Ineffective Esophageal Motility Patients Research Articles

High-Resolution Manometry Diagnosis of Ineffective Esophageal Motility Is Associated with Higher Reflux Burden.

Ineffective esophageal motility (IEM) is the most commonly diagnosed abnormality on high-resolution manometry (HRM). However, the clinical significance of IEM and associated reflux burden remains unclear. Our primary aim was to compare reflux patterns between IEM versus normal motility on HRM. HRM and reflux studies in patients with IEM and normal motility were retrospectively reviewed. Esophageal pressure topography parameters, reflux variables, and patient-reported outcome questionnaires were explored. A total of 239 patients with IEM were explored. Of these, 146 underwent reflux monitoring. Additionally, 100 patients with normal HRM all of whom had undergone reflux monitoring were included. IEM patients were more likely to have an abnormal number of reflux events compared to normal (22.7% vs. 9.0%, p < 0.01). Including only off-proton pump inhibitor (PPI) testing, IEM patients had higher mean total acid exposure time (AET) and total reflux events compared to normal motility (p = 0.02). Within IEM patients, higher AET modestly correlated with increased percentage of impaired swallows. Increased reflux events modestly correlated with higher impaired swallows and decreased lower esophageal sphincter (LES) resting pressure. Reflux burden increased with higher esophagogastric junction (EGJ) subtype, driven mostly by subtype III, although there was no difference in the distribution of EGJ subtypes between the IEM and normal HRM cohorts. Patients with HRM diagnosis of IEM may be more prone to acid reflux while off-PPI and non-acid reflux while on-PPI. Reflux burden appears to be worse in IEM patients who have lower resting LES pressure, higher EGJ subtype, or higher percentage of impaired swallows.

Influence of prucalopride on esophageal secondary peristalsis in reflux patients with ineffective motility.

Ineffective esophageal motility (IEM) is associated with gastroesophageal reflux disease. Secondary peristalsis contributes to esophageal clearance. Prucalopride promotes secondary peristalsis by stimulating 5-hydroxytrypatamine 4 receptors in the esophagus. We aimed to determine whether prucalopride would augment secondary peristalsis in gastroesophageal reflux disease patients with IEM. After a baseline recording of primary peristalsis, secondary peristalsis was stimulated by slow and rapid mid-esophageal injections of air in 15 patients with IEM. Two separate sessions with 4-mg oral prucalopride or placebo were randomly performed. Prucalopride significantly increased primary peristaltic wave amplitude (68.1±10.0 vs 55.5±8.8mmHg, P=0.02). The threshold volume for triggering secondary peristalsis was significantly decreased by prucalopride during slow (9.3±0.8 vs 12.0±0.8mL; P=0.04) and rapid air injection (4.9±0.3 vs 7.1±0.1mL; P=0.01). Secondary peristalsis was triggered more frequently after application of prucalopride (55% [43-70%]) than placebo (45% [33-50%]) (P=0.008). Prucalopride did not change pressure wave amplitudes during slow air injection (84.6±8.1 vs 57.4±13.8mmHg; P=0.19) or pressure wave amplitudes during rapid air injection (84.2±8.6 vs 69.5±12.9mmHg; P=0.09). Prucalopride enhances primary peristalsis and mechanosensitivity of secondary peristalsis with limited impact on secondary peristaltic activities in IEM patients. Our study suggests that prucalopride appears to be useful in augmenting secondary peristalsis in patients with IEM only via sensory modulation of esophageal secondary peristalsis.

Severity of ineffective esophageal motility is associated with utilization of skeletal muscle relaxant medications.

Ineffective esophageal motility (IEM) is the most common finding on high-resolution esophageal manometry (HREM). The underlying mechanisms for IEM remain to be fully elucidated. The aim of this study was to determine if utilization of skeletal muscle relaxants is associated with IEM, and with more severe subtypes of the disorder. Patients with diagnosis of IEM were gender and age matched to patients with normal HREM. Demographic information, symptoms, endoscopic findings, medication usage and medical comorbidities were recorded. Patients with a diagnosis of IEM were divided into subgroups based on mean distal contractile integral (DCI) and percentage of ineffective swallows, and assessed for clinically significant differences among patients with varying severity of underlying IEM. A total of 118 patients were included in each group. There were no significant clinical differences between the group of patients with IEM and the group of patients with normal manometry. Within the group of IEM patients, those with mean DCI<250mmHg/s/cm were more likely to be prescribed skeletal muscle relaxants (27.8% vs 11.0%, P=.044), and those using skeletal muscle relaxants had a larger mean percentage of ineffective swallows (81.1% vs 71.5%, P=.029). There were no significant differences across mean DCI subgroups in usage of any other medication, or in any of the demographic variables or disease comorbidities examined in this study. Use of skeletal muscle relaxants is associated with more severe IEM, which may suggest a causal association between this class of medications and weaker esophageal peristalsis.

