Margot Selleslagh

Objective assessment of swallow function in children with suspected aspiration using pharyngeal automated impedance manometry.

Objectives: The purpose of the present study was to apply a new method, pharyngeal automated impedance manometry (AIM), as an objective assessment tool of swallow function relevant to aspiration, in a cohort of paediatric patients with dysphagia. Methods: We studied 20 children (mean age 6 years [5 months to 13.4 years]) referred for videofluoroscopy to assess aspiration risk with simultaneous manometry–impedance. Fluoroscopic evidence of aspiration was scored using a validated aspiration–penetration score. Pressure–flow profiles were analysed using AIM analysis measuring peak pressure, pressure at nadir impedance, time from nadir impedance to peak pressure, and flow interval. These variables were combined into a swallow risk index (SRI). Results: Six of 20 children presented with deglutitive aspiration during videofluoroscopic assessment of swallowing. Of 58 liquid swallows analysed, in 9 aspiration was observed. Multiple logistic regression identified longer flow interval (P < 0.05), higher SRI (P < 0.05) and increased pressure in the upper oesophageal sphincter during maximal bolus flow (P < 0.05) to be the dominant risk variables predictive of aspiration in children. Each of these nonradiologically derived pressure–flow variables correlated with higher aspiration scores on videofluoroscopy (P < 0.01). Conclusions: We present novel, preliminary findings in children with deglutitive aspiration, suggesting that pharyngeal AIM can detect alterations in pressure–flow characteristics of swallowing that predispose to aspiration risk.

Pressure flow analysis in the assessment of preswallow pharyngeal bolus presence in Dysphagia.

Objectives. Preswallow pharyngeal bolus presence is evident in patients with oropharyngeal dysphagia. Pressure flow analysis (PFA) using high resolution manometry with impedance (HRMI) with AIMplot software is a method for objective interpretation of pharyngeal and upper esophageal sphincter (UES) pressures and bolus flow patterns during swallowing. This study aimed to observe alterations in PFA metrics in the event of preswallow pharyngeal bolus presence as seen on videofluoroscopy (VFSS). Methods. Swallows from 40 broad dysphagia patients and 8 controls were recorded with a HRMI catheter during simultaneous VFSS. Evidence of bolus presence and level reached prior to pharyngeal swallow onset was recorded. AIMPlot software derived automated PFA functional metrics. Results. Patients with bolus movement to the pyriform sinuses had a higher SRI, indicating greater swallow dysfunction. Amongst individual metrics, TNadImp to PeakP was shorter and flow interval longer in patient groups compared to controls. A higher pharyngeal mean impedance and UES mean impedance differentiated the two patient groups. Conclusions. This pilot study identifies specific altered PFA metrics in patients demonstrating preswallow pharyngeal bolus presence to the pyriform sinuses. PFA metrics may be used to guide diagnosis and treatment of patients with oropharyngeal dysphagia and track changes in swallow function over time.

The complexity of globus: a multidisciplinary perspective

Globus is a topic of interest for many specialties including otorhinolaryngology, gastroenterology and psychiatry/psychosomatic medicine, but, although many hypotheses have been suggested, key questions about its aetiology remain. This Review provides an overview of the extensive literature concerning this topic and discusses the quality of the evidence to date. Globus has been associated with oropharyngeal structural lesions, upper oesophageal sphincter disorders, oesophageal disorders, GERD, psychosocial factors and psychiatric comorbidity. However, findings are often contradictory and the literature remains highly inconclusive. Indeed, with the exception of patients with structural-based globus, the Rome III criteria for functional globus only apply to a subgroup of patients with idiopathic globus. In clinical reality, there exists a group of patients who present with idiopathic (nonstructural) globus, but nevertheless have dysphagia, odynophagia or GERD—exclusion criteria for globus diagnosis according to Rome III. The symptomatology of patients with globus might be broader than previously thought. It is therefore crucial to approach globus not from one single perspective, but from a multifactorial point of view, with focus on the coexistence and/or interactions of different mechanisms in globus pathogenesis. This approach could be translated to clinical practice by adopting a multidisciplinary method to patients presenting with globus.

Balloon dilation of the esophago‐gastric junction affects lower and upper esophageal sphincter function in achalasia

Pneumatic dilation of the lower esophageal sphincter (LES) in achalasia has an unappreciated effect on upper esophageal sphincter (UES) function. We studied UES pressure patterns at baseline and alterations in UES parameters resulting from therapy.

