Median Integrated Relaxation Pressure Research Articles

Achalasia: diagnostic delay and manometric characteristics with high-resolution solid-state and perfusion equipment.

The early diagnosis of achalasia requires a high degree of clinical suspicion, and delays in diagnosis are frequent. High-resolution oesophageal manometry (HRM) is the gold standard for its diagnostic confirmation. There are two HRM systems, perfusion and solid-state, which allow its classification into three subtypes: I, or classical; II, or with pan-oesophageal pressurization; and III, or spastic. To determine the clinical and manometric characteristics of the three subtypes with high-resolution perfusion and solid-state equipment and the time of evolution until diagnosis. This was a multicentre, observational, retrospective study of patients from the INTEGRA database of the Spanish Association of Neurogastroenterology and Motility who were diagnosed with primary achalasia confirmed by HRM, who fell under the Chicago Classification v3.0, and who had not been treated. The study included 110 patients (subtype I, N = 14; subtype II, N = 73; subtype III, N = 23). The HRM equipment was perfusion for 49 and solid-state for 61. The mean age was 61.8 ± 14 years (age range 44-81), the age was lower in subtype II, and the sex distribution was similar. The time of clinical evolution until diagnosis was > 12 months (51.6%), subtype II being the one that was diagnosed earlier and the most often (66.3%). Dysphagia was the most frequent symptom (90.5%). According to the comparative analysis by high-resolution perfusion and solid-state oesophageal manometry equipment, the baseline pressure of the lower oesophageal sphincter was higher in the solid-state oesophagus, but the difference was not statistically significant. The median integrated relaxation pressure at 4 seconds (IRP4) was similar (21 mmHg) between the perfusion and solid-state measurements. We describe the ranges of IRP4 in achalasia patients with both systems and confirm the possibility of achalasia even when IRP4 is within the normal range. Achalasia in our environment has a significant diagnostic delay. No significant differences were observed in the oesophagogastric junction between the two groups diagnosed with perfusion and solid-state equipment.

Midesophageal diverticulum with elevated intrabolus pressure: a case report

BackgroundEsophageal diverticulum is commonly associated with esophageal motility disorders, which can be diagnosed using high-resolution manometry (HRM) according to the Chicago classification. Although midesophageal diverticulum (M-ED) is associated with inflammatory processes, esophageal motility disorders have been recently identified as an etiology of M-ED.Case presentationWe present the case of a patient with M-ED and elevated intrabolus pressure (IBP), which did not meet the criteria for esophageal motility disorders according to the Chicago classification. A 71-year-old man presented with gradually worsening dysphagia for two years and was diagnosed as having an 8-cm-long M-ED and multiple small diverticula in lower esophagus. HRM revealed a median integrated relaxation pressure of 14.6 mmHg, a distal latency of 6.4 s, and an average maximum IBP of 35.7 mmHg. He underwent thoracoscopic resection of the M-ED and myotomy, which successfully alleviated the symptoms and reduced the intrabolus pressure to normal levels.ConclusionsIt is important to recognize the esophageal diverticulum pathology with HRM findings even in cases where the results may not meet the Chicago classification and to include myotomy based on the results.

Impaired esophagogastric junction relaxation and lung transplantation outcomes.

The implications of impaired esophagogastric junction relaxation (i.e. esophagogastric junction outflow obstruction and achalasia) in lung transplants recipients (LTRs) are unclear. Thus, we examined the prevalence and clinical outcomes of LTRs with an abnormally elevated integrated relaxation pressure (IRP) on high-resolution manometry before lung transplantation (LTx). After IRB approval, we reviewed data on LTRs who underwent LTx between January 2019 and August 2022 with a preoperative median IRP >15mmHg. Differences in overall survival and chronic lung allograft dysfunction (CLAD)-free survival between LTRs with a normalized median IRP after LTx (N-IRP) and those with persistently high IRP (PH-IRP) were assessed using Kaplan-Meier curves and the log-rank test. During the study period, 352 LTx procedures were performed; 44 (12.5%) LTRs had an elevated IRP before LTx, and 37 (84.1%) completed a postoperative manometry assessment (24 [70.6%] males; mean age, 65.2 ± 9.1years). The median IRP before and after LTx was 18.7 ± 3.8mmHg and 12 ± 5.6mmHg, respectively (P < 0.001); the median IRP normalized after LTx in 24 (64.9%) patients. Two-year overall survival trended lower in the N-IRP group than the PH-IRP group (77.2% vs. 92.3%, P =0.086), but CLAD-free survival (P =0.592) and rates of primary graft dysfunction (P =0.502) and acute cellular rejection (P =0.408) were similar. An abnormally elevated IRP was common in LTx candidates; however, it normalized in roughly two-thirds of patients after LTx. Two-year survival trended higher in the PH-IRP group, despite similar rates of primary graft dysfunction and acute cellular rejection as well as similar CLAD-free survival between the groups.

