Emily Tucker

Rumination variations: aetiology and classification of abnormal behavioural responses to digestive symptoms based on high‐resolution manometry studies

Rumination is the voluntary, albeit subconscious return of gastric contents to the mouth. Currently, rumination syndrome and repetitive belching disorders are considered separate diagnoses, as defined by Rome III criteria and high‐resolution oesophageal manometry (HRM).

Measurement of esophago-gastric junction cross-sectional area and distensibility by an endolumenal functional lumen imaging probe for the diagnosis of gastro-esophageal reflux disease

Measurement of esophago‐gastric junction (EGJ) cross‐sectional area (CSA) and distensibility by an Endolumenal Functional Lumen Imaging Probe (EndoFLIP®) may distinguish between gastro‐esophageal reflux disease (GERD) patients and healthy volunteers (HV). We aimed to assess the agreement of EndoFLIP® measurements with clinical and physiologic diagnosis of GERD.

Rapid Drink Challenge in high-resolution manometry: an adjunctive test for detection of esophageal motility disorders

The Chicago Classification for diagnosis of esophageal motility disorders by high‐resolution manometry (HRM) is based on single water swallows (SWS). Emerging data suggest that a “Rapid Drink Challenge” (RDC) increases sensitivity for motility disorders. This study establishes normal values and diagnostic thresholds for RDC in clinical practice.

Diagnostic yield of high-resolution manometry with a solid test meal for clinically relevant, symptomatic oesophageal motility disorders: serial diagnostic study

BACKGROUND The use of high-resolution manometry (HRM) to diagnose oesophageal motility disorders is based on ten single water swallows (SWS); however, this approach might not be representative of oesophageal function during the ingestion of normal food. We tested whether inclusion of a standardised solid test meal (STM) to HRM studies increases test sensitivity for major motility disorders. Additionally, we assessed the frequency and cause of patient symptoms during STM. METHODS Consecutive patients who were referred for investigation of oesophageal symptoms were recruited at Nottingham University Hospitals (Nottingham, UK) in the development study and at University Hospital Zürich (Zürich, Switzerland) in the validation study. HRM was done in the upright, seated position with a solid-state assembly. During HRM, patients ingested ten SWS, followed by a standardised 200 g STM. Diagnosis of oesophageal motility disorders was based on the Chicago Classification validated for SWS (CCv3) and with STM (CC-S), respectively. These studies are registered with ClinicalTrials.gov, numbers NCT02407938 and NCT02397616. FINDINGS The development cohort included 750 patients of whom 360 (48%) had dysphagia and 390 (52%) had reflux or other symptoms. The validation cohort consisted of 221 patients, including 98 (44%) with dysphagia and 123 (56%) with reflux symptoms. More patients were diagnosed with a major motility disorder by use of an STM than with SWS in the development set (321 [43%] patients diagnosed via STM vs 163 [22%] via SWS; p<0·0001) and validation set (73 [33%] vs 49 [22%]; p=0·014). The increase was most evident in patients with dysphagia (241 [67%] of 360 patients on STM vs 125 [35%] patients on SWS in the development set, p<0·0001), but was also present in those referred with reflux symptoms (64 [19%] of 329 patients vs 32 [10%] patients in the development set, p=0·00060). Reproduction of symptoms was reported by nine (1%) of 750 patients during SWS and 461 (61%) during STM (p<0·0001). 265 (83%) of 321 patients with major motility disorders and 107 (70%) of 152 patients with minor motility disorders reported symptoms during the STM (p=0·0038), compared with 89 (32%) of 277 patients with normal motility as defined with CC-S (p<0·0001). INTERPRETATION The diagnostic sensitivity of HRM for major motility disorders is increased with use of the STM compared with SWS, especially in patients with dysphagia. Observations made during STM can establish motility disorders as the cause of oesophageal symptoms. FUNDING None.

Development and validation of a large, modular test meal with liquid and solid components for assessment of gastric motor and sensory function by non‐invasive imaging

Current investigations of stomach function are based on small test meals that do not reliably induce symptoms and analysis techniques that rarely detect clinically relevant dysfunction. This study introduces the large ‘Nottingham Test Meal’ (NTM) for assessment of gastric motor and sensory function by non‐invasive imaging.

