Low Lower Esophageal Sphincter Pressure Research Articles

Measurement of oesophageal hiatus surface area by multiplanar reconstruction of MDCT: relationship with lower oesophageal sphincter pressure and acid reflux

To evaluate the relationship between oesophageal hiatus surface area (OHSA) and gastro-oesophageal reflux disease (GERD). Patients who underwent 24-h pH monitoring, oesophageal high-resolution manometry, and upper abdominal contrast-enhanced multidetector computed tomography (MDCT) during 2014-2021 were enrolled. Patients with a hiatus hernia (HH) on MDCT or who had a history of gastro-oesophageal surgery were excluded. Multiplanar reconstruction (MPR) of the MDCT image was used for the measurement of OHSA. Correlations of OHSA with acid exposure time (AET) and lower oesophageal sphincter (LOS) pressure of all patients were analysed. Seventy-eight patients were included in the study. OHSA was much less in the AET <4% group than in the AET >6% group (1.61±0.42 versus 2.09±0.55 cm2, p<0.001). Correlation analysis reveals that OHSA correlated positively with AET (correlation coefficient=0.47, p<0.001). Receiver operating characteristic (ROC) curve analysis reveals that OHSA can significantly distinguish patients in different groups divided by AET (area under the ROC curve [AUC]=0.76, 95% confidence interval [CI]: 0.63-0.90). OHSA was not related to LOS pressure (correlation coefficient=-0.268, p=0.051). There was no difference in OHSA between the low LOS pressure group and the normal LOS pressure group (1.84±0.61 versus 1.74±0.50 cm2, p=0.52). OHSA significantly correlated with AET but has no relationship with LOS pressure. It may be an independent risk factor of GERD.

Hiatal hernias associated with acid reflux: size larger than 2cm matters.

Hiatal hernia (HH) is associated with gastroesophageal reflux disease (GERD); the effect of HH size on GERD is not well defined. To evaluate the relationship between HH size as measured by high-resolution esophageal manometry (HREM) and reflux parameters on esophageal pH-impedance testing (multichannel intraluminal impedance-pH [MII-pH]) to define HH sizes associated with GERD. HREM and MII-pH studies were reviewed. The relationship of HH size to other parameters was analyzed with multivariable logistic regression. Correlation coefficients were determined using Spearman and Pearson's tests. A total of 897 patients underwent both HREM and MII-pH. There were 529 (58.9%) patients with HH size <1cm, 203 (22.6%) with HH 1.0-1.9cm, and 165 (18.4%) with HH ≥2cm. Larger HH size was associated with lower esophageal sphincter (LES) basal and residual pressures (r = -0.43 and r = -0.48, p < 0.01), higher acid exposure time (AET) (r = 0.17, p < 0.01), number of acidic refluxes (r = 0.16, p < 0.05), and number of reflux episodes detected by impedance (total r = 0.22, p < 0.01). HH ≥ 2cm compared with smaller size HH was associated with higher proximal AET%, acidic refluxes, and reflux episodes detected by impedance (p < 0.05). Increasing HH size was associated with older age, higher AET, and number of reflux episodes. HH ≥2cm was associated with multiple worsened GERD parameters. Low LES pressure was weakly associated with an increase in the number of reflux episodes. Larger HHs, particularly >2cm, are associated with more severe GERD parameters.

High-resolution manometry features of paraesophageal hernia.

Paraesophageal hernias (PEH) can be associated with obstructive symptoms, but high-resolution manometry (HRM) characteristics have not been described in detail. HRM studies of confirmed PEH patients (n=60, 66.3±1.5years, 76.7% F), axial hernias (n=125, 56.1±1.1years, 58.4% F), and healthy controls (n=20, 27.9±0.7years, 45% F) were analyzed. Axial hernias (type 1) were compared to PEH subtyped as isolated PEH (type 2), PEH with axial hernia (type 3), PEH with herniated abdominal organs (type 4), and unknown. Distal contractile integral (DCI), esophageal length, lower esophageal sphincter pressures (LESP), EGJ contractile integral (EGJ-CI), and integrated relaxation pressure (IRP) were extracted. Intra-luminal pressures were measured proximal (intrabolus pressure, IBP) and distal (intragastric pressure, IGP) to EGJ. Univariate and multivariate analyses were performed to characterize esophageal and EGJ motor physiology in PEH. PEH patients had LESP and EGJ-CI similar to controls; axial hernia patients had lower LESP. While IRP was within normal limits, PEH had elevated IBP and IGP, and shorter esophageal length compared to axial hernia and normal controls (P≤.0001 across groups). Short esophageal length was consistent across PEH subtypes (P=.06). On multivariate regression analysis, IBP remained an independent predictor of PEH (P<.0001). Within PEH subtypes, gastric pressure was higher when axial HH was also present, in contrast to isolated PEH (P=.03); other metrics did not differ. Luminal pressure increase both upstream and downstream of the EGJ on HRM likely represents obstructive phenomena in PEH, identification of which may support suspicion of PEH.

