Classifying Esophageal Motility by FLIP Panometry: A Study of 722 Subjects With Manometry.

INTRODUCTION: Functional luminal imaging probe (FLIP) panometry can evaluate esophageal motility in response to sustained esophageal distension at the time of sedated endoscopy. This study aimed to describe a classification of esophageal motility using FLIP panometry and evaluate it against high-resolution manometry (HRM) and Chicago Classification v4.0 (CCv4.0). METHODS: Five hundred thirty-nine adult patients who completed FLIP and HRM with a conclusive CCv4.0 diagnosis were included in the primary analysis. Thirty-five asymptomatic volunteers ("controls") and 148 patients with an inconclusive CCv4.0 diagnosis or systemic sclerosis were also described. Esophagogastric junction (EGJ) opening and the contractile response (CR) to distension (i.e., secondary peristalsis) were evaluated with a 16-cm FLIP during sedated endoscopy and analyzed using a customized software program. HRM was classified according to CCv4.0. RESULTS: In the primary analysis, 156 patients (29%) had normal motility on FLIP panometry, defined by normal EGJ opening and a normal or borderline CR; 95% of these patients had normal motility or ineffective esophageal motility on HRM. Two hundred two patients (37%) had obstruction with weak CR, defined as reduced EGJ opening and absent CR or impaired/disordered CR, on FLIP panometry; 92% of these patients had a disorder of EGJ outflow per CCv4.0. DISCUSSION: Classifying esophageal motility in response to sustained distension with FLIP panometry parallels the swallow-associated motility evaluation provided with HRM and CCv4.0. Thus, FLIP panometry serves as a well-tolerated method that can complement, or in some cases be an alternative to HRM, for evaluating esophageal motility disorders.

Multiple rapid swallows and rapid drink challenge in patients with esophagogastric junction outflow obstruction on high-resolution manometry.

BACKGROUND: Esophagogastric junction outflow obstruction (EGJOO) as defined by Chicago Classification of esophageal motility disorders (CCv3.0) encompasses a broad range of diagnoses, thus posing clinical challenges. Our aims were to evaluate multiple rapid swallow (MRS) and rapid drink challenge (RDC) during high-resolution manometry (HRM) to aid identifying clinically relevant EGJOO. METHODS: Patients with a HRM diagnosis of EGJOO based on CCv3.0 that also completed MRS and RDC during HRM and barium esophagram were retrospectively identified. Radiographic EGJOO (RAD-EGJOO) was defined by either liquid barium retention or delayed passage of a barium tablet on barium esophagram. Thirty healthy asymptomatic controls that completed HRM were also included. MRS involved drinking 2 mL for 5 successive swallows. RDC involved rapid drinking of 200 mL liquid. Integrated relaxation pressure (IRP) and presence of panesophageal pressurization (PEP) during MRS and RDC were assessed. KEY RESULTS: One hundred one patients, mean (SD) age 56 (16) years, were included; 32% had RAD-EGJOO, 68% did not. RAD-EGJOO patients more frequently had elevated (>12 mmHg) upright IRP (100%), MRS-IRP (56%), RDC-IRP (53%), and PEP during RDC (66%) than both controls [17%; 0%; 7%; 3%] and patients without RAD-EGJOO [83%; 35%; 39%; 41%] Having IRP >12 mmHg during both MRS and RDC was twice as likely to be associated with RAD-EGJOO (19%) than those without RAD-EGJOO (9%) among patients with upright IRP >12 mmHg. CONCLUSIONS AND INFERENCES: Adjunctive HRM maneuvers MRS and RDC appear to help identify clinically significant EGJOO. While future outcome studies are needed, comprehensive multimodal evaluation helps clarify relevance of EGJOO on HRM.

[High-resolution Manometry for Esophageal Motility Disorders].

