Normal High-resolution Manometry Research Articles

Dysphagia associated with esophageal wall thickening in patients with nonspecific high-resolution manometry findings: Understanding motility beyond the Chicago classification version 4.0.

Previous studies have demonstrated that 50% of patients with normal high-resolution manometry (HRM) findings or ineffective esophageal motility (IEM) may have abnormal functional luminal imaging probe (FLIP) results. However, the specific HRM findings associated with abnormal FLIP results are unknown. Herein, we investigated the relationship between nonspecific manometry findings and abnormal FLIP results. We retrospectively analyzed 684 patients who underwent HRM at a tertiary care center in Seoul, Korea, based on the Chicago Classification version 4.0 protocol. Among the 684 patients, 398 had normal HRM findings or IEM. Of these 398 patients, eight showed esophageal wall thickening on endoscopic ultrasonography or computed tomography; however, no abnormalities were seen during esophagogastroduodenoscopy. Among these eight patients, seven showed repetitive simultaneous contractions (RSCs) in at least one of the two positions: 61% (±29%) in 10 swallows in the supine position and 51% (±30%) in five swallows in the upright position. Four patients who underwent FLIP had a significantly decreased esophagogastric junction distensibility index (1.0 ± 0.5 at 60 mL). Two of these patients underwent per-oral endoscopic myotomy (POEM) due to a lack of response to medication. Esophageal muscle biopsy revealed hypertrophic muscle with marginal eosinophil infiltration. A subset of patients (2%) with normal HRM findings or IEM and RSCs experienced dysphagia associated with poor distensibility of the thickened esophageal wall. FLIP assessment or combined HRM and impedance protocols may help better define these patients who may respond well to POEM.

Contraction reserve in high resolution manometry is correlated with lower esophageal acid exposure time in patients with normal esophageal motility: A retrospective observational study.

In high resolution manometry (HRM), distal contractile integral post multiple rapid swallow augmentation is considered as contraction reserve. The relationship between contraction reserve and esophageal acid reflux remains unclear. The aim of this study was to explore the correlation between contraction reserve and esophageal acid exposure in ineffective esophageal motility (IEM) and normal HRM. Patients who underwent HRM and ambulatory reflux monitoring were retrospectively screened. Those with diagnosis of normal HRM or IEM were included in the analysis. The proportion of patients with abnormal acid exposure time (AET) was compared between patients with and without contraction reserve. Multivariate regression analysis was performed to determine the predictors of abnormal AET and contraction reserve. A total of 338 patients, including 264 normal HRM and 74 IEM, were included in the analysis. In patients with normal HRM, proportion of abnormal total AET (AET > 6.0%) was significantly lower in patients with supine contraction reserve than patients without contraction reserve (13.85% vs. 24.63%, p = 0.027). Multivariate regression analysis showed that supine contraction reserve could independently predict abnormal total AET (OR = 0.468, 95% CI: 0.249-0.948, p = 0.034), while upright contraction reserve trended strongly (OR = 0.558, 95% CI: 0.290-1.071, p = 0.079). Subgroup analysis showed that upright contraction reserve was an independent predictor of abnormal total AET in patients with 50-70% infective swallows (OR = 0.205, 95% CI: 0.051-0.821, p = 0.025), whereas supine contraction reserve did not have predictive value (p = 0.359). Supine contraction reserve correlates with esophageal acid reflux in patients with normal HRM, while only upright contraction reserve correlates with esophageal acid reflux in patients with infective swallows of 50-70%.

Endoscopic impedance planimetry versus high-resolution manometry (HRM) for pre-operative motility evaluation in anti-reflux surgery.