The relationship between acid reflux and esophageal motility, esophagitis and cardiac morphology in gastroesophageal reflux disease

Objective: To analyze the relationship between the severity of esophageal acid reflux and esophageal motility, esophageal mucosal injury and morphological anatomy of gastroesophageal junction (GEJ) in patients with gastroesophageal reflux disease (GERD). Methods: The clinicaldata of GERD patients who underwent 24 h pH-impedance monitoring, gastroscopy and high-resolution manometry (HRM) from January 2016 to January 2019 in the Gastroesophageal Surgery Department of PLA Rocket Force Characteristic Medical Center were retrospectively analyzed. The patients were divided into non-pathological acid reflux group, mild pathological acid reflux group and moderate to severe pathological acid reflux group according to the DeMeester score. The gender and age of each group were matched, with 60 cases in each group. Statistical analysiswas performed to analyze thedifferences in upper esophageal sphincter pressure, lower esophageal sphincter pressure (LES), LES length, length of ventral LES, percentage of ineffective swallowing, esophagitis, Hill grade of GEJ, and hiatus hernia (HH) in each group. The comparison and correlation analysis are also carried out between the groups. Results: The male-female ratio was 33/27, and the age was (57±13) years in each group. Non-parametric analysis showed that the LES pressure and the length of the ventral LES decreased with the severity of acid reflux, and there was a statistical difference (P= 0.033, P=0.015). The detection rate of HH by HRM increased significantly (χ(2)=0.001) as well. Esophagitis score increased with the severity of acid reflux and there was statistical difference (P<0.001).The detection rate of esophagitis increased significantly (χ(2)<0.001) as well. Hill grading score of GEJ increased with the severity of acid reflux, and there was statistical difference (P<0.001).The detection rate of HH by endoscopy increased significantly (χ(2)<0.001) as well. The correlation between DeMeester score and LES pressure, length of ventral LES, percentage of ineffective swallowing, esophagitis score, and Hill grade score were statistically significant (P<0.05). Conclusions: The esophageal low motility (such as low LES pressure) and anatomical abnormalities (abdominal esophageal shortening, GEJ flabbiness, and even HH formation) of the GEJ regionare significantly associated with the severity of acid reflux. These factors may be important causes of increased acid reflux. In addition, the aggravation of acid reflux can also increase the incidence and severity of esophagitis.

ENDOSCOPIC EVALUATION OF MANOMETRIC PROFILE OF GASTRO ESOPHAGEAL REFLUX DISEASE

Background: Gastro esophageal reflux disease leads to poor quality of life to patients because of pain and discomfort. Some studies also reported that incidence of adenocarcinoma of esophagus and Barrett's esophagus among patients with reflux disease. The abnormal esophageal motility act as a major risk factors and also reported with severity and prognosis of the disease.&#x0D; Material &amp; Methods: In present study 50 patients of heart burn or acid regurgitation (GERD) for at least more than 3 months were enrolled from outdoor and from ward by simple random sampling. Clearance from Institutional Ethics Committee was taken before start of study. Written informed consent was taken from each study participant.&#x0D; Results: 15 (30%) had non-erosive reflux disease and 35 (70%) had erosive reflux disease. Among the patients of non-erosive reflux disease, 13 (26%) had normal lower esophageal sphincter pressure and 2 (4%) had Low Lower esophageal sphincter pressure. Among the patients of erosive reflux disease, 32 (64%) had normal lower esophageal sphincter pressure and 3 (6%) had Low Lower esophageal sphincter pressure (P value &gt;0.05). Among the patients of non-erosive reflux disease, 10 (20%) had normal esophageal motility and 5 (10%) had Ineffective esophageal motility. Among the patients of erosive reflux disease, 25 (50%) had normal esophageal motility and 10 (20%) had Ineffective esophageal motility (P value &gt;0.05).&#x0D; Conclusion: Low Lower esophageal sphincter and Ineffective or abnormal esophageal motility pressure was non-significantly associated with non-erosive and erosive reflux disease. Ineffective esophageal motility and Low LES pressure was the main cause for gastro esophageal reflux disease&#x0D; Keywords: GERD, High Resolution Manometry, Ineffective peristalsis.

