Multiple Rapid Swallows Research Articles

Patterns of esophageal dysmotility elicited by multiple rapid swallows

High-resolution manometry (HRM) is a gastrointestinal motility diagnostic system that measures intraluminal pressures using closely aligned sensors. Multiple rapid swallows (MRS) are used in conjunction with HRM to assess esophageal physiology prior to anti-reflux and hiatal hernia procedures. A retrospective, qualitative study was conducted on 90 patients who underwent HRM with MRS in a single community clinic. 80 patients met the inclusion criteria. MRS testing consisted of rapid 2mL swallows in 2-3s intervals with patients in a seated, upright position. Clinical information was reviewed including indications for HRM, prior diagnostic workup, manometry, distal contractile integral (DCI), and integrated residual pressure (IRP). HRM studies were visualized using Manoview Analysis Software v3.0 (Medtronic). Certain esophageal dysmotility and pressurization manometry patterns were previously undetected on HRM alone. In our study, the addition of MRS was clinically helpful in (1) assessing contraction reserve, (2) highlighting features of jackhammer, (3) stimulating esophageal spasm, and (4) visualizing distal esophageal pressurization pattern with mechanical obstruction. Additionally, abnormal pathophysiology such as (5) paradoxical LES contraction (achalasia) and (6) loss of deglutition inhibition were identified. MRS had a diagnostic utility of 21.25% (n = 17) among the 80 patients. An intolerance rate of 7.7% (n = 7) was observed in patients unable to complete the protocol. Augmentation of HRM with MRS produces unique manometric features that have clinical utility in uncovering esophageal disorders. MRS provocation testing is a practical, inexpensive, well-tolerated addition to HRM that may yield useful clinical information to guide complicated diagnoses and medical management.

Application of a novel straight leg raise test during high-resolution manometry can predict esophageal contractile reserve in patients with gastroesophageal reflux disease.

Increased intra-abdominal pressure from abdominal compression augments esophageal peristalsis during high-resolution manometry (HRM), and straight leg raise (SLR) while supine increases intra-abdominal pressure. We determined if water swallows performed during SLR can mimic contraction reserve seen with multiple rapid swallows (MRS). Consecutive patients evaluated for GERD symptoms completed validated GERD questionnaires, esophageal HRM, and upper endoscopy. Distal contractile integral (DCI) was analyzed during single water swallows (10×5mL), MRS (5×2mL), and during SLR (5x5mL). Peristaltic breaks were measured using software tools with a 20mmHg isobaric contour. Univariate correlational analyses were performed to compare esophageal motor patterns and DCI values during single water swallows, MRS, and SLR. Of 103 study patients (mean age: 46.7±12.3years, 56.3% female), 50 (48.5%) had ineffective esophageal motility (IEM). Contraction reserve was observed on MRS in 62% with IEM, and 35.8% with normal motility (p=0.008). DCI was significantly higher during SLR compared to mean single swallow DCI in both IEM and normal motility patients (p<0.001 for each comparison). In IEM patients, SLR significantly reduced swallows with peristaltic breaks (6.1±3.7 vs 3.6±3.6; p<0.001) and shortened the length of the largest break (4.8±3.4 vs 3.0±3.0cm; p<0.001). DCI response following MRS correlated with DCI with swallows during SLR, with a correlational coefficient (Pearson's r) of 0.70 (p<0.001). Swallowing against the resistance of increased intra-abdominal pressure from SLR improves esophageal body peristaltic performance and predicts esophageal body contraction reserve.

S0445 Comparative Analysis of Added Value Between Multiple Rapid Swallows and Apple Viscous Swallows in High-Resolution Manometry for Diagnosing Esophageal Motility Disorders

S0445 Comparative Analysis of Added Value Between Multiple Rapid Swallows and Apple Viscous Swallows in High-Resolution Manometry for Diagnosing Esophageal Motility Disorders

Contraction Reserve With Ineffective Esophageal Motility on Esophageal High-Resolution Manometry is Associated With Lower Acid Exposure Times Compared With Absent Contraction Reserve.

