA in enhancing vagal tone. To explore the effect of STEA on LESP in GERD and possible mechanisms involving autonomic functions. Sixty patients were randomly allocated into a STEA group (45 patients) and sham-TEA group (15 patients). The ECG was recorded for the assessment of the autonomic function, followed with an esophageal high-resolution manometry (HRM) test. When the test was completed, the STEA or sham-TEA treatment was performed for 30 minutes. Then the HRM test was repeated. STEA increased LESP from 21.9 to 31.9 mmHg in GERD patients (p < 0.001). A negative correlation between the percentage of STEA-induced increase in LESP and basal LESP was observed (R = -0.471, p = 0.001). STEA reduced the number of ineffective esophageal contractions (p < 0.05). STEA rather than sham-TEA increased vagal activity (0.27 ± 0.14 vs. 0.36 ± 0.18, p < 0.001) and decreased sympathetic activity (0.73 ± 0.14 vs. 0.64 ± 0.18, p < 0.001). Acute STEA augments LESP in GERD and the percentage of the increase in LESP was negatively correlated with basal LESP. The effect of STEA on LESP might be mediated via autonomic function. The authors reported no conflict of interest.

Validation of the oesophageal hypervigilance and anxiety scale for chronic oesophageal disease.

Oesophageal hypervigilance and anxiety can drive symptom experience in chronic oesophageal conditions, including gastro-oesophageal reflux disease, achalasia and functional oesophageal disorders. To date, no validated self-report measure exists to evaluate oesophageal hypervigilance and anxiety. This study aims to develop a brief and reliable questionnaire assessing these constructs, the oesophageal hypervigilance and anxiety scale (EHAS). Questions for the EHAS were drawn from 4 existing validated measures that assessed hypervigilance and anxiety adapted for the oesophagus. Patients who previously underwent high-resolution manometry testing at a university-based oesophageal motility clinic were retrospectively identified. Patients were included in the analysis if they completed the EHAS as well as questionnaires assessing symptom severity and health-related quality of life at the time of the high-resolution manometry. Nine hundred and eighty-two patients aged 18-85 completed the study. The EHAS demonstrates excellent internal consistency (α=0.93) and split-half reliability (Guttman=0.87). Inter-item correlations indicated multicollinearity was not achieved; thus, no items were removed from the original 15-item scale. Principal components factor analysis revealed two subscales measuring symptom-specific anxiety and symptom-specific hypervigilance. Construct validity for total and subscale scores was supported by positive correlations with symptom severity and negative correlations with health-related quality of life. The EHAS is a 15-item scale assessing oesophageal hypervigilance and symptom-specfic anxiety. The EHAS could be useful in evaluating the role of these constructs in several oesophageal conditions in which hypersensitivity, hypervigilance and anxiety may contribute to symptoms and impact treatment outcomes.

Normal Values of High-Resolution Manometry in Supine and Upright Positions in a Thai Population.

Although cut-off values used in high-resolution manometry (HRM) to diagnose esophageal motility disorders are based on representative samples of the US population and assume a supine position, differences in population and body positioning can reportedly affect results. To establish normal HRM values for Thai people in both supine and upright positions. Forty-one healthy subjects were recruited, each of whom underwent solid-state HRM with ten 5-mL swallows of water in both the supine and upright positions. Measuring parameters according to the Chicago classification criteria (CC v3.0) were included, for which the mean, median and 5th and 95th percentiles (PCTLs) were calculated. The results corresponded with the CC v3.0 criteria, except for the mean, and 5th PCTL of the distal contractile integral (DCI), which were lower for this population. In the upright position, the mean and median values for DCI, intrabolus pressure and integrated relaxation pressure were significantly decreased, whereas the length of the transitional zone was significantly increased. The limitations of this study include: (1) the relatively low number of participants, (2) the limited recruitment of participants only at Ramathibodi Hospital and (3) the limited recruitment of only young and middle-aged participants. We established normal values for the HRM parameters in a representative sample of the Thai population. Our supine results still prove that the use of the CC v3.0 is preferable. HRM testing in patients measured in the upright position should be analyzed based on the normative values obtained from upright swallow studies.

Esophagogastric junction contractility for clinical assessment in patients with GERD: a real added value?

