Jackhammer Esophagus Research Articles

The Utility of Repeat High-Resolution Esophageal Manometry (HREM) in Patients with a Normal Index Manometry

Introduction: High Resolution Esophageal Manometry (HREM) is an invaluable tool for evaluation of dysphagia and chest pain and plays an important role in preoperative planning for foregut surgeries. However, the utility of serial HREMs is unclear. A few studies have reported the manometric progression of various motility disorders or treatment effects of interventions. However, there are no studies to date reporting the natural progression of normal HREM. Methods: We performed a retrospective review of all patients who had >1 HREM performed at the Cleveland Clinic from January 1, 2004 to April 1, 2016. Of these HREMs, all patients who had an abnormal index HREM were excluded. The indications, final diagnoses, and demographic features of the remaining HREMs were analyzed. Results: A total of 543 patients who underwent 1,151 HREM were analyzed. 490 (90%) patients had 2, 43 (8%) had 3, and 9 (2%) and 1 (0.2%) patients had 4 and 5 HREMs. Indications include hiatal hernia in 232 (43%), lung transplant in 140 (26%), dysphagia in 67 (12%), chest pain in 35 (6%), cough in 44 (8%), and dyspepsia in 31 (6%) patients. 338 (62%) patients were female with a mean (SD) age of 62 (13) years. 160 (29%) patients had at least one HREM which was abnormal. Abnormal diagnoses include Ineffective Esophageal Motility (IEM) in 95 (17%), nutcracker esophagus in 16 (3%), jackhammer esophagus in 15 (3%), distal esophageal spasm in 14 (3%), esophagogastric junction outflow tract obstruction in 7 (1%), and achalasia and absent contractility in 3 (0.5%) patients each. Of note, of the patients who had at least one HREM with a diagnosis of IEM, 9 patients' HREM changed from normal to IEM and back to normal. In univariate analyses, patients' age, gender, and indication were not associated with change in diagnosis. However, when time between repeat HREM was categorized into quartiles, repeat HREM between 200 and 800 days after index (RR 2.18, 95%CI 1.25-3.81, p=0.006), and more than 800 days after the index (RR 3.18, 95%CI 1.85-5.48, p < 0.001) was associated with increasingly higher chance of a change in manometry results, when compared to repeated manometries the first 100 days after the index study. Conclusion: Our data show 12% of patients develop a major disorder and a further 17% develop a minor disorder of esophageal motility after initially being diagnosed with normal HREM. Time lapsed between repeat HREMs is a risk factor for the progression of diagnosis of normal HREM into abnormal.

Positional Variation in Response to Multiple Rapid Swallows While Supine vs Sitting

Introduction: Provocative testing with multiple rapid swallows (MRS) during high resolution esophageal manometry (HRM) has emerged as a valuable tool in the evaluation of esophageal peristaltic reserve. The goal of this study was to evaluate the consistency of the response to MRS in two different body positions, supine and sitting, and to identify any association between discordant MRS findings and Chicago Classification 3.0 (CC) diagnosis. Methods: Retrospective analysis was carried out on 100 consecutive patients undergoing HRM for any indication at a tertiary referral motility lab. Patients were first placed in the supine position and underwent ten 5mL wet swallows at 30 second intervals for baseline peristalsis and five 5mL rapid wet swallows at 2 second intervals constituting MRS. This was then repeated in the sitting position. A solid state catheter with 36 pressure sensors spaced 1cm apart (Given/Medtronic) was utilized. Analysis included LES Integrated Relaxation Pressure, Distal Latency, and Distal Contractile Integral (DCI) with characterization by CC. Augmentation of peristalsis was defined as ratio > 1 of DCI following MRS compared to the DCI of the wet swallows. Results: Twenty-five patients were excluded due to not having data in both positions (patient intolerance). Of the remaining 75, the mean age was 51.2 years, and 74% were female. 53 patients were classified as normal on CC, with 66% concordance between response to MRS in the supine and sitting position. Nine patients were classified as ineffective esophageal motility, with 44% positional concordance. The rate of failure to augment following MRS was 44% while supine and 78% while sitting. Nine patients were classified as EGJ outflow obstruction, with 44% concordance between the two positions. Eleven patients were diagnosed with achalasia, but only one tolerated MRS in both positions with concordant results. There were only a few patients with other CC diagnoses, including diffuse esophageal spasm, jackhammer esophagus, and fragmented peristalsis. Conclusion: While there was broad consistency in response to MRS in the sitting versus supine position, variation was more likely to occur when the CC diagnosis was EGJ outflow obstruction or ineffective esophageal motility, suggesting that MRS is more likely to be affected by gravity with these two underlying conditions. Patient position during HRM appears to be relevant when interpreting response to MRS.Figure 1Figure 2Figure 3

