Hala M. Imam

Flow time through esophagogastric junction derived during high-resolution impedance-manometry studies: a novel parameter for assessing esophageal bolus transit

This study aimed to develop and validate a method to measure bolus flow time (BFT) through the esophagogastric junction (EGJ) using a high-resolution impedance-manometry (HRIM) sleeve. Ten healthy subjects were studied with concurrent HRIM and videofluoroscopy; another 15 controls were studied with HRIM alone. HRIM studies were performed using a 4.2-mm-outer diameter assembly with 36 pressure sensors at 1-cm intervals and 18 impedance segments at 2-cm intervals (Given Imaging, Los Angeles, CA). HRIM and fluoroscopic data from four barium swallows, two in the supine and two in the upright position, were analyzed to create a customized MATLAB program to calculate BFT using a HRIM sleeve comprising three sensors positioned at the crural diaphragm. Bolus transit through the EGJ measured during blinded review of fluoroscopy was almost identical to BFT calculated with the HRIM sleeve, with the nadir impedance deflection point used as the signature of bolus presence. Good correlation existed between videofluoroscopy for measurement of upper sphincter relaxation to beginning of flow [R = 0.97, P < 0.001 (supine) and R = 0.77, P < 0.01 (upright)] and time to end of flow [R = 0.95, P < 0.001 (supine) and R = 0.82, P < 0.01 (upright)]. The medians and interquartile ranges (IQR) of flow time though the EGJ in 15 healthy subjects calculated using the virtual sleeve were 3.5 s (IQR 2.3-3.9 s) in the supine position and 3.2 s (IQR 2.3-3.6 s) in the upright position. BFT is a new metric that provides important information about bolus transit through the EGJ. An assessment of BFT will determine when the EGJ is open and will also provide a useful method to accurately assess trans-EGJ pressure gradients during flow.

Majority of symptoms in esophageal reflux PPI non-responders are not related to reflux.

Genesis of persistent gastro‐esophageal reflux symptoms despite proton pump inhibitor (PPI) therapy is not fully understood. We aimed at determining reflux patterns on 24‐h pH‐impedance monitoring performed on PPI and correlating impedance patterns and symptom occurrence in PPI non‐responders.

The four phases of esophageal bolus transit defined by high-resolution impedance manometry and fluoroscopy

We aimed to model esophageal bolus transit based on esophageal pressure topography (EPT) landmarks, concurrent intrabolus pressure (IBP), and esophageal diameter as defined with fluoroscopy. Ten healthy subjects were studied with high-resolution impedance manometry and videofluoroscopy. Data from four 5-ml barium swallows (2 upright, 2 supine) in each subject were analyzed. EPT landmarks were utilized to divide bolus transit into four phases: phase I, upper esophageal sphincter (UES) opening; phase II, UES closure to the transition zone (TZ); phase III, TZ to contractile deceleration point (CDP); and phase IV, CDP to completion of bolus emptying. IBP and esophageal diameter were analyzed to define functional differences among phases. IBP exhibited distinct changes during the four phases of bolus transit. Phase I was associated with filling via passive dilatation of the esophagus and IBP reflective of intrathoracic pressure. Phase II was associated with auxotonic relaxation and compartmentalization of the bolus distal to the TZ. During phase III, IBP exhibited a slow increase with loss of volume related to peristalsis (auxotonic contraction) and passive dilatation in the distal esophagus. Phase IV was associated with the highest IBP and exhibited isometric contraction during periods of nonemptying and auxotonic contraction during emptying. IBP may be used as a marker of esophageal wall state during the four phases of esophageal bolus transit. Thus abnormalities in IBP may identify subtypes of esophageal disease attributable to abnormal distensibility or neuromuscular dysfunction.

Patient reported and anatomical outcomes after surgery for pelvic organ prolapse

Primary aim was to modify Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) to assess pelvic organ prolapse (POP) in Arabic Muslim women. Secondary aim was to compare functional and anatomical outcomes of POP repair.