Role of Esophageal Dilation in Patients With Ineffective Esophageal Motility

Introduction: Ineffective Esophageal Motility (IEM)is diagnosed by manometry based on the strength of contractions in the esophagus. Patients with IEM may report dysphagia, angina, globus, regurgitation and acid reflux. The mechanism behind this diagnosis involves an imbalance of inhibitory and excitatory forces on the esophagus. Furthermore, there hasn't been sufficient evidence supporting any treatment. Esophageal dilation is frequently used in IEM patients with dysphagia. Objective: To evaluate effectiveness of esophageal dilation in relieving dysphagia in IEM patients. Methods: Retrospective cohort analysis of 130 adult patients with IEM between 2006 and 2015. Of the 130 patients with IEM, 37 underwent EGD with dilation. Of the 37 who were dilated, 31 returned for a follow-up appointment. Resolution or return of dysphagia was recorded. Data was then analyzed to determine if dilatation improved dysphagia.FigureTable: Table. Patients with IEM who had one EGD with dilationTable: Table. Patients with IEM who had multiple EGD with dilationResults: 28% underwent EGD with dilation. 73% were female mean age was 53 see. figure and table. Conclusion: This data suggests that esophageal dilation may, at least temporarily, help relieve dysphagia in about 40% of patients with IEM. Unfortunately, half of those had recurrence of dysphagia within a few months. Further studies are needed to better define the role of esophageal dilation in this population.

Randomized Placebo-Controlled Double-Blind Crossover Trial of Buspirone in Functional Dysphagia and Ineffective Esophageal Motility

Introduction: Functional Dysphagia (FD) is a syndrome in which patients report dysphagia without evidence of Gastroesophageal Reflux Disease (GERD) or a histopathology-based esophageal motility disorder. There are data that argue that Ineffective Esophageal Motility (IEM) is the manometric correlate of FD. IEM is defined as a High Resolution Esophageal Manometry (HREM) with 50% or more of the swallows having a Distal Contractile Index (DCI) of. Methods: We performed a prospective, double-blind, placebo-controlled, cross-over trial of 10 patients with both FD and IEM. Patients were randomized to one of two groups for a period of six total weeks. Group A patients were treated with buspirone for two weeks followed by a two-week washout period and subsequently treated with placebo. Patients in Group B were treated with placebo for the first two weeks and buspirone the last two weeks. Outcomes measured at baseline, end of week 2, and week 6 include the Mayo Dysphagia Questionnaire-14 (MDQ-14), the GERD-HRQL, and HREM. A sample size of 10 patients was found to have 80% power to detect a difference of 25% in the number of failed or weak swallows. Results: The mean age of our 10 patients was 53 +/- 9 years and 70% were female. While 70% of the patients treated with placebo had IEM, only 50% of those treated with buspirone had IEM. However, this difference was not statistically significant. Furthermore, when comparing those treated with placebo with those treated with buspirone, there was no statistically significant difference in resting lower esophageal sphincter pressure, median integrated residual pressure, mean DCI, or percentage of swallows weak, failed, or normal (Table 1). There was also no statistically significant difference in any of the questions in the MDQ-14 or the GERD-HRQL (Table and Figure 1). Of note, patients had a statistically significant decrease in the total GERD-HRQL total score when treated with placebo compared to baseline levels.Figure: Percentage of Patients with Dysphagia at Baseline, With Placebo, and After Buspirone.Table: Table. Buspirone versus Placebo in Functional Dysphagia and Ineffective Esophageal MotilityConclusion: Despite previous data showing improved motility in healthy volunteers, our study shows no difference in terms of HREM parameters or symptom scores in FD and IEM patients treated with buspirone compared to placebo. Further research is necessary to identify novel agents.

Ineffective esophageal motility: clinical, manometric, and outcome characteristics in patients with and without abnormal esophageal acid exposure.

