Diagnostic differences in high-resolution esophageal motility in a large Mexican cohort based on geographic distribution.

High-resolution esophageal manometry [HRM] has become the gold standard for the evaluation of esophageal motility disorders. It is unclear whether there are HRM differences in diagnostic outcome based on regional or geographic distribution. The diagnostic outcome of HRM in a diverse geographical population of Mexico was compared and determined if there is variability in diagnostic results among referral centers. Consecutive patients referred for HRM during 2016-2020 were included. Four major referral centers in Mexico participated in the study: northeastern, southeastern, and central (Mexico City, two centers). All studies were interpreted by experienced investigators using Chicago Classification 3 and the same technology. A total of 2293 consecutive patients were included. More abnormal studies were found in the center (61.3%) versus south (45.8%) or north (45.2%) P < 0.001. Higher prevalence of achalasia was noted in the south (21.5%) versus center (12.4%) versus north (9.5%) P < 0.001. Hypercontractile disorders were more common in the north (11.0%) versus the south (5.2%) or the center (3.6%) P.001. A higher frequency of weak peristalsis occurred in the center (76.8%) versus the north (74.2%) or the south (69.2%) P < 0.033. Gastroesophageal junction obstruction was diagnosed in (7.2%) in the center versus the (5.3%) in the north and (4.2%) in the south p.141 (ns). This is the first study to address the diagnostic outcome of HRM in diverse geographical regions of Mexico. We identified several significant diagnostic differences across geographical centers. Our study provides the basis for further analysis of the causes contributing to these differences.

Current practice in the care of children with functional constipation: What is the hold up?

OBJECTIVES: For children with intractable functional constipation (FC), there are no evidence-based guidelines for subsequent evaluation and treatment. Our objective was to assess the practice patterns of a large, international cohort of pediatric gastroenterologists. METHODS: We administered a survey to physicians who attended the 2nd World Congress of Pediatric Neurogastroenterology and Motility held in Columbus, Ohio (USA) in September 2023. The survey included 29 questions on diagnostic testing, nonpharmacological and pharmacological treatment, and surgical options for children with intractable FC. RESULTS: Ninety physicians from 18 countries completed the survey. For children with intractable FC, anorectal manometry was the most commonly used diagnostic test. North American responders were more likely than Europeans to use stimulant laxatives (97% vs. 77%, p = 0.032), prosecretory medications (69% vs. 8%, p < 0.001), and antegrade continence enemas (ACE; 83% vs. 46%, p = 0.009) for management. Europeans were more likely than North Americans to require colonic transit testing before surgery (85% vs. 30%, p < 0.001). We found major differences in management practices between Americans and the rest of the world, including use of prosecretory drugs (73% vs. 7%, p < 0.001), anal botulinum toxin injections (81% vs. 58%, p = 0.018), ACE (81% vs. 58% p = 0.018), diverting ileostomies (56% vs. 26%, p = 0.006), and colonic resections (42% vs. 16%, p = 0.012). No differences were found when respondents were compared by years of experience. CONCLUSIONS: Practice patterns in the evaluation and treatment of children with intractable FC differ widely among pediatric gastroenterologists from around the world. A clinical guideline regarding diagnostic testing and surgical decision-making is needed.

Esophagogastroduodenoscopy findings that do no not explain dysphagia are associated with underutilization of high-resolution manometry.

