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Sa1322 Combined Distal Contractile Integral and Integrated Relaxation Pressure in High Resolution Esophageal Manometry Predict Bolus Clearance of the Esophagus
AGA Abstracts
pH (19 Abnormal AET, 3 positive SAA). Others were 22 functional heartburn (FH) (negative endoscopy, normal AET and bolus exposure and negative SAA) and 47 non GERD. EGJCI was lower in hiatal hernia (13+6 mmHg-cm) or EE (25+20 mmHg-cm) than others without EE (62 + 37 mmHg-cm, p<0.05). EGJ- CI was lower in positive (abnormal AET 34+22 mmHg-cm, and positive SAA, 21 +14 mmHg-cm) compared with negative pH (55+38 mmHg-cm, p < 0.05). EGJ CI was not different between FH and non GERD (61+37 vs. 73+34 mmHg-cm) and it was not different between abnormal bolus exposure and others (41+32 vs 56+28 mmHg-cm). The ROC analysis showed 0.80 of AUC (0.68-0.92,p<0.01) when comparing EE vs. non GERD and 0.80(0.68-0.92 p<0.01) ) when comparing positive pH vs. non GERD. The EGJ-CI cut-off values showing the optimal performance in identifying erosive esophagitis and GERD at impedance-pH were 33 mmHg-cm as (sensitivity 89%specificity 76%) and 40 mmHg-cm (sensitivity 73%-specificity 77%), respectively. Conclusions: EGJ-CI is the parameter of HRM predicting GERD at impedance-pH monitoring and erosive esophagitis.
(p£0.03 compared to other diagnoses), while minor motor disorders had the lowest (p<0.05; Table 1). Major motor disorders had highest symptom burden by GSS (p=0.02), lowest with normal studies (p<0.01). Of 199 subjects with dominant symptoms, 90 (45.2%) reported symptoms within the reflux realm, while 64 (32.2%) had dysphagia; the remainder had nonspecific symptoms. GSS was highest in the dysphagia group; the nonspecific group had lower GSS when compared to dysphagia (p=0.02) and reflux (p=0.06) groups (Table 2). GERDQ impact scores were highest in the reflux group (p<0.001 across groups); the nonspecific group had lower scores compared to the reflux group (p<0.001). Similarly, MDQ scores demonstrated a gradient, highest in the dysphagia group and lowest in the nonspecific group (p<0.001 across groups). HRQOL on SF-36 was poorest in patients with dysphagia (p=0.07). VSI scores were similar across groups. Conclusions:Diagnosis categories under the Chicago Classification reflect a gradient of symptom burden and HRQOL, most profound in disorders with esophageal outflow obstruction and major motor disorders. Patients with a defined dominant symptom, especially transit symptoms, have poorer HRQOL and higher symptom burden compared to nonspecific symptoms. Our findings support focus on transit symptoms for motor investigation, and use of Chicago Classification designations for diagnostic stratification. Table 1: Symptom Burden and HRQOL Across Chicago Classification 3.0 Diagnoses
Sa1322 Combined Distal Contractile Integral and Integrated Relaxation Pressure in High Resolution Esophageal Manometry Predict Bolus Clearance of the Esophagus Nina Zhang, Hui Ye, John O. Clarke, Ellen M. Stein, Sameer Dhalla, Pankaj J. Pasricha, Jieyun Yin, Jiande Chen BACKGROUND: In Chicago Classification, integrated relaxation pressure (IRP) in high resolution esophageal manometry (HREM) is used to define esophageal gastric junction outflow obstruction. However, in clinical practice, we have found that IRP plays a limited role in differentiating incomplete bolus transit from complete bolus transit, and that distal contractile integral (DCI) is also an important factor contributing to esophageal bolus transit. AIMS: The aim of this study was to investigate the diagnostic accuracy of the combination of DCI and IRP for differentiating incomplete from complete bolus transit based on the impedance measurement. METHODS: A total of 994 wet swallows were analyzed in 100 patients (53 male, mean age of 46) who underwent the simultaneous HREM and impedance testing. Each swallow was classified as complete or incomplete bolus clearance according to the impedance measurement. The diagnostic accuracies of DCI and DCI/IRP ratio were assessed with ROC curve analyses. For each ROC, a cutoff point was determined as the value of the parameter that maximized the sum of specificity and sensitivity. Positive likelihood ratio (PLR), negative likelihood ratio (NLR) and diagnostic odds ratio (DOR) were calculated for each parameter. RESULTS (see Table 1): 1) With an IRP value of 15 mmHg, the sensitivity and specificity of the diagnostic accuracy for bolus clearance was 41% and 75%, respectively. The PLR was 2.06, NLR 0.79 and DOR 2.06. 