The etiology and clinical impact of ineffective esophageal motility (IEM) remain poorly understood. Unless gastroesophageal acid reflux (GERD) is identified, symptomatic patients with IEM are challenging to treat. We sought to determine whether any clinical or functional characteristics could distinguish those patients with IEM and either normal or abnormal esophageal acid exposure.In this retrospective cohort study, we identified 46 consecutive patients presenting with heartburn, and other GER symptoms who underwent clinical, endoscopic, and functional evaluation that included high-resolution manometry (HRM) and ambulatory pH monitoring. IEM was defined using the Chicago Classification criteria (v.3) as ≥50% ineffective swallows (DCI ≤ 450 mmHg.s.cm). Esophageal acid exposure by ambulatory pH monitoring was considered abnormal when total time with esophageal pH < 4 exceeded 4.2%.Of the 46 IEM patients identified, 19 (mean age: 42 years, 37% female), had normal esophageal acid exposure and 27 patients, mean age 54 years, 33% female, evidence of pathologic acid reflux. There was a 12 years age difference between the groups, with those with normal acid exposure being significantly younger (P < 0.01); the mean body mass index (BMI) was 22.6 ± 0.6 in the normal group and 25.4 ± 0.7 in the abnormal group (P < 0.001); otherwise the groups were endoscopically and histologically similar. Symptoms were not discriminatory and heartburn and regurgitation were the most prevalent in both groups. HRM did not discriminate symptomatic patients with IEM and either normal or abnormal esophageal acid exposure. Proton pump inhibition (PPI) therapy was significantly more effective (74% vs. 10%) in patients with pathologic acid reflux (P < 0.001). As pH exposure becomes abnormal in the context of IEM, there is dominance for supine reflux.IEM appears to be an early, primary event, eventually associated with pathologic acid exposure, particularly supine. Higher BMI is also associated with abnormal esophageal acid exposure in such patients. GER symptoms are not discriminatory in patients with IEM with and without underlying pathologic acid reflux. Clinical response to PPI in such patients depends on the presence of esophageal pathologic acid exposure. Those with IEM and normal acid exposure remain symptomatic and mostly resistant to therapy.

Manometric Subtypes of Ineffective Esophageal Motility.

Objectives:Ineffective esophageal motility (IEM) is characterized by well-defined manometric criteria. However, much variation exists within the diagnosis: Some patients exhibit exactly the required five weak swallows to make the diagnosis. Others show consistently ineffective swallows with total absence of any normal swallow. “We hypothesize” there are two different manometric subtypes of IEM; IEM Alternans (IEM-A) and IEM Persistens (IEM-P).Methods:A total of 231 IEM patients were identified by high-resolution manometry (HRM). IEM defined by distal contractile integral (DCI) <450 mm Hg/s/cm in ≥50% of test swallows. Abnormal reflux study was defined by excess total number of reflux episodes, abnormal esophageal acid exposure, or positive symptom association.Results:A total of 195 (84%) patients had IEM-A and 36 (16%) had IEM-P. A striking gender difference with 34% of IEM-A being males compared to 53% of IEM-P. (P=0.03). Mean age of IEM-P (59.6 years+/−13.1) was greater than IEM-A (55.5 years+/−13.6) (P=0.04). Mean lower esophageal sphincter (LES) resting pressure was significantly lower in IEM-P (20.8 mm Hg+/−1.4) than IEM-A (29 mm Hg+/−1.2) (P=0.002). There was no difference in LES-integrated relaxation pressure (IRP), bolus transit, or manometric presence of hiatal hernia between the two groups. Out of 146, 89 (61%) patients had abnormal reflux study. Esophageal acid exposure in upright position was significantly higher in IEM-P than IEM-A (3.5 vs. 1.7%, P=0.04). Poor gastric acid control on proton pump inhibitor (PPI) was more prevalent among IEM-P patients (58%) than IEM-A (27%) (P=0.007). In subgroup analysis of 41 IEM patients with dysphagia, DCI for liquid swallows was significantly lower in IEM-P (111+/−142 mm Hg/s/cm) compared to IEM-A (421+/−502 mm Hg/s/cm) (P=0.04), lower mean LES resting pressure in IEM-P (16.6+/−9 mm Hg) than IEM-A (31.7+/−18 mm Hg) (P=0.01).Conclusions:There are two distinct manometric IEM subtypes; IEM-P with an older male predominance, more advanced reflux disease, weaker LES, and worse response to PPI; likely a more advanced manifestation than IEM-A. However, the question if there are different etiologies underlying the two subtypes remains to be answered.

Ineffective Esophageal Motility (IEM): the Old-New Frontier in Esophagology.

Ineffective esophageal motility (IEM) is characterized by distal esophageal contraction amplitude of <30 mmHg on conventional manometry (Blonski et al. Am J Gastroenterol. 103(3):699-704, 2008), or a distal contractile integral (DCI) < 450 mmHg*s*cm on high-resolution manometry (HRM) (Kahrilas et al. Neurogastroenterol Motil. 27(2):160-74, 2015) in≥50 % of test swallows. IEM is the most common abnormality on esophageal manometry, with an estimated prevalence of 20-30 % (Tutuian and Castell Am J Gastroenterol. 99(6):1011-9, 2004; Conchillo et al. Am J Gastroenterol. 100(12):2624-32, 2005). Non-obstructive dysphagia has been considered to be frequently associated with severe esophageal peristaltic dysfunction. Defective bolus transit (DBT) on multichannel intraluminal impedance testing was found in more than half of IEM patients who presented with dysphagia (Tutuian and Castell Am J Gastroenterol. 99(6):1011-9, 2004), highlighting the functional defect of this manometric finding. Treatment of IEM has been challenging because of lack of promotility agents that have a definite effect on esophageal function.