Relationship between esophageal motility and severity of gastroesophageal reflux disease according to the Los Angeles classification

The current study aimed to investigate the relationship between the severity of gastroesophageal reflux disease (GERD) according to the Los Angeles (LA) classification and esophageal motility using high-resolution manometry (HRM) and 24-hour esophageal pH monitoring.We examined 124 patients with GERD from January 2016 to June 2018. The LA classification of each patient was determined by endoscopy. HRM was performed by the intraluminal water infusion method. HRM and 24-hour esophageal pH monitoring parameters of the patients were studied and statistically compared.On HRM examination, GERD symptoms were found to be associated with worsened distal contractile integral (DCI), ineffective esophageal motility (IEM), peristalsis break (PB), lower esophageal sphincter (LES) pressure, and the 4-second integrated relaxation pressure (IRP4s) of LES pressure along with the grade of LA classification, especially in patients having grade C and D GERD who had transverse mucosal breaks. The 24-hour pH monitoring study revealed that patients classified as having grade C or D GERD had an esophageal pH < 4.0 for a longer time than those with grade O, A, or B GERD. Similar results were found regarding the duration of the longest reflux event, the number of reflux episodes longer than 5 minutes, and the number of reflux episodes. Patients with higher grade esophagitis had higher De Meester scores, which suggested greater esophageal acid exposure. Hiatal hernia (HH) was more closely related to LES pressure, IRP4s, and acid exposure, whereas DCI, IEM, and PB were not statistically different between patients with GERD with and without HH.Patients with severe esophagitis may have motor dysfunction not only in the LES but also in the esophageal body, with resulting increased esophageal acid exposure, which causes esophagitis. Low LES pressure might be the main reason that patients with HH develop esophagitis. GERD without HH may be due to a variety of motor dysfunctions.

Effects of transcutaneous electro acupuncture stimulation on esophageal motility of forty-five patients with refractory gastroesophageal reflux disease

Objective To investigate the effects of transcutaneous electro acupuncture stimulation (TEA) on esophageal motility of patients with refractory gastroesophageal reflux disease (RGERD) by high resolution manometry (HRM), and to provide a new treatment option for RGERD. Methods From February 2014 to June 2015, a total of 45 patients with RGERD were enrolled. TEA instrument was used for electro acupuncture stimulation at the points of Zusanli and Neiguan. HRM was carried out before and after treatment. The changes of HRM parameters such as lower esophageal sphincter pressure (LESP), distal contractile integral (DCI), and amplitude of 3 cm, 7 cm above lower esophageal sphincter (LES), esophageal body velocity and contractile front velocity (CFV) were also compared. The paired-samples t test was performed for statistical analysis. Results According to LESP value, 45 patients were divided into low LESP group (10 patients) and normal LESP group (35 patients). According to parameter of esophageal motility function, patients were divided into esophageal dysmotility group (25 patients) and normal esophageal motility group (20 patients). After TEA treatment, the LESP of lower LESP group was (14.83±4.17) mmHg (1 mmHg=0.133 kPa), which was higher than that before treatment ((9.54±2.42) mmHg), and the difference was statistically significant (t=4.92, P=0.001). LESP of esophageal dysmotility group was (19.04±5.91) mmHg, which was higher than that before treatment ((16.20±6.09) mmHg), and the difference was statistically significant (t=4.92, P=0.001). There was no statistically significant difference in LESP of normal LESP group and normal esophageal motility group before and after treatment (both P>0.05). After treatment, DCI of esophageal dysmotility group was (530.76±215.53) mmHg·cm·s, which was higher than that before treatment ((363.92±279.17) mmHg·cm·s), and the difference was statistically significant (t=2.86, P 0.05). There was no statistically significant difference in all of the esophageal motility parameters in normal esophageal motility group before and after treatment (all P>0.05). Conclusion TEA can increase LESP and DCI in RGERD patients with esophageal motility dysfunction, improve contraction of entire esophagus and raise esophageal clearance capacity. Key words: Refractory gastroesophageal reflux disease; Transcutaneous electro acupuncture stimulation; High resolution manometry, esophageal; Esophageal motility

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.