2) When DCI was used alone for the prediction of bolus transit, a cut-off DCI value of 607 mmHg.s.cm yielded a sensitivity of 70%, specificity of 93%, PLR of 9.88, NLR of 0.32 and DOR of 31.05. The area under curve (AUC) of DCI in differentiate incomplete bolus transit from complete bolus transit was 0.854 (95% CI, 0.828-0.880). 3) The combinational use of DCI and IRP (with DCI<607mmHg.s.cm and IRP‡15 mmHg) increased the diagnostic sensitivity to 72% and specificity of 99% for discriminating incomplete bolus transit from complete bolus transit with a PLR of 91.35, NLR of 0.28 and DOR of 325. 4) The use of DCI/IRP ratio (with a cutoff value of 67) also led to high predictive values (see bottom row of the table). CONCLUSIONS: Esophageal bolus transit is dependent on not only IRP but also DCI and DCI is of more predictive value than IRP. The combinational use of DCI and IRP predicts incomplete bolus transit with very high specificity and relatively high sensitivity. Diagnostic performance of IRP and DCI in differentiating incomplete bolus transit from complete bolus transit
*p<0.05 compared to other groups SF-36: Short Form 36; MDQ: Mayo Dysphagia Questionnaire, VSI: Visceral Sensitivity Index; GSS: Global Symptom Severity Table 2. Symptom Burden and HRQOL Across Dominant Symptom Groups
*p£0.03 compared to other groups Nonspecific: belching, cough, wheezing SF-36: Short Form 36; MDQ: Mayo Dysphagia Questionnaire, VSI: Visceral Sensitivity Index; GSS: Global Symptom Severity
Sa1324 Effects of Prucalopride on Esophageal Secondary Peristalsis in Humans Chien-Lin Chen, Chih-Hsun Yi, Tso-Tsai Liu, Wei-Yi Lei, Jui-Sheng Hung Background/aim: Prucalopride, a high-affinity 5-hydroxytrypatamine 4 (5-HT4) receptors agonist, has been shown to improve colon motility in adults. Secondary peristalsis is important for the clearance of refluxate or retained food debris from the esophagus, but the effects of prucalopride on secondary peristalsis are yet unclear in humans. We aimed to investigate the effects of prucalopride on esophageal distension-induced secondary peristalsis in healthy adults. Methods: In this double-blind, placebo-control, randomized study, two separate sessions with 4mg prucalopride and placebo were performed in 11 healthy adults to test their effects on esophageal secondary peristalsis. Secondary peristalsis was generated by slow and rapid mid-esophageal injections of air after a baseline recording of esophageal motility. Results: Prucalopride significantly decreased the threshold volume to generate secondary peristalsis during slow air injection (9.8 ± 1.4 vs. 14.4 ± 0.9 mL, p = 0.005) and rapid air injection (3.9 ± 0.3 vs. 5.2 ± 0.4 mL, p = 0.008). Secondary peristalsis was more frequently induced by rapid air injection after application of prucalopride (80% [70-100%] vs. 70% [60-73%], p = 0.01). Prucalopride increased the wave amplitude of distal esophagus during slow air injection (147.9 ± 28.5 vs. 104.2 ± 16.8 mmHg, p = 0.048) and rapid air injection (128.0 ± 13.3 vs. 105.7 ± 12.3 mmHg, p = 0.016). Prucalopride also significantly increased the amplitudes of primary peristalsis as well as basal pressure of lower esophageal sphincter. Conclusion: Prucalopride enhances mechanosensitivity to distension-induced secondary peristalsis and promotes esophageal peristaltic contractility. These findings suggest that prucalopride, a highly 5-HT4 receptors agonist, could be a therapeutic option for the treatment of subjects with esophageal hypomotility.