Multiple Rapid Swallow Maneuver Enhances the Clinical Utility of High-Resolution Manometry in Patients Showing Ineffective Esophageal Motility.

The clinical significance of ineffective esophageal motility (IEM) together with multiple rapid swallow (MRS) has not been yet evaluated in the Chicago Classification v3.0. This study evaluated the adjunctive role of MRS in IEM and determined the criteria of abnormal MRS to maximize the utility of IEM. We analyzed 186 patients showing IEM or normal esophageal motility (NEM), who underwent esophageal high-resolution impedance–manometry for esophageal symptoms. Two different criteria for abnormal MRS were applied to IEM subjects, resulting in 2 corresponding subgroups: IEM-A when distal contractile integral (DCI) ratio between an average wet swallows and MRS contraction was <1 and IEM-B when MRS contraction DCI was <450 mm Hg-s-cm. One IEM subject inadequately performed MRS. Among the remaining 52 IEM subjects, 18 (34.6%) were classified into IEM-A and 23 (44.2%) into IEM-B. IEM subjects showed less complete bolus transit (median 0.0%, interquartile range 0.0–20.0% vs 60.0%, 30.0–80.0; P < 0.001) resulting in higher impaired bolus transit than NEM subjects (98.1% vs 66.9%, P = 0.001). IEM-B subjects showed additionally higher pathologic bolus exposure than NEM subjects (55.6% vs 29.3%, P = 0.001), whereas IEM-A subjects could not. Although IEM-B subjects had the highest prevalence of gastroesophageal reflux disease among the subjects groups, it did not reach statistical significance. In conclusion, IEM patients with abnormal MRS contraction have an increased risk of prolonged bolus clearance, poor bolus transit, and pathologic bolus exposure. IEM patients need to be assessed concerning whether MRS contraction DCI is <450 mm Hg-s-cm to segregate clinically relevant patients.

High Resolution Esophageal Manometric (HREM) Findings in Patients With Systemic Sclerosis

Introduction: Esophageal dysmotility is reported in up to 96% patients with SSc. The classic manometric finding is absence of peristalsis in the distal two-thirds of smooth muscle of the esophagus with low lower esophageal sphincter (LES) pressure. With earlier detection of esophageal involvement, different manometric abnormalities are seen on HREM. Our aim was to characterize esophageal motility disturbances in patients with SSc using HREM. Methods: Patients with SSc who underwent HREM between January 2008 and October 2014 at our institution were identified. All HREM studies were reinterpreted using the Chicago Classification of Esophageal Motility Disorders, v3.0 criteria. We also reviewed patients' age, gender, race, tobacco and alcohol use, as well as medications. Data are presented as mean ± standard deviation, median or frequency (percent). For all univariate analyses, analysis of variance (ANOVA), non-parametric Kurksal-Wallis, Pearson's chi-square, Fisher's Exact tests were used when appropriate. Results: 122 patients underwent HREM during the study period of which 92 were women and 30 were men. The mean age was 54.2 ± 13.6 years. The HREM diagnoses were normal in 23, ineffective esophageal motility (IEM) in 22, absent contractility (AC) in 73 and one case each of Type II Achalasia, EGJ outflow obstruction, hypercontractile esophagus, and distal esophageal spasm. The mean basal LES pressure was 17.1mm Hg [8.1, 27.0] and the mean IRP was 3.4 mm Hg[1.2, 6.3]. We compared the demographic, clinical and manometric data between patients with normal contractility, IEM and AC. Patients with AC were younger than other two groups (Table 1). There is higher prevalence of antidepressant use in patients with normal HREM and higher prevalence of pulmonary hypertension in IEM patients. The basal meanLES pressure was lowest in AC (Table 2). There was no statistically significant difference in gender, race, tobacco, alcohol use and other medication use among the three groups of patients (Table 1).Table 1: Patient CharacteristicsTable 2: High Resolution Manometry FindingsConclusion: Diverse motility abnormalities were noted on HREM in SSc with over 78% of patients having IEM or AC. Patients with AC were younger than other groups suggestive of an early, aggressive phenotype. Future prospective studies are needed to identify and intervene in patients before they develop severe esophageal dysfunction.