Ineffective esophageal motility (IEM) is a minor motor disorder with potential reflux implications. Contraction reserve, manifested as augmentation of esophageal body contraction after multiple rapid swallows (MRS), may affect esophageal acid exposure time (AET) in IEM. Esophageal high-resolution manometry (HRM) and ambulatory reflux monitoring studies were reviewed over 2 years to identify patients with normal HRM, IEM (≥50% ineffective swallows), and absent contractility (100% failed swallows). Single swallows and MRS were analyzed using HRM software tools (distal contractile integral, DCI) to determine contraction reserve (mean MRS DCI to mean single swallow DCI ratio >1). Univariate analysis and multivariable regression analyses were performed to determine motor predictors of abnormal AET in the context of contraction reserve. Of 191 eligible patients, 57.1% had normal HRM, 37.2% had IEM, and 5.8% had absent contractility. Contraction reserve had no affect on AET in normal HRM. Nonsevere IEM (5-7 ineffective swallows) demonstrated significantly lower proportions with abnormal AET in the presence of contraction reserve (30.4%) compared with severe IEM (8-10 ineffective swallows) (75.0%, P = 0.03). Abnormal AET proportions in nonsevere IEM with contraction reserve (32.7%) resembled normal HRM (33.0%, P = 0.96), whereas that in severe IEM with (46.2%) or without contraction reserve (50.0%) resembled absent contractility (54.5%, P ≥ 0.6). Multivariable analysis demonstrated contraction reserve to be an independent predictor of lower upright AET in nonsevere (odds ratio 0.44, 95% confidence interval 0.23-0.88) but not severe IEM. Contraction reserve affects esophageal reflux burden in nonsevere IEM. Segregating IEM into severe and nonsevere cohorts has clinical value.

Postreflux swallow-induced peristaltic wave index from pH-impedance monitoring associates with esophageal body motility and esophageal acid burden.

Postreflux swallow-induced peristaltic wave (PSPW) on pH-impedance monitoring and contraction vigor on high-resolution manometry (HRM) both assess esophageal peristaltic response. We aimed to evaluate relationships between PSPW and esophageal peristalsis on HRM in the context of reflux disease in this multicenter cohort study. pH-impedance and HRM studies performed on patients with persisting reflux symptoms were reviewed from 6 centers (5 in Europe and 1 in US). Total, upright and supine acid exposure time (AET) were evaluated from pH-impedance studies; PSPW index (PSPWI) and mean nocturnal baseline impedance (MNBI) were calculated using standard methodology. Esophageal body contraction vigor was analyzed using distal contractile integral (DCI), and DCI ratio>1 between single swallows and multiple rapid swallows (MRS) defined presence of contraction reserve. Student's t test, ANOVA, and linear regression were utilized to investigate relationships between PSPW, contraction vigor, and contraction reserve. Of 296 patients (52.8±0.8yr, 63% F), median PSPWI was 0.475. Only 24.0% had intact DCI; the remainder had varying degrees of hypomotility. As hypomotility increased, PSPWI and MNBI decreased significantly, while total AET and reflux episodes had an inverse response (P≤.002 for each). MRS data were available in 167 (56.4%), 72.5% had contraction reserve. MRS cohorts with normal PSPWI had significantly lower reflux burden compared to low PSPWI, regardless of presence or absence of contraction reserve (P≤.001). PSPWI correlates with esophageal hypomotility and reflux burden, and complements clinical reflux evaluation. Intact PSPW is more relevant to esophageal reflux clearance than contraction reserve.

New developments in esophageal function testing and esophageal manifestations of connective tissue disorders.

This work summarizes new and emerging metrics and tools in esophageal function testing and their potential clinical impact. Because the diagnostic sensitivity and reliability of conventional impedance-pH variables are suboptimal, several novel impedance parameters, such as the postreflux swallow-induced peristaltic wave index and the mean nocturnal baseline impedance, as well as mucosal impedance, are entering a validation stage prior to general clinical use. The accurate diagnosis of behavioral disorders in patients with rumination syndrome and supragastric belching using ambulatory multiple intraluminal impedance-pH can lead directly to behavioral interventions in patients with refractory gastroesophageal reflux disease (GERD). New provocative measures, such as multiple rapid swallows and the rapid drink challenge, have been developed to overcome the limitations of standard high-resolution esophageal manometry, aiming at further clarifying esophageal dysmotility. Furthermore, the current diagnostic and therapeutic challenges in patients with esophageal involvement in Sjogren's syndrome and scleroderma, who tend to have severe forms of GERD, are entering a new investigative and clinical phase.