The Impact of Chronic Cannabis Use on Esophageal Motility in Patients Referred for Esophageal Manometry.

Tetrahydrocannabinol, the main psychoactive compound in cannabis, binds with high affinity to the cannabinoid 1 receptor. Small randomized controlled studies using conventional manometry have shown that the cannabinoid 1 receptor can modulate esophageal function, namely transient lower esophageal sphincter relaxation frequency and lower esophageal sphincter tone. The effect of cannabinoids on esophageal motility in patients referred for esophageal manometry has not been fully elucidated using high-resolution esophageal manometry (HREM). We aimed to characterize the clinical effect of chronic cannabis use on esophageal motility utilizing HREM. Patients who underwent HREM from 2009 to 2019 were identified at 4 academic medical centers. The study group consisted of patients with a noted history of chronic cannabis use, a diagnosis of cannabis-related disorder, or a positive urine toxicology screen. Age and gender-matched patients with no history of cannabis use were selected to form the control group. Data on HREM metrics based on the Chicago classification V3, and the prevalence of esophageal motility disorders were compared. Confounding effects of BMI and medications on esophageal motility were adjusted for. Chronic cannabis use was found to be an independent negative predictor of weak swallows (β=-8.02, P =0.0109), but not a predictor of failed swallows ( P =0.6890). The prevalence of ineffective esophageal motility was significantly lower in chronic cannabis users compared with nonusers (OR=0.44, 95% CI 0.19-0.93, P =0.0384). There was no significant difference in the prevalence of other esophageal motility disorders between the 2 cohorts. In patients with dysphagia as their primary indication for HREM, chronic cannabis use was found to be independently associated with increased median integrated relaxation pressure (β=6.638, P =0.0153) and increased mean lower esophageal sphincter resting pressure (β=10.38, P =0.0084). Chronic cannabis use is associated with decreased weak swallows and reduced prevalence of ineffective esophageal motility in patients referred for esophageal manometry. In patients referred for dysphagia, chronic cannabis use is associated with increased integrated relaxation pressure and lower esophageal sphincter resting pressure, though not to levels above the normal range.

A212 SYMPTOMS IN PATIENTS WITH NORMAL ESOPHAGEAL MOTILITY MAY DIFFER BASED ON AGE AND SEX

Abstract Background High resolution esophageal manometry (HREM) is used to diagnose esophageal motility disorders. While esophageal symptoms including dysphagia are common and seen in up to 20% of adults, a minority of symptomatic patients have esophageal dysmotility, when defined by the Chicago Classification v4 (CCv4). The generation of esophageal symptoms in a patient with normal esophageal motor function is complex, but may relate to visceral hypersensitivity, inappropriate pain perception or unidentified contraction abnormalities. The Esophageal Symptom Questionnaire (ESQ-30) is a validated tool in the assessment of esophageal symptoms and measures the frequency and severity of dysphagia, reflux and globus through three separate sub-scales (ESQ-D, ESQ-R, ESQ-G respectively). Aims To determine age and sex in esophageal symptoms (as measured by ESQ-30 sub-scales) in a population of symptomatic patients with normal esophageal motility. Methods Retrospective analysis of consecutive reports from HRM studies performed between October 2021 – March 2023 who provided consent for inclusion in the motility databank and completed ESQ-30 questionnaires. All values expressed as median (IQR: 25-75-centile). Spearman’s bivariate correlations were performed between ESQ-D, ESQ-R, ESQ-G and manometric variables (IRP, DCI, % failed, and % weak) as well as demographic variables (age). Group means were compared with the non-parametric Mann-Whitney U test. Results Within the study period, 681 patients underwent HREM and had complete ESQ-30 questionnaires. Of these patients, 151 female and 73 male participants (mean age 51.8 +/- 15.2 years) had normal esophageal motility by CCv4. ESQ-D and ESQ-R scores were significantly higher in women in comparison to men. ESQ-D was 10 in women and 5 in men (p=.021), and ESQ-R was 28 in women and 19 in men (p=.029). There was a weak negative correlation between age and reflux symptoms (R2 -.139, p = 0.038). There was no significant difference in manometric parameters between males and females (p ampersand:003E .05 for all comparisons). Dysphagia and globus weakly negatively correlated with median IRP (R2 -.156, p = .019 and R2 -.139, p = .038 for dysphagia and globus respectively). Conclusions In a population of symptomatic patients with normal esophageal motility, symptom profile differed based on age and sex. Women had higher dysphagia and reflux symptoms compared to men, while older patients had lower reflux symptoms. These findings suggest that esophageal sensitivity may vary with age and sex in patients with normal esophageal motility. The finding of higher dysphagia and globus symptoms in patients with lower median IRP (integrated relaxation pressure) is an unexpected finding and may reflect reflux effect. Further studies to assess for the impact of GERD (using 24h pH-metry/MII) on patients with normal esophageal motor function are warranted. Funding Agencies None

