Multichannel Intraluminal Impedance And Esophageal Manometry Research Articles

Esophageal Motility and Rikkunshito Treatment for Proton Pump Inhibitor-Refractory Nonerosive Reflux Disease: A Prospective, Uncontrolled, Open-Label Pilot Study Trial

BackgroundOnly a few reports focused on esophageal motility in patients with proton pump inhibitor (PPI)-refractory nonerosive reflux disease (NERD) and there has been no established strategy for treatment. ObjectiveTo clarify the characteristics of esophageal motility in patients with PPI-refractory NERD, we evaluated esophageal function using combined multichannel intraluminal impedance and esophageal manometry (MII-EM). In addition, we evaluated the efficacy of rikkunshito (RKT), which is a gastrointestinal prokinetic agent. MethodsThirty patients with NERD were enrolled and underwent MII-EM. After 8 weeks of RKT (7.5 g/d) treatment, MII-EM was repeated on patients with PPI-refractory NERD. Symptoms were assessed by the Gastrointestinal Symptom Rating Scale. ResultsIn patients with PPI-refractory NERD, measures of complete bolus transit, peristaltic contractions, and residual pressure of the lower esophageal sphincter during swallowing deviated from the standard values and esophageal clearance was found to be deteriorated. RKT significantly improved the peristaltic contractions (P < 0.05), the complete bolus transit (P < 0.01), and the residual pressure of lower esophageal sphincter (P < 0.05) in these patients. The overall score (P < 0.01) and the subscale scores of acid reflux syndrome (P < 0.05), abdominal pain (P < 0.05), and indigestion syndrome (P < 0.01) in the Gastrointestinal Symptom Rating Scale were significantly improved by the 8-week RKT treatment. ConclusionsIn the pilot study, patients with PPI-refractory NERD had disorders of esophageal and lower esophageal sphincter motility that were improved by RKT. Further studies examining esophageal motor activity of RKT in PPI-refractory NERD are required. University hospital Medical Information Network (UMIN) Clinical Trial Registry identifier: UMIN000003092.

Characteristics of Consecutive Esophageal Motility Diagnoses After a Decade of Change.

Combined multichannel intraluminal impedance and esophageal manometry (MII-EM) measures concomitantly bolus transit and pressure changes allowing determination of the functional impact of esophageal motility abnormalities. Ten years ago our laboratory reported MII-EM results in 350 consecutive patients. Since then high-resolution impedance manometry (HRIM) became available and the definitions of ineffective esophageal motility (IEM) and nutcracker esophagus were revised. The aim of this study was to assess the impact of these developments on esophageal function testing. From August 2012 through May 2013, HRIM was performed in 350 patients referred for esophageal function testing. Each patient received 10 liquid and 10 viscous swallows. While taking advantage of the new technology and revised criteria, HRIM findings were classified according to the conventional criteria to allow more appropriate comparison with our earlier analysis. Compared with the study performed 10 years ago, the prevalence of normal manometry (36% vs. 35%), achalasia (7% vs. 8%), scleroderma (1% vs. 1%), hypertensive lower esophageal sphincter (LES) (7% vs. 7%), and hypotensive LES (1% vs. 2%) remained the same, whereas the prevalence of distal esophageal spasm (9% vs. 3%), nutcracker esophagus (9% vs. 3%), and poorly relaxing LES (10% vs. 3%) decreased and the prevalence of IEM increased (20% vs. 31%) significantly. Compared with the early study, normal liquid bolus transit was significantly different in patients with hypertensive LES (96% vs. 57%) and poorly relaxing LES (55% vs. 100%). This study brings to light the increase in prevalence of IEM. In addition, it suggests that the hypertensive LES and poorly relaxing LES may each affect bolus transit in about half of these patients.

