Kristle Lynch

Esophageal distensibility measurement: impact on clinical management and procedure length

Luminal distensibility measurement has demonstrated relevance to various disease processes, though its effects on clinical decision-making have been less well understood. This study aims to characterize the clinical impact of impedance planimetry measurement as well as the learning curve associated with its use in the esophagus. A single provider performed distensibility measurement in conjunction with upper endoscopy for a variety of clinical indications with the functional lumen imaging probe (FLIP) over a period of 21 months. Procedural data were prospectively collected and, along with medical records, retrospectively reviewed. Seventy-three procedures (70 patients) underwent esophageal distensibility measurement over the timeline of this study. The most common procedural indications were known or suspected achalasia (32.9%), dysphagia with connective tissue disease (13.7%), eosinophilic esophagitis (12.3%), and dysphagia with prior fundoplication (9.6%). FLIP results independently led to a change in management in 29 (39.7%) cases and supported a change in management in an additional 15 (20.5%) cases. The most common change in management was a new or amended therapeutic procedure (79.5%). Procedural time added by distensibility measurement was greater among earlier cases than among later cases. The median time added overall was 5 minutes and 46 seconds. Procedural time added varied significantly by procedural indication, but changes in management did not. Distensibility measurement added meaningful diagnostic information that impacted therapeutic decision-making in the majority of cases in which it was performed. Procedural time added by this modality is typically modest and decreases with experience.

Tu1978 LES Pressures Are Inversely Correlated to Esophagogastric Junction Diameter and Cross-Sectional Area in Achalasia

G A A b st ra ct s each method are shown in Table 1. Among these candidate methods, optimal discrimination from type I achalasia was achieved using the 4s-IRP method and receiver operating curve analysis revealed an optimal threshold %EGJR to be (<40%, sensitivity 100%, specificity 88%). The Figure shows %EGJR data using the 4s-IRP method for all patients compared to controls. As a single metric, the IRP exhibited superior discriminative performance to %EGJR among diagnoses. However, in certain instances, %EGJR was a useful secondary metric. Specifically, 100%(25 patients) of the Jackhammer group, a classification which may present with an elevated IRP and have an erroneous diagnosis of type III achalasia, fell within the normative range for percent EGJ relaxation. However, with low baseline EGJ pressure, %EGJR performed poorly in discriminating between patients with absent peristalsis(24/25 of whom had a collagen vascular disease or reflux disease) and type I achalasia. Conclusions: This study discounts the viability of the %EGJR metric as a stand-alone tool for assessing the adequacy of EGJ relaxation within the framework of the CC of motility disorders. However, there may be a supplementary role for this metric in identifying borderline cases of achalasia from mechanical causes of EGJ outflow obstruction and in differentiating Jackhammer cases from type III achalasia.

Mo1308 Liquid and Solid Gastric Scintigraphy Are Frequently Abnormal in Symptomatic Patients With Systemic Sclerosis

Background: Different mechanisms underlie gastroparesis. Patients with gastroparesis (GP) commonly have gastric dysrhythmias such as tachygastria. A subset of patients with GP has normal 3 cpm gastric myoelectrical activity with increased amplitude, suggesting normal corpus-antral electrocontractile function and the possibility of pyloric dysfunction. Our Aim was to assess the effect of pyloroplasty on symptoms, weight and gastric emptying in patients with GP, normal 3 cpm electrical activity and positive response to Botulinum A toxin injection or balloon dilation of the pylorus. Methods: Clinical databases were reviewed to identify patients with GP measured by scintigraphy (EggBeaters meal), normal 3 cpm gastric myoelectrical activity measured by electrogastrogram recording with water load test, and positive symptom response after Botulinum A injection or balloon dilation of the pylorus. Endoscopy excludedmechanical obstruction at the pylorus. Eighteen patients were identified; four underwent pyloroplasty; these patients also had gastric emptying and myoelectrical recordings 57 months after operation. Results: The four patients were women, ages 29 to 41 yrs. Three patients had idiopathic and one had diabetic GP. Nausea, vomiting and early satiety were the dominant symptoms. Percentage of meal retained at 4 hrs. was 24%, 34% and 96% (normal <9%) and one patient had 80% retained at 2 hr. (normal <60%). Botulinum A toxin injections (100 mg) ranged from 2-12 and balloon dilations ranged from 5-9. Pyloroplasty operations were performed laparoscopically and without complications. Patients reported improvement in nausea, vomiting and early satiety at their post-pyloroplasty clinic visits. Three patients gained 1, 5 and 20 pounds and one lost 7 pounds after pyloroplasty. Gastric emptying tests improved to normal in the three patients with idiopathic GP (% retained at 4 hrs. was 9%, 7%, and 1%) and improved from 96% to 27 % retained at 4 hrs. in the patient with DG. Water load volumes ingested before and after pyloroplasty were 481 ml and 325 ml, respectively. After pyloroplasty two patients had mixed gastric dysrhythmia and two had tachygastria after the water load test. Conclusion: Gastric emptying rates normalized or improved and symptoms decreased after pyloroplasty in carefully selected patients with GP, normal 3 cpm myoelectrical activity and positive pre-operative responses to pyloric therapies. These findings indicate that neuromuscular dysfunction of the pylorus results in functional obstructive GP, a key pathophysiological mechanism in this subset of GP.