High-resolution manometry (HRM) has significant contribution in the field of esophageal motility disorders recently. The development of HRM has categorized various esophageal motility disorders focusing on patterns of esophageal motor function. Additionally, the Chicago classification criteria are widely used for manometric diagnosis. HRM provides functional imaging of the esophagus. HRM has closely spaced pressure sensors and displays pressure variations as pressure topography plots. In the analysis of HRM according to the Chicago classification, a hierarchical categorization of motility disorders is made after evaluation of the individual swallow patterns. First the lower esophageal sphincter (LES) function, and subsequently the esophageal pressure patterns are used to make a diagnosis. The hierarchical flow-chart has 4 groups; (1) incomplete LES relaxation( achalasia or esophagogastric junction outflow obstruction), (2) major motility disorders, (3) minor motility disorders, (4) normal esophageal motility. HRM is the gold standard for diagnosis of esophageal motility disorders.

A pictorial presentation of 3. 0 Chicago Classification for esophageal motility disorders / Apresentação em imagens da Classificação de Chicago versão 3. 0 das doenças da motilidade esofagiana

ABSTRACT High resolution manometry changed several esophageal motility paradigms. The 3.0 Chicago Classification defined manometric criteria for named esophageal motility disorders. We present a pictorial atlas of motility disorders. Achalasia types, esophagogastric junction obstruction, absent contractility, distal esophageal spasm, hypercontractile esophagus (jackhammer), ineffective esophageal motility, and fragmented peristalsis are depicted with high-resolution manometry plots.

RESUMO A manometria de alta resolução mudou vários paradigmas da motilidade digestiva. A Classificação de Chicago, na versão 3.0, definiu critérios manométricos para as doenças da motilidade esofagiana. O presente artigo é um atlas das dismotilidades descritas. Tipos de acalásia, obstrução ao nível da junção esofagogástrica, contrações ausentes, espasmo esofagiano distal, esôfago hipercontrátil, motilidade esofagiana ineficaz e peristalse fragmentada são mostradas em traçados de manometria de alta resolução.

[Esophageal motility disorders]. / Motilitätsstörungen des Ösophagus.

Esophageal motility disorders are a group of diseases that result in swallowing dysfunction due to changes in neuromuscular structures, which coordinate esophageal function. Besides achalasia, which is the best defined functional disturbance of the esophagus, there are other motility disorders, namely hypercontractile (diffuse esophageal spasm, nutcracker or jackhammer esophagus, hypertensive lower esophageal sphincter) and hypocontractile disorders, whose origins and disease mechanisms are not yet well understood. The main symptoms are dysphagia and thoracic pain. Diagnosis is usually made by means of esophageal manometry, while endoscopy and barium swallow are essential to exclude inflammatory or neoplastic changes. The introduction of high resolution manometry (HRM) with up to 36 pressure points that are simultaneously measured on the esophageal catheter has changed diagnosis and assessment, and has led­with the Chicago Classification­to a new functional classification of esophageal motility disorders. In the following review, the most important motility disorders of the esophagus are introduced.

Current Therapeutic Options for Esophageal Motor Disorders as Defined by the Chicago Classification.

With the development of high-resolution manometry and specific metrics to characterize esophageal motility, the Chicago Classification has become the gold standard for the diagnosis of esophageal motor disorders. Major and significant disorders, that is, never observed in healthy subjects, are achalasia, esophagogastric junction outflow obstruction, distal esophageal spasm, absent peristalsis, and hypercontractile (Jackhammer) esophagus. Achalasia subtyping is relevant to predict the response to endoscopic and surgical therapies as several studies suggest that, pneumatic dilation is less effective than Heller myotomy, in type III achalasia. Peroral endoscopic myotomy, initially developed in expert centers, is a promising technique for the treatment of achalasia. The medical therapeutic options for distal esophageal spasm and hypercontractile esophagus are smooth muscle relaxants and pain modulators. Intraesophageal injection of botulinum toxin might be an interesting option for treatment of these disorders but further studies are required to determine the optimal injection protocol and the best candidates based on manometric patterns. The treatment of hypotensive motility disorders is disappointing and relies mainly on dietary and lifestyle changes as no effective esophageal prokinetic is currently available.

Botulinum toxin injection for hypercontractile or spastic esophageal motility disorders: may high-resolution manometry help to select cases?