Impedance nadir values correlate with barium bolus amount

We examined the value of impedance monitoring in measuring bolus volume compared with videoesophagram. Eighty consecutive subjects were studied with simultaneous impedance-manometry-videoesophagram. A catheter with both an impedance electrode pair and a pressure transducer at four sites (5, 10, 15, 20 cm above lower esophageal sphincter) was passed per nares. Six 10-cc boluses of 45% barium mixed with 0.9% NaCl were swallowed at 20- to 30-second intervals. When impedance fell to below 1000 ohms, other than that occurring during administered swallows, the videofluoroscopic image corresponding to the time of impedance nadir was reviewed. If barium was present at the impedance site, barium area was calculated. The video was reviewed for the cause of abnormal barium transit causing barium presence. We found 38/80 subjects had a total of 169 impedance falls to below 1000 ohms. Ninety-seven percent (164/169) of impedance falls had barium present at the impedance site, and there was good correlation (r = 0.83, P < 0.001) between impedance nadir value and barium area. The impedance nadir value : barium area relationship was similar for the three causes of barium presence identified by video: failed bolus clearing; gastroesophageal reflux; and esophageal escape. Impedance nadir values 700-999 ohms usually had a small barium area. In contrast, nadir values <400 ohms had a large barium area covering all or most of the catheter and filling the esophagus at the impedance site. Impedance falls from >1000 ohms to a low nadir value from all forms of abnormal esophageal bolus transit imply a large bolus amount.

Role of endoscopic ultrasound-guided fine needle aspiration and ultrasound-guided fine-needle aspiration in diagnosis of cystic pancreatic lesions

Background and Objective: The addition of fine-needle aspiration (FNA) to different imaging modalities has raised the accuracy for diagnosis of cystic pancreatic lesions. We aim to differentiate benign from neoplastic pancreatic cysts by evaluating cyst fluid carcinoembryonic antigen (CEA), carbohydrate antigen (CA19-9), and amylase levels and cytopathological examination, including mucin stain. Patients and Methods: This prospective study included 77 patients with pancreatic cystic lesions. Ultrasound-FNA (US-FNA) or endoscopic ultrasound-FNA (EUS-FNA) was done according to the accessibility of the lesion. The aspirated specimens were subjected to cytopathological examination (including mucin staining), tumor markers (CEA, CA19-9), and amylase level. Results: Cyst CEA value of 279 or more showed high statistical significance in differentiating mucinous from nonmucinous lesions with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 73%, 60%, 50%, 80%, and 65%, respectively. Cyst amylase could differentiate between neoplastic and nonneoplastic cysts at a level of 1043 with sensitivity of 58%, specificity of 75%, PPV of 73%, NPV of 60%, and accuracy of 66%. CA19-9 could not differentiate between neoplastic and nonneoplastic cysts. Mucin examination showed a sensitivity of 85%, specificity of 95%, PPV of 92%, NPV of 91%, and accuracy of 91% in differentiating mucinous from non-mucinous lesions. Cytopathological examination showed a sensitivity of 81%, specificity of 94%, PPV of 94%, NPV of 83%, and accuracy of 88%. Conclusion: US or EUS-FNA with analysis of cyst CEA level, CA19-9, amylase, mucin stain, and cytopathological examination increases the diagnostic accuracy of cystic pancreatic lesions.

High-resolution manometry compared with the University of California, Los Angeles Scleroderma Clinical Trials Consortium GIT 2.0 in Systemic Sclerosis

OBJECTIVES To study esophageal high resolution manometry (HRM) in systemic sclerosis (SSc) patients and the correlation of findings to The University of California, Los Angeles Scleroderma Clinical Trials Consortium gastrointestinal tract 2.0 (UCLA SCTC_GIT 2.0). METHODS Forty SSc patients were administered to the UCLA SCTC GIT 2.0. Patients underwent HRM study (Solar GI MMS). HRM data were compared with 15 healthy volunteers. RESULTS Forty patients with mean age 46 ± 7 years and disease duration 9.3 ± 7 years reported upper (85.7%), lower GI symptoms (75%), while 5% reported no symptoms. Mean ± SD scores of UCLA SCTC_GIT 2.0 items were as follows: reflux 1.2 ± 0.8, distention 1.6 ± 1.2, fecal soiling 0.3 ± 0.9, diarrhea 0.8 ± 1, social 1 ± 1, emotional 1 ± 1.1, constipation 0.5 ± 0.9, and total GIT score 0.9 ± 0.6. Lower esophageal sphincter (LES) pressure and distal esophageal amplitude were significantly lower in SSc patients than controls. Main manometric findings were decreased LES resting pressure (40%) and aperistalsis (40%). Regression analyses showed distal esophageal amplitude and LES resting pressure negatively correlated with reflux score (r = -0.64; p = 0.001 and r = -0.46; p = 0.019, respectively), and total GIT score (r = -0.54; p = 0.007 and r = -0.42; p = 0.03, respectively). LES resting pressure had negative correlations with diarrhea score (r = -0.062; p = 0.002). CONCLUSIONS Decreased distal esophageal amplitude encountered as hypoperistalsis or even aperistalsis was associated with increased reflux and GIT scores (negatively correlated) UCLA SCTC_GIT 2.0 questionnaires. The GIT2.0 is easy to use and can serve as an indicator that further testing of the GI tract, including the esophagus, is indicated.

