- Email: [email protected]
Sa1341 Post-Reflux Swallow-Induced Peristaltic Wave Index, Esophageal Intraluminal Baseline Impedance and GERD Symptoms
AGA Abstracts
Table 1. The number of cases for each EGJ morphology type and GEFV grade
Table 2. The prevalence of gastroesophageal reflux disease
Fig 1. Changes in EGJ distensibility after PD.
* p<0.01 against the low risk group
Sa1340 Causative Effect of Gastroesophageal Reflux on Supragastric Belching (SGB): Reactive and Proactive SGB Jay Patel, Joseph A. Roscamp, Ismail Miah, Terence Wong, Jafar Jafari Background: An SGB is characterised by rapid antegrade and retrograde flow of air in the esophagus that does not reach the stomach*. Whilst proactive SGB is a behavioural phenomenon, reactive SGB occurs in response to a particular stimulus. Currently treatment for SGB is behavioural therapy however this may not be the most appropriate treatment for patients with reactive SGB. Aims: We aimed to ascertain prevalence of proactive versus reactive SGB in response to a certain pathological stimulus i.e. GER. Methods: Database of the Esophageal Physiology Laboratory at Guy's Hospital London were retrospectively searched (November 2014 - present) for patients diagnosed with SGB (>13 SGBs within 24hrs). The 24-hour pH-impedance studies were analysed to differentiate proactive SGB from reactive (proactive SGB being an SGB without preceding reflux event (or preceding event lasting < 1 second), and reactive SGB being an SGB with preceding reflux event (> 1 second)). A patient was then labelled as having predominantly reactive SGB (PR-SGB) if >60% of their SGB was reactive and having predominantly proactive SGB (PP-SGB) if >60% of their SGB was proactive. Reflux Diseases Questionnaire (RDQ) score was obtained for all patients. P value <0.05 was considered significant. Results: 28 patients identified for this study (14 males (M), 14 females (F), mean age 51 [27-75]). 82% of patients had PP-SGB events, 11% PR-SGB and 7% had the same number of proactive and reactive SGB. The most common symptoms in patients with PR-SGB were: heartburn 66.6%, belching 66.6% and throat burning sensation 66.6% and, in patients with PP- SGB: belching 68%, heartburn 39% and regurgitation 21%. In total, in all 28 patients, proactive SGBs accounted for 1124 and reactive 216 of SGB events (19.22% of all SGBs being reactive). The 3 patients with PRSGB had an average RDQ of 3.53, whilst the average RDQ for the patients with PP- SGB was significantly lower 2.36 (p = 0.00004). There was 1 patient with 100% proactive SGB and no patient with purely reactive SGB. The median presentation of reactive SGB was 15.38%. Conclusion: Treating GERD may resolve SGB in a small group of patients and ameliorate potential psychological stress caused by a behavioural therapy referral. Whether the remaining SGB events are purely behavioural or in reaction to other types of stimuli other than GER requires further investigation. Having a high RDQ score may help in identifying patients with PR-SGB. References: * Bredenoord, A. J. et al. (2004) Aerophagia, gastric, and supragastric belching: a study using intraluminal electrical impedance monitoring. Gut. [Online] 53 (11), 1561-1565.
Fig 2. ROC of the EGJ distensibility at predicting clinical response after PD.