Su1076 Measurement of Esophago-Gastric Junction Cross-Sectional Area and Distensibility by Endoflip® (Endolumenal Functional Lumen Imaging Probe) for the Diagnosis of Patients With Gastro-Esophageal Reflux Disease (GERD)

Introduction EndoFLIP ® (Crospon, Ireland) is an innovative device designed to assess the cross sectional area (CSA) and distensiblilty of the esophagogastric junction (EGJ) by combined impedance planimetry and pressure measurement. Initial studies have suggested that this probe may distinguish between gastro-oesophageal reflux disease (GERD) patients and healthy volunteers (HV). Aim To assess the diagnostic agreement of EndoFLIP ® measurements with clinical and physiologic GERD diagnosis. Methods 22 healthy volunteers, (HV; female=16, age 21–46, mean body mass index (BMI) 24.3 kg/m 2 ) and 20 patients with GERD symptoms (female=14, age 19–78, mean BMI 33.2 kg/m 2 ) were studied. Patients were older (p ® balloon volume were measured. A Bravo capsule (Given Imaging, Israel) was attached 6 cm above the Z-line and a 48 h wireless esophageal pH recording acquired. The ability of EndoFLIP ® measurements to discriminate (1) patient group and (2) individuals with pathologic acid exposure (>5.6% time Results Complete measurements were acquired except in one patient with early detachment of Bravo capsule. Distensibility could not be measured in one patient and one volunteer with negative endoFLIP® balloon pressures. 7/22 (32%) HVs and 7/19 (37%) of patients had oesophagitis (six patients with hiatus hernia). 3/22 (14%) HVs and 9/19 (47%) patients had pathologic acid exposure (p=0.126). EGJ CSA was higher in healthy volunteers than the patient group, at 20 ml (p=0.018) and 30 ml (p=0.058, Abstract PTU-178 figure 1) endoFLIP® balloon volume. EGJ distensibility was lower in patients than HVs at 20 ml (p=0.001) and 30 ml balloon volume, (p=0.020, Abstract PTU-178 figure 1). EndoFLIP® measurements were similar in participants with and without pathologic acid exposure (median CSA 40 mm 2 vs 34 mm 2 p=1.0 at 20 ml, 98 mm 2 vs 107 mm 2 , p=0.789 at 30 ml) and distensibility at 20 ml (p=0.574) and 30 ml balloon volume (p=0.704). Post-hoc analysis revealed an inverse association between BMI and CSA (R 2 =0.214, p=0.003) and negative association with distensibility (R 2 =0.211, p=0.003). BMI was associated also with a trend to increased acid exposure (p=0.116). Conclusion EndoFLIP® is not useful for GERD diagnosis as EGJ CSA and distensibilty do not distinguish between HVs and GERD patients defined by clinical presentation or pH measurement. This unexpected result may be due to an important interaction of obesity with EndoFLIP® measurements. Competing interests None declared.

Gastric motor and sensory function in health assessed by magnetic resonance imaging: Establishment of reference intervals for the Nottingham test meal in healthy subjects

Current investigations of gastric emptying rarely identify the cause of symptoms or provide a definitive diagnosis in patients with dyspepsia. This study assessed gastric function by magnetic resonance imaging (MRI) using the modular “Nottingham test meal” (NTM) in healthy volunteers (HVs).

Tu1788 Comparison of Post-Operative Physiology Parameters Between Asymptomatic and Symptomatic Patients After Anti-Reflux Surgery

Background: A TLESR is a major mechanism of acid reflux in healthy subjects and patients with reflux esophagitis and we have noticed that the amplitude of primary peristalsis and EGJ pressure, following a TLESR, is accompanied by a forceful contraction, when compared with before a TLESR. The aim of this study is to investigate whether or not primary peristalsis and EGJ pressure, when accompanied by a forceful contraction and following a TLESR, is a characteristic finding of a TLESR. Methods: 10 healthy subjects underwent esophageal high-resolution manometry with a 21-lumen perfused assembly, which monitored pressure in the pharynx, the upper esophageal sphincter, the esophageal body, LES and the proximal stomach. The EGJ was evaluated using ten side holes, spaced at 1-cm intervals. Recordings were then taken, in the sitting position, for 1 hour after a meal (692 kcal, 33 % fat). A TLESR is defined as previously described. Data were analyzed, using Trace! Software (Dr. G.S Hebbard, The Royal Melbourne Hospital, Australia). The contractile integral (CI) of the distal esophageal segment (D-CI: volume of the domain above 20 mmHg), excluding the EGJ segment, was measured both before and after a TLESR, and the CI of the EGJ (EGJCI) (volume of the domain above 0 mmHg), was measured for 8 seconds after primary peristalsis reached the EGJ, both before and after a TLESR. Results: 56 TLESRs were measured during the study. The D-CI (1603 mmHg s cm (1177-2120), median (interquartile range)) following a TLESR was significantly greater than before a TLESR (484 (323-1079)) and more than a 50% increase of D-CI in 35 (62.5%) of the 56 TLESRs was observed. The EGJCI (790 (465-1009)) following a TLESR was significantly greater than before a TLESR (238 (186-308)) and more than a 50% increase in the EGJ-CI in 48 (85.7%) of the 56 TLESRs was observed. Conclusions: The D-CI and the EGJ-CI following a TLESR, were significantly greater than before a TLESR and this tendency was evident in the EGJ-CI, although it can, at times, be difficult to evaluate a TLESR. If the focus is on a forceful contraction of primary peristalsis or on the EGJ, it may be easier to detect and evaluate a TLESR.