Su1098 Esophageal High Resolution Manometry (HRM) in Systemic Sclerosis: Correlation With University of California Los Angeles Scleroderma Clinical Trial Consortium GIT 2.0 (UCLA SSc_GIT 2.0) Questionnaire

Esophageal HRM is a new method to assess esophageal pressure characteristics. The UCLA SSc_GIT 2.0 is a validated disease-specific HRQOL instrument for evaluation of GIT-related activity and severity in systemic sclerosis (SSc). Aim: We studied HRM in SSc patients and the correlation of findings to the UCLA SSc_GIT 2.0 scores. Methods: Forty SSc patients administered UCLA SSc GIT 2.0 that includes multi-item scales: reflux, distention, diarrhea, fecal soiling, constipation, emotional well-being, social functioning, and total GIT score. Twenty out of 40 patients underwent esophageal HRM study (Solar GI MMS). HRM studies were analyzed for LES resting and residual pressures, esophageal amplitude and peristalsis integrity, duration and velocity of distal esophageal contraction, and UES resting and residual pressures. HRM data were compared with 15 healthy volunteers. Stepwise multiple linear regression analysis was done to test if HRM parameters could predict UCLA SSc_GIT 2.0 variables. Results: Forty patients (32 females), mean age 46 +/7 years, mean disease duration 9.3 +/7 years, reported upper (85.7%) and lower GI symptoms (75%), while 5% reported no symptoms. 31 patients had diffuse cutaneous systemic sclerosis (dcSSc), and 9 had limited cutaneous systemic sclerosis (LcSSc). Mean (SD) score of UCLA SSc_GIT 2.0 items for those who underwent HRM were as follow: reflux 1.2 +/0.8, distention 1.6 +/1.2, fecal soiling 0.3 +/0.9, diarrhea 0.8 +/1, social 1 +/1, emotional 1 +/1.1, constipation 0.5 +/0.9, and total GIT score 0.9 +/0.6. LES resting pressure and distal esophageal amplitude were significantly lower in SSc patients than control (table 1). Main manometric findings were decrease LES resting pressure (40%), aperistalsis (40%), small and large peristaltic breaks in mid and distal esophagus (55%), and low amplitude of proximal esophagus (25%) of patients. While, normal manometric findings were found in (15%) of SSc patients. Regression analyses showed distal esophageal amplitude and LES resting pressure negatively correlated with reflux score (r= -0.64; p= 0.001 and r= -0.46; p= 0.019 respectively), and total GIT score (r= -0.54; p= 0.007 and r=-0.42; p=0.03 respectively). While LES resting pressure only had negative correlation with diarrhea score (r= -0.062 p=0.002). No correlation was found between other HRM parameters and symptoms score. Conclusion: LES resting pressure and distal esophageal amplitude correlate with the UCLA SSc_GIT 2.0 questionnaire, and can be a predictor of the GIT affection in SSc. HRM parameters among SSc patients and control.

Mo1912 Phenotypes of PPI Non-Responders Using Esophageal pH-Impedance Monitoring: How Are They Different?