Pre-operative evaluation of patients with gastroesophageal reflux disease (GERD) includes assessment of esophageal motility. High-resolution manometry (HRM) is the gold standard; endoscopic impedance planimetry (IP) with Endoflip 2.0 is increasingly utilized in esophageal disorders of motility. We hypothesized that normal IP motility would correlate with normal HRM motility and tested this in a prospective cohort study. Patients presenting for surgical evaluation of GERD between 9/2020 and 10/2021 were prospectively enrolled under an IRB-approved protocol. Patients with prior esophageal/gastric surgery, known motility disorders, or large paraesophageal hernias were excluded. All underwent HRM and IP, with normal motility defined by Chicago 3.0 classification for HRM and the presence of repetitive antegrade contractions for IP. Logistic regression and t test were used to analyze the data; p value < 0.05 was considered significant. Of 63 patients enrolled, 48 completed both IP and HRM testing. The cohort was 50% male with a median age of 52.5 [42.0, 66.0] years, mostly ASA class 1-2 (75.1%, n = 36) and had an average BMI of 31.4 ± 6.3kg/m2. Normal motility tracings were in 62.5% of IP and 75% of HRM tests. Using HRM as the gold standard, IP detected normal motility with a sensitivity of 65.8% and a specificity of 50% (positive predictive value 83.3%, negative predictive value 27.8%). Normal IP was not statistically significant in predicting normal HRM (OR 3.182, 95% CI 0.826-12.262, p = 0.0926). Tolerability of IP was significantly better than HRM with lower rates of discomfort (10.9% vs. 93.4%, p < 0.0001) and higher willingness to repeat testing (100% vs. 47.8%, p < 0.0001). Esophageal motility testing with Endoflip 2.0 is well tolerated by patients. The low specificity (50%), poor negative predictive value (27.8%), and lack of statistically significant concordance between IP and HRM raises concern for the reliability of this test as a stand-alone replacement for HRM in the pre-operative evaluation for GERD.

S592 Discrepancy in Esophageal Dysphagia Severity in Patients With Normal High-Resolution Manometry at a Safety Net vs Tertiary Hospital

S592 Discrepancy in Esophageal Dysphagia Severity in Patients With Normal High-Resolution Manometry at a Safety Net vs Tertiary Hospital

Dysphagia Worsens With Increasing Ineffective Swallows Among Patients With Ineffective Esophageal Motility.

Ineffective esophageal motility (IEM) is the most common motility disorder identified on esophageal high-resolution manometry (HRM), but patients with this finding may be asymptomatic. Therefore, we aimed to identify specific HRM findings predictive of symptoms in IEM. Adult patients (≥18y) who underwent HRM between March 2016 and July 2019 were retrospectively evaluated and reclassified according to Chicago Classification 4.0 (CC4.0). Demographic information, HRM parameters, and gastroesophageal reflux disease Health-Related Quality of Life Questionnaire responses were captured among those with normal manometry or IEM. We evaluated the association between heartburn, regurgitation, and dysphagia, with respect to HRM findings including ineffective swallows. Of 379 patients, 243 (64.1%) had a normal manometry, 136 (35.9%) were on IEM spectrum, and 73 (19.3%) had conclusive IEM by CC4.0. Mean dysphagia scores were significantly higher in those with conclusive IEM compared with those with normal HRM (2.00 vs. 1.36, P=0.002), as was the percentage of individuals reporting dysphagia affecting daily activities (21.9% vs. 11.4%, P=0.02). Heartburn and regurgitation symptoms did not differ between groups. In a multivariable model of IEM patients, the percentage of ineffective swallows independently predicted a higher dysphagia burden (β regression coefficient: 0.032, P=0.04). Applying the CC4.0 definition for conclusive IEM identifies a group of patients with worse dysphagia symptoms. Within this group, the percentage of ineffective swallows was an independent predictor of dysphagia severity. These findings may help practitioners and patients contextualize the heterogeneous diagnosis of IEM.

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.

