- Email: [email protected]
Sa1325 Optimizing the High Resolution Manometry (HRM) Study Protocol
Sa1325 a
Significant only between LSBE and NERD groups; b Significant between NERD and Barrett's patients, but not between LSBE and SSBE groups; NS - Not significant
Optimizing the High Resolution Manometry (HRM) Study Protocol Amit Patel, Faiz Mirza, C. Prakash Gyawali Common causes of prolonged HRM studies include gagging, retching, repetitive swallowing and intolerance of the HRM catheter at the start of the study protocol. In particular, some patients have difficulty refraining from swallowing to allow for the landmark phase for baseline sphincter location and pressures. We assessed the impact of obtaining the landmark phase at the end of the study when the patient has acclimatized to the HRM catheter. METHODS: All patients undergoing esophageal HRM (Given Imaging, Los Angeles, CA) over a 1 year period (2011) were eligible for inclusion. The swallow protocol consisted of the landmark phase, 10 five mL water swallows 20-30 s apart, and one set of multiple rapid swallows where 5 two mL swallows were administered in rapid succession (standard protocol). Technicians performing the procedure were instructed to obtain the landmark phase at the end of the swallow protocol if a 2 min swallow free period was not possible at the beginning of the study, at their discretion (modified protocol). Duration of the HRM study, technical characteristics of the studies, indications and motor findings were extracted from the computerized medical record. These parameters were compared between subjects with landmark phase at the start and at the end of the study, and predictors of poor tolerance of the HRM catheter were assessed. RESULTS: Of the 475 patients (mean age 55.6 ±0.7 years, 60% female) referred for HRM studies, 429 (90.4%) underwent a standard protocol, with mean study duration of 12.3±0.2 min (median 10.9 min). In these patients, the time to landmark phase was 1.8±0.1 min (median 1.3 min, 95th percentile 5.1 min), time to first swallow was 3.2±0.1 min (median 2.4 min) and time taken for swallow phase was 9.1±0.2 min (median 8.1 min). A swallow/artifact free phase at the start of the study was not possible in 46 patients (9.6%). In these patients, time to first swallow (mean 5.7±0.7 min, median 3.5 min) and total duration of the study (mean 15.2±0.9 min, median 13.4 min) were significantly longer than the standard protocol group (p ,0.0001 for each comparison), but duration of swallow phase was similar (mean 8.7±0.6 min, median 8.1 min). On assessing study indication and motor abnormalities, only cough as an indication for the HRM study was significantly more frequent with the modified protocol (19.6%) compared to standard protocol (9.8%, p ,0.05). Interpretation was not impacted by moving the landmark phase to the end of the study. CONCLUSIONS: Modification of the HRM study protocol, with the landmark phase obtained at the end of the study, shortens study duration without compromising study quality in patients who are intolerant of the HRM catheter. We propose moving the landmark phase to the end of the study if a swallow/artifact free period cannot be obtained within the first 5 minutes of the study.
