Monika A. Kwiatek

Achalasia: A New Clinically Relevant Classification by High-Resolution Manometry

BACKGROUND & AIMSnAlthough the diagnosis of achalasia hinges on demonstrating impaired esophagogastric junction (EGJ) relaxation and aperistalsis, 3 distinct patterns of aperistalsis are discernable with high-resolution manometry (HRM). This study aimed to compare the clinical characteristics and treatment response of these 3 subtypes.nnnMETHODSnOne thousand clinical HRM studies were reviewed, and 213 patients with impaired EGJ relaxation were identified. These were categorized into 4 groups: achalasia with minimal esophageal pressurization (type I, classic), achalasia with esophageal compression (type II), achalasia with spasm (type III), and functional obstruction with some preserved peristalsis. Clinical and manometric variables including treatment response were compared among the 3 achalasia subtypes. Logistic regression analysis was performed using treatment success as the dichotomous dependent variable controlling for independent manometric and clinical variables.nnnRESULTSnNinety-nine patients were newly diagnosed with achalasia (21 type I, 49 type II, 29 type III), and 83 of these had sufficient follow-up to analyze treatment response. Type II patients were significantly more likely to respond to any therapy (BoTox [71%], pneumatic dilation [91%], or Heller myotomy [100%]) than type I (56% overall) or type III (29% overall) patients. Logistic regression analysis found type II to be a predictor of positive treatment response, whereas type III and pretreatment esophageal dilatation were predictive of negative treatment response.nnnCONCLUSIONSnAchalasia can be categorized into 3 subtypes that are distinct in terms of their responsiveness to medical or surgical therapies. Utilizing these subclassifications would likely strengthen future prospective studies of treatment efficacy in achalasia.

Classifying Esophageal Motility by Pressure Topography Characteristics: A Study of 400 Patients and 75 Controls

AIM:This study aimed to devise a scheme for the systematic analysis of esophageal high-resolution manometry (HRM) studies displayed using topographic plotting.METHODS:A total of 400 patients and 75 control subjects were studied with a 36-channel HRM assembly. Studies were analyzed in a stepwise fashion for: (a) the adequacy of deglutitive esophagogastric junction (EGJ) relaxation, (b) the presence and propagation characteristics of distal esophageal persitalsis, and (c) an integral of the magnitude and span of the distal esophageal contraction.RESULTS:Two strengths of pressure topography plots compared to conventional manometric recordings were: (a) the ability to delineate the spatial limits, vigor, and integrity of individual contractile segments along the esophagus, and (b) the ability to distinguish between loci of compartmentalized intraesophageal pressurization and rapidly propagated contractions. Making these distinctions objectified the identification of distal esophageal spasm (DES), vigorous achalasia, functional obstruction, and nutcracker esophagus subtypes. Applying these distinctions made the diagnosis of spastic disorders quite rare: (a) DES in 1.5% patients, (b) vigorous achalasia in 1.5%, and (c) a newly defined entity, spastic nutcracker, in 1.5%.CONCLUSIONS:We developed a systematic approach to analyzing esophageal motility using HRM and pressure topography plots. The resultant scheme is consistent with conventional classifications with the caveats that: (a) hypercontractile conditions are more specifically defined, (b) distinctions are made between rapidly propagated contractions and compartmentalized esophageal pressurization, and (c) there is no “nonspecific esophageal motor disorder” classification. We expect that pressure topography analysis, with its well-defined functional implications, will prove valuable in the clinical management of esophageal motility disorders.

Mechanical Properties of the Esophagus in Eosinophilic Esophagitis

BACKGROUND & AIMSnThis study aimed to analyze the mechanical properties of the esophagus in eosinophilic esophagitis (EoE) using the functional luminal imaging probe (EndoFLIP; Crospon Medical Devices, Galway, Ireland).nnnMETHODSnThirty-three EoE patients (22 male; age range, 23-67 years) and 15 controls (6 male; age range, 21-68 years) were included. Subjects were evaluated during endoscopy with the EndoFLIP probe, comprised of a compliant cylindrical bag (maximal diameter 25 mm) with 16 impedance planimetry segments. Stepwise bag distensions from 2 to 40 mL were conducted and the associated intrabag pressure and intraluminal geometry were analyzed.nnnRESULTSnThe EndoFLIP clearly displayed the tubular esophageal geometry and detected esophageal narrowing and localized strictures. Stepwise distension progressively opened the esophageal lumen until a distension plateau was reached such that the narrowest cross-sectional area (CSA) of the esophagus maximized despite further increases in intra-bag pressure. The esophageal distensibility (CSA vs pressure) was reduced in EoE patients (P = .02) with the distension plateau of EoE patients substantially lower than that of controls (median: CSA 267 mm(2) vs 438 mm(2); P < .01). Mucosal eosinophil count, age, sex, and current proton pump inhibitor treatment did not predict this limiting caliber of the esophagus (P ≥ 0.20).nnnCONCLUSIONSnEsophageal distensibility, defined by the change in the narrowest measurable CSA within the distal esophagus vs intraluminal pressure was significantly reduced in EoE patients compared with controls. Measuring esophageal distensibility may be an important adjunct to the management of EoE, as it is capable of providing an objective means to measure the outcomes of medical or dilation therapy.