Response to multiple rapid swallows shows impaired inhibitory pathways in distal esophageal spasm patients with and without concomitant esophagogastric junction outflow obstruction.

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. The normal response to multiple rapid swallows (MRS) is deglutitive inhibition of the esophageal body during the MRS sequence. Our aim was to compare the response to MRS in DES patients and healthy control subjects. Response to MRS during HRM was evaluated in 19 DES patients (8 with and 11 without concomitant esophagogastric junction outflow obstruction [EGJOO]) and 24 asymptomatic healthy controls. Patients with prior gastroesophageal surgery, peroral endoscopic myotomy, pneumatic dilation, esophageal botulinum toxin injection within 6months of HRM, opioid medication use, and esophageal stricture were excluded. Response to MRS was evaluated for complete versus impaired inhibition (esophageal body contractility with distal contractile integral [DCI] > 100mmHg-sec-cm during MRS), presence of post-MRS contraction augmentation (DCI post MRS greater than single swallow mean DCI), and integrated relaxation pressure (IRP). Impaired deglutitive inhibition during MRS was significantly more frequent in DES compared to controls (89% vs. 0%, P < 0.001), and frequency was similar for DES with versus without concomitant EGJOO (100% vs. 82%, P =0.48). 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 (3360.0 vs. 1238.9, P = 0.009). IRP was lower during MRS compared to single swallows in all patients, and IRP during MRS was normal in 5 of 8 patients with DES and EGJOO. Our study suggests that impaired deglutitive inhibition during MRS is present in the majority of patients with DES regardless of whether they have concomitant EGJOO, and future studies should explore the usefulness of incorporating response to MRS in the diagnosis of DES.

Opioids Interfere With Deglutitive Inhibition Assessed by Response to Multiple Rapid Swallows During High-Resolution Esophageal Manometry.

Normal response to multiple rapid swallows (MRS) during high-resolution esophageal manometry is deglutitive inhibition; opioids may interfere with this. The aim of this study was to evaluate the response to MRS in patients on opioids, not on opioids, and healthy controls. Response to MRS was evaluated for complete vs impaired inhibition in 72 chronic opioid users, 100 patients not on opioids, and 24 healthy controls. Impaired deglutitive inhibition was significantly more frequent in chronic opioid users compared with patients not on opioids and healthy controls (54% vs 14% vs 0%; P < 0.0001). Impaired deglutitive inhibition during MRS is frequent in opioid users, supporting that opioids interfere with esophageal inhibitory signals.

Opioid-induced esophageal dysfunction.

Chronic opioid use is common and can cause opioid-induced esophageal dysfunction (OIED). We will discuss the pathophysiology, diagnosis, and management of OIED. OIED is diagnosed based on symptoms, opioid use, and manometric evidence of distal esophageal spasm, esophagogastric junction outflow obstruction, achalasia type III, or jackhammer esophagus. Chronic opioid use appears to interfere with inhibitory signals involved in control of esophageal motility, allowing for unchecked excitatory stimuli, and leading to spastic contractility and impaired esophagogastric junction relaxation. Patients may present with dysphagia and chest pain. OIED is significantly more prevalent in patients taking the stronger opioids oxycodone and hydrocodone compared with the weaker opioid tramadol. Based on 24-h morphine equivalent doses, patients with OIED take higher opioid doses than those without OIED. Impaired inhibitory signaling was recently demonstrated in a study showing reduced deglutitive inhibition during multiple rapid swallows in patients taking opioids. OIED is frequent in chronic opioid users undergoing manometry for esophageal symptoms, especially at higher doses or with stronger opioids. OIED appears to be due to impaired inhibitory signals in the esophagus. Opioid cessation or dose reduction is recommended, but studies examining management of OIED are lacking.

Influence of sildenafil on esophageal motor function in humans: Studies using high-resolution manometry.

