Lubomyr Boris

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.

Distensibility of the esophagogastric junction assessed with the functional lumen imaging probe (FLIP™) in achalasia patients

The functional lumen imaging probe (FLIP), measures esophagogastric junction (EGJ) distensibility (cross‐sectional area/luminal pressure) during volume‐controlled distension. The aim of this study is to apply this tool to the assessment of the EGJ in untreated and treated achalasia patients and to compare EGJ distensibility with other diagnostic tools utilized in managing achalasia.

Increased Risk for Persistent Intestinal Metaplasia in Patients With Barrett's Esophagus and Uncontrolled Reflux Exposure Before Radiofrequency Ablation

BACKGROUND & AIMS Radiofrequency ablation (RFA) is a safe alternative to esophagectomy for patients with dysplastic Barretts esophagus (BE). Although some studies have indicated that RFA is effective at eradicating dysplasia, most have found that RFA is not as effective in eradicating intestinal metaplasia. We investigated whether uncontrolled reflux is associated with persistent intestinal metaplasia after RFA. METHODS Thirty-seven patients with BE underwent RFA, high-resolution manometry, and 24-hour impedance-pH testing; they received proton pump inhibitors twice daily. Patients returned every 2 months for repeat treatment or standard surveillance. Patients were classified as complete responders (CRs) if all intestinal metaplasia was eradicated in fewer than 3 ablation sessions. We analyzed clinical parameters to identify factors associated with a CR or incomplete responder (ICR). RESULTS Among the 37 patients, 22 had a CR and 15 had an ICR. Mann-Whitney U tests revealed that length of BE, size of hiatal hernia, and frequency of reflux, but not acid reflux, differed between CRs and ICRs. CRs had fewer weakly acidic events than ICRs (29.5 vs 52; P < .05) and total reflux events (33.5 vs 60; P < .05), and a trend toward fewer weakly alkaline events (1.0 vs 5.0; P = .06). No other clinical or manometric features differed between groups. CONCLUSIONS Uncontrolled, predominantly weakly acidic reflux despite twice-daily proton pump inhibitor therapy before RFA increases the incidence of persistent intestinal metaplasia after ablation in patients with BE. Length of BE and size of hiatal hernia also were associated with persistent intestinal metaplasia after RFA.

Refining the criterion for an abnormal Integrated Relaxation Pressure in esophageal pressure topography based on the pattern of esophageal contractility using a classification and regression tree model

Background  The Integrated Relaxation Pressure (IRP) is the esophageal pressure topography (EPT) metric used for assessing the adequacy of esophagogastric junction (EGJ) relaxation in the Chicago Classification of motility disorders. However, because the IRP value is also influenced by distal esophageal contractility, we hypothesized that its normal limits should vary with different patterns of contractility.

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.

Many patients continue using proton pump inhibitors after negative results from tests for reflux disease.

BACKGROUND & AIMS Ambulatory reflux testing is used to evaluate symptoms of gastroesophageal reflux disease (GERD) refractory to protein pump inhibitors (PPIs). We investigated the prevalence of PPI use in patients with negative results from Bravo pH or multichannel intraluminal impedance-pH (MII-pH) tests and factors that might predict the use of PPIs. METHODS We analyzed data from patients who had undergone Bravo pH monitoring or MII-pH testing at Northwestern University, without evidence of reflux disease. Demographics, endoscopy findings, pathology results, and provider recommendations were obtained via chart review. Eligible patients (n = 90) were contacted by telephone, and a cross-sectional survey was administered with questions about symptom severity, demographics, medication use, and health behaviors. Patients were compared by current PPI use, and statistical analyses were performed by using SAS version 9.2 software. RESULTS Thirty-eight patients (42.2%) reported current PPI use despite a negative result from a pH study. Only 17 patients (18.9%) recalled being instructed to stop taking PPIs; chart review showed documented instructions to stop PPI therapy for 15 patients (16.7%). There were no significant differences in demographic or clinical characteristics among patients compared by current PPI use. Patients taking a PPI were more likely than those not taking a PPI to report troublesome symptoms that affected their daily life, as measured by a questionnaire for the diagnosis of GERD (the GerdQ). CONCLUSIONS More than 42% of patients with negative results from pH monitoring studies continue PPI therapy despite physiological data that they do not have GERD.

Regional variation in distal esophagus distensibility assessed using the functional luminal imaging probe (FLIP)

This study aimed to evaluate the spatial variation in esophageal distensibility in normal subjects using a novel multichannel functional luminal imaging probe (FLIP).

The acoustic cough monitoring and manometric profile of cough and throat clearing.

