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Inter-Observer Agreement in High Resolution Esophageal Pressure Topography Interpretation Using the Chicago Classification
peristalsis (n=9), hypertensive peristalsis (n=1) and normal (n=11). There was 80% concordance in these by the junior clinicians and 73% by the non-clinician. The most frequent discordance concerned normal vs weak peristalsis (50% of discordance for the non clinician) and weak vs frequent failed peristalsis (50% of discordance for the junior, 25% for the non clinician). Conclusion: The inter-observer agreement for EPT metric measurements was almost perfect or substantial for junior clinicians after minimal training. The major discrepancies in applying these metrics to establish diagnoses in the Chicago Classification pertained to selecting among frequent failed, weak, and absent peristalsis; all distinctions of unknown clinical significance.
Sa1383
Background Anxiety, depression and ′somatization′ levels are high in globus patients, but it is unclear how these relate to globus symptom levels. Moreover, visceral sensitivity of the upper esophageal sphincter (UES) and esophageal body (EB) and their relationship with symptom levels has not been studied in globus. Aim To study the association between sensitivity and compliance of the UES and EB, psychiatric symptoms and ‘somatization’ (i.e. a psychological tendency to report multiple somatic symptoms) on the one hand and globus symptom levels on the other. Methods Patients with globus underwent an UES and EB barostat study. UES and EB sensitivity and compliance were assessed by esophageal balloon distension using stepwise isobaric distensions (2mmHg) with the balloon located in the high pressure zone of the UES and 10 cm below the UES. UES and EB discomfort thresholds (pressure & volume) and compliance were determined. Globus symptoms were measured using the validated Glasgow-Edinburgh Throat Scale. Depression, ′somatization′ and different forms of anxiety (post-traumatic stress, social anxiety, anxiety sensitivity and gastrointestinalspecific anxiety) were measured using validated self-report questionnaires. Correlation analysis and multiple linear regression were used to study the association of these patient characteristics with globus symptoms. Results 28 patients participated in this ongoing study (mean age 50.1±14.1, 19 women). Mean discomfort threshold (pressure, volume) & compliance were 12.3±8.4 mmHg, 7.6±6.8 ml and 0.65±0.23 ml/mmHg, respectively, for the UES and 22.1±8.0 mmHg, 21.7±17.1 ml and 0.90±0.44 ml/mmHg, respectively, for the EB. Correlations of globus symptoms with UES & EB discomfort threshold, psychiatric symptoms and ‘somatization’ are shown in Table 1 & 2, respectively. No significant correlations with UES and EB sensitivity parameters were found, but UES compliance as well as depression and ′somatization′ correlated significantly with globus symptoms. A trend was found for post-traumatic stress. In multiple linear regression, ′somatization′ (B=0.39,p=.040) and UES compliance (B=0.42,p=.029) were significantly and independently associated with globus symptoms (model R2=.36, p=.012). Conclusion We present the first study demonstrating that psychiatric symptoms (especially depression), ′somatization′ and UES compliance are associated with globus symptom levels. These results indicate that assessment of psychiatric and somatic symptoms as well as UES function testing may be important in globus patients. Table 1
Sa1385 Upper Esophageal Sphincter Compliance and ′Somatization′ Are Independently Associated With Symptom Levels in Globus Patients Nathalie Rommel, Athanasios A. Papathanasopoulos, Rita Vos, Lieselot Holvoet, Stephanie Depeyper, Raf Bisschops, Joris Arts, Jan F. Tack, Lukas Van Oudenhove
Heterogeneity in Esophageal Motility in Reflux Patients With Different Symptom Presentation: Studies With Combined Impedance and Manometry Chien-Lin Chen, Chih-Hsun Yi, Tso-Tsai Liu, William C. Orr Background/aim: Ineffective esophageal motility (IEM) is common in patients with gastroesophageal reflux disease (GERD). Subtype of IEM related peristaltic dysfunction is associated with esophageal symptom experienced in GERD. Multi-channel intraluminal impedance and manometry (MII-EM) allows detection of esophageal contractile characteristics and bolus transit. We aimed to test the hypothesis whether GERD patients with different symptom profiles may exhibit a different pattern of esophageal motility, and to detect any difference in esophageal function between these patients by the application