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Sa1329 Bolus Clearance in Esophagogastric Junction Outflow Obstruction Is Associated With Strength of Peristalsis
AGA Abstracts
(Table 1). Comparison of controls, NM with IDQ < 7 and NM with IDQ ‡ 7 indicated differences across all measures between both patient groups and controls, but similar results between NM groups defined by symptom score ( Table 2). Two NM patients had ‡ 2 swallows with DCI+ > 8,000 mmHg•s•cm (i.e. potential motility classification changed by application of DCI+), 1 had an IDQ ‡ 7. Seven NM patients had at least one swallow with DCI+ > 8,000 mmHg•s•cm; 3 (43%) had IDQ ‡ 7. Conclusions: 1) The phenomenon of hypercontractility involves the LES as well as distal esophageal segments S2 and S3. 2) Manometric measurement of the LES aftercontraction, either by extension of the DCI domain to include the LES or focused measure of the LES aftercontraction may classify some patients as hypercontractile that would otherwise be considered normal. 3) In this small series, 3/7 (43%) of such reclassified patients had abnormal IDQ scores. Table 1. Standard and aftercontractile HRM metrics of the swallow with the greatest distal contractile integral (DCI).
0.2 s, p<0.001). There was a significant correlation between BPT and BFT for children with normal motility (Figure 1; r=0.94, p<0.001), but not for achalasia patients (Figure 2; r= 0.13, p=0.71). Conclusions: In children with normal esophageal motility, bolus presence across the EGJ and bolus flow through the EGJ are correlated. This finding is consistent with synchronization of the mechanisms of esophageal bolus transport to the EGJ and esophageal emptying. The calculation of BPT and BFT may help determine when one or both of these mechanisms are aberrant. In the context of achalasia, this may help further quantify the degree of flow resistance at the EGJ for diagnosis as well as longitudinal objective assessment of therapeutic effects.
Figure 1 - Correlation between bolus presence time and bolus flow time at the esophagogastric junction for children with a normal Chicago Classification diagnosis.
Values reflect median (5th - 95th percentile). *Reflects DCI+ minus DCI and could be negative if peristalsis lasted longer than 15 seconds. 1Comparison with controls, p-value < 0.05. 2Comparison with hypercontractile, p-value < 0.05. Table 2. Comparison of HRM metrics by symptom score in patients with normal motility (NM).
Figure 2 - Correlation between bolus presence time and bolus flow time at the esophagogastric junction for children with achalasia according to the Chicago Classification, subtyped by category.
Values obtained from the swallow with the greatest distal contractile integral (DCI) are reported as median (interquartile range). 1Comparison with controls, p-value < 0.05. There were no differences in parameters among patient groups by impaction-dysphagia questionnaire (IDQ) score (<7 vs ‡7).
Sa1329 Bolus Clearance in Esophagogastric Junction Outflow Obstruction Is Associated With Strength of Peristalsis Anand Jain, Jason Baker, Joel H. Rubenstein, Joan W. Chen
Sa1328 High-Resolution Impedance Manometry Measurement of Bolus Flow Time in Pediatric Achalasia Maartje Singendonk, Rachel Rosen, Samuel Nurko, Nathalie Rommel, Michiel P. van Wijk, Marc A. Benninga, Taher Omari
Background: The high-resolution manometric diagnosis of esophagogastric junction outflow obstruction (EGJOO) can be associated with a variety of pathogenic mechanisms and carries an uncertain clinical significance. Sensitivity of standard barium esophagram and endoscopy for assessing bolus stasis is low. High-resolution impedance manometry (HRIM) offers a way to assess bolus clearance in patients with EGJOO and achalasia. Aims: To assess esophageal bolus clearance in patients with EGJOO, achalasia, and controls using HRIM and to determine whether subgrouping EGJOO patients based on integrated relaxation pressure (IRP) and distal contractile integral (DCI) can predict clearance. Methods: We included consecutive patients presenting to our institution for HRIM testing between July 2013 and August 2015 diagnosed with EGJOO based on the Chicago Classification. Records were reviewed to exclude those with alternative diagnoses (i.e Nissen fundoplication or esophageal stenosis). Bolus clearance on HRIM was assessed qualitatively using colored impedance contour (functional clearance - FC) and quantitatively using impedance line tracings (complete bolus transit - CBT) overlaying isobaric contour plots for each of the 10 wet swallows. 