Mean Distal Contractile Integral Research Articles

OGBN O06 Enhancing Surgical Decision-Making with High-Resolution Manometry and Distal Contractile Integral in Preoperative Assessment for Magnetic Sphincter Augmentation (LINX)

Abstract Background Preoperative assessment for magnetic sphincter augmentation (MSA) (LINX) involves evaluating the Mean Distal Amplitude (MDA) on conventional manometry to assess the patient suitability and risk of post-operative dysphagia. In the last decade high-resolution manometry (HRM) has superseded conventional manometry owing to obtaining more clinical information on the oesophageal motility, including the Distal Contractile Integral (DCI) that incorporates contractile amplitude, duration and contractility propagation length within the oesophageal body. The purpose of this study is to translate the MDA to modern DCI as preoperative marker to MSA. Methods This retrospective study includes patients referred to oesophageal laboratory at Guy’s Hospital between March and May 2023. Patients underwent HRM with ten 5ml water swallows that provided manometric information to compute mean DCI and MDA (MDA waveforms at 11cm, 7cm and 3cm above the GOJ were used). Statistical analysis investigated the relationship between MDA and mean DCI using Pearson correlation, Student t-test, ROC curve analysis and relevant metrics assess the cut-off threshold accuracy and reliability in classifying normal MDA. Results 270 patients were included in the study (female:male=190:80 males, mean age 52.1 years). There was strong direct correlation between MDA and mean DCI (r=0.71, p<0.0001) (Figure 1). Patients with normal MDA had a significantly higher mean DCI compared with weak MDA at 11cm (601mmHgscm vs 167.15mmHgscm, p<0.0001) 7cm (286.4mmHgscm vs 741mmHgscm, p<0.001), 3cm (592mmHgscm vs 192.6mmHgscm, p<0.0001) and overall MDA (714.2mmHgscm vs 259mmHgscm, p<0.001) (Figure 2). ROC curve analysis revealed the mean DCI thresholds for normal MDA to be 615mmHgscm at 11cm, 419mmHgscm at 7cm, 318mmHgscm at 3cm and 453mmHgscm for the overall MDA (Table 1). Conclusions The findings of this study show HRM and the clinical measurement DCI may be a suitable preoperative assessment for MSA. This translation of MDA to modernisation in manometry may assist surgeons adopt DCI which is regarded as more robust assessment that offers more detailed clinical information of the oesophageal motility health and disorder.

A132 ACHALASIA FOLLOWING A SARS-COV-2 INFECTION: A CASE REPORT

BackgroundSARS-CoV-2 is a novel virus currently causing a major pandemic. Recent studies have shown that SARS-CoV-2 has an affinity to ACE2 receptors which are present in the olfactory epithelium as well as the pulmonary and gastrointestinal (GI) systems. It is stipulated that these receptors are responsible for the entry of the virus into cells explaining the respiratory and GI symptoms of this infection. The anosmia related to COVID-19 is likely due to an aberrant immune response to the virus rather than direct damage to the olfactory epithelium. Similarly, achalasia is also believed to result from an aberrant immune response through which there is degeneration of inhibitory neurons in the myenteric plexus. In this case report, we present the first case of achalasia thought to be linked to a SARS-CoV-2 infection in contemporary literature.AimsWe hypothesize that SARS-CoV-2 caused an aberrant immune response in our patient, leading him to develop achalasia. We hope to expose clinicians to this potential complication of COVID-19, allowing them to consider it sooner in their differential.MethodsThe patient’s file was reviewed to extract the relevant information. A second gastroenterologist’s opinion was obtained on the manometry to confirm the diagnosis of type III achalasia.ResultsA 61-year-old man with a medical history of myasthenia gravis, chronic obstructive pulmonary disease, hypothyroidism, and chronic renal failure was treated in our establishment for a SARS-CoV-2 pneumonia. He experienced new severe dysphagic symptoms, regurgitations, and lost 10 pounds during his hospitalization. He also developed anosmia and diarrhea. A CT-scan of his neck and thorax showed no extrinsic compression of his esophagus. No neoplasm was found on his gastroscopy. A barium study was then conducted showing a stagnation of contrast in the distal third of his esophagus. No relaxation of the inferior gastroesophageal sphincter was noted. A manometry was then performed and confirmed a type III achalasia. The mean lower esophageal sphincter residual pressure was elevated at 43.7 mmHg. A calculated 69% of wet swallows were premature contractions with a distal latency value less than 4.5 seconds. The mean distal contractile integral was 13613 mmHg. This corroborates the spastic nature of type III achalasia.ConclusionsConsidering that our patient developed anosmia and knowing its pathogenesis in the context of COVID-19, an inappropriate immune response to SARS-CoV-2 could have equally taken place in the esophagus. This inflammatory response might have caused the degeneration of the inhibitory neurons in the myenteric plexus responsible for the achalasia. Furthermore, given the fact that our patient had diarrhea, this suggests that the virus has a GI tropism supporting our hypothesis. We therefore believe that achalasia may be a potential complication of COVID-19. High resolution esophageal motility study showing a type III achalasia pattern.Funding AgenciesNone

Analysis of contractile segment impedance during straight leg raise maneuver using high-resolution impedance manometry increases diagnostic yield in reflux disease.