Pre- and post-intervention oesophageal pressure topography metrics in the three subtypes of achalasia: A pilot study on Indian adults

BackgroundAchalasia is characterized by failure of relaxation of the lower oesophageal sphincter (LOS) and abnormal peristalsis during swallowing. The study aimed to observe the effects of intervention in three sub-types of achalasia and compare the intervention outcomes among the three sub-types. MethodsForty-one patients underwent Eckardt scoring for severity of achalasia, followed by high-resolution manometry (HRM). After three and six months of intervention (pneumatic dilatation or 'Heller's Cardiomyotomy), Eckardt scoring and HRM were repeated and compared with the initial results. ResultsOut of the 41 patients, 13 were diagnosed with type I achalasia (31.71%), 18 with type II (43.90%), and 10 with type III (24.39%). Significant differences between the pre- and post-intervention values of median integrated relaxation pressure (IRP) and Eckardt score were found in all three sub-types. Although the beneficial effect of intervention lasted up to six months postintervention, it was less than three months postintervention values. The intervention success rates were highest for both laparoscopic Heller's myotomy (LHM) and pneumatic dilatation (PD) in Type II Achalasia at three and six months postintervention, respectively. ConclusionOne-time intervention is effective in all three sub-types. This benefit tends to taper over time but remains significant after six months of intervention. Type II Achalasia shows the best intervention outcomes compared to the other two sub-types at three months and six months post-intervention. Type III Achalasia shows the least response compared to other sub-types and is the poorest responder to intervention. The benefit of one-time intervention also deteriorates most in type III achalasia at the end of six months.

A280 DOES THE PLACEMENT OF A MANOMETRY PROBE WITH ENDOSCOPY AND CONSCIOUS SEDATION EFFECT MEASUREMENTS ON ENSUING HIGH RESOLUTION MANOMETRY? A RETROSPECTIVE COHORT STUDY IN PATIENTS POST-PERORAL ENDOSCOPIC MYOTOMY

Abstract Background High resolution manometry (HRM) is the gold standard for diagnosis of esophageal motility disorders. This is traditionally conducted without sedation, using intranasal intubation with a manometry probe. Inserting the HRM probe immediately after endoscopic examination allows for endoscopic visualization and sedation for probe placement. This method is used commonly used for our patients who are post-peroral endoscopic myotomy (POEM). However, it is unclear whether short acting sedative drugs administered during endoscopy can affect contractility measurements during HRM. Purpose The purpose of this study was to determine if conscious sedation with short-acting anaesthetic agents (Midazolam and Fentanyl) influenced HRM readings in patients undergoing evaluation post-perioral endoscopic myotomy (POEM). Method We conducted a retrospective cohort study, comparing patients post-POEM who had endoscopy under conscious sedation with placement of the manometry probe versus those without preceeding endoscopy/sedation. Post-POEM patients who had undergone HRM over a 3-year period (2019-2022) were identified from motility lab records. Electronic charts were reviewed for data abstraction, and HRM parameters (resting lower esophageal pressure and integrated relaxation pressure) were determined for both groups and compared using t-tests, and error listed as standard error of the mean. Result(s) From 2019-2022, 15 patients underwent manometry using a non-endoscopic approach with no sedation and 25 underwent manometry following endoscopy with conscious sedation and placement of the probe during the procedure. In the latter group, HRM occurred within 2 hours of probe placement. The mean doses of fentanyl and midazolam were 115mcg (+/-29.7) and 3.3mg (+/-1.3) respectively. The mean end-expiratory lower esophageal sphincter pressure was 9.8 mmHg (+/- 2.9) in the non-endoscopic group and 26.24mmHg (+/- 5) in the endoscopy group (p &amp;lt;0.02). The median integrated relaxation pressure was 11.2 mmHg (+/-1.2) in the non-endoscopic group and 14.52mmHg (+/- 0.9) in those in the endoscopy group (p &amp;lt;0.04). Conclusion(s) In conclusion, this small, retrospective cohort study shows that manometry probe placement after endoscopy with conscious sedation may affect esophgeal HRM measurement parameters in the post-POEM patient population. Physicians should consider delaying HRM measurements for &amp;gt;4 hours to maximize clearance of the sedative medications. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Comparing Patients Diagnosed With Ineffective Esophageal Motility by the Chicago Classification Version 3.0 and Version 4.0 Criteria.