Relevance of ineffective esophageal motility to secondary peristalsis in patients with gastroesophageal reflux disease

The study aimed to investigate the hypothesis whether the presence of Ineffective esophageal motility would affect physiological characteristics of secondary peristalsis. Secondary peristalsis was performed with slow and rapid air injections into mid-esophagus of 18 ineffective esophageal motility patients and 15 age-matched controls. Severity of ineffective esophageal motility was defined by the application of combined multichannel intraluminal impedance and manometry. Ineffective esophageal motility patients included 11 patients without impedance abnormality and seven patients with impedance abnormality during liquid and/or viscous swallowing. The prevalence of failed secondary peristaltic response during slow air injection was significantly greater in ineffective esophageal motility patients without impedance abnormality (3/11 [27%], P < 0.001) and with impedance abnormality (4/7 [57%], P = 0.04) than healthy subjects. The threshold volume for inducing secondary peristalsis during rapid air injection was significantly greater in ineffective esophageal motility patients with impedance abnormality (6.1 ± 0.3 mL) than healthy subjects (4.6 ± 0.3 mL, P < 0.05) and ineffective esophageal motility patients without impedance abnormality (4.1 ± 0.4 mL, P < 0.05). The frequency of peristaltic response during rapid air injection was significantly lower in ineffective esophageal motility patients with impedance abnormality (40% [20-50%] than healthy subjects (90% [90-100%], P < 0.05). Defective activation of secondary peristalsis is present in ineffective esophageal motility patients with impedance abnormality. Our study indicates that increased ineffective esophageal motility severity associated with defective triggering of secondary peristalsis may contribute to impaired esophageal clearance in patients with gastroesophageal reflux disease.

Effects of mosapride on secondary peristalsis in patients with ineffective esophageal motility

Objective. Ineffective esophageal motility is frequently found in patients with gastroesophageal reflux diseases. Secondary peristalsis contributes to esophageal acid clearance. Mosapride improves gastrointestinal (GI) motility by acting on 5-hydroxytrypatamine4 receptors. The authors aimed to evaluate the effect of mosapride on secondary peristalsis in patients with ineffective esophageal motility. Material and methods. After recording primary peristalsis baseline, secondary peristalsis was stimulated by slowly and rapidly injecting mid-esophageal air in 18 patients. Two separate experiments were randomly performed with 40 mg oral mosapride or placebo. Results. Mosapride had no effect on the threshold volume of secondary peristalsis during slow air distension (9.8 ± 0.97 vs. 10.2 ± 1.0 mL; p = 0.84), but decreased the threshold volume during rapid air distension (4.1 ± 0.2 vs. 4.6 ± 0.3 mL; p = 0.001). The efficiency of secondary peristalsis during rapid air distension increased with mosapride (70% [40–95%]) compared with placebo (60% [10–85%]; p = 0.0003). Mosapride had no effect on the amplitudes of distal pressure wave of secondary peristalsis during slow (94.3 ± 9 vs. 101.9 ± 9.1 mmHg; p = 0.63) or rapid air distension (89.3 ± 9 vs. 95.2 ± 8.3 mmHg; p = 0.24). Conclusions. Mosapride improves esophageal sensitivity of secondary peristalsis by abrupt air distension but has limited effect on the motor properties of secondary peristalsis in ineffective esophageal motility patients. Despite its well-known prokinetic effect, mosapride enhances the efficiency of secondary peristalsis in patients with ineffective esophageal motility through augmenting esophageal sensitivity instead of motility.

Habitual rapid food intake and ineffective esophageal motility

To study non-cardiac chest pain (NCCP) in relation to ineffective esophageal motility (IEM) and rapid food intake. NCCP patients with a self-reported habit of fast eating underwent esophageal manometry for the diagnosis of IEM. Telephone interviews identified eating habits of additional IEM patients. Comparison of manometric features was done among IEM patients with and without the habit of rapid food intake and healthy controls. A case study investigated the effect of 6-mo gum chewing on restoration of esophageal motility in an IEM patient. The Valsalva maneuver was performed in IEM patients and healthy controls to assess the compliance of the esophagus in response to abdominal pressure increase. Although most patients diagnosed with NCCP do not exhibit IEM, remarkably, all 12 NCCP patients who were self-reporting fast eaters with a main complaint of chest pain (75.0%) had contraction amplitudes in the mid and distal esophagus that were significantly lower compared with healthy controls [(23.45 mmHg (95%CI: 14.06-32.85) vs 58.80 mmHg (95%CI: 42.56-75.04), P < 0.01 and 28.29 mmHg (95%CI: 21.77-34.81) vs 50.75 mmHg (95%CI: 38.44-63.05), P < 0.01, respectively)]. In 7 normal-eating IEM patients with a main complaint of sensation of obstruction (42.9%), the mid amplitude was smaller than in the controls [30.09 mmHg (95%CI: 19.48-40.70) vs 58.80 mmHg (95%CI: 42.56-75.04), P < 0.05]. There was no statistically significant difference in manometric features between the fast-eating and normal-eating groups. One NCCP patient who self-reported fast eating and was subsequently diagnosed with IEM did not improve with proton-pump inhibition but restored swallow-induced contractions upon 6-mo gum-chewing. The Valsalva maneuver caused a markedly reduced pressure rise in the mid and proximal esophagus in the IEM patients. Habitual rapid food intake may lead to IEM. A prospective study is needed to validate this hypothesis. Gum-chewing might strengthen weakened esophageal muscles.