The role of esophagogastric junction contractile integral (EGJ-CI) as assessed by high-resolution manometry (HRM) is unclear. We aimed to correlate the EGJ-CI with impedance-pH findings in gastro-esophageal reflux disease (GERD) patients. Consecutive patients with GERD symptoms were enrolled. All patients underwent upper endoscopy, HRM, and impedance-pH testing. The EGJ-CI was calculated using the distal contractile integral tool box during three consecutive respiratory cycles. The value was then divided by the duration of these cycles. A value below 13 was considered as a defective EGJ-CI. We also assessed EGJ morphology, esophageal acid exposure time (AET), number of reflux episodes (NRE), and symptom association analysis (SAA). A positive impedance-pH monitoring was considered in case of abnormal AET and/or NRE and/or positive SAA. Among 130 patients we enrolled, 91 had GERD (abnormal AET and/or elevated NRE and/or positive SAA) and 39 had functional heartburn (FH) (negative endoscopy, normal AET, normal NRE, and negative SAA). The GERD patients had a lower median value of EGJ-CI (11 [3.1-20.7] vs 22 [9.9-41], p<0.02) compared to FH patients. Patients with a defective EGJ-CI had, more frequently, a positive impedance-pH monitoring or esophageal mucosal lesions at endoscopy (p<0.05 and p<0.05, respectively) than patients with a normal EGJ-CI. An EGJ-CI cut-off value of 5mmHgcm yielded the optimal performance in identifying GERD at impedance-pH (sensitivity 89%-specificity 63%). A defective EGJ-CI at HRM is clearly associated with evidence of GERD at impedance-pH monitoring. Evaluating EGJ-CI may be useful to predict an abnormal impedance-pH testing.

Esophagogastric junction morphology is associated with a positive impedance‐pH monitoring in patients with GERD

High-resolution manometry (HRM) provides information on esophagogastric junction (EGJ) morphology, distinguishing three different subtypes. Data on the correlation between EGJ subtypes and impedance-pH detected reflux patterns are lacking. We aimed to correlate the EGJ subtypes with impedance-pH findings in patients with reflux symptoms. Consecutive patients with suspected gastroesophageal reflux disease (GERD) were enrolled. All patients underwent HRM and impedance-pH testing off-therapy. EGJ was classified as: Type I, no separation between the lower esophageal sphincter (LES) and crural diaphragm (CD); Type II, minimal separation (>1 and <2 cm); Type III, ≥ 2 cm separation. We measured esophageal acid exposure time (AET), number of total reflux episodes and symptom association analysis. We enrolled 130 consecutive patients and identified 46.2% Type I EGJ, 38.5% Type II, and 15.4% Type III patients. Type III subjects had a higher number of reflux episodes (61 vs 45, p < 0.03, vs 25, p < 0.001), a greater mean AET (12.4 vs 4.2, p < 0.02, vs 1.5, p < 0.001) and a greater positive symptom association (75% vs 72%, p = 0.732 vs 43.3%, p < 0.02) compared with Type II and I patients, respectively. Furthermore, Type II subjects showed statistically significant (overall p < 0.01) increased reflux when compared with Type I patients. Type III and II EGJ morphologies had a more frequent probability to show a positive multichannel intraluminal impedance pH monitoring than Type I (95% vs 84% vs 50%, p < 0.001). Increasing separation between LES and CD can cause a gradual and significant increase in reflux. EGJ morphology may be useful to estimate an abnormal impedance-pH testing in GERD patients.

Comparing Diagnostic Tests in Dyssynergic Defecation-Constipation

Introduction: Idiopathic chronic constipation is a common medical problem, with an average reported prevalence of 15% in North America. The prevalence of constipation is higher in women. Normal transit constipation, colonic inertia, and dyssynergic defecation (DD) are subtypes of idiopathic chronic constipation. There is limited agreement among tests to diagnose dyssynergic defecation. Dyssynergic defecatory symptoms, failure to expel a 60-mL balloon during a balloon expulsion test, and anal sphincter dyssynergic pattern on manometry testing are frequently used for diagnosing pelvic floor dyssynergia. The aim of this study is to compare the result of different studies in predicting DD. Methods: From January 2013 to May 2014, 143 consecutive constipated patients referred for pelvic floor testing were included in the study and the results of their work-ups were collected. Detailed questionnaires regarding patients’ defecatory symptoms, pertinent medical and surgical history, medication use, and digital rectal exam by gastroenterologists with motility expertise were collected prior to anorectal high-resolution manometry testing. Results: Our study includes 143 patients with constipation who were referred by their primary physician or gastroenterologist to our tertiary care center for pelvic floor testing. The mean age of the patients was 50 years with the majority of the patients being female (87%). Mean resting pressures were 62±6 mm Hg, mean squeeze pressures 143±13 mm Hg, and maximum tolerated volume was 201±63 mL; 111 patients (78%) had symptoms on questionnaire suggestive of DD. While 80 patients (56%) had an expert-performed digital rectal exam suggestive of DD, high-resolution manometry diagnosed dyssynergic pattern in 83 patients (58%). Expert-performed digital rectal exam is 87% sensitive and 85% specific for diagnosing DD versus dyssynergia documented by high-resolution manometry as the gold standard. Balloon expulsion test was abnormal (more than 2 minutes) in 57 subjects (40%). Among 32 patients with DD on manometry test who had normal balloon expulsion test (<2 min), 14 (43%) patients had resting anal pressure less than 45 mm Hg. Conclusion: Defecation is a complex process, influenced by stool consistency and pelvic floor neuromuscular sensation and function. While, there is no single criterion in diagnosing dyssynergic defecation (DD), the ability to expel a 60-mL balloon does not exclude the presence of pelvic floor dyssynergia. Therefore, a careful interpretation of the test results is important in making the correct diagnosis.