The Chicago Classification version 4.0 (CCv4.0) of ineffective esophageal motility (IEM) is more stringent than the Chicago Classification version 3.0 (CCv3.0) definition. We aimed to compare the clinical and manometric features of patients meeting CCv4.0 IEM criteria (group 1) versus patients meeting CCv3.0 IEM but not CCv4.0 criteria (group 2). We collected retrospective clinical, manometric, endoscopic, and radiographic data on 174 adults diagnosed with IEM from 2011 to 2019. Complete bolus clearance was defined as evidence of exit of the bolus by impedance measurement at all distal recording sites. Barium studies included barium swallow, modified barium swallow, and barium upper gastrointestinal series studies, and collected data from these reports include abnormal motility and delay in the passage of liquid barium or barium tablet. These data along with other clinical and manometric data were analyzed using comparison and correlation tests. All records were reviewed for repeated studies and the stability of the manometric diagnoses. Most demographic and clinical variables were not different between the groups. A lower mean lower esophageal sphincter pressure was correlated with greater percent of ineffective swallows in group 1 (n = 128) (r = -0.2495, P = 0.0050) and not in group 2. In group 1, increased percent of failed contractions on manometry was associated with increased incomplete bolus clearance (r = 0.3689, P = 0.0001). No such association was observed in group 2. A lower median integrated relaxation pressure was correlated with greater percent of ineffective contractions in group 1 (r = -0.1825, P = 0.0407) and not group 2. Symptom of dysphagia was more prevalent (51.6% versus 69.6%, P = 0.0347) in group 2. Dysphagia was not associated with intrabolus pressure, bolus clearance, barium delay, or weak or failed contractions in either group. In the small number of subjects with repeated studies, a CCv4.0 diagnosis appeared more stable over time. CCv4.0 IEM was associated with worse esophageal function indicated by reduced bolus clearance. Most other features studied did not differ. Symptom presentation cannot predict if patients are likely to have IEM by CCv4.0. Dysphagia was not associated with worse motility, suggesting it may not be primarily dependent on bolus transit.

Integrated Relaxation Pressure (IRP) Distinguishes between Reflux-Predominant and Dysphagia-Predominant Phenotypes of Esophageal "Absent Contractility".

Patients with absent contractility (AC) often suffer from either reflux or dysphagia. It remains unclear what factors determine which phenotype patients present with. We sought to evaluate if high-resolution manometry metrics, especially integrated relaxation pressure (IRP), could explain this. Cases of AC from three medical centers were reviewed for demographic, clinical, and manometric data. Cases with an IRP between 10-15 mmHg or subsequent diagnosis of achalasia were excluded. 69 subjects were included (mean age 56.1; 71% female). A total of 41 (59.4%) were reflux-predominant. The reflux-predominant group was younger (51.1 vs. 63.5, p = 0.002) and had lower median LES basal pressures (7.5 vs. 12.5 mmHg, p = 0.014) and IRP values (1.5 vs. 5.6 mmHg, p &lt; 0.001) compared to the dysphagia group. When divided into tertiles, the trend in symptoms between LES basal pressure tertiles was not significant. However, the trend for IRP was significant (p &lt; 0.001). For example, in the lowest IRP tertile, 91.3% of subjects were reflux-predominant compared to only 26.1% in the highest tertile, while the dysphagia-predominant group increased from 8.7% to 73.9%. In a regression model controlling for age and using IRP tertile 1 as the reference, having an IRP in tertile 2 increased the likelihood of having dysphagia-predominant disease by 7, while being in tertile 3 increased the likelihood by 22. IRP helps distinguish between the reflux-predominant and dysphagia-predominant phenotypes of AC. This may have therapeutic clinical consequences as procedures such as fundoplication to tighten the LES may benefit patients with reflux and a low IRP, while procedures like peroral endoscopic myotomy (POEM) to disrupt the LES may benefit patients with dysphagia and a relatively high IRP.