Sildenafil induces smooth muscle relaxation of the esophagus by blocking type 5 phosphodiesterase that degrades cyclic guanine monophosphate. We aimed to characterize the effects of sildenafil on esophageal peristalsis and contraction reserve using high-resolution manometry (HRM). Fifteen healthy adults (12 men, age 21-39, mean 27years) participated in this study using HRM following either sildenafil 50mg or placebo. HRM with ten wet swallows and five multiple rapid swallows was performed in all participants. HRM metrics included esophagogastric junction contractile integral (EGJ-CI), basal lower esophageal sphincter (LES) pressure, 4-second integrated relaxation pressure (IRP-4s), distal contractile integral (DCI), distal latency, resting upper esophageal sphincter pressure (UESP), and the response to MRS. Sildenafil significantly lowered EGJ-CI (P<.001), LES pressure (P=.04), IRP-4s (P=.02), and DCI (P<.001). There was no difference in UESP (P=.87) between sildenafil and placebo. Sildenafil significantly decreased peristaltic vigor, inducing absent peristalsis in 12 subjects and ineffective esophageal motility in 3 subjects. Peristaltic response and augmentation following MRS were significantly inhibited following sildenafil (7% vs 100%, P<.001, and none vs 73%, P<.001). Sildenafil attenuates EGJ barrier function, resting LES pressure, and LES relaxation. Both esophageal body contractility and contraction reserve are inhibited by sildenafil in healthy adults.

Minor esophageal functional disorders: are they relevant?

High resolution esophageal manometry (HRM) has expanded understanding of esophageal motor function. The Chicago Classification scheme has allowed systematic categorization of the myriad of manometric parameters identified during HRM. Multichannel intraluminal impedance pH has enhanced ambulatory reflux monitoring through complete assessment of esophageal content transit. However, the clinical implications of identified minor esophageal functional disorders remain unclear. Esophagogastric junction outlet obstruction is defined by esophagogastric junction obstruction with preserved peristalsis and may be managed expectantly, or in a manner similar to achalasia. Hypercontractile esophagus has been associated with dysphagia and non-cardiac chest pain, but the clinical significance is unclear as a majority of patients will improve without specific therapy. Additionally, these findings may be confounded by chronic opiate use. Ineffective esophageal motility is characterized by diminished esophageal contraction amplitude, potentially causing dysphagia and GERD. However, this is commonly identified in asymptomatic volunteers and may represent a normal variant. The multiple rapid swallow sequence can assess esophageal contraction reserve, which may predict post fundoplication dysphagia. The post-swallow induced peristaltic wave can serve as a surrogate of gastric refluxate clearance, providing important prognostic value. However, the associated time burden and lack of alternative therapeutic options limit its clinical utility. Minor esophageal functional disorders provide new therapeutic targets for symptomatic patients. However, these findings have inconsistent associations with symptoms and poorly defined therapeutic options. Minor esophageal function disorders should not be interpreted in isolation, with management decisions accounting for clinical, endoscopic, and radiographic factors in addition.

390 Opioids Interfere With Deglutitive Inhibition Assessed by Response to Multiple Rapid Swallows During High Resolution Esophageal Manometry