Sa1323 Impact of Esophageal Symptoms and Motor Diagnoses on Disease Burden and Health-Related Quality of Life (HRQOL) Chanakyaram A. Reddy, Amit Patel, C. Prakash Gyawali Background: Esophageal high-resolution manometry (HRM) provides objective motor data to complement patient symptoms. However, the correlation between symptoms and findings on diagnostic testing remains imprecise. We prospectively quantified the impact of the patient-reported dominant symptom, and HRM motor diagnosis on symptom burden and HRQOL. Methods: 211 subjects (56.8±1.0 yrs, 66.8% F) undergoing esophageal HRM over 1 year were prospectively enrolled, of which 199 subjects (56.9±1.0 yrs, 65.8% F) identified a dominant symptom on enrollment. Subjects completed symptom questionnaires [GERDQ, Mayo Dysphagia Questionnaire (MDQ), Visceral Sensitivity Index (VSI), Short-Form 36 (SF36), and global symptom severity (GSS) on a 100-mm visual analog scale]. Dominant symptoms included dysphagia (difficulty swallowing liquids or solids), reflux-related (heartburn, regurgitation, chest pain), or nonspecific (belching, cough, wheezing). Subjects with incomplete questionnaire data or unintelligible studies were excluded. Burden and HRQOL were compared within and between cohorts segregated according to the reported dominant symptom and motor diagnoses (Chicago Classification v 3.0). Results: Of the total cohort, 15.6% had evidence of esophagogastric junction (EGJ) outflow obstruction including achalasia, 9.0% had major motor disorders, 18.5% had minor motor disorders, and 56.9% were normal. Disorders with EGJ outflow obstruction had highest MDQ frequency and severity
AGA Abstracts
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pH (19 Abnormal AET, 3 positive SAA). Others were 22 functional heartburn (FH) (negative endoscopy, normal AET and bolus exposure and negative SAA) and 47 non GERD. EGJCI was lower in hiatal hernia (13+6 mmHg-cm) or EE (25+20 mmHg-cm) than others without EE (62 + 37 mmHg-cm, p<0.05). EGJ- CI was lower in positive (abnormal AET 34+22 mmHg-cm, and positive SAA, 21 +14 mmHg-cm) compared with negative pH (55+38 mmHg-cm, p < 0.05). EGJ CI was not different between FH and non GERD (61+37 vs. 73+34 mmHg-cm) and it was not different between abnormal bolus exposure and others (41+32 vs 56+28 mmHg-cm). The ROC analysis showed 0.80 of AUC (0.68-0.92,p<0.01) when comparing EE vs. non GERD and 0.80(0.68-0.92 p<0.01) ) when comparing positive pH vs. non GERD. The EGJ-CI cut-off values showing the optimal performance in identifying erosive esophagitis and GERD at impedance-pH were 33 mmHg-cm as (sensitivity 89%specificity 76%) and 40 mmHg-cm (sensitivity 73%-specificity 77%), respectively. Conclusions: EGJ-CI is the parameter of HRM predicting GERD at impedance-pH monitoring and erosive esophagitis.