of MII-EM. Methods: Eligible patients were sub-classified according to their predominant symptom of heartburn (HB) or acid regurgitation (AR). All patients underwent MII-EM with 10 liquid and 10 viscous boluses to be swallowed. IEM is defined as >30% liquid swallows with contraction amplitude <30 mm Hg in the distal esophagus. Functional abnormality in IEM was further graded according to the presence of esophageal transit abnormalities which is defined as abnormal bolus transit if >30% of liquid and >40% of viscous swallows had incomplete bolus transit. Results: Sixteen HB patients (9 women, age 49, 25-60 yrs) and twenty-four AR patients (10 women, age 47, 34-65 yrs) were included in this study. HB patients had greater distal esophageal peristaltic amplitude than AR patients (83.9 ± 10.2 vs. 58.7 ± 4.8 mmHg, p = 0.04). Normal esophageal peristalsis was found slightly more in HB patient than AR patients during liquid swallowing (85% vs. 70%; p = 0.056), but was similar during viscous swallowing (91% vs. 83%; p = NS). AR patients had a significantly lower percentage of complete bolus transit compared to HB patients during liquid (p < 0.001) and viscous swallowing (p = 0.038), although total bolus transit time did not differ between the groups (both p = NS). IEM occurred more frequently in AR patients than HB patients (42.7% vs. 12.5%, p = 0.049). In patients with IEM, severe functional abnormality was found more in AR patients than HB patients (p < 0.05). Conclusions: GERD patients with different symptom profiles appear to exhibit different esophageal motility as detected by MII-EM. Patients with prominent symptom of acid regurgitation are characterized by greater IEM and defective bolus clearance. Heterogeneity in esophageal motility between subsets of GERD patients may indicate the complex interactions between esophageal body dysfunction and reflux symptomatology. Sa1384 Inter-Observer Agreement in High Resolution Esophageal Pressure Topography Interpretation Using the Chicago Classification Sabine Roman, Monika A. Kwiatek, Daniel Luger, Lubomyr Boris, Peter J. Kahrilas, John E. Pandolfino
Table 2
Background: The Chicago Classification of clinical high resolution esophageal pressure topography (EPT) studies is based on the application of novel metrics to quantify abnormalities in peristaltic or sphincteric function. Utilizing this classification in clinical practice requires good reproducibility. Our aims were to evaluate the inter-observer agreement for the calculation and application of the metrics used to formulate the Chicago Classification. Methods: 30 clinical EPT studies randomly selected from among 2,000 consecutive studies were reviewed by a junior clinician, a senior clinician and a non-clinician skilled in digestive motility. Clinicians, but not the non-clinician, attended training sessions with an expert. Integrated relaxation pressure (IRP), distal contractile integral (DCI), contractile front velocity (CFV), and distal contractile latency (DL) (interval from UES contraction to the onset of contraction at the contractile deceleration point) were measured for each swallow. Each swallow was characterized as having absent peristalsis, small (2-5 cm) or large (>5 cm) breaks in the 20-mmHg isobaric contour), hypertensive peristalsis (DCI>5,000 mmHg-cms), rapid contraction (CFV>9cm/s), reduced latency (DL<3.5 s), or normal. Inter-observer agreement was evaluated using kappa coefficient. A clinical diagnosis was made for each study according to the Chicago Classification and compared to the diagnosis of an expert. Results: The inter-observer agreement for abnormal measurements ranged from moderate to almost perfect (Table 1). Swallow characterization was substantial between junior and senior clinicians and moderate between the senior clinician and the non-clinician. 77% of the disagreements between the senior and the non-clinician concerned classification of normal vs 20 mmHg isobaric contour breaks. The expert diagnoses were: achalasia (n=2), functional obstruction (n=2), absent peristalsis (n=1), frequent failed peristalsis (n=4), weak
