Esophago-gastric junction findings on high resolution impedance manometry in children with esophageal atresia.

OBJECTIVES: Using high resolution impedance manometry (HRIM), this study characterized the esophago-gastric junction (EGJ) dynamics in children with esophageal atresia (EA). METHOD: Esophageal HRIM was performed in patients with EA aged less than 18 years. Objective motility patterns were analyzed, and EGJ data reported. Controls were pediatric patients without EA undergoing investigations for consideration of fundoplication surgery. RESULTS: Seventy-five patients (M:F = 43:32, median age 1 year 3 months [3 months-17 years 4 months]) completed 133 HRIM studies. The majority (64/75, 85.3%) had EA with distal tracheo-esophageal fistula. Compared with controls, liquid swallows were poorer in patients with EA, as evident by significant differences in distension pressure emptying and bolus flow time (BFT). The integrated relaxation pressure for thin liquid swallows was significantly different between EA types, as well as when comparing patients with EA with and without previous esophageal dilatations. The BFT for solid swallows was significantly different when compared with EA types. CONCLUSIONS: We have utilized HRIM in patients with EA to demonstrate abnormalities in their long-term EGJ function. These abnormalities correlate with poorer esophageal compliance and reduced esophageal peristalsis across the EGJ. Understanding the EGJ function in patients with EA will allow us to tailor long-term management to specific patients.

Mucosal impedance as a diagnostic tool for gastroesophageal reflux disease: an update for clinicians.

Mucosal impedance is a marker of esophageal mucosal integrity and a novel technique for assessing esophageal function and pathology. This article highlights its development and clinical application for gastroesophageal reflux disease (GERD), Barrett's esophagus, and eosinophilic esophagitis. A narrative review of key publications describing the development and use of mucosal impedance in clinical practice was conducted. A low mean nocturnal baseline impedance (MNBI) has been shown to be an independent predictor of response to anti-reflux therapy. MNBI predicts medication-responsive heartburn better than distal esophageal acid exposure time. Patients with equivocal evidence of GERD using conventional methods, with a low MNBI, had an improvement in symptoms following the initiation of PPI therapy compared to those with a normal MNBI. A similar trend was seen in a post fundoplication cohort. Strong clinical utility for the use of mucosal impedance in assessing eosinophilic esophagitis has been repeatedly demonstrated; however, there is minimal direction for application in Barrett's esophagus. The authors conclude that mucosal impedance has potential clinical utility for the assessment and diagnosis of GERD, particularly when conventional investigations have yielded equivocal results.

Gastric emptying and myoelectrical activity testing in children with esophageal atresia: A pilot study.

Objectives: Abnormalities of gastric function in children with esophageal atresia (EA) could potentially contribute to gastrointestinal symptoms and reduced quality of life (QOL). Therefore, we aimed to determine the feasibility and clinical usefulness of gastric function testing in children with EA. Methods: The validated PedsQL Gastrointestinal Symptoms Questionnaire (PedsQL-GI) was completed to assess gastrointestinal symptoms and symptom-related QOL. Gastric emptying and gastric myoelectrical activity were studied using 13C-gastric emptying octanoic acid breath test (13C-GEBT) and surface electrogastrography (EGG). Correlations between 13C-GEBT and EGG parameters and PedsQL-GI scores were investigated. Results: Fifteen patients (four males) were included (median age: 6 [3.0-8.5] years). Mean PedsQL-GI scores as reported by the children were comparable to the healthy population. However, parents reported a diminished QOL. Gastric function tests (gastric emptying and/or surface EGG) showed abnormalities in 12 patients (80%). Patients with abnormal slow waves showed abnormal gastric emptying coefficient more often. There was no significant association between 13C-GEBT nor EGG results and PedsQL-GI scores. Conclusions: 13C-GEBT and EGG can be used to evaluate gastric function in patients with EA. Abnormal gastric function tests were present in 80% of our cohort. However, abnormal gastric function did not significantly correlate with reported gastrointestinal symptom-related QOL.

Development and validation of an electronic version of Sydney Swallow Questionnaire.