Contractile segment impedance (CSI) obtained from high-resolution impedance manometry (HRIM) is a measure of mucosal integrity that predicts gastroesophageal reflux disease (GERD). While straight leg raise (SLR) maneuver augments esophageal peristaltic vigor, it remains unclear whether SLR affects CSI values. This study was aimed to evaluate whether CSI with SLR is feasible and useful to complement the diagnosis of GERD. We prospectively recruited 48 patients with typical GERD symptoms who underwent esophagogastroduodenoscopy, HRIM with SLR maneuver, and multichannel intraluminal impedance-pH (MII-pH) testing. The capability of mean nocturnal baseline impedance (MNBI), resting baseline impedance (RBI), CSI with or without SLR maneuver in predicting GERD was assessed using receiver operating characteristics (ROC) analysis. Among 20 GERD patients and 28 non-GERD patients, all values of impedance-based metrics were lower in GERD patients compared to non-GERD patients (p<0.001). For GERD identification, area under receiver operating characteristic curve (AUROC) values of CSI with SLR maneuver, CSI, MNBI, and RBI were 0.901, 0.858, 0.865, and 0.797. Particularly in ineffective esophageal motility (IEM) patients, SLR maneuver increased mean distal contractile integral from 436 to 828.7mmHg.s.cm (p=0.018) and enhanced AUROC values of CSI for GERD identification from 0.917 to 0.958. CSI measurement during HRIM appears to be a reliable, time-saving, and less invasive tool for complementing GERD diagnosis. Our results also suggest a simple SLR maneuver during HRIM could enhance diagnostic accuracy of CSI for GERD identification especially in IEM patients.

More beads, more peristaltic reserve, better outcomes: factors predicting postoperative dysphagia after magnetic sphincter augmentation.

Magnetic sphincter augmentation (MSA) offers a minimally invasive anti-reflux alternative to fundoplication for gastroesophageal reflux disease. The most common side effect of MSA is dysphagia, which may require dilation or even device removal. The incidence of dysphagia may be reduced by MSA sizing and preoperative motility studies. Multiple rapid swallows (MRS) is a provocative maneuver during high-resolution esophageal manometry (HRM) that assesses peristaltic reserve. We evaluated factors predicting development of dysphagia following MSA. A retrospective review of a prospectively maintained database identified patients undergoing MSA. Preoperative work-up included barium swallow, esophagogastroduodenoscopy, and esophageal manometry. Peristaltic augmentation was defined as a ratio > 1 of the distal contractile integral (DCI) following MRS and the mean DCI of the 10 baseline wet swallows during manometry. Demographics, MSA implant size, and postoperative symptom data were gathered on all patients. Sixty-eight patients underwent MSA. Mean age was 51.7 years, average BMI was 25.8 kg/m2. 15 (22.1%) of patients had severe dysphagia requiring endoscopic dilation. Peristaltic augmentation with MRS was significantly higher in patients without dysphagia (46.1% vs 6.3% p = 0.026). 33.3% of patients requiring dilatation exhibited complete absence of smooth muscle contraction following MRS (DCI = 0). The ratio of the DCI of MRS/wet swallows predicting dysphagia following MSA was 0.56. Patients with a small (12-14 beads) versus a larger MSA implant (15-17 beads) had a significantly higher rate of postoperative dysphagia (58.5% vs 30.0% p = 0.026). Adequate peristaltic reserve and larger device size correlate with decreased incidence of dysphagia following MSA implantation without compromising the anti-reflux barrier. Routine assessment of peristaltic reserve during preoperative HRM should be considered prior to MSA placement.

Jackhammer esophagus: Prevalence and demographic, clinical, and manometric characteristics

Introduction and aimsJackhammer esophagus is a recently identified motility disorder. Experience with the novel pathologic condition has been reported in different studies but there is little information on the subject in Latin America. Our case series conducted in Bogota, Colombia, describes the prevalence of jackhammer esophagus and its demographic, clinical, and manometric characteristics. Materials and methodsA retrospective, observational, cross-sectional study included consecutive patients diagnosed with jackhammer esophagus that were referred for high-resolution esophageal manometry. Their clinical and manometric records were reviewed, and the pertinent information for the present study was collected. ResultsWithin the study period, 6445 patients were evaluated through esophageal manometry, 27 of whom were diagnosed with jackhammer esophagus (prevalence of 0.42%). The majority of those patients were women (n = 17, 63%) in the sixth decade of life. The most common symptom was regurgitation (n = 17, 63%), followed by dysphagia (n = 15, 56%). The mean distal contractile integral was 9384 (5,095−18,546) mmHg·s·cm. Dysphagia was more common in patients > 60 years of age (79%, p < 0.01) and regurgitation was more frequent in patients < 60 years of age (92%, p < 0.03). ConclusionsThe present study is the first to characterize the prevalence of jackhammer esophagus and its demographic, clinical, and manometric characteristics in Latin American patients. The prevalence of jackhammer esophagus in our study population was considerably lower than that reported in international case series. Our findings suggest that there are important geographic differences in the prevalence and clinical presentation of jackhammer esophagus, compared with data from other international centers.