Automatische Impedantie Manometrie (AIM): objectieve diagnostiek van oro-faryngale dysfagie

Automated Impedance Manometry (AIM): objective diagnosis of oropharyngeal dysphagiaThis review article aims to demonstrate the clinical potential of Automated Impedance Manometry (AIM) as a new, non-radiological technique for screening and diagnosis of oro-pharyngeal dysphagia. An integrated – rather than separate – analysis of pressure and impedance patterns generated in the pharynx when swallowing a food bolus, can be a useful complement to the radiological investigations considered as gold standard today. Major advantages are the objective nature of this technique and the fully automated calculation of various swallow parameters. A global measure of swallowing function can be derived (a Swallow Risk Index, SRI) and is related to (the severity of) the risk of aspiration and the presence of pharyngeal post-swallow residue. It was shown that aspiration on videofluoroscopy was accurately detected by using AIM with a sensitivity of 0.88 and a specificity of 0.96. AIM analysis can be performed quickly and is reliable in the hands of different end users. Various parameters are sufficiently sensitive to detect changes in bolus consistency and – as was recently found – are influenced by swallowing manoeuvers. Furthermore, different patterns of deviant swallow parameters can be found in different patient populations. Whether this observation can provide specific diagnoses and – as a consequence – more targeted treatments is currently under investigation.SamenvattingDit overzichtsartikel wil het klinisch potentieel aantonen van Automatische Impedantie Manometrie (AIM) als nieuwe, niet-radiologische techniek voor screening en diagnostiek van faryngale dysfagie, zijnde slikstoornissen in de mond, keelholte en bovenste slokdarm. Deze AIM-techniek maakt gebruik van een katheter met druksensoren en impedantie-elektroden om slikken kwantitatief te beschrijven. Een geïntegreerde – eerder dan afzonderlijke – analyse van de gemeten druk- en impedantiepatronen die ontstaan bij het doorslikken van een voedselbolus, kan een zinvolle aanvulling zijn op de dynamische beeldvormingsonderzoeken die vandaag de dag als gouden standaard worden gezien. Belangrijke voordelen zijn het objectieve karakter van de techniek en de geautomatiseerde berekening van diverse slikparameters. Een globale maat voor de slikfunctie kan worden bekomen (Slik Risico Index, SRI) en houdt verband met (de ernst van) het aspiratierisico van de patiënt en de aanwezigheid van bolusresidu. Zo kan een accurate detectie van aspiratie met een sensitiviteit van 0,88 en specificiteit van 0,96 niet via radiologisch onderzoek bereikt worden. Verschillende slikparameters zijn ook voldoende gevoelig om veranderingen in voedselconsistentie te detecteren en om de effecten van slikmanoeuvres objectief te beschrijven. Recent werd ook aangetoond dat deze AIM-analyse snel en betrouwbaar kan worden uitgevoerd door clinici met variërende ervaring en opleiding. Bovendien worden in verschillende patiëntengroepen andere patronen van afwijkende slikparameters aangetroffen. Of deze observatie aanleiding kan geven tot specifieke slikdiagnoses en dus meer gerichte behandelingen is momenteel onderwerp van onderzoek.

Tu1200 Swallow Function and Post-Swallow Residue in Dysphagic Patients With and Without a History of Pneumonia

BACKGROUND: Automated Impedance Manometry (AIM) analysis defines swallow metrics indicative of bolus timing and presence, contractile vigour and luminal diameter. The Swallow Risk Index (SRI) and integrated nadir impedance to impedance ratio (iZn/Z) are global indices correlating with aspiration risk and post-swallow residue respectively (Omari et al., Gastroenterology 2011; Omari et al., Neurogastro. Mot. 2012). This study compared the SRI and iZn/Z ratio for controls and dysphagic patients with and without a history of pneumonia. METHODS: 87 asymptomatic controls 20-91y (39M, mean 59y) and 201 dysphagic patients 17-91y (117 male, mean 67y) were investigated. 33 patients had history of pneumonia. Swallowing of 5-10ml liquid boluses was recorded by solid state manometryimpedance catheter (OD 3.2mm, 36 pressure at 1cm, 12 impedance at 2cm). AIMplot software was used to derive SRI and iZn/Z indices. RESULTS: 140 patients had abnormal swallow function (SRI>15). 123 patients had significant post-swallow residue (iZn/Z.500). The SRI and iZn/Z ratio were higher in relation to dysphagia. Furthermore, the iZn/Z ratio was higher in dysphagic patients with a history of pneumonia compared to those with no history (See Figure). The latency from bolus flow to pharyngeal contraction was shorter and pharyngeal bolus dwell time was longer in relation to pneumonia (ANOVA p,0.001, p,0.05 for all pairwise comparisons). Pharyngeal pressures and UES relaxation pressures were not significantly different in relation to pneumonia. CONCLUSIONS: Pharyngeal HRIM with AIM analysis can detect increased swallow dysfunction and post-swallow residue in dysphagic patients. Patients with a history of pneumonia have higher post swallow residues.