Sa1387 Esophageal Epithelial ASIC3 is Associated With Increase in Severity of Symptoms in Patients With Gastro-Esophageal Reflux Disease (GERD) Yang C. Chua, Andrew Hubball, Madusha Peiris, Kee S. Ng, Sarah F. Hughes, Joanne Chin Aleong, Sean L. Preston, Bijendra Patel, Asif Chaudry, Pauline M. Levey, Joanne E. Martin, Qasim Aziz, Charles H. Knowles Introduction: Acid-induced esophageal hypersensitivity is an important mechanism in gastroesophageal reflux disease (GERD) symptom generation. The molecular basis of peripheral sensitisation leading to hypersensitivity has not been determined. Aim: to correlate changes in distal oesophageal epithelial ASIC3 expression with symptom severity in patients with GERD and controls. Methods: Esophageal mucosal biopsy samples from 36 patients (age 19-59 years, 17 females with or without GERD undergoing gastroscopy) were studied using immunohistochemistry for PGP 9.5 and ASIC3. Clinical symptoms were assessed using visual analogue scale (VAS) adapted from a validated questionnaire (ReQUEST TM). The symptoms assessed were: general feeling, acid complaints, upper abdominal complaints, lower abdominal complaints, nausea, and sleep disturbance. Results: Nerve fibre penetration
S-295
AGA Abstracts
AGA Abstracts
peristalsis is unclear. We investigated whether esophageal distension-induced secondary peristalsis could be modulated by baclofen and mosapride. Methods: In all 15 healthy subjects (5 female, mean age 22, range 20-26 yr), secondary peristalsis was generated by slow and rapid mid-esophageal injections of air after a baseline recording of esophageal motility. Three separate sessions with 40 mg oral baclofen, 40 mg oral mosapride or placebo were randomly performed to test their effects on esophageal secondary peristalsis with at least a 1-week interval. Results: Baclofen significantly increased the threshold volume for triggering secondary peristalsis during slow air distension (P = 0.003) and rapid air distension (P = 0.002). Baclofen significantly reduced the rate of secondary peristalsis by rapid air distension from 90% to 30% (P = 0.0002). Despite increasing basal LES pressure (P = 0.03), baclofen did not affect any of peristaltic parameters by primary or secondary peristalsis. Mosapride significantly decreased the threshold volume for triggering secondary peristalsis during rapid air distension (P = 0.04). Secondary peristalsis was triggered more frequently in response to rapid air distension after application of mosapride (P = 0.02). Mosapride significantly increased pressure wave amplitudes of secondary peristalsis during slow (P = 0.001) and rapid air distension (P = 0.002). Conclusions: Inhibition of baclofen on the triggering of secondary peristalsis presents during esophageal distension, indicating that sensory part of secondary peristalsis is probably mediated by the GABAB receptors. However, baclofen does not lead to any motility change in secondary peristalsis as induced by either slow or rapid air distension. Mosapride appears to enhance sensitivity to distension-induced secondary peristalsis and facilitates secondary peristaltic contractility, suggesting the involvement of 5-HT4 in the modulation of esophageal secondary peristalsis in humans.
Sa1383
Background Anxiety, depression and ′somatization′ levels are high in globus patients, but it is unclear how these relate to globus symptom levels. Moreover, visceral sensitivity of the upper esophageal sphincter (UES) and esophageal body (EB) and their relationship with symptom levels has not been studied in globus. Aim To study the association between sensitivity and compliance of the UES and EB, psychiatric symptoms and ‘somatization’ (i.e. a psychological tendency to report multiple somatic symptoms) on the one hand and globus symptom levels on the other. Methods Patients with globus underwent an UES and EB barostat study. UES and EB sensitivity and compliance were assessed by esophageal balloon distension using stepwise isobaric distensions (2mmHg) with the balloon located in the high pressure zone of the UES and 10 cm below the UES. UES and EB discomfort thresholds (pressure & volume) and compliance were determined. Globus symptoms were measured using the validated Glasgow-Edinburgh Throat Scale. Depression, ′somatization′ and different forms of anxiety (post-traumatic stress, social anxiety, anxiety sensitivity and gastrointestinalspecific anxiety) were measured using validated self-report questionnaires. Correlation analysis and multiple linear regression were used to study the association of these patient characteristics with globus symptoms. Results 28 patients participated in this ongoing study (mean age 50.1±14.1, 19 women). Mean discomfort threshold (pressure, volume) & compliance were 12.3±8.4 mmHg, 7.6±6.8 ml and 0.65±0.23 ml/mmHg, respectively, for the UES and 22.1±8.0 mmHg, 21.7±17.1 ml and 0.90±0.44 ml/mmHg, respectively, for the EB. Correlations of globus symptoms with UES & EB discomfort threshold, psychiatric symptoms and ‘somatization’ are shown in Table 1 & 2, respectively. No