Non-obstructive Dysphagia Research Articles

Impact of nadir lower oesophageal sphincter pressure on bolus clearance assessed by combined manometry and multi‐channel intra‐luminal impedance measurement

This study aimed to assess the relationship between nadir lower oesophageal sphincter pressure (LOSP) and wave amplitude (WA) in oesophageal bolus clearance. Concurrent oesophageal manometry and impedance were performed in 146 subjects [41 healthy, 24 non-obstructive dysphagia (NOD) and 81 gastro-oesophageal reflux (GOR)]. Patients with achalasia and diffuse oesophageal spasm were excluded. Swallow responses were categorized by nadir LOSP. For each category of nadir LOSP, WA at the distal 2 recording sites were grouped into bins of 10 mmHg and the proportion of waves in each bin associated with a normal bolus presence time (BPT) was determined. Nadir LOSP, distal BPT, total bolus transit time and the proportion of impaired oesophageal clearance in patients with NOD were greater than those of healthy subjects and patients with GOR. Overall, responses with impaired oesophageal clearance had significantly lower WA (54 +/- 1 vs 81 +/- 1 mmHg; P < 0.0001) and higher nadir LOSP (2.7 +/- 0.4 vs 1.0 +/- 0.1 mmHg, P < 0.001). For each level of nadir LOSP, there was a direct relationship between distal WA and successful bolus clearance of both liquid and viscous boluses from the distal oesophagus. As nadir LOSP increased, the relationship between WA and bolus clearance shifted to the right and higher amplitudes were required to achieve the same effectiveness of clearance. Hypotensive responses with nadir LOSP > or = 3 mmHg were less likely to clear than those with nadir LOSP < 3 mmHg, for both liquid (7/29 vs 162/276; P < 0.001) or viscous boluses (11/46 vs 176/279; P < 0.0001). Nadir LOSP is an important determinant of bolus clearance from the distal oesophagus, particularly in patients with NOD.

Routine Screening for Eosinophilic Esophagitis in Patients Presenting with Dysphagia

Purpose: To identify the prevalence of pathologic eosinophilic esophagitis (EoE) in a cohort of adult patients who present for specialty care in the gastroenterology clinic with the complaint of esophageal dysphagia. Methods: A prospective, unblinded multicenter study with a total of 111 patients (60 males and 51 females) with a chief complaint of dysphagia and age >18 were enrolled. Exclusion criteria included patients <18 years of age, pregnancy, patients who demonstrated a clear obstructive etiology, or patients utilizing inhaled or systemic corticosteroids. If no obstructive etiology could be found at the time of endoscopy, patients underwent systematic biopsy of the duodenum, stomach and esophagus. A total of 20 biopsies (4 from the duodenum, 4 from the stomach, 4 from the distal esophagus, 4 from the mid esophagus and 4 from the proximal esophagus) were taken. The biopsies of the stomach and duodenum were utilized to exclude the diagnosis of eosinophilic gastroenteritis, which is a completely separate entity than EoE. A single pathologist was utilized in processing of the tissue samples, with an eosinophil count of >15 per high power field being considered positive for EoE. Results: Of 111 patients, 80 patients (72%) were found to have non-obstructive dysphagia, 20 patients (18%) were found to have obstructive dysphagia, and 11 patients (10%) withdrew their consent or did not show for their procedure. Patients who withdrew consent or did not show for their procedure were counted as having obstructive dysphagia and were excluded from primary analysis. Of those patients with non-obstructive dysphagia, 17 patients (21.25% 95%CI: 12.21%-30.21%) were found to have histologic characteristics of EoE. In the same group, 31% of males vs. 10.5% of females had histologic characteristics of EoE (p-value 0.024). 25% of Caucasians with non-obstructive dysphagia vs. 6.2% of non-Caucasians had histologic evidence of EoE (p-value 0.091). The mean age of patients with non-obstructive dysphagia presenting with histologic evidence of EoE was 34.3. Conclusion: Patients with non-obstructive dysphagia have a greater than 1 in 5 chance of having histologic evidence of EoE on esophageal biopsy. Therefore, all adult patients undergoing upper endoscopy for the complaint of dysphagia should have esophageal biopsies obtained if no mechanical cause for their dysphagia is readily apparent.