137c Globus Patients are Characterized by Abnormal Sensitization of the Esophageal Body Upon Repeated Balloon Distensions

participating 15 refused, 10 were deceased secondary to unrelated conditions, 5 were medically incapacitated for unrelated reasons, and 2 could not be reached. Of the 94 participants, 68% were female with a mean age of 53 years old. Manometric findings were normal in 63 (67%), weak peristalsis in 23 (25%), frequent failed peristalsis in 2 (2%), and hypertensive peristalsis in 6 (6%). No patients with normal studies or borderline manometric abnormalities had undergone myotomy or dilation. Further, PPI use and fundoplication rates were similar in patients with borderline manometric abnormalities when compared to those with normal esophageal manometry. Significant dysphagia at follow up (IDQ>8) was rare, seen in only 9 patients. The main indications for HRM were dysphagia (46%) and gastroesophageal reflux (35%), with no association between these indications and peristaltic abnormalities or persistence of dysphagia at follow up. (Table) Conclusion: Patients defined as normal or having borderline esophageal motor function using the Chicago classification appear to have minimal symptoms or medical interventions related to esophageal dysfunction during a 5 year follow-up.Only 14% of patients had significant dysphagia. Thus, identification of normal and borderline motor function is a good prognostic indicator as these patterns are associated with minimal long term consequences. Natural history of peristalsis patterns on HRM

Tu1980 Radiological Correlates of Esophageal Pressure-Flow Variables Derived by Automated Impedance Manometry (AIM) Analysis

INTRODUCTION: Pressure-flow analysis may quantify the interactions between bolus transport and pressure generation during bolus swallowing. The functional relevance of pressure flow metrics is still to be fully elucidated and therefore we undertook a pilot study to assess the interrelationships between pressure-flow metrics and fluoroscopically determined bolus clearance and bolus transport across the EGJ. We hypothesise that differences in pressureflow metrics would correlate with changes in bolus clearance and reduced flow across the EGJ. METHODS: Videofluoroscopic images, impedance and pressure were recorded simultaneously in 16 control subjects (19-44y, 8m) tested with liquid (L), semi-solid (SS) and solid barium boluses (S). A 3.6mm diameter solid-state catheter with 36x1cm pressure/ 16x2cm impedance was used (Solar GI system, MMS). Swallowed bolus clearance was videofluroscopically assessed using a validated 7-point bolus transport scale; higher score = poor bolus clearance. The cumulative period of bolus flow across the EGJ was also measured (EGJ flow time). Pressure Flow Index (PFI) was used to integrate bolus pressurisation and flow timing and Impedance Ratio (IR) was used to assess the effectiveness of bolus clearance. Subjects were asked to report the level of perception of bolus transit using a 5 point scale. RESULTS: in total 92 swallows were simultaneously acquired. A higher transport score, indicating more severe levels of bolus transport failure, correlated with higher Impedance Ratios (L r = 0.617 p<0.001; SS r= 0.580 p<0.001; S 0.841 p<0.001). IR had strong prognostic value for detecting incomplete bolus clearance (ROC area for transport score ≥3 was L 0.902; SS 0.782; S 0.906). When subjects perceived bolus transit this was associated with a higher bolus transport score (2.0 vs. 4.6 for perception score 1 vs. score 2-5 respectively p=0.04). PFI and IR were used in combination to distinguish individual swallows on grounds of abnormal bolus pressurisation and/or clearance. Figure A demonstrates how solid swallows could be separated into 3 groups based on high or low PFI/IR : Group 1 Low PFI/ low IR, Group 2 low PFI /high IR and Group 3 high PFI. Comparisons among these groups in relation to fluoroscopic measures shows bolus transport abnormalities in Group 2 only (Fig B). EGJ flow time was shortest in Group 3 (Fig C). CONCLUSIONS: Different pressureflow signatures are associated with altered bolus clearance and/or flow across the EGJ. A high PFI pattern is associated with diminished flow across the EGJ, possibly due to increased flow resistance in the distal esophagus whilst a high IR is consistent with failed bolus transport to the EGJ. This study provides radiological confirmation that patterns of abnormal PFI and/or IR in dysphagia patients are consistent with abnormal flow patterns, possibly explaining patient symptoms.