Endoscopic injections of botulinum toxin in the cardia or distal esophagus have been advocated to treat achalasia and spastic esophageal motility disorders. We conducted a retrospective study to evaluate whether manometric diagnosis using the Chicago classification in high-resolution manometry (HRM) would be predictive of the clinical response. Charts of patients with spastic and hypertensive motility disorders diagnosed with HRM and treated with botulinum toxin were retrospectively reviewed at two centers. HRM recordings were systematically reanalyzed, and a patient's phone survey was conducted. Forty-five patients treated between 2008 and 2013 were included. Most patients had achalasia type 3 (22 cases). Other diagnoses were jackhammer esophagus (8 cases), distal esophageal spasm (7 cases), esophagogastric junction outflow obstruction (5 cases), nutcracker esophagus (1 case), and 2 unclassified cases. Botulinum toxin injections were performed into the cardia only in 9 cases, into the wall of the distal esophagus in 19 cases, and in both locations (cardia and distal esophagus) in 17 cases. No complication occurred in 31 cases. Chest pain was noticed for less than 7 days in 13 cases. One death related to mediastinitis occurred 3 weeks after botulinum toxin injection. Efficacy was assessed in 42 patients: 71% were significantly improved 2 months after botulinum toxin, and 57% remained satisfied for more than 6 months. No clear difference was observed in terms of response according to manometric diagnosis; however, type 3 achalasia previously dilated and with normal integrated relaxation pressure (4s-integrated relaxation pressure < 15 mmHg) had the worst outcome: none of these patients responded to the endoscopic injection of botulinum toxin. Endoscopic injections of botulinum toxin may be effective in some patients with spastic or hypercontractile esophageal motility disorders. The manometric Chicago classification diagnosis does not seem to predict the results. Prospective randomized trials are required to identify patients most likely to benefit from esophageal botulinum toxin treatment.

Medical and surgical management of esophageal and gastric motor dysfunction.

he occurrence of esophageal and gastric motor dysfunctions happens, when the software of the esophagus and the stomach is injured. This is really a program previously established in the enteric nervous system as a constituent of the newly called neurogastroenterology. The enteric nervous system is composed of small aggregations of nerve cells, enteric ganglia, the neural connections between these ganglia, and nerve fibers that supply effectors tissues, including the muscle of the gut wall. The wide range of enteric neuropathies that includes esophageal achalasia and gastroparesis highlights the importance of the enteric nervous system. A classification of functional gastrointestinal disorders based on symptoms has received attention. However, a classification based solely in symptoms and consensus may lack an integral approach of disease. As an alternative to the Rome classification, an international working team in Bangkok presented a classification of motility disorders as a physiology-based diagnosis. Besides, the Chicago Classification of esophageal motility was developed to facilitate the interpretation of clinical high-resolution esophageal pressure topography studies. This review covers exclusively the medical and surgical management of the esophageal and gastric motor dysfunction using evidence from well-designed studies. Motor control of the esophagus and the stomach, motor esophageal and gastric alterations, treatment failure, side effects of PPIs, overlap of gastrointestinal symptoms, predictors of treatment, burden of GERD medical management, data related to conservative treatment vs. antireflux surgery, and postsurgical esophagus and gastric motor dysfunction are also taken into account.

High-resolution impedance manometry findings in patients with nutcracker esophagus.

BACKGROUND AND AIM: The objective of this study was to evaluate the association between high-resolution manometry (HRM) and impedance findings and symptoms in patients with nutcracker esophagus (NE). METHODS: After institutional review board approval retrospective review of a prospectively maintained database identified patients who were diagnosed with NE as per the Chicago classification (distal contractile integral [DCI] > 5000 mmHg-s-cm) at Creighton University between October 2008 and October 2010. Patients with achalasia or a history of previous foregut surgery were excluded. NE patients were sub-divided into: (i) Segmental (mean distal esophageal amplitude [DEA] at 3 and 8 cm above lower esophageal sphincter [LES] < 180 mmHg) (ii) Diffuse (mean DEA at 3 and 8 cm above LES > 180 mmHg) and (iii) Spastic (DCI > 8000 mmHg-s-cm). RESULTS: Forty-one patients (segmental: 13, diffuse: 4, spastic: 24) satisfied study criteria. Patients with segmental NE would have been missed by conventional manometry criteria as their DEA < 180 mmHg. A higher percentage of patients with spastic NE (63%) had chest pain when compared to patients with segmental NE (23%) and diffuse NE (25%). There was a significant positive correlation between chest pain severity score and DCI while there was no significant correlation between dysphagia severity and DCI. CONCLUSIONS: In patients diagnosed with NE using the Chicago classification presence and intensity of chest pain increases with increasing DCI. The present criteria (> 5000 mmHg-s-cm) seems to be too sensitive and has poor symptom correlation. Adjusting the criteria to 8000 mmHg-s-cm is more relevant clinically.