The Impact of Age on Esophageal Function and Quality of Life in Patients with Non-Obstructive Dysphagia

The Impact of Age on Esophageal Function and Quality of Life in Patients with Non-Obstructive Dysphagia

Concordance Between Liquid and Viscous Esophageal Manometry and Impedance in Patients with Non-obstructive Esophageal Dysphagia

Purpose: Esophageal manometry is the traditional method for evaluating non-obstructive dysphagia, but only measures peristaltic sequence. Impedance allows for measurement of bolus movement, and when combined with manometry offers additional information in these patients. We have performed combined manometry/impedance in all patients with non-obstructive dysphagia using both liquid and viscous media since 2006. The first 58 patients in which this approach was used were analyzed for concordance in diagnosis for liquid and viscous media. Methods: We reviewed all charts of patients between 2006 and 2008, and we examined the manometric and impedance findings of 58 consecutive patients with esophageal dysphagia as their primary symptom. We excluded patients with classic achalasia, since they did not receive viscous media during routine testing in our laboratory. Liquid and viscous manometry and impedance were compared separately and then in combination. Esophageal contractions and motility disorders were classified using previously published criteria. Concordance was defined as agreement between liquid and viscous findings. Results: 72% of patients were female. The patients had a variety of diagnostic findings based on manometry/impedance: 40% normal, 33% Ineffective Esophageal Motility, and 24% Distal Esophageal Spasm, 3% Nutcracker. Concordance of manometry between liquid and viscous findings was 67%. Concordance of impedance between liquid and viscous results was 67%. Overall, combined manometry and impedance showed 50% concordance between liquid and viscous findings. Conclusion: Our data reveal less than optimal concordance between liquid and viscous manometry and impedance. The clinical importance of these findings will require prospective study to more fully assess their significance.

W1864 Esophageal Bolus Retention During Saline and Viscous Swallows in Healthy Volunteers and Patients with Non-Obstructive Dysphagia (NOD)

W1864 Esophageal Bolus Retention During Saline and Viscous Swallows in Healthy Volunteers and Patients with Non-Obstructive Dysphagia (NOD)

Achalasia and Nonachalasia Esophageal Motility Disorders

Dysphagia and chest pain often occur in adults, and most patients with persistent symptoms initially undergo evaluation to rule out reflux esophagitis, esophageal cancer, and cardiovascular disease. When the findings of these evaluations are normal, esophageal manometry is performed. Esophageal motility disorders, which include achalasia, diffuse esophageal spasm, nutcracker esophagus, hypertensive lower esophageal sphincter, and nonspecific esophageal motility disorder, are often identified in these patients. In our series, 78% of patients with nonobstructive dysphagia or unexplained (noncardiac) chest pain or both have an esophageal motility disorder (achalasia, 44%; diffuse esophageal spasm, 5%; nutcracker esophagus, 2%; and nonspecific esophageal motility disorder, 27%). Therefore, in patients who present with dysphagia or chest pain or both, an esophageal motility disorder should be suspected.

Review article: intra‐oesophageal impedance monitoring for the assessment of bolus transit and gastro‐oesophageal reflux