significant correlations with UES and EB sensitivity parameters were found, but UES compliance as well as depression and ′somatization′ correlated significantly with globus symptoms. A trend was found for post-traumatic stress. In multiple linear regression, ′somatization′ (B=0.39,p=.040) and UES compliance (B=0.42,p=.029) were significantly and independently associated with globus symptoms (model R2=.36, p=.012). Conclusion We present the first study demonstrating that psychiatric symptoms (especially depression), ′somatization′ and UES compliance are associated with globus symptom levels. These results indicate that assessment of psychiatric and somatic symptoms as well as UES function testing may be important in globus patients. Table 1
Sa1385 Upper Esophageal Sphincter Compliance and ′Somatization′ Are Independently Associated With Symptom Levels in Globus Patients Nathalie Rommel, Athanasios A. Papathanasopoulos, Rita Vos, Lieselot Holvoet, Stephanie Depeyper, Raf Bisschops, Joris Arts, Jan F. Tack, Lukas Van Oudenhove
Heterogeneity in Esophageal Motility in Reflux Patients With Different Symptom Presentation: Studies With Combined Impedance and Manometry Chien-Lin Chen, Chih-Hsun Yi, Tso-Tsai Liu, William C. Orr Background/aim: Ineffective esophageal motility (IEM) is common in patients with gastroesophageal reflux disease (GERD). Subtype of IEM related peristaltic dysfunction is associated with esophageal symptom experienced in GERD. Multi-channel intraluminal impedance and manometry (MII-EM) allows detection of esophageal contractile characteristics and bolus transit. We aimed to test the hypothesis whether GERD patients with different symptom profiles may exhibit a different pattern of esophageal motility, and to detect any difference in esophageal function between these patients by the application of MII-EM. Methods: Eligible patients were sub-classified according to their predominant symptom of heartburn (HB) or acid regurgitation (AR). All patients underwent MII-EM with 10 liquid and 10 viscous boluses to be swallowed. IEM is defined as >30% liquid swallows with contraction amplitude <30 mm Hg in the distal esophagus. Functional abnormality in IEM was further graded according to the presence of esophageal transit abnormalities which is defined as abnormal bolus transit if >30% of liquid and >40% of viscous swallows had incomplete bolus transit. Results: Sixteen HB patients (9 women, age 49, 25-60 yrs) and twenty-four AR patients (10 women, age 47, 34-65 yrs) were included in this study. HB patients had greater distal esophageal peristaltic amplitude than AR patients (83.9 ± 10.2 vs. 58.7 ± 4.8 mmHg, p = 0.04). Normal esophageal peristalsis was found slightly more in HB patient than AR patients during liquid swallowing (85% vs. 70%; p = 0.056), but was similar during viscous swallowing (91% vs. 83%; p = NS). AR patients had a significantly lower percentage of complete bolus transit compared to HB patients during liquid (p < 0.001) and viscous swallowing (p = 0.038), although total bolus transit time did not differ between the groups (both p = NS). IEM occurred more frequently in AR patients than HB patients (42.7% vs. 12.5%, p = 0.049). In patients with IEM, severe functional abnormality was found more in AR patients than HB patients (p < 0.05). Conclusions: GERD patients with different symptom profiles appear to exhibit different esophageal motility as detected by MII-EM. Patients with prominent symptom of acid regurgitation are characterized by greater IEM and defective bolus clearance. Heterogeneity in esophageal motility between subsets of GERD patients may indicate the complex interactions between esophageal body dysfunction and reflux symptomatology. Sa1384 Inter-Observer Agreement in High Resolution Esophageal Pressure Topography Interpretation Using the Chicago Classification Sabine Roman, Monika A. Kwiatek, Daniel Luger, Lubomyr Boris, Peter J. Kahrilas, John E. Pandolfino
Table 2