High-resolution esophageal manometry: using technical advances for clinical advantages.

BACKGROUND: High-resolution manometry (HRM) is a new technique to investigate the motor function of the esophagus. It differs from conventional manometry in recording pressures by solid state microtransducers at 12 points around the circumference at every centimeter of esophageal length, and displaying the data in pseudo-three-dimensional format using a topographic plot, where esophageal pressures within a given range are represented by different colors. RATIONALE: The large amount of data and the capacity to analyze and display it intuitively has afforded many new insights into esophageal dysfunction. Among these insights are the ability to distinguish three different subtypes of achalasia and predict their response to therapy, better understanding of the relationship between the lower esophageal sphincter (LES) and the crural diaphragm, the development of novel quantitative parameters to understand the nature of the dysfunction in non-specific esophageal motor disorders, and the elucidation of a newly described motility disorder characterized by failure of peristalsis at the transitional zone between the upper skeletal muscle and the more distal smooth muscle portion of the esophagus. It is also ideally suited to analysis of the effect of prokinetic medications. The method is quicker and less uncomfortable for patients and the analysis is visually appealing and intuitively comprehensible. CONCLUSION: Despite these potential advantages, there are currently no data to demonstrate a clinical advantage in treatment. The results of such studies will be crucial to the acceptance of this novel technology.

Gastroparesia: temas de atualização e revisão em clínica médica / Gastroparesis: themes of updating and revision in medical clinic

Gastroparesia é uma dificuldade no esvaziamento gástrico sem que haja qualquer obstrução mecânica ao livre trânsito gastroduodenal. Trata-se de condição estritamente relacionada à função do estômago, podendo decorrer de distúrbios neural (p. ex.: diabetes mellitus), eletrolítico (p. ex.: hipopotassemia) ou hormonal (p. ex.: hipotireoidismo), dentre outros. Náuseas, vômitos, plenitude pós-prandial e saciedade precoce estão presentes. Não existe exame laboratorial capaz de identificar a gastroparesia, no entanto, eles podem indicar a etiologia da mesma. A radiografia simples de abdome pode demonstrar distensão gástrica; a seriografia gastroduodenal, bem como a endoscopia digestiva, são mais úteis na avaliação de obstrução mecânica. Na atualidade, o padrão ouro para o diagnóstico da gastroparesia é cintilografia gástrica.

Gastroparesis is a difficulty in gastric emptying without any mechanical obstruction gastroduodenal. Is is strictly related to the condition of the stomach, likely to arise of neural disorder (diabetes mellitus), electrolytic (hipopotassemy), or hormone (hypothyroidism), among others. Nausea, vomiting, early postprandial and early satiety are present. There is no laboratory examination identifies the gastroparesis, however, they can indicate the etiology. The simple radiography may demonstrate abdominal distension, gastroduodenal seriography, as well digestive endoscopy, are most useful in evaluating mechanical obstruction. Today the gold standard for the diagnosis of gastroparesis is gastric scintigraphy.

Oesophageal high-resolution manometry: moving from research into clinical practice.