Esophagogastric junction distensibility assessed with an endoscopic functional luminal imaging probe (EndoFLIP)

BACKGROUNDnIncreased esophagogastric junction (EGJ) compliance is a key abnormality in GERD leading to increased volumes of reflux. To date, EGJ distensibility has been measured only with investigational barostat-based prototype devices.nnnOBJECTIVESnThe aim of the study was to test the endoscopic functional luminal imaging probe (EndoFLIP), a new commercially available technology designed to measure intraluminal distensibility, by assessing the EGJ of GERD patients and controls.nnnDESIGNnProspective case-control series.nnnSETTINGnTertiary referral center.nnnSUBJECTSnTwenty GERD patients and 20 controls studied during a routine esophagogastroduodenoscopy.nnnMETHODSnThe EndoFLIP was passed through the endoscopic instrumentation channel and positioned across the EGJ. The EndoFLIP uses impedance planimetry to measure 16 cross-sectional areas (CSA) along with the corresponding intrabag pressure within a 4.6-cm cylindrical segment of a fluid-filled bag.nnnMAIN OUTCOME MEASUREMENTnEGJ distensibility was assessed with 10- to 40-mL volume-controlled distentions.nnnRESULTSnIn both groups, the least distensible locus at the EGJ was usually at the hiatus. As a group, GERD patients exhibited two- to threefold increased EGJ distensibility compared with controls, particularly at 20- to 30-mL distention volumes, values quantitatively similar to previous measurements with barostat-based devices. The endoscopic estimation of EGJ distensibility, the flap valve grade, correlated poorly with EndoFLIP measurements.nnnLIMITATIONSnHeterogeneity of GERD patients.nnnCONCLUSIONSnMeasurement of EGJ distensibility with EndoFLIP is feasible during clinical endoscopy. Stratifying GERD patients according to this physiological parameter may facilitate the identification of patient subgroups responsive or unresponsive to medical or surgical treatments.

Functional Esophagogastric Junction Obstruction with Intact Peristalsis: A Heterogeneous Syndrome Sometimes Akin to Achalasia

BackgroundSome patients with suspected achalasia are found on manometry to have preserved peristalsis, thereby excluding that diagnosis. This study evaluated a series of such patients with functional esophagogastric junction (EGJ) obstruction.MethodsAmong 1,000 consecutive high-resolution manometry studies, 16 patients had functional EGJ obstruction characterized by impaired EGJ relaxation and intact peristalsis. Eight patients with post-fundoplication dysphagia and similarly impaired EGJ relaxation were studied as a comparator group with mechanical obstruction. Intrabolus pressure (IBP) was measured 1xa0cm proximal to the EGJ. Sixty-eight normal controls were used to define normal IBP. Patients’ clinical features were evaluated.ResultsFunctional EGJ obstruction patients presented with dysphagia (96%) and/or chest pain (42%). IBP was significantly elevated in idiopathic and post-fundoplication dysphagia patients versus controls. Among the idiopathic EGJ obstruction group treated with pneumatic dilation, BoToxTM, or Heller myotomy, only the three treated with Heller myotomy responded well. Among the post-fundoplication dysphagia patients, three of four responded well to redo operations.ConclusionFunctional EGJ obstruction is characterized by pressure topography metrics demonstrating EGJ outflow obstruction of magnitude comparable to that seen with post-fundoplication dysphagia. Affected patients experience dysphagia and/or chest pain. In some cases, functional EGJ obstruction may represent an incomplete achalasia syndrome.

Distal Esophageal Spasm in High-Resolution Esophageal Pressure Topography: Defining Clinical Phenotypes