In patients with dysphagia that is not explained by upper endoscopy, high-resolution esophageal manometry (HRM) is the next logical step in diagnostic testing. This study investigated predictors of failure to refer for HRM after an upper endoscopy that was performed for but did not explain dysphagia. This was a retrospective cohort study of patients >18 years of age who underwent esophagogastroduodenoscopy (EGD) for dysphagia from 2015 to 2021. Patients with EGD findings that explained dysphagia (e.g. esophageal mass, eosinophilic esophagitis, Schatzki ring, etc.) were excluded from the main analyses. The primary outcome was failure to refer for HRM within 1 year of the index non-diagnostic EGD. We also investigated delayed referral for HRM, defined as HRM performed after the median. Multivariable logistic regression modeling was used to identify risk factors that independently predicted failure to refer for HRM, conditioned on the providing endoscopist. Among 2132 patients who underwent EGD for dysphagia, 1240 (58.2%) did not have findings to explain dysphagia on the index EGD. Of these 1240 patients, 148 (11.9%) underwent HRM within 1 year of index EGD. Endoscopic findings (e.g. hiatal hernia, tortuous esophagus, Barrett's esophagus, surgically altered anatomy not involving the gastroesophageal junction, and esophageal varices) perceived to explain dysphagia were independently associated with failure to refer for HRM (adjusted odds ratio 0.45, 95% confidence interval 0.25-0.80). Of the 148 patients who underwent HRM within 1 year of index EGD, 29.7% were diagnosed with a disorder of esophagogastric junction outflow, 17.6% with a disorder of peristalsis, and 2.0% with both disorders of esophagogastric outflow and peristalsis. The diagnosis made by HRM was similar among those who had incidental EGD findings that were non-diagnostic for dysphagia compared with those who had completely normal EGD findings. Demographic factors including race/ethnicity, insurance type, and income were not associated with failure to refer for HRM or delayed HRM. Patients with dysphagia and endoscopic findings unrelated to dysphagia have a similar prevalence of esophageal motility disorders to those with normal endoscopic examinations, yet these patients are less likely to undergo HRM. Provider education is indicated to increase HRM referral in these patients.

Pudendal Nerve Terminal Motor Latency Compared by Anorectal Manometry Diagnosing Fecal Incontinence: A Retrospective Study.

OBJECTIVE: The aim of the study was to compare the clinical value of pudendal nerve terminal motor latency in fecal incontinence patients with that of another diagnostic test-anorectal manometry. DESIGN: This study used a cross-sectional design. Medical records of fecal incontinence patients who underwent pudendal nerve terminal motor latency and anorectal manometry testing were reviewed. Greater than 2.4 ms of pudendal nerve terminal motor latency was determined to be abnormal. Anorectal manometry was performed using a station pull-through technique. Mean resting anal pressure, maximal resting anal pressure, mean squeezing anal pressure, and maximal squeezing anal pressure were investigated. For normal and abnormal pudendal nerve terminal motor latency groups, comparative analyses were performed on anorectal manometry results. RESULTS: A total of 31 patients were included. Thirteen patients showed normal pudendal nerve terminal motor latency. For anorectal manometry results, there was no significant difference between normal and abnormal pudendal nerve terminal motor latency groups. Fourteen patients had diabetes mellitus. Subgroup analysis of the 14 diabetic patients showed no significant difference between normal and abnormal pudendal nerve terminal motor latency groups. For 17 nondiabetic patients, there was a significant difference between the groups with positive correlations with mean/maximal resting anal pressures. CONCLUSIONS: Pudendal nerve terminal motor latency significantly correlates with anorectal manometry in fecal incontinence only in nondiabetic patients.

Aging steepens the slope of power spectrum density of 30-minute continuous blood pressure recording in healthy human subjects.

BACKGROUND: The increase of blood pressure (BP) variability (BPV) is recognized as an important additional cardiovascular risk factor in both normotensive subjects and hypertensive patients. Aging-induced atherosclerosis and autonomic dysfunction impair the baroreflex and, in turn, augment 24-hour BPV. In small and large animal experiments, impaired baroreflex steepens the slope of the power spectrum density (PSD) of continuous BP in the frequency range of 0.01 to 0.1 Hz. Although the repeated oscillometric BP recording over 24 hours or longer is a prerequisite to quantify BPV in humans, how the very short-term continuous BP recording reflects BPV remains unknown. This study aimed to evaluate the impact of aging on the very short-term (30-min) BPV in healthy human subjects by frequency analysis. METHODS: We recorded continuous BP tonometrically for 30 min in 56 healthy subjects aged between 28 and 85 years. Considering the frequency-dependence of the baroreflex dynamic function, we estimated the PSD of BP in the frequency range of 0.01 to 0.1 Hz, and compared the characteristics of PSD among four age groups (26-40, 41-55, 56-70 and 71-85 years). RESULTS: Aging did not significantly alter mean and standard deviation (SD) of BP among four age groups. PSD was nearly flat around 0.01 Hz and decreased gradually as the frequency increased. The slope of PSD between 0.01 and 0.1 Hz was steeper in older subjects (71 years or older) than in younger subjects (55 years or younger) (p < 0.05). CONCLUSIONS: Aging steepened the slope of PSD of BP between 0.01 and 0.1 Hz. This phenomenon may partly be related to the deterioration of the baroreflex in older subjects. Our proposed method to evaluate very short-term continuous BP recordings may contribute to the stratification of BPV.