Intra-oesophageal impedance monitoring can be used to assess the clearance of a swallowed bolus (oesophageal transit) and to detect gastro-oesophageal reflux independent of its acidity. To discuss the clinical application of the impedance technique for the assessment of bolus transit and gastro-oesophageal reflux. Review of the literature on intra-oesophageal impedance monitoring of bolus transit and gastro-oesophageal reflux. Using impedance criteria, normal oesophageal bolus clearance can be defined as complete clearance of at least 80% of liquid boluses and at least 70% of viscous boluses. Impedance recording identifies oesophageal function abnormalities in non-obstructive dysphagia patients and in patients with postfundoplication dysphagia. The impedance technique seems to be less suitable for the most severe end of the dysphagia spectrum like achalasia. Intra-oesophageal impedance monitoring detects reflux events independent of the pH of the refluxate, which allows identification of non-acid reflux episodes. In addition, use of impedance monitoring enables assessment of the composition (liquid, gas, mixed) and proximal extent of the refluxate. Combined impedance-pH monitoring is more accurate than pH alone for the detection of both acid and weakly acidic reflux. Furthermore, addition of impedance monitoring to pH increases the yield of symptom association analysis both in patients off and on proton pump inhibitor therapy. Intra-oesophageal impedance monitoring is a feasible technique for the assessment of bolus transit and gastro-oesophageal reflux. Combined impedance-manometry provides clinically important information about oesophageal function abnormalities and combined impedance-pH monitoring identifies the relationship between symptoms and all types of reflux events regarding acidity and composition.

Identification of impaired oesophageal bolus transit and clearance by secondary peristalsis in patients with non‐obstructive dysphagia

Impaired secondary peristalsis has been shown in non-obstructive dysphagia (NOD). The relationship between such changes and alterations in bolus transport has not been studied. The aim of this study was to evaluate the integrity and characteristics of oesophageal bolus transit by secondary peristalsis in NOD patients with multichannel intraluminal impedance (MII). Eleven healthy volunteers and 10 consecutive patients underwent combined MII recording and manometry. Secondary peristalsis was stimulated by mid-oesophageal injections of saline. Values for bolus presence time at each of the recording sites and bolus transit time were calculated. Bolus transit was considered to be complete when impedance defined complete bolus clearance at all recording sites. Secondary peristaltic responses were triggered significantly less frequently in patients with NOD than in controls (P < 0.001). The proportion of secondary peristalsis demonstrating complete bolus transit was lower in NOD patients than in controls (P < 0.001). Oesophageal bolus transit time by secondary peristalsis was longer in NOD patients than in controls (P = 0.005), as was bolus presence time at each of the recording sites (P < 0.05). When compared with controls, NOD patients demonstrated a higher proportion of incomplete bolus transit in response to normal secondary peristalsis (P < 0.001). Abnormal bolus transit occurred more often associated with ineffective and synchronous responses than normal responses in both groups studied (P < 0.001). Multichannel intraluminal impedance identifies functional defects of oesophageal bolus clearance by secondary peristalsis in NOD patients and such defects are characterized by a longer oesophageal dwell and a prolonged clearance time.

W1898 Interobserver Agreement for Impedance Manometry Findings in Patients with Non-Obstructive Dysphagia

Introduction: Impedance manometry (MII-EM) allows a more comprehensive evaluation of esophageal function by concomitantly measuring pressure changes and bolus transit. Still, there is limited information on the reliability and inter-observer agreement on MII-EM findings in patients with non-obstructive dysphagia. Aim: To evaluate the inter-observer agreement for impedance manometry readings in patients with non-obstructive dysphagia during liquid and solid swallows. Methods: Patient referred for evaluation of dysphagia underwent stationary MII-EM using a solid state catheter with 5 pressure channels and 5 impedance segments. Pressure changes were measured in the esophageal body 5, 10, 15 and 20cm above the lower esophageal sphincter (LES) and bolus presence data 2, 5, 10, 15 and 20 cm above the LES. Each subject received 10 saline and 10 yoghurt swallows in recumbent position. Tracings were reviewed independently by 4 investigators. Bolus presence time (BTT), distal esophageal amplitude (DEA) and lower esophageal sphincter residual pressure (LESRP) were quantified. Overall manometric and bolus transit abnormalities were based on previously established criteria (Am J Gastroenterol. 2004;99:1011). Results: From 20 patients (12 f, mean age 50, range 21-69 years) 15 (75%) had normal manometry, 2 IEM, 2 nutcracker esophagus and 1 poorly relaxing LES. 80% of patients had normal bolus transit. We found an excellent correlation between the readings of all 4 raters for DEA (intraclass correlation coefficient (ICC) 0.999), BTT (ICC 0.991) and LESRP (ICC 0.979). There was a very good interobserver agreement for both manometric and impedance findings with kappa values ranging from 0.77 to 0.99 (Table 1) Conclusion: The good inter-observer agreement for bothmanometric and bolus transit findings supports the reliability of combined impedance-manometry in clinical practice. Table 1: Kappa statistics for manometry and impedance findings