Sa1339 Assessment of Esophago-Gastric Junction Morphology and Barrier Function by Combined High Resolution Manometry and Endoscopy for Evaluating a Risk of Gastroesophageal Reflux Disease Shiko Kuribayashi, Hiroko Hosaka, Akiyo Kawada, Junichi Akiyama, Yasumori Fukai, Takeshi Kobayashi, Tetsuo Nakayama, Taku Tomizawa, Hidetoshi Yasuoka, Tatsuya Ohyama, Masafumi Mizuide, Norio Horiguchi, Yuichi Yamazaki, Yasuyuki Shimoyama, Ken Sato, Satoru Kakizaki, Osamu Kawamura, Masanobu Yamada, Motoyasu Kusano Background: Esophago-gastric junction (EGJ) morphology, as assessed by high resolution manometry (HRM) to distinguish the lower esophageal sphincter from the crural diaphragm, has been shown to be an important factor of EGJ barrier function in gastroesophageal reflux (GER). The gastroesophageal flap valve (GEFV), as evaluated by esophagogastroduodenoscopy (EGD), has also been reported to be related to the presence of hiatal hernia and the occurrence of GER. EGJ morphology type II or III and GEFV grade III or IV are considered as risk factors for GER. The aim of the study was to clarify the association between EGJ morphology and GEFV, and to assess the efficacy of evaluating this association to determine the risk of gastroesophageal reflux disease (GERD). Material and Methods: A total 307 consecutive cases in which esophageal HRM was performed at Gunma University Hospital were assessed retrospectively. Patients with achalasia, patients who did not undergo EGD at our hospital, and patients whose EGJ morphology could not be assessed were excluded. EGJ morphology was evaluated during HRM in the supine position. GEFV was evaluated by retroflex view of endoscopic images from the stomach. Patients with esophagitis or who were taking anti-acids (proton pump inhibitor or histamine receptor 2 antagonist) were considered as having GERD. Results: A total 215 patients were evaluated. The number of patients with each EGJ morphology type and GEFV grade are shown in Table 1. The prevalence of EGJ morphology type II or III was 34/215 (16%), while the prevalence of GEFV grade III or IV was 94/215 (44%). There was a significant difference in the prevalence of a risk of GER between EGJ morphology and GEFV (p<0.01). The prevalence of GERD in patients with EGJ morphology type II or III and GEFV grade III or IV (high risk group) was significantly higher than those with EGJ morphology type I and GEFV grade I or II (low risk group) (88% vs. 39%, respectively, p<0.01, Table 2). In addition, the prevalence of GERD in patients with EGJ morphology type I and GEFV grade III or IV (only GEFV risk group) was also significantly higher than the low risk group (74% vs. 39%, respectively, p<0.01). The prevalence of GERD in patients with EGJ morphology type II or III and GEFV grade I or II (only EGJ morphology risk group) was higher than the low risk group, but the difference did not reach statistical significance, likely due to the small sample size (67% vs. 39%, respectively, p>0.05). Conclusions: The nature of EGJ morphology can be assessed by HRM, and barrier function against air insufflation into the stomach can be assessed by EGD. Although many factors such as transient lower esophageal relaxation and esophageal motility are related to the pathophysiology of GERD, the combination assessment of EGJ morphology and GEFV may be useful for evaluating the risk of GERD.
Sa1341 Post-Reflux Swallow-Induced Peristaltic Wave Index, Esophageal Intraluminal Baseline Impedance and GERD Symptoms Joon Seong Lee, Young Kyu Cho, Tae Hee Lee, Su Jin Hong, Jae Pil Han, Jun-Hyung Cho, Seong Ran Jeon, Hyun Gun Kim, Jin-Oh Kim Background/Aims Post-reflux swallow-induced peristaltic wave (PSPW) index and esophageal intraluminal baseline impedance (BI) are known as novel impedance parameters evaluating esophageal chemical clearance and mucosal integrity. These are improving diagnosis of GERD. However, their relationships with reflux symptoms are not known. We aimed to evaluate the correlation of between PSPW index, baseline impedance and GERD symptoms. Methods We performed a retrospective review of impedance-pH tracings from patients with suspected GERD. Reflux symptoms including heartburn and dysphagia were also reviewed from checklist with ordinal scales of severity (0-4) and frequency (0-4) in each symptom before impedance-pH monitoring. Degree of each symptoms were calculated from add of severity and frequency scales. PSPW index was defined as the number of refluxes followed within 30 s by a swallow-induced peristaltic wave divided by the number of total refluxes. BI was measured in six lesions of esophagus from proximal (z1) to distal (z6). We used bivariate (Pearson) correlation to analysis relationship between PSPW index, BI and degree of each symptoms. Results One-hundred-forty-three patients were analyzed for impedancepH monitoring. PSPW index resulted significantly lower in patients who has heartburn and correlated with degree of heartburn (r = -0.186; p<0.05). On the contrary, PSPW index was not significantly correlated with degree of dysphagia (r = -0.091; p=0.