BACKGROUND AND AIMS: Accurate assessment of patient-reported oropharyngeal dysphagia (OPD) is essential to guide appropriate management and evaluate response. The Sydney Swallow Questionnaire (SSQ) is a paper-based 17-item inventory developed and validated to objectively detect risk of OPD. An easy-to-use electronic version with digital output has significant potential in streamlining patient assessment. This study aims to develop and validate an electronic version of the SSQ (eSSQ) against the original paper version. METHOD: The English-based paper SSQ was adapted on the online REDcap (Research Electronic Data Capture) platform to be accessible on computer and mobile devices. Patients with OPD and asymptomatic controls completed both electronic and paper versions in randomized order. Patients with stable symptoms then repeated the eSSQ after ≥14 days for test-retest reliability. Paper-based and eSSQs were also collected from an independent cohort for external validation. Agreement of total scores between both versions and eSSQ test-retest reliability were calculated using two-way mixed-effects intra-class correlation coefficient (ICC). RESULTS: 47 dysphagic patients, 32 controls, and 31 patients from an external validation cohort were recruited. The most common underlying etiology was head and neck cancer. Mean eSSQ total score was 789 in dysphagic patients, and 68 in controls. eSSQ had excellent agreement with paper SSQ in total scores among all participants, with ICC 0.97 (95% CI [0.93, 0.98]) in controls, 0.97 (95% CI [0.94, 0.98]) in dysphagic patients and 0.96 (95% CI [0.92, 0.98]) in validation cohort. Test-retest reliability was also excellent (ICC 0.96, 95% CI [0.90, 0.98]). CONCLUSION: The newly developed eSSQ shows excellent agreement with the paper version and test-retest reliability. Future applications of its use may allow for more efficient and accessible patient assessment.

The herbal preparation, STW5-II, reduces proximal gastric tone and stimulates antral pressures in healthy humans.

BACKGROUND: The herbal preparation, STW5-II, improves upper gastrointestinal symptoms, including abdominal fullness, early satiation, and epigastric pain, in patients with functional dyspepsia, and in preclinical models decreases fundic tone and increases antral contractility. The effects of STW5-II on esophago-gastric junction pressure, proximal gastric tone and antropyloroduodenal pressures, disturbances of which may contribute to symptoms associated with disorders of gut-brain interaction, including functional dyspepsia, in humans, have, hitherto, not been evaluated. METHODS: STW5-II or placebo (matched for color, aroma, and alcohol content) were each administered orally, at the recommended dose (20 drops), to healthy male and female volunteers (age: 27 ± 1 years) in a double-blind, randomized fashion, on two separate occasions, separated by 3-7 days, to evaluate effects on (i) esophago-gastric junction pressures following a standardized meal using solid-state high-resolution manometry (part 1, n = 16), (ii) proximal gastric volume using a barostat (part 2, n = 16), and (iii) antropyloroduodenal pressures assessed by high-resolution manometry (part 3, n = 18), for 120 min (part 1) or 180 min (parts 2, 3). KEY RESULTS: STW5-II increased maximum intrabag volume (ml; STW5-II: 340 ± 38, placebo: 251 ± 30; p = 0.007) and intrabag volume between t = 120 and 180 min (p = 0.011), and the motility index of antral pressure waves between t = 60 and 120 min (p = 0.032), but had no effect on esophago-gastric junction, pyloric, or duodenal pressures. CONCLUSIONS & INFERENCES: STW5-II has marked region-specific effects on gastric motility in humans, which may contribute to its therapeutic efficacy in functional dyspepsia.

Assessment of biomechanical behavior of immature non-vital incisors with various treatment modalities by means of three-dimensional quasi-static finite element analysis.

The objectives of this study were to evaluate the stress distribution and risk of fracture of a non-vital immature maxillary central incisor subjected to various clinical procedures using finite element analysis (FEA). A three-dimensional model of an immature central incisor was developed, from which six main models were designed: untreated immature tooth (C), standard apical plug (AP), resin composite (RC), glass-fibre post (GFP), regeneration procedure (RET), and regeneration with induced root maturation (RRM). Mineral trioxide aggregate (MTA) or Biodentine® were used as an apical or coronal plug. All models simulated masticatory forces in a quasi-static approach with an oblique force of 240 Newton at a 120° to the longitudinal tooth axis. The maximum principal stress, maximum shear stress, risk of fracture, and the strengthening percentage were evaluated. The mean maximum principal stress values were highest in model C [90.3 MPa (SD = 4.4)] and lowest in the GFP models treated with either MTA and Biodentine®; 64.1 (SD = 1.7) and 64.0 (SD = 1.6) MPa, respectively. Regarding the shear stress values, the dentine tooth structure in model C [14.4 MPa (SD = 0.8)] and GFP models [15.4 MPa (SD = 1.1)] reported significantly higher maximum shear stress values compared to other tested models (p < 0.001), while no significant differences were reported between the other models (p > 0.05). No significant differences between MTA and Biodentine® regarding maximum principal stress and maximum shear stress values for each tested model (p > 0.05). A maximum strain value of 4.07E-03 and maximum displacement magnitude of 0.128 mm was recorded in model C. In terms of strengthening percentage, the GFP models were associated with the highest increase (22%). The use of a GFP improved the biomechanical performance and resulted in a lower risk of fracture of a non-vital immature maxillary central incisor in a FEA model.