Sa1323 Is the Chicago Classification for Esophageal Motility Disorders Useful to Predict Symptom Severity? Sabine Roman, Francois Mion, Sophie Marjoux, Amandine Mourthe, Frank Zerbib Background The latest iteration of the Chicago classification segregates esophageal motility disorders into disorders with impaired esophago-gastric junction (EGJ) relaxation (achalasia, EGJ outflow obstruction), motility disorders not observed in normal subjects (absent peristalsis, distal esophageal spasm, hypercontractile esophagus) and statistically defined peristaltic abnormalities (weak/frequent failed peristalsis, nutcracker, rapid peristalsis). However the clinical relevance of the latter group remains to be determined. Our aim was to evaluate dysphagia severity according to this classification. Patients and methods Within a randomized study to evaluate the impact of esophageal high resolution manometry (HRM) in patients with dysphagia, we selected all patients with a manometric diagnosis according to the Chicago classification. Seventy-five patients (30 men, mean age 54 years, range 18-88) included between March 2011 and November 2012 were thus analyzed. Sydney swallow questionnaire (1) was administrated to patients: this questionnaire included 15 questions on dysphagia characteristics and 2 questions on quality of life (QOL). The maximal score was 1700 and was lower than 200 in healthy controls in the validation study (1). Scores were expressed as median (range) and compared between groups using Kruskal Wallis or Mann-Whitney test. Results Esophageal motility disorders are presented in the table. Among patients with impaired EGJ relaxation, 19 presented achalasia and 6 EGJ outflow obstruction. Sydney score was significantly different between the 3 groups (p ,0.01) as well as QOL (p,0.01). Patients with impaired EGJ relaxation had higher Sydney score than those with normal motility (p,0.01) and those with weak/frequent failed peristalsis (p=0.07). QOL was also more altered in patients with impaired EGJ relaxation compared to those with normal motility (p,0.01) and those with weak/frequent failed peristalsis (p=0.06). Finally Sydney score and QOL were similar between normal and weak/frequent failed peristalsis (p=0.36 and p=0.22 respectively). Sydney score was normal ( ,200) in 10 patients (6 with normal esophageal motility, 4 with weak or frequent failed peristalsis). Conclusion Our study confirmed that dysphagia was more severe in patients with achalasia than in those with normal or weak/frequent failed peristalsis. Dysphagia severity and impact on quality of life were similar in patients with weak/frequent failed peristalsis and normal esophageal motility. These results suggest that the Chicago classification might accurately segregate esophageal motility disorders according to the symptom severity. The impact of weak/ frequent failed peristalsis on quality of life might be modest if it exits. Reference: (1) Wallace et al. Gastroenterology 2000
Sa1326 Psychosocial Predictors of Self Ratings of Health in Moderate to Severe IBS Patients: What's Involved in Feeling Healthy Besides the Severity of GI Symptoms? Jeffrey M. Lackner, Gregory D. Gudleski, Laurie Keefer, Darren M. Brenner, Travis J. Stewart, Gary Iacobucci, Rebecca Firth, Camille Simonetti, Christopher Radziwon, Susan S. Krasner, Michael D. Sitrin, Leonard A. Katz, Sarah Quinton, Elyse Sklar Background. Irritable bowel syndrome (IBS) is a common, potentially disabling GI disorder characterized by abdominal pain and altered bowel habits. Because these symptoms lack a reliable biomarker, clinical decision making involves asking patients to appraise and communicate their health status. One of the most common ways of characterizing health status is to ask patients to rate their overall health as excellent, good, fair, or poor. Prognostically, selfratings of health (SRH) have proven better than physician ratings at predicting mortality (La Rue et al.,1979), but little is known about how they relate to outcomes relevant to a medically benign condition like IBS (e.g., quality of life [QOL], IBS symptom severity, abdominal pain). Also unclear is how IBS patients derive health self-appraisals but the broader health research suggests people rely on psychosocial referents to describe their health. This study examined what psychosocial factors, if any, predict self-rated health among a cohort of more severely affected IBS patients. Subjects. 235 Rome III-diagnosed IBS patients (M age = 41 yrs, F=78%) without comorbid organic GI disease were administered a psychosocial test battery that covered 3 core domains (somatic, mental, social) of health. Instruments included the SF-12, BSI, Negative Social Interactions Scale, Perceived Stress Scale, State Trait Anxiety Inventory, Beck Depression Inventory, Visceral Sensitivity Index, Medical Comorbidity Checklist, IBS Symptom Severity Scale, abdominal pain intensity
Sa1324 Diagnosis of Esophageal Achalasia Using Water-Perfused Catheter High Resolution Manometry Vicente Ortiz, Günter P. Poppele, Concepción Castellano, Vicente Garrigues Background: Currently, achalasia is diagnosed using Chicago classification criteria based on studies carried out with high resolution manometry equipment that uses 36 pressure sensing transducers (Manoscan & Manoview, Sierra Scientific Instruments Inc, USA). The four