Dysmotility and reflux disease

In the last decade, with the advent of new oesophageal testing [i.e. 24-h impedance-pH monitoring, combined impedance-manometry, high-resolution manometry (HRM)], relevant progress in understanding the mechanisms contributing to the development of gastro-oesophageal reflux disease (GORD) has been made, allowing a better management of patients with this disorder. The aim of our review is to report the state-of-the-art about oesophageal motor disorders in patients with reflux disease and to stimulate new research in this field. Hypotensive lower oesophageal sphincter (LOS), transient LOS relaxations, impairment of oesophagogastric junction including hiatal hernia, oesophageal bolus transit abnormalities and presence of ineffective oesophageal motility have been strongly implicated in GORD development. In particular, the majority of recent studies carried out with HRM and impedance-pH testing reported that these motor abnormalities are increasingly prevalent with increasing severity of GORD, from nonerosive reflux disease and erosive oesophagitis to Barrett's oesophagus. Defining and characterizing oesophageal dysmotility in patients with reflux disease is of maximum importance in order to properly diagnose these patients and to treat them with the best management of care. New studies are needed in order to better understand the physiomechanic basis of oesophageal dysmotility in GORD patients.

Review of current diagnosis and management of diffuse esophageal spasm, nutcracker esophagus/spastic nutcracker and hypertensive lower esophageal sphincter

To cover the diagnosis and management of diffuse esophageal spasm, nutcracker esophagus/spastic nutcracker and hypertensive lower esophageal sphincter. An outline of the presentation and manometric features of these conditions will precede a discussion of therapies. All of these diagnoses are made manometrically, even though they may be suspected by presentation and by findings at video fluoroscopic swallow or gastroscopy testing. The advent of high-resolution manometry testing has allowed a better understanding of these motility disorders, and the ability to standardize the diagnoses by the use of the Chicago Classification is a major step forward. Recent developments show that botulinum toxin and perioral myotomy can be an effective treatment for some patients. This should bring more therapies to the fore in the future, but at present there is still the need for more prospective study of best therapies. The important point to remember for all of these conditions is that unlike achalasia, there is no definite pathological correlation to the manometrically observed abnormalities. This therefore makes the management challenging and means that treatment pathways are not as well set out as for some other upper gastrointestinal motility problems.

The Natural History of Esophagogastric Junction Outflow Obstruction and Treatment Outcomes

Purpose: Esophagogastric junction outflow obstruction (EGJOO) is a diagnosis made by high resolution manometry (HRM) that represents a heterogeneous group of disorders that cause dysphagia. Potential causes of EGJOO include evolving achalasia, strictures, extrinsic compression by tumors or the aorta, and functional obstruction where no cause is found. The focus after encountering EGJOO should be in determining the cause of the obstruction, then treating the cause. Little is known about the natural history of EGJOO. Methods: We conducted a retrospective chart review and cross sectional phone survey of patients (25-92 years old) with a diagnosis of EGJOO by HRM between June 2010 to June 2012. EGJOO was defined as a minimum integrated relaxation pressure (IRP) of 15 mmHg as well as at least one normal or weak swallow on HRM. Exclusion criteria included diagnosis other than EGJOO on HRM and a history of prior surgical procedure causing the EGJOO. Chart review measures included patient demographic and clinical characteristics (documented symptoms, prior endoscopies, endoscopic ultrasound, and treatments). Patients were contacted via telephone between November 2012 and April 2013 and asked to rate specific symptoms on a severity scale both before and after diagnosis with manometry, and whether improvement in symptoms had been achieved. Results: Ninety-four patients with EGJOO based on HRM data were initially included in the analysis. 16 patients that had a surgical cause of the EGJOO were excluded, and 21 patients were unable to complete the phone survey for various reasons. Dysphagia was the predominant symptom that initiated HRM testing (46%), followed by chest pain (32%), heartburn (20%), or nausea and vomiting (19%). Of the patients contacted by phone (N=57), 61.4% reported overall improvement in their symptoms; however, many of these patients did not receive treatment for EGJOO (54.4%). There were proportionally more patients reporting improvement in symptoms who received treatment (69.2%) compared to those who did not (54.8%), but this did not reach statistical significance (P=0.115). Conclusion: Dysphagia is the most common presenting symptom in patients with a diagnosis of EGJOO, although other atypical symptoms such as heartburn, regurgitation, and nausea and vomiting may be present, likely due to the diversity of causes. The majority of patients reported improvement in symptoms over time. Future research should involve prospective, well designed studies with a greater number of patients to evaluate the effect of different treatment modalities on patient outcomes.Table: Table. Demographics, swallow characteristics, and treatmentsTable: Table. Improvement by treatment status

PTU-164 The clinical utility of the endoscopic functional luminal imaging probe in eosinophilic oesophagitis: a case series

IntroductionDisease severity assessment in eosinophilic oesophagitis (EoE) is limited by the poor correlation of endoscopic appearance and histological eosinophil density with symptoms. Our aim is to ascertain whether having a...