Spectrum of GastroEsophageal Reflux Disease (GERD) in Systemic Sclerosis (SSc)-Associated Esophageal Dysmotility as Defined by High Resolution Esophageal Manometry (HREM)

Introduction: The worsening esophageal dysmotility and incompetent lower esophageal sphincter(LES) are major contributors of GERD in patients with SSc. The spectrum of GERD can vary from nonerosive disease to severe esophagitis with stricturing. Our aim was to see if degree of esophageal dysmotility as defined by HREM correlated with the severity of GERD in SSc patients. Methods: This is a retrospective chart review of all SSc patients who underwent HREM at our institution from January 2008 to October 2014. The following data were collected: demographic features (age, gender, and race), medications, tobacco and alcohol use, esophagogastroduodenoscopy(EGD) findings, pH studies, and barium esophagogram results. All HREM were reinterpreted using the Chicago Classification of Esophageal Motility Disorders, v3.0 criteria. Data are reported as mean ± standard deviation, median, or frequency (percent). For univariate analyses, we used analysis of variance(ANOVA), non-parametric Kurksal-Wallis, Pearson's chi-square, or Fisher's Exact tests, where appropriate. Results: A total of 122 patients with SSc underwent HREM of which 73 had absent contractility(AC), 22 had ineffective esophageal motility(IEM), and 23 had a normal study. On upper endoscopy, erosive esophagitis, hiatal hernia and esophageal strictures were more common in AC than in other two groups. There were no statistically significant differences in other endoscopic findings in all three groups (Table 1). On barium esophagogram, esophageal dysmotility and dilated esophageal lumen were more prevalent in AC group. Of note, 6 out of 78 patients had barium esophagograms suggestive of achalasia but HREM showed AC with low LES pressure. Conversely, one patient had Type II Achalasia on HREM but the barium esophagogram showed normal primary peristalsis with retrograde escape and impediment to passage of 13 mm barium tablet at gastroesophageal junction. Esophageal pH testing showed no association with severity of esophageal dysmotility.Table 1: Esophageal Testing in SSc hiaConclusion: In this large cohort of SSc patients who underwent HREM, the severity of GERD related endoscopic and barium esophagogram findings correlated with the degree of esophageal dysmotility. However, a similar association was not observed between esophageal dsymotility and pH study results in patients with SSc.

Pathophysiology of gastroesophageal reflux disease: new understanding in a new era.

The prevalence of gastroesophageal reflux disease (GERD) has increased in the last decades and it is now one of the most common chronic diseases. Throughout time our insight in the pathophysiology of GERD has been characterized by remarkable back and forth swings, often prompted by new investigational techniques. Even today, the pathophysiology of GERD is not fully understood but it is now recognized to be a multifactorial disease. Among the factors that have been shown to be involved in the provocation or increase of reflux, are sliding hiatus hernia, low lower esophageal sphincter pressure, transient lower esophageal sphincter relaxation, the acid pocket, obesity, increased distensibility of the esophagogastric junction, prolonged esophageal clearance, and delayed gastric emptying. Moreover, multiple mechanisms influence the perception of GERD symptoms, such as the acidity of the refluxate, its proximal extent, the presence of gas in the refluxate, duodenogastroesophageal reflux, longitudinal muscle contraction, mucosal integrity, and peripheral and central sensitization. Understanding the pathophysiology of GERD is important for future targets for therapy as proton pump inhibitor-refractory GERD symptoms remain a common problem. In this review we provide an overview of the mechanisms leading to reflux and the factors influencing perception, in the light of historical developments. It is clear that further research remains necessary despite the recent advances in the understanding of the pathophysiology of GERD.

OC-071 Oesophageal physiology findings in 80 patients with recurrent dysphagia post-achalasia treatment: retest before retreating