Cough and throat clearing might be difficult to differentiate when trying to detect them acoustically or manometrically. The aim of this study was to assess the accuracy of acoustic monitoring for detecting cough and throat clearing, and to also determine whether these two symptoms present with different manometric profiles on esophageal pressure topography. Ten asymptomatic volunteers (seven females, mean age 31.1) were trained to simulate cough and throat clearing in a randomized order every 6 minutes during simultaneous acoustic monitoring and high-resolution manometry. The accuracy of automated acoustic analysis and two blinded reviewers were compared. The pattern of the events and the duration of the pressure changes were assessed using the 30 mmHg isobaric contour. There were 50 cough and 50 throat-clearing events according to the protocol. The sensitivity and specificity of automated acoustic analysis was 84% and 50% for cough, while the blinded analysis using sound revealed a sensitivity and specificity of 94% and 92%. The manometric profile of both cough and throat clearing was similar in terms of qualitative findings; however, cough was associated with a greater number of repetitive pressurizations and a more vigorous upper esophageal sphincter contraction compared with throat clearing. The acoustic analysis software has a moderate sensitivity and poor specificity to detect cough. The profile of cough and throat clearing in pressure topography revealed a similar qualitative pattern of pressurization with more vigorous pressure changes and a greater rate of repetitive pressurizations in cough.

Sa1184 Does EGJ Distensibility Measured by Endoflip AID in Diagnosis or Follow-up of Achalasia Patients? a Comparison Study With High Resolution Manometry and Timed Barium Esophagogram

Systemic sclerosis (SSc) or scleroderma is an autoimmune illness which frequently involves the gastrointestinal apparatus. Patients affected by scleroderma have frequently lower LES pressure, ineffective esophageal motility (IEM), delayed gastric emptying (GE) and prolonged oro-cecal transit time (OCTT). Our aim was to assess prospectively the correlation between delayed OCTT and esophageal motility abnormalities in a cohort of SSc patients. We enrolled 50 (7M/43F; median age 57) consecutive SSc patients and 60 healthy volunteers (HVs; 12M/ 48F; median age 47). Both groups underwent 50g oral glucose breath test (GBT) to exclude small intestine bacterial overgrowth, 10g lactulose hydrogen and octanoic acid breath tests (LHBT and OBT) to measure OCTT [normal value = 105min] and GE [normal value = 146min], and manometry to evaluate esophageal motility patterns according to international criteria (Spechler and Castell). Median LES pressure and distal esophageal wave amplitude were lower in SSc patients compared to HVs (15 vs. 25 and 35 vs. 86 mmHg, P 180min, P<0.01). We showed that abnormalities of both esophageal and small intestine motility are frequent in SSc patients and that, when the small bowel is involved by the disease, in most cases also esophageal motility is altered. Delayed GE plays a limited role in prolonging OCTT. LHBT is a noninvasive, cheap, well-tolerated diagnostic tool that may be useful to estimate intestinal involvement and also to predict a higher risk of esophageal hypomotility in SSc patients.

Esophageal Eosinophilia and Wall Distensibility in Eosinophilic Esophagitis (EoE) Before and After Treatment: Preliminary Outcomes

Background: Data suggests that food is a primary trigger for the development of esophageal eosinophilia in children. Six food elimination diets are effective in adults, but the efficacy of an elemental diet in adult patients with eosinophilic esophagitis (EoE) has not been reported. Aims: To determine whether adult patients with EoE exhibit clinical and histologic improvement to an elemental diet compared to their normal diet. To determine the time of response of esophageal eosinophilia to elemental diet. Methods: EoE was diagnosed by esophageal obstructive symptoms (dysphagia, chest pain, food impaction, heartburn) and esophageal biopsies demonstrating >20 eosinophils/HPF in the setting of high dose acid suppression. All subjects underwent a second EGD/biopsies 2-3 weeks after their initial EGD/biopsies to confirm stability of disease while maintaining their normal diet. After the 2nd EGD/biopsies, all patients were started on an elemental diet (Elecare, Abbott Laboratories, Columbus, Ohio) and underwent a 3d EGD/biopsies after 2 weeks of Elecare. If subjects did not completely respond (eos 20/HPF at 2nd EGD) and completed at least 2 weeks of the Elecare diet. Five subjects dropped out of the trial after 2 weeks (2 due to poor tolerance of the diet, 3 for personal reasons). One patient responded completely at 2 weeks (1 eos/hpf). The remaining 20 patients completed a 4 week trial of Elecare. Eosinophil counts did not vary significantly between the 1st and 2nd EGDs (distal 44 to 43 eos/HPF, proximal 33 to 40 eos/HPF respectively, p =0.43, p=0.43). Dramatic decreases in eosinophils were seen at 2 weeks after starting Elecare (average distal 13 eos/HPF and proximal 14 eos/HPF, p <0.001 for both) and decreases correlated with an overall clinical response to therapy at 4 weeks. Response continued less profoundly between 2 and 4 weeks on Elecare (distal 11 eos/HPF and proximal 8 eos/HPF). 11/21 (52%) responded with counts less than 8 eos/HPF by week 4. Discussion: Elemental diet resulted in marked improvement in esophageal eosinophilia in a substantial number of adults with EoE. Histologic response occurs within 2 weeks of starting the elemental diet and profound decreases in eosinophilia at 2 weeks are maintained at 4 weeks on diet. Elemental diets are useful in the treatment of EoE to provide rapid relief of symptoms and tissue eosinophilia.