INTRODUCTION: We previously showed an association between chronic opioid use and esophageal motor dysfunction characterized by esophagogastric junction outflow obstruction, distal esophageal spasm, achalasia type III, and Jackhammer esophagus. 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 MRS followed by an augmented contraction with higher vigor than single swallows. Hypothesis: during MRS, opioids may interfere with deglutitive inhibition and may enhance post MRS contraction. Aim: compare response to MRS in opioid users, non-users and healthy controls. METHODS: Response to MRS was evaluated in 200 patients with esophageal symptoms (100 chronic opioid users on oxycodone, hydrocodone, or tramadol for ≥3 months, 100 not on opioids), and 19 asymptomatic healthy controls that underwent HRM. Patients with prior gastroesophageal surgery, pneumatic dilation, esophageal botulinum toxin injection within 6 months of HRM, esophageal stricture, achalasia type I or II, and scleroderma were excluded. Demographic and symptom data were extracted from a prospectively maintained motility database. Response to MRS was evaluated for complete versus incomplete inhibition (contractility with DCI &gt;100 mmHg-sec-cm during MRS), and presence of post MRS contraction augmentation (DCI post MRS greater than mean DCI for single swallows). Categorical variables were analyzed by chi square. RESULTS: Patients were older than controls (Table 1). HRM indications are shown in Table 2. Incomplete inhibition during MRS was significantly more frequent in chronic opioid users compared to patients not on opioids and healthy controls (26% vs 11% vs 0% P = 0.002; Figure 1). There was a significant difference in the rate of incomplete MRS inhibition for patients on oxycodone, hydrocodone, and tramadol (27% vs 34% vs 22% P = 0.002). The proportion of patients with augmentation post MRS was similar for opioid users, non-opioid users and healthy controls (P = 0.05). CONCLUSION: Impaired deglutitive inhibition during MRS was significantly more frequent among opioid users compared to non-opioid users and healthy controls. This was more common with stronger opioids (oxycodone and hydrocodone) compared to tramadol. These findings support our hypothesis that opioids interfere with inhibitory signals in the esophagus.

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.

417 Lack of Peristaltic Reserve as Detected by Multiple Rapid Swallows on HRM Predicts Development of Dysphagia Following Magnetic Sphincter Augmentation for GERD

INTRODUCTION: Magnetic Sphincter Augmentation (MSA) is an antireflux procedure that can be performed on patients with normal esophageal motor function. The most common side-effect of MSA is dysphagia, which occurs in 34-38% of patients and may require dilation (Lipham JC et al, 2015). Multiple rapid swallows (MRS) is a provocative maneuver during high resolution esophageal manometry (HRM) that assesses peristaltic reserve; impaired MRS has previously been shown to predict the development of dysphagia following fundoplication (Shaker A et al, 2013). We hypothesized that impaired MRS may predict which patients experience dysphagia following laparoscopic MSA. METHODS: Retrospective review of all patients who underwent MSA at a tertiary academic center from May 2015 to May 2018. All patients completed a standardized esophageal questionnaire and pre-operative HRM which included MRS. Peristaltic augmentation with MRS was defined as a ratio &gt;1 of the distal contractile integral (DCI) following MRS and the median DCI of the 10 baseline wet swallows. Demographics, MSA implant size, and symptom data from post-operative follow-up of at least 6 months was gathered on all patients. RESULTS: 29 patients (age 52 ± 17 years, 59% female, BMI 25 ± 4.2 kg/m2) were identified. Postoperatively, 15 patients developed dysphagia, 9 of them within the first 2 weeks. 5 patients required balloon dilatation for symptom relief. Among the patients that did not develop dysphagia, peristaltic augmentation with MRS was present in 42.9% compared to 6.7% of patients who developed dysphagia (P-value 0.03). 40% of the patients that required balloon dilatation exhibited complete absence of any smooth muscle contraction following MRS (DCI = 0). Having a small MSA implant (13 or 14 beads) versus a large MSA implant (15, 16 or 17 beads) trended towards an association with developing dysphagia (47% versus 29%, P-value 0.18). The DCI ratio of MRS/wet swallows that predicted development of dysphagia following MSA was 0.59. CONCLUSION: Intact peristaltic reserve, as assessed by augmented contraction following MRS, was protective of developing dysphagia following MSA. MRS should be given important consideration in the evaluation of patients under consideration for antireflux surgery specifically with regards to counseling patients on their individual risk of developing dysphagia and the potential need for additional procedures such as dilation.

393 7 Patterns of Esophageal Motility Disorders Detected by Multiple Rapid Swallows