Introduction Achalasia is a relatively rare primary oesophageal motor disorder characterised by absent peristalsis and failure of relaxation of the lower oesophageal sphincter (LOS). The standards of treatment for achalasia are pneumatic balloon dilatation and surgical myotomy. Although 85–95% success at 2 years is reported with these procedures, in the longer term, dysphagia may return in over 50%, prompting consideration of re-treatment. The definition of recurrence is often based on symptom evaluation, particularly dysphagia. Treatment of dysphagia in achalasia is targeted at the LOS, but in some patients dysphagia may be multifactorial and may not be improved by attempting to further lower LOS pressure. We aimed to evaluate the GI physiological findings of patients undergoing studies in our tertiary referral unit to investigate recurrence of dysphagia post-treatment. Method We interrogated our database for patients undergoing high resolution oesophageal manometry +/- 24-hour pH studies due to dysphagia post-treatment for achalasia between 2010–2014. We recorded achalasia subtype, LOS relaxation pressure (known as integrated relaxation pressure, or IRP), and reflux study results if performed. Results 80 eligible patients (38 female; age range 11–83 years, median 46 years) were identified with recurrent dysphagia. All had high resolution oesophageal manometry performed, and 18 patients had 24-hour pH studies due to concomitant heartburn and/or regurgitation. 52 patients had undergone at least one previous pneumatic dilatation, 23 had undergone surgical myotomy, and 5 had no response to Botox injection. 40 patients were found to have type 1 achalasia, 25 had type 2 achalasia, and 6 had type 3 achalasia. 9 patients had normal peristalsis unlikely to be consistent with a diagnosis of achalasia. 22 of the 80 patients had an IRP >15 mmHg (upper range of normal). 10 patients had a very low ( Conclusion We investigated a large cohort of patients with recurrent dysphagia post-treatment of achalasia. The most frequent achalasia subtype was type 1. Although 28% patients had high residual LOS pressures, a significant proportion of patients had findings not consistent with a need to re-treat with dilatation or myotomy (due to very low LOS pressure, gastro-oesophageal reflux disease, or possible incorrect diagnosis). These results highlight the need to carefully re-evaluate patients presenting with recurrent dysphagia after achalasia treatment before deciding on repeat therapy. Disclosure of interest None Declared.

Predictive value of routine esophageal high-resolution manometry for gastro-esophageal reflux disease.

Using conventional manometry, gastro-esophageal reflux disease (GERD) was associated with a reduced lower esophageal sphincter (LES) pressure and impaired peristalsis. However, with a large overlap between GERD patients and controls, these findings are of limited clinical relevance. It is uncertain whether the more detailed information of high-resolution manometry (HRM) can discriminate GERD patients. Therefore, we aimed to determine to which extent HRM findings can predict GERD. HRM measurements in 69 patients with GERD and 40 healthy subjects were compared and the predictive value of HRM for the diagnosis of GERD was explored. GERD patients had a significantly lower contraction amplitude (55 vs 64 mmHg; p = 0.045) and basal LES pressure (10 vs 13.2 mmHg; p = 0.034) than healthy controls. GERD patients more often had a hiatal hernia than healthy subjects (30% vs 7%; p = 0.005). Patients with reflux esophagitis had a lower DCI than patients without reflux esophagitis (558 vs 782 mmHg cm s; p = 0.045). No significant difference was seen in contractile front velocity, distal latency, number of peristaltic breaks, residual LES pressure and LES length. On multivariate logistic regression analysis, both esophagogastric junction type I (OR 4.971; 95% CI 1.33-18.59; p = 0.017) and mean wave amplitude (OR 0.95; 95% CI 0.90-0.98; p = 0.013) were found to be independent predictors of GERD. However, the sensitivity and specificity of these findings were low. Hiatal hernia, low contraction amplitude and LES pressure are associated with GERD, but do not predict the disease with sufficient accuracy. Routine esophageal HRM can therefore not be used to distinguish GERD patients from healthy subjects.

The University of Chicago contribution to the treatment of gastroesophageal reflux disease and its complications: a tribute to David B. Skinner 1935-2003.

To highlight the contributions from the University of Chicago under the leadership of Dr David B. Skinner to the understanding of gastroesophageal reflux disease (GERD) and its complications. The invention of the esophagoscope confirmed that GERD was a premorbid condition. The medical world was divided between those who believed in a morphological lower esophageal sphincter (LES) and those who did not. Those who did not believe attempted to rearrange the anatomy of the foregut organs to stop reflux with minimal success. The discovery of the LES focused attention on the sphincter as the main deterrent to reflux and the hope that measurement of a low LES pressure would mark the presence of GERD. This turned out not to be so. In July 1973, with this history of confusion, Dr Skinner at the age of 36 assumed the chair of surgery at the University of Chicago. The publications of the University of Chicago's esophageal group were collected from private and public (PubMed) databases, reviewed, and seminal contributions selected. Twenty-four-hour esophageal pH monitoring led to the understanding of the LES, its contribution to GERD, and the complication of Barrett's esophagus. The relationship of Barrett's to adenocarcinoma was clarified. The rising incidence of esophageal adenocarcinoma led to contributions in the staging of esophageal cancer and its treatment with an en bloc resection. Ten years after the death of Dr Skinner, we can appreciate the monumental contributions to benign and malignant esophageal disease under his leadership.