Impedance technology for the management of esophageal disorders

BACKGROUND: Esophageal impedance measurements are increasingly used to identify and quantify the presence of fluids in the esophagus. METHOD: A review of the available literature on clinical applications of impedance including combined impedance-manometry testing and combined impedance-pH monitoring is done. RESULTS: Combined impedance-manometry testing offers the opportunity to quantify esophageal bolus transit and clarifies the implications of esophageal motility abnormalities on esophageal function. This is of particular interest in patients with non-obstructive dysphagia and in patients with post-fundoplication dysphagia. Combined impedance-pH monitoring allows the detection of gastroesophageal reflux episodes independent of pH. This is of particular importance when evaluating patients with persistent symptoms on acid suppressive therapy. The ability to detect gastroesophageal reflux episodes with pH > 4 unfolds new questions on the optimal approach to patients with symptomatic non-acid reflux. CONCLUSIONS: Impedance technology allows the detection of fluid movements in the esophagus; further studies will determine the clinical utility of this new information.

W1793 Identification of Impaired Bolus Transit and Clearance By Secondary Peristalsis in Patients with Non-Obstructive Dysphagia

W1793 Identification of Impaired Bolus Transit and Clearance By Secondary Peristalsis in Patients with Non-Obstructive Dysphagia

Clinical correlates of dysphagia to oesophageal dysmotility: studies using combined manometry and impedance

This study aimed to elucidate the mechanism of dysphagia by determining the simultaneous relationships between subjective perception of swallow with oesophageal motility and bolus transport in patients with non-obstructive dysphagia (NOD). Combined oesophageal manometry and impedance was performed in 18 consecutive NOD patients and 14 healthy controls. Swallow was abnormal if the amplitude of distal oesophageal contractions was less than 30 mmHg or simultaneous contractions occurred. Bolus transit was abnormal if bolus exit was not found at one or more of the measuring sites. Perception of each swallow was assessed using a standardized scoring system and was enhanced if score was >1. The prevalence of complete bolus transit was lower in NOD patients compared with healthy controls (P = 0.001). Abnormal liquid bolus transit was found in 40% of patients with normal motility and 38% of patients with abnormal motility, whereas abnormal viscous bolus transit was observed in 38% of patients with normal motility and 70% of patients with abnormal motility. Agreement between enhanced perception and impedance was poor during liquid (kappa = 0.12, 95% CI: -0.003 to 0.233) and viscous swallowing (kappa = 0.12, 95% CI: -0.004 to 0.244). Agreement between enhanced perception and manometry was even poorer during liquid (kappa = -0.16, 95% CI: -0.302 to 0.022) and viscous swallowing (kappa = -0.12, 95% CI: -0.25 to 0.002). NOD patients show poor correlation between dysphagia and oesophageal motility parameters. The results suggest that, in patients with NOD, oesophageal motor dysfunction may play a limited role, if any, in the generation of dysphagia.

Empiric Dilation in Non-obstructive Dysphagia

To study practice patterns in the management of non-obstructive dysphagia among U.S. gastroenterologists. Endoscopic data repository from 100 U.S. gastroenterology practices during 1998-2003 (Clinical Outcomes Research Initiative, CORI). All initial esophago-gastro-duodenoscopies (EGDs) performed in adult patients between 1998 and 2003 (n = 181,261) were evaluated for demographic data, endoscopic findings, and the occurrence of esophageal dilation. A case population of 7,256 patients receiving empiric dilation for dysphagia for non-obstructive dysphagia was compared to a control population of 5764 patients with dilation for peptic strictures. The group of patients with empiric dilation was younger than the group of patients with peptic strictures and contained more women. Reflux symptoms and erosive esophagitis were less frequent in the empiric dilation group than in the strictures group. Empiric dilations were mostly performed using rubber bougies, whereas strictures were most frequently dilated over a guidewire. For all types of dilators, the diameters were significantly larger in empiric than stricture dilation. Repeat dilations within 1 year after the initial procedure occurred in 4% of the empiric and 13% of the stricture dilations. Compared with the dilation of peptic strictures, empiric dilation of non-obstructive dysphagia is a more common clinical practice that is performed in a different patient population and utilizes different techniques.