Comparative Analysis of Heller Myotomy With Dor Versus Toupet Fundoplication for Achalasia Cardia

Background Heller myotomy (HM) with partial fundoplication is the standard of care for achalasia cardia. However, the choice of partial fundoplication is controversial. In this study, we compared both types of fundoplication concerning subjective and objective parameters. Methodology This prospective comparative study comprised a total of 30 consecutive patients who underwent laparoscopic/robotic HM with either Dor fundoplication (DF) (n = 15) or Toupet fundoplication (TF) (n = 15). Preoperative baseline characteristics, intraoperative details, and postoperative complications were recorded. Patients were followed with Eckardt score, quality of life-related scores, 24-hour pH study, and high-resolution manometry (HRM) at the one-year follow-up. Results There was no significant difference between the two groups regarding preoperative baseline parameters, length of hospital stay, and postoperative complications. The HM+DF group had four (27%) patients with recurrence/failure with none in the HM+TF, but it was not significant (p = 0.79). Symptom scores were similar between the groups at six and 12 months of follow-up. One patient in the HM+DF group and two in the HM+TF group had significant pathological acid reflux (p = 0.483). On HRM, HM+TF showed a trend toward significance in terms of esophagogastric junction (EGJ) relaxation (p = 0.058) with a non-significant difference in median integrated relaxation pressure (p = 0.081). Conclusions The study showed a trend toward lower failure rates and improved EGJ relaxation with similar reflux rates in patients who underwent HM+TF compared to HM+DF. However, long-term follow-up is required to validate our findings with well-defined subjective and objective criteria.

Changes in the esophagogastric junction outflow obstruction manometric feature based on the Chicago Classification updates.

BACKGROUNDThe critical diagnostic criteria for esophagogastric junction outflow obstruction (EGJOO) were published in the latest Chicago Classification version 4.0 (CCv4.0). In addition to the previous criterion [elevated integrated relaxation pressure (IRP) in supine position], manometric diagnosis of EGJOO requires meeting the criteria of elevated median-IRP during upright wet swallows and elevated intrabolus pressure. However, with the diagnostic criteria modification, the change in manometric features of EGJOO remained unclear.AIMTo evaluate the esophageal motility characteristics of patients with EGJOO and select valuable parameters for confirming the diagnosis of EGJOO.METHODSWe performed a retrospective analysis of 370 patients who underwent high-resolution manometry with 5 mL water swallows × 10 in supine, × 5 in upright position and the rapid drink challenge (RDC) with 200 mL water from November 2016 to November 2021 at Peking University First Hospital. Fifty-one patients with elevated integrated supine IRP and evidence of peristalsis were enrolled, with 24 patients meeting the updated manometric EGJOO diagnosis (CCv4.0) as the EGJOO group and 27 patients not meeting the updated EGJOO criteria as the isolated supine IRP elevated group (either normal median IRP in upright position or less than 20% of supine swallows with elevated IBP). Forty-six patients with normal manometric features were collected as the normal high-resolution manometry (HRM) group. Upper esophageal sphincter (UES), esophageal body, and lower esophageal sphincter (LES) parameters were compared between groups.RESULTSCompared with the normal HRM group, patients with EGJOO (CCv4.0) had significantly lower proximal esophageal contractile integral (PECI) and proximal esophageal length (PEL), with elevated IRP on RDC (P < 0.05 for each comparison), while isolated supine IRP elevated patients had no such feature. Patients with EGJOO also had more significant abnormalities in the esophagogastric junction than isolated supine IRP elevated patients, including higher LES resting pressure (LESP), intrabolus pressure, median supine IRP, median upright IRP, and IRP on RDC (P < 0.05 for each comparison). Patients with dysphagia had significantly lower PECI and PEL than patients without dysphagia among the fifty-one with elevated supine IRP. Further multivariate analysis revealed that PEL, LESP, and IRP on RDC are factors associated with EGJOO. The receiver-operating characteristic analysis showed UES nadir pressure, PEL, PECI, LESP, and IRP on RDC are parameters supportive for confirming the diagnosis of EGJOO.CONCLUSIONBased on CCv4.0, patients with EGJOO have more severe esophagogastric junction dysfunction and are implicated in the proximal esophagus. Additionally, several parameters are supportive for confirming the diagnosis of EGJOO.

Modified Peroral Endoscopic Myotomy Technique for Type II Achalasia: A Multicenter Retrospective Study.