Swallowing biomechanics in tracheostomised critically ill patients compared to age- and gender-matched healthy controls.

Objective: The mechanistic effects of a tracheostomy on swallowing are unclear. Pharyngeal high-resolution manometry with impedance (P-HRM-I) is a novel swallow assessment tool providing quantifiable metrics. This study aimed to characterise swallowing biomechanics in tracheostomised critically ill (non-neurological) patients. Design: Cohort study. Setting: Australian tertiary hospital intensive care unit. Participants: Tracheostomised adults, planned for decannulation. Main outcome measures: Swallowing assessment using P-HRM-I, compared to healthy age- and gender-matched controls. Results: In this tracheostomised cohort (n = 10), the Swallow Risk Index, a global measure of swallow function, was significantly elevated (p < 0.001). At the upper oesophageal sphincter (UOS), hypopharyngeal intrabolus pressure and UOS integrated relaxation pressure were significantly elevated (control 0.65 mmHg [-1.02, 2.33] v tracheostomy 13.7 mmHg [10.4, 16.9], P < 0.001; control -4.28 mmHg [-5.87, 2.69] v tracheostomy 12.2 mmHg [8.83, 15.6], P < 0.001, respectively). Furthermore, UOS opening extent and relaxation time were reduced (control 4.83 mS [4.60, 5.07] v tracheostomy 4.33 mS [3.97, 4.69], P = 0.002; control 0.52 s [0.49, 0.55] v tracheostomy 0.41 s [0.37, 0.45], P < 0.001, respectively). Total pharyngeal contractility (PhCI) measuring pharyngeal pressure generation was significantly elevated (control 199.5 mmHg cm.s [177.4, 221.6] v tracheostomy 326.5 mmHg cm.s [253.3, 399.7]; P = 0.001). Conclusion: In a critically ill tracheostomised cohort, UOS dysfunction was the prevalent biomechanical feature, with elevated pharyngeal pressures. Pharyngeal weakness is not contributing to dysphagia in this cohort. Instead, elevated pharyngeal pressures may represent a compensatory mechanism to overcome the UOS dysfunction. Further studies to extend these findings may inform the development of timely and targeted rehabilitation.

Response to Letter to the Editor.

It is crucial to consider the possible influence of anesthetic agents on esophageal function testing. Dexmedetomidine has been shown to affect primary peristalsis during esophageal manometry. In the two case reports presented by Toaz et al., secondary peristalsis during FLIP panometry was also affected. This may be attributed to an alternate pharmacodynamic effect, with a transient direct α2-mediated effect on esophageal smooth muscle, associated with a high plasma concentration following bolus injection, prior to the onset of sympathetic inhibition.

The effect of different kinematics on apical debris extrusion with a single-file system.

To compare the amount of extruded debris caused by different motions using a single-file system. Fifty mandibular first molar teeth were randomized into 5 groups (n = 10) according to the motion tested: Optimize Torque Reverse (OTR), TF Adaptive Motion (TFA), continuous rotation (CR), reciprocation motion (+ 150°, -30°) (REC), and Jeni motion (Jeni). One Curve single file 25/06 (Micro-Mega, Besançon, France) was used in all experimental groups. The root canals were irrigated with 2.5% NaOCl, and the extruded debris were collected at pre-weighted glass vials. The glass vials were kept inside an incubator for one week at 70 °C to dry out the irrigating solution. The extruded debris was quantified by subtracting the pre-instrumentation from the post-instrumentation weight of the glass vials. The time required for each instrumentation procedure was digitally recorded. All data were analyzed statistically with one way ANOVA and post hoc Tukey test (P < 0.05). All the motions extruded apically debris with Jeni mode caused significantly less debris extrusion than TFA, REC, and CR (P < 0.05) while no significant difference emerged with OTR. Preparation time was not significantly different in all groups. Within the limits of the present study, all the kinematics produced apically debris extrusion, with Jeni reporting a similar amount of debris compared with OTR and significantly less than TFA, REC, and CR. Preparation time was similar among the tested kinematics.