High-Resolution Esophageal Manometric Features in Eosinophilic Esophagitis Patients: A Retrospective Study

<h3>Background and Aims</h3> Eosinophilic esophagitis (EoE) is an immune-mediated esophageal disease characterized by symptoms related to esophageal dysfunction and eosinophil-predominant inflammation. The aims of our study included (1) to assess esophageal motility patterns of EoE by topographic analysis of high-resolution manometry (HRM) and (2) to establish a relationship between symptoms of EoE and motility abnormalities seen on HRM. <h3>Methods</h3> A retrospective study in which all adult patients over 18 years of age with EoE diagnosed by endoscopy and histology and who underwent HRM were included in the study during the study period. Motility patterns in patients with EoE under HRM were analyzed. Data were presented as frequencies and percentages with inference by Pearson's chi-square test or Fisher's exact test. <h3>Results</h3> Seven hundred patients diagnosed with EoE were noted, and of these, 38 patients had undergone esophageal HRM. Fifty-eight percent of these patients were noted to have an esophageal motility abnormality on HRM. Thirty-seven percent of the patients showed absent peristalsis with pan-esophageal pressurization but normal integrate relaxation pressure; 21% of the patients showed peristaltic dysfunction; and 42% of the patients had a normal HRM. Seventy-one percent of the patients with pan-esophageal pressurization presented with food impaction requiring endoscopy for disimpaction and esophageal dilation (<i>P</i> = .015). <h3>Conclusion</h3> The most common abnormality noted was aperistalsis with pan-esophageal pressurization. This abnormality correlated with the clinical presentation of bolus impaction requiring an endoscopic intervention (<i>P</i> = .015).

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.

Physiological and pathological roles of the accommodation response in lower esophageal sphincter relaxation during wet swallows

The preparatory accommodation response of lower esophageal sphincter (LES) before swallowing is one of the mechanisms involved in LES relaxation during wet swallows, however, the physiological and/or pathological roles of LES accommodation remain to be determined in humans. To address this problem, we conducted a prospective observational study of 38 patients with normal high-resolution manometry (HRM) and 23 patients with idiopathic esophagogastric junction outflow obstruction (EGJOO) to assess dry and wet swallows. The LES accommodation measurement was proposed for practical use in evaluating the LES accommodation response. Although swallow-induced LES relaxation was observed in both dry and wet swallows, LES accommodation (6.4, 3.1–11.1 mmHg) was only observed in wet swallows. The extent of LES accommodation was impaired in idiopathic EGJOO (0.6, − 0.6–6 mmHg), and the LES accommodation measurement of patients with idiopathic EGJOO (36.8, 29.5–44.3 mmHg) was significantly higher in comparison to those with normal HRM (23.8, 18–28.6 mmHg). Successful LES relaxation in wet swallowing can be achieved by LES accommodation in combination with swallow-induced LES relaxation. Impaired LES accommodation is characteristic of idiopathic EGJOO. In addition to the IRP value, the LES accommodation measurement may be useful for evaluating the LES relaxation function in clinical practice.