Normal Values and Associated Factors in Highresolution Anorectal Manometry in Healthy Vietnamese Adults / Valores normais e fatores associados na manometria anorretal de alta resolução em adultos vietnamitas saudáveis

Abstract Introduction The present study aims to identify normal high-resolution anorectal manometry (HRAM) values and related factors in healthy Vietnamese adults. Methods The present cross-sectional study was conducted at the Viet Duc hospital, Hanoi, Vietnam, during April and May 2019. Healthy volunteers were recruited to participate in the study. Anorectal measurement values from the digestive tract, including pressure, were recorded. Results A total of 76 healthy volunteers were recruited. The mean functional anal canal length was 4.2 ± 0.5 cm, while the mean anal high-pressure zone length was 3.4 ± 0.5 cm. Themean defecation index was 1.4 ± 0.8, with values ranging from 0.3 to 5.0. The mean threshold volume to elicit the rectoanal inhibitory reflex (RAIR) was 18.1 mL. The mean rectal sensation values were 32.4mL, 81.6mL, and 159 mL for first sensation, desire to defecate, and urge to defecate, respectively. Dyssynergic patterns occurred in ~ 50% of the study participants and included mainly types I (27.6%) and III (14.6%). There were significant differences between male and female patients in terms of maximum anal squeeze pressure, maximum anal cough pressure, maximum anal strain pressure, maximum rectal cough pressure, and maximum rectal strain pressure (all p<0.01). Conclusions The present study establishes normal HRAM values in healthy Vietnamese adults, particularly regarding normal values of anorectal pressure and rectal sensation. Further studies that include larger sample sizes should be conducted to further confirm the constants and their relationships.

Resumo Introdução O presente estudo tem como objetivo identificar valores normais de manometria anorretal de alta resolução e fatores relacionados em adultos vietnamitas saudáveis. Métodos O presente estudo transversal foi conduzido no hospital Viet Duc, Hanói, Vietnã, durante abril e maio de 2019. Voluntários saudáveis foram recrutados para participar do estudo. Valores de medição anorretal, incluindo pressão do trato digestivo, foram registrados. Resultados Um total de 76 voluntários saudáveis foram recrutados. O comprimento funcional médio do canal anal foi de 4,2 ± 0,5 cm, enquanto o comprimento médio da zona anal de alta pressão foi de 3,4 ± 0,5 cm. O índice médio de defecação foi de 1,4 ± 0,8, com valores variando de 0,3 a 5,0. O volume limite médio para eliciar o reflexo inibitório retoanal (RAIR, sigla em inglês) foi de 18,1 mL. Os valores médios da sensação retal foram 32,4mL, 81,6mL e 159 mL para a primeira sensação, o desejo de defecar e a urgência de defecar, respectivamente. Os padrões dissinérgicos ocorreram em aproximadamente 50% dos participantes do estudo e incluíram principalmente os tipos I (27,6%) e III (14,6%). Houve diferenças significativas entre homens e mulheres na pressão de compressão anal máxima, pressão de tosse anal máxima, pressão de distensão anal máxima, pressão de tosse retal máxima e pressão de distensão retal máxima (todos p<0,01). Conclusões O presente estudo estabelece valores normais de HRAM em adultos vietnamitas saudáveis, particularmente no que diz respeito aos valores normais de pressão anorretal e sensação retal. Mais estudos que incluam tamanhos de amostra maiores devemser realizados a fim de confirmar melhor as constantes e suas relações.

Characterization of esophageal motor activity, gastroesophageal reflux, and evaluation of prokinetic effectiveness in mechanically ventilated critically ill patients: a high-resolution impedance manometry study.