Effects of the GABA(B) agonist baclofen on volitional swallowing in normal subjects.

The GABA(B) receptor agonist baclofen is known to suppress the rate of spontaneous swallowing but not pharyngeal muscle contraction. The extent to which baclofen may alter volitional swallowing is not currently known. We investigated the effects of baclofen in healthy subjects, hypothesizing that baclofen exposure would alter volume-regulation and/or piecemeal deglutition behaviors during volitional swallowing attempts. Pharyngeal high-resolution manometry impedance (P-HRM-I) protocol was used to assess swallowing function of 22 healthy adult volunteers (median 29 years) who were investigated on two occasions, receiving 40 mg baclofen (oral) 1 h before study, or placebo (randomized). Standard swallow function variables recommended by the pharyngeal HRM Working Group were derived for 5 ml, 10 ml, and 20 ml volumes of thin and extremely thick liquid challenges. Multiple swallow behaviors, comprising two swallows <5 s apart, were characterized. The spontaneous swallow rate was also determined. Baclofen exposure had no overall significant effect on swallow variables. Upper esophageal sphincter pressure was weaker during exposure to baclofen, during both the pre-deglutitive and post-deglutitive phases of the swallow (p < 0.05 during thick liquid swallows). Piecemeal swallows, where the bolus is separated in two potions, were significantly more common during 20 ml boluses (p = 0.002). Baclofen decreased the frequency of piecemeal deglutition overall. Baclofen has limited to no effect on volitional swallowing measures, however, does reduce the likelihood of initiation of piecemeal deglutition to large volume challenges.

Effects of dexmedetomidine on pharyngeal swallowing and esophageal motility-A double-blind randomized cross-over study in healthy volunteers.

BACKGROUND: Sedative agents increase the risk of pulmonary aspiration, where an intact swallowing function is an important defense mechanism. Dexmedetomidine is an α2 -adrenoceptor agonist widely used during procedural sedation due to beneficial properties with minimal respiratory effects. The effects of dexmedetomidine on pharyngeal swallowing and esophageal motility are not known in detail. METHODS: To determine the effects of dexmedetomidine on pharyngeal swallowing and esophageal motility, nineteen volunteers were included in this double-blinded, randomized placebo-controlled cross-over study. Study participants received target-controlled dexmedetomidine and placebo infusions. Recordings of pressure and impedance data were acquired using a manometry and impedance solid-state catheter. Data were analyzed from three bolus swallows series: baseline, during dexmedetomidine/placebo infusion at target plasma concentrations 0.6 ng ml-1 and 1.2 ng ml-1 . Subjective swallowing difficulties were also recorded. KEY RESULTS: On pharyngeal swallowing, dexmedetomidine affected the upper esophageal sphincter with decreased pre- and post-swallow contractile pressures and an increase in residual pressure during swallow-related relaxation. On esophageal function, dexmedetomidine decreased contractile vigor of the proximal esophagus and increased velocity of the peristaltic contraction wave. Residual pressures during swallow-related esophagogastric junction (EGJ) relaxation decreased, as did basal EGJ resting pressure. The effects on the functional variables were not clearly dose-dependent, but mild subjective swallowing difficulties were more common at the higher dose level. CONCLUSIONS AND INFERENCES: Dexmedetomidine induces effects on pharyngeal swallowing and esophageal motility, which should be considered in clinical patient management and also when a sedative agent for procedural sedation or for manometric examination is to be chosen.

Using high resolution manometry impedance to diagnose upper esophageal sphincter and pharyngeal motor disorders.