S0452 Impact of EndoFLIP in an Esophageal Clinical Practice

INTRODUCTION: High resolution manometry (HRM) with Chicago Classification (CC) interpretation is the gold standard for defining esophageal motility disorders. However, HRM may reveal abnormalities that do not meet CC criteria, or may be normal in patients with esophageal symptoms. Also, EGJ outflow obstruction (EGJOO) comprises a heterogeneous group of disorders that may require disparate treatments. We have utilized EndoFLIP for suspected dysmotility, and have reviewed our experience to explore the impact of EndoFLIP on management. METHODS: We reviewed medical records for patients in our Center for Esophageal Disease with EndoFLIP performed November 2018-March 2020. We recorded EGJ diameter (D) and distensibility index (DI) at the 60 mL volume, and topography contraction patterns [repetitive antegrade (RACs), repetitive retrograde, disorganized diminished, hypercontractile, and sustained esophageal contractions (SECs), or absent contractility] at the 40 and 60 mL volumes. We also recorded CC diagnosis, symptoms [Eckardt score and Brief Esophageal Dysphagia Questionnaire (BEDQ)], working diagnosis, and EndoFLIP-guided change of therapy (botulinum injection, pneumatic dilation, or myotomy). RESULTS: We performed EndoFLIP on 249 patients with esophageal symptoms who had HRM and no prior foregut surgery. Table 1 shows D, DI, symptom scores, and EndoFLIP impact on diagnosis and therapy. Endoflip confirmed the diagnosis in all patients with achalasia by HRM and did not alter management. Among 97 patients with EGJOO, 50/97 (52%) of EGJOO patients had low DI (mean 1.3) with abnormal patterns on FLIP in all cases and were considered to have a primary EGJOO dysmotility disorder. These cases were also less likely to have any RACs compared to those with normal DI (12% v 32%, P < 0.05). In 2 (18%) of 11 patients with absent contractility and IRP <15 mmHg, a low DI on Endoflip suggested a diagnosis of achalasia. Among 49 patients with ineffective esophageal motility (IEM), 12 (24%) had low DI (mean 1.4) and 6 (12%) had SECs. In 37 patients with a normal HRM, 9 (24%) had SECs. CONCLUTION: We found EndoFLIP especially useful in evaluation of patients with EGJOO, IEM and absent contractility in whom it supported dysmotility on the achalasia spectrum in 52%, 24%, and 18% of patients respectively. Overall, we found Endoflip guided escalation of therapy in 9% of patients. The clinical implications of the FLIP topography in these cases requires further investigation.Table 1.: Endoflip characteristics and Clinical Impact by HRM associated Diagnosis

S0402 Esophagogastric Junction Outflow Obstruction Is Associated with Impaired Bolus Clearance Compared to Controls

INTRODUCTION: The manometric diagnosis of esophagogastric junction outflow obstruction (EGJOO) can be ambiguous and not indicate true functional obstruction at the lower esophageal sphincter (LES). The aim of our study was to identify the presence of impaired esophageal bolus clearance in patients with EGJOO diagnosed via high-resolution manometry (HRM), and compare to a group controls (patients with normal HRM studies) who presented with dysphagia and similar symptoms. METHODS: 12 months of High-Resolution Impedance Manometry (HRIM) results at a large academic center (Wake Forest Baptist Medical Center) were reviewed. Studies diagnostic for EGJOO based on the Chicago Classification of Esophageal disorders (CCv3) were identified. In the group of patients with EGJOO, those with impaired bolus clearance were identified. Impaired bolus clearance was defined as patients with bolus clearance <80%. As a control, a group of HRIM labeled as normal studies were also identified. Incidence of impaired bolus clearance in this group was also recorded, and later compared to that of the EGJOO group. RESULTS: After reviewing the HRIM results, 121 patients were found to have HRIM consistent with the diagnosis of EGJOO. Another 121 patients were identified as having normal manometries. Using the criteria for impaired bolus clearance (<80%), each group was divided into normal vs impaired clearance. In the EGJOO group, 64 (52.9%) patients were found to have impaired clearance, vs 57 (47.1%) which had normal bolus clearance. This was compared to the normal HRIM group, where 16 (13.2%) patients were found to have impaired bolus clearance, while 105 (86.8%) patients were found to have normal bolus clearance. Using a chi square calculation, results were found to be significant (P < 0.01). Table 1 summarizes demographics. Table 2 summarizes the bolus clearance data. CONCLUSION: Patients with EGJOO diagnosed with HRIM were found to have significantly impaired bolus clearance compared to normal subjects. Abnormal liquid bolus transit on impedance analysis may be a useful measure to define clinically significant outflow obstruction. Further investigation of these patients’ subsequent studies, such as timed barium esophagrams, is warranted to fully assess esophageal emptying.Table 1.: DemographicsTable 2.: Results

S0401 Higher Rates of Chronic Opioid Use Found in Patients With Esophagogastric Junction Outflow Obstruction Compared to Controls

