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Sa1336 Chicago Classification v 3.0 Identifies Esophageal Body Contraction Wave Abnormalities (CWA) More Precisely But Less Frequently Than v 2.0 on Esophageal High Resolution Manometry
have exaggerated esophageal neuromotor responses characterized by prolonged esophageal body contractile activity and may be related to heightened sensitivity of both skeletal and smooth muscle as exhibited by more rapid peristaltic and LES reflex recruitment. Further modulation of these responses with survival and maturation in infants with birth asphyxia may be the determining factor for feeding and GER related aerodigestive consequences. *Supported in part by RO1 DK068158
Sa1337 Age-Related Impairment of EGJ Relaxation and Bolus Flow Time Charles Cock, Laura K. Besanko, Carly Burgstad, Richard Heddle, Robert J. Fraser, Taher Omari
AGA Abstracts
BACKGROUND: A novel measure of esophago-gastric junction bolus flow time (BFT) has been developed to compliment the integrated relaxation pressure as an indicator of EGJ function. BFT is reduced due to incomplete emptying in all subtypes of achalasia (Lin 2015); and due to esophageal stasis in cases with incomplete bolus transport (Lin 2014). An increased frequency of intra-esophageal stasis and incomplete EGJ emptying has been reported with advancing age. We performed high-resolution impedance manometry (HRIM) and compared BFT and other pressure and/or flow parameters between young and aged (>80yrs) healthy subjects. METHODS: Data from 15 young controls (9M, mean age 26±4 years) and 15 aged subjects (11M, 85±4 yrs) were compared. Data were acquired in the upright posture using a 3.2mm solid-state catheter (Solar GI system, MMS) with 25 pressure (1cm spacing) and 12 impedance segments (2cm intervals). Five swallows each of 5 ml liquid (L) and viscous (V) bolus were analysed for standard esophageal pressure topography measures, as well as impedance based bolus presence at the EGJ (BPT) and flow time (BFT). A P value <0.05 was considered significant. RESULTS: For both bolus consistencies, IRP4 was increased (L 12±2 vs. 6±1 mmHg; P=0.02 and V 15±2 vs. 7±1 mmHg; P=0.02) and BFT was reduced (L 1.7±0.3 vs. 3.8±0.2 sec; P<0.001 and V 1.9±0.3 vs 3.8±0.2 sec; P<0.001) in aged subjects compared to young. Aged subjects with poor bolus clearance had weaker esophageal contractility, which reached significance for viscous swallows (DCI 342±94 vs. 580±56 mmHg.cm-1.s-1; P=0.006) and a further reduced BFT (figure) due to reduced bolus presence (BPT) above the EGJ. The intrabolus pressures were not different between age groups. CONCLUSION: Reduced bolus flow through the EGJ can be quantified in asymptomatic individuals over eighty years. Bolus flow was reduced more than bolus presence in older subjects suggesting that both ineffective transport and increased EGJ resistance contribute to decreased BFT. Despite an elevated IRP, there was no increase in intrabolus pressures above the EGJ, due to weak esophageal propulsion. Improved understanding of the pathogenesis of impaired EGJ bolus transit in older individuals may provide a guide to treatment strategies for dysphagia in this group.
Data presented as mean ± SEM or as %.
Sa1336 Chicago Classification v 3.0 Identifies Esophageal Body Contraction Wave Abnormalities (CWA) More Precisely But Less Frequently Than v 2.0 on Esophageal High Resolution Manometry Amit Patel, Nitin Sainani, Dan Wang, Faiz Mirza, Satish Munigala, C. Prakash Gyawali Background: The Chicago Classification (CC) uses two software metrics, distal contractile integral (DCI) and distal latency (DL), to address vigor and timing of esophageal body contraction in defining major and minor esophageal motor disorders. However, contraction wave abnormalities (CWA) with low contraction vigor and normal DL may not make CC criteria for an esophageal motor diagnosis. We evaluated the performance of CC v2.0 and 3.0 criteria in a cohort of patients with CWA. Methods: All patients undergoing esophageal HRM over a 6-year period (2006-2011) were eligible for inclusion. Patients with absent contractility in the esophageal body were excluded. The following CWA were evaluated: mean averaged amplitudes ‡180 mmHg (nutcracker esophagus, NE), >20% simultaneous contraction (SC) with contraction front velocity >6.8 cm/s, multiple peaked waves with or without broad contraction wave >5.7 s (MPW/BW), double peaked waves >15% (DPW), and distal shift in amplitudes (150-179 mmHg). A comparison group consisted of normal esophageal body on HRM without CWA. All HRM