Patients with Gastroesophageal Reflux Disease and Subjective Dysphagia Are Commonly Misdiagnosed with Jackhammer Esophagus

Patients with Gastroesophageal Reflux Disease and Subjective Dysphagia Are Commonly Misdiagnosed with Jackhammer Esophagus

A Rare Case of Mid-Esophageal Pulsion Diverticulum Resulting from Jackhammer Esophagus

A Rare Case of Mid-Esophageal Pulsion Diverticulum Resulting from Jackhammer Esophagus

Do Jackhammer contractions lead to achalasia? A longitudinal study.

Jackhammer esophagus (JE) is a rare esophageal motility disorder defined in the Chicago Classification of Esophageal Motility by presence of excessively high distal contractile integral (DCI) on high-resolution manometry (HRM), with unknown natural manometric course. We examined the development of achalasia over time in patients with JE. Through a retrospective longitudinal design, patients with Jackhammer contractions who had more than one HRM between 2005 and 2015 were identified. Any change in manometric finding was assessed for the presence of achalasia. Demographic and manometric risk factors for this progression were then sought in univariate analysis. Of 3363 HRM studies, 229 subjects had multiple manometries, accounting for 528 studies. Twelve subjects met our inclusion criteria for JE on any of the multiple tests, represented by 27 studies for a total of 347 patient-months of manometric follow-up. Subjects with JE whose manometry included impedance demonstrated consistent esophageal bolus clearance. Of 12 subjects with Jackhammer contractions, three subjects progressed to type III achalasia, over a mean of 24months (range: 19-31months). At the time of diagnosis with JE, impaired esophago-gastric junction relaxation was seen in all three subjects and was the only risk factor that could predict progression to achalasia (P<.01). In this unique study of the natural course of JE, we have shown that JE can progress to achalasia. Manometric findings at the time of JE diagnosis might predict this progression.

Frequency of Jackhammer Esophagus as the Extreme Phenotypes of Esophageal Hypercontractility Based on the New Chicago Classification.

Jackhammer Esophagus is defined as intact esophageal peristaltic contractions with extremely elevated amplitudes. We conducted a retrospective study to identify the frequency of esophageal hypercontractility and the clinical characteristics of Jackhammer Esophagus. Charts for the patients referred for manometric study at a tertiary-care motility center were reviewed. Data were collected utilizing the new Chicago classification criteria for Jackhammer Esophagus. Concomitant clinical variables were also explored. Eight patients were identified with Jackhammer Esophagus from a total of 205 (127 female/77 male) patients referred for high-resolution esophageal manometry. Jackhammer patients had an average distal contractile integral (DCI) of 9061 mmHg/ sec/ cm and median maximal DCI of 16,433 mmHg/ sec/ cm. The greatest DCI from 15 swallows was 28,875 mmHg/ sec/ cm. Hypercontractility was associated with multipeaked contractions in every Jackhammer patient. The mean lower esophageal sphincter (LES) pressure was 41 mm Hg with 4 patients having a hypertensive pressure of >40 mm Hg. Three of the 8 (37.5%) Jackhammer group had incomplete LES relaxation by integrated relaxation pressure criteria (>15 mm Hg residual pressure). Dysphagia (8/8) was the dominant indication for the manometric study, whereas the clinical background setting was gastroesophageal reflux disease (4/8) and hiatal hernia (1/8). Treatments included smooth muscle relaxation, antireflux regimens, and pneumatic dilation of the LES. Jackhammer Esophagus, an extreme manometric phenotype, was identified in 4.0% of patients referred to a University Motility Center. The patients with these esophageal hypercontractility states present mainly with dysphagia. A subgroup of Jackhammer did have accompanying incomplete LES relaxation and responded to targeted therapy with pneumatic dilatation.

