The 2018 ISDE achalasia guidelines.

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

Calculation of esophagogastric junction vector volume using three-dimensional high-resolution manometry.

Lower esophageal sphincter vector volume (V-V) was developed in the late 1980s by Bombeck, as a quantification of sphincter integrity used to select reflux patients with a defective valve who may benefit from surgery. Its calculation required motorized pull-through of an 8-lumen water perfused manometry catheter with subsequent computerized reconstruction of sphincter morphology. Recently, a three-dimensional high-resolution manometry (3D-HRM) assembly (Given Imaging, Duluth, GA, USA) has been developed with the potential to assess real-time V-V. The aim of this study was to assess the feasibility of the calculation of V-V using the 3D-HRM assembly and to compare measures of its value using real-time 3D-HRM to simulated analogous measures. Eight asymptomatic controls (4F, ages 26-49) were studied in a supine position with a solid-state 3D-HRM assembly positioned across the esophagogastric junction (EGJ). The 9-cm 3D segment comprised 12 rings of 8 radially dispersed pressure sensors, each 2.5 mm long and spaced 7.5 mm apart on center. Recordings were done during normal respiration: (i) with the 3D-HRM segment in a stationary position across the EGJ; and (ii) during a station pull-through of the 3D-HRM segment withdrawing it across the EGJ at 5-mm increments with each position held for 30 seconds. EGJ cross-sectional vector areas (CSVAs) were computed using the irregular polygon area formula: [Formula in text], and n = 8 radial sensors. V-V was computed as the sum of CSVAs at inspiration and end-expiration by three methods: real-time 3D-HRM, three-station composite, and single-sensor ring measurements. There were no statistic differences among the methods, and all methods showed significant differences between inspiration and expiration. Calculation of real-time V-V is feasible using the 3D-HRM. Moreover, the results of this study highlighted the potential primary role of the diaphragmatic hiatus in the pathophysiology of gastroesophageal reflux disease and the underrecognized but crucial role of the crural repair during the antireflux surgery.

Role of a health psychologist in the management of functional esophageal complaints.

Upper gastrointestinal complaints are common among patients in a gastrointestinal clinic. Outside of typical gastroesophageal reflux disease symptoms that are treated with medication, the symptom presentations of esophageal patients, particularly those with functional conditions, are often difficult to treat and account for high health-care utilization. This manuscript describes the role of a health psychologist in the treatment of esophageal disorders using behavioral medicine interventions. Observations over the course of a 1-year period indicate that the sample presents with a relatively low level of psychological distress but reports negative effects of their symptoms on health-related quality of life. Five case examples of commonly treated disorders (globus, non-cardiac chest pain, functional dysphagia, rumination syndrome, supragastric belching) are described to highlight how behavioral treatment can improve patients' symptoms, decrease health-care utilization, and improve overall quality of life in a timely and relatively simple manner. Successful treatment outcomes are associated with a collaborative working alliance between patient, health psychologist, and gastroenterologist. Results indicate the benefit of referring appropriate esophageal patients to a health psychologist with specialization in gastroenterology.

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.

Utilization of wireless pH monitoring technologies: a summary of the proceedings from the esophageal diagnostic working group.

Gastroesophageal reflux disease (GERD) can be difficult to diagnose - symptoms alone are often not enough, and thus, objective testing is often required. GERD is a manifestation of pathologic levels of reflux into the esophagus of acidic, nonacidic, and/or bilious gastric content. However, in our current evidence-based knowledge approach, we only have reasonable outcome data in regards to acid reflux, as this particular type of refluxate predictably causes symptoms and mucosal damage, which improves with medical or surgical therapy. While there are data suggesting that nonacid reflux may be responsible for ongoing symptoms despite acid suppression in some patients, outcome data about this issue are limited. Therefore, this working group believes that it is essential to confirm the presence of acid reflux in patients with 'refractory' GERD symptoms or extraesophageal symptoms thought to be caused by gastroesophageal reflux before an escalation of antireflux therapy is considered. If patients do not have pathologic acid reflux off antisecretory therapy, they are unlikely to have clinically significant nonacid or bile reflux. Patients who do not have pathologic acid gastroesophageal reflux parameters on ambulatory pH monitoring then: (i) could attempt to discontinue antisecretory medications like proton pump inhibitors and H2-receptor antagonists (which are expensive and which carry risks - i.e. C. diff, etc.); (ii) may undergo further evaluation for other causes of their esophageal symptoms (e.g. functional heartburn or chest pain, eosinophilic esophagitis, gastroparesis, achalasia, other esophageal motor disorders); and (iii) can be referred to an ear, nose, and throat/pulmonary/allergy physician for assessment of non-GERD causes of their extraesophageal symptoms.