studies were re-evaluated using Manoview ESO 3.0, and CC diagnosis recorded according to v 2.0 and 3.0. Patients completed a questionnaire from which dominant symptom intensity (DSI, product of symptom severity and frequency measured on 5-point Likert scales), and global symptom severity (GSS, from 10-cm visual analog scales) were acquired. Symptom burden using DSI and GSS, and proportions of patients meeting CC criteria with v2.0 and 3.0 were compared within CWA cohorts. Results: Over the study period, 884 (33.6%, 57.7±0.5 yr, 67.1% F) of a total of 2634 HRM studies had CWA while 959 (36.4%, 51.6±0.5 yr, 63.5% F) had normal studies. Within CWA, 113 had NE, 113 SC, 131 MPW/BW, 421 DPW, and 106 had distal shift in amplitudes. Proportions with dominant heartburn or dysphagia, mean DSI, and mean GSS were similar across CWA categories (p>0.06); DSI was numerically lower with normal studies (p=0.16). 472 (53.4%) and 326 (36.9%) of CWA met CC v2.0 and 3.0 criteria, respectively, for a major or minor motor diagnosis. Likelihood for CC diagnosis was highest for NE (89.4%, 67.3% with CC v2.0 and 3.0, respectively) and SC (76.1%, 54.0%), and lowest for DPW (39.7%, 27.8%) (p<0.001; Figure). Mean DSI and GSS were similar regardless of whether CC 2.0 criteria were met (DSI: 10.5±0.3 vs 10.1±0.3, p=0.35; GSS: 6.0±0.1 vs 5.7±0.1, p=0.16). However, symptom burden was higher if CC 3.0 criteria were met (DSI: 10.9±0.3 vs 10.0±0.3, p=0.048; GSS: 6.1±0.2 vs 5.7±0.1, p=0.064). Conclusions: Despite significant symptom burden, half of esophageal body CWA do not meet thresholds for a CC 2.0 diagnosis, and two-thirds do not meet thresholds for a CC 3.0 diagnosis. Although less sensitive in identification of CWA, CC v3.0 distinguishes CWA with highest symptom burden more precisely compared to CC v2.0.
Sa1338 Endolumenal Functional Lumen Imaging Probe (EndoFLIP) is an Accurate Intra-Operative Tool That Predicts Short-Term Outcome Following Pneumatic Dilatation (PD) for Idiopathic Achalasia Peter Wu, Michal Szczesniak, Philip I. Craig, Lennart Choo, Jeff Engelman, Jason M. Hui, Benjamin Terkasher, Ian J. Cook Background: Between 30-70% of patients with idiopathic achalasia require a "series" of 2 to 3 sequential PD to achieve a good clinical response. The need for multiple dilatation sessions is at least in part due to a lack of an intra-operative tool that predicts clinical outcome. Current predictive tools including timed barium swallow and manometry are only feasible in conscious patients after PD. Aims: To determine the optimal biomechanical criteria of Esophageal-Gastric junction (EGJ) compliance that predict clinical outcome in patients with idiopathic achalasia undergoing PD. Methods: We prospectively studied 23 patients (26 dilatations) with achalasia (Eckardt score >3) undergoing PD. Our practice is to use a 35mm (Rigiflex) balloon at index diltatation in all patients < 60yrs. EndoFLIP measurement of the EGJ was performed under sedation both before and immediately following PD. EGJ distensibility was defined as the ratio of the narrowest cross-sectional area and the corresponding intra-bag pressure during the distension (mm2/mmHg). Clinical response was defined as an Eckardt score £3 at 3-month follow-up. Results: We performed twelve 30mm; eleven 35mm and three 40mm dilatations. Short-term response rate was 83% (10/12) in newly diagnosed patients; 83% (5/6) in patients undergoing "salvage" PD for relapse after previous PD; and 40% (2/5) in patients undergoing salvage PD for relapse following prior Laparoscopic Heller's Myotomy (LHM). There were no perforations. Patients with prior LHM had higher EGJ distensibility than those without LHM (7.4 vs 0.8mm2/ mmHg, p=0.02) at 40ml distension. In responders, the EGJ distensibility increased by an average of 4.2 mm2/mmHg ±1.1 (p<0.01) at 40ml distension. In non-responders, PD caused no significant change in EGJ distensibility (-0.2 mm2/mmHg ±0.5, p=0.7) (Fig 1). ROC analysis showed a within subject EGJ distensibility changes of 1.7 mm2/mmHg after PD at 40ml distension predicts clinical success at the highest sensitivity (100%) and specificity (88.2%) with AUROC being 0.96 (p<0.001) (Fig 2). Conclusion: EndoFLIP is a sensitive intra-operative tool that predicts short-term outcome following PD with high accuracy. Its predictive value in medium-/long-term relapse is currently under evaluation. This technique may have the potential to dictate an immediate "step-up" in dilator size within a single endoscopy session, which could obviate the need for treatment delays and inherent costs.