INTRODUCTION: Esophagogastric junction outflow obstruction (EGJOO) is defined by the Chicago Classification of Esophageal disorders (CC) as an incomplete relaxation (elevated median IRP) along with an intact or weak peristalsis. There are a number of etiologies of EGJOO, from medication effects to mechanical processes. Preliminary studies have suggested that opioids may impair lower esophageal function. The aim of our study was to assess this in a patient population by comparing the frequency of chronic opioid use in patients diagnosed with EGJOO versus patients with normal manometries. METHODS: 12 months of High-Resolution Manometry (HRM) results from a single academic center (Wake Forest Baptist Medical Center) were reviewed. Studies were designated as normal or EGJOO based on CCv3. Retrospectively, all patient’s home medications were examined, with a focus on prescription opioids. Patients who were prescribed daily opioids for greater than 6 months leading up to their HRM were labeled as chronic opioid users. The number of chronic opioid users in the normal result group were compared to the number of chronic opioid users in the EGJOO group. RESULTS: After reviewing the HRM results, 121 patients had normal manometries and 121 patients were found to have HRM consistent with EGJOO. After reviewing patient’s medication lists, 9 of the normal manometry group were found to have chronic daily opioid use (7.44%), while 20 of the EGJOO group were found to have chronic opioid use (16.53%). Using a chi square analysis, it was found there was a statistically significant difference (P-value 0.0294, P < 0.05) in number of chronic opioid users found in the EGJOO group (16.53%) compared to the group with normal HRM findings (7.44%). Table 1 summarizes the demographics. Table 2 details the initial chief complaint of the patients. CONCLUSION: In our study, chronic opioid use was found to be more prevalent in patients with the manometric diagnosis EGJOO than those with normal manometries. These results support chronic opioid use as a suspected etiology in EGJOO. As daily opioid use has become more common in recent decades, disorders of esophageal motility are one of the many adverse effects. This supports a trial off opioids in patients diagnosed with EGJOO with dysphagia to assess if symptoms resolve. Identifying opiates as a potential etiology, and improvement of symptoms after discontinuation of medications could potentially prevent other unnecessary procedures or therapies.Table 1.: DemographicsTable 2.: Chief Complaints

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.

Esophageal Function Tests are Not Associated with Barium Swallow Findings in Advanced Lung Disease.

Gastroesophageal reflux disease and esophageal dysmotility are common in patients with advanced lung disease (ALD) and are associated with worse outcomes. Assessing esophageal function in these patients is relevant for determining pulmonary transplant eligibility and prognosticating post-transplant outcomes. Barium Swallow (BaS) is a non-invasive testing modality often performed as a complement to formal esophageal function tests (EFTs), but its role and clinical utility in this context is unknown. Therefore, we aimed to determine the relationship between BaS and EFTs with high-resolution manometry (HRM) and 24-h ambulatory pH-metry in patients with ALD. We performed a retrospective study of 226 consecutive patients undergoing evaluation for lung transplantation at a single center. All patients underwent EFTs and BaS independent of clinical history or symptoms per institutional protocol. Appropriate statistical tests were performed to evaluate the relationship between EFTs and BaS. Mucosal, reflux and motility findings were categorized. Abnormal motility was reported in 133 (59%) patients by BaS and 99 (44%) by HRM, with a significant difference in the proportions of patients with abnormal studies (p < 0.01). There were 7 (26%) patients with abnormal barium tablet passage who had normal HRM. The sensitivity (35%) and specificity (77%) for detecting pathologic reflux with BaS was poor. Inducibility of reflux and barium column height were not associated with pH-metry results. No clinically significant luminal irregularities were identified. In conclusion, while BaS can non-invasively assess esophageal mucosa, its findings are not associated with EFTs in patients with ALD.

VALIDATION OF A NEW WATER-PERFUSED HIGH-RESOLUTION MANOMETRY SYSTEM.