Ineffective esophageal motility and gastroesophageal reflux disease: A close relationship?

An association between ineffective esophageal motility and gastroesophageal reflux disease is already known, but there are also some conflicting data. We evaluated the association between ineffective esophageal motility and gastroesophageal reflux disease in patients who underwent ambulatory pH monitoring for the evaluation of reflux symptoms at Gazi University, Gastroenterology Clinic. A total of 239 patients who underwent endoscopy, esophageal manometry and ambulatory 24-h pH monitoring due to reflux symptoms were enrolled. Of them, we selected patients who had normal esophageal motility and ineffective esophageal motility. The endoscopy and ambulatory pH monitoring findings were compared between the two groups. Of the 239 patients who presented with reflux symptoms, pathologic acid reflux or endoscopic esophagitis was found in 114 (48%). Ineffective esophageal motility was found in 18 (16%) in the pathologic reflux group and in 4 (3%) in the functional reflux group (p=0.01). Ambulatory pH, manometric and demographic findings were compared in ineffective esophageal motility and normal motility groups. Lower esophageal sphincter (LES) pressures were lower in the ineffective esophageal motility group (19.7 versus 16.2; p=0.01), and total reflux times in both supine and upright position were higher (10.3 versus 4.9; p=0.01) inthe ineffective esophageal motility group. Ineffective esophageal motility patients were older and more obese than normal motility group patients. This study points to a clear association between ineffective esophageal motility and gastroesophageal reflux disease as defined by ambulatory pH monitoring.

Su1087 Heartburn and Condition of Distal Part of Esophagus in Pregnancy

Ineffective esophageal motility (IEM) has been observed in erosive and non-erosive reflux disease (NERD) patients and may account for delayed bolus transit and impaired esophageal reflux clearance. It has been demonstrated that conventional manometry findings cannot predict reflux clearance in GERD patients. High resolution manometry (HRM) allows an accurate analysis of esophageal motility. Distal contractile integral (DCI) integrates the length, contractile vigour, and duration of contraction of the first two segments of the distal esophagus. Aim: To assess the correlation between HRM findings and reflux clearance in GERD patients. Methods: Following a 3-week washout from PPI and/or H2 antagonists, HRM and 24-hour ambulatory multichannel pH-impedance (pH-MII) monitoring were performed in 37 consecutive GERD patients, with no evidence of hiatal hernia at endoscopy. Patients were analyzed in the supine position, a catheter with 36 solid state pressure sensors located at 1 cm intervals (MMS, HRIM, Enschede, The Netherlands) was used. Data were stored and analyzed using dedicated software. A total of 10 saline (5 ml) swallows, at 30sec intervals were analyzed in each subject. The pH-impedance assembly was positioned with the pH electrode at 5cm above the LES and impedance measuring segments at 3, 5, 7, 9, 15 and 17cm above LES (Sandhill Scientific, USA). Reflux episodes were classified according to standardized criteria. Mean reflux clearance time (RCT) and reflux exposure time (RET) were calculated using Bioview software analysis, after a manual analisys of each pH-MII tracing. DCI was calculated and correlated to RCT and RET values by means of linear regression analysis. HRM tracings were analyzed according to the Chicago classification. IEM was defined by the presence of hypothensive or absent peristaltic waves in >20% of deglutitions. Results: Of the 37 patients, 30 showed normal esophageal motility and 7 IEM. Mean DCI values were 1562 (95% CI, 1203-1921) mmHg*s−1*cm−1 in all patients and 182 (95% CI, 122-242) mmHg*s−1*cm−1 in the 7 patients with IEM (p<0.001). Mean RCT and RET were 12.2 sec. and 3.6% of total recording time in all 37 patients, 13.5 sec. and 6.5% in the 7 IEM patients. No correlation was found between DCI and mean RCT and RET (r= 0.3 and 0.25, respectively). Weak correlation was found between DCI and mean RCT in the subgroup of IEM patients (r= 0.65, p<0.05). Conclusions: failure of esophageal motility seems to play a weak role in the clearing of gastroesophageal reflux episodes. DCI is not correlated to impaired esophageal reflux clearing whose occurrence could depend on the balance between the magnitude of the motility weakness and of the flow resistance at esophago-gastric junction.