Proportions of contraction wave abnormalities fulfilling diagnostic criteria for major or minor motor disorders with Chicago Classification v2.0 compared to v3.0. NE: nutcracker esophagus; SC: simultaneous contraction >20%; MPW/BW: multiple peaked waves and/or broad wave duration >5.7s; DPW: double peaked waves >15%; distal shift in amplitude: distal amplitude 150-179 mmHg.
AGA Abstracts
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Sa1337 Age-Related Impairment of EGJ Relaxation and Bolus Flow Time Charles Cock, Laura K. Besanko, Carly Burgstad, Richard Heddle, Robert J. Fraser, Taher Omari
AGA Abstracts
BACKGROUND: A novel measure of esophago-gastric junction bolus flow time (BFT) has been developed to compliment the integrated relaxation pressure as an indicator of EGJ function. BFT is reduced due to incomplete emptying in all subtypes of achalasia (Lin 2015); and due to esophageal stasis in cases with incomplete bolus transport (Lin 2014). An increased frequency of intra-esophageal stasis and incomplete EGJ emptying has been reported with advancing age. We performed high-resolution impedance manometry (HRIM) and compared BFT and other pressure and/or flow parameters between young and aged (>80yrs) healthy subjects. METHODS: Data from 15 young controls (9M, mean age 26±4 years) and 15 aged subjects (11M, 85±4 yrs) were compared. Data were acquired in the upright posture using a 3.2mm solid-state catheter (Solar GI system, MMS) with 25 pressure (1cm spacing) and 12 impedance segments (2cm intervals). Five swallows each of 5 ml liquid (L) and viscous (V) bolus were analysed for standard esophageal pressure topography measures, as well as impedance based bolus presence at the EGJ (BPT) and flow time (BFT). A P value <0.05 was considered significant. RESULTS: For both bolus consistencies, IRP4 was increased (L 12±2 vs. 6±1 mmHg; P=0.02 and V 15±2 vs. 7±1 mmHg; P=0.02) and BFT was reduced (L 1.7±0.3 vs. 3.8±0.2 sec; P<0.001 and V 1.9±0.3 vs 3.8±0.2 sec; P<0.001) in aged subjects compared to young. Aged subjects with poor bolus clearance had weaker esophageal contractility, which reached significance for viscous swallows (DCI 342±94 vs. 580±56 mmHg.cm-1.s-1; P=0.006) and a further reduced BFT (figure) due to reduced bolus presence (BPT) above the EGJ. The intrabolus pressures were not different between age groups. CONCLUSION: Reduced bolus flow through the EGJ can be quantified in asymptomatic individuals over eighty years. Bolus flow was reduced more than bolus presence in older subjects suggesting that both ineffective transport and increased EGJ resistance contribute to decreased BFT. Despite an elevated IRP, there was no increase in intrabolus pressures above the EGJ, due to weak esophageal propulsion. Improved understanding of the pathogenesis of impaired EGJ bolus transit in older individuals may provide a guide to treatment strategies for dysphagia in this group.
Data presented as mean ± SEM or as %.
Sa1336 Chicago Classification v 3.0 Identifies Esophageal Body Contraction Wave Abnormalities (CWA) More Precisely But Less Frequently Than v 2.0 on Esophageal High Resolution Manometry Amit Patel, Nitin Sainani, Dan Wang, Faiz Mirza, Satish Munigala, C. Prakash Gyawali Background: The Chicago Classification (CC) uses two software metrics, distal contractile integral (DCI) and distal latency (DL), to address vigor and timing of esophageal body contraction in defining major and minor esophageal motor disorders. However, contraction wave abnormalities (CWA) with low contraction vigor and normal DL may not make CC criteria for an esophageal motor diagnosis. We evaluated the performance of CC v2.0 and 3.0 criteria in a cohort of patients with CWA. Methods: All patients undergoing esophageal HRM over a 6-year period (2006-2011) were eligible for inclusion. Patients with absent contractility in the esophageal body were excluded. The following CWA were evaluated: mean averaged amplitudes ‡180 mmHg (nutcracker esophagus, NE), >20% simultaneous contraction (SC) with contraction front velocity >6.8 cm/s, multiple peaked waves with or without broad contraction wave >5.7 s (MPW/BW), double peaked waves >15% (DPW), and distal shift in amplitudes (150-179 mmHg). A comparison group consisted of normal esophageal body on HRM without CWA. All HRM studies were re-evaluated using Manoview ESO 3.0, and CC diagnosis recorded according to v 2.0 and 3.0. Patients completed a questionnaire from which dominant symptom intensity (DSI, product of symptom severity and frequency measured on 5-point Likert scales), and global symptom severity (GSS, from 10-cm visual analog scales) were acquired. Symptom burden using DSI and GSS, and proportions of patients meeting CC criteria with v2.0 and 3.0 were compared within CWA cohorts. Results: Over the study period, 884 (33.6%, 57.7±0.5 yr, 67.1% F) of a total of 2634 HRM studies had CWA while 959 (36.4%, 51.6±0.5 yr, 63.5% F) had normal studies. Within CWA, 113 had NE, 113 SC, 131 MPW/BW, 421 DPW, and 106 had distal shift in amplitudes. Proportions with dominant heartburn or dysphagia, mean DSI, and mean GSS were similar across CWA categories (p>0.06); DSI was numerically lower with normal studies (p=0.16). 