Daniel Luger

Mechanical Properties of the Esophagus in Eosinophilic Esophagitis

BACKGROUND & AIMS This study aimed to analyze the mechanical properties of the esophagus in eosinophilic esophagitis (EoE) using the functional luminal imaging probe (EndoFLIP; Crospon Medical Devices, Galway, Ireland). METHODS Thirty-three EoE patients (22 male; age range, 23-67 years) and 15 controls (6 male; age range, 21-68 years) were included. Subjects were evaluated during endoscopy with the EndoFLIP probe, comprised of a compliant cylindrical bag (maximal diameter 25 mm) with 16 impedance planimetry segments. Stepwise bag distensions from 2 to 40 mL were conducted and the associated intrabag pressure and intraluminal geometry were analyzed. RESULTS The EndoFLIP clearly displayed the tubular esophageal geometry and detected esophageal narrowing and localized strictures. Stepwise distension progressively opened the esophageal lumen until a distension plateau was reached such that the narrowest cross-sectional area (CSA) of the esophagus maximized despite further increases in intra-bag pressure. The esophageal distensibility (CSA vs pressure) was reduced in EoE patients (P = .02) with the distension plateau of EoE patients substantially lower than that of controls (median: CSA 267 mm(2) vs 438 mm(2); P < .01). Mucosal eosinophil count, age, sex, and current proton pump inhibitor treatment did not predict this limiting caliber of the esophagus (P ≥ 0.20). CONCLUSIONS Esophageal distensibility, defined by the change in the narrowest measurable CSA within the distal esophagus vs intraluminal pressure was significantly reduced in EoE patients compared with controls. Measuring esophageal distensibility may be an important adjunct to the management of EoE, as it is capable of providing an objective means to measure the outcomes of medical or dilation therapy.

Phenotypes and clinical context of hypercontractility in high-resolution esophageal pressure topography (EPT).

OBJECTIVES:This study aimed to refine the criteria for esophageal hypercontractility in high-resolution esophageal pressure topography (EPT) and to examine the clinical context in which it occurs.METHODS:A total of 72 control subjects were used to define the threshold for hypercontractility as a distal contractile integral (DCI) greater than observed in normals. In all, 2,000 consecutive EPT studies were reviewed to find patients exceeding this threshold. Concomitant EPT and clinical variables were explored.RESULTS:The greatest DCI value observed in any swallow among the control subjects was 7,732 mm Hg-s-cm; the threshold for hypercontractility was established as a swallow with DCI >8,000 mm Hg-s-cm. A total of 44 patients were identified with a median maximal DCI of 11,077 mm Hg-s-cm, all with normal contractile propagation and normal distal contractile latency, thereby excluding achalasia and distal esophageal spasm. Hypercontractility was associated with multipeaked contractions in 82% of instances, leading to the name “Jackhammer Esophagus.” Dysphagia was the dominant symptom, although subsets of patients had hypercontractility in the context of esophagogastric junction (EGJ) outflow obstruction, reflux disease, or as an apparent primary motility disorder.CONCLUSIONS:We describe an extreme phenotype of hypercontractility characterized in EPT by the occurrence of at least a single contraction with DCI >8,000 mm Hg-s-cm, a value not encountered in control subjects. This phenomenon, branded “Jackhammer Esophagus,” was usually accompanied by dysphagia and occurred both in association with other esophageal pathology (EGJ outflow obstruction, reflux disease) or as an isolated motility disturbance. Further studies are required to define the pathophysiology and treatment of this disorder.

The contractile deceleration point: an important physiologic landmark on oesophageal pressure topography.

Background  This study aimed to correlate oesophageal bolus transit with features of oesophageal pressure topography (OPT) plots and establish OPT metrics for accurately measuring peristaltic velocity.

High-Resolution Manometry Studies Are Frequently Imperfect but Usually Still Interpretable

BACKGROUND & AIMS Clinical esophageal manometry can be technically challenging. We investigated the prevalence and causes of technically imperfect, high-resolution esophageal pressure topography (EPT) studies at a tertiary referral hospital. METHODS We reviewed 2000 consecutive clinical EPT studies that had been performed with consistent technique and protocol. A study was considered technically imperfect if there was a problem with pressure signal acquisition, if the catheter did not pass through the esophagogastric junction (EGJ), or if there were fewer than 7 evaluable swallows (without double-swallowing, and so forth). Data from the technically imperfect studies were interpreted blindly to determine a diagnosis; this diagnosis was compared with the diagnosis based on chart review. RESULTS We identified 414 technically imperfect studies (21% of the series). These were attributed to fewer than 7 evaluable swallows (58%), inability to traverse the EGJ (29%), sensor or thermal compensation malfunction (7%), and miscellaneous artifacts (6%). The most frequent causes of failure to traverse the EGJ were a large hiatal hernia (50%) and achalasia (24%). The condition most frequently associated with an incomplete swallow protocol was achalasia (33%). Despite the limitations, the diagnosis of achalasia was achieved correctly by blinded interpretation in 77% of cases and nonblinded interpretation in 94% of cases. CONCLUSIONS Technically imperfect EPT studies are common in a tertiary care center; large hiatal hernia and achalasia were the most frequent causes. However, despite the technical limitations, the data still could be interpreted, especially in the context of associated endoscopic and radiographic data.