Clinical characteristics associated with esophageal motility function.

Esophageal motility disorders (EMDs) affect coordinated esophageal contractility. Recent developments in high-resolution manometry have improved diagnosis of EMDs; however, the etiology of EMDs remains to be determined. This study aimed to determine which clinical characteristics are associated with esophageal motility. From May 2013 to July 2014, 97 patients (54 women, 43 men; age, 16-89 years) with suspected EMDs were assessed by high-resolution manometry in Kyushu University Hospital. Esophageal motility was evaluated by measuring the distal contractile integral (DCI), basal lower esophageal sphincter pressure, and integrated relaxation pressure (IRP). Data on age, gender, body mass index (BMI), Brinkman Index, and blood tests were retrospectively collected and analyzed. Fifty patients were diagnosed as normal, nine with achalasia, twelve with esophagogastric junction outflow obstruction, four with distal esophageal spasm, one with jackhammer esophagus, six with absent peristalsis, ten with frequent failed peristalsis, and five with weak peristalsis. The median DCI was 1229.0 mmHg-s-cm, the median basal lower esophageal sphincter pressure was 25.3 mmHg, and the median IRP was 9.6 mmHg. Patients with major motility disorders were excluded from analysis. By multivariate regression analysis, BMI (P = 0.029) and total cholesterol (P = 0.023) were negatively associated with DCI, while BMI (P = 0.007) was negatively associated with IRP and glucose (P = 0.044) was positively associated with IRP. Both BMI and total cholesterol could be highly predictive factors for esophageal body contractility, while BMI and glucose could be predictive factors for lower esophageal sphincter contractile function.

Clinical features and its pathophysiology of patients with esophageal hypertensive peristalsis based on esophageal high resolution manometry

Objective To analyze the clinical features, esophageal motility characteristics and pathophysiological significance of patients with esophageal hypertensive peristalsis. Methods From January 2012 to April 2015, 543 patients with upper gastrointestinal symptoms who received esophageal high resolution manometry (HRM) were retrospectively analyzed. Patients with esophageal hypertensive peristalsis were enrolled. At the same time, 17 healthy volunteers were also enrolled. All subjects received a questionnaire survey of dysphagia. According to the results of HRM, patients were divided into Jackhammer esophagus and other kindsot hypertensive peristalsis esophagus (hypertensive peristalsis at esophageal body, normal lower esophageal sphincter (LES) relaxation, however distant contraction integration (DCI) not meeting the criteria of Jackhammer esophagus according to Chicago classification). Esophageal motility of them was also analyzed. Part of the patients underwent 24 h pH-impedance monitoring.Mann-Whitney U test, Fisher exact test and Spearman test were applied for statistical analysis. Results Among the 543 patients, 64 (11.8%) had hypertensive peristalsis at esophageal body. Ten (15.6%) had Jackhammer esophagus, and the others (43 cases, 67.2%) had hypertensive peristalsis esophagus. Five cases presented esophageal spasm in ten patients with Jackhammer esophagus in upper gastrointestinal angiography. And the incidence of esophageal spasm in other hypertensive peristalsis esophagus group was 30.2% (13/43). No statistically significant difference was found between these two groups (P>0.05). Except for the difference in amplitude of esophgeal peristalsis, there was no significant difference in the clinical symptoms and LES functions between patients with Jackhammer esophagus and patients with other kinds of hypertensive peristalsis esophagus (all P>0.05). The dysphagia questionnaire investigations were completed in 34 patients. There were negative correlations between frequency of solid food dysphagia and esophageal DCI, the esophageal peristaltic amplitude at 3 cm above LES, the esophageal peristaltic amplitude at 3 cm to 7 cm above LES (r=-0.445, P=0.008; r=-0.354, P=0.040, r=-0.459, P=0.006). Negative correlations were found between severity of solid food dysphagia and average DCI, amplitude 3 cm to 7 cm above LES (r=-0.349, P=0.043; r=-0.400, P=0.019). Among the 17 patients with 24 h esophageal pH-impedance monitoring, ten had pathological gastroesophageal reflux. Conclusions Among patients with upper gastrointestinal syndromes, patients with hypertensive peristalsis at esophageal body are not uncommon. Except for the difference in amplitude of esophgeal peristalsis, there is no significant difference in clinical and esophageal motility features between Jackhammer esophagus and other kinds of hypertensive peristalsis esophagus, so maybe they are different degrees of esophageal motility disorder of the same. Key words: Esophagus; Peristalsis; Manometry; Pathology, clinical