Aim This retrospective study is aimed at evaluating the outcomes of a modified peroral endoscopic myotomy (POEM) technique in patients with type II achalasia. Methods We performed a modified POEM procedure, which involved a shorter (total myotomy length = 4 cm), full-thickness myotomy, on 31 patients with type II achalasia. Clinical success rates, technical success rates, pre- and postoperative esophageal manometry results, complications, and reflux-related adverse events were evaluated. Results The clinical success (Eckardt score ≤ 3) rates were 100% and 88.9% within 2 years and beyond 2 years postoperatively, respectively. The median lower esophageal sphincter pressures (LESP) decreased from 31.6 (26.7-49.7) mmHg preoperatively to 13.4 (10.5-21.6) and 11.8 (7.4-16.7) mmHg (P < 0.001) at 6 and 12 months postoperatively, respectively. The median integrated relaxation pressure (IRP) decreased from 27.8 (20.6-37.5) mmHg preoperatively to 12.9 (11.3-23.4) and 11.6 (9.6-16.8) mmHg (P < 0.001) at 6 and 12 months after POEM, respectively. Only one case (3.2%) of mucosal injury, four (12.9%) cases of reflux esophagitis, and two (6.5%) cases of gastroesophageal reflux symptoms were reported. Conclusions The modified POEM technique showed excellent outcomes in patients with type II achalasia.

Chicago Classification ver. 4.0: Diagnosis of Achalasia and Esophagogastric Junction Outflow Obstruction

Achalasia is a common esophageal motility disorder characterized by inappropriate relaxation of the lower esophageal sphincter and a loss of normal peristalsis in the esophageal body. The newly suggested Chicago Classification ver. 4.0 recommends conclusive diagnoses of types 1, 2, and 3. A conclusive diagnosis of type 3 achalasia requires no appreciable peristalsis compared to the previously used ver. 3.0. In the case of inconclusive diagnosis of achalasia, additional tests, including timed barium esophagogram (TBE) or functional lumen imaging probe (FLIP), are strongly recommended in ver. 4.0. Esophagogastric junction outflow obstruction (EGJOO) in Chicago Classification ver. 3.0 was defined as an elevated median integrated relaxation pressure (IRP) without evidence of achalasia. On the other hand, the diagnosis of EGJOO in Chicago Classification ver. 4.0 requires elevated IRP in both positions, elevated intrabolus pressure, positive clinical symptoms, and additional positive test by TBE or FLIP. The newly suggested Chicago Classification Classification ver. 4.0 will be helpful in an accurate diagnosis of esophageal motility disorders, including achalasia and EGJOO.

Symptomatic and Physiological Outcomes Following Laparoscopic Heller Myotomy for Achalasia Cardia: Is There a Correlation?

Symptomatic evaluation using Eckardt score and achalasia-specific health-related quality-of-life and physiological evaluation using timed barium examination (TBE) and high-resolution manometry is integral to the diagnosis of achalasia. However, the correlation of physiological outcomes with symptomatic outcomes and their role in routine follow-up after laparoscopic Heller cardiomyotomy (LHCM) is controversial. In this study, we evaluated the role of physiological testing in achalasia patients undergoing LHCM and its correlation with symptomatic evaluation. Case records of patients undergoing LHCM for achalasia between January 2017 and March 2020 were reviewed for symptom scores (Eckardt score and achalasia-specific health-related quality-of-life) and physiological parameters [5-min column height on TBE and median integrated relaxation pressure (IRP) on high-resolution manometry]. Sixty-one patients with complete data in the preoperative period and on follow-up were included in the study. The data was analyzed for symptomatic and physiological outcomes and their correlation using paired t test and the Spearman correlation test. At a median follow-up of 16 months following LHCM, there was a significant improvement in Eckardt score (7.03±1.53 to 0.93±1.10, P<0.001), achalasia-specific health-related quality-of-life (58.34±7.81 to 14.57±13.45, P<0.001), column height on TBE (115.14±46.9 to 27.89±34.31, P<0.001) and IRP (23.95±8.26 to 4.61±4.11, P<0.001). Eckardt score correlated significantly with achalasia-specific health-related quality-of-life scores preoperatively (ρ=0.410, P<0.001) and on follow-up (ρ=0.559, P<0.001). There was no correlation between symptomatic parameters and physiological parameters. In patients of achalasia, LHCM leads to significant improvement in symptomatic and physiological parameters. Symptom scores correlate among themselves but not with physiological scores. Thus, physiological testing may not be needed for routine follow-up.

S3570 One and Done? Revisiting Need for Repeat Esophageal Manometry in Patients With Persistent Symptoms