(p£0.03 compared to other diagnoses), while minor motor disorders had the lowest (p<0.05; Table 1). Major motor disorders had highest symptom burden by GSS (p=0.02), lowest with normal studies (p<0.01). Of 199 subjects with dominant symptoms, 90 (45.2%) reported symptoms within the reflux realm, while 64 (32.2%) had dysphagia; the remainder had nonspecific symptoms. GSS was highest in the dysphagia group; the nonspecific group had lower GSS when compared to dysphagia (p=0.02) and reflux (p=0.06) groups (Table 2). GERDQ impact scores were highest in the reflux group (p<0.001 across groups); the nonspecific group had lower scores compared to the reflux group (p<0.001). Similarly, MDQ scores demonstrated a gradient, highest in the dysphagia group and lowest in the nonspecific group (p<0.001 across groups). HRQOL on SF-36 was poorest in patients with dysphagia (p=0.07). VSI scores were similar across groups. Conclusions:Diagnosis categories under the Chicago Classification reflect a gradient of symptom burden and HRQOL, most profound in disorders with esophageal outflow obstruction and major motor disorders. Patients with a defined dominant symptom, especially transit symptoms, have poorer HRQOL and higher symptom burden compared to nonspecific symptoms. Our findings support focus on transit symptoms for motor investigation, and use of Chicago Classification designations for diagnostic stratification. Table 1: Symptom Burden and HRQOL Across Chicago Classification 3.0 Diagnoses
Sa1322 Combined Distal Contractile Integral and Integrated Relaxation Pressure in High Resolution Esophageal Manometry Predict Bolus Clearance of the Esophagus Nina Zhang, Hui Ye, John O. Clarke, Ellen M. Stein, Sameer Dhalla, Pankaj J. Pasricha, Jieyun Yin, Jiande Chen BACKGROUND: In Chicago Classification, integrated relaxation pressure (IRP) in high resolution esophageal manometry (HREM) is used to define esophageal gastric junction outflow obstruction. However, in clinical practice, we have found that IRP plays a limited role in differentiating incomplete bolus transit from complete bolus transit, and that distal contractile integral (DCI) is also an important factor contributing to esophageal bolus transit. AIMS: The aim of this study was to investigate the diagnostic accuracy of the combination of DCI and IRP for differentiating incomplete from complete bolus transit based on the impedance measurement. METHODS: A total of 994 wet swallows were analyzed in 100 patients (53 male, mean age of 46) who underwent the simultaneous HREM and impedance testing. Each swallow was classified as complete or incomplete bolus clearance according to the impedance measurement. The diagnostic accuracies of DCI and DCI/IRP ratio were assessed with ROC curve analyses. For each ROC, a cutoff point was determined as the value of the parameter that maximized the sum of specificity and sensitivity. Positive likelihood ratio (PLR), negative likelihood ratio (NLR) and diagnostic odds ratio (DOR) were calculated for each parameter. RESULTS (see Table 1): 1) With an IRP value of 15 mmHg, the sensitivity and specificity of the diagnostic accuracy for bolus clearance was 41% and 75%, respectively. The PLR was 2.06, NLR 0.79 and DOR 2.06. 2) When DCI was used alone for the prediction of bolus transit, a cut-off DCI value of 607 mmHg.s.cm yielded a sensitivity of 70%, specificity of 93%, PLR of 9.88, NLR of 0.32 and DOR of 31.05. The area under curve (AUC) of DCI in differentiate incomplete bolus transit from complete bolus transit was 0.854 (95% CI, 0.828-0.880). 3) The combinational use of DCI and IRP (with DCI<607mmHg.s.cm and IRP‡15 mmHg) increased the diagnostic sensitivity to 72% and specificity of 99% for discriminating incomplete bolus transit from complete bolus transit with a PLR of 91.35, NLR of 0.28 and DOR of 325. 4) The use of DCI/IRP ratio (with a cutoff value of 67) also led to high predictive values (see bottom row of the table). CONCLUSIONS: Esophageal bolus transit is dependent on not only IRP but also DCI and DCI is of more predictive value than IRP. The combinational use of DCI and IRP predicts incomplete bolus transit with very high specificity and relatively high sensitivity. Diagnostic performance of IRP and DCI in differentiating incomplete bolus transit from complete bolus transit