S-263
AGA Abstracts
AGA Abstracts
seconds integrated relaxation pressure in the lower esophageal sphincter (4-s IRP) . 15 mmHg is a required diagnostic criteria Aim: To evaluate the 4-s IRP as a required diagnostic criterion in previously untreated patients with esophageal achalasia using 22-channel waterperfused catheter high resolution manometry. Materials and Methods: All patients with esophageal achalasia diagnosed from June 2009 to November 2012 were included in the study. The diagnosis was made using water-perfused catheter high resolution manometry (Medical Measurement Systems, The Netherlands). No prior treatment of the achalasia had been carried out. In order to establish the diagnosis of achalasia, the absence of primary esophageal contraction waves and the existence of incomplete relaxation ( ,80%) of the lower esophageal sphincter in the conventional manometric record were required. Achalasia was categorized into 3 subtypes: achalasia with minimal esophageal pressurization (type I, classic), achalasia with esophageal compression (type II), achalasia with spasm (type III). All records were checked to ensure the correct location of esophagogastric junction. The 4s IRP was evaluated automatically through the analysis program provided by the owner of the equipment. Results: A total of 34 patients (26 male and 8 female) were included, with a median age of 56 years (limits 29-78), with diagnosis of primary achalasia, nine of them with type I achalasia (26.5%), 22 with type II (64.7%), three with type III (8.8%). The median basal lower esophageal sphincter pressure was 29 mmHg (range 12-66), the median distal contractile integral was 515 mmHg-s-cm (range 98-4040). The median 4-s IRP was 15.4 mmHg (range 6.7-42). In the individualized analysis, the 4-s IRP was under 15 mmHg in 16 patients (47%); and under 10 mmHg in 4 patients (11.7 %). Conclusion: The diagnostic criteria for esophageal achalasia when water-perfused catheter high resolution manometry (MMS) is used, should be reviewed. The 4-s IRP values for the diagnosis should be modified.
Significant only between LSBE and NERD groups; b Significant between NERD and Barrett's patients, but not between LSBE and SSBE groups; NS - Not significant
Optimizing the High Resolution Manometry (HRM) Study Protocol Amit Patel, Faiz Mirza, C. Prakash Gyawali Common causes of prolonged HRM studies include gagging, retching, repetitive swallowing and intolerance of the HRM catheter at the start of the study protocol. In particular, some patients have difficulty refraining from swallowing to allow for the landmark phase for baseline sphincter location and pressures. We assessed the impact of obtaining the landmark phase at the end of the study when the patient has acclimatized to the HRM catheter. METHODS: All patients undergoing esophageal HRM (Given Imaging, Los Angeles, CA) over a 1 year period (2011) were eligible for inclusion. The swallow protocol consisted of the landmark phase, 10 five mL water swallows 20-30 s apart, and one set of multiple rapid swallows where 5 two mL swallows were administered in rapid succession (standard protocol). Technicians performing the procedure were instructed to obtain the landmark phase at the end of the swallow protocol if a 2 min swallow free period was not possible at the beginning of the study, at their discretion (modified protocol). Duration of the HRM study, technical characteristics of the studies, indications and motor findings were extracted from the computerized medical record. These parameters were compared between subjects with landmark phase at the start and at the end of the study, and predictors of poor tolerance of the HRM catheter were assessed. RESULTS: Of the 475 patients (mean age 55.6 ±0.7 years, 60% female) referred for HRM studies, 429 (90.4%) underwent a standard protocol, with mean study duration of 12.3±0.2 min (median 10.9 min). In these patients, the time to landmark phase was 1.8±0.1 min (median 1.3 min, 95th percentile 5.1 min), time to first swallow was 3.2±0.1 min (median 2.4 min) and time taken for swallow phase was 9.1±0.2 min (median 8.1 min). A swallow/artifact free phase at the start of the study was not possible in 46 patients (9.6%). In these patients, time to first swallow (mean 5.7±0.7 min, median 3.5 min) and total duration of the study (mean 15.2±0.9 min, median 13.4 min) were significantly longer than the standard protocol group (p ,0.0001 for each comparison), but duration of swallow phase was similar (mean 8.7±0.6 min, median 8.1 min). On assessing study indication and motor abnormalities, only cough as an indication for the HRM study was significantly more frequent with the modified protocol (19.6%) compared to standard protocol (9.8%, p ,0.05). Interpretation was not impacted by moving the landmark phase to the end of the study. CONCLUSIONS: Modification of the HRM study protocol, with the landmark phase obtained at the end of the study, shortens study duration without compromising study quality in patients who are intolerant of the HRM catheter. We propose moving the landmark phase to the end of the study if a swallow/artifact free period cannot be obtained within the first 5 minutes of the study.