Physiology of the LES.

The purpose of this review is to consider the neuromuscular mechanism of LES contractility both by itself and in relation to the esophagogastric junction (EGJ) complex in order to appreciate the intricacies of EGJ valvular function.

The Kagoshima consensus on esophageal achalasia.

Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and a lower esophageal sphincter that fails to relax appropriately in response to swallowing. This article summarizes the most salient issues in the diagnosis and management of achalasia as discussed in a symposium that took place in Kagoshima, Japan, in September 2010 under the auspices of the International Society for Diseases of the Esophagus.

Esophageal symptoms questionnaire for the assessment of dysphagia, globus, and reflux symptoms: initial development and validation.

Esophageal symptoms often co-occur. A validated self-report measure encompassing multiple esophageal symptoms is necessary to determine their frequency and severity both independently and in association with each other. Such a questionnaire could streamline the diagnostic process and guide patient management. We aimed to develop an integrative measure that provides a clinical 'snapshot' of common esophageal symptoms. Internal reliability and content validity of a 38-item self-report Esophageal Symptoms Questionnaire (ESQ), measuring the frequency and severity of typical esophageal symptoms using Likert-rating scales were assessed in 211 patients presenting to gastroenterology and ENT outpatient tertiary care clinics. Reproducibility, concurrent and predictive validity were evaluated using the reduced-item ESQ. The 38-item ESQ had high internal reliability. Principal component analyses and item reduction methods identified three components, to which 30 of 38 items contributed significantly, providing 59% of total variance. The test-retest correlations were moderate-to-strong for 24 of 30 new items (r(s) ≥ 0.44, P < 0.05). The resultant subscales measuring dysphagia (ESQ-D), globus (ESQ-G), and reflux (ESQ-R) compared well against concurrent physician's 'working' diagnosis (odds ratio 1.04-1.09). The receiver operating characteristics were adequate-to-good for ESQ-D (area under the curve [AUC]= 0.87) and ESQ-G (AUC = 0.74), but poor for ESQ-R (AUC = 0.61) although it matched the content of the validated Reflux Disease Questionnaire. The brief 30-item ESQ shows good internal reliability and content validity as a summary of the extent of dysphagia, globus and reflux symptoms. As a tool measuring more than one esophageal symptom, ESQ could guide patient management by indicating which of the coexisting symptoms needs to be addressed first.

Do patients with globus sensation respond to hypnotically assisted relaxation therapy? A case series report.

Globus sensation is a bothersome and difficult symptom to treat. The aims of this study were to evaluate the acceptability and utility of hypnotically-assisted relaxation (HAR) in decreasing the perception of globus sensation and the effect of HAR on interdeglutitive upper esophageal sphincter (UES) pressure. Sixteen subjects with persistent globus sensation unresponsive to therapy for reflux disease and with normal esophageal/laryngeal imaging studies were invited to participate in a 7-session clinical protocol. Before and after HAR, subjects completed standard questionnaires including the esophageal symptoms questionnaire. High-resolution manometric assessment of respiratory augmentation and average resting UES pressure were assessed before and after HAR. Ten of the 16 subjects agreed to participate in the protocol. All participants were women with median age 51.5 (range 30-72 years). The participants found HAR acceptable and completed the entire 7-session trial. Globus symptom severity varied widely pre-treatment (median=52.5, range 16-72), and 9 of 10 subjects reported a reduction in globus symptomatology following treatment (median=14.0, range 3-19; P=.007). Only 1 subject exhibited abnormal respiratory augmentation of UES pressure (>27 mm Hg) prior to treatment and was normal following treatment (9.9 mm Hg). Resting UES pressure was normal in all subjects (<118 mm Hg). Group respiratory augmentation and average resting UES pressure were unaffected by HAR (P=.48, .89). This case series suggests that HAR can provide a substantial improvement in globus sensation irrespective of cause. UES function was unaffected. We suggest that HAR therapy is an acceptable and useful intervention for patients with globus sensation.