Viscous impedance is an important indicator of abnormal esophageal motility

Non-obstructive Dysphagia (NOD) is one of the most common symptoms evaluated using esophageal manometry. Although manometry is considered the gold standard, many NOD patients have normal evaluations. Esophageal function testing with combined multichannel intraluminal impedance and esophageal manometry (MII-EM) is performed using ten 5-mL swallows of a liquid and a viscous material and provides supplemental information about bolus transit. The aim of this study was to evaluate esophageal function using combined MII-EM in patients with NOD who had normal evaluations with liquid manometry. Multichannel intraluminal impedance and esophageal manometry was performed in consecutive patients presenting for evaluation of NOD. Patients were excluded if any abnormality was detected during liquid manometry. Viscous manometry and liquid and viscous impedance data were analyzed to detect manometric or bolus transit abnormalities. Patients referred for GERD evaluation without any swallowing complaints were used as patient controls and were subject to the same exclusion criteria as the NOD group. All swallow evaluations were performed with 10 liquid and 10 viscous swallows. Data from 240 patients were evaluated, 129 with NOD and 111 patient controls. In the NOD group, 9% (12/129) had abnormal liquid impedance and 29% (37/129) had abnormal viscous impedance. In the control group, 4% (4/111) had abnormal liquid impedance and 16% (18/111) had abnormal viscous impedance. Chi-square analysis showed a significant difference between the two study groups for viscous impedance (P=0.02) but not for liquid impedance (P=0.12). Our data support our belief that a normal liquid manometry with an abnormal viscous impedance analysis in a patient with NOD indicates abnormal esophageal motility. Therefore, viscous impedance should be performed on all patients during the evaluation of NOD.

Correlation between obstructive sleep apnea hypopnea syndrome and gastroesophageal reflux disease

To discuss the occurrence correlation between obstructive sleep apnea hypopnea syndrome (OSAHS) and gastroesophageal reflux disease (GERD). Forty-three patients suspected of laryngopharyngeal reflux disease underwent combined multichannel intraluminal impedance and esophageal manometry (MII-EM), twenty-four-hour esophageal and pharyngeal pH and impedance monitoring and PSG. Subjects were grouped according to the detections. The difference of the measurement between groups were Compared. The possible relationship between the two diseases was analyzed. Fourteen of all the subjects can be diagnosed to have GERD (32.6%). Twenty-six can be diagnosed to have OSAHS (60.5%). There were 10 patients had OSAHS and GERD simultaneously, which took over 38.5% of the OSAHS group, and 71.4% of the GERD group. BMI (P = 0.000) and lower esophageal sphincter (LES) residual pressure (P = 0.021) were significantly different among the four groups OSAHS, GERD, OSAHS and GERD, and control (non-OSAHS and non-GERD), but no linear relationship between LES residual pressure and prevalence or severity of the two diseases was found. In OSAHS group, AHI were positively correlated with the following indictors: the DeMeester score (r = 0.45), acid exposure of the distal esophagus (r = 0.491). There seems to be no Linear correlation among reflux indicators, sleep indicators, and esophageal functional indicators in GERD group. Linear correlation was not found among reflux indicators, sleep indicators, and esophageal functional indicators in OSAHS and GERD group (P > 0.05). The incidence and the severity of GERD and OSAHS were related to each other. Reflux events may aggravate OSAHS. The two diseases may have some relationship on the esophageal function, especially on the regulation of the LES pressure.

Examination of the Effects of Vardenafil on Esophageal Function Using Multichannel Intraluminal Impedance and Manometry

Background/AimsTo evaluate the effects of the phosphodiesterase type 5 (PDE5) inhibitor vardenafil on esophageal function, including bolus transit, using multichannel intraluminal impedance and esophageal manometry (MII-EM).MethodsSixteen healthy volunteers (15 men) underwent an MII-EM study including 10 liquid swallows and 10 viscous swallows in a seated position after fasting. Then, each subject was asked to ingest 50 mL distilled water or 10 mg vardenafil dissolved in 50 mL water, in a double-blind manner. After 25 minutes, the MII-EM study was repeated.ResultsEight men received vardenafil and eight subjects received water. Resting and residual lower esophageal sphincter pressures differed significantly only in the vardenafil group (from 18 ± 6.7 to 6.6 ± 5.3 mmHg, P < 0.001 and from 4.9 ± 2.6 to 2.1 ± 3.6 mmHg, P = 0.006, respectively). Mean distal esophageal amplitude decreased significantly only in the vardenafil group (from 86.7 ± 41.6 to 34.0 ± 38.0 mmHg, P < 0.05). Complete bolus transits of liquid and viscous meals decreased significantly only after vardenafil ingestion (from 80.2% ± 13.8% to 49.4% ± 27.9%, P < 0.05 and from 72.8% ± 33.6% to 21.5% ± 29.0%, P = 0.01, respectively).ConclusionsVardenafil decreased esophageal bolus transit in the seated position, despite decreased lower esophageal sphincter pressure.