472 (53.4%) and 326 (36.9%) of CWA met CC v2.0 and 3.0 criteria, respectively, for a major or minor motor diagnosis. Likelihood for CC diagnosis was highest for NE (89.4%, 67.3% with CC v2.0 and 3.0, respectively) and SC (76.1%, 54.0%), and lowest for DPW (39.7%, 27.8%) (p<0.001; Figure). Mean DSI and GSS were similar regardless of whether CC 2.0 criteria were met (DSI: 10.5±0.3 vs 10.1±0.3, p=0.35; GSS: 6.0±0.1 vs 5.7±0.1, p=0.16). However, symptom burden was higher if CC 3.0 criteria were met (DSI: 10.9±0.3 vs 10.0±0.3, p=0.048; GSS: 6.1±0.2 vs 5.7±0.1, p=0.064). Conclusions: Despite significant symptom burden, half of esophageal body CWA do not meet thresholds for a CC 2.0 diagnosis, and two-thirds do not meet thresholds for a CC 3.0 diagnosis. Although less sensitive in identification of CWA, CC v3.0 distinguishes CWA with highest symptom burden more precisely compared to CC v2.0.
Sa1338 Endolumenal Functional Lumen Imaging Probe (EndoFLIP) is an Accurate Intra-Operative Tool That Predicts Short-Term Outcome Following Pneumatic Dilatation (PD) for Idiopathic Achalasia Peter Wu, Michal Szczesniak, Philip I. Craig, Lennart Choo, Jeff Engelman, Jason M. Hui, Benjamin Terkasher, Ian J. Cook Background: Between 30-70% of patients with idiopathic achalasia require a "series" of 2 to 3 sequential PD to achieve a good clinical response. The need for multiple dilatation sessions is at least in part due to a lack of an intra-operative tool that predicts clinical outcome. Current predictive tools including timed barium swallow and manometry are only feasible in conscious patients after PD. Aims: To determine the optimal biomechanical criteria of Esophageal-Gastric junction (EGJ) compliance that predict clinical outcome in patients with idiopathic achalasia undergoing PD. Methods: We prospectively studied 23 patients (26 dilatations) with achalasia (Eckardt score >3) undergoing PD. Our practice is to use a 35mm (Rigiflex) balloon at index diltatation in all patients < 60yrs. EndoFLIP measurement of the EGJ was performed under sedation both before and immediately following PD. EGJ distensibility was defined as the ratio of the narrowest cross-sectional area and the corresponding intra-bag pressure during the distension (mm2/mmHg). Clinical response was defined as an Eckardt score £3 at 3-month follow-up. Results: We performed twelve 30mm; eleven 35mm and three 40mm dilatations. Short-term response rate was 83% (10/12) in newly diagnosed patients; 83% (5/6) in patients undergoing "salvage" PD for relapse after previous PD; and 40% (2/5) in patients undergoing salvage PD for relapse following prior Laparoscopic Heller's Myotomy (LHM). There were no perforations. Patients with prior LHM had higher EGJ distensibility than those without LHM (7.4 vs 0.8mm2/ mmHg, p=0.02) at 40ml distension. In responders, the EGJ distensibility increased by an average of 4.2 mm2/mmHg ±1.1 (p<0.01) at 40ml distension. In non-responders, PD caused no significant change in EGJ distensibility (-0.2 mm2/mmHg ±0.5, p=0.7) (Fig 1). ROC analysis showed a within subject EGJ distensibility changes of 1.7 mm2/mmHg after PD at 40ml distension predicts clinical success at the highest sensitivity (100%) and specificity (88.2%) with AUROC being 0.96 (p<0.001) (Fig 2). Conclusion: EndoFLIP is a sensitive intra-operative tool that predicts short-term outcome following PD with high accuracy. Its predictive value in medium-/long-term relapse is currently under evaluation. This technique may have the potential to dictate an immediate "step-up" in dilator size within a single endoscopy session, which could obviate the need for treatment delays and inherent costs.
Proportions of contraction wave abnormalities fulfilling diagnostic criteria for major or minor motor disorders with Chicago Classification v2.0 compared to v3.0. NE: nutcracker esophagus; SC: simultaneous contraction >20%; MPW/BW: multiple peaked waves and/or broad wave duration >5.7s; DPW: double peaked waves >15%; distal shift in amplitude: distal amplitude 150-179 mmHg.
AGA Abstracts
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