Esophageal Disorders

Functional esophageal disorders consist of a disease category that present with esophageal symptoms (heartburn, chest pain, dysphagia, globus) not explained by mechanical obstruction (stricture, tumor, eosinophilic esophagitis), major motor disorders (achalasia, EGJ outflow obstruction, absent contractility, distal esophageal spasm, jackhammer esophagus), or gastroesophageal reflux disease (GERD). While mechanisms responsible are unclear, it is theorized that visceral hypersensitivity and hypervigilance play an important role in symptom generation, in the context of normal or borderline function. Treatments directed at improving borderline motor dysfunction or reducing reflux burden to sub-normal levels have limited success in symptom improvement. In contrast, strategies focused on modulating peripheral triggering and central perception are mechanistically viable and clinically meaningful. However, outcome data from these treatment options are limited. Future research needs to focus on understanding mechanisms underlying visceral hypersensitivity and hypervigilance so that appropriate targets and therapies can be developed.

Diagnostic significance of esophageal high-resolution manometry in 233 patients with non-obstructive dysphagia

Objective To explore the etiologies and characteristics of esophageal motility in patients with non-obstructive dysphagia by esophageal high-resolution manometry (HRM). Methods From November 2011 to August 2015, 233 patients with non-obstructive dysphagia diagnosed by HRM were retrospectively analyzed. All the patients received gastroendoscopy to exclude obstructive dysphagia. Results Among 233 patients with non-obstructive dysphagia, there were 160 cases of achalasia, 38 cases of nonspecific esophageal motor disorder (13 cases of low amplitude peristalsis or absent peristalsis, seven cases of synchronous contraction or rapid contraction, three cases of distal esophageal spasm, six cases of increased resting upper esophageal sphincter pressure (UESP), three cases of reduced UESP, six cases of lower esophageal sphincter (LES) incomplete relaxation), five cases of gastroesophageal reflux disease, four cases of scleroderma, two cases of Jackhammer esophagus, and 24 cases with normal esophageal motility. Conclusions Achalasia is the most common cause of non-obstructive dysphagia, followed by non-specific esophageal motor disorder. Esophageal HRM is an important method for the diagnosis of non-obstructive dysphagia, especially for unexplained dysphagia. Key words: High-resolution manometry, esophageal; Dysphagia; Esophageal motor disorder

Peroral endoscopic myotomy for Jackhammer esophagus: to cut or not to cut the lower esophageal sphincter.

Background and study aims: With the success of peroral endoscopic myotomy (POEM) in treatment of achalasia, its successful application to other spastic esophageal motility disorders such as Jackhammer esophagus has been noted. The question of whether the lower esophageal sphincter (LES) should be included in the myotomy for Jackhammer esophagus is a topic of current debate. Here, we report our experience and results with four patients with Jackhammer esophagus treated with POEM. The clinical and manometric results are presented and their potential implications are discussed. Patients and methods: Between January 2014 and July 2015, four patients underwent POEM for treatment of Jackhammer esophagus at our center. Manometry was performed prior to and after POEM. All patients met the Chicago classification criteria for Jackhammer esophagus and received a barium esophagram and endoscopic examination before having POEM. Results: All patients had uneventful procedures without any intraoperative or post-procedure complications. Patients in which the LES was included during POEM had resolution or significant improvement in symptoms. One patient in whom the LES was preserved had resolution of chest pain but developed significant dysphagia and regurgitation. Subsequently this individual received a repeat POEM which included the LES, resulting in symptom resolution. Conclusions: POEM is a suitable treatment for patients with Jackhammer esophagus. Until there are larger-scale randomized studies, we speculate that based on our clinical experience and physiologic and manometric observations, obligatory inclusion of the LES is justified to reduce the risk of symptom development from iatrogenic ineffective esophageal motility or subsequent progression to achalasia.