Su1069 Diagnosis of Gastro-Esophageal Reflux Disease (GERD) and Prediction of Treatment Response to Proton Pump Inhibitors (PPI) by Prolonged Wireless pH Monitoring: A Prospective Assessment

Introduction Increasing duration of pH studies improves consistency of GERD diagnosis but clinical utility of the method is not established. Aim: (1) to identify measurements from prolonged pH studies that discriminate healthy volunteers (HVs) and GERD patients (2) to compare prediction of PPI response from prolonged and standard measurement. Methods HVs and patients with reflux symptoms entered a prospective trial. Quality of life (RAND-36) and symptom severity (Eraflux) was assessed on and off PPI and after 2 weeks ×2/day PPI. Endoscopy recorded mucosal disease. Wireless pH system (Bravo®, Given Imaging) measured acid reflux and symptoms up to 4 days. Receiver Operating Curve (ROC) assessed prediction of PPI response. For each prediction 80% of patients were randomly selected as training set, remaining 20% constituted test set. This was repeated 200 times producing average ROC with SEs. Area under Curve (AUC) quantified quality of prediction. Results Complete data were available from 25/33 HVs (18F, age 20–56) and 70/108 patients (31F, age 18–77), >320 days in total. Oesophagitis was present in 9 HVs (32%: Grade A) and 26 patients (33%: Grade A=19, B=2, C-D=5). Acid exposure time was elevated (AET >5.6%) in 3 (12%) HVs and 35 (50%) patients. Eraflux off-PPI was >25 (consistent with GERD) in 60/63 patients and fell by mean 7 (95% CI 5 to 10) on PPI, 46% reported positive response (>3 fall). Diagnosis: Endoscopy, AET and reflux-symptom association analysis (Symptom Index (SI)) did not discriminate health/disease; but reflux-associated symptoms/day (nRS/Day) covered different ranges for HV and patients. Logistic regression with bootstrap validation identified that ≥3 RS/day corresponded to ∼50% probability that participant was a patient. PPI response: Clinical parameters and AET did not predict outcome. SI (9.2 vs 30.2, p=0.0023) and nRS/Day (1 vs 2.6, p=0.012) were higher in responders. RAND-36 scores for poor physical role and pain were higher in non-responders (p∼0.1). SI ROC had an AUC of 0.73 (CI 0.51 to 0.92). SI >25 was the optimal cut-off for identifying PPI responders (Abstract PTU-197 figure 1). Prediction quality from 24 h studies was lower (AUC 0.69) and CIs for all parameters were wider with lower CI. Conclusion Diagnostic consistency for all parameters increases with study duration. A simple count of nRS/Day best discriminates HVs from patients on pH studies. SI >25 provides single best prediction of PPI response; but quality of predictions was modest in this population with low PPI response. Competing interests None declared.

The efficacy of antibiotics against Propionibacterium acnes biofilm infections on spinal implant material

Treated groups One group of mature biofilms was exposed to Penicillin G alone and the other with combination of Penicillin G with Rifampicin for 96 hrs respectively. Again, the discs were retrieved, sonicated and the number of viable bacteria were counted by chemilumiluminesence and culture Results All P.acnes biofilms responded to treatment with a significant reduction in bacterial numbers. Combination therapy was more effective and produced greater reductions (96.6%) of viable bacteria populating the biofilms than penicillin alone, 93.3% (p < 0.01). Complete eradication of the biofilm was not achieved in any cases.