S0439 Prucalopride Improves Esophageal Contractility Ineffective Esophageal Motility: Prospective Clinical Trial

INTRODUCTION: Ineffective esophageal motility (IEM) is a manometric diagnosis defined by the Chicago Classification (v3.0) as ≥50% of swallows achieving a distal contractile integral (DCI) of < 450 mmHg-cm-s and maybe associated with dysphagia. This pilot study assesses the effectiveness of prucalopride a 5-HT4 enterokinetic drug in IEM patients with dysphagia. METHODS: Symptomatic patients with dysphagia diagnosed with IEM following high-resolution manometry (HRM) with impedance at a tertiary care motility lab were enrolled between August 2017 and September 2019. Patients with uncontrolled GERD (DeMeester score >14.7), endoscopic erosive esophagitis, eosinophilic esophagitis, use of other prokinetic drugs, or narcotics were excluded. Patients received prucalopride 4mg PO once daily for 5 days and then underwent repeat HRM. Outcome measures included pre- and post- prucalopride esophageal HRM values, dysphagia symptom questionnaire (DSQ), and quality of life (Eq5d-3L). These outcomes were compared with paired T-test, Wilcoxon signed ranks test and McNemar test as appropriate. Patients were classified into definite or indefinite for heartburn, acid regurgitation, and GERD based on the MDQ-30 subscale. IRB-approved study (NCT03244553). RESULTS: Twenty-nine patients were enrolled; analysis was performed on twenty-five patients (13M:12F; mean age of 53.3 yrs (±13.97 SD) who completed the study. All patients had symptoms of dysphagia to solids. 76% of patients were on a PPI. The median time and IQR between baseline and post-HRM were 12 [8–18] wks. 18 patients (72%) had an improvement in mean DCI. There was a significant increase in DCI (mean 727.1 ± 548.7 vs 439.5 ± 286.7, P = 0.006), maximum DCI (mean 1198.7 ± 1198.67819.8 ± 540.5, P = 0.013), and decrease in the percentage of failed swallows (median 40 [IQR 25–70] vs 20 [10–50], P = 0.05), and acid regurgitation (P = 0.05) after prucalopride use. No improvement was seen in dysphagia or quality of life. Change in DCI correlated weakly with IRP (Spearman’s r =0.461, P = 0.021). The most common side effects were headaches (48%) and diarrhea (52%). A majority of patients (88%) reported a side effect, leading to discontinuation in 4%. CONCLUSION: In this short duration pilot study, prucalopride significantly improved the DCI, maximum DCI, number of failed swallows, and acid regurgitation in patients with IEM; however, no improvement in dysphagia or quality of life was seen. This pilot study warrants a larger study.Table 1.: Pairwise comparison of manometric values and patient-reported outcomes pre- and post- prucalopride therapyFigure 1.: Representative Pre and post-HRM picture of 3 patients who displayed significant improvement after prucalopride.

S0357 Differences in Clinical Features and Treatment Outcomes Between Patients With Dysphagia-Predominant and Chest Pain-Predominant Esophagogastric Junction Outflow Obstruction (EGJOO)

INTRODUCTION: Esophagogastric junction outflow obstruction (EGJOO) is the condition in which high-resolution manometry reveals elevated integrated relaxation pressure (IRP) with some preserved peristalsis. EGJOO may be an achalasia variant, a manifestation of disorders that infiltrate or push on the esophagus, or a spurious finding. Dysphagia and/or chest pain are the typical symptoms of EGJOO, and it is not clear how presenting symptoms relate to other features of the condition. We aimed to compare clinical features, manometric findings, and treatment outcomes between EGJOO patients with dysphagia-predominant (DP) vs. chest pain-predominant (CPP) symptoms. METHODS: We searched our manometry database for patients with a diagnosis of EGJOO, and excluded those with a structural cause for EGJOO or prior foregut surgery. We collected demographic data and manometric data including median IRP, distal contractile integral (DCI), and distal latency (DL). Symptoms were evaluated using the Eckardt score and Brief Esophageal Dysphagia Questionnaire (BEDQ), both of which are obtained routinely in patients seen in our Center for Esophageal Diseases. Patients were categorized as DP or CPP based on whichever score (dysphagia or chest pain) was higher on the Eckardt questionnaire. Medical records were reviewed for treatments and response. RESULTS: Among 187 patients with EGJOO, 101 were excluded for intrinsic esophageal pathology, extrinsic esophageal compression, or prior foregut surgery. Among 86 patients with idiopathic EGJOO, 31 were DP and 13 were CPP; 23 were excluded because dysphagia and chest pain scores were equal, and 19 had neither dysphagia nor chest pain. DP patients were older (63.5 vs 45.9 years, P < 0.05) and more likely to be female (65% vs 54%, P = 0.5) than CPP patients. The groups were similar in total Eckardt score (4 in both groups) and BEDQ score (12 DP vs 11 CPP, P = 0.8). The median IRP (22.1 DP vs 20.9 CPP mmHg, P = 0.6) and mean DL (6.7 DP vs 6.2 CPP seconds, P = 0.5) were similar, but the mean DCI was higher in the DP group (3256 DP vs 1534 CPP mmHg-cm-sec, P = 0.4). DP patients were more likely to respond to balloon dilation (the most frequently used treatment) than CPP patients (42% vs 0%, P < 0.05), and were more likely to report symptom improvement on follow up than CPP patients (29% vs 3%, P = 0.05). CONCLUSION: Compared to CPP patients, DP patients with EGJOO were older and predominantly female. DP patients had a significantly higher mean DCI and better response to treatment than CPP patients.