The relationship between esophageal acid exposure and the esophageal response to volumetric distention.

BACKGROUND: Increased esophagogastric junction (EGJ) distensibility is thought to contribute to gastroesophageal reflux disease (GERD). Using the functional lumen imaging probe (FLIP), we aimed to assess the esophageal response to distension among patients undergoing esophageal pH monitoring. METHODS: 25 patients (ages 22-73; 13 females) who underwent ambulatory wireless esophageal pH testing while off proton-pump inhibitors were evaluated with FLIP during sedated upper endoscopy. Esophageal reflux was quantified by total percent acid exposure time (AET; <6% was considered normal). FLIP studies were analyzed using a customized program generate FLIP topography plots to identify esophageal contractility patterns and to calculate the EGJ-distensibility index (DI). Reflux symptoms were assessed with the GERDQ. Values reflect median (interquartile range). RESULTS: Among all patients, the AET was 7.2% (3.7-11.1) and EGJ-DI was 4.2 (2.5-7.6) mm2 /mm Hg. Repetitive antegrade contractions (RACs) were induced in 19/25 (76%) of patients; AET was lower among patients with (6.1%, 3-7.8) than without (14.9, 8.5-22.3) RACs (P = .009). Correlation was weak and insignificant between AET and EGJ-DI, GERDQ and AET, and GERDQ and EGJ-DI. Patients with abnormal AET (n = 16) and normal AET (n = 9) had similar EGJ-DI, 4.6 mm2 /mm Hg (2.9-9.2) vs 3.2 (2.2-5.1), P = .207 and GERDQ, P = .138. CONCLUSIONS: Abnormal esophageal acid exposure was associated with an impaired contractile response to volume distention of the esophagus. This supports that acid exposure is dependent on acid clearance mechanisms.

Correlation between novel 3D high-resolution manometry esophagogastric junction metrics and pH-metry in reflux disease patients.

BACKGROUND AND AIMS: We recently developed 2 novel 3D high-resolution manometry (HRM) metrics of esophagogastric junction (EGJ) contractility to differentiate the lower esophageal sphincter (LES) and crural diaphragm (CD) elements of EGJ pressure. This study aimed to compare these metrics to the EGJ-contractile integral (EGJ-CI) and to analyze their correlation with esophageal acid exposure time (AET) on pH-metry. METHODS: Thirty-one gastro-oesophageal reflux disease (GERD) patients and 20 control subjects underwent 24-hour pH-metry and HRM using a 3D-HRM catheter. EGJ metrics were calculated during 3 consecutive respiratory cycles at rest. The EGJ-CI was calculated using the DCI tool in the ManoView software. 3D LES pressure (3D-LESP) and 3D-DHA, a metric quantifying the CD component of the 3D-HRM pressure topography, were calculated using a MATLAB program. Pearson correlation was used to calculate correlations with AET. KEY RESULTS: 3D-LESP, 3D-DHA, and EGJ-CI were all significantly lower in GERD patients than in control subjects (P < .05) and all were significantly correlated with AET (R = -.48, -.42, -.52, respectively, all P < .01). The 3D-DHA and EGJ-CI also strongly correlated with each other (R = .84, P < .001). CONCLUSIONS & INFERENCES: Both 3D-EGJ metrics were correlated with AET emphasizing the importance of both LES and CD function as a determinant of EGJ competence. 3D-DHA also strongly correlated with the EGJ-CI suggesting that EGJ-CI is strongly driven by the asymmetrical CD pressure component.

High-resolution manometry assessment of the lower esophageal sphincter after-contraction: Normative values and clinical correlation.