BACKGROUND: Oro-pharyngeal pathophysiology, including upper esophageal sphincter (UES) and pharyngeal disorders, can be assessed by pharyngeal high-resolution manometry impedance (P-HRM-I). We aimed to establish methodology to diagnose disorders utilizing P-HRM-I, hypothesizing that the objective measures could be used to diagnose disordered deglutition evidenced by greater aspiration scores. METHODS: Patients (n = 509, 18-91 years) were compared to controls (n = 120, 20-94 years). Variables measuring UES relaxation, UES opening extent, intrabolus pressure, and pharyngeal contractile strength were derived for 10 ml liquid swallows. Three associated pharyngeal pressurization patterns, which may be indicative of obstructed flow, were characterized: pan-pressurization (Type 1), distal compartmentalized pressurization (Type 2), and transient pressurization (Type 3). Deglutitive aspiration was determined from video fluoroscopy. RESULTS: UES relaxation pressure was best able to differentiate patients from controls (T 6.528, p < 0.0001). Patients with abnormal relaxation pressure (>8 mmHg) more frequently exhibited pharyngeal pressurization patterns and had adjunct evidence of reduced luminal distensibility (high intrabolus pressure and/or reduced UES opening). Utilizing this information, a diagnostic scheme was devised identifying 138 patients with UES disorder. A further 96 patients without evidence of UES disorder had abnormally weak pharyngeal pressures, confirming propulsive disorder. Amongst a sub-sample of 320 patients undergoing video fluoroscopy, those with pharyngeal pressurizations and adjunct evidence of reduced UES relaxation and/or distensibility had higher aspiration scores (Chi-square 60.169, p < 0.0001). CONCLUSION: P-HRM-I can provide evidence for UES disorder based on pharyngeal pressurization patterns and abnormal findings for UES relaxation pressure, UES opening, and intrabolus pressure. Measuring pharyngeal contractility requires further optimization.

A CBCT based cross sectional study on the prevalence and anatomical feature of C shaped molar among Jordanian.

The prevalence and anatomical features of C-Shaped Mandibular Second Molars (MSMs) are rarely studied in Jordanian sub-population. This study then took a part to evaluate the prevalence of C-shaped in MSMs using cone-beam computed tomography (CBCT) in the Jordanian sub-population. It used a cross-sectional design and three thousand scans collected over eight years between 2011 and 2019. The data were then reviewed for whether they were fully formed of MSMs. A total of 2037 cases that had 2845 MSMs were evaluated to identify C-shaped canals at coronal, middle, and apical sites. An oblique slicing module perpendicular to the long axis of MSMs was used to evaluate the teeth. The type and frequency of C-shaped canals, as well as the correlations between sex and side (right/left) and between sex and groove direction (buccal/lingual) were measured using the chi-square test on SPSS software at the significance level of 95%. A total of 342 teeth of 243 patients were C-shaped molars, which comprised 12% of the patient's teeth and 99 of them as a bilateral C-shaped canal with mean age of 40 years and sex ratio of 2:1 between female and male. With the limitations of this study, the lingual groove and type 3 were the most common properties of MSM. Besides, the Jordanian population mostly had C-shaped canals.

Transient Hiatal Separation During Straight Leg Raise Can Predict Reflux Burden in Gastroesophageal Reflux Disease Patients With Ineffective Esophageal Motility.

Background/Aims: Straight leg raise (SLR) can be utilized to evaluate the integrity of the esophagogastric junction during high-resolution manometry (HRM). We aim to assess the value of transient hiatal separation during SLR in symptomatic reflux patients. Methods: Consecutive reflux patients undergoing esophageal HRM and pH monitoring were included. Transient hiatal separation was defined by a ≥ 1 cm separation between the lower esophageal sphincter and crural diaphragm during SLR. We compared esophageal motor patterns and reflux monitoring parameters between patients with normal, transiently abnormal and consistently abnormal esophagogastric junction morphology during SLR. Results: Of 85 (56.3% female, mean age: 46.7 ± 12.3 years) completed SLR, esophagogastric junction morphology was normal in 31 (36.5%), transient hiatal separation in 19 (22.3%), and consistently hiatal hernia in 35 (41.2%). The values of total acid exposure time (P = 0.016), longest acid reflux episodes (P = 0.024), and DeMeester scores (P = 0.016) were higher in hiatal hernia compared to patients with non-transient hiatal separation, but there were no differences between those with and without transient hiatal separation. Within ineffective esophageal motility, the presence of transient hiatal separation during SLR significantly associated with a higher total acid exposure time (P = 0.014), higher DeMeester scores (P = 0.019), higher total acid reflux events (P = 0.037), and higher longest acid reflux episodes (P = 0.006). Conclusion: Our work suggests that SLR may have value as a provocative test during HRM, and future outcome studies are warranted to elucidate the clinical relevance of motor abnormalities depicted from SLR.