S0412 A Large Retrospective Review of Medications as Risk Factors for Esophagogastric Junction Outflow Obstruction

INTRODUCTION: The etiologies and pathogenesis of esophagogastric junction outflow obstruction (EGJOO) remain unclear in the literature, contributing to a lack of standard guidelines for management of this disorder. We performed one of the largest review studies to evaluate the potential effect of medications as causes of EGJOO. METHODS: We conducted a retrospective chart review of 100 patients diagnosed with EGJOO based on the Chicago Classification and 100 control patients with dysphagia and normal esophageal manometry findings from 2010 to 2019. Data including age, sex, body mass index, past surgeries, and medications was collected. Statistical analysis was performed, and Spearman correlation co-efficient and P-value were used to determine statistical significance. RESULTS: Of the 100 patients diagnosed with EGJOO, 65 were female and 35 were male. There were significant positive relationships between benzodiazepines and integrated relaxation pressure (IRP) (rs = 0.27588, P = 0.0055), benzodiazepines and lower esophageal sphincter mean resting pressure (LESMRP) (rs = 0.21515, P = 0.0363), antidepressants and LESMRP (rs = 0.20585, P = 0.0454), narcotics and LESMRP (rs = 0.20936, P = 0.0417), and narcotics to distal contractile integral (DCI) (rs = 0.21186, P = 0.0343). Anticonvulsants and number of swallows with complete bolus transfer (CBT) had a negative correlation (rs = -0.26578, P = 0.0310), while anticonvulsants and DCI had a positive correlation (rs = 0.19693, P = 0.0496). The differences in mean IRP, LESMRP, DCI, and CBT between the control group and the EGJOO patients with and without use of benzodiazepines, antidepressants, narcotics, and anticonvulsants were significant (P < 0.02).The mean IRP in EGJOO patients with use of benzodiazepines, narcotics, antidepressants or anticonvulsants was 24.05, 22.17, 21.32, and 25.02, respectively. The mean IRP in EGJOO patients without use of benzodiazepines, narcotics, antidepressants or anticonvulsants was 20.38, 20.72, 21.01, and 20.86, respectively. CONCLUSION: Our study demonstrates significant correlations between particular medication classes, including benzodiazepines, narcotics, antidepressants and anticonvulsants, and esophageal function metrics in patients with EGJOO. There were also higher mean IRPs in the EGJOO patients with use of the listed medications than in EGJOO patients without their use. While our study demonstrates a strong association between the diagnosis of EGJOO and these medications, further studies should be performed to confirm causality.Table 1Table 2Table 3

372 ESOPHAGEAL BODY PERISTALSIS CORRELATES FOR DYSPHAGIA AND REGURGITATION: AN ASSESSMENT BASED ON BARIUM ESOPHAGRAM

Abstract Because it offers real-time assessment, barium esophagram should be the modality of choice when studying esophageal peristalsis. However, no standard reporting method is available for BE results. Presently, peristaltic disorders are defined according to high-resolution manometry (HRM), but HRM findings do not correlate with clinical symptoms. The aim of this study was to stratify esophageal peristaltic function via standardized evaluation of BE, and to define the association between esophageal peristalsis and dysphagia and regurgitation. Methods After IRB approval, a prospectively maintained database was reviewed for patients who underwent both HRM and BE from 08/01/2016 to 12/31/2019. Patients with conditions associated with outflow impairment were excluded. BEs were re-examined in blinded fashion and assigned subjective scores (0, 1, or 2) for dilation grade (DG) and contractility grade (CG). Patients were categorized according to the sum of the DG and CG: Group A = 0, Group B = 1–2, and Group C = 3–4. Mean distal contractile integral (DCI), number of failed contractions on HRM, and number of patients with dysphagia/regurgitation in each group were analyzed and compared. Results In all, 124 patients were included. The mean DCI (mmHg*cm*s) was 2539.1 ± 1357.8 in Group A, 884.4 ± 916.9 in Group B, and 77.4 ± 192.3 in Group C (p &amp;lt; 0.001). The mean number of failed contractions were 0.7 ± 1.3, 3.4 ± 3.4, and 8.6 ± 3.2, respectively (p &amp;lt; 0.001). Table 1 shows the distribution of patients with dysphagia or regurgitation across groups. The proportion of patients with dysphagia in Group C was higher than in Groups A or B (OR 3.75, p = 0.02; and OR 2.58, p = 0.07, respectively). Similarly, Group C was significantly more often associated with regurgitation than in Groups A or B (OR 4.69, p = 0.009; and OR 4.42, p = 0.005). Conclusion The combined DG and CG allowed us to identify the patients with a grade of peristaltic disfunction that was significantly more associated with dysphagia or regurgitation (Group C). However, in order to achieve a clearer definition of the different peristaltic disfunction levels according to their propensity to cause dysphagia or regurgitation, a more objective assessment of both DG and CG should be provided; therefore, further studies are required.