Critical Evaluation of Esophageal Dilation in Nonobstructive Dysphagia With and Without Esophageal Rings

To evaluate the therapeutic efficacy of esophageal dilation compared with medical treatment in patients with nonobstructive dysphagia (NOD). Clinical studies evaluating the role of esophageal dilation in patients with NOD have reported conflicting results. In addition, studies suggesting beneficial effects of esophageal dilation in this group of patients have not compared it with medical treatment. We conducted a retrospective study in 107 patients with NOD and divided these patients into 2 groups. Group 1 included patients who received esophageal dilation with a polyvinyl bougie along with adjunctive medical treatment, and group 2 included patients who received medical treatment alone. Complete resolution of symptoms occurred in 41 of the 60 patients (68.3%) who received esophageal dilation. In the group that received medical treatment alone (n=47), 28 patients (59.5%) had complete resolution of symptoms. There was no statistically significant difference in symptom resolution between the 2 groups. In addition, among 22 patients with esophageal rings, 17 patients (77%) had complete symptomatic relief with dilation, as compared with 63% patients without esophageal rings. Although there was a trend towards higher frequency of dysphagia resolution with esophageal dilation in patients with NOD and esophageal rings, the difference failed to reach statistical significance. Esophageal dilation and medical therapy are equally efficacious (60% to 70% of cases) in resolving symptoms of dysphagia in patients with NOD. Patients with NOD and esophageal rings may represent the subgroup of patients who are more likely to benefit from esophageal dilation.

Technology Review: Esophageal Impedance Monitoring

Intraluminal impedance monitoring is a new technique that can be used to detect the flow of liquids and gas through hollow viscera. In combination with manometry, it is used for esophageal function testing and while manometry provides information on contractile activity, impedance provides information on esophageal bolus transit. This is especially useful in patients with nonobstructive dysphagia. However, impedance monitoring appears to be less suitable for the evaluation of patients with achalasia. When used in combination with esophageal pH monitoring, impedance monitoring makes gastroesophageal reflux monitoring more complete because it allows recognition of both acidic and weakly acidic reflux episodes. The results of several studies suggest that impedance-pH monitoring is useful in the evaluation of patients with PPI-resistant typical reflux symptoms, chronic unexplained cough, excessive belching, and rumination.

Topographical Mapping of Esophageal Motor Function during Liquid and Solid Swallows Using High-Resolution, Solid-State Manometry in Patients with Non-Obstructive Dysphagia (NOD)

Topographical Mapping of Esophageal Motor Function during Liquid and Solid Swallows Using High-Resolution, Solid-State Manometry in Patients with Non-Obstructive Dysphagia (NOD)

Multichannel Intraluminal Impedance Monitoring in the Evaluation of Patients with Non-Obstructive Dysphagia

Non-obstructive dysphagia (NOD) often poses diagnostic problems. The aim of this study was to evaluate the value of the addition of multichannel intraluminal impedance (MII) recording to esophageal manometry in the work-up of patients with NOD. A total of 40 consecutive patients with NOD underwent combined esophageal MII recording and perfusion manometry. Ten liquid and 10 viscous boluses were tested in each patient. Values for bolus presence time (BPT) at each of the four recording sites and total bolus transit time (TBTT) were calculated. Bolus transit (BT) was considered to be normal when BPT at all sites and TBTT were within the normal limits defined in 42 healthy subjects. Patients were judged to have normal transit if >or=80% of liquid and >or=70% of viscous swallows showed normal transit. The following manometric diagnoses were made: normal motility (20), ineffective esophageal motility (IEM) (13), diffuse esophageal spasm (DES) (4), and achalasia (3). Abnormal transit for liquid and/or viscous boluses was found in 35.3% of patients with normal motility, in 66.7% of DES patients, and in 100% of achalasia patients. In patients with achalasia quantification of BT was often made impossible by low initial impedance baseline. Two IEM patients (15.4%) showed normal liquid and viscous transit. Swallows showing normal transit had significantly longer duration of LES relaxation in patients with normal manometry and IEM (p < 0.05). MII recording identifies esophageal function abnormalities in NOD patients with normal manometry, IEM, and DES. The MII technique seems to be less suitable for the most severe end of the dysphagia spectrum like achalasia.