5 studies of each achalasia subtype and 6 normal controls were also analyzed for comparison. CBT was compared according to DCI and IRP using chi-square test. A DCI cutoff of 1200 mmHg-s-cm and IRP of 20mmHg were chosen based on visual inspection of a scatterplot of all swallows. Results: 46 patients with idiopathic EGJOO were included. Demographic data of the EGJOO patients are included in Table 1. Agreement between CBT and FC across swallows in EGJOO, achalasia, and control subjects was excellent (kappa= 0.82). Proportions of complete bolus clearance across swallows in the different subject groups using CBT and FC respectively were as follows - type 1 achalasia: 14%, 0%; type 2: 8%, 0%; type 3: 42%, 12%; EGJOO: 79%, 73%; control: 98%, 97%. Significant differences in clearance were found between EGJOO and control groups (p<0.0001 for both CBT and FC) and between EGJOO and achalasia (p<0.0001 for all) as shown in Figure 1. DCI <1200 mmHg-s-cm correlated with impaired clearance (66.1% vs. 94.3%, p<0.0001); however,
Background: In achalasia, absent peristalsis and reduced esophagogastric junction (EGJ) relaxation and compliance underlie dysphagia symptoms. Flow across the EGJ is a function of mechanisms which transport swallowed bolus and flow resistance at the level of the EGJ. A novel high-resolution impedance manometry (HRIM) metric, the bolus flow time (BFT), has been developed to estimate the duration of EGJ opening and trans-EGJ bolus flow (Lin et al., 2014 & 2015). The aim of this study was to apply the BFT parameter to a cohort of children with dysphagia and/or gastro-esophageal reflux related symptoms, who underwent diagnostic HRIM and esophageal pressure topography based diagnosis of esophageal motor disorders using the Chicago Classification. We specifically compared children with normal esophageal motility with children diagnosed with achalasia. Methods: HRIM recordings from 10 children who fulfilled the Chicago Classification (V3) criteria for achalasia (5M; 13.5 ± 2.3 yrs; BMI 19.0 ± 7.4) were compared with recordings of 10 children who had normal esophageal motility and no other evidence suggestive for achalasia based on clinical evaluation, endoscopy and/or timed barium swallow (6M; 12.7 ± 3.5 yrs; BMI 18.3 ± 8.3). All patients were studied in the semi-upright position and received a standardized protocol of 10 water swallows. HRIM tracings were analyzed using Manoview version 3.0 (Medtronic Inc). Bolus presence time across the EGJ (BPT) and the BFT were calculated according to the method of Lin et al. (2014) using Matlab-based analysis software. Results: Eight patients were diagnosed with type II achalasia, one with type I and one with type III. Both BPT and BFT were significantly reduced in achalasia patients compared to children with normal esophageal motility (BPT 3.0 vs. 5.6 p<0.001; BFT 0.9 vs. 4.6, p<0.001). BFT was significantly shorter than BPT (achalasia difference -2.1 ± 0.2 s, p=0.001 and normal difference -1.0 ±
AGA Abstracts
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(5-ml) mixed with barium (5-ml) for three times. The impedance profiles were converted to ASCII files and analyzed using the MATLAB program (MathWorks, Natick, MA) by an experienced bioengineer (Figure 1). VII was plotted after transforming the data to a cubic spline interpolation, followed by resampling of the manometry position at 0.2-cm intervals. BE was performed, and remnant barium in the lumen of the esophageal body was measured using LabVIEW 2013 program (National Instruments, Austin, TX) after each swallowing. Response surface analysis was conducted to investigate the relationship between VII and BE based on the time lapse and length of the transition zone (TZ). Results: A total of 51 HRIM and BE images were analyzed. With regard to non-achalasia, the response between VII and BE by a 20- or 30-mm Hg isobaric contour was maximally correlated at the 10-cm TZ. Their responses showed the decreased correlation by time lapse and change of TZ. However, with regard to achalasia, the response between VII and BE by a 20- or 30-mm Hg isobaric contour was significantly correlated regardless of the length of the TZ or time lapse (Figure 2). Conclusions: The newly developed VII method appears to have a close relationship with the currently using BE despite different protocols. A large prospective study that investigates the additive role of VII in determining esophageal bolus transit and diagnosing esophageal motility disorder might be warranted.