The prevalence of gastro-esophageal reflux disease and esophageal dysmotility in Chinese patients with idiopathic pulmonary fibrosis.

BackgroundThe cause of idiopathic pulmonary fibrosis (IPF) remains unknown, yet gastro-esophageal reflux disease (GERD) is highly prevalent in this population. GERD prevalence was studied, and esophageal function tests (EFT) were assessed in Chinese IPF patients.MethodsWe prospectively studied 69 IPF patients who undertook both stationary High Resolution esophageal Manometry/Impedance (HRiM) and 24-hour esophageal Multi-Channel Intraluminal Impedance with pH Recordings (MII/pH). Patients were divided into GERD+ and GERD- groups according to pH results. Controls were HRiM treated healthy volunteers, and patients without IPF received HRiM and MII/pH diagnosed with GERD.Results69 IPF patients, 62 healthy volunteers, and 88 IPF negative GERD patients were selected. GERD prevalence in IPF was 43/69 (62.3%), and 58.1% of patients presented with at least one typical symptom. Symptoms had a sensitivity of 58.1%, a specificity of 61.6%, a positive predictive value of 71.4% and a negative predictive of 47.1%. Compared with healthy volunteers, IPF patients had significantly decreased lower esophageal sphincter pressure (LESP), upper esophageal sphincter pressure (UESP) and complete bolus transit rate (CBTR). By contrast, IPF patients had increased total bolus transit time and prevalence of weak peristalsis. MII/pH showed that one third of IPF patients had abnormal distal and proximal reflux, especially non-acid reflux. Compared with GERD patients without IPF, GERD patients with IPF had significantly decreased CBTR and UESP with increased bolus exposure time.ConclusionsGERD prevalence in IPF was high, but symptoms alone were an unreliable predictor of reflux. IPF patients had lower LESP and UESP, impaired esophageal peristalsis and bolus clearance function with more proximal reflux events.

Detection of GERD With Esophageal Manometry With Impedance

Introduction: To investigate the value, if any, of reflux patterns seen on esophageal manometry with impedance. Methods: Studies using esophageal manometry with impedance (Given, Inc.) from Temple University Hospital Digestive Disease Center were examined from 2010-2012. Patients with reflux pattern on impedance were identified. The reflux pattern most often seen is a bolus clearance and a V-shaped bolus reflux pattern from the stomach back up into the esophagus. Control data was taken from normal patients without any upper GI symptoms undergoing esophageal manometry with impedance, along with patients without a reflux pattern on impedance. This group was further subdivided into those with a positive pH study for reflux and those with a negative study. Resting lower esophageal sphincter (LES) pressure, residual LES, presence and size of hiatal hernia, number of reflux episodes on impedance, and mean refluxate height were recorded and analyzed with independent samples T-test using SPSS 22. Results: Seventeen patients had esophageal reflux on impedance. Average reflux height was 11 cm with σ± 3.46, average number of reflux episodes was 9 σ± 3.3. Six of these 17 patients also had a positive pH study while 11 did not (Table 1). Twenty-eight patients did not have an esophageal reflux pattern on impedance; 19 had a positive ambulatory pH study and 9 had a negative pH study. The presence and size of hiatus hernia were larger in the reflux group. There were trends for the refluxate group to have lower LES pressures compared to non-refluxate (Table 2).Table 1: Comparison Between +/− pH study with Refluxate on ImpedanceTable 2: Comparison Between Refluxate on Impedance and Without RefluxateConclusion: Reflux can be detected on the esophageal manometry impedance studies. Patients with reflux pattern on esophageal manometry with impedance have lower resting LES pressures and residual LES pressures but this is not statistically significant, this may be due to the small sample size. Hiatal hernia sizes are larger in those with reflux patterns on impedance. This study suggests that reflux pattern on impedance manometry may define a population of GERD patients with different physiologic parameters than those GERD patients without a reflux pattern.