Manometry measures pressure within the oesophageal lumen and sphincters, and provides an assessment of the neuromuscular activity that dictates function in health and disease. It is performed to investigate the cause of functional dysphagia, unexplained "non-cardiac" chest pain, and in the pre-operative work-up of patients referred for anti-reflux surgery. Manometric techniques have improved in a step-wise fashion from a single pressure channel to the development of high-resolution manometry (HRM) with up to 36 pressure sensors. At the same time, advances in computer processing allow pressure data to be presented in real time as a compact, visually intuitive "spatiotemporal plot" of oesophageal pressure activity. HRM recordings reveal the complex functional anatomy of the oesophagus and its sphincters. Spatiotemporal plots provide objective measurements of the forces that move food and fluid from the pharynx to the stomach and determine the risk of reflux events. The introduction of commercially available HRM has been followed by rapid uptake of the technique. This review examines the current evidence that supports the move of HRM from the research setting into clinical practice. It is assessed whether a detailed description of pressure activity identifies clinically relevant oesophageal dysfunction that is missed by conventional investigation, increasing diagnostic yield and accuracy. The need for a new classification system for oesophageal motor activity based on HRM recordings is discussed. Looking ahead the potential of this technology to guide more effective medical and surgical treatment of oesophageal disease is considered because, ultimately, it is this that will define the success of HRM in clinical practice.

Prevalencia de los diferentes trastornos motores primarios del esófago: Estudio prospectivo de 5.440 casos / Primary esophageal motor disturbances among patients with esophageal symptoms

Background: The esophagus can suffer several motor disturbances of striated or smooth muscle. Aim: To determine the presence of primary motor disturbances of the esophagus among a group of patients with esophageal symptoms. Material and methods: Prospective study of 5,440 patients consulting for heartburn, chest pain or dysphagia, with primary esophageal motor disturbances, studied between 1994 and 2004. AH were subjected to an esophageal manometry with eight perfused catheters connected to pressure transducers. Results: Nineteen percent of subjects had a normal esophageal manometry, 60 percent had unspecific motor disturbances usually associated to gastroesophageal reflux, 13 percent had a nutcracker esophagus, 5 percent had diffuse esophageal spasm, 2 percent had achalasia and 0,3 percent had an hypertensive sphincter. Conclusions: Primaryesophageal motor disturbances are common among patients with esophageal symptoms. A manometry should be performed to these patients.

[Non-specific esophageal motility disorders: manometric abnormalities with unknown causes].

OBJECTIVE: To study a group of patients with abnormalities of esophageal motility in manometric investigation. METHODS: From 1990 to 1999, 14 patients with dysphagia (9), chest pain (3), or both (2) were studied. All patients denied symptoms of heartburn, regurgitation, odynophagia, epigastric discomfort, and investigation failed to show any evidence of ischemic heart disease. A perfused catheter with 4 separate lumens was used and connected to output transducers (Medtronic, PC Polygraf HR). RESULTS: Of the 14 patients, 11 had motor disorders of the esophageal body including simultaneous contractions without normal peristalsis (5), alternative occurrence of simultaneous contractions and normal peristalsis (3), aperistalsis (2) and very low amplitude peristalsis (1). Seven patients were diagnosed with motility disorders of the lower esophageal sphincter including incomplete relaxation or no relaxation on swallowing (6), short relaxation duration (1). Four patients had more than one abnormal manometric findings. CONCLUSIONS: Non-specific esophageal motility disorder is not a real diagnostic entity, but only a group of manometric abnormalities. The relationship between the symptoms of the patients and the manometric findings was analysed. It is uncertain that these disorders have a common etiology. The revision of these abnormalities is difficult because the pathogenesis is unknown.

Oesophageal motility disorders.

Oesophageal motility disorders comprise various abnormal manometric patterns which usually present with dysphagia or chest pain. Some, such as achalasia, are diseases with a well defined pathology, characteristic manometric features, and good response to treatments directed at the pathophysiological abnormalities. Other disorders, such as diffuse oesophageal spasm and hypercontracting oesophagus, have no well defined pathology and could represent a range of motility changes associated with subtle neuropathic changes, gastro-oesophageal reflux, and anxiety states. Although manometric patterns have been defined for these disorders, the relation with symptoms is poorly defined and the response to medical or surgical therapy unpredictable. Hypocontracting oesophagus is generally caused by weak musculature commonly associated with gastro-oesophageal reflux disease. Secondary oesophageal motility disorders can be caused by collagen vascular diseases, diabetes, Chagas' disease, amyloidosis, alcoholism, myxo-oedema, multiple sclerosis, idiopathic pseudo-obstruction, or the ageing process.

