Higher Distal Contractile Integral 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.

Evaluating the impact of position, volume, and consistency on high-resolution esophageal manometry outcomes.

The Chicago classification primarily utilizes ten 5 mL liquid swallows in a supine position as the standard high-resolution esophageal manometry (HRM) protocol. HRM can be performed with varying volumes and consistencies and in an upright position. We aimed to determine the impact on HRM results by (1) position, (2) swallows of differing volume and consistency, and (3) perception of bolus passage. HRM was performed in healthy volunteers (HV) with the following protocol of swallows: liquids 10 × 5 mL, 5 × 10 mL, and 3 × 10 mL multiple rapid swallows; applesauce 5 × 5 mL and 5 × 10 mL; and bread 5 × 2 × 2 cm and 5 × 4 × 4cm. HV rated difficulty of each swallow on a 5-point Likert scale. All HVs performed the protocol in supine position first and then in "semi-upright" (sitting 70 degrees in a bed) and "upright" (sitting in a chair) in a randomized order. Thirty-seven HVs, median age 27 years, 64% female completed this study. Median distal contractile integral (DCI) and integrated relaxation pressure 4 s (IRP4) of 5 mL liquid swallows significantly differed (all p < 0.01) between position performed. Large volume swallows resulted in higher DCI and lower IRP4. IRP4 results were significantly increased for 2 × 2 cm pieces of bread compared to 5 mL water swallows. DCI results were higher for 2 × 2 cm pieces of bread compared to 5 mL water swallows. Distal latency was shorter in more upright positions. Among this cohort of HV, perceived difficulty of bolus passage was more likely to occur with solid boluses. The volume and consistency of a swallow and the position it is performed in, significantly alter HRM metrics. Interpretation of HRM studies should incorporate different normative values which are specific to the position and bolus type.

Differences in clinical characteristics between conservative-treatment-response group and refractory (surgical-treatment) group in patients with jackhammer esophagus.

Jackhammer esophagus (JE) is a rare disease with unclear clinical features. The objective of this study was to retrospectively compare the clinical characteristics of patients with JE whose symptoms were controlled with conservative treatment, such as observation or medication, versus those who were required surgical treatment, such as surgical myotomy or per oral endoscopic myotomy. Eighteen patients with JE were included in this study. The patients were divided into two groups: patients who responded to conservative treatment (C group) and patients who were refractory to conservative treatment and underwent surgery (S group). Patient age, sex, disease duration before treatment, symptoms, esophagogastroduodenoscopic (EGD) findings, esophagographic findings, esophageal wall thickness on computed tomography, number of swallows with hypercontractile peristalsis in 10 water swallows, and maximum distal contractile integral (DCI) were compared between the groups. Thirteen of 18 patients (72%) were in the C group and five of 18 (28%) were in the S group. There were no significant differences in age, sex, disease duration before treatment, symptoms, EGD findings, esophagographic findings, esophageal wall thickness, or number of swallows with hypercontractile peristalsis between the groups. On Starlet high-resolution manometry, the median maximum DCI value was significantly higher in the S group (32,651mmHg-s-cm) than in the C group (17,926mmHg-s-cm) (P = 0.0136). JE treatment should be carefully considered because some patients require surgery, whereas others are controlled with conservative treatment alone. A higher DCI value in patients with JE may predict resistance to conservative treatment.

442 Strength of Peristalsis and Its Association With Bolus Clearance in Esophageal Motility Disorders

INTRODUCTION: High resolution manometry (HRM) is a valuable tool increasingly used in clinical practice for diagnosis of esophageal disorders. Impedance measurement was recently added to the manometry catheter to assess bolus clearance. However, clinical utility of this metric and its association with esophageal motility disorders are currently unknown. The aims of this study are to a) evaluate the association between strength of peristalsis and bolus clearance and b) compare the strength of peristalsis and bolus clearance between normal patients and patients with various esophageal motility disorders. METHODS: A retrospective review of patients referred for HRM at our tertiary academic center from January 2016 to October 2018 was performed. All studies were interpreted by two HRM-trained GI specialists and reported in accordance with the Chicago classification of esophageal motility disorders, version 3.0. Distal Contractile Integral (DCI) was used to measure strength of peristalsis. Bolus clearance was measured by visual assessment of color topography clearance of bolus in each swallow. Greater than 50% complete bolus clearance was considered as effective peristalsis. Demographic and manometry data were analyzed using STATA 15.1. RESULTS: 1,323 consecutive studies were included in the analysis. The mean age was 59.6± 14.5 years. Of these 898 (67.9%) were women. Women were overall older with an average of 60.1 ± 0.5 years compared to men (58.5 ± 0.8 Years, P = 0.0332). The most commonly diagnosed motility disorder was ineffective esophageal motility (IEM) (284, 21.5%). There was moderate correlation between DCI and intrabolus pressure (r = 0.29, P &lt; 0.001). Patients with normal esophageal motility had higher DCI (1875.9 vs 551.8, P &lt; 0.0001) and complete bolus clearance (85.8% vs 56.8%, P &lt; 0.0001) compared to patients with IEM. In contrast, patients with spastic motility disorders (Achalasia and Esophagogastric Junction Outflow Obstruction) had lower bolus clearance (43.2% vs 85.2%, P &lt; 0.0001) despite higher DCI than normal patients (4661 vs 1875, P &lt; 0.0001). ROC analysis showed that a DCI of 320 mmHgcm2 had greater accuracy in predicting complete clearance of bolus in &gt;50% of swallows (96.5% sensitivity, 24.8% specificity) compared to 450 mmHgcm2 (accuracy 83.1% vs 79.3%, P &lt; 0.0001). CONCLUSION: In our large cohort of patients, HRM peristaltic metrics suggest that a DCI cut-off value of 320 mmHgcm2 had greater accuracy for predicting complete bolus clearance.