Introduction: Achalasia is a motility disorder characterized by the absence of esophageal peristalsis and failure of the LES to relax in response to swallowing. High resolution manometry (HRM) has been established as the gold standard for diagnosis; however, the utility of repeat manometry has been investigated in only a limited number of reports. Whether repeat manometry provides new information or changes the diagnosis remains unclear Case Description/Methods: 70y/o female with GERD, PUD, cervical spondylosis, and rheumatoid arthritis, presented in 2015 with dysphagia to solids. Initial work-up included EGD which showed an esophageal web. She was started on acid suppression therapy without improvement. In 2017 she underwent HRM which showed an abnormal median integrated relaxation pressure of 39.6(n< 15mmHg) and an elevated upper esophageal sphincter relaxation pressure of 13.7(n< 12mmHg). 70% of swallows were failed with 30% of swallows peristaltic with normal distal contractile integral. There was incomplete bolus clearance in all swallows. Patient met Chicago Classification 3.0 criteria for esophagogastric junction outflow obstruction. However, given the large presence of non-peristaltic swallows, the possibility of an evolving achalasia was considered. Due to worsening symptoms, patient underwent barium esophagram (BE) ;in 2018 which did not suggest achalasia. There was however, small residual of contrast in the distal esophagus with delayed emptying suggesting a motility disorder. She then underwent video swallow study which was unrevealing. She again underwent BE; in 2019 revealing a prominent cricopharyngeus muscle causing narrowing of the esophageal lumen during the swallowing phase. She subsequently underwent repeat HRM which was consistent with Type II Achalasia per Chicago classification 3.0. LES pressure was elevated at 43.8 mmHg, UES pressure was normal (6.2 mmHg). 100% of all contractions had pan esophageal pressurization deeming them non-peristaltic. Patient had incomplete bolus clearance in all swallows. Of note, patient was not on any medications, including benzodiazepines or opioids, that would impact motility studies. Due to persistent symptoms, patient underwent peroral endoscopic myotomy with significant improvement of symptoms. Discussion: HRM is the gold standard for identifying causes of esophageal dysmotility. In patients whose symptoms progress over time, there is high utility in performing repeat manometry to evaluate the cause of their dynamic symptoms, as treatment options may change

Effects of Age on Esophageal Motility: A High-Resolution Manometry Study.

BackgroundStudies have found possible physiologic changes to esophageal motility with aging currently not taken into account in routine high-resolution manometry (HRM) interpretation. We aimed to quantify the relationship between these physiologic changes and aging to improve HRM interpretation.MethodsWe conducted a retrospective analysis of patients who underwent HRM at a tertiary hospital center between 2015 and 2019. Inclusion criteria were patients aged ≥18 years with normal HRM. Exclusion criteria were abnormal HRM, abnormal upper digestive endoscopy or imagery. Outcomes were median integrated relaxation pressure (IRP), lower esophageal sphincter (LES) pressure, distal contractal integral (DCI), distal latency (DL), and peristaltic break (PB) according to the v4.0 Chicago classification criteria. Effect of age was examined through univariate and multivariate linear regression analysis.ResultsWe identified 1,917 patients with HRM and included 722 patients with normal exams (median age 56 years (interquartile range (IQR) 46 - 66), 63.8% female). Indications for HRM included dysphagia (39.6%), gastroesophageal reflux disease (29.5%), and chest pain (11.5%). There was statistically significant relationship between age and IRP (r = 0.20, P < 0.0001) as well as DCI (r = 0.12, P = 0.001) and DL (r = -0.09, P = 0.02). No statistically significant relationship was found between age and LES pressure or PB.ConclusionWe found that IRP, DCI, and to a lesser extent, DL, are significantly correlated with the normal aging process in symptomatic patients. These findings should be taken into consideration when interpreting esophageal HRM.

Gastro-esophageal reflux disease (GERD) after peroral endoscopic myotomy (POEM)

Peroral endoscopic myotomy (POEM) is gaining traction as a minimally invasive treatment of achalasia. Increased reflux is reported after POEM but the incidence, type and severity of reflux are not fully understood. We aimed to study the prevalence and nature of reflux after POEM and correlate reflux with endoscopy and pH-impedance findings. This is a prospective cohort study of achalasia patients undergoing POEM since 2014. Data from Eckardt and GERD symptom scores, high-resolution oesophageal manometry (HRM) and gastroscopy were performed pre-procedure and repeated at 1-year follow-up. Data from 24-h pH-impedance, if performed, were also recorded. A standardized questionnaire was used to determine the severity and frequency of heartburn symptoms and the composite score for each patient was calculated. 58 patients underwent POEM between January 2014 and October 2018. The efficacy of POEM at 1year was 93.0%. We observed reduction of median Integrated Relaxation Pressure (IRP) from 23.5 ± 33.1mmHg to 13.4 ± 7.71mmHg (p = 0.005) and mean Eckardt score improved from 6.09 ± 2.43 points to 1.16 ± 1.70 points (p < 0.001). At 1year, 43.1% (n = 25) had symptomatic reflux. Of the 40 patients who underwent repeated gastroscopy, 60.0% (n = 24) had endoscopic evidence of oesophagitis with seven patients (18%) diagnosed with Grade C or D oesophagitis. 43.1% (n = 25) of patients had pH-impedance done post-POEM off PPIs. 14 patients (56%) had increased acid exposure. Sixteen percent of reflux episodes were acidic and 77.3% were weakly acidic. POEM was an effective treatment for achalasia. However, GERD was common after POEM with incidence of 43% on symptom score, 60% on endoscopy and 56% on pH-impedance test. Post-POEM reflux appeared to be predominantly acidic in nature. Routine surveillance for GERD after POEM is recommended.