Esophageal solid bolus transit: studies using combined multichannel intraluminal impedance and manometry in healthy volunteers

The purpose of this study is to apply combined multichannel intraluminal impedance and esophageal manometry (MII-EM) to test esophageal function during solid swallowing in a normal healthy population. We determined whether combined MII-EM with solid bolus is more sensitive than that with viscous bolus in the detection of motility abnormality. Eighteen healthy volunteers (11 men and 7 women; mean age 22 years, range 20-26 years) underwent combined MII-EM with a catheter containing four impedance-measuring segments and five solid-state pressure transducers. Each subject received 10 viscous and 10 solid materials. Tracings were analyzed manually for bolus presence time, total bolus transit time, contraction amplitude, duration, and onset velocity. Three hundred and sixty swallows including viscous and solid materials were analyzed. Contraction amplitude for the viscous swallows was higher at 20 cm above the lower esophageal sphincter (LES) (P= 0.049) but lower at 15 cm above the LES (P < 0.001). Duration of contractions for the solid swallows was longer at 15 cm (P= 0.002) and 10 cm above the LES (P= 0.011) compared with viscous swallows. The total bolus transit time for solid was significantly shorter than that for viscous boluses (6.8 vs. 7.7 seconds, P < 0.001). Bolus presence time appeared to be similar between viscous and solid boluses (except in the proximal esophagus). The percentage of swallows with ineffective peristalsis by manometry, as well as those with incomplete bolus transit by impedance, did not differ between viscous and solid swallows. The proportion of manometrically ineffective solid swallows with incomplete bolus transit was greater than that of viscous swallows (62.1% vs. 34.8%, P= 0.05). Application of solid boluses may potentially enhance diagnostic capability of esophageal function testing. Solid boluses can be regarded as a valuable complement to viscous boluses in the detection of esophageal motility abnormalities when applied with combined MII-EM.

Impact of Total Fundoplication on Esophageal Transit

Laparoscopic total fundoplication is considered the most effective surgical option for gastroesophageal reflux (GER) disease. Some authors assume that total fundoplication may expose the patient to delayed transit of the swallowed bolus and increased risk of dysphagia, particularly when peristaltic dysfunction is present. We undertook this study to evaluate by means of combined multichannel intraluminal impedance and esophageal manometry (MII-EM) the impact of fundoplication on esophageal physiology. An objective measurement of the influence of the total wrap on bolus transit may be helpful in refining the optimal antireflux wrap (ie, partial vs. total). In this study, 25 consecutive patients who underwent laparoscopic Nissen-Rossetti fundoplication had MII-EM and combined 24-hour pH and multichannel intraluminal impedance (MII-pH) before and after the surgical procedure. All patients completed preoperative and postoperative symptom questionnaires. The following were calculated for liquid and viscous deglutition lower esophageal sphincter pressure and relaxation, distal esophageal amplitude, the number of complete esophageal bolus transits and the mean total bolus transit time. The acid and nonacid GER episodes were calculated by MII-pH with the patient in both upright and recumbent positions. The postoperative MII-EM showed an increased lower esophageal sphincter pressure (P < 0.05), whereas lower esophageal sphincter relaxation and distal esophageal amplitude did not change after surgery (P = NS). Complete esophageal bolus transits and bolus transit time did not change for liquid swallows (P = NS), but was more rapid for viscous after surgery (P < 0.05). Twenty-four hour pH monitoring confirmed the postoperative reduction of both acid and nonacid reflux (P < 0.05). Laparoscopic Nissen-Rossetti is effective in controlling both acid and nonacid GER without impairment of esophageal function. Appropriate preoperative investigation, meticulous patient selection and correct surgical technique are extremely important in securing good results.