Lower prevalence of gastroesophageal reflux disease in patients with noncardiac chest pain on opiates: a cross-sectional study.

Opiates can cause heartburn and spastic esophageal dysmotility but their role in noncardiac chest pain (NCCP) is not known. Our aim was to characterize opiate effects on esophageal function using esophageal pH monitoring and high-resolution manometry (HREM) in these patients.We performed a cross sectional study of opiate users with NCCP who underwent HREM and esophageal pH study from 2010 to 2017 using opiate nonusers as a comparison group. Demographic data, symptoms, opiate use, endoscopic findings, esophageal pH study parameters, and HREM data were abstracted.Thirty three patients with NCCP on opiates were compared to 144 opiate non-users. Compared to opiate nonusers, opiate users had lower total acid exposure (2.3% vs. 3%, P = 0.012), lower upright acid exposure (1.2% vs. 3.1%, P = 0.032) and lower DeMeester score (6.5 vs. 12.7, P = 0.016). Opiate users also had higher lower esophageal sphincter integrated relaxation pressure (LES-IRP) (7.0 mm Hg [2.2, 11.7] vs. 3.7 mm Hg [1.1, 6.2] P = 0.011) and greater mean distal contractile integral (DCI) (2575 mm.Hg.s.cm [1134, 4466] vs. 1409 mm.Hg.s.cm [796, 3003] P = 0.03) than opiate non-users. The prevalence of hypertensive motility disorders (15.2% vs. 11.1%) and achalasia (12.1% vs. 2.1%) was higher in opiate users (P = 0.039) but did not reach significance on multivariate analysis.In patients presenting with NCCP, opiate users had lower esophageal acid exposure compared to opiate nonusers. This might be due to higher LES pressures preventing reflux and higher DCI leading to more rapid acid esophageal clearance.

Jackhammer esophagus: A meta-analysis of patient demographics, disease presentation, high-resolution manometry data, and treatment outcomes.

Jackhammer esophagus (JE) is a newly described esophageal motility disorder. However, there are limited data on JE and this entity remains misunderstood. We performed a systematic review of clinical series on JE through MEDLINE, EMBASE, and Web of Science. Data from included studies were then extracted, and random-effects meta-analyses were performed. Thirty-eight studies met inclusion criteria. The pooled prevalence of JE was 1.97% [95% CI: 1.39%-2.78%] among patients referred for high-resolution manometry (HRM). The mean age at diagnosis was 60.8years [95% CI: 57.1-64.4] and 65% [95% CI: 58%-72%] of patients were female. JE was significantly more prevalent in postlung transplant patients and morbidly obese patients undergoing HRM (23.99% [95% CI: 9.00%-38.97%] and 5.18% [95% CI: 1.76%-14.3%] respectively). Dysphagia was the most common presentation of JE (64% [95% CI: 52%-77%]) followed by gastroesophageal reflux disease (46% [95% CI: 26%-67%]). The pooled mean distal contractile integral (DCI) of all standard HRM swallows was 9249mmHg·s·cm [95% CI: 7834-10663], and the pooled mean integrated relaxation pressure (IRP) was 13.9mmHg [95% CI: 8.2-19.7]. Overall, 73.6% [95% CI: 64.0%-83.1%] of JE patients who underwent treatment achieved clinical symptom improvement (79% [95% CI: 74%-85%] for endoscopic treatment and 63% [95% CI: 47%-79%] for medical treatment). The pooled clinical success rate of peroral endoscopic myotomy (POEM) specifically was 82% [95% CI: 75%-90%]. JE is a new motility disorder most commonly presenting with dysphagia. High clinical suspicion is important because the diagnosis can only be made through HRM.

Mosapride Improves Lower Esophageal Sphincter and Esophageal Body Function in Patients With Minor Disorders of Esophageal Peristalsis.

