Severe Ineffective Esophageal Motility Research Articles

217. LAPAROSCOPIC FUNDOPLICATION EFFECTIVE IN TREATING REFLUX MICRO-ASPIRATION

Abstract Pulmonary micro-aspiration has become increasingly recognised subtype of severe gastro-oesophageal reflux disease (GORD). Acid suppression can help with symptoms in proportion of patients, however, does not reduce pulmonary contamination with gastric content. Laparoscopic fundoplication was found to be effective in reducing rates of reflux micro-aspiration. The aim of this study was to examine outcomes of surgical treatment of GORD in patients with confirmed reflux micro-aspiration on novel reflux scintigraphy. Data was extracted from prospectively populated single centre database. Patients with confirmed reflux aspiration by validated novel protocol scintigraphy and treated with laparoscopic 360-degree Nissen fundoplication between 2006–2018 were included. Primary outcome was resolution of reflux micro-aspiration on post-operative scintigraphy. Secondary outcomes included manometry and scintigraphy findings associated with ongoing aspiration, surgical complications, and patient-reported quality of life outcomes. Inclusion criteria were met by 159 patients (66% female); average age 58 (SD 14, range 18–88). Most common presenting symptoms were regurgitation and cough. Laparoscopic fundoplication was associated with resolution of reflux micro-aspiration in 138 (86.8%) of patients. Strongest predictors of persistent aspiration following surgery were severe ineffective oesophageal motility (p = 0.001) and reduced oesophageal clearance (p = 0.003). Complications (Clavien-Dindo grade III and above) occurred in 4 patients (2.5%). There was no perioperative death in this cohort. Patient satisfaction rate with surgery was 94%. Laparoscopic fundoplication is effective in treating reflux micro-aspiration with best outcomes observed in patients with normal oesophageal motility and good oesophageal clearance.

High prevalence of esophagitis in patients with severe ineffective esophageal motility: need for a new diagnostic cutoff.

BackgroundA new classification criterion for diagnosing ineffective esophageal motility (IEM) was proposed at the 2018 Stanford symposium, but limited data exists about the utility of this criterion.MethodsWe conducted a cross-sectional study among 3826 patients treated at the Institute of Gastroenterology and Hepatology, Hanoi, Vietnam, between March 2018 and May 2020. Patients were classified as having normal motility, mild IEM, severe IEM, or absent contractility based on the Chicago classification version 3.0 and the new IEM criterion (severe IEM was defined as having >70% ineffective swallows). We examined the association between these 4 motility subgroups and the presence of erosive esophagitis and Barrett’s esophagus, using multivariate logistic regression analysis.ResultsThe mean age of the study sample was 44.7 years and 66.3% were women. The prevalence of symptoms, hiatal hernia, and Helicobacter pylori-positive patients was similar in the 4 study groups. The 4-second integrated relaxation pressures and lower esophageal sphincter resting pressures were lower in patients with severe IEM and absent contractility. Severe IEM and absent contractility, but not mild IEM, were significantly associated with Los Angeles (LA) grade B-D esophagitis (relative risk ratio [RRR] for severe IEM 1.81, 95% confidence interval [CI] 1.17-2.80; and RRR for absent contractility 2.37, 95%CI 1.12-5.04). None of the hypomotility subgroups were associated with LA grade A esophagitis and Barrett’s esophagus.ConclusionsPatients with severe IEM have a high prevalence of severe erosive esophagitis. These findings suggest the need for a more meaningful classification criterion for IEM.

Pitfalls in the Interpretation of Chicago Classification for Esophageal Motility Disorders.

High-resolution manometry permitted the creation of the Chicago classification, that is the categorization for esophageal motility disorders most currently used. Despite its wide acceptance, there are few pitfalls for the correct interpretation of the tests. This technique review illustrates some difficult cases that may lead to misinterpretation of the results. Difficult cases are analyzed, such as the distinction of: (1) esophagogastric junction morphology and lower esophageal sphincter excursion, (2) intrabolus pressure pattern or common cavity, (3) hypercontractile esophagus (jackhammer) and achalasia type III, (4) absent contractility and severe ineffective esophageal motility or achalasia type I, and (5) simultaneous distal esophageal spasm and ineffective esophageal motility.

Ineffective esophageal motility assessment in patients with and without pathological esophageal acid reflux.