BACKGROUND: Motility disorders of upper gastrointestinal tract are common in critical illness and associated with significant clinical consequences. However, detailed quantitative and qualitative analyses of esophageal motor functions are lacking. Therefore, we aimed to characterize the key features of esophageal motility functions using high-resolution impedance manometry (HRIM) and to evaluate an objective link between esophageal motor patterns, gastric emptying, and gastroesophageal reflux. We also studied the prokinetic effects of metoclopramide. METHODS: We prospectively performed HRIM for 16 critically ill hemodynamically stable patients. Patients were included if they had low gastric volume (LGV; < 100 mL/24 h, n = 8) or high gastric volume (HGV; > 500 mL/24 h, n = 8). The HRIM data were collected for 5 h with intravenous metoclopramide administration (10 mg) after the first 2 h. RESULTS: The findings were grossly abnormal for all critically ill patients. The esophageal contraction vigor was markedly increased, indicating prevailing hypercontractile esophagus. Ineffective propulsive force was observed for 73% of esophageal activities. Panesophageal pressurization was the most common pressurization pattern (64%). Gastroesophageal reflux predominantly occurred with transient lower esophageal sphincter relaxation. The common features of the LGV group were a hyperreactive pattern, esophagogastric outflow obstruction, and frequent reflux. Ineffective motility with reduced lower esophageal sphincter tone, and paradoxically fewer reflux episodes, was common in the HGV group. Metoclopramide administration reduced the number of esophageal activities but did not affect the number of reflux episodes in either group. CONCLUSION: All critically ill patients had major esophageal motility abnormalities, and motility patterns varied according to gastric emptying status. Well-preserved gastric emptying and maintained esophagogastric barrier functions did not eliminate reflux. Metoclopramide failed to reduce the number of reflux episodes regardless of gastric emptying status. Trial registration ISRCTN, ISRCTN14399966. Registered 3.9.2020, retrospectively registered. https://www.isrctn.com/ISRCTN14399966 .

Optimal cutoff value of integrated relaxation pressure on the esophagogastric junction to detect outflow obstruction using starlet high-resolution manometry system.

BACKGROUND: Achalasia and esophagogastric junction outflow obstruction (EGJOO) are idiopathic esophageal motility disorders characterized by impaired deglutitive relaxation of the lower esophageal sphincter (LES). High-resolution manometry (HRM) provides integrated relaxation pressure (IRP) which represents adequacy of LES relaxation. The Starlet HRM system is widely used in Japan; however, IRP values in achalasia/EGJOO patients assessed with the Starlet system have not been well studied. We propose the optimal cutoff of IRP for detecting achalasia/EGJOO using the Starlet system. METHODS: Patients undergone HRM test using the Starlet system at our institution between July 2018 and September 2020 were included. Of these, we included patients with either achalasia or EGJOO and those who had normal esophageal motility without hiatal hernia. Abnormally impaired LES relaxation (i.e., achalasia and EGJOO) was diagnosed if prolonged esophageal emptying was evident based on timed barium esophagogram (TBE). RESULTS: A total of 111 patients met study criteria. Of these, 48 patients were diagnosed with achalasia (n = 45 [type I, n = 20; type II, n = 22; type III, n = 3]) or EGJOO (n = 3). In the 48 patients who had a prolonged esophageal clearance based on TBE, IRP values distributed along a wide-range of minimal 14.1 to a maximal of 72.2 mmHg. The optimal cutoff value of IRP was 24.7 mmHg with sensitivity of 89.6% and specificity of 84.1% (AUC 0.94). CONCLUSION: The optimal cutoff value of IRP to distinguish achalasia/EGJOO was ≥ 25 mmHg using the Starlet HRM system in our cohort. This indicates that the current proposed cutoff of 26 mmHg appears to be relevant.

Provider Variability in the Management Patterns of Increased Nonacid Reflux.

INTRODUCTION: Increased nonacid reflux is diagnosed in a subgroup of patients with gastroesophageal reflux disease who often present with reflux symptoms refractory to proton-pump inhibitor therapy. Despite the prevalence of this condition, the management approach for patients with increased nonacid reflux can often be varied and unclear. AIMS: Our primary aim was to investigate physician management patterns for patients who had received a diagnosis of increased nonacid reflux on impedance-pH studies. METHODS: Reflux studies in patients with increased nonacid reflux per Lyon Consensus criteria and management approaches were retrospectively reviewed. Reflux symptom survey, manometry findings, reflux symptom association (RSA) on reflux testing, immediate posttesting management information, and managing provider information were assessed. RESULTS: A total of 43 subjects in total were analyzed. Management plan after a diagnosis of increased nonacid reflux was decided by a gastroenterologist in over 95% of cases and varied greatly with no changes being the most common. Even among subjects with + RSA on reflux monitoring, no change in management was the most common action, although this occurred much less frequently compared to subjects with - RSA (28.6% vs. 78.6%, p < 0.01). When change in therapy occurred, medical treatment with baclofen was the most common choice (21.4%). Other management changes included medications for visceral hypersensitivity and antireflux surgery, although these changes occurred rarely. CONCLUSIONS: Abnormally increased nonacid reflux is frequently encountered on impedance-pH studies; however, management decisions vary significantly among gastroenterologists. When treatment change is implemented, they are variable and can include lifestyle modifications, medication trials, or antireflux surgery. Future development of standardized management algorithms for increased nonacid reflux is needed.