Background/AimsHigh-resolution manometry (HRM) has broadened the awareness of minor esophageal peristaltic disorders. However, the treatments for these minor disorders are limited and the role of prokinetics has been controversial. This study evaluates the effect of mosapride in patients with minor peristaltic disorders.MethodsThis study prospectively enrolled 21 patients with esophageal symptoms who were diagnosed with minor peristaltic disorders by gastroscopy and HRM using the Chicago classification version 3.0. Patients received mosapride 30 mg daily for 2 weeks. Symptoms were assessed using the abbreviated World Health Organization quality of life scale (WHOQOL-BREF) and a HRM study was performed before and after 2 weeks of treatment.ResultsHRM metrics of lower esophageal sphincter (LES) respiratory mean pressure (median 14.6 mmHg vs 17.3 mmHg; interquartile range [IQR] 8.7-22.5 mmHg vs 12.5-25.9 mmHg; P = 0.004) and distal contractile integral (median 343.8 mmHg·sec·cm vs 698.1 mmHg·sec·cm; IQR 286.5-795.9 mmHg·sec·cm vs 361.0-1127.6 mmHg·sec·cm; P = 0.048) were significantly increased after treatment. Complete response (≥ 80.0%), satisfactory response (≥ 50.0%), partial response (< 50.0%), and refractory response rates were 19.0%, 52.4%, 14.3%, and 14.3%, respectively. However, there was no statistical difference in all WHOQOL-BREF scores before and after treatment. Univariate analysis showed LES respiratory mean pressure (P = 0.036) was associated with symptom improvement (complete + satisfactory group). However, no statistical difference was found in other factors after multivariate analysis.ConclusionsMosapride improved esophageal symptoms and significantly increased LES respiratory mean pressure and distal contractile integral. Therefore, mosapride could enhance LES and esophageal body contraction pressures in patients with minor peristaltic disorders.

Gastroesophageal Reflux Disease Is Not Associated With Jackhammer Esophagus: A Case-control Study.

Background/AimsThe pathophysiology of jackhammer esophagus (JE) remains unknown but may be related to gastroesophageal reflux disease or medication use. We aim to determine if pathologic acid exposure or the use of specific classes of medications (based on the mechanism of action) is associated with JE.MethodsHigh-resolution manometry (HRM) studies from November 2013 to March 2019 with a diagnosis of JE were identified and compared to symptomatic control patients with normal HRM. Esophageal acid exposure and medication use were compared between groups. Multivariate regression analysis was performed to look for predictors of mean distal contractile integral.ResultsForty-two JE and 127 control patients were included in the study. Twenty-two (52%) JE and 82 (65%) control patients underwent both HRM and ambulatory pH monitoring. Two (9%) JE patients and 14 (17%) of controls had evidence of abnormal acid exposure (DeMeester score > 14.7); this difference was not significant (P = 0.290). Thirty-six (86%) JE and 127 (100%) control patients had complete medication lists. Significantly more JE patients were on long-acting beta agonists (LABA) (JE = 5, control = 4; P = 0.026) and calcium channel blockers (CCB) (JE = 5, control = 3; P = 0.014). Regular opioids (β = 0.298, P = 0.042), CCB (β = 0.308, P = 0.035), and inhaled anticholinergics (β = 0.361, P = 0.049) predicted mean distal contractile integral (R2 = 0.082, F = 4.8; P = 0.003).ConclusionsPathologic acid exposure does not appear to be associated with JE. JE patients had increased CCB and LABA use. The unexpected finding of increased LABA use warrants more investigation and may provide support for a cholinergic etiology of JE.

High-resolution manometry findings after Linx procedure for gastro-esophageal reflux disease.

Magnetic sphincter augmentation with the Linx® system is a novel laparoscopic procedure for the treatment of gastro-esophageal reflux disease (GERD). Only few data are available regarding the impact of Linx on high-resolution manometry (HRM) variables. The prospectively collected database of patients who underwent Linx procedure at a single institution was queried. All patients who completed pre- and postoperative HRM, GERD health-related quality of life (GERD-HRQL) questionnaire, and functional outcome swallowing scale (FOSS) questionnaire were included in the study. Forty-five out of 304 patients were included. At a median follow-up of 12months (IQR 10) after surgery, a statistically significant increase of lower esophageal sphincter (LES) total length (P=.002), intra-abdominal length (P=.001), integrated relaxation pressure (IRP), intrabolus pressure (IBP), and esophagogastric contractile integral (EGJ-CI) was noted (P<.001). Distal esophageal amplitude (P=.004), mean distal contractile integral (DCI) (P<.001), post multiple repeated swallows DCI (P=.001), and the percent of normal peristalsis increased (P=.040). All patients were relieved of reflux symptoms. Ineffective esophageal motility reversed to normal in 36% of patients after surgery. The only factor significantly associated with postoperative dysphagia was preoperative dysphagia (P=.006). Postoperatively, a significant correlation between IRP and DCI (r=0.361 and P=.019) and between IBP and DCI (r=0.443 and P=.003) was found. The Linx procedure had a remarkable effect on esophageal motility in the short-term follow-up. It appears that the overall postoperative increase of IRP and IBP may justify the higher DCI values. Preoperative dysphagia was the only factor associated with postoperative dysphagia.