Figure 1. A three-dimensional surface plot of inverted impedance, with which the volume of Inverted Impedance (VII, S•s•cm) was calculated. Note that the X axis is time (seconds), Y axis is esophageal distance (cm), and Z axis is inverted impedance (also known as conductance, mS).
Sa1330 New Bolus Transit Parameter in High-resolution Impedance Manometry: Validation with Simultaneous Barium Esophagography Kee Wook Jung, Jeonghoon Kwon, Segyeong Joo, Hwoon-Yong Jung, Seung-Jae Myung, Jungbok Lee, Doyeon Kim, Hee Kyong Na, Ji Yong Ahn, Jeong Hoon Lee, Do Hoon Kim, Kee Don Choi, Ho June Song, Gin Hyug Lee, Jin-Ho Kim
Figure 2. The response surface of difference of volume of inverted impedance (VII) and barium esophagography (BE) according to the time lapse and length of the transition zone (TZ) in achalasia patients. Note that the X- and Y-axis are length of TZ (cm), the time lapse (frame) at 30 frames per second, and the Z-axis depicts the difference between VII and BE.
Background: High-resolution impedance manometry (HRIM) is used to detect and differentiate between complete versus incomplete bolus transits. The three-dimensional volume (3D) of inverted impedance (VII) was developed to measure the remnant impedance volume between each swallow. However, its clinical usefulness and value has not been completely evaluated. Barium esophagography (BE) has been used to determine bolus transit in esophageal motor disorders. Here, we aimed to investigate the absolute measurement of bolus transit based on the 3-D volume of inverted impedance and its clinical meaning by assessing its relationship with simultaneous BE. Methods: Seventeen patients (M: F = 8:9, age range, 21-85 years) who underwent simultaneous HRIM and BE were enrolled in this study, of whom 5 were diagnosed with achalasia and 12 were diagnosed with normalcy or ineffective esophageal motility. Each patient underwent HRIM using a catheter with 32 circumferential pressure and 16 impedance sensors. They were asked to swallow a total of 10-ml of saline
Sa1331 Abnormal Isometric Relaxation in Jackhammer Esophagus Yinglian Xiao, Dustin A. Carlson, Zhiyue Lin, Nicolas Rinella, Min-hu Chen, John Pandolfino Background and aims: Jackhammer (JH) is a motility disorder defined by at least 2 hypercontractile swallows (Distal Contractile Integral (DCI) >8000 mmHg.cm.s) among the total 10 supine liquid swallows in the Chicago classification 3.0. Although it is described as a hypercontractile disorder, we hypothesize that JH may also be associated with abnormal isometric relaxation. Thus, we developed a method to distinguish the components of isometric
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AGA Abstracts
AGA Abstracts
the IRP distinction at 20 mmHg did not correlate with clearance (88.1% vs. 81.3%, p = 0.0944). Conclusions: Bolus clearance based on quantitative and qualitative assessment of HRIM data in EGJOO patients is not as severely impaired as in patients with achalasia; however, it is impaired compared to the normal population. In EGJOO patients, weak peristalsis, indicated by low DCI, is closely associated with poor bolus clearance. In patients with DCI greater than 1200 mmHg-s-cm, a manometric finding of EGJOO is unlikely to be clinically significant. Table 1. Demographic Data.