Loss of Peristaltic Reserve, Determined by Multiple Rapid Swallows, Is the Most Frequent Esophageal Motility Abnormality in Patients With Systemic Sclerosis.

We assessed peristaltic reserve using multiple rapid swallows (MRS) during esophageal high-resolution manometry (HRM) of 111 patients with systemic sclerosis (89 women; ages, 42-64 y). We performed a retrospective analysis of HRM studies that included MRS in patients with systemic sclerosis, performed at 2 tertiary referral centers, and compared data with those from 18 healthy volunteers (controls). HRM findings were analyzed according to the Chicago Classification to provide an esophageal motility diagnosis. Response to MRS was evaluated for the presence of contraction and for augmentation, defined as the distal contractile integral after MRS greater than the median distal contractile integral of 10 supine swallows. Esophageal motility diagnoses included 41% with absent contractility, 31% with normal motility, 23% with ineffective esophageal motility, and 5% that met the criteria for other esophageal motility disorders. Contraction (37%) and peristaltic augmentation (18%) after MRS were observed less frequently in patients with systemic sclerosis than in controls (83% and 100%, respectively). Impaired peristaltic reserve, as assessed with MRS during HRM, is therefore the most common esophageal motility finding among patients with systemic sclerosis.

Submucosal tunnel endoscopy: Peroral endoscopic myotomy and peroral endoscopic tumor resection.

Peroral endoscopic myotomy (POEM) is an innovative, minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic surgery procedures, and since the first human case performed by Inoue in 2008, showed exciting results in international level, with more than 4000 cases globally up to now. POEM showed superior characteristics than the standard 100-year-old surgical or laparoscopic Heller myotomy (LHM), not only for all types of esophageal achalasia [classical (I), vigorous (II), spastic (III), Chicago Classification], but also for advanced sigmoid type achalasia (S1 and S2), failed LHM, or other esophageal motility disorders (diffuse esophageal spasm, nutcracker esophagus or Jackhammer esophagus). POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction (EGJ) and myotomy. Finally the mucosal entry is closed with endoscopic clip placement. POEM permitted relatively free choice of myotomy length and localization. Although it is technically demanding procedure, POEM can be performed safely and achieves very good control of dysphagia and chest pain. Gastroesophageal reflux is the most common troublesome side effect, and is well controllable with proton pump inhibitors. Furthermore, POEM opened the era of submucosal tunnel endoscopy, with many other applications. Based on the same principles with POEM, in combination with new technological developments, such as endoscopic suturing, peroral endoscopic tumor resection (POET), is safely and effectively applied for challenging submucosal esophageal, EGJ and gastric cardia tumors (submucosal tumors), emerged from muscularis propria. POET showed up to know promising results, however, it is restricted to specialized centers. The present article reviews the recent data of POEM and POET and discussed controversial issues that need further study and future perspectives.

Progression of Jackhammer Esophagus to Type II Achalasia.

It has been suggested that patients with certain motility disorders may progress overtime to develop achalasia. We describe a 66 year-old woman who presented with dysphagia for solids and liquids for a period of 18 months. Her initial workup showed normal endoscopy and non-specific esophageal motility disorder on conventional manometry. Six months later, due to persistence of symptoms, the patient underwent a high resolution esophageal manometry (HREM) demonstrating jackhammer esophagus. The patient was treated with a high dose proton pump inhibitor but without resolution of her symptoms. During the last year, the patient reported repeated episodes of food regurgitation and a significant weight loss. A repeat HREM revealed type II achalasia. Multiple case reports, and only a few prospective studies have demonstrated progression from certain esophageal motility disorders to achalasia. However, this report is the first to describe a case of jackhammer esophagus progressing to type II achalasia.