Swallow Evaluation During Multichannel Intraluminal Impedance and pH

Twenty-four-hour multichannel intraluminal impedance and pH (MII-pH) esophageal monitoring allows detection of both acid and nonacid gastroesophageal reflux episodes. The MII-pH catheter contains 6 impedance segments placed 3, 5, 7, 9, 15, and 17 cm above the lower esophageal sphincter (LES), plus a pH electrode at 5 cm. Multichannel intraluminal impedance and esophageal manometry (MII-EM) allows both functional and manometric evaluation of the esophagus. The MII-EM catheter contains 4 impedance measuring segments (5, 10, 15, and 20 cm above LES) and 5 solid state pressure transducers (within the LES and 5, 10, 15, and 20 cm above LES). Five milliliter saline boluses are given in the recumbent position when performing an MII-EM study. In our laboratory, all patients have an MII-EM study performed before an MII-pH study. In many laboratories, MII-pH is done without earlier MII-EM. To assess accuracy of swallows given before ambulatory MII-pH monitoring in detecting esophageal transit abnormalities. Hundred consecutive adult patients, prospectively studied (64 female; mean age = 52.6 y), presenting to our laboratory for MII-EM and 24-hours MII-pH study, also received 10 saline swallows in the recumbent position at the beginning of the MII-pH study. Impedance for these swallows was assessed for the presence of complete or incomplete transit; defined as presence of bolus entry in the 17 cm segment and bolus exit in the 15, 9, and 5 cm segments; defined by a rise in impedance above 50% between baseline and the nadir, and remaining above this value for at least 5 seconds. Of 10 swallows, the presence of 8 or more complete swallows satisfies the MII-EM criterion for diagnosis of complete transit. These findings were blindly compared with those of the 10 saline swallows on the MII-EM study. In 93% of patients, the MII-pH swallows gave identical transit diagnosis to the MII-EM. In 2 patients, the diagnosis changed from incomplete transit on MII-EM to complete on MII-pH, and in 5 patients from complete transit on MII-EM to incomplete on MII-pH. With both methods, there were 64 patients with complete transit and 29 with incomplete transit. Thus, MII-pH swallows had a sensitivity of 94% and a specificity of 93% for detection of esophageal transit abnormalities.Comparing the swallow diagnosis for each patient, we found that there was a highly significant correlation (P < 0.0001) for the number swallows with complete (Pearson r = 0.89) and incomplete bolus transits (Pearson r = 0.89). There was also a significant correlation (P < 0.0001) in bolus transit time between both methods (Pearson r = 0.64). Use of 10 saline swallows at the beginning of MII-pH studies is accurate, missing bolus transit abnormality in only 2 of 100 patients. It is also highly sensitive and specific for detection of esophageal transit abnormalities. This method allows detection of patients in whom further evaluation of esophageal function may be warranted.

Manometry and Impedance Characteristics of Achalasia. Facts and Myths

Achalasia is defined manometrically by an aperistaltic esophagus. Variations in the manometric findings occur in achalasia suggesting that all manometric features should not be required to diagnose achalasia. Combined multichannel intraluminal impedance and esophageal manometry (MII-EM) allows both a functional and a manometric evaluation of esophageal motility and identifies chronic fluid retention. To compare manometric and MII characteristics in patients with achalasia. Retrospective review of 73 MII-EM tracings from patients with achalasia done in our laboratory between October 2001 and December 2004 (38 females; mean age=53.5 y). Patients with previous esophageal interventions were excluded. Manometric and MII characteristics were identified and compared during 10 liquid and 10 viscous swallows. Patients were also divided into 2 groups: vigorous achalasia (VA) and achalasia. Twenty-two of the seventy-one (31%) achalasia patients had a hypertensive lower esophageal sphincter (LES). The mean lower esophageal sphincter pressure (LESP) for the 71 patients with achalasia was 37.9+/-21.2 mm Hg compared with 27.3+/-9.3 mm Hg (P<0.05) in the 73 patients with normal motility. The mean LESP in patients with achalasia was 36+/-20.3 mm Hg compared with 47+/-23.2 mm Hg (P<0.05) in patients with VA. Elevated intraesophageal pressure (IEP) was noted in 45/73 (61.6%). The mean LESP in this group was 41.1+/-22.9 mm Hg compared with 32.5+/-17 mm Hg (P<0.05) with normal IEP. The mean baseline impedance for achalasia was 801+/-732 compared with 1265.2+/-829.5 Omega (P<0.05) for the VA patients. Most patients with achalasia have elevated IEP, elevated LES residual pressure, normal LES pressure, and low baseline impedance. All manometric features should not be required to diagnose achalasia. Patients with an elevated IEP are likely to have an elevated LES pressure and LES residual pressure. Low MII values identify chronic fluid retention and helps confirm the diagnosis.