Effects of Large Hiatal Hernias on Esophageal Peristalsis

HYPOTHESIS Anatomic changes induced by large hiatal hernia may alter esophageal pressure topography measurements made during high-resolution manometry. DESIGN Retrospective study. SETTING Single-institution tertiary hospital. PATIENTS Ninety patients with large (>5 cm) hiatal hernias on endoscopy were compared with a control group of 46 patients without hernia selected from the same database of 2000 consecutive clinical high-resolution manometry studies. INTERVENTION High-resolution manometry with at least 7 evaluable swallows for analysis. MAIN OUTCOMES MEASURES Esophageal pressure topography was analyzed for lower esophageal sphincter pressure, distal contractile integral, contraction amplitude, contractile front velocity, and distal latency time. Esophageal length was measured on esophageal pressure topography from the distal border of the upper esophageal sphincter to the proximal border of the lower esophageal sphincter. Esophageal pressure topography diagnosis was based on the Chicago Classification. RESULTS The manometry catheter was coiled in the hernia and did not traverse the diaphragm in 44 patients (49%) with large hernia. Patients with large hernias had lower average lower esophageal sphincter pressures, a lower distal contractile integral, slower contractile front velocity, and shorter distal latency time than patients without hernia. They also exhibited a shorter mean esophageal length. However, the distribution of peristaltic abnormalities was not different in patients with and without large hernia. CONCLUSIONS Patients with large hernias had an alteration of esophageal pressure topography measurements and a shortened esophagus. However, the distribution of peristaltic disorders was unaffected by the presence of hernia.

Jackhammer Esophagus: A Symptomatic Phenotype of Hypertensive Contraction in High Resolution Esophageal Pressure Topography (EPT)

Background: Although hypertensive esophageal motor disorders have been linked to symptoms of chest pain and dysphagia, hypertensive peristalsis is heterogeneous, ranging from a normal variant to extreme degrees of hypercontractility. This study aimed to define an extreme phenotype of hypertensive peristalsis found in symptomatic patients that is not encountered in asymptomatic controls. Methods: A series of 2,000 consecutive clinical EPT studies performed from January 2007 until May 2010, all with consistent methodology (Sierra), were reviewed. After excluding patients with previous upper GI surgery, duplicate studies and technically-limited studies, we identified 30 subjects with ≥2 test swallows followed by a contraction with a DCI greater than 8,000 mmHg-cm-s (the maximal value observed in 72 controls). Because of their frequent repetitive vigorous morphology these contractions were branded the “jackhammer” pattern. Swallows exhibiting jackhammer contractions were then further analyzed for associated Integrated Relaxation Pressure (IRP), Contractile Front Velocity (CFV), Distal contractile Latency (DL), presence of repetitive contractions, and a novel metric describing the proportion of the distal segment concurrently contracting. The maximal Vertical Contraction (VC) length was calculated by exporting data files into MATLAB. A spatial pressure variation function of the greatest contractile pressure along the esophagus was calculated to identify the proximal (P) and the distal troughs (D). Using a fixed threshold of 30 mmHg, the contraction was search to find the instant characterized by maximal VC segment length between the P and D, expressed as a percentage of PD length and in cm. Results: Among the 30 patients, 4 had spastic achalasia and 1 DES. The 25 remaining patients (11 males, mean age 57 years, range 28-82) had jackhammer contractions with normal CFV and DL. Five of them had a mean IRP greater than 15 mmHg (range 15.7-51.2). Their main symptom was dysphagia in 19, chest pain in 2 and reflux in 4. The EPT findings of these subjects are described in the Table. Notably, only 9 patients of 25 fulfilled the criteria of spastic nutcracker as described in the Chicago Classification, circa 2009 [1] (mean DCI of all 10 swallows >8,000). Conclusion: We describe a phenotype of hypertensive contractions associated with multiple peaks and a longer vertical length of contraction (VC) compared to asymptomatic controls. These repetitive contractions evoke the action of jackhammer and we propose the name “jackhammer esophagus” to supplant the prior category “spastic nutcracker” which was not widely accepted. Jackhammer esophagus (2 peristaltic contractions with DCI >8,000) appears to be a physiologically homogeneous entity that is usually associated with dysphagia. [1] Pandolfino JE, et al. Neurogastroenterol Motil 2009;21:796.