Bolus retention in hiatal hernia identified by high-resolution esophageal manometry with impedance

Esophageal acid retention in a hiatal hernia (HH) may play a role in gastro-esophageal reflux. The aims of this study were to determine the prevalence of bolus retention (BR) in HH and to compare pressure profiles in patients with HH with BR in the hernia to those with bolus clearance (BC) through the hernia using high-resolution esophageal manometry with impedance (HREMI). Clinical HREMI studies with HH ≥1.5cm were analyzed for lower esophageal sphincter (LES) and crural diaphragm (CD) pressures and pressure profiles during 12 saline swallows. Impedance was analyzed for swallow retention in the HH. Bolus retention in a HH was present in 35 of 53 (66%) patients with a HH. Patients with BR had overall lower pressure profiles including a lower basal LES pressure (14.8±10.6 vs 28.9±16.8mmHg; p=0.0001), LES-CD gradient (6.8±17.9 vs 20.6±12.2mmHg; p=0.002), residual LES pressure (2.5±4.6 vs 6.1±12.2mmHg; p=0.017), amplitude of distal esophageal contractions (83.2±38.8 vs 111.2±42.8mmHg; p=0.020), and distal contractile integral (1487±1016 vs 2608±1221mmHg-cm-sec; p=0.001) compared to the BC group. Patients with BR were more likely to have a larger sized HH compared to the BC group (3.1±1.6 vs 2.1±0.6cm; p=0.016); similar pressure changes were found when the groups were divided up by HH sizes. Bolus retention was seen in 66% of patients with HH. Bolus retention in the HH was associated with larger HH size, lower LES pressure, and lower esophageal contractile pressures compared to those with BC.

Nocturnal and daytime esophageal acid exposure in normal-weight, overweight, and obese patients with reflux symptoms

This study aimed to investigate the association between BMI and esophageal acid exposure in a cohort of patients referred for esophageal pH monitoring. The contributing roles of hiatal hernia, lower esophageal sphincter (LES) pressure, and intragastric pressure (IGP) were investigated, with an emphasis on reflux in the supine position. Esophageal manometry and 24-h pH-metry results were extracted from a prospectively collected database, and supplemental data (body mass, endoscopy results) from patient files. In total, 245 patients (mean age 52.2±14 years, 54% men) were included in this study. In the normal-weight subgroup (n=87), the median acid exposure time was 1.1% [0-8.1] in the supine position (with interquartile range 25-75%) and 7.7% [2.5-14.8] in the upright position; the total acid exposure time was 7.4% [2.7-11.7]/24 h. In the overweight subgroup (n=104), the median acid exposure time was 4.9% [0.3-13.3] in the supine position and 11.1% [5.4-16.9] in the upright position; the total acid exposure time was 8.9% [4.7-15.8]/24 h. In the obesity subgroup (n=54), the median acid exposure time was 4.1% [0.7-14.3] in the supine position and 10.5% [5-17.5] in the upright position; the total acid exposure time was 8.3% [5.3-14.7]/24 h. Supine acid exposure was significantly higher in overweight and obese patients than in normal-weight patients (both P=0.02). In overweight patients, a hiatal hernia was predictive of supine and total acid exposure, as was a decreasing LES pressure in both the supine and the upright position. In obese patients, increased IGP contributed toward an increased total acid exposure. Although an association between increasing BMI and acid exposure was observed, BMI was not independently predictive. Overweight and obesity is associated with increased reflux, especially in the supine position. The most important factors that contribute toward reflux are the presence of a hiatal hernia and a lower LES pressure in overweight patients and an increased IGP in obese patients.

A study of pathophysiological factors associated with gastro‐esophageal reflux disease in twins discordant for gastro‐esophageal reflux symptoms

Differences in lower esophageal sphincter (LES) and peristaltic function and in transient LES relaxations (TLESR) have been described in patients with gastro-esophageal reflux disease (GERD). However, some of these differences may be the result of chronic GERD rather than being an underlying contributory factor. Twins discordant for GERD symptoms, i.e., only one twin had GERD symptoms, underwent standard LES and esophageal body manometry, and then using a sleeve sensor prolonged LES and pH monitoring, 30 min before and 60 min after a 250 mL 1200 kcal lipid meal. Eight monozygotic and 24 dizygotic female twins were studied. Although there was no difference in preprandial LES pressure (symptomatic 13.2 ± 7.1 mmHg vs asymptomatic 15.1 ± 6.2 mmHg, P = 0.4), LES pressure fell further postprandially in symptomatic twins (LES pressure area under the curve 465 ± 126 vs 331 ± 141 mmHg h, P < 0.01). 12/37 (32%) of acid reflux episodes in symptomatic twins occurred due to low LES pressure or deep inspiration/strain and 0/17 in asymptomatic twins (P = 0.01). There was no difference between symptomatic and asymptomatic twins in: peristaltic amplitude, ineffective esophageal body motility, hiatus hernia prevalence, or LES length. There was also no difference in TLESR frequency preprandially (symptomatic median 1(range 0-2) vs asymptomatic 0(0-2), P = 0.08) or postprandially (2.5(1-8) vs 3(1-6), P = 0.81). Twins with GERD symptoms had lower postprandial LES pressure and given the close genetic link between the twins, it is possible that such differences are caused by GERD. Acid reflux episodes associated with a hypotensive LES were seen in symptomatic, but not in asymptomatic twins.