Ineffective esophageal motility (IEM), defined as minor esophageal motility disorder, is also the most common esophageal motility disorder. The relationship between gastro-esophageal reflux disease is still controversial. Our aim in this study is to evaluate whether there are differences in terms of demographic, endoscopic, or motility findings between IEM patients with pathological esophageal acid reflux and physiological reflux.Patients diagnosed with IEM according to the Chicago classification v3 with high-resolution manometry (HRM) before acid monitoring constituted the study group of our investigation. The patients were divided into 2 groups as patients with pathological esophageal reflux and patients with physiological reflux according to 24-hour acid monitoring. Demographic data, endoscopic findings, and HRM findings were compared between 2 groups.A total of 62 patients who were diagnosed with IEM according to the Chicago classification v3 were included in the study. Patients in the physiological reflux group were 7 years younger on average than the pathological reflux group. Esophagitis rates were significantly higher in the pathological reflux group (P = .033). Lower esophageal sphincter resting pressure, integrated relaxation pressure, and the presence of hernia were found to be similar in the 2 groups (P = 392, P = 182, P = 657, respectively). The rate of severe IEM was also similar between the 2 groups (P = .143).The fact that the physiological reflux patient group is younger may suggest that the IEM develops in the early period and then reflux accompanies the picture with advancing age.

Reflux Aspiration Associated with Oesophageal Dysmotility but Not Delayed Liquid Gastric Emptying

Introduction: Severe oesophageal dysmotility is associated with treatment-resistant reflux and pulmonary reflux aspiration. Delayed solid gastric emptying has been associated with oesophageal dysmotility; however, the role of delayed liquid gastric emptying (LGE) in the pathophysiology of severe reflux disease remains unknown. The purpose of this study is to examine the relationship between delayed LGE, reflux aspiration, and oesophageal dysmotility. Methods: Data were extracted from a prospectively populated database of patients with severe treatment-resistant gastro-oesophageal reflux disease. All patients with validated reflux aspiration scintigraphy and oesophageal manometry were included in the analysis. Patients were classified by predominant clinical subtype as gastro-oesophageal reflux (GOR) or laryngopharyngeal reflux. LGE time of 22 min or longer was considered delayed. Results: Inclusion criteria were met by 631 patients. Normal LGE time was found in 450 patients, whilst 181 had evidence of delayed LGE. Mean liquid half-clearance was 22.81 min. Reflux aspiration was evident in 240 patients (38%). Difference in the aspiration rates between delayed LGE (42%) and normal LGE (36%) was not significant (p = 0.16). Severe ineffective oesophageal motility (IOM) was found in 70 patients (35%) and was independent of LGE time. Severe IOM was strongly associated with reflux aspiration (p < 0.001). GOR dominant symptoms were more common in patients with delayed LGE (p = 0.03). Conclusion: Severe IOM was strongly associated with reflux aspiration. Delayed LGE is not associated with reflux aspiration or severe IOM. Delayed LGE is more prevalent in patients presenting with GOR dominant symptoms.

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

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.

Electrical lower esophageal sphincter augmentation in patients with GERD and severe ineffective esophageal motility\u2014a safety and efficacy study

BackgroundLaparoscopic fundoplication (LF), even if performed in specialized centers, can be followed by long-term side effects such as dysphagia, gas bloating or inability to belch. Patients with an ineffective esophageal motility (IEM) and concurrent GERD are prone to postoperative dysphagia after LF. The aim of this study is to evaluate the safety and efficacy of electrical lower esophageal sphincter stimulation in patients with IEM and GERD.MethodsThis is a prospective, open-label single center study. Patients with PPI-refractory GERD and ineffective esophageal motility were included for lower esophageal sphincter electrical stimulation (LES-EST). Patients underwent prospective follow-up including physical examination, interrogation of the device and were surveyed for changes in the health-related quality of life score.ResultsAccording to power analysis, 17 patients were included in this study. Median distal contractile integral (DCI) was 64 mmHg s cm (quartiles 11.5–301). Median total % pH < 4 was 8.9 (quartiles 4–21.6). Twelve patients (70.6%) underwent additional hiatal repair. At 1-month follow-up, none of the patients showed any clinical or radiological signs of dysphagia. There were no procedure related severe adverse events. Mean total HQRL improved from baseline 37.53 (SD 15.07) to 10.93 (SD 9.18) at follow-up (FUP) (mean difference 24.0 CI 15.93–32.07) p < 0.001.ConclusionsLES-EST was introduced as a potential technique to avoid side effects of LF. LES-EST significantly improved health related quality of life and does not impair swallowing in patients with GERD and ineffective esophageal motility.