Comparison of Esophageal Motility in Patients with Solid Dysphagia and Mixed Dysphagia

It is unclear whether there is any difference in esophageal motor abnormalities between patients complaining of dysphagia for solids or both solids and liquids. The aim of this study was to determine any difference in the manometric findings between patients with dysphagia for solids and those with mixed dysphagia. Manometric tracings were performed in 200 consecutive patients (66 M, 134 F; mean age = 51 years) with nonobstructive dysphagia. Ambulatory pH studies were performed in all patients. Subjects were divided into two groups: patients with solid dysphagia (n = 94, 33 M, 61 F; mean age = 51 years) and those with mixed dysphagia (n = 106, 33 M, 73 F; mean age = 51 years). A normal motility study was the most frequent finding. Achalasia occurred more frequently in patients with mixed dysphagia than in those with solid dysphagia (12% vs. 3%, p < 0.01). Gastroesophageal reflux disease (GERD) was observed in 59% of patients with solid dysphagia compared with 29% of patients with mixed dysphagia (p < 0.02). The most common esophageal motility abnormality is nonspecific esophageal motility disorders. This study has shown that abnormal esophageal motility occurs slightly more in mixed dysphagia than solid dysphagia. The clinical utility of a symptomatic differentiation of patients with solid or mixed dysphagia appears to be limited.

Esophageal Function Testing: Role of Combined Multichannel Intraluminal Impedance and Manometry

Combined multichannel intraluminal impedance and manometry (MII-EM) is a relatively new technique that allows simultaneous measurement of intraesophageal pressures and bolus transit. Combined MII-EM has the ability to identify what percentage of manometric normal/peristaltic, ineffective, and simultaneous swallows have complete or incomplete bolus transit. Predictors of normal bolus transit in patients with ineffective esophageal motility are the distal esophageal amplitude, the number of sites with low amplitudes, and the overall number of manometric ineffective contractions. Outcome studies are necessary to evaluate whether combined MII-EM is superior to traditional manometry in evaluating patients with nonobstructive dysphagia and in identifying patients at risk for developing dysphagia after antireflux surgery.

Esophageal Function Testing

During the past 25 years, there has been an evolution in our ability to evaluate esophageal function and to perform shortand long-term monitoring of the patient with symptoms suspected to be due to gastroesophageal reflux disease (GERD). The growing use of laparoscopic antireflux surgery and now endoscopic antireflux therapy mandates a careful evaluation of patients preparing for these procedures. Patients with atypical chest pain, nonobstructive dysphagia, and other extraesophageal symptoms of gastroesophageal reflux disease present a clinical and diagnostic dilemma. Improvements in the methodology of esophageal function testing now allow us to measure intraluminal pressure and coordination of pressure activity of the muscles of the esophagus accurately and provide qualitative and quantitative assessment of these esophageal pressures and their coordination and motility. The availability of multichannel intraluminal impedance testing allows us to measure changes in resistance to alternating current between two electrodes and to evaluate bolus movement with liquid and viscous material in the antegrade and retrograde directions. Ambulatory pH monitoring can be accomplished with singleor multiplechannel intraluminal electrodes to assess intragastric, intraesophageal, and pharyngeal pH and has become the backbone of our understanding of GERD and the antisecretory capability of proton pump inhibitors. The addition of wireless pH monitoring (Bravo capsule) has added to our armamentarium, and the development of combined multichannel intraluminal impedance and pH Gastrointest Endoscopy Clin N Am