Background: The Chicago Classification of clinical high resolution esophageal pressure topography (EPT) studies is based on the application of novel metrics to quantify abnormalities in peristaltic or sphincteric function. Utilizing this classification in clinical practice requires good reproducibility. Our aims were to evaluate the inter-observer agreement for the calculation and application of the metrics used to formulate the Chicago Classification. Methods: 30 clinical EPT studies randomly selected from among 2,000 consecutive studies were reviewed by a junior clinician, a senior clinician and a non-clinician skilled in digestive motility. Clinicians, but not the non-clinician, attended training sessions with an expert. Integrated relaxation pressure (IRP), distal contractile integral (DCI), contractile front velocity (CFV), and distal contractile latency (DL) (interval from UES contraction to the onset of contraction at the contractile deceleration point) were measured for each swallow. Each swallow was characterized as having absent peristalsis, small (2-5 cm) or large (>5 cm) breaks in the 20-mmHg isobaric contour), hypertensive peristalsis (DCI>5,000 mmHg-cms), rapid contraction (CFV>9cm/s), reduced latency (DL<3.5 s), or normal. Inter-observer agreement was evaluated using kappa coefficient. A clinical diagnosis was made for each study according to the Chicago Classification and compared to the diagnosis of an expert. Results: The inter-observer agreement for abnormal measurements ranged from moderate to almost perfect (Table 1). Swallow characterization was substantial between junior and senior clinicians and moderate between the senior clinician and the non-clinician. 77% of the disagreements between the senior and the non-clinician concerned classification of normal vs 20 mmHg isobaric contour breaks. The expert diagnoses were: achalasia (n=2), functional obstruction (n=2), absent peristalsis (n=1), frequent failed peristalsis (n=4), weak
Sa1387 Esophageal Epithelial ASIC3 is Associated With Increase in Severity of Symptoms in Patients With Gastro-Esophageal Reflux Disease (GERD) Yang C. Chua, Andrew Hubball, Madusha Peiris, Kee S. Ng, Sarah F. Hughes, Joanne Chin Aleong, Sean L. Preston, Bijendra Patel, Asif Chaudry, Pauline M. Levey, Joanne E. Martin, Qasim Aziz, Charles H. Knowles Introduction: Acid-induced esophageal hypersensitivity is an important mechanism in gastroesophageal reflux disease (GERD) symptom generation. The molecular basis of peripheral sensitisation leading to hypersensitivity has not been determined. Aim: to correlate changes in distal oesophageal epithelial ASIC3 expression with symptom severity in patients with GERD and controls. Methods: Esophageal mucosal biopsy samples from 36 patients (age 19-59 years, 17 females with or without GERD undergoing gastroscopy) were studied using immunohistochemistry for PGP 9.5 and ASIC3. Clinical symptoms were assessed using visual analogue scale (VAS) adapted from a validated questionnaire (ReQUEST TM). The symptoms assessed were: general feeling, acid complaints, upper abdominal complaints, lower abdominal complaints, nausea, and sleep disturbance. Results: Nerve fibre penetration
S-295
AGA Abstracts
AGA Abstracts
peristalsis is unclear. We investigated whether esophageal distension-induced secondary peristalsis could be modulated by baclofen and mosapride. Methods: In all 15 healthy subjects (5 female, mean age 22, range 20-26 yr), secondary peristalsis was generated by slow and rapid mid-esophageal injections of air after a baseline recording of esophageal motility. Three separate sessions with 40 mg oral baclofen, 40 mg oral mosapride or placebo were randomly performed to test their effects on esophageal secondary peristalsis with at least a 1-week interval. Results: Baclofen significantly increased the threshold volume for triggering secondary peristalsis during slow air distension (P = 0.003) and rapid air distension (P = 0.002). Baclofen significantly reduced the rate of secondary peristalsis by rapid air distension from 90% to 30% (P = 0.0002). Despite increasing basal LES pressure (P = 0.03), baclofen did not affect any of peristaltic parameters by primary or secondary peristalsis. Mosapride significantly decreased the threshold volume for triggering secondary peristalsis during rapid air distension (P = 0.04). Secondary peristalsis was triggered more frequently in response to rapid air distension after application of mosapride (P = 0.02). Mosapride significantly increased pressure wave amplitudes of secondary peristalsis during slow (P = 0.001) and rapid air distension (P = 0.002). Conclusions: Inhibition of baclofen on the triggering of secondary peristalsis presents during esophageal distension, indicating that sensory part of secondary peristalsis is probably mediated by the GABAB receptors. However, baclofen does not lead to any motility change in secondary peristalsis as induced by either slow or rapid air distension. Mosapride appears to enhance sensitivity to distension-induced secondary peristalsis and facilitates secondary peristaltic contractility, suggesting the involvement of 5-HT4 in the modulation of esophageal secondary peristalsis in humans.