Gastrointestinal: Severe ineffective esophageal motility presenting as rumination syndrome.

Gastrointestinal: Severe ineffective esophageal motility presenting as rumination syndrome.

Bethanechol Does Not Improve Dysphagia in Patients With Ineffective Esophageal Motility and Defective Bolus Transit

Introduction: Ineffective esophageal motility (IEM) is a common motility disorder, defined as ≥ 50% weak swallows (distal contractile integral (DCI) < 450 mmHg-cm-sec). It is frequently associated with defective bolus transit and may present with dysphagia. Bethanechol, a direct-acting muscarinic receptor agonist, has been shown in pilot studies to increase distal esophageal contraction amplitude in healthy volunteers and patients with IEM. Methods: 9-weeks, randomized, double-blind, placebo-controlled, cross-over study was conducted in patients with severe IEM with a main presenting complaint of dysphagia. Aim of study: Assess the effect of bethanechol (50 mg TID) on dysphagia & manometric changes in patients with IEM. Patients were given placebo or bethanechol for 4 weeks each in a stepwise fashion, then were crossed-over after a 1-week washout. Mayo Dysphagia Questionnaire-30 (MDC-30) and high-resolution impedance manometry (HRIM) obtained at baseline and at the completion of each arm. Adverse effects profile was assessed during the study. Statistical analysis: Non-parametric Friedman’s test was used to compare outcomes for bethanechol, placebo, and baseline. Mean differences and confidence intervals were estimated for the 3 groups<./p> Results: 10 patients completed the study (70% females). Mean age 57.3 years (SD+/-11.9). 1 patient dropped-out because of chest pain while on placebo. 44% of patients developed transient adverse effects that resolved within a week of bethanechol initiation. Median DCI for bethanechol was slightly higher, although it did not reach significance level: 307, Interquartile range (IQR) 39-1306 bethanechol; 208, IQR 72-1171 placebo; 225, IQR 62-495 baseline (P=0.39) (Figure 1). MDC-30 score was slightly lower for bethanechol: 4 (on scale of 0-10), IQR 0-8 bethanechol; 5, IQR 1-8 placebo; 5, IQR 3-10 baseline (P=0.34) (Figure 2).399_A Figure 1 No Caption available.399_B Figure 2 No Caption available.Conclusion: Bethanechol increased distal esophageal contraction amplitude to some extent and decreased sensation of dysphagia at 30-days compared to placebo and more profoundly to baseline. Though, these differences did not reach significance level. Our study’s small sample size likely underestimated the effect of bethanechol. Bethanechol was well-tolerated with absence of serious adverse events, with less than half of patients experienced minor adverse effects that resolved within 1 week of therapy. This pilot study opens the door to explore more the utility of bethanechol in the treatment of IEM.

Severity of ineffective esophageal motility is associated with utilization of skeletal muscle relaxant medications.

Ineffective esophageal motility (IEM) is the most common finding on high-resolution esophageal manometry (HREM). The underlying mechanisms for IEM remain to be fully elucidated. The aim of this study was to determine if utilization of skeletal muscle relaxants is associated with IEM, and with more severe subtypes of the disorder. Patients with diagnosis of IEM were gender and age matched to patients with normal HREM. Demographic information, symptoms, endoscopic findings, medication usage and medical comorbidities were recorded. Patients with a diagnosis of IEM were divided into subgroups based on mean distal contractile integral (DCI) and percentage of ineffective swallows, and assessed for clinically significant differences among patients with varying severity of underlying IEM. A total of 118 patients were included in each group. There were no significant clinical differences between the group of patients with IEM and the group of patients with normal manometry. Within the group of IEM patients, those with mean DCI<250mmHg/s/cm were more likely to be prescribed skeletal muscle relaxants (27.8% vs 11.0%, P=.044), and those using skeletal muscle relaxants had a larger mean percentage of ineffective swallows (81.1% vs 71.5%, P=.029). There were no significant differences across mean DCI subgroups in usage of any other medication, or in any of the demographic variables or disease comorbidities examined in this study. Use of skeletal muscle relaxants is associated with more severe IEM, which may suggest a causal association between this class of medications and weaker esophageal peristalsis.