Evaluation of esophageal high-resolution manometry combined with 24-hour pH monitor in detecting endoscopy-negative chest pain of esophageal origin

Objective To investigate esophageal high-resolution manometry （HRM） combined with 24-hour pH monitor in detecting endoscopy-negative chest pain of esophageal origin. Methods Test results of esophageal HRM combined with 24-hour pH monitor from 40 patients with recurring chest pain of esophageal origin were retrospectively analyzed. Results In 40 patients, 27 （67. 5% ） were diagnosed as gastroesophageal reflux disease with an average DeMeester scores at 18.3 ± 3.4, including 19 patients with esophageal body dismotility and 11 with reduced lower esophageal sphincter pressure （LESP） at a mean reduction of 5.7 mm Hg. There were 6 cases （ 15.0% ） of achalasia, in which 1 （2. 5% ） was type Ⅰ and 5 （ 12. 5% ） was type Ⅱ , with an average relaxation ratio of lower esophageal sphincter （RRLES） at （ 30. 1 ± 2. 3 ） %. There were 4 cases of diffuse esophageal spasm （DES）, with an average contraction frontal velocity （CFV） of 12. 3 ± 2. 4 cm.s^- 1 and abnormal contraction waves in esophageal body, spontaneous synchronous contraction waves were observed in 3 of 4 patients LESP increased in 1 patient with DES and remained normal in other 3. RRLES decreased in 2 cases with DES and remained normal in other 2. There were 2 cases （5. 0% ） of nutcracker esophagus, with an average distal contractile integral at 6745.5 ± 175.2 mm Hg.cm^-1 .s^-1 and an average CFV at4. 3 ±0. 4 cm.s^-1. There was 1 case （2. 5% ） with absence of esophageal peristalsis, with a low LESP at 2 mmHg and DeMeester scores at 38. 3. The patient was finally diagnosed as systemic sclerosis according to esophageal biopsy and other auxiliary examination. Conclusion HRM combined with 24-hour pH monitor is valuable in detecting endoscopy-negative chest pain of esophageal origin. Key words: Chest pain; Esophageal high-resolution manometry; Ambulatory esophageal pHmonitoring; Diagnosis

WHAT IS THE REAL IMPAIRMENT ON ESOPHAGEAL MOTILITY IN PATIENTS WITH GASTROESOPHAGEAL REFLUX DISEASE?

Impairment of esophageal motility is a common finding in patients with gastroesophageal reflux disease (GERD) as reduced lower esophageal sphincter (LES) basal pressure. A very low LES pressure might facilitate the occurrence of more gastroesophageal reflux whereas abnormal esophageal peristalsis may contribute to impaired esophageal clearance after reflux. Evaluate the esophageal motor function of the lower esophageal sphincter and esophageal body in the various forms of gastroesophageal reflux disease. The manometrics records of 268 patients, who had evaluation of the esophageal motility as part of the diagnostic gastroesophageal reflux disease were split into four groups, as follows: 33 patients who had no esophagitis; 92 patients who had erosive esophagitis; 101 patients who had short Barrett's esophagus and 42 patients who had long Barrett's esophagus. The group who had long Barrett's esophagus showed smaller mean LES pressure and higher percentage of marked LES hypotonia; in the distal segment of the esophageal body the this group showed higher percentage of marked hypocontractility of the distal segment (<30 mm Hg); this same group showed higher percentage of esophageal motility disorders. The most intense esophageal motility disorders and lower pressure of lower esophageal sphincter were noted in the group with long Barrett's esophagus. Those with reflux esophagitis and short Barrett's esophagus had esophageal motility impairment, intermediate among patients with esophagitis and long Barrett's esophagus. Patients with typical symptoms of gastroesophageal reflux but without esophagitis by endoscopy study showed no impairment of esophageal motility.