Sa1323 Is the Chicago Classification for Esophageal Motility Disorders Useful to Predict Symptom Severity? Sabine Roman, Francois Mion, Sophie Marjoux, Amandine Mourthe, Frank Zerbib Background The latest iteration of the Chicago classification segregates esophageal motility disorders into disorders with impaired esophago-gastric junction (EGJ) relaxation (achalasia, EGJ outflow obstruction), motility disorders not observed in normal subjects (absent peristalsis, distal esophageal spasm, hypercontractile esophagus) and statistically defined peristaltic abnormalities (weak/frequent failed peristalsis, nutcracker, rapid peristalsis). However the clinical relevance of the latter group remains to be determined. Our aim was to evaluate dysphagia severity according to this classification. Patients and methods Within a randomized study to evaluate the impact of esophageal high resolution manometry (HRM) in patients with dysphagia, we selected all patients with a manometric diagnosis according to the Chicago classification. Seventy-five patients (30 men, mean age 54 years, range 18-88) included between March 2011 and November 2012 were thus analyzed. Sydney swallow questionnaire (1) was administrated to patients: this questionnaire included 15 questions on dysphagia characteristics and 2 questions on quality of life (QOL). The maximal score was 1700 and was lower than 200 in healthy controls in the validation study (1). Scores were expressed as median (range) and compared between groups using Kruskal Wallis or Mann-Whitney test. Results Esophageal motility disorders are presented in the table. Among patients with impaired EGJ relaxation, 19 presented achalasia and 6 EGJ outflow obstruction. Sydney score was significantly different between the 3 groups (p ,0.01) as well as QOL (p,0.01). Patients with impaired EGJ relaxation had higher Sydney score than those with normal motility (p,0.01) and those with weak/frequent failed peristalsis (p=0.07). QOL was also more altered in patients with impaired EGJ relaxation compared to those with normal motility (p,0.01) and those with weak/frequent failed peristalsis (p=0.06). Finally Sydney score and QOL were similar between normal and weak/frequent failed peristalsis (p=0.36 and p=0.22 respectively). Sydney score was normal ( ,200) in 10 patients (6 with normal esophageal motility, 4 with weak or frequent failed peristalsis). Conclusion Our study confirmed that dysphagia was more severe in patients with achalasia than in those with normal or weak/frequent failed peristalsis. Dysphagia severity and impact on quality of life were similar in patients with weak/frequent failed peristalsis and normal esophageal motility. These results suggest that the Chicago classification might accurately segregate esophageal motility disorders according to the symptom severity. The impact of weak/ frequent failed peristalsis on quality of life might be modest if it exits. Reference: (1) Wallace et al. Gastroenterology 2000
Sa1326 Psychosocial Predictors of Self Ratings of Health in Moderate to Severe IBS Patients: What's Involved in Feeling Healthy Besides the Severity of GI Symptoms? Jeffrey M. Lackner, Gregory D. Gudleski, Laurie Keefer, Darren M. Brenner, Travis J. Stewart, Gary Iacobucci, Rebecca Firth, Camille Simonetti, Christopher Radziwon, Susan S. Krasner, Michael D. Sitrin, Leonard A. Katz, Sarah Quinton, Elyse Sklar Background. Irritable bowel syndrome (IBS) is a common, potentially disabling GI disorder characterized by abdominal pain and altered bowel habits. Because these symptoms lack a reliable biomarker, clinical decision making involves asking patients to appraise and communicate their health status. One of the most common ways