Clinical experience with four cases of jackhammer esophagus

Although jackhammer esophagus (JE) requires proper treatment, many aspects of its clinical course remain unknown. The 4 cases were in patients diagnosed with JE among the 447 patients who underwent high-resolution manometry (HRM) at our hospital between January 2009 and October 2014, and we assessed the patients’ background, their HRM, gastrointestinal endoscopy, and contrast esophagography findings, whether they had esophageal muscle thickening, and their clinical course. All 4 cases were treated for proton pump inhibitor–resistance nonerosive reflux disease, and all of them were ultimately diagnosed as JE. The test findings revealed an esophageal hiatal hernia and esophageal muscle thickening in every case, contrast esophagography showed abnormal contractions in 3/4 cases. During a mean follow-up period of 3.3 years, progression from nutcracker esophagus [NE; the Chicago Classification (2012 version)] to JE was observed during the course of 2 of the 4 patients. In 1 of the 4 patients, the symptoms improved in the absence of treatment. Among the 3 patients who received treatment, the symptoms of 2 patients were controlled within tolerable intensity by conservative treatment, but surgical treatment was selected in the other case. However, because the symptoms recurred after the operation, peroral endoscopic myotomy was performed in addition. Because the pathology at the onset and clinical course of JE are not uniform, it is necessary to tailor treatment policy to each individual case and to consider altering treatment policy according to the patient’s clinical course.

Esophageal diverticula are associated with propagating peristalsis: a study utilizing high-resolution manometry.

Esophageal diverticula have been associated with esophageal motility disorders, most commonly achalasia. We aimed to evaluate high-resolution manometry (HRM) motility diagnoses and pressurization patterns in patients with esophageal diverticula. Patients were retrospectively identified for distal esophageal diverticula and previously completed HRM. High-resolution manometries were analyzed according to the Chicago Classification, and the pressure slope of the compartmentalization phase (time between upper esophageal sphincter closure and the transition zone) of esophageal bolus transit was measured. Pressure slopes were also measured in 10 asymptomatic volunteers (controls) for comparison. Nineteen patients (ages 31-83) were included. Eight (42%) patients had normal motility, five (26%) had esophagogastric junction outflow obstruction, and two (11%) had jackhammer esophagus; four patients had other motility diagnoses including only one patient with achalasia. A total of six patients (32%) had at least one hypercontractile swallow. Greater compartmentalization phase pressure slopes were observed in patients at the mid-esophageal body in both supine (median [interquartile range]: 1.9 mmHg/s [0.9, 3.6]) and upright (1.1 [0.1, 3.1]) positions than in controls (supine: -1.3 [-2.4, -0.11], p = 0.001; upright; -0.71 [-2.1, -0.02], p = 0.005). Propagating peristalsis, often with hypercontractility, was commonly seen in our cohort of patients with esophageal diverticula. Abnormal compartmentalization phase pressurization may indicate a relationship of abnormal esophageal wall mechanics and/or compliance with diverticula; however whether these findings are causal or reactionary remains unclear.

Frequency of Jackhammer Esophagus as the Extreme Phenotypes of Esophageal Hypercontractility Based on the New Chicago Classification

Introduction: Jackhammer Esophagus defined as intact esophageal peristaltic contractions with extremely elevated amplitudes. We conducted a retrospective study to identify the frequency of esophageal hypercontractility and the clinical characteristics of Jackhammer Esophagus. Methods: Charts for the patients referred for manometric study at a tertiary-care motility center were reviewed. Data were collected utilizing the new Chicago classification criteria for Jackhammer Esophagus. Concomitant clinical variables were also explored. Results: From a total of 205 patients (127 F/77 M), 8 patients met criteria for Jackhammer Esophagus from a total of. Jackhammer patients had an average distal contractile integral (DCI) of 9,061 mm Hg-sec-cm and median maximal DCI of 16,433 mm Hg-sec-cm. The greatest DCI from 15 swallows was 28,875 mm Hg-sec-cm. Hypercontractility was associated with multipeaked contractions in every Jackhammer patient. The mean lower esophageal sphincter (LES) pressure was 41 mmHg (4 patients > 40). 37.5% of Jackhammer group had incomplete LES relaxation by Integrated Relaxation Pressure (IRP) criteria. Dysphagia (8/8) was the dominant indication for the manometric study, while the clinical background setting was gastroesophageal reflux disease (4/8) and hiatal hernia (1/8). Treatments included smooth muscle relaxation, anti-reflux regiments, and pneumatic dilation of the LES. Conclusion: 1) Jackhammer Esophagus, an extreme manometric phenotype, was identified in 4.0% of patients referred to a University Motility Center; 2) The patients with these esophageal hypercontractility states present mainly with dysphagia; 3) a subgroup of Jackhammer did have accompanying incomplete LES relaxation and responded to a targeted therapeutic with pneumatic dilatation.