Distension contraction plots of pharyngeal/esophageal peristalsis: next frontier in the assessment of esophageal motor function.

Esophageal peristalsis consists of initial inhibition (relaxation) followed by excitation (contraction), both of which move sequentially in the aboral direction. Initial inhibition results in receptive relaxation and bolus-induced luminal distension, which allows propulsion by the contraction with minimal resistance to flow. Similar to the contraction wave, luminal distension has unique waveform characteristics in normal subjects; both are modulated by bolus volume, bolus viscosity, and posture, suggesting a possible cause-and-effect relationship between the two. Distension contraction plots in patients with dysphagia with normal bolus clearance [high-amplitude esophageal contractions (HAECs), esophagogastric junction outflow obstruction (EGJOO), and functional dysphagia (FD)] reveal two major findings: 1) unlike normal subjects, there is luminal occlusion distal to bolus during peristalsis in certain patients, i.e., with type 3 achalasia and nonobstructive dysphagia; and 2) bolus travels through a narrow lumen esophagus during peristalsis in patients with HAECs, EGJOO, and FD. Aforementioned findings indicate a relative dynamic obstruction to the bolus flow during peristalsis and reduced distensibility of esophageal wall in the bolus segment of the esophagus. We speculate that a normal or supernormal contraction wave pushing bolus against resistance is the mechanism of dysphagia sensation in significant number of patients. Representations of distension and contraction, combined with objective measures of flow timing and distensibility are complementary to the current scheme of classifying esophageal motility disorders based solely on the characteristics of contraction phase of peristalsis. Better understanding of the distensibility of the bolus-containing segment of the esophagus during peristalsis will lead to the development of novel medical and surgical therapies in the treatment of dysphagia in significant number of patients.

Pharyngeal tongue base augmentation for dysphagia therapy: A prospective case series in patients post head and neck cancer treatment.

BACKGROUND: Dysphagia post head and neck cancer (HNC) multimodality treatment is attributed to reduced pharyngeal strength. We hypothesized that pharyngeal tongue base augmentation for dysphagia (PAD therapy) would increase pharyngeal pressures during swallowing thereby improving swallow symptoms. METHODS: Adults with moderate-severe dysphagia post-HNC treatment had PAD therapy using a temporary filler (hyaluronic acid [HA]), with follow-up long-lasting lipofilling. Swallowing preprocedure and postprocedure was assessed with the Sydney Swallow Questionnaire (SSQ), High-Resolution Pharyngeal Manometry (HRPM), and Videofluoroscopic Swallowing Study (VFSS). Statistical comparison utilized paired tests. RESULTS: Six participants (all male; median age 64 years [IQR 56, 71]) underwent PAD therapy at a median of 47 [IQR 8, 95] months post-treatment. SSQ scores reduced from baseline (mean 1069 [95%CI 703, 1434]) to post-HA (mean 579 [76, 1081], p > 0.05), and post-lipofilling (491 [95%CI 913, 789], p = 0.003, n = 4). Individual participants demonstrated reduced Swallow Risk Index, Bolus Presence Time, and increased Upper Esophageal Sphincter opening, but mesopharyngeal contractile pressures were unchanged. VFSS measures of aspiration, residue, and severity were unchanged. CONCLUSIONS: Novel PAD therapy is safe and improves dysphagia symptoms. Biomechanical swallowing changes are suggestive of more efficacious bolus propulsion with conservative filler volume, but this was unable to resolve residue or aspiration measures.

Management of Gastroesophageal Reflux Disease in Esophageal Atresia Patients: A Cross-Sectional Survey amongst International Clinicians.