Water-perfused high resolution manometry system. High-resolution manometry is more costly but clinically superior to conventional manometry. Water-perfused systems may decrease costs, but it is unclear if they are as reliable as solid-state systems, and reference values are interchangeable. To validate normal values for a new water-perfusion high-resolution manometry system. Normative values for a 24-sensors water perfused high-resolution manometry system were validated by studying 225 individuals who underwent high resolution manometry for clinical complaints. Patients were divided in four groups: group 1 - gastroesophageal reflux disease; group 2 - achalasia; group 3 - systemic diseases with possible esophageal manifestation; and group 4 - dysphagia. In group 1, a hypotonic lower esophageal sphincter was found in 49% of individuals with positive 24 h pH monitoring, and in 28% in pH-negative individuals. In groups 2 and 3, aperistalsis was found in all individuals. In group 4, only one patient (14%) had normal high-resolution manometry. The normal values determined for this low-cost water-perfused HRM system with unique peristaltic pump and helicoidal sensor distribution are discriminatory of most abnormalities of esophageal motility seen in clinical practice.

High-resolution manometry in the diagnosis of diffuse esophageal spasm: A rare motility disorder

Background: Diffuse esophageal spasm (DOS) is a rare motility disorder. High-resolution manometry (HRM) is used for the diagnosis of DOS in patients confirmed with non-cardiac chest pain and/or dysphagia. The body of the esophagus and the lower esophageal sphincter (LOS) exhibit various motility characteristics that are typical to DOS. The study was conducted to study the HRM patterns in DOS using a 16-channel water perfusion high-resolution esophageal manometer. Aims and Objectives: The objective of the study was to analyze the various motility patterns in DOS with the help of HRM and also to look for those patients who, at the time of the HRM recording, did not reveal overt patterns of motility that is typical to DOS. Materials and Methods: HRM was performed in 13 adult patients (mean age = 61 years) referred as cases of DOS, out of which three had HRM features of DOS. All patients were subjected to HRM following which the results were analyzed. Results: Ten cases had essentially normal HRM findings. The other three patients had a high basal LOS pressure (BLOSP) and elevated distal wave amplitudes. However, all three cases had a normal LOS relaxation pattern. Manometric features of DOS may not be obvious in all referred cases of DOS, and hence, false-negative results are likely. DOS often has high BLOSP along with very high distal wave amplitudes. However, the LOS relaxation during swallows does not get affected. Although the mean age for DOS is 71 years, yet it can also occur in younger adults. Conclusion: Most of the DOS patients may not manifest manometrically at the time when they are actually undergoing the recording, which leaves a number of cases with a normal HRM finding. Thus, it would not be reasonable to rule out DOS in the absence of HRM confirmation.

Analysis of clinical features and motility characteristics of ineffective esophageal motility

Objective To clarify the correlation between the clinical characteristics, esophageal motility features and esophageal acid exposure in patients with ineffective esophageal motility (IEM). Methods From January 2016 to March 2018, at Peking University First Hospital, 22 IEM patients diagnosed by esophagus high-resolution manometry (HRM) and 24 individuals with normal HRM results were enrolled. Clinical features, parameters of esophageal HRM and results of esophageal 24-hour pH monitoring of IEM patients and the individuals with normal HRM results were compared. According to the median distal contraction integral (DCI) of ten swallows, the IEM patients were divided into mild-IEM group (DCI 250-450 mmHg·s·cm (1 mmHg=0.133 kPa)) (14 cases) and severe-IEM group (DCI<250 mmHg·s·cm) (eight cases). The clinical features and esophageal motility were compared between normal HRM group, mild-IEM group and severe-IEM group. T test, chi-square test and one-way analysis of various were used for statistical analysis. Results The age of IEM group was older than that of normal HRM group ((64.5±11.2) years vs. (50.3±18.2) years), and the difference was statistically significant (t=-3.135, P=0.003). The lower esophageal sphincter pressure (LESP) of IEM group was lower than that of normal HRM group ((17.0±6.8) mmHg vs. (22.3±7.2) mmHg), and the difference was statistically significant (t=2.516, P=0.016). There were 15 cases in normal HRM group and 14 patients in IEM group who underwent esophageal 24-hour pH monitoring and there were five and two patients with abnormal acid exposure time (AET) in normal HRM group and IEM group, respectively. The length of proximal esophageal body (PEB) pressure zone of severe-IEM group was shorter than those of normal HRM group and mild-IEM group ((2.8±1.5) cm vs.(4.2±0.7) cm and (4.6±0.9) cm), and the differences were statistically significant (t=2.397 and 3.432, P=0.044 and 0.003). The integrated relaxation pressure (IRP) and LESP of normal HRM group were both higher than those of mild-IEM group ((9.3±2.9) mmHg vs. (7.2±3.3) mmHg, (22.3±7.2) mmHg vs. (15.4±7.1) mmHg), and the differences were statistically significant (t=2.148 and 2.843, P=0.038 and 0.007). There were six and eight patients in mild-IEM group and severe-IEM group who underwent esophageal 24-hour pH monitoring, respectively, and two patients in mild-IEM had abnormal AET. Conclusions The LESP of IEM patients is low. The clinical features and AET of IEM patients are not associated with the severity of IEM. In patients with severe IEM, the proximal and distal esophageal contractility is weakened, and the length of PEB pressure zone is shortened. Key words: Esophageal sphincter, upper; Ineffective esophageal motility; High-resolution manometry; Proximal esophageal body