Radiofrequency Catheter Ablation for Atrial Fibrillation Elicited "Jackhammer Esophagus": A New Complication Due to Vagal Nerve Stimulation?

Radiofrequency catheter ablation (RFCA) is a potentially curative method for treatment of highly symptomatic and drug-refractory atrial fibrillation (AF). However, this technique can provoke esophageal and nerve lesion, due to thermal injury. To our knowledge, there have been no reported cases of a newly described motor disorder, the Jackhammer esophagus (JE) after RFCA, independently of GERD. We report a case of JE diagnosed by high-resolution manometry (HRM), in whom esophageal symptoms developed 2 weeks after RFCA, in absence of objective evidence of GERD. A 65-year-old male with highly symptomatic, drug-refractory paroxysmal AF was candidate to complete electrical pulmonary vein isolation with RFCA. Prior the procedure, the patient underwent HRM and impedance-pH to rule out GERD or hiatal hernia presence. All HRM parameters, according to Chicago classification, were within normal limits. No significant gastroesophageal reflux was documented at impedance pH monitoring. Patient underwent RFCA with electrical disconnection of pulmonary vein. After two weeks, patient started to complain of dysphagia for solids, with acute chest-pain. The patient repeated HRM and impedance-pH monitoring 8 weeks after RFCA. HRM showed in all liquid swallows the typical spastic hypercontractile contractions consistent with the diagnosis of JE, whereas impedance-pH monitoring resulted again negative for GERD. Esophageal dysmotility can represent a possible complication of RFCA for AF, probably due to a vagal nerve injury, and dysphagia appearance after this procedure must be timely investigated by HRM.

The Clinical Significance of Jackhammer Esophagus (JE): Comparison of High-Resolution Manometry Features, Demographics, Symptom Presentation, and Response to Therapy in Patients With JE Versus Nutcracker Esophagus (NE)

The Clinical Significance of Jackhammer Esophagus (JE): Comparison of High-Resolution Manometry Features, Demographics, Symptom Presentation, and Response to Therapy in Patients With JE Versus Nutcracker Esophagus (NE)

Pathogenesis of Patients With Double-Dose PPI-Resistant NERD

Introduction: The proportion of patients with non-erosive reflux disease (NERD), who respond to a standard dose of PPI, is about 50%. Various types of pathogenesis have been suggested as an explanation for PPI failure in patients with double-dose PPI-resistant NERD, however, the proportion of patients with this pathogenesis is not clear. Methods: 53 patients with NERD, who had persistent reflux symptoms despite taking double-dose PPI, were included in this study. Firstly, esophagogastroduodenoscopy (EGD) was carried out, after which 3 esophageal biopsies were taken from the middle to the lower esophagus in order to diagnose eosinophilic esophagitis (EoE). If EoE was not found, high-resolution manometry was carried out in order to diagnose esophageal motility disorder, in accordance with the Chicago classification. In situations where patients did not have an esophageal motility disorder, 24-hour combined multiple intraluminal impedance (Mll)-pH monitoring was carried out on because the cause of their symptoms was still unclear. A positive symptom index (SI) was declared if at least half of the symptoms were preceded by liquid reflux episodes within five minutes. With regard to gas-only reflux episode-related symptoms, the relationship between each gas-only reflux episode and the symptom was investigated. Results: 1 of 53 patients had EoE, 4 had esophageal motility disorders, 3 had Jackhammer esophagus and 1 had rapid contractions with normal latency (by Chicago classification 2011 version). Mll-pH monitoring was carried out on the remaining 48 patients. 22 patients had a positive SI to a liquid reflux episode (4 with SI (+) for an acid reflux episode, 15 with SI (+) for a weakly acid reflux episode, 2 with SI (+) for both acid and weakly acid reflux episodes, 1 with SI (+) for a liquid reflux episode) and 2 had a positive SI for a gas-only reflux episode. The remaining 24 patients had a negative SI. Conclusion: The pathogenesis in 55% of patients, who had double-dose PPI-resistant NERD became clear. Although weakly acid reflux episodes are a major mechanism of underlying reflux symptoms, esophageal motility disorders are also an important cause.