of characterizing health status is to ask patients to rate their overall health as excellent, good, fair, or poor. Prognostically, selfratings of health (SRH) have proven better than physician ratings at predicting mortality (La Rue et al.,1979), but little is known about how they relate to outcomes relevant to a medically benign condition like IBS (e.g., quality of life [QOL], IBS symptom severity, abdominal pain). Also unclear is how IBS patients derive health self-appraisals but the broader health research suggests people rely on psychosocial referents to describe their health. This study examined what psychosocial factors, if any, predict self-rated health among a cohort of more severely affected IBS patients. Subjects. 235 Rome III-diagnosed IBS patients (M age = 41 yrs, F=78%) without comorbid organic GI disease were administered a psychosocial test battery that covered 3 core domains (somatic, mental, social) of health. Instruments included the SF-12, BSI, Negative Social Interactions Scale, Perceived Stress Scale, State Trait Anxiety Inventory, Beck Depression Inventory, Visceral Sensitivity Index, Medical Comorbidity Checklist, IBS Symptom Severity Scale, abdominal pain intensity
Sa1324 Diagnosis of Esophageal Achalasia Using Water-Perfused Catheter High Resolution Manometry Vicente Ortiz, Günter P. Poppele, Concepción Castellano, Vicente Garrigues Background: Currently, achalasia is diagnosed using Chicago classification criteria based on studies carried out with high resolution manometry equipment that uses 36 pressure sensing transducers (Manoscan & Manoview, Sierra Scientific Instruments Inc, USA). The four
S-263
AGA Abstracts
AGA Abstracts
seconds integrated relaxation pressure in the lower esophageal sphincter (4-s IRP) . 15 mmHg is a required diagnostic criteria Aim: To evaluate the 4-s IRP as a required diagnostic criterion in previously untreated patients with esophageal achalasia using 22-channel waterperfused catheter high resolution manometry. Materials and Methods: All patients with esophageal achalasia diagnosed from June 2009 to November 2012 were included in the study. The diagnosis was made using water-perfused catheter high resolution manometry (Medical Measurement Systems, The Netherlands). No prior treatment of the achalasia had been carried out. In order to establish the diagnosis of achalasia, the absence of primary esophageal contraction waves and the existence of incomplete relaxation ( ,80%) of the lower esophageal sphincter in the conventional manometric record were required. Achalasia was categorized into 3 subtypes: achalasia with minimal esophageal pressurization (type I, classic), achalasia with esophageal compression (type II), achalasia with spasm (type III). All records were checked to ensure the correct location of esophagogastric junction. The 4s IRP was evaluated automatically through the analysis program provided by the owner of the equipment. Results: A total of 34 patients (26 male and 8 female) were included, with a median age of 56 years (limits 29-78), with diagnosis of primary achalasia, nine of them with type I achalasia (26.5%), 22 with type II (64.7%), three with type III (8.8%). The median basal lower esophageal sphincter pressure was 29 mmHg (range 12-66), the median distal contractile integral was 515 mmHg-s-cm (range 98-4040). The median 4-s IRP was 15.4 mmHg (range 6.7-42). In the individualized analysis, the 4-s IRP was under 15 mmHg in 16 patients (47%); and under 10 mmHg in 4 patients (11.7 %). Conclusion: The diagnostic criteria for esophageal achalasia when water-perfused catheter high resolution manometry (MMS) is used, should be reviewed. The 4-s IRP values for the diagnosis should be modified.