BACKGROUND: The Chicago Classification v3.0 proposed extending the distal contractile integral (DCI) measurement domain to include the lower esophageal sphincter (LES) to enhance the detection of esophageal hypercontractility. However, normative and clinical data for this approach are unreported. We aimed to describe the application of an extended DCI measurement in asymptomatic controls and patients. METHODS: High-resolution manometry (HRM) of 65 asymptomatic controls and 72 patients with normal motility were evaluated retrospectively. Dysphagia and chest pain symptoms were assessed using the brief esophageal dysphagia questionnaire (BEDQ); ≥10 was considered abnormal. HRM studies of 10 supine swallows were evaluated via the standard DCI and an extended DCI measurement domain (DCI+) to include the lower esophageal sphincter (LES) during and after the peristaltic wave. The DCI-increment was calculated as the DCI+ minus DCI. KEY RESULTS: Among controls, the median (5-95th percentile) DCI+ was 1915 (1359-6921) mm Hg/cm/s and DCI-increment was 534 (126-1488) mm Hg/cm/s. Two patients (3%) had ≥2 swallows with DCI+ >8000 mm Hg/cm/s and seven (10%) patients had at least one swallow with DCI+ >8000 mm Hg/cm/s, ie, had potential motility reclassification by application of DCI+. Seven of these nine patients (78%) were evaluated for dysphagia or chest pain, but only 3/9 (33%) had an abnormal BEDQ. CONCLUSIONS AND INFERENCES: Extension of the DCI measurement domain may aid quantifying hypercontractility that involves the LES. However, adjusting management strategies based on reclassification of patients with otherwise normal motility should be cautiously considered.

Upper sphincter function during transient lower oesophageal sphincter relaxation (tLOSR); it is mainly about microburps.

Transient lower oesophageal sphincter relaxations (tLOSRs) are both a dominant mechanism of reflux and an element of the belch reflex. This study aimed to analyse the interplay between reflux and upper oesophageal sphincter (UOS) activity during meal-induced tLOSRs. Fifteen normal subjects were studied with a solid-state high-resolution manometry assembly positioned to record from the hypopharynx to the stomach and a catheter pH electrode 5 cm above the LOS. Subjects ate a 1000-calorie high-fat meal and were monitored for 120 min in a sitting posture. The relationship among tLOSRs, common cavities, pressure changes within the oesophagus and UOS contractile activity were analysed. A total of 218 tLOSRs occurred among the 15 subjects. The majority (79%) were coupled with UOS relaxation and 84% (145/173) of these occurred in association with a common cavity. Upper oesophageal sphincter relaxation was usually preceded by a pressure change in the oesophagus; however, some relaxations (16%) occurred without a discernable increase in pressure or before the pressure increase began. Acid reflux did not appear to play a role in determining UOS response to tLOSRs. The majority of post-prandial tLOSRs were associated with brief periods of UOS relaxation, likely permissive of gas venting (microburps). Intraoesophageal pressure changes likely modulate this UOS response; however, an anticipatory characteristic was evident in some subjects. Whether or not GORD patients with extra-oesophageal symptoms exhibit an exaggeration of the UOS relaxation response during reflux is yet to be determined.

Could the peristaltic transition zone be caused by non-uniform esophageal muscle fiber architecture? A simulation study.

BACKGROUND: Based on a fully coupled computational model of esophageal transport, we analyzed how varied esophageal muscle fiber architecture and/or dual contraction waves (CWs) affect bolus transport. Specifically, we studied the luminal pressure profile in those cases to better understand possible origins of the peristaltic transition zone. METHODS: Two groups of studies were conducted using a computational model. The first studied esophageal transport with circumferential-longitudinal fiber architecture, helical fiber architecture and various combinations of the two. In the second group, cases with dual CWs and varied muscle fiber architecture were simulated. Overall transport characteristics were examined and the space-time profiles of luminal pressure were plotted and compared. KEY RESULTS: Helical muscle fiber architecture featured reduced circumferential wall stress, greater esophageal distensibility, and greater axial shortening. Non-uniform fiber architecture featured a peristaltic pressure trough between two high-pressure segments. The distal pressure segment showed greater amplitude than the proximal segment, consistent with experimental data. Dual CWs also featured a pressure trough between two high-pressure segments. However, the minimum pressure in the region of overlap was much lower, and the amplitudes of the two high-pressure segments were similar. CONCLUSIONS & INFERENCES: The efficacy of esophageal transport is greatly affected by muscle fiber architecture. The peristaltic transition zone may be attributable to non-uniform architecture of muscle fibers along the length of the esophagus and/or dual CWs. The difference in amplitude between the proximal and distal pressure segments may be attributable to non-uniform muscle fiber architecture.

High-resolution impedance manometry parameters enhance the esophageal motility evaluation in non-obstructive dysphagia patients without a major Chicago Classification motility disorder.