Jackhammer Esophagus: Symptom Presentation, Associated Distal Contractile Integral, and Assessment of Bolus Transit.

The aim of our study was to characterize jackhammer esophagus symptoms and their relationship with the distal contractile integral (DCI) and bolus transit. Jackhammer esophagus is defined by the Chicago Classification version 3.0. This diagnosis is relatively new, with the most current definition being established in 2014. The forerunners of this diagnosis, nutcracker (or hypercontractile) esophagus, have been associated with noncardiac chest pain (NCCP). A retrospective chart review was performed of motility studies from 2011 to 2016. Studies with a diagnosis of jackhammer esophagus, hypercontractile esophagus, nutcracker, esophagogastric junction outflow obstruction, or hypertensive lower esophageal sphincter were reread using Chicago Classification version 3.0, and were included if they met criteria for jackhammer esophagus. Unpaired t-tests were used for analysis (P≤0.05). In total, 142 studies were identified with the above diagnoses. After excluding 84 studies, 58 remained for analysis and 17 were found to have jackhammer esophagus (29%). The mean age was 54 (28 to 75), 5 (29%) were males and 12 (71%) were females. The primary indications were NCCP (5), dysphagia (8), and other causes (4) (cough, heartburn, or regurgitation). The mean DCIs were 17,245 mm Hg×s×cm (NCCP), 14,669 mm Hg×s×cm (dysphagia), and 11,264 mm Hg×s×cm (other causes). The mean DCIs were compared: NCCP versus dysphagia (P=0.41), and NCCP versus other causes (P=0.05). Fifteen (88%) had normal bolus transit for both liquid and viscous swallows. In our small sample size, dysphagia was frequently the presenting symptom followed by NCCP. Those with NCCP have a trend toward a higher DCI. Bolus transit appeared to be normal in this patient population. More data are needed to further elucidate the genesis of symptoms and how they relate to the degree of contractility.

Preoperative High‐Resolution Manometry Criteria are Associated with Dysphagia After Nissen Fundoplication

Dysphagia after Nissen fundoplication is challenging for patients. High-resolution manometry (HRM) has rarely been studied preoperatively to determine whether manometry values correlated with postoperative dysphagia after fundoplication. We aim to determine whether HRM criteria could predict dysphagia after Nissen fundoplication. A retrospective review of single-institution laparoscopic Nissen fundoplications (LNF) from 2013 to 2015 was completed. Dysphagia was graded using a standard scale. Four groups were: those with new postoperative dysphagia (ND), never had dysphagia (NV), continued dysphagia (CD), and resolved dysphagia (RD). Manometry criteria included distal contractile integral (DCI), contraction front velocity (CFV), distal latency (DL), integrated relaxation pressure (IRP), percent peristalsis (PP), and distal esophageal contraction amplitude (DECA). Statistical bootstrapping was used to power sample sizes for ANOVA analysis. Ninety-four patients were included in the original cohort. Statistical bootstrapping sample size was 2992 patients. Among patients who did not have dysphagia prior to LNF, no HRM metric was associated with developing new dysphagia. Among those with dysphagia prior to LNF, a higher DCI, CFV, DL, PP, and DECA were associated with resolution of dysphagia. The RD group was 2.77 times more likely to have a DCI ≥ 1000mmHg-s-cm compared with the CD group. HRM criteria could not predict the development of postoperative dysphagia. However, in those with preoperative dysphagia and strong manometry criteria, dysphagia is more likely to resolve after Nissen fundoplication. Meanwhile, in those with preoperative dysphagia and weak manometry, dysphagia may persist and these patients may be better served with a partial fundoplication.