High-Resolution Colonic Manometry Pressure Profiles Are Similar in Asymptomatic Diverticulosis and Controls.

BACKGROUND: Elevated colonic pressures and increased colonic activity have been thought to contribute to the pathophysiology of diverticulosis. However, evidence for this has been limited to low-resolution manometry, which is of limited accuracy. AIMS: This study aimed to evaluate the contraction pressures, counts, and distance of propagation recorded by high-resolution colonic manometry in diverticulosis vs control patients. METHODS: High-resolution colonic manometry was used to record descending and sigmoid colon activity pre- and post-meal in patients with established, asymptomatic diverticulosis and in healthy controls. Antegrade and retrograde propagating contractions, distance of propagation (mm), and mean contraction pressures (mmHg) in the descending and sigmoid colon were compared between patients and controls for all isolated propagating contractions, the cyclic motor pattern, and high-amplitude propagating contractions independently. RESULTS: Mean manometry pressures were not different between controls and diverticulosis patients (p > 0.05 for all comparisons). In the descending colon, diverticulosis patients had lower post-meal mean distance of propagation for all propagating contractions [10.8 (SE1.5) mm vs 20.0 (2.0) mm, p = 0.003] and the cyclic motor pattern [6.0 (2.5) mm vs 17.1 (2.8) mm, p = 0.01]. In the sigmoid colon, diverticulosis patients showed lower post-meal mean distance of propagation for all propagating contractions [10.8 (1.5) mm vs 20.2 (5.9) mm, p = 0.01] and a lower post-meal increase in retrograde propagating contractions (p = 0.04). CONCLUSIONS: In this first high-resolution colonic manometry study of patients with diverticular disease, we did not find evidence for increased manometric pressures or increased colonic activity in patients with diverticular disease.

Comparing oscillometric and tonometric methods to assess pulse wave velocity: a population-based study.

BACKGROUND: Oscillometric pulse wave velocity (o-PWV) represents an attractive, non invasive and non operator-dependent method to estimate arterial stiffness. Tonometric carotid-femoral measurements (cf-PWV),are considered the gold-standard for non-invasive aortic stiffness assessment. To date, no studies in the general population comparing the two methods have been performed. METHODS AND RESULTS: 1162 subjects were analysed. O-PWV and cf-PWV showed a mean difference of -0.31 m/sec(p ≤ 0.001). No significant differences between cf-PWV and o-PWVs were observed in patients without cardiovascular risk factors. The Bland and Altman analysis showed a moderate agreement between 24 h-o-PWV and cf-PWV (mean difference -0.99, LoA 4.23 to -6.22m/s). O-PWVs underestimate and overestimate arterial stiffness under and over 50 years respectively(p ≤ 0.001). Systolic blood pressure (SBP) and age differently impact cf-PWV and in office o-PWV variability (r2 0.35 and 0.88 respectively). In younger subjects a strong relationship between o-PWV and SBP reducing as age increases was found. Analysing the impact of age, an opposite trend was noticed. CONCLUSIONS: Oscillometric PWV estimates provide reliable values in the general population. An o-PWV tendency to underestimate arterial stiffness in younger subjects and in subjects with diseases known to increase arterial stiffness and to overestimate it with increasing age was found, even if scarcely relevant in clinical perspective. Overall the present findings underline an acceptable and satisfactory agreement between oscillometric and tonometric methods for the PWV assessment. KEY MESSAGES Oscillometric and tonometric PWV estimates showed a good and satisfactory agreement in the general population, above all in subjects without cardiovascular risk factors or a documented vascular damage. In comparison with tonometric values, oscillometric PWV estimates showed, however, the tendency to underestimate arterial stiffness in younger subjects and to overestimate it with increasing age, while diverging when diseases known to increase arterial stiffness are present. The magnitude of differences in PWV estimates between tonometric and oscillometric methods found in the general population appears most likely not to be significant in everyday clinical practice.

Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review.

BACKGROUND: Fecal incontinence is a disabling condition affecting up to 20% of women. OBJECTIVE: We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials. METHODS: We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019. RESULTS: In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies. CONCLUSION: Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.

Clinical Features and Associations of Descending Perineum Syndrome in 300 Adults with Constipation in Gastroenterology Referral Practice.

BACKGROUND: Outlet obstruction constipation accounts for about 30% of chronic constipation (CC) cases in a referral practice. AIMS: To assess the proportion of patients with CC diagnosed with descending perineum syndrome (DPS) by a single gastroenterologist and to compare clinical, radiological, and associated features in DPS compared to patients with constipation. METHODS: We conducted a review of records of 300 consecutive patients evaluated for constipation by a single gastroenterologist from 2007 to 2019, including medical, surgical, and obstetrics history, digital rectal examination, anorectal manometry, defecation proctography (available in 15/23 with DPS), treatment, and follow-up. DPS was defined as > 3 cm descent of anorectal junction on imaging or estimated perineal descent on rectal examination. Logistic regression with univariate and multivariate analysis compared factors associated with DPS to non-DPS patients. RESULTS: Twenty-three out of 300 (7.7%, all female) patients had DPS; these patients were older, had more births [including more vaginal deliveries (84.2% vs. 31.2% in non-DPS, p < 0.001)], more instrumental or traumatic vaginal deliveries, more hysterectomies, more rectoceles on proctography (86.7% vs. 28.6% non-DPS, p = 0.014), lower squeeze anal sphincter pressures (p < 0.001), and lower rectal sensation (p = 0.075) than non-DPS. On univariate logistic regression, history of vaginal delivery, hysterectomy, and Ehlers-Danlos syndrome increased the odds of developing DPS. Vaginal delivery was confirmed as a risk factor on multivariate analysis. CONCLUSIONS: DPS accounts for almost 10% of tertiary referral patients presenting with constipation. DPS is associated with age, female gender, and number of vaginal (especially traumatic) deliveries.

Peroral endoscopic shorter versus longer myotomy for the treatment of achalasia: a comparative retrospective study.

INTRODUCTION: Peroral esophageal myotomy (POEM) is a novel endoscopic treatment for achalasia. It has gained popularity worldwide among surgeons and endoscopists, but no studies have compared peroral endoscopic short with long myotomy for achalasia. We aimed to compare the clinical efficacy and safety between peroral endoscopic shorter and longer myotomy. METHODS: The retrospective study enrolled 129 achalasia patients who underwent POEM from July 2011 to September 2017. Based on the myotomy length (ML), patients were divided into shorter myotomy (SM) group (ML ≤ 7 cm, n = 36) and longer myotomy (LM) group (ML > 7 cm, n = 74). Procedure-related parameters, symptom scores, adverse events and manometric data were compared between two groups. RESULTS: The mean ML was 6.0 ± 0.6 cm in SM group, and 11.5 ± 3.1 cm in LM group (p < 0.001). The mean operation time was significantly less in SM group than LM group (46.6 ± 18.5 min vs 62.1 ± 25.2 min, p = 0.001). During a mean follow-up period of 28.7 months, treatment success (Eckardt score ≤ 3) was achieved in 94.4% (34/36) of patients in SM group and 91.9% (68/74) in LM group (p = 0.926). There was no statistical difference in the incidence of intraoperative complications (8.4% vs 8.2%, p = 0.823) and reflux rate (8.3% vs. 14.9%, p = 0.510) between two groups. CONCLUSIONS: Peroral endoscopic shorter myotomy is comparable with longer myotomy for treating achalasia with regard to clinical efficacy and has the advantage of shorter procedure time.

Fecal Urgency: Clinical and Manometric Characteristics in Patients With and Without Diarrhea.