Symptom and Function Heterogenicity Among Patients with Distal Esophageal Spasm: Studies Using Combined Impedance-Manometry

Combined multichannel intraluminal impedance and esophageal manometry (MII-EM) is a clinically available tool that assesses the functional defect of various manometric abnormalities. The aim of our study was to evaluate esophageal bolus transit in patients with manometrically defined distal esophageal spasm (DES). Patients referred for esophageal function testing underwent combined MII-EM studies including 10 liquid and 10 viscous swallows. Individual swallows were classified using previously published manometric and impedance criteria. DES is traditionally defined as > or =20% simultaneous contractions in the distal esophagus. Diagnosis of esophageal transit abnormalities was defined by the presence of > or =30% incomplete liquid or > or =40% incomplete viscous swallows. Data from 71 patients (43 female, mean age 57 yr, range 16-85) with a manometric diagnosis of DES were analyzed. During liquid swallows, patients with chest pain had higher (p < 0.05) distal esophageal amplitudes (202.3 +/- 34.5 mmHg) and a higher (p < 0.05) percentage of swallows with complete bolus transit (89%+/- 3%) compared to patients presenting with dysphagia (amplitude 117.8 +/- 8.7 mmHg; percentage of complete transit 69%+/- 5%) and patients with reflux symptoms (amplitude 116.4 +/- 12.7 mmHg; percentage of complete transit 74%+/- 5%). Fifty-one percent of the DES patients had a normal bolus transit for liquid and viscous, 24% abnormal bolus transit for one substance, and 25% abnormal bolus transit for liquid and viscous. Pressure and bolus transit information in patients with manometrically defined DES points toward heterogenicity of this group of patients. Outcomes data are warranted to evaluate whether stratifying DES patients based on pressure and bolus transit information may improve the clinical approach.

Esophageal impedance recording: Clinical utility and limitations

Multichannel intraluminal impedance (MII) is a new technique available for the evaluation of esophageal bolus transit and reflux similar to barium swallow, but without the hazards of radiation exposure. Combined MII and pH monitoring (MII-pH) allows evaluation of the nature and pH of the refluxate and the proximal extent of a reflux event. Thus, MII-pH is useful in evaluation of nonacid reflux in patients with persistent typical or atypical symptoms of gastroesophageal reflux disease that are refractory to acid suppression therapy. Additionally, combined MII and esophageal manometry (MII-EM) affords concurrent assessment of esophageal function (bolus transit) and motility. Therefore, it provides a more complete esophageal function test than esophageal manometry alone. The few limitations of impedance monitoring include the complexity of interpreting the tracings and the lack of data in the diseased population. However, continued improvements in the software and increasing studies in different patient populations will aid in overcoming these limitations.

Combined multichannel intraluminal impedance and esophageal manometry (MII-EM) clarifies function defects during swallowing

in length between emitter and receiver during 2rain before to 30 sec after pain and the 2.5min preceding period. Acid reflux and/or high amplitude or simultaneous contractions were checked dunng the same periods Results: Recordings were technically satisfactory (> 15hs) in 6 patients. Esophageal shortening could not be measured in 2 patients due to early loss of the emitter mucosal clip. One patient was asymptomatic dunng the study. We analysed 46 pain events in 5 patients (1-16/pat). In 4 patients, 16 pain events (f-7/pat) were associated with a prolonged oral LES excursion of 7.8 • 06 ram. Esophageal shortening started 7 0 + 10 sec before the pain events and lasted 124-+26sec. Acid reflux was present in 5 and abnormal manometry in 10 pain events associated with esophageal shortening. Conclusion: Continuous ambulatory monitoring of esophageal shortening in man is possible. Ongoing studies will provide further information about the possible association between esophageal symptoms and abnormal contraction of the esophageal longitudinal muscle leading to prolonged esophageal shortening.

Evaluation of patients with achalasia using combined multichannel intraluminal impedance and esophageal manometry (MII/EM)

Evaluation of patients with achalasia using combined multichannel intraluminal impedance and esophageal manometry (MII/EM)