INTRODUCTION: High resolution manometry (HRM) has improved the ability to detect esophageal motility abnormalities. In conjunction with HRM, the Chicago Classification has been widely used to classify these disorders. Provocative tests, such as multiple rapid swallows, are used as a preoperative assessment for GERD and hiatal hernia. Our study assesses the utility of MRS beyond its use as a preoperative assessment. METHODS: After completion of the standard protocol, patients perform multiple rapid swallows under the instruction and supervision of a trained RN. MRS consists of a series of rapid 2-mL swallows at 2-3 second intervals. Patient repeats MRS with the goal of 3-4 MRS. RESULTS: In this cohort, we had a total of 90 patient: 3 patients were excluded from MRS due to high suspicion of achalasia. 5 patients did not complete MRS protocol. 2 cases only tolerated 1 MRS. MRS aided in the diagnosis of 16 patients, with a diagnostic utility of 20%. We identified the following 7 patterns: 1) loss of peristaltic reserve, 2) presence of good reserve, 3) repetitive spasm pattern, 4) unmasking hypercontractility, 5) paradoxical LES contractions, 6) loss of deglutition inhibition, 7) distal esophageal pressurization. CONCLUSION: Currently, HRM studies involve a series of single swallows, which do not represent normal swallowing physiology. In contrast, MRS comprises series of wet swallows, which may better represent deglutition pathophysiology as it inhibits esophageal smooth muscles contraction and relaxes the lower esophageal sphincter (LES). Thus, MRS is hypothesized to serve as a non-invasive substitute to evaluate esophagus integrity. In our study, MRS had a high diagnostic yield in assessing peristaltic reserve, unmasking underlying hypercontractility and esophageal spasm, and confirming true outflow obstruction with pressurization pattern. Pathophysiology was also detected such as paradoxical LES contraction and loss of deglutition inhibition, which helped with diagnosing cases of achalasia variant and esophageal spasm. MRS is an effective, simple, and inexpensive technique to identify esophageal disorders. It was very well tolerated by majority of patients and did not add cost to the procedure. We recommend standardizing MRS in HRM protocol as it provides a better understanding of esophageal disorders. Stoikes, Nathaniel et al. “The value of multiple rapid swallows during preoperative esophageal manometry before laparoscopic antireflux surgery.” 2012: 3401-7.

Effects of GABA-B agonist baclofen on esophageal motility: Studies using high-resolution manometry.

Baclofen inhibits transient lower esophageal sphincter (LES) relaxation. This study aimed to investigate the effect of baclofen on esophageal peristaltic function and contraction reserve in healthy adults using high-resolution manometry (HRM). Fifteen subjects underwent HRM with ten water swallows and five multiple rapid swallows (MRS) 90minutes after oral intake of either baclofen or placebo on separate days at least 1week apart. HRM parameters assessed included esophagogastric junction contractile integral (EGJ-CI), resting LES pressure, 4-second integrated relaxation pressure (IRP-4s), distal contractile integral (DCI), distal latency, peristaltic breaks, resting upper esophageal sphincter (UES) pressure, and contractile response to MRS. Baclofen significantly increased EGJ-CI (P=.007), IRP-4s (P=.003), and LES pressure (P=.004). UES pressure, latency, and DCI were similar between baclofen and placebo (P=.87, P=.84, and P=.54, respectively). There was no difference in contractile response and peristaltic augmentation following MRS between baclofen and placebo (93% vs 100%, P=.30; 53% vs. 73%, P=.26, respectively). Baclofen increases resting LES pressure and EGJ barrier function, but has no effect on primary peristalsis or contraction reserve.

The Utility of Esophageal Motility Testing in Gastroesophageal Reflux Disease (GERD).

Here, we discuss how esophageal motor testing plays important roles in patients with suspected gastroesophageal reflux disease (GERD). In addition to guiding appropriate placement of catheters for ambulatory reflux monitoring, esophageal high-resolution manometry (HRM) rules out confounding diagnoses, such as achalasia spectrum disorders, that can present with symptoms similar to that of GERD, but are managed very differently. HRM performed with impedance in the post-prandial setting (PP-HRIM) can assess for rumination syndrome or supragastric belching, which should be directed towards behavioral interventions. The recent GERD Classification of Motor Function recommends a hierarchical approach, focusing on (1) the esophagogastric junction (EGJ), (2) the esophageal body, and (3) esophageal contraction reserve, which can be assessed with provocative maneuvers at HRM, such as multiple rapid swallows (MRS). This approach can inform the appropriate tailoring of antireflux surgery. Novel esophageal motility metrics, such as the EGJ-contractile integral from HRM, or post-reflux swallow-induced peristaltic wave indices from 24-h pH-impedance monitoring, may also assist with GERD diagnosis. Assessment of esophageal motor function can contribute in a significant manner to the care of patients with suspected GERD, particularly when esophageal symptoms do not improve with antisecretory therapy, and/or when surgical or endoscopic antireflux therapies are under consideration.