Esophageal dysmotility and gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) produces a spectrum of symptoms ranging from mild to severe. While the role of the lower esophageal sphincter in the pathogenesis of GERD has been studied extensively, less attention has been paid to esophageal peristalsis, even though peristalsis governs esophageal acid clearance. The aim of this study was to evaluate the following in patients with GERD: (1) the nature of esophageal peristalsis and (2) the relationship between esophageal peristalsis and gastroesophageal reflux, mucosal injury, and symptoms. One thousand six consecutive patients with GERD confirmed by 24-hour pH monitoring were divided into three groups based on the character of esophageal peristalsis as shown by esophageal manometry: (1) normal peristalsis (normal amplitude, duration, and velocity of peristaltic waves); (2) ineffective esophageal motility (IEM; distal esophageal amplitude < 30 mm Hg or >30% simultaneous waves); and (3) nonspecific esophageal motility disorder (NSEMD; motor dysfunction intermediate between the other two groups). Peristalsis was classified as normal in 563 patients (56%), IEM in 216 patients (21%), and NSEMD in 227 patients (23%). Patients with abnormal peristalsis had worse reflux and slower esophageal acid clearance. Heartburn, respiratory symptoms, and mucosal injury were all more severe in patients with IEM. These data show that esophageal peristalsis was severely impaired (IEM) in 21% of patients with GERD, and this group had more severe reflux, slower acid clearance, worse mucosal injury, and more frequent respiratory symptoms. We conclude that esophageal manometry and pH monitoring can be used to stage the severity of GERD, and this, in turn, should help identify those who would benefit most from surgical treatment.

Laparoscopic esophagomyotomy with posterior partial fundoplication for primary esophageal motility disorders.

BACKGROUND: The outcomes of a laparoscopic esophagomyotomy with posterior partial fundoplication were compared between groups of patients with primary motility disorders. METHODS: In this study, 47 patients (26 women and 21 men, ages 24 to 77 years; mean, 47 years) with significant dysphagia or chest pain who failed conservative treatment underwent a laparoscopic esophagomyotomy and posterior partial fundoplication. Preoperative evaluation revealed four groups of primary motility disorders: achalasia (n = 12), nutcracker esophagus (n = 12), hypertensive lower esophageal sphincter (LES) (n = 16), and diffuse esophageal spasm (n = 7). Statistical analysis was performed by Cramer's V test. RESULTS: Average follow-up period was 30.3 months. There was no mortality or early morbidity. Late morbidity included dysphagia or chest pain over 6 weeks in 10 patients (21%), recurrent gastroesophageal reflux disease (GERD) in 3 patients (6%), and recurrent motility disorder in 2 patients (4%). Overall, 94% of the patients ultimately had complete resolution of dysphagia or chest pain. There was no significant difference in outcomes between groups. CONCLUSION: Early results suggest that laparoscopic esophagomyotomy with posterior partial fundoplication provides safe and effective relief from dysphagia and chest pain in patients with each of the primary motility disorders.

Trastornos de motilidad esofágica / Disturbances of esophageal motility

Se describe las características de los trastornos motores esofágicos más frecuentes. Es importante pensar en estos cuadros frente a dolores torácicos de causa no cardíaca. De éstos el más común parece ser el esófago en cascanueces. Se analiza la fisiopatología, clínica, diagnóstico y tratamiento de los principales, haciendo énfasis especial en el tratamiento quirúrgico, el que con el advenimiento de la laparoscopia, representa una buena alternativa frente al tratamiento médico convencional, de tan pobres resultados

Diagnosis of esophageal motility disorders.

Esophageal motility disorders are now known to be a heterogeneous group of conditions that commonly cause dysphagia and chest pain. Motor dysphagia is usually provoked by solids and liquids (in contrast to mechanical dysphagia, which is usually provoked by solids only). Chest pain with these disorders is nonspecific and can mimic angina pectoris. In many patients with diffuse esophageal spasm or nutcracker esophagus, pain appears to be caused by abnormal sensory function rather than contraction abnormalities. Barium esophagography and esophageal manometry are complementary studies in the evaluation of motility disorders.