BACKGROUNDnThe manometric diagnosis of distal esophageal spasm (DES) uses simultaneous contractions as a defining criterion, ignoring the concept of short latency distal contractions as an important feature. Our aim was to apply standardized metrics of contraction velocity and latency to high-resolution esophageal pressure topography (EPT) studies to refine the diagnosis of DES.nnnMETHODSnTwo thousand consecutive EPT studies were analyzed for contractile front velocity (CFV) and distal latency to identify patients potentially having DES. Normal limits for CFV and distal latency were established from 75 control subjects. Clinical data of patients with reduced distal latency and/or rapid CFV were reviewed.nnnRESULTSnOf 1070 evaluable patients, 91 (8.5%) had a high CFV and/or low distal latency. Patients with only rapid contractions (n = 186 [17.4%] using conventional manometry criteria; n = 85 [7.9%] using EPT criteria) were heterogeneous in diagnosis and symptoms, with the majority ultimately categorized as weak peristalsis or normal. In contrast, 96% of patients with premature contraction had dysphagia, and all (n = 24; 2.2% overall) were ultimately managed as spastic achalasia or DES.nnnCONCLUSIONSnThe current DES diagnostic paradigm focused on simultaneous contractions identifies a large heterogeneous set of patients, most of whom do not have a clinical syndrome suggestive of esophageal spasm. Incorporating distal latency into the diagnostic algorithm of EPT studies improves upon this by isolating disorders of homogeneous pathophysiology: DES with short latency and spastic achalasia. We hypothesize that prioritizing measurement of distal latency will refine the management of these disorders, recognizing that outcomes trials are necessary.

Manometric features of eosinophilic esophagitis in esophageal pressure topography

Backgroundu2002 Although most of the patients with eosinophilic esophagitis (EoE) have mucosal and structural changes that could potentially explain their symptoms, it is unclear whether EoE is associated with abnormal esophageal motor function. The aims of this study were to evaluate the esophageal pressure topography (EPT) findings in EoE and to compare them with controls and patients with gastro‐esophageal disease (GERD).

Esophageal Pressure Topography Criteria Indicative of Incomplete Bolus Clearance: A Study Using High-Resolution Impedance Manometry

OBJECTIVES:This study used high-resolution impedance manometry (HRIM) to determine pressure topography thresholds of peristaltic integrity predictive of incomplete esophageal bolus clearance.METHODS:A total of 16 normal controls and 8 patients with dysphagia were studied using a solid-state HRIM assembly incorporating 36 manometric sensors and 12 impedance segments. Each of the 10 saline swallows in each study was dichotomously scored as either complete or incomplete bolus clearance by impedance criteria, and peristaltic integrity was evaluated using pressure topography isobaric contours ranging from 10 to 30u2009mmu2009Hg in 5-u2009mmu2009Hg increments. Each isobaric contour plot was characterized by the location and length of breaks in the isobaric contour.RESULTS:All subjects had normal esophagogastric junction (EGJ) relaxation and none met the pressure topography criteria of hiatus hernia. In all, 70 (29%) of the 240 individual swallows had incomplete bolus clearance. In every case, an intact ≥20u2009mmu2009Hg isobaric contour was associated with complete bolus clearance. The largest defect in the 20 and 30u2009mmu2009Hg isobaric contours associated with complete bolus clearance measured 1.7 and 3.0u2009cm, respectively, in length, whereas the smallest defect predictive of incomplete bolus clearance measured 2.1 and 3.2u2009cm, respectively.CONCLUSIONS:In individuals with normal EGJ relaxation and morphology, peristaltic contractions with breaks <2u2009cm in the 20u2009mmu2009Hg isobaric contour or <3u2009cm in the 30u2009mmu2009Hg isobaric contour are associated with complete bolus clearance, and longer breaks predict incomplete bolus clearance.

Esophagogastric Junction Distensibility After Fundoplication Assessed with a Novel Functional Luminal Imaging Probe

ObjectiveThe aim of the study was to compare the esophagogastric junction (EGJ) compliance in response to controlled distension in fundoplication (FP) patients and controls using the functional luminal imaging probe (FLIP).BackgroundFP aims to replicate normal EGJ distensibility. FLIP is a new technology that uses impedance planimetry to measure intraluminal cross-sectional area (CSA) during controlled distension.MethodsTen controls and ten FP patients were studied with high-resolution esophageal pressure topography (HREPT) and then the FLIP placed across the EGJ. Deglutitive and interdeglutitive EGJ distensibility was assessed with volume-controlled distension. The FLIP measured eight CSAs spaced 4xa0mm apart within a cylindrical saline-filled bag along with the corresponding intrabag pressure.ResultsThe EGJ formed an hourglass shape during distensions with the central constriction at the diaphragmatic hiatus. The distensibility of the hiatus was significantly greater during deglutitive relaxation in both subject groups, but FP patients exhibited reduced EGJ distensibility and compliance compared to controls. During the interglutitive period, the corresponding increase in intrabag pressures at larger volumes were also greater in FP patients implying a longer segment of EGJ constriction. The EGJ distensibility characteristics did not correlate with HREPT measures.ConclusionsFLIP technology was used to compare EGJ distensibility in FP patients and control subjects. The least distensible locus within the EGJ was always at the hiatus. EGJ distensibility was significantly reduced, and the length of constriction increased in FP patients. Future FLIP studies will compare patients with and without post-FP dysphagia and gas bloat, symptoms suggestive of an overly restrictive FP.

The adult eosinophilic oesophagitis quality of life questionnaire: a new measure of health-related quality of life

Aliment Pharmacol Ther 2011; 34: 790–798