BACKGROUND: Fecal urgency is classically associated with diarrhea, but is also common in individuals with normal bowel habits or constipation. Its etiology, particularly in non-diarrhea individuals, is unclear. METHODS: We examined data from 368 individuals with and without diarrhea who underwent three-dimensional high-resolution anorectal manometry and balloon expulsion test. All patients completed the Rome III constipation module and the pelvic floor distress inventory (PDFI-20) survey. Patients were considered to have fecal urgency if they reported being bothered "moderately" or "quite a bit" by it in the past 3 months. RESULTS: A total of 103 patients (28.0%) met our definition of fecal urgency. These patients were significantly more likely to meet criteria for irritable bowel syndrome and to report fecal incontinence, urinary incontinence, and diarrhea. Fecal urgency was associated with rectal hypersensitivity in those with diarrhea, but not in those without diarrhea. Fecal urgency was associated with urinary urge incontinence in those without diarrhea, but not those with diarrhea. CONCLUSIONS: In patients with diarrhea, fecal urgency is associated with rectal hypersensitivity, whereas in patients without diarrhea, fecal urgency is associated with urinary urge incontinence. This suggests that fecal urgency has different pathophysiological mechanisms in patients with different underlying bowel habits.

Predictors of reflux aspiration and laryngo-pharyngeal reflux.

BACKGROUND: Gastro-esophageal reflux disease (GERD) can present with typical or atypical or laryngo-pharyngeal reflux (LPR) symptoms. Pulmonary aspiration of gastric refluxate is one of the most serious variants of reflux disease as its complications are difficult to diagnose and treat. The aim of this study was to establish predictors of pulmonary aspiration and LPR symptoms. METHODS: Records of 361 consecutive patient from a prospectively populated database were analyzed. Patients were categorized by symptom profile as predominantly LPR or GERD (98 GER and 263 LPR). Presenting symptom profile, pH studies, esophageal manometry and scintigraphy and the relationships were analyzed. RESULTS: Severe esophageal dysmotility was significantly more common in the LPR group (p = 0.037). Severe esophageal dysmotility was strongly associated with isotope aspiration in all patients (p = 0.001). Pulmonary aspiration on scintigraphy was present in 24% of patients. Significant correlation was established between total proximal acid on 24-h pH monitoring and isotope aspiration in both groups (p < 0.01). Rising pharyngeal curves on scintigraphy were the strongest predictors of isotope aspiration (p < 0.01). CONCLUSIONS: Severe esophageal dysmotility correlates with LPR symptoms and reflux aspiration in LPR and GERD. Abnormal proximal acid score on 24-h pH monitoring associated with pulmonary aspiration in reflux patients. Pharyngeal contamination on scintigraphy was the strongest predictor of pulmonary aspiration.

Changes in high-resolution manometric diagnosis over time: implications for clinical decision-making.

Although High resolution esophageal manometry (HRM) is the gold standard to assess esophageal motility, little is known about the stability of the manometric diagnosis over time and its implications for management. To assess the stability and usefulness of repeat HRM in patients presenting with esophageal symptoms over time we performed this retrospective study of patients with esophageal symptoms. Medical records, questionnaires, and HRM tracing were independently reviewed using the Chicago classification. The primary objective was to assess the stability of the manometric diagnosis over time; secondary objective was its change (positive or negative). At least one repeat study was performed in 86 patients (36% women, ages 20-86, with mild to moderate symptoms), while 26 had a third procedure. Mean intervals between studies were 15 ± 1.6 months (for baseline v. first study) and 13 ± 0.8 months (for second to third study). Of the 27 patients initially with a normal study, 11 changed (five had esophago-gastric junction outflow obstruction [EGJOO], two diffuse esophageal spasm [DES], one jackhammer esophagus [JE], and three ineffective esophageal motility [IEM] [41% change]). Of the 24 patients with initial EGJOO, only nine retained it (65.2% change). Of nine patients with initial DES, four changed (44.4% change). Similarly, different diagnosis was seen in 7 of 24 initial IEM patients (22.7% change). Only one patient had achalasia initially and this remained stable. Additional changes were noted on a third HRM. Fluidity in the HRM diagnosis over time questions its validity at any timepoint and raises doubts about the need for intervention.

Pseudoachalasia: a systematic review of the literature.