Do Large Hiatal Hernias Affect Esophageal Peristalsis

Background: Large hiatal hernias (LHH) can be associated with esophageal shortening and/ or a tortuous esophagus. We hypothesized that these anatomic changes may induce motility changes that would systematically alter high resolution esophageal pressure topography (EPT) measurements. Aim: To compare EPT measures of esophageal motility in patients with LHH to those of matched patients without hernia. Methods: Among 2000 consecutive clinical EPT, we identified 49 patients with LHH on endoscopy (hernia >5 cm) and with at least 7 evaluable swallows on EPT. Within the same database (after exclusion of patients with achalasia, absent peristalsis, or previous gastrointestinal surgery) a control group without hernia on endoscopy was selected, matched for gender, age, and symptoms (dysphagia, reflux). EPT were subsequently analyzed for: lower esophageal sphincter (LES) or esophagogastric junction (EGJ) pressure, intragastric pressure, Integrated Relaxation Pressure (IRP), Distal Contractile Integral (DCI), Contractile Front Velocity (CFV) and Distal Latency time (DL) between the onset of contraction at the upper esophageal sphincter (UES) and the contractile deceleration point. Esophageal length was measured on EPT from the distal border of UES to the proximal border of LES at 20-mmHg isobaric contour. EGJ morphology was also characterized, and an EPT diagnosis (Chicago Classification) was made for each patient based on individual swallow characteristics. EPT characteristics were summarized as median (IQR).The two groups were then compared using the chi-squared test for categorical data and the Mann Whitney test for continuous data. Results: Patients with LHH had a significant shorter esophagus than patients without hernia (21 (18.9-23.3) cm vs 25.4 (24.2-27.2), p<0.01). In patients with LHH, EPT studies were classified as normal (n=21), weak peristalsis (n=18), frequent failed peristalsis (n=4), spasm (n=1), rapid contractions with normal latency (n=3), hypertensive peristalsis (n=1) and functional obstruction (n=1). The distribution of motility disorder diagnoses was not different in patients with LHH and in the matched patients without hernia (p = 0.82). Significant differences were seen in EGJ pressures, IRP, intragastric pressure, DCI and DL between groups (Table). However the correlation between the esophageal length and the mean DCI was weak (r=0.23, p=0.02) as well as the correlation between the esophageal length and the DL (r=0.24, p=0.02). Conclusions: In addition to a lower pressure at the EGJ, patients with LHH also had significantly lower DCI and shorter DL on EPT as a consequence of the associated shortened esophagus. However, despite these differences in individual parameters, the final diagnosis and distribution of motility disorders was unaffected by the presence of a hernia.

T1135 The Complementary Role of Impedance Color Contours for Analysis of Impedance-pH Tracings During Esophageal Reflux Monitoring

Medical management of adults with osteoarthritis (OA) who require non-steroidal anti-inflammatory drugs (NSAIDs) must be decided after assessing gastrointestinal (GI) and cardiovascular (CV) risks in the individual patient. Aim: To evaluate the gastrointestinal and cardiovascular risk profile of OA patients who require NSAIDs. Methods: We conducted a transversal, multicenter and observational study in consecutive patients with OA who were considered candidates for NSAID treatment and were visited by 374 unselected rheumatologists throughout the National Health System. Patients were classified into three risk groups (low, moderate and high) for their GI and CV characteristics. These were defined attending to the presence of a number of well-established GI risk factors (Lanas & Hunt, Ann Med 2006; 38, 415-28) or to the application of the European SCORE model (Conroy et al. 2003; EurHeart J 24, 987-1003) for assessing the overall risk for cardiovascular disease, respectively. Results: The study sample was composed of 3293 patients; mean age was 64.7±10.9 years, the majority of whom were women (73.2%). The mean time from diagnosis was 5.4 years, with 66.6% of the patients diagnosed with axial OA of the spine and 81.1% with peripheral OA of the hand, hip and knee. Most patients (86.6%) (2880/3248) were at increased GI risk, and a significant number (22.3%) (724/3248) were at high GI risk. The CV risk was high in 44.2% of the patients (1440/3261), moderate in 19.9% (648/3261) and low in 36% (1173/3261). Only 26.4% of those at high CV risk were on ASA, whereas 22.7% of all ASA users (104/457) were taking concomitantly Ibuprofen. Overall, 15.5% (504/3248) of patients presented a very high-risk profile, having both high GI and CV risks. The type of NSAID prescription was similar regardless of the associated GI and CV risk profile. Conclusion: Most patients with osteoarthritis requiring NSAIDs for pain control showed a high prevalence of GI and CV risk factors. Over half of the patients were at either high GI or CV risk or both, such that the prescription of OA treatments should be very carefully considered.