(Table 1). Comparison of controls, NM with IDQ < 7 and NM with IDQ ‡ 7 indicated differences across all measures between both patient groups and controls, but similar results between NM groups defined by symptom score ( Table 2). Two NM patients had ‡ 2 swallows with DCI+ > 8,000 mmHg•s•cm (i.e. potential motility classification changed by application of DCI+), 1 had an IDQ ‡ 7. Seven NM patients had at least one swallow with DCI+ > 8,000 mmHg•s•cm; 3 (43%) had IDQ ‡ 7. Conclusions: 1) The phenomenon of hypercontractility involves the LES as well as distal esophageal segments S2 and S3. 2) Manometric measurement of the LES aftercontraction, either by extension of the DCI domain to include the LES or focused measure of the LES aftercontraction may classify some patients as hypercontractile that would otherwise be considered normal. 3) In this small series, 3/7 (43%) of such reclassified patients had abnormal IDQ scores. Table 1. Standard and aftercontractile HRM metrics of the swallow with the greatest distal contractile integral (DCI).
0.2 s, p<0.001). There was a significant correlation between BPT and BFT for children with normal motility (Figure 1; r=0.94, p<0.001), but not for achalasia patients (Figure 2; r= 0.13, p=0.71). Conclusions: In children with normal esophageal motility, bolus presence across the EGJ and bolus flow through the EGJ are correlated. This finding is consistent with synchronization of the mechanisms of esophageal bolus transport to the EGJ and esophageal emptying. The calculation of BPT and BFT may help determine when one or both of these mechanisms are aberrant. In the context of achalasia, this may help further quantify the degree of flow resistance at the EGJ for diagnosis as well as longitudinal objective assessment of therapeutic effects.
Figure 1 - Correlation between bolus presence time and bolus flow time at the esophagogastric junction for children with a normal Chicago Classification diagnosis.
Values reflect median (5th - 95th percentile). *Reflects DCI+ minus DCI and could be negative if peristalsis lasted longer than 15 seconds. 1Comparison with controls, p-value < 0.05. 2Comparison with hypercontractile, p-value < 0.05. Table 2. Comparison of HRM metrics by symptom score in patients with normal motility (NM).
Figure 2 - Correlation between bolus presence time and bolus flow time at the esophagogastric junction for children with achalasia according to the Chicago Classification, subtyped by category.
Values obtained from the swallow with the greatest distal contractile integral (DCI) are reported as median (interquartile range). 1Comparison with controls, p-value < 0.05. There were no differences in parameters among patient groups by impaction-dysphagia questionnaire (IDQ) score (<7 vs ‡7).
Sa1329 Bolus Clearance in Esophagogastric Junction Outflow Obstruction Is Associated With Strength of Peristalsis Anand Jain, Jason Baker, Joel H. Rubenstein, Joan W. Chen
Sa1328 High-Resolution Impedance Manometry Measurement of Bolus Flow Time in Pediatric Achalasia Maartje Singendonk, Rachel Rosen, Samuel Nurko, Nathalie Rommel, Michiel P. van Wijk, Marc A. Benninga, Taher Omari
Background: The high-resolution manometric diagnosis of esophagogastric junction outflow obstruction (EGJOO) can be associated with a variety of pathogenic mechanisms and carries an uncertain clinical significance. Sensitivity of standard barium esophagram and endoscopy for assessing bolus stasis is low. High-resolution impedance manometry (HRIM) offers a way to assess bolus clearance in patients with EGJOO and achalasia. Aims: To assess esophageal bolus clearance in patients with EGJOO, achalasia, and controls using HRIM and to determine whether subgrouping EGJOO patients based on integrated relaxation pressure (IRP) and distal contractile integral (DCI) can predict clearance. Methods: We included consecutive patients presenting to our institution for HRIM testing between July 2013 and August 2015 diagnosed with EGJOO based on the Chicago Classification. Records were reviewed to exclude those with alternative diagnoses (i.e Nissen fundoplication or esophageal stenosis). Bolus clearance on HRIM was assessed qualitatively using colored impedance contour (functional clearance - FC) and quantitatively using impedance line tracings (complete bolus transit - CBT) overlaying isobaric contour plots for each of the 10 wet swallows. 