Prognostic yield of esophageal manometry in chronic intestinal pseudo‐obstruction: a retrospective cohort of 116 adult patients

Chronic intestinal pseudo-obstruction (CIPO) refers to a wide and heterogeneous group of neuromuscular disorders, which classically involve the small intestine. However, further investigation is required to determine if motility disturbances involve all parts of the gastrointestinal (GI) tract. Medical records and follow-up examinations of 116 adult CIPO patients [70F, median age 28 (0-79) years] were reviewed and performed at our institution since 1980. Manometry (esophageal, small bowel and anorectal) and gastric emptying scintigraphy reports were retrieved and analyzed. Survival, home parenteral nutrition requirement, and the inability to maintain sufficient oral feeding was analyzed using univariate and multivariate analysis. The median follow-up time was 6 (0.1-30) years. In all, 90% of patients who underwent at least one motility test, with the exception of small bowel manometry, exhibited at least one abnormal pattern. Esophageal manometry was abnormal in 73% of the cases, including 51% with severe ineffective esophageal motility. Anorectal manometry was abnormal in 59% of the cases, including only 17% with severe abnormalities. Gastric emptying was abnormal in 61% of the cases. Only esophageal motor disorders had significant predicting values for survival, home parenteral nutrition requirement, and an inability to maintain sufficient oral feeding. Our study showed that CIPO was associated with a diffuse involvement of all parts of the GI tract and was not restricted to the small intestine in 90% of the cases studied. Esophageal manometry had a significant prognostic yield and should be systematically performed in CIPO patients.

Esophageal Motor Disorders in Adults with Eosinophilic Esophagitis

An association between eosinophilic esophagitis (EoE) and esophageal motility disorders has been described in small studies. The aim of this study was to describe the prevalence of esophageal motor disorders in a large cohort of adults with EoE and examine whether an association exists between esophageal dysmotility and dysphagia. A retrospective review of esophageal manometry studies in adult EoE patients was performed. Tracings were reviewed for abnormalities including nutcracker esophagus and ineffective swallows, defined as low amplitude peristalsis (<30 mmHg) or non-propagating contractions. Ineffective esophageal motility (IEM) was categorized as mild (30-40% ineffective swallows), moderate (50-60% ineffective swallows), and severe (≥70% ineffective swallows). Dysphagia was graded on a 0-3 scale for frequency and severity. Seventy-five tracings from EoE patients were reviewed (85% male, mean age 41 ± 12 years). IEM was identified in 25 patients and categorized as mild (n = 13), moderate (n = 6), and severe (n = 6). Nutcracker esophagus was found in three patients. There was no significant difference in eosinophil count among the motility groups: normal 46.5 ± 3.1, mild IEM 56.9 ± 36.9, moderate IEM 45.5 ± 23.7, severe IEM 34.3 ± 12.6 (P = 0.157). In this cohort of EoE patients, the majority had normal esophageal motility studies, although a subset of these patients had some esophageal dysmotility. It is unlikely that esophageal dysmotility is a major contributing factor to dysphagia, although it is reasonable to consider esophageal manometry testing in EoE patients to identify potential abnormalities of the smooth muscle esophagus.

Pyridostygmine, A Potential Therapy for Dysphagia Secondary to Ineffective Esophageal Motility

Purpose: Clinical Presentation: A 47-year-old white woman with GERD initially presented 7 years ago for possible anti-reflux surgery evaluation due to heartburn and severe dysphagia of solids and liquids. She was previously treated with multiple antireflux regimens and endoscopic dilations without improvement. Esophageal impedance manometry testing confirmed the diagnosis of severe ineffective esophageal motility (IEM). Over the next 4 years, acid control therapy was continually altered and a prolonged trial of bethanechol yielded little improvement. Repeat testing continued to reveal severe IEM, normal number of reflux episodes and esophageal acid exposure, and negative symptom association. She was then started on Mestinon 30 mg BID based on recent studies showing increased esophageal contraction amplitudes. Within the next 3 months the patient's dysphagia drastically improved as evidenced by a 15 lb weight gain. Although repeat esophageal impedance manometry continued to show severe IEM, distal contraction amplitudes improved and the patient's dose of Mestinon was increased to 60 mg BID. Most recently the patient still struggled with heartburn but her dysphagia has disappeared, and her biggest health concern currently is obesity having since gained >60 lb since initiation of Mestinon! Discussion: IEM was redefined by the presence of greater than or equal to 50% liquid swallows with contraction amplitude <30 mm Hg in one of the two distal sites in the lower esophagus. Although antireflux therapy has been the mainstay of IEM treatment, restoration of esophageal smooth muscle contractility by the muscarinic receptor agonist, bethanechol, improved esophageal contraction pressures as well as bolus transit. Recent comparison of oral pyridostygmine (Mestinon), buspirone, and bethanechol was undertaken after short-acting acetylcholinesterase inhibitors were shown to increase esophageal contraction amplitude and duration. After our patient failed to improve with antireflux therapy and a trial of bethanechol, addition of Mestinon was attempted. Although the addition of Mestinon did not change her diagnosis of severe IEM, it did increase distal contraction amplitudes and overall bolus transit of both solids and liquids, but more importantly completely cured the symptom of dysphagia as evidenced by the patient's drastic weight gain over the follow 3 years. Conclusion: The addition of pyridostygmine greatly improved the distal esophageal contraction amplitudes and bolus transit in this patient. Although the degree of improvement was not enough to change her diagnosis of severe IEM, the therapeutic benefit has proven to dramatically improve this woman's quality of life and cure her dysphagia.