Evaluation of Esophageal Contraction Reserve Using HRM in Symptomatic Esophageal Disease.

Esophageal high resolution manometry (HRM) is the gold standard for assessment of esophageal motor disorders, but motor responses to the standard 5 mL water swallow protocol may not provide precision in defining minor motor disorders. Provocative maneuvers, particularly multiple rapid swallows (MRS), have been used to assess deglutitive inhibition during the repetitive swallows, and the contractile response following the final swallow of the sequence. The augmentation of esophageal smooth muscle contraction following MRS is termed contraction reserve. This is determined as the ratio between esophageal body contraction vigor (distal contractile integral, DCI) following MRS to the mean DCI after single swallows, which is ≥1 in the presence of contraction reserve. Reliable assessment of contraction reserve requires the performance of 3 MRS maneuvers during HRM. Absence of contraction reserve is associated with a higher likelihood of late postfundoplication dysphagia and may correlate with higher esophageal reflux burden on ambulatory reflux monitoring. Esophageal motor responses to abdominal compression, functional lumen imaging probe (FLIP) balloon distension, and pharmacologic testing (using edrophonium and cisapride) may correlate with contraction reserve. Other provocative tests useful during HRM include rapid drink challenge, solid and viscous swallows, and standardized test meals, which are more useful in evaluation of esophageal outflow obstruction and dysphagia syndromes than in identification of contraction reserve. Provocative maneuvers have been recommended as part of routine HRM protocols, and while useful clinical information can be gleaned from these maneuvers, further research is necessary to determine the precise role of provocative testing in clinical esophagology.

Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium.

Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450mm Hgcms) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure<upper limit of normal) on esophageal high-resolution manometry (HRM). Ineffective esophageal motility is not consistently related to disease states or symptoms and may be seen in asymptomatic healthy individuals. A 1-day symposium of esophageal experts reviewed existing literature on IEM, and this review represents the conclusions from the symposium. Severe IEM (>70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.

Multiple Rapid Swallows (MRS) Complements Single-Swallow (SS) Analysis for High-Resolution Esophageal Manometry (HREM)

Multiple rapid swallows (MRS) during HREM assess post-deglutitive inhibition, LES relaxation, and subsequent esophageal contraction. (1) To determine the relationship between MRS and single-swallow (SS) responses and (2) to determine if MRS provides information for symptomatic patients. Healthy volunteers (HVs) and patients underwent HREM [30-s landmark, ten 5-mL SS, MRS (5 consecutive 2-mL swallows every 2-3s)] and were analyzed with ManoView software version 3 with CC version 3.0. In 20 HVs, MRS response consisted of: (1) reduction in GEJ pressure; (2) absence of esophageal contractile activity during MRS; and (3) post-MRS peristaltic contraction greater than SS contractions. In 20 HVs and 403 patients, MRS IRP correlated with SS IRP (r = 0.65; p < 0.0001) and post-MRS contraction DCI correlated with SS DCI (r = 0.76; p < 0.0001). Abnormally elevated MRS IRP was seen in 68% type 2 achalasia, 50% type 3 achalasia, 47% EGJOO, and 9% jackhammer. Increased MRS DCI was seen in 53% type 2 achalasia, 92% type 3 achalasia, 10% EGJOO, 22% jackhammer, and 18% DES. Increased DCI post-MRS was seen in 38% patients with jackhammer, 8% type 3 achalasia, 12% EGJOO, and 9% DES. 14 out of 143 (10%) patients with normal or indeterminate results on SS analysis had at least one abnormality on MRS. MRS IRP correlated with SS IRP, and post-MRS DCI correlated with SS DCI. Patients with defined CC disorders have abnormalities on MRS. There were MRS abnormalities in some patients with normal SS studies, most notably suggesting impaired LES relaxation and/or spastic esophageal motility. MRS may complement the baseline SS study analysis.