BACKGROUND: High-resolution impedance manometry (HRIM) allows evaluation of esophageal bolus retention, flow, and pressurization. We aimed to perform a collaborative analysis of HRIM metrics to evaluate patients with non-obstructive dysphagia. METHODS: Fourteen asymptomatic controls (58% female; ages 20-50) and 41 patients (63% female; ages 24-82), 18 evaluated for dysphagia and 23 for reflux (non-dysphagia patients), with esophageal motility diagnoses of normal motility or ineffective esophageal motility, were evaluated with HRIM and a global dysphagia symptom score (Brief Esophageal Dysphagia Questionnaire). HRIM was analyzed to assess Chicago Classification metrics, automated pressure-flow metrics, the esophageal impedance integral (EII) ratio, and the bolus flow time (BFT). KEY RESULTS: Significant symptom-metric correlations were detected only with basal EGJ pressure, EII ratio, and BFT. The EII ratio, BFT, and impedance ratio differed between controls and dysphagia patients, while the EII ratio in the upright position was the only measure that differentiated dysphagia from non-dysphagia patients. CONCLUSIONS & INFERENCES: The EII ratio and BFT appear to offer an improved diagnostic evaluation in patients with non-obstructive dysphagia without a major esophageal motility disorder. Bolus retention as measured with the EII ratio appears to carry the strongest association with dysphagia, and thus may aid in the characterization of symptomatic patients with otherwise normal manometry.

Benchmarks for the interpretation of esophageal high-resolution manometry.

BACKGROUND: Competent interpretation of esophageal high-resolution manometry (HRM) is integral to a quality study. Currently, methods to assess physician competency for the interpretation of esophageal HRM do not exist. The aim of this study was to use formal techniques to (i) develop an HRM interpretation exam, and (ii) establish minimum competence benchmarks for HRM interpretation skills at the trainee, physician interpreter, and master level. METHODS: A total of 29 physicians from 8 academic centers participated in the study: 9 content experts separated into 2 study groups-expert test-takers (n=7) and judges (n=2), and 20 HRM inexperienced trainees ("trainee test-taker"; n=20). We designed the HRM interpretation exam based on expert consensus. Expert and trainee test-takers (n=27) completed the exam. According to the modified Angoff method, the judges reviewed the test-taker performance and established minimum competency cut scores for HRM interpretation skills. KEY RESULTS: The HRM interpretation exam consists of 22 HRM cases with 8 HRM interpretation skills per case: identification of pressure inversion point, hiatal hernia >3 cm, integrated relaxation pressure, distal contractile integral, distal latency, peristaltic integrity, pressurization pattern, and diagnosis. Based on the modified Angoff method, minimum cut scores for HRM interpretation skills at the trainee, physician interpreter, and master level ranged from 65-80%, 85-90% (with the exception of peristaltic integrity), and 90-95%, respectively. CONCLUSIONS & INFERENCES: Using a formal standard setting technique, we established minimum cut scores for eight HRM interpretation skills across interpreter levels. This examination and associated cut scores can be applied in clinical practice to judge competency.

Validation of criteria for the definition of transient lower esophageal sphincter relaxations using high-resolution manometry.

BACKGROUND: Criteria for transient lower esophageal sphincter relaxations (TLESRs) are well-defined for Dentsleeve manometry. As high-resolution manometry (HRM) is now the gold standard to assess esophageal motility, our aim was to propose a consensus definition of TLESRs using HRM. METHODS: Postprandial esophageal HRM combined with impedance was performed in 10 patients with gastroesophageal reflux disease. Transient lower esophageal sphincter relaxations identification was performed by 17 experts using a Delphi process. Four investigators then characterized TLESR candidates that achieved 100% agreement (TLESR events) and those that achieved less than 25% agreement (non-events) after the third round. Logistic regression and decision tree analysis were used to define optimal diagnostic criteria. KEY RESULTS: All diagnostic criteria were more frequently encountered in the 57 TLESR events than in the 52 non-events. Crural diaphragm (CD) inhibition and LES relaxation duration >10 seconds had the highest predictive value to identify TLESR. Based on decision tree analysis, reflux on impedance, esophageal shortening, common cavity, upper esophageal sphincter relaxation without swallow and secondary peristalsis were alternate diagnostic criteria. CONCLUSION & INFERENCES: Using HRM, TLESR might be defined as LES relaxation occurring in absence of swallowing, lasting more than 10 seconds and associated with CD inhibition.

Slimline vs. glass pH electrodes: what degree of accuracy should we expect?