Multiple rapid swallowing: a complementary test during standard oesophageal manometry

Multiple rapid swallowing (MRS) stimulates neural inhibition resulting in abolition of contractions in the oesophageal body (OB) and complete lower oesophageal sphincter (LOS) relaxation which is followed by peristalsis and LOS contraction. The aim of this study was to evaluate the yield of MRS to detect abnormalities in inhibitory or excitatory oesophageal mechanisms in patients with oesophageal symptoms and either normal standard manometry or ineffective oesophageal motility (IOM). MRS (five water swallows, 2 mL, separated by 2-3 s) was evaluated in 23 healthy subjects, 109 symptomatic patients with normal standard sleeve manometry and in 48 patients with IOM. Healthy subjects had complete inhibition of OB motility during MRS and a strong motor response after MRS, i.e. amplitude of OB contractions in the oesophageal body and LOS tone being higher than after single swallows. Almost 70% of patients with oesophageal symptoms and normal manometry had abnormal MRS, mainly consistent on inability to increase amplitude of OB contractions after MRS. Nearly, half of the patients with IOM were able to normalize OB contractions after MRS. MRS is a simple complementary test that can be added to standard oesophageal manometry. Two-thirds of patients with normal manometry show abnormal MRS that could potentially underlie their symptoms. A normal response to MRS in patients with severe IOM might be used to predict response to prokinetic treatment.

Revised Criterion for Diagnosis of Ineffective Esophageal Motility Is Associated With More Frequent Dysphagia and Greater Bolus Transit Abnormalities

Ineffective esophageal motility (IEM) has been defined by the presence of > or = 30% liquid swallows with contraction amplitude < 30 mmHg (ineffective swallows) in the distal esophagus ("old" IEM). A recent study with combined multichannel intraluminal impedance and manometry (MII-EM) raised the question whether the manometric diagnosis of IEM should be based on a new definition: > or = 50% ineffective liquid swallows ("new" IEM). The aim of this study was to evaluate the association between the number of ineffective liquid swallows and symptoms and bolus transit in patients with "new" or "old" IEM who underwent MII-EM studies using 10 liquid and 10 viscous swallows. There were 150 patients with "old" IEM included in the study. The patients diagnosed with "old" IEM (N = 150) (group A) were compared with those who retained a manometric diagnosis of IEM by the new definition (N = 101) (group B). The patients who did not retain their manometric diagnosis of IEM by the new definition (N = 49) (group C) were compared with group B. IEM was characterized as mild (normal bolus transit for both liquid and viscous swallows), moderate (abnormal bolus transit either for liquid or viscous swallows), or severe (abnormal bolus transit for both liquid and viscous swallows). There was no statistical difference in frequency of mild, moderate, or severe IEM and frequency of symptoms between group A and B. Group C had a significantly higher frequency of mild IEM and significantly lower frequency of severe IEM than group B. Heartburn (25.7%vs 10.2%, P= 0.03) and dysphagia (24.8%vs 12.3%, P= 0.08) showed a trend towards a greater frequency in group B than in group C. Our study indicates that IEM with > or = 50% ineffective liquid swallows is frequently associated with bolus transit abnormalities and esophageal symptoms. Our results underscore the rationale for using the new definition of IEM.