434 Response to Multiple Rapid Swallows Shows Impairment of Inhibitory Pathways in Patients With Distal Esophageal Spasm

INTRODUCTION: Distal esophageal spasm (DES) is a motility disorder characterized by premature contraction of the esophageal body during single swallows. It is thought to be due to impairment of esophageal inhibitory pathways, but studies to support this are limited. Assessment of response to multiple rapid swallows (MRS) during high-resolution esophageal manometry (HRM) enables detection of impaired inhibition during MRS. Healthy subjects respond to MRS by deglutitive inhibition during the MRS sequence. We hypothesize that deglutitive inhibition is impaired in DES patients. Aim: compare response to MRS in DES patients and healthy controls. METHODS: Response to MRS was evaluated in 19 DES patients and 24 asymptomatic healthy controls. Demographic and symptom data were extracted from a prospectively maintained motility database. Patients with history of prior gastroesophageal surgery, endoscopic myotomy (POEM), pneumatic dilation, esophageal botulinum toxin injection within 6 months of HRM, and esophageal stricture were excluded. HRM was performed with a solid state catheter with 36 circumferential pressure sensors 1-cm apart; ten 5-ml liquid swallows were given followed by MRS sequence, analyzed with Manoview software (Medtronic). Esophagogastric junction integrated relaxation pressure (IRP), distal contractile integral (DCI), and distal latency (DL) were calculated, and Chicago Classification v3.0 was applied to diagnose DES (defined by ≥ 2 swallows with DL ≤ 4.5 sec). Response to MRS was evaluated for complete versus impaired inhibition (contractility with DCI &gt; 100 mmHg-sec-cm during MRS), and presence of post MRS contraction augmentation (DCI post MRS greater than single-swallow mean DCI). Chi-Square and Fisher’s exact test were used for statistical analysis. RESULTS: Demographics and symptom data are shown in Table 1. Patients with DES were older and more symptomatic than controls. Impaired inhibition of peristalsis during MRS was significantly more frequent in DES compared to controls (89% vs 0%, P &lt; 0.001, Figure 1). The proportion of subjects with augmentation post MRS was similar for both groups (37% vs 38%, P = 1.00), but mean DCI post MRS was higher in DES than controls (3788 vs 1239, P = 0.013). CONCLUSION: Impaired deglutitive inhibition during MRS is present in the majority of patients with DES, supporting impaired inhibitory pathways in the esophagus as a mechanism of action in this disorder.

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

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

High-resolution Manometry Findings During Solid Swallows Correlate With Delayed Reflux Clearance and Acid Exposure Time in Non-erosive Reflux Disease Patients.

Background/AimsThe role of esophageal motility in determining gastroesophageal reflux disease (GERD) severity has not been completely evaluated. A few studies have investigated high-resolution manometry (HRM) patterns during solid swallows. The present study evaluates the HRM patterns of non-erosive reflux disease (NERD) patients during both liquid and solid swallows and their correlation with the severity of GERD.MethodsIn 23 NERD patients and 15 healthy volunteers (HVs) HRM was performed during a standard solid meal in a seated position, followed by 24-hour impedance-pH monitoring.ResultsOf the 31 patients, 10 showed a pathological acid exposure time (AET; NERD patients), 13 a normal pH profile with positive symptom association probability (SAP; reflux hypersensitivity patients), and 8 normal AET and SAP (functional heartburn patients). Mean distal contractile integral and distal latency values, in all patient groups and HVs, were significantly higher during solid swallows. In the group of 10 NERD patients, the number of large breaks of the esophageal peristalsis was 16 out of 100 liquid swallows (16%) and 31 out of 171 solid swallows (18%). Fourteen out of 100 liquid swallows (14%) and 25 out of 171 solid swallows (15%) resulted ineffective. Mean reflux clearing time at multichannel intraluminal impedance-pH was 17.6 ± 3.7 seconds. NERD patients presented, during solid swallows, a significantly higher proportion of large peristaltic breaks and of ineffective swallows than reflux hypersensitivity and functional heartburn patients.ConclusionHRM during solid swallows reveals motor abnormalities, undetected during liquid swallows, which might be involved in delaying reflux and acid clearance in patients with GERD.

Provocative testing in patients with jackhammer esophagus: evidence for altered neural control.