Chicago Classification update (version 4.0): Technical review on diagnostic criteria for achalasia.

The recommended diagnostic criteria for achalasia have been recently updated by Chicago Classification version 4.0 (CCv4.0), the widely accepted classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). CCv4.0 continued upon prior versions by subtyping achalasia into type I, type II, and type III on HRM. The achalasia subgroup of the CCv4.0 Working Group developed both conclusive and inconclusive statements for the HRM diagnoses of achalasia subtypes. Conclusive achalasia on HRM is defined as an abnormal median integrated relaxation pressure (IRP) in the primary position of wet swallows along with 100% failed peristalsis, with type I achalasia having 100% failed peristalsis without panesophageal pressurization (PEP), type II achalasia with PEP in at least 20% of swallows, and type III achalasia having at least 20% of swallows premature with no appreciable peristalsis. An inconclusive HRM diagnosis of achalasia can arise when there is an integrated relaxation pressure (IRP) that is borderline or at the upper limit of normal in at least one position, there is an abnormal IRP in both positions but evidence of peristalsis with PEP or premature swallows, or there is peristalsis in the secondary position after apparent achalasia in the primary position. In patients with dysphagia and an inconclusive HRM diagnosis of achalasia, supportive testing beyond HRM such as a timed barium esophagram (TBE) for functional lumen imaging probe (FLIP) is recommended. The review recommends a diagnostic algorithm for achalasia, discusses therapeutic options for the disease, and outlines future needs on this topic.

Esophagogastric junction outflow obstruction.

In the Chicago Classification version 4.0 (CCv4), esophagogastric junction outflow obstruction (EGJOO) is manometrically defined as an elevated median integrated relaxation pressure (IRP) and elevated intrabolus pressure (IBP) during supine wet swallows, and persistently elevated median IRP in the upright position. A clinically relevant conclusive diagnosis of EGJOO requires a manometric diagnosis of EGJOO and associated symptoms such as dysphagia and/or chest pain with at least one of the following supportive investigations (pharmacologic provocation, timed barium esophagogram, and/or endoflip). The Chicago Classification is intended for diagnosis of primary esophageal motor disorders, and thus history and endoscopic evaluation are important to exclude conditions (eg, previous surgery, strictures, or masses) that can secondarily generate the EGJOO pattern on HRM. While a manometric finding of EGJOO is often made and can be an early sign of achalasia, more often it is a manometric finding without clinical implications. The proposed changes in CC4.0 have attempted to make the diagnosis more specific, in order to reduce the number of clinically irrelevant diagnoses and avoid confusion by patients and physicians alike.

Alteration in Integrated Relaxation Pressure During Successive Swallows in Subjects With Normal Manometry Versus Those With Esophagogastric Junction Outflow Obstruction.

Background/AimsIntegrated relaxation pressure (IRP) is defined as the average minimum esophagogastric junction pressure for 4 seconds of relaxation (contiguous or noncontiguous) within 10 seconds of swallowing. The durability of IRP values during successive swallows in the supine position remains to be elucidated. The aim is to determine alteration in IRP values during successive swallows among subjects with normal esophageal manometry versus those with esophagogastric junction outflow obstruction (EGJOO).MethodsConsecutive subjects, who underwent high-resolution esophageal manometry (HREM) were included in the study. Individuals had to have either normal manometry or EGJOO. A total of 10 wet swallows of 5 mL water were performed after an adaptation period of a minimum of 3 minutes. Mean IRP was analyzed for both subject groups for each individual swallow.ResultsThirty-one patients with EGJOO and seventy patients with normal manometry were included. As expected, the median IRP was higher in EGJOO patients compared to those with normal HREM (mean 23.92 vs 5.34, P < 0.001). The mean IRP of the last swallow was 40% lower than the mean IRP of the first swallow in the normal subjects (P = 0.015). In contrast, the difference in the mean IRP value in the EGJOO group between the first and the last swallow was 19% (P = 0.018).ConclusionsThis study demonstrated that there is a significant decline in the mean IRP during successive swallows in subjects with normal esophageal manometry and those with EGJOO, despite adequate adaptation periods. This decline in IRP was less pronounced in EGJOO.