Pseudoachalasia, also known as secondary achalasia, is a clinical condition mimicking idiopathic achalasia but most commonly caused by malignant tumors of gastroesophageal junction (GEJ). Our aim was to systematically review and present all available data on demographics, clinical features, and diagnostic modalities involved in patients with pseudoachalasia. A systematic search of literature published during the period 1978-2019 was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (end-of-search date: June 25th, 2019). Two independent reviewers extracted data with regards of study design, interventions, participants, and outcomes. Thirty-five studies met our inclusion criteria and were selected in the present review. Overall, 140 patients with pseudoachalasia were identified, of whom 83 were males. Mean patient age was 60.13 years and the mean weight loss was 13.91 kg. A total of 33 (23.6%) patients were wrongly 'treated' at first for achalasia. The most common presenting symptoms were dysphagia, food regurgitation, and weight loss. The median time from symptoms' onset to hospital admission was 5 months. Most common etiology was gastric cancer (19%). Diagnostic modalities included manometry, barium esophagram, endoscopy, and computed tomography (CT). Pseudoachalasia is a serious medical condition that is difficult to be distinguished from primary achalasia. Clinical feature assessment along with the correct interpretation of diagnostic tests is nowadays essential steps to differentiate pseudoachalasia from idiopathic achalasia.

Baseline Impedance Measured During High-resolution Esophageal Impedance Manometry in Patients With Rumination Syndrome is as Abnormal as in Patients With GERD.

GOALS AND BACKGROUND: Baseline impedance measured during high-resolution impedance manometry (HRIM) can distinguish patients with gastroesophageal reflux disease (GERD) from controls, presumably due to differences in esophageal acid exposure. The characteristics of regurgitation and reflux in rumination syndrome and GERD are very different, and thus we investigated whether baseline esophageal impedance would differ in these 2 patient groups compared with controls. STUDY: We compared 20 patients with rumination syndrome with 20 patients who had GERD and 40 controls. Baseline impedance was measured over 15 seconds during the landmark period of HRIM in all 18 impedance sensors on a HRIM catheter. RESULTS: The mean distal baseline impedance measured in ohms during HRIM was 1336 Ω [95% confidence interval (CI)=799, 1873) in patients with GERD, 1536 Ω in rumination syndrome (95% CI=1012, 2061), and 3379 Ω in controls (95% CI=2999, 3759) (P<0.0001). Proximal impedance was significantly lower in the GERD and rumination groups compared with controls; rumination syndrome (2026; 95% CI=1493, 2559 Ω), GERD (2572; 95% CI=2027, 3118 Ω), and controls (3412; 95% CI=3026, 3798 Ω) (P<0.001). CONCLUSIONS: Baseline impedance measured during HRIM in patients with rumination syndrome is significantly lower than controls and appears similar to patients with GERD both in the proximal and distal esophagus. These findings suggest that the postprandial regurgitation in rumination syndrome alters both the distal and proximal esophageal mucosal barrier.

Esophageal Manometry, pH Testing, Endoscopy, and Videofluoroscopy in Patients With Globus Sensation.

OBJECTIVES/HYPOTHESIS: Combine techniques commonly employed in the clinical workup of patients with isolated globus sensation to identify the most common pharyngoesophageal abnormality. The primary aim was to retrospectively review high-resolution manometry, pH probe testing, contrast videofluoroscopy, and endoscopy studies in patients with a primary complaint of globus sensation. The specific hypothesis was esophageal high-resolution manometry identifies the most significant proportion of abnormalities compared to all other modalities. STUDY DESIGN: Retrospective cohort study. METHODS: An inclusive retrospective chart review was performed for patients evaluated between 2009 and 2016 with the primary complaint of globus sensation. Age at testing, self-identified gender, associated diagnoses, and results from each modality were collected. Descriptive statistics and pairwise comparisons were performed as well as sensitivity and specificity calculations. RESULTS: One hundred seventy-two patients met inclusion criteria. The cohort had an age range of 22.7 to 88.5 years and was predominantly female. Esophageal manometry identified abnormalities in 62.8% of patients, and pH testing identified abnormal acidification in approximately 20%. The esophagram identified abnormalities in 24% of patients, and esophagogastroduodenoscopy identified abnormalities in 22%. Modified barium swallows were normal in 93% of patients. Measures of sensitivity and specificity of other modalities were poor compared to esophageal manometry and pH testing. CONCLUSIONS: Patients with isolated globus sensation have evidence of esophageal dysmotility and laryngopharyngeal and gastroesophageal reflux disease in high proportions. Esophageal high-resolution manometry testing identifies the greatest proportion of abnormalities of the investigated modalities. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2120-2125, 2020.