Jackhammer esophagus (JE) is a hypercontractile disorder, the pathogenesis of which is incompletely understood. Multiple rapid swallows (MRS) and rapid drink challenge (RDC) are complementary tests used during high-resolution manometry (HRM) that evaluate inhibitory and excitatory neuromuscular function and latent obstruction, respectively. Our aim was to evaluate esophageal pathophysiology using MRS and RDC in 83 JE patients (28 men; median age: 63 yr; IQR: 54-70 yr). Twenty-one healthy subjects (11 men; median age: 28 yr; range: 26-30 yr) were used as a control group. All patients underwent solid-state HRM with ten 5-ml single swallows (SS) and one to three 10-ml MRS; 34 patients also underwent RDC. Data are shown as median (interquartile range). Abnormal motor inhibition was noted during at least one MRS test in 48% of JE patients compared with 29% of controls ( P = 0.29). Mean distal contractile integral (DCI) after MRS was significantly lower than after SS [6,028 (3,678-9,267) mmHg·cm·s vs. 7,514 (6,238-9,197) mmHg·cm·s, P = 0.02], as was highest DCI ( P < 0.0001). Consequently, 66% of JE patients had no contraction reserve. At least one variable of obstruction during RDC (performed in 34 patients) was outside the normal range in 25 (74%) of JE patients. Both highest DCI after SS and pressure gradient across the esophagogastric junction (EGJ) during RDC were higher in patients with dysphagia versus those without ( P = 0.04 and 0.01, respectively). Our data suggest altered neural control in JE patients with heterogeneity in inhibitory function. Furthermore, some patients had latent EGJ obstruction during RDC, which correlated with the presence of dysphagia. NEW & NOTEWORTHY Presence of abnormal inhibition was observed during multiple rapid swallows (MRS) in some but not all patients with jackhammer esophagus (JE). Unlike healthy subjects, JE patients were more strongly stimulated after single swallows than after MRS. An obstructive pattern was frequently observed during rapid drink challenge (RDC) and was related to presence of dysphagia. MRS and RDC during high-resolution manometry are useful to show individual pathophysiological patterns in JE and may guide optimal therapeutic strategies.

Clinical features and long-term outcomes of lower esophageal sphincter-dependent and lower esophageal sphincter-independent jackhammer esophagus.

The most recent Chicago Classification expanded the criteria for diagnosis of jackhammer esophagus (JHE) to include the distal contractile integral (DCI) of the lower esophageal sphincter (LES). The clinical impact of the manometric inclusion of LES hypercontractility remains unclear. We aimed to analyze the clinical features and long-term outcomes of measured LES-dependent (LD-JHE) and LES-independent (LI-JHE) jackhammer esophagus. Patients meeting diagnostic criteria for JHE were identified at two academic medical centers. High-resolution esophageal manometry data were re-analyzed with inclusion and exclusion of the LES DCI. LD-JHE was defined by falling outside JHE diagnostic criteria with exclusion of the LES. A telephone survey was conducted for follow-up utilizing the impact dysphagia (IDQ-10) questionnaire. Eighty-one patients met study inclusion criteria, with 12 (14.8%) classified as LD-JHE. LD-JHE patients had a significantly lower mean DCI and fewer swallows with DCI >8000mmHg-s-cm. Basal LES pressure was higher in patients with dysphagia to solids than those with dysphagia to solids and liquids. Clinical and manometric parameters were otherwise similar between groups. Sixty-six patients had clinical or phone follow-up at a median of 46.6months. Forty-one patients (62.1%) received therapies directed at JHE. There was no difference in symptom improvement for treated vs untreated patients or for JHE subtype. Our findings suggest that LD-JHE and LI-JHE are clinically indistinguishable and thus support existing diagnostic criteria. Furthermore, our long-term follow-up data suggest that JHE, irrespective of LES involvement, may improve without treatment. Further study is needed to clarify which patients merit therapeutic intervention.

Routine esophageal manometry is not useful in patients with normal videoesophagram.

Videoesophagram (VEG) and esophageal manometry (EM) are components of the preoperative evaluation for foregut surgery. EM is able to identify motility disorders and diminished contractility that may alter surgical planning. However, there are no clearly defined criteria to guide this. Reliable manometry is not always easily obtained, and therefore its necessity in routine preoperative evaluation is unclear. We hypothesized that if a patient has normal videoesophagram, manometry does not reveal clinically significant esophageal dysfunction. We reviewed patients who underwent protocolized videoesophagram and manometry at our institution. Measures of esophageal motility including the mean distal contractile integral (DCI), mean wave amplitude (MWA), and percent of peristaltic swallows (PPS) were analyzed. The Chicago Classification was used for diagnostic criteria of motility disorders. Normal VEG was defined as stasis of liquid barium on less than three of five swallows. There were 418 patients included. 231 patients (55%) had a normal VEG, and 187 patients (45%) had an abnormal VEG. In the normal VEG group, only 2/231 (0.9%) patients had both abnormal DCI and PPS, 1/231 (0.4%) patients had both abnormal DCI and MWA and no patients had both abnormal MWA and PPS. There were no patients with achalasia or absent contractility and 1 patient with ineffective esophageal motility (IEM) in the normal VEG group. This was significantly different from the abnormal VEG group which included 4 patients with achalasia, 1 with absent contractility and 22 with IEM (p < 0.0001). The negative predictive value of VEG was 99.6% and the sensitivity was 96.4%. A normal videoesophagram reliably excluded the presence of clinically significant esophageal dysmotility that would alter surgical planning. Routine manometry is not warranted in patients with normal videoesophagram, and should be reserved for patients with abnormal VEG.