*p<0.05 compared to other groups SF-36: Short Form 36; MDQ: Mayo Dysphagia Questionnaire, VSI: Visceral Sensitivity Index; GSS: Global Symptom Severity Table 2. Symptom Burden and HRQOL Across Dominant Symptom Groups
*p£0.03 compared to other groups Nonspecific: belching, cough, wheezing SF-36: Short Form 36; MDQ: Mayo Dysphagia Questionnaire, VSI: Visceral Sensitivity Index; GSS: Global Symptom Severity
Sa1324 Effects of Prucalopride on Esophageal Secondary Peristalsis in Humans Chien-Lin Chen, Chih-Hsun Yi, Tso-Tsai Liu, Wei-Yi Lei, Jui-Sheng Hung Background/aim: Prucalopride, a high-affinity 5-hydroxytrypatamine 4 (5-HT4) receptors agonist, has been shown to improve colon motility in adults. Secondary peristalsis is important for the clearance of refluxate or retained food debris from the esophagus, but the effects of prucalopride on secondary peristalsis are yet unclear in humans. We aimed to investigate the effects of prucalopride on esophageal distension-induced secondary peristalsis in healthy adults. Methods: In this double-blind, placebo-control, randomized study, two separate sessions with 4mg prucalopride and placebo were performed in 11 healthy adults to test their effects on esophageal secondary peristalsis. Secondary peristalsis was generated by slow and rapid mid-esophageal injections of air after a baseline recording of esophageal motility. Results: Prucalopride significantly decreased the threshold volume to generate secondary peristalsis during slow air injection (9.8 ± 1.4 vs. 14.4 ± 0.9 mL, p = 0.005) and rapid air injection (3.9 ± 0.3 vs. 5.2 ± 0.4 mL, p = 0.008). Secondary peristalsis was more frequently induced by rapid air injection after application of prucalopride (80% [70-100%] vs. 70% [60-73%], p = 0.01). Prucalopride increased the wave amplitude of distal esophagus during slow air injection (147.9 ± 28.5 vs. 104.2 ± 16.8 mmHg, p = 0.048) and rapid air injection (128.0 ± 13.3 vs. 105.7 ± 12.3 mmHg, p = 0.016). Prucalopride also significantly increased the amplitudes of primary peristalsis as well as basal pressure of lower esophageal sphincter. Conclusion: Prucalopride enhances mechanosensitivity to distension-induced secondary peristalsis and promotes esophageal peristaltic contractility. These findings suggest that prucalopride, a highly 5-HT4 receptors agonist, could be a therapeutic option for the treatment of subjects with esophageal hypomotility.
Sa1323 Impact of Esophageal Symptoms and Motor Diagnoses on Disease Burden and Health-Related Quality of Life (HRQOL) Chanakyaram A. Reddy, Amit Patel, C. Prakash Gyawali Background: Esophageal high-resolution manometry (HRM) provides objective motor data to complement patient symptoms. However, the correlation between symptoms and findings on diagnostic testing remains imprecise. We prospectively quantified the impact of the patient-reported dominant symptom, and HRM motor diagnosis on symptom burden and HRQOL. Methods: 211 subjects (56.8±1.0 yrs, 66.8% F) undergoing esophageal HRM over 1 year were prospectively enrolled, of which 199 subjects (56.9±1.0 yrs, 65.8% F) identified a dominant symptom on enrollment. Subjects completed symptom questionnaires [GERDQ, Mayo Dysphagia Questionnaire (MDQ), Visceral Sensitivity Index (VSI), Short-Form 36 (SF36), and global symptom severity (GSS) on a 100-mm visual analog scale]. Dominant symptoms included dysphagia (difficulty swallowing liquids or solids), reflux-related (heartburn, regurgitation, chest pain), or nonspecific (belching, cough, wheezing). Subjects with incomplete questionnaire data or unintelligible studies were excluded. Burden and HRQOL were compared within and between cohorts segregated according to the reported dominant symptom and motor diagnoses (Chicago Classification v 3.0). Results: Of the total cohort, 15.6% had evidence of esophagogastric junction (EGJ) outflow obstruction including achalasia, 9.0% had major motor disorders, 18.5% had minor motor disorders, and 56.9% were normal. Disorders with EGJ outflow obstruction had highest MDQ frequency and severity
AGA Abstracts
X : 10052$CH01 03-28-16 00:57:27 PDFd : 10052B : e
S-282
Page 282