5 studies of each achalasia subtype and 6 normal controls were also analyzed for comparison. CBT was compared according to DCI and IRP using chi-square test. A DCI cutoff of 1200 mmHg-s-cm and IRP of 20mmHg were chosen based on visual inspection of a scatterplot of all swallows. Results: 46 patients with idiopathic EGJOO were included. Demographic data of the EGJOO patients are included in Table 1. Agreement between CBT and FC across swallows in EGJOO, achalasia, and control subjects was excellent (kappa= 0.82). Proportions of complete bolus clearance across swallows in the different subject groups using CBT and FC respectively were as follows - type 1 achalasia: 14%, 0%; type 2: 8%, 0%; type 3: 42%, 12%; EGJOO: 79%, 73%; control: 98%, 97%. Significant differences in clearance were found between EGJOO and control groups (p<0.0001 for both CBT and FC) and between EGJOO and achalasia (p<0.0001 for all) as shown in Figure 1. DCI <1200 mmHg-s-cm correlated with impaired clearance (66.1% vs. 94.3%, p<0.0001); however,
Background: In achalasia, absent peristalsis and reduced esophagogastric junction (EGJ) relaxation and compliance underlie dysphagia symptoms. Flow across the EGJ is a function of mechanisms which transport swallowed bolus and flow resistance at the level of the EGJ. A novel high-resolution impedance manometry (HRIM) metric, the bolus flow time (BFT), has been developed to estimate the duration of EGJ opening and trans-EGJ bolus flow (Lin et al., 2014 & 2015). The aim of this study was to apply the BFT parameter to a cohort of children with dysphagia and/or gastro-esophageal reflux related symptoms, who underwent diagnostic HRIM and esophageal pressure topography based diagnosis of esophageal motor disorders using the Chicago Classification. We specifically compared children with normal esophageal motility with children diagnosed with achalasia. Methods: HRIM recordings from 10 children who fulfilled the Chicago Classification (V3) criteria for achalasia (5M; 13.5 ± 2.3 yrs; BMI 19.0 ± 7.4) were compared with recordings of 10 children who had normal esophageal motility and no other evidence suggestive for achalasia based on clinical evaluation, endoscopy and/or timed barium swallow (6M; 12.7 ± 3.5 yrs; BMI 18.3 ± 8.3). All patients were studied in the semi-upright position and received a standardized protocol of 10 water swallows. HRIM tracings were analyzed using Manoview version 3.0 (Medtronic Inc). Bolus presence time across the EGJ (BPT) and the BFT were calculated according to the method of Lin et al. (2014) using Matlab-based analysis software. Results: Eight patients were diagnosed with type II achalasia, one with type I and one with type III. Both BPT and BFT were significantly reduced in achalasia patients compared to children with normal esophageal motility (BPT 3.0 vs. 5.6 p<0.001; BFT 0.9 vs. 4.6, p<0.001). BFT was significantly shorter than BPT (achalasia difference -2.1 ± 0.2 s, p=0.001 and normal difference -1.0 ±
AGA Abstracts
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(5-ml) mixed with barium (5-ml) for three times. The impedance profiles were converted to ASCII files and analyzed using the MATLAB program (MathWorks, Natick, MA) by an experienced bioengineer (Figure 1). VII was plotted after transforming the data to a cubic spline interpolation, followed by resampling of the manometry position at 0.2-cm intervals. BE was performed, and remnant barium in the lumen of the esophageal body was measured using LabVIEW 2013 program (National Instruments, Austin, TX) after each swallowing. Response surface analysis was conducted to investigate the relationship between VII and BE based on the time lapse and length of the transition zone (TZ). Results: A total of 51 HRIM and BE images were analyzed. With regard to non-achalasia, the response between VII and BE by a 20- or 30-mm Hg isobaric contour was maximally correlated at the 10-cm TZ. Their responses showed the decreased correlation by time lapse and change of TZ. However, with regard to achalasia, the response between VII and BE by a 20- or 30-mm Hg isobaric contour was significantly correlated regardless of the length of the TZ or time lapse (Figure 2). Conclusions: The newly developed VII method appears to have a close relationship with the currently using BE despite different protocols. A large prospective study that investigates the additive role of VII in determining esophageal bolus transit and diagnosing esophageal motility disorder might be warranted.