OBJECTIVES: After surgical repair, up to 70% of esophageal atresia (EA) patients suffer from gastroesophageal reflux disease (GERD). The ESPGHAN/NASPGHAN guidelines on management of gastrointestinal complications in EA patients were published in 2016. Yet, the implementation of recommendations on GERD management remains poor.We aimed to assess GERD management in EA patients in more detail, to identify management inconsistencies, gaps in current knowledge, and future directions for research. METHODS: A digital questionnaire on GERD management in EA patients was sent to all members of the ESPGHAN EA working group and members of the International network of esophageal atresia (INoEA). RESULTS: Forty responses were received. Thirty-five (87.5%) clinicians routinely prescribed acid suppressive therapy for 1-24 (median 12) months. A fundoplication was considered by 90.0% of clinicians in case of refractory GERD with persistent symptoms despite maximal acid suppressive therapy and in 92.5% of clinicians in case of GERD with presence of esophagitis on EGD. Half of clinicians referred patients with recurrent strictures or dependence on transpyloric feeds. Up to 25.0% of clinicians also referred all long-gap EA patients for fundoplication, those with long-term need of acid suppressants, recurrent chest infections and feedings difficulties. CONCLUSIONS: Respondents' opinions on the optimal duration for routine acid suppressive therapy and indications for fundoplication in EA patients varied widely. To improve evidence-based care for EA patients, future prospective multicenter outcome studies should compare different diagnostic and treatment regimes for GERD in patients with EA. Complications of therapy should be one of the main outcome measures in such trials.

Characterizing Esophageal Motility in Neonatal Intensive Care Unit Patients Using High Resolution Manometry.

OBJECTIVE: To characterize esophageal motility and esophago-gastric junction (EGJ) function during feeding in neonatal intensive care unit (NICU) patients. PATIENTS AND METHODS: High resolution manometry with impedance (HRIM) was used to investigate esophageal motility and EGJ function in patients admitted to the NICU. Twenty-eight preterm born infants with bronchopulmonary dysplasia (BPD), 12 born with isolated congenital diaphragmatic hernia (iCDH), and 10 with esophageal atresia (EA) were included. Thirteen healthy infants were included as controls. Esophageal motility and EGJ function were analyzed using objective esophageal bolus transport parameters. RESULTS: Normal esophageal peristaltic wave patterns were observed in all investigated infants without EA. Nine of 10 patients with EA presented with abnormal esophageal motor wave patterns. A total of 224 nutritive swallows were analyzed (controls, n = 48; BPD, n = 96; iCDH, n = 60; EA, n = 20). Infants with BPD and iCDH had similar distal contractile strength (DCI) compared to healthy controls, while in patients with EA, DCI was significantly lower (Kruskal-Wallis test, p = 0.001). In most infants, EGJ relaxation after swallowing was unaffected. EGJ barrier function, in terms of EGJ-contractile integral, also appeared well-developed and did not differ significantly among patient groups. CONCLUSIONS: We conclude that esophageal motility studies using pressure-impedance analysis are feasible in young infants. Bolus transport mechanisms following nutritive swallows appeared well-established in all investigated infants with the exception of those with EA. EGJ relaxation was also functional after deglutition and EGJ function as an anti-reflux barrier appeared well-developed in all investigated NICU groups.

Pediatric Eosinophilic Esophagitis is Associated With Low Baseline Impedance.

BACKGROUND AND AIMS: Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder that requires repeat endoscopic evaluation(s) to assess response to treatment. This results in high health care costs and a procedural burden in affected children. Noninvasive alternate modalities to reassess disease activity have not been established. Low baseline impedance measured by multichannel pH impedance (pH-MII) is seen in adults with EoE, in keeping with poor mucosal integrity. We aimed to investigate the relationship between esophageal eosinophilia (or severity of eosinophilic infiltration) and baseline impedance in children with EoE. METHODS: We retrospectively identified 15 children diagnosed with EoE at our institution who had undergone pH-MII within 30 days of 3-level esophageal biopsy. This group were not concurrently prescribed proton pump inhibitors and had negligible reflux parameters on pH-MII. Average impedance baseline was calculated upper, mid, and lower esophageal segments via baseline impedance automated analysis (RIAA) and mean nocturnal baseline impedance (MNBI) methods. Eosinophil count data for upper, mid, and lower esophageal segments in the EoE group was collated. RESULTS: A significantly lower baseline impedance was seen across the esophageal length in children with EoE, compared with 30 controls who had no differences in age or reflux burden on nonparametric testing. A relationship between baseline impedance and eosinophil number at corresponding esophageal segments was not established. CONCLUSIONS: Baseline impedance may be an important, less invasive adjunct in clinical practice to monitor treatment response in children with EoE. Larger prospective cohort studies should delineate optimally predictive baseline impedance thresholds for active and inactive disease.