BACKGROUND: Ambulatory pH monitoring is considered the gold standard for measuring oesophageal acid exposure, however, data comparing antimony and glass electrodes are limited. AIM: To compare the accuracy of the Slimline antimony pH monitoring system and a conventional glass electrode catheter pH monitoring system during ambulatory conditions. METHODS: Eighteen subjects (13 males, 23-45 years) underwent simultaneous pH monitoring using the Slimline antimony pH electrode and MIC M3 glass pH electrode pH monitoring systems for 12 h. Acid exposure was analysed and compared by manual extraction of the data onto an excel spreadsheet. RESULTS: There was no statistical difference in the median per cent time the pH was <4 recorded by the two systems (Slimline, 3%, Glass MIC M3, 2%, P = 0.77) and the correlation was excellent (r = 0.84). The difference in recorded reflux events was also not significantly different between the two systems, with the absolute difference being 23 events (s.d., 26). Point-by-point discrepancy was 28% (s.d., 18%), however, the agreement in terms of reflex events was excellent (Kappa value, 0.89, s.d., 0.09). CONCLUSION: Despite substantial point-by-point disagreement, the antimony Slimline pH catheter compares favourably to the Glass MIC M3 pH catheter in terms of measuring standard pH parameters.

Pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography-a normative study of younger and older adults.

BACKGROUND: We aimed to define normative values for novel pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography. The effects of age, gender, and bolus properties were examined. METHODS: Concurrent high-resolution manometry (HRM) and videofluoroscopy data were collected from 22 younger (aged 21-40) and 22 older (aged 60-80) healthy subjects. Pressure topography was analyzed by correlating pressure domains with videofluoroscopic events. Nine pressure topography metrics of the pharyngeal and proximal esophageal swallow were extracted; four of these were also compared with previously obtained esophageal HRM studies to assess the effects of catheter diameter. KEY RESULTS: Older individuals exhibited more vigorous contractility in the pharynx than did younger subjects with all bolus types, but the greatest values for both groups were with effortful swallow and on that measure the age groups were similar. Upper esophageal sphincter (UES) intrabolus pressure during sphincter opening was also greater in the older subjects. Some gender differences were observed, particularly related to proximal esophageal contractile vigor. Bolus consistency had no consistent effect. Studies using the larger catheter diameter resulted in significantly greater contractile vigor in the UES and proximal esophagus. CONCLUSIONS & INFERENCES: Older adults exhibited more vigorous pharyngeal contractions than young adults, albeit within a similar range of capacity, perhaps reflecting a compensatory response to other age-related physiological changes. Greater UES intrabolus pressures observed during bolus transit in the older group likely reflect reduced UES compliance with age. Normative data on novel HRM metrics collected in this study can serve as a reference for future clinical studies.

Development and validation of the brief esophageal dysphagia questionnaire.

BACKGROUND: Esophageal dysphagia is common in gastroenterology practice and has multiple etiologies. A complication for some patients with dysphagia is food impaction. A valid and reliable questionnaire to rapidly evaluate esophageal dysphagia and impaction symptoms can aid the gastroenterologist in gathering information to inform treatment approach and further evaluation, including endoscopy. METHODS: 1638 patients participated over two study phases. 744 participants completed the Brief Esophageal Dysphagia Questionnaire (BEDQ) for phase 1; 869 completed the BEDQ, Visceral Sensitivity Index, Gastroesophageal Reflux Disease Questionnaire, and Hospital Anxiety and Depression Scale for phase 2. Demographic and clinical data were obtained via the electronic medical record. The BEDQ was evaluated for internal consistency, split-half reliability, ceiling and floor effects, and construct validity. KEY RESULTS: The BEDQ demonstrated excellent internal consistency, reliability, and construct validity. The symptom frequency and severity scales scored above the standard acceptable cutoffs for reliability while the impaction subscale yielded poor internal consistency and split-half reliability; thus the impaction items were deemed qualifiers only and removed from the total score. No significant ceiling or floor effects were found with the exception of 1 item, and inter-item correlations fell within accepted ranges. Construct validity was supported by moderate yet significant correlations with other measures. The predictive ability of the BEDQ was small but significant. CONCLUSIONS & INFERENCES: The BEDQ represents a rapid, reliable, and valid assessment tool for esophageal dysphagia with food impaction for clinical practice that differentiates between patients with major motor dysfunction and mechanical obstruction.