386 Delayed Esophago-Gastric Junction Relaxation in Patients With Jackhammer Esophagus Suggest That the Hypercontractile Peristalsis May Be a Compensatory Mechanism

INTRODUCTION: Jackhammer esophagus (JE) is esophageal motility disorder characterized by hypercontractile peristalsis, diagnosed by high resolution manometry (HRM) showing increased contractile vigor distal contractile integral (DCI) &gt;8000 mmHg/s/cm. Hypothesis: hypercontractile peristalsis in JE may be a compensatory mechanism for impaired EGJ relaxation, which even with normal integrated relaxation pressure (IRP), may be expressed as delayed onset of relaxation. We compare time to onset of EGJ relaxation in JE patients with normal IRP, control patients presenting for evaluation of esophageal symptoms with normal HRM, and asymptomatic healthy volunteers. METHODS: We compared time to onset of EGJ relaxation in 44 patients (24 JE, 20 with normal HRM) and 21 asymptomatic healthy volunteers who underwent HRM. Demographic characteristics and validated esophageal questionnaires (GERDQ, BEDQ, Eckardt) collected in all subjects. HRM performed by administering ten 5-ml liquid swallows, Chicago Classification v3.0 used to diagnose JE and normal esophageal motility. Time to onset of EGJ relaxation after swallow initiation was measured in seconds, from time of upper esophageal sphincter opening to EGJ opening. EGJ opening was determined at an isobaric contour of 23 mmHg, based on analysis in the healthy volunteers showing persistent EGJ effacement at this value in 100% of the volunteers. Median times to onset of relaxation for the study groups were compared by Wilcoxon rank sum test. RESULTS: Demographics, questionnaire scores, and HRM metrics in Table 1; patients were older and had higher scores compared to healthy volunteers; HRM metrics were different among the study groups with the exception of DL. Median times to onset of relaxation after swallow initiation shown in Figure 1. There was no difference in median time to onset of relaxation for volunteers compared to patient controls with normal HRM 0.20 s vs 0.90 s, P = 0.149. Median time to onset of relaxation was significantly longer in JE patients compared to volunteers and patient controls 3.30s vs 0.20 s vs 0.90 s, P = 0.001. CONCLUSION: Patients with JE and normal EGJ relaxation by IRP have significantly delayed onset of EGJ relaxation compared to healthy subjects and control patients with normal HRM. Hypercontractile peristalsis in these JE patients could be a compensatory mechanism to overcome outflow obstruction manifested as delayed EGJ relaxation. Therefore, if our findings are confirmed, therapies to address impaired EGJ relaxation could be considered.