Introduction Different phenotypes of GERD-suspected patients who do not respond to proton pump inhibitor (PPI) therapy might be identified using pH-impedance monitoring. Our aim was to describe demographic, manometric and impedance patterns associated with phenotypes of PPI non-responders. Patients and methods PPI non-responders (without previous foregut surgery, scleroderma or achalasia) referred for 24-h esophageal pH-impedance monitoring on PPI were recruited. Demographic data, results of upper GI endoscopy and high resolution manometry were collected. Two investigators reviewed pH-impedance studies; a 3rd one arbitrated disagreements. Based on impedance pattern, reflux events were characterized as belch, supragastric belch, reflux starting with belch, reflux induced by supragastric belch, reflux associated with belch, reflux associated with supragastric belch, proximal liquid reflux, swallow-induced reflux, distal liquid reflux. Patients were classified into 3 groups: persistent acid reflux (acid esophageal exposure time (AET; esophageal pH 5% of total time), reflux sensitive esophagus (AET<5%, symptom index (SI)≥50%), and functional heartburn (AET<5%, SI<50%, absence of Barretts esophagus). Data are presented as percentage or median (range) and compared using Chi2 or Mann Whitney test. Results Eighty PPI non-responders (30 males, mean age 51 years (range 19-76), mean body mass index (BMI) 29.5 kg/m2 (range 18.6-44.1)) were included. AET was 0.5% (0.0-35.5) of total time and median number of reflux events (liquid, gas or mixed) was 45 (4-221). Eight patients (10%) had persistent acid reflux, 29 (36.2%) reflux sensitive esophagus and 43 (53.8%) functional heartburn. Characteristics of these groups are described in Table 1. Patients with persistent acid reflux had less frequently normal esophageal motility than the other patients groups (29% vs 46%, p<0.01). Patients with reflux sensitive esophagus or functional heartburn tended to present more frequently supra-gastric belch than patients with persistent acid reflux (60% vs 25, p=0.067). Distribution of dominant impedance patterns is presented in the Table 2. Conclusions The mechanistic reflux profile in PPI non-responders is heterogeneous. Although liquid reflux events were the most common mechanism of reflux in all three PPI non-responder subtypes, patients with reflux sensitivity and functional heartburn had much more variability in their mechanistic profile with a large proportion being associated with both suband supra-gastric belching. These different mechanistic profiles may have clinical implications as therapy targeting the dominant mechanism in each patient may be more effective. Table 1

Mo1913 Reflux Associated With Symptoms: Does the Impedance Pattern Matter?

Introduction Different phenotypes of GERD-suspected patients who do not respond to proton pump inhibitor (PPI) therapy might be identified using pH-impedance monitoring. Our aim was to describe demographic, manometric and impedance patterns associated with phenotypes of PPI non-responders. Patients and methods PPI non-responders (without previous foregut surgery, scleroderma or achalasia) referred for 24-h esophageal pH-impedance monitoring on PPI were recruited. Demographic data, results of upper GI endoscopy and high resolution manometry were collected. Two investigators reviewed pH-impedance studies; a 3rd one arbitrated disagreements. Based on impedance pattern, reflux events were characterized as belch, supragastric belch, reflux starting with belch, reflux induced by supragastric belch, reflux associated with belch, reflux associated with supragastric belch, proximal liquid reflux, swallow-induced reflux, distal liquid reflux. Patients were classified into 3 groups: persistent acid reflux (acid esophageal exposure time (AET; esophageal pH 5% of total time), reflux sensitive esophagus (AET<5%, symptom index (SI)≥50%), and functional heartburn (AET<5%, SI<50%, absence of Barretts esophagus). Data are presented as percentage or median (range) and compared using Chi2 or Mann Whitney test. Results Eighty PPI non-responders (30 males, mean age 51 years (range 19-76), mean body mass index (BMI) 29.5 kg/m2 (range 18.6-44.1)) were included. AET was 0.5% (0.0-35.5) of total time and median number of reflux events (liquid, gas or mixed) was 45 (4-221). Eight patients (10%) had persistent acid reflux, 29 (36.2%) reflux sensitive esophagus and 43 (53.8%) functional heartburn. Characteristics of these groups are described in Table 1. Patients with persistent acid reflux had less frequently normal esophageal motility than the other patients groups (29% vs 46%, p<0.01). Patients with reflux sensitive esophagus or functional heartburn tended to present more frequently supra-gastric belch than patients with persistent acid reflux (60% vs 25, p=0.067). Distribution of dominant impedance patterns is presented in the Table 2. Conclusions The mechanistic reflux profile in PPI non-responders is heterogeneous. Although liquid reflux events were the most common mechanism of reflux in all three PPI non-responder subtypes, patients with reflux sensitivity and functional heartburn had much more variability in their mechanistic profile with a large proportion being associated with both suband supra-gastric belching. These different mechanistic profiles may have clinical implications as therapy targeting the dominant mechanism in each patient may be more effective. Table 1