Tu1191 Impaired Bolus Transit of Esophageal Swallows May Play an Important Role in Eliciting Globus: A Study Using High-Resolution Impedance Manometry

Background/Aims: Although gastroesophageal reflux disease (GERD) has been suggested to be a major etiology of globus, there is still considerable debate about the causative role of GERD in globus patients. We aimed to investigate the new etiology of globus and its mechanism using high-resolution impedance manometry (HRIM). Methods: A total of 57 consecutive patients with globus sensation, who underwent HRIM, impedance-pH monitoring, and upper endoscopy at Samsung Medical Center, Seoul, Korea, between June 2011 and August 2012, were identified. In addition, 9 normal subjects were recruited and included into analysis. The patients were divided according to the presence of GERD and impaired bolus transit (IBT) for analysis. Using HRIM, esophageal peristalsis parameters, esophageal hypomotility markers including intersegmental trough (IST), extended IST, proximal latency (PL), prolonged PL and fragmented or failed sequence, and bolus transit pattern were evaluated. Esophageal motility abnormality was determined according to the Chicago classification. Results: Of the 57 globus patients, 28 (49.1%) were male and the mean age was 52.3 ± 13.0 (SD) years. Thirteen globus patients (22.8%) were diagnosed with GERD and 42 (73.7%) showed IBT. In comparison between globus patients and normal controls, globus patients were older and more likely to have IBT and had higher integrated relaxation pressure and longer peristaltic break and IST than normal controls (P,0.05). However, there were no significant differences between the two groups with regard to sex, body mass index, reflux esophagitis, other peristalsis parameters, motility abnormality, and other hypomotility markers. In comparison between GERD-related and non GERD-related globus groups, no significant differences were identified with regard to age, sex, body mass index, underlying disease, concomitant symptom, peristalsis parameters, motility abnormality, hypomotility markers, and IBT. Regardless of GERD, the majority of globus patients showed IBT: 9 (69.2%) in GERD-related globus group and 33 (75.0%) in non GERD-related globus group (P=0.73). In comparison between IBT and normal bolus transit globus groups, IBT globus group had higher distal contractile integral and contractile front velocity and longer peristaltic break, IST, and PL and was more likely to have motility abnormality and fragmented or failed sequence than normal bolus transit globus group (P,0.05). Although the majority of globus patients (20/21, 95.2%) with motility abnormality showed IBT, a significant portion of globus patients (22/42, 52.4%) with IBT did not have motility abnormality. Conclusion: IBT may be a major etiologic factor in globus patients. Esophageal motility abnormality alone does not explain the IBT enough, suggesting that other mechanisms are involved in determining IBT in globus patients.

Tu1193 Impaired Bolus Transit of Esophageal Swallows May Play an Important Role in Eliciting Non-Cardiac Chest Pain: A Study Using High-Resolution Impedance Manometry

Background/Aims: Although gastroesophageal reflux disease (GERD) has been suggested to be a major etiology of globus, there is still considerable debate about the causative role of GERD in globus patients. We aimed to investigate the new etiology of globus and its mechanism using high-resolution impedance manometry (HRIM). Methods: A total of 57 consecutive patients with globus sensation, who underwent HRIM, impedance-pH monitoring, and upper endoscopy at Samsung Medical Center, Seoul, Korea, between June 2011 and August 2012, were identified. In addition, 9 normal subjects were recruited and included into analysis. The patients were divided according to the presence of GERD and impaired bolus transit (IBT) for analysis. Using HRIM, esophageal peristalsis parameters, esophageal hypomotility markers including intersegmental trough (IST), extended IST, proximal latency (PL), prolonged PL and fragmented or failed sequence, and bolus transit pattern were evaluated. Esophageal motility abnormality was determined according to the Chicago classification. Results: Of the 57 globus patients, 28 (49.1%) were male and the mean age was 52.3 ± 13.0 (SD) years. Thirteen globus patients (22.8%) were diagnosed with GERD and 42 (73.7%) showed IBT. In comparison between globus patients and normal controls, globus patients were older and more likely to have IBT and had higher integrated relaxation pressure and longer peristaltic break and IST than normal controls (P,0.05). However, there were no significant differences between the two groups with regard to sex, body mass index, reflux esophagitis, other peristalsis parameters, motility abnormality, and other hypomotility markers. In comparison between GERD-related and non GERD-related globus groups, no significant differences were identified with regard to age, sex, body mass index, underlying disease, concomitant symptom, peristalsis parameters, motility abnormality, hypomotility markers, and IBT. Regardless of GERD, the majority of globus patients showed IBT: 9 (69.2%) in GERD-related globus group and 33 (75.0%) in non GERD-related globus group (P=0.73). In comparison between IBT and normal bolus transit globus groups, IBT globus group had higher distal contractile integral and contractile front velocity and longer peristaltic break, IST, and PL and was more likely to have motility abnormality and fragmented or failed sequence than normal bolus transit globus group (P,0.05). Although the majority of globus patients (20/21, 95.2%) with motility abnormality showed IBT, a significant portion of globus patients (22/42, 52.4%) with IBT did not have motility abnormality. Conclusion: IBT may be a major etiologic factor in globus patients. Esophageal motility abnormality alone does not explain the IBT enough, suggesting that other mechanisms are involved in determining IBT in globus patients.