P.19.3 ESOPHAGEAL HIGH RESOLUTION MANOMETRY FINDINGS DO NOT CORRELATE WITH CLEARANCE OF GASTRO-ESOPHAGEAL REFLUX IN GERD PATIENTS

Ineffective esophageal motility (IEM) has been observed in erosive and non-erosive reflux disease (NERD) patients and may account for delayed bolus transit and impaired esophageal reflux clearance. It has been demonstrated that conventional manometry findings cannot predict reflux clearance in GERD patients. High resolution manometry (HRM) allows an accurate analysis of esophageal motility. Distal contractile integral (DCI) integrates the length, contractile vigour, and duration of contraction of the first two segments of the distal esophagus. Aim: To assess the correlation between HRM findings and reflux clearance in GERD patients. Methods: Following a 3-week washout from PPI and/or H2 antagonists, HRM and 24-hour ambulatory multichannel pH-impedance (pH-MII) monitoring were performed in 37 consecutive GERD patients, with no evidence of hiatal hernia at endoscopy. Patients were analyzed in the supine position, a catheter with 36 solid state pressure sensors located at 1 cm intervals (MMS, HRIM, Enschede, The Netherlands) was used. Data were stored and analyzed using dedicated software. A total of 10 saline (5 ml) swallows, at 30sec intervals were analyzed in each subject. The pH-impedance assembly was positioned with the pH electrode at 5cm above the LES and impedance measuring segments at 3, 5, 7, 9, 15 and 17cm above LES (Sandhill Scientific, USA). Reflux episodes were classified according to standardized criteria. Mean reflux clearance time (RCT) and reflux exposure time (RET) were calculated using Bioview software analysis, after a manual analisys of each pH-MII tracing. DCI was calculated and correlated to RCT and RET values by means of linear regression analysis. HRM tracings were analyzed according to the Chicago classification. IEM was defined by the presence of hypothensive or absent peristaltic waves in >20% of deglutitions. Results: Of the 37 patients, 30 showed normal esophageal motility and 7 IEM. Mean DCI values were 1562 (95% CI, 1203-1921) mmHg*s−1*cm−1 in all patients and 182 (95% CI, 122-242) mmHg*s−1*cm−1 in the 7 patients with IEM (p<0.001). Mean RCT and RET were 12.2 sec. and 3.6% of total recording time in all 37 patients, 13.5 sec. and 6.5% in the 7 IEM patients. No correlation was found between DCI and mean RCT and RET (r= 0.3 and 0.25, respectively). Weak correlation was found between DCI and mean RCT in the subgroup of IEM patients (r= 0.65, p<0.05). Conclusions: failure of esophageal motility seems to play a weak role in the clearing of gastroesophageal reflux episodes. DCI is not correlated to impaired esophageal reflux clearing whose occurrence could depend on the balance between the magnitude of the motility weakness and of the flow resistance at esophago-gastric junction.

Prevalence of Ineffective Esophageal Motility and Its Relevance to Symptoms and Esophageal Acid Exposure in Korean Patients Referred for Foregut Symptoms

Background/Aims: The prevalence and clinical significance of ineffective esophageal motility (IEM) in a population with low prevalence of gastroesophageal reflux disease are not known. Our aim was to investigate the prevalence and its relevance to symptoms and esophageal acid exposure in Korean patients referred for foregut symptoms. Methods: A total of 112 consecutive patients who underwent esophageal manometry, 24-hour esophageal pH monitoring and endoscopy for foregut symptoms were analyzed. IEM was defined as >20% of wet swallows with amplitudes of <30 mm Hg or lack of peristalsis. Results: IEM and abnormal acid exposure were observed in respectively 29 and 19% of all subjects. The prevalence of individual symptoms did not differ between IEM and non-IEM groups. Hypotensive lower esophageal sphincter (LES) was significantly more prevalent in IEM patients. The prevalence of abnormal acid exposure in IEM and non-IEM groups was comparable. The prevalence of IEM was similar between patients with and without abnormal acid exposure. Erosive reflux esophagitis was significantly more prevalent in IEM patients compared with non-IEM patients. Conclusion: IEM is not a significant marker for a specific symptom or abnormal acid exposure. However, the presence of IEM is associated with a higher prevalence of hypotensive LES and erosive reflux esophagitis.