Figure 1. A three-dimensional surface plot of inverted impedance, with which the volume of Inverted Impedance (VII, S•s•cm) was calculated. Note that the X axis is time (seconds), Y axis is esophageal distance (cm), and Z axis is inverted impedance (also known as conductance, mS).
Sa1330 New Bolus Transit Parameter in High-resolution Impedance Manometry: Validation with Simultaneous Barium Esophagography Kee Wook Jung, Jeonghoon Kwon, Segyeong Joo, Hwoon-Yong Jung, Seung-Jae Myung, Jungbok Lee, Doyeon Kim, Hee Kyong Na, Ji Yong Ahn, Jeong Hoon Lee, Do Hoon Kim, Kee Don Choi, Ho June Song, Gin Hyug Lee, Jin-Ho Kim
Figure 2. The response surface of difference of volume of inverted impedance (VII) and barium esophagography (BE) according to the time lapse and length of the transition zone (TZ) in achalasia patients. Note that the X- and Y-axis are length of TZ (cm), the time lapse (frame) at 30 frames per second, and the Z-axis depicts the difference between VII and BE.
Background: High-resolution impedance manometry (HRIM) is used to detect and differentiate between complete versus incomplete bolus transits. The three-dimensional volume (3D) of inverted impedance (VII) was developed to measure the remnant impedance volume between each swallow. However, its clinical usefulness and value has not been completely evaluated. Barium esophagography (BE) has been used to determine bolus transit in esophageal motor disorders. Here, we aimed to investigate the absolute measurement of bolus transit based on the 3-D volume of inverted impedance and its clinical meaning by assessing its relationship with simultaneous BE. Methods: Seventeen patients (M: F = 8:9, age range, 21-85 years) who underwent simultaneous HRIM and BE were enrolled in this study, of whom 5 were diagnosed with achalasia and 12 were diagnosed with normalcy or ineffective esophageal motility. Each patient underwent HRIM using a catheter with 32 circumferential pressure and 16 impedance sensors. They were asked to swallow a total of 10-ml of saline
Sa1331 Abnormal Isometric Relaxation in Jackhammer Esophagus Yinglian Xiao, Dustin A. Carlson, Zhiyue Lin, Nicolas Rinella, Min-hu Chen, John Pandolfino Background and aims: Jackhammer (JH) is a motility disorder defined by at least 2 hypercontractile swallows (Distal Contractile Integral (DCI) >8000 mmHg.cm.s) among the total 10 supine liquid swallows in the Chicago classification 3.0. Although it is described as a hypercontractile disorder, we hypothesize that JH may also be associated with abnormal isometric relaxation. Thus, we developed a method to distinguish the components of isometric
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AGA Abstracts
the IRP distinction at 20 mmHg did not correlate with clearance (88.1% vs. 81.3%, p = 0.0944). Conclusions: Bolus clearance based on quantitative and qualitative assessment of HRIM data in EGJOO patients is not as severely impaired as in patients with achalasia; however, it is impaired compared to the normal population. In EGJOO patients, weak peristalsis, indicated by low DCI, is closely associated with poor bolus clearance. In patients with DCI greater than 1200 mmHg-s-cm, a manometric finding of EGJOO is unlikely to be clinically significant. Table 1. Demographic Data.