365 The Prevalence and Clinical Significance of Esophageal Motility Disorders in Patients Presenting With Laryngopharyngeal Reflux (LPR) Symptoms

INTRODUCTION: Esophageal motor dysfunction may underlie impaired bolus and refluxate clearance in laryngopharyngeal reflux (LPR). However, the prevalence of co-existing esophageal dysmotility and correlation with reflux parameters and symptoms in LPR is unknown. METHODS: We conducted a retrospective study of consecutive patients with suspected LPR referred for high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance and pH testing (HEMII-pH) at a tertiary center in 3/2018-5/2019. Validated symptom surveys were prospectively collected at the time of testing, including Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease Questionnaire (GERD-Q), and 12-item short-form health survey (SF-12). HRM findings were categorized using the Chicago Classification v3.0. Statistical analyses were performed using ANOVA or Fisher’s exact test. RESULTS: 113 patients (64% female, mean age 54.9 years) were included, with 52 (46%) having abnormal findings on HRM. The most common diagnosis was ineffective esophageal motility (IEM) [n = 37 (32.7%)]. 19 (16.8%) patients were found to have either a disorder of esophagogastric junction (EGJ) outflow or a major disorder of peristalsis, of which EGJ outflow obstruction (EGJOO) was the most prevalent diagnosis [n = 11 (9.7%)] (Table 1). With the exception of increased distal acid exposure time (AET) among patients with hypercontractile motility disorders (9% vs 2% in patients with normal HRM, P = 0.03), there were no differences in pharyngeal bolus reflux events, total bolus reflux events on impedance, and AET across HRM findings. Reporting throat symptoms as a primary complaint on presentation was associated with greater odds of having abnormal HRM compared to esophageal symptoms alone (OR 5.5, P = 0.005) (Figure 1). However, the presence and specific type of motility disorder were not associated with symptom severity as measured on RSI, GERD-Q, or health-related quality of life on the SF-12. CONCLUSION: Esophageal motility disorders are prevalent among patients with suspected LPR symptoms, including up to one of six with either a disorder of EGJ outflow or major disorder of peristalsis. Patients with these conditions are more likely to report throat symptoms as a primary complaint. However, there was no correlation between HRM findings and symptom severity. The role of esophageal motor dysfunction in patients with LPR symptoms remains to be further defined.

High-Resolution Manometry Diagnosis of Ineffective Esophageal Motility Is Associated with Higher Reflux Burden.

Ineffective esophageal motility (IEM) is the most commonly diagnosed abnormality on high-resolution manometry (HRM). However, the clinical significance of IEM and associated reflux burden remains unclear. Our primary aim was to compare reflux patterns between IEM versus normal motility on HRM. HRM and reflux studies in patients with IEM and normal motility were retrospectively reviewed. Esophageal pressure topography parameters, reflux variables, and patient-reported outcome questionnaires were explored. A total of 239 patients with IEM were explored. Of these, 146 underwent reflux monitoring. Additionally, 100 patients with normal HRM all of whom had undergone reflux monitoring were included. IEM patients were more likely to have an abnormal number of reflux events compared to normal (22.7% vs. 9.0%, p < 0.01). Including only off-proton pump inhibitor (PPI) testing, IEM patients had higher mean total acid exposure time (AET) and total reflux events compared to normal motility (p = 0.02). Within IEM patients, higher AET modestly correlated with increased percentage of impaired swallows. Increased reflux events modestly correlated with higher impaired swallows and decreased lower esophageal sphincter (LES) resting pressure. Reflux burden increased with higher esophagogastric junction (EGJ) subtype, driven mostly by subtype III, although there was no difference in the distribution of EGJ subtypes between the IEM and normal HRM cohorts. Patients with HRM diagnosis of IEM may be more prone to acid reflux while off-PPI and non-acid reflux while on-PPI. Reflux burden appears to be worse in IEM patients who have lower resting LES pressure, higher EGJ subtype, or higher percentage of impaired swallows.