Multichannel Intraluminal Impedance Monitoring in the Evaluation of Patients with Non-Obstructive Dysphagia

Non-obstructive dysphagia (NOD) often poses diagnostic problems. The aim of this study was to evaluate the value of the addition of multichannel intraluminal impedance (MII) recording to esophageal manometry in the work-up of patients with NOD. A total of 40 consecutive patients with NOD underwent combined esophageal MII recording and perfusion manometry. Ten liquid and 10 viscous boluses were tested in each patient. Values for bolus presence time (BPT) at each of the four recording sites and total bolus transit time (TBTT) were calculated. Bolus transit (BT) was considered to be normal when BPT at all sites and TBTT were within the normal limits defined in 42 healthy subjects. Patients were judged to have normal transit if >or=80% of liquid and >or=70% of viscous swallows showed normal transit. The following manometric diagnoses were made: normal motility (20), ineffective esophageal motility (IEM) (13), diffuse esophageal spasm (DES) (4), and achalasia (3). Abnormal transit for liquid and/or viscous boluses was found in 35.3% of patients with normal motility, in 66.7% of DES patients, and in 100% of achalasia patients. In patients with achalasia quantification of BT was often made impossible by low initial impedance baseline. Two IEM patients (15.4%) showed normal liquid and viscous transit. Swallows showing normal transit had significantly longer duration of LES relaxation in patients with normal manometry and IEM (p < 0.05). MII recording identifies esophageal function abnormalities in NOD patients with normal manometry, IEM, and DES. The MII technique seems to be less suitable for the most severe end of the dysphagia spectrum like achalasia.

Ineffective or “Insignificant” Esophageal Motility Disorder in Gastroesophageal Reflux Disease (GERD)

Purpose: Ineffective esophageal motility (IEM) is a common finding in patients with GERD. Laparoscopic nissen fundoplication (LNF) is the surgical treatment of choice for GERD. However, dysphagia may be reported following surgery. Patients with IEM may have dysphagia pre-surgically secondary to their underlying motility disorder, which may worsen after LNF. We aimed to evaluate the prevalence of IEM in GERD, and compare symptoms of dysphagia pre- and post LNF in IEM vs non-IEM patients. Methods: LNFs performed between Jan and Dec 2004 were evaluated. Of 36 patient records, 35 completed esophageal manometry study (Solid-state esophageal manometry was performed following an overnight fast) and pre-op symptom assessment questionnaire. Seventeen patients completed pH-metry, and 34 completed EGD. All patients had a post-op follow up at 1 to 8 months. Results: Thirty six fundoplications were performed; 33 laparoscopic and 3 open. Indications included GERD (30), achalasia (4), and paraesophageal (13) and large hiatal hernia (2) repairs (median age 61 y, range 21–85; 21 F; 34 caucasian, 2 hispanic). Thirty (83%) patients had either subjective or objective GERD (EGD/pH); 9 of 30 (30%) had IEM on manometry tracings (4 [13%] in subjective reflux only, 0 in objective reflux only, and 5 [17%] in both). IEM and non-IEM groups did not differ in age, gender, or race (64y ± 12; 80% F; 100% caucasian vs 59y ± 14; 59% F; 91% caucasian). Pre- and post-op dysphagia was noted in 30% and 40%, respectively, in IEM group and 50% (OR 0.43 [.09, 2.1]) and 43% (OR 0.96 [.21, 4.4]), respectively, in non-IEM group. Three of 9 (33%) IEMs had either symptomatic paraesophageal hernia or large hiatal hernia. Six of 9 (67%) IEMs had reduced lower esophageal sphincter pressures. Interestingly, 2 of 6 Toupet's were performed in GERD patients with IEM, which resulted in relief of pre-op dysphagia. Conclusions: Ineffective esophageal motility may be a common finding in gastroesophageal reflux disease; however, the clinical significance remains unclear as the rate of pre- and post-op dysphagia did not differ between IEM vs non-IEM group. Well-designed prospective studies are needed to better elucidate the impact of esophageal dysmotility disorders on outcomes following esophageal surgery for GERD.

Ineffective esophageal motility is a primary motility disorder in gastroesophageal reflux disease.

The relationship between esophageal motor abnormalities and GERD has been widely studied. The purpose of this study was to identify the prevalence of ineffective esophageal motility (IEM) in patients with GERD. In addition, we also evaluated esophageal acid exposure, acid clearance, and endoscopic esophagitis in GERD patients with IEM. Of 89 patients enrolled in this study, 47 (52.8%) were found to have nonspecific esophageal motility disorder (NEMD). Forty-four of the 47 (93.6%) patients with NEMD met the diagnostic criteria for IEM. The overall incidence of IEM in GERD patients was 49.4%. Patients with IEM had significant increases in upright and recumbent mean fraction of time pH < 4 (6.70% and 4.38%) and mean recumbent esophageal acid clearance (12.45 min/reflux) when compared to those with other motility findings. Seventeen of the 44 (39%) IEM patients did not have endoscopic esophagitis. On the other hand, 26 of the 39 (67%) patients with normal manometry had endoscopic esophagitis. We concluded that not only is the prevalence of IEM high in GERD, but also that IEM patients have more recumbent gastroesophageal reflux and delayed acid clearance. Combined with endoscopic findings, we propose that IEM can be viewed as a specific entity of primary esophageal motility disorder in patients with GERD.