Relevance of mild ineffective oesophageal motility (IOM) and potential pharmacological reversibility of severe IOM in patients with gastro‐oesophageal reflux disease

Several studies showed high prevalence of ineffective oesophageal motility (IOM) in gastro-oesophageal reflux disease (GERD) and suggested an important role for ineffective oesophageal motility in increased acid exposure. However, impedance-manometric studies proposed that only severe ineffective oesophageal motility might affect oesophageal clearance. (i) To re-assess the relevance of mild IOM in GERD and (ii) to test the reversibility of IOM. Oesophageal motility, clearance and acid exposure were assessed in 191 GERD patients: 99 without IOM; 58 with mild IOM (30-80% ineffective contractions) and 34 with severe IOM (>80% ineffective contractions). In 30 patients with oesophagitis, the potential reversibility of IOM was evaluated with edrophonium intravenously. Patients with mild IOM had identical oesophageal clearance and acid exposure in comparison with those without IOM. Patients with severe IOM had a higher probability of prolonged supine clearance and acid exposure [odds ratio: 2.88 (1.16-7.17); 2.48 (0.99-6.17)]. This effect was independent of the presence of hiatal hernia and male sex. Severe IOM could be transiently reverted in 55% of patients. Mild IOM does not affect oesophageal clearance. Only severe IOM is associated with prolonged clearance and acid exposure, particularly in supine periods. The edrophonium test might be useful to predict severe IOM response to prokinetic medications.

Bethanechol Improves Smooth Muscle Function in Patients With Severe Ineffective Esophageal Motility

There is no therapeutic intervention that reliably restores smooth muscle contractility for patients with ineffective esophageal motility (IEM). Bethanechol, a direct-acting muscarinic receptor agonist, has been shown in healthy volunteers to produce a significant increase in peristaltic amplitude in the distal esophagus. To identify whether bethanechol improves smooth muscle contractility and bolus transit in patients with IEM. Seven patients diagnosed with severe IEM documented by combined multichannel intraluminal impedance and esophageal manometry were asked to participate. IEM was defined by using the new proposed criteria of greater than or equal to 50% saline swallows with contraction amplitude <30 mm Hg either 5 and/or 10 cm above the lower esophageal sphincter (LES). In the supine position, the patients were given 10 swallows of 5 mL of normal saline then 10 swallows of viscous solution, each 20 to 30 seconds apart. Patients were then given 50 mg oral bethanechol. After 20 and 40 minutes, 5 swallows of saline and viscous solution were repeated. Studies were then analyzed by an investigator blinded to the relationship of bethanechol administration to the swallows. The analysis included measurement of distal esophageal amplitude (DEA) or the mean amplitude at 5 and 10 cm above the LES. The use of bethanechol significantly increased (P<0.05) the esophageal contraction pressures at 5 and 10 cm above the LES. The DEA increased (P<0.05) for liquid and viscous, 20 minutes after its administration. Forty minutes after bethanechol administration, DEA and also individual pressures at 5 and 10 cm above the LES were still increased (P<0.05) for liquid, but only the DEA increased (P<0.05) with viscous solution. There was also a significant increase in complete bolus transit for saline swallows, both 20 and 40 minutes (P=0.03 and 0.01, respectively) after bethanechol. Oral bethanechol significantly improves contraction pressures and bolus transit in the smooth muscle portion of the esophagus in patients with severe IEM.

Bethanechol chloride is beneficial for patients with severe ineffective oesophageal motility,

Bethanechol chloride is beneficial for patients with severe ineffective oesophageal motility,

Effect of an acute intraluminal administration of capsaicin on oesophageal motor pattern in GORD patients with ineffective oesophageal motility

Ineffective oesophageal motility (IOM) is a functional disorder affecting about 50% of gastro-oesophageal reflux disease (GORD) patients. This disease in a severe form limits the clearing ability of the oesophagus and is considered one of the predictive factors for poorer GORD resolution. Capsaicin, the active compound of red pepper, exerts a prokinetic effect on oesophageal motility in healthy subjects by increasing the amplitude of body waves, even if no evidence exists on its possible role in situations of reduced motility. The aim of the study was to evaluate the effect of an acute administration of capsaicin on the oesophageal motor pattern in a group of GORD patients affected by severe IOM. Twelve GORD patients with severe IOM received an intra-oesophageal administration of 2 mL of a red pepper-olive oil mixture and 2 mL of olive oil alone serving as a control during a stationary manometry. The motor patterns of the oesophageal body and lower oesophageal sphincter (LOS) were analysed at baseline and after the infusion of the two stimuli. The administration of capsaicin induced a significant improvement in oesophageal body contractility when compared with baseline. The velocity of propagation of waves and the LOS basal tone remained unchanged. The motor pattern was unaltered by the administration of olive oil alone. An acute administration of capsaicin seems to improve the motor performance of the oesophageal body in patients with ineffective motility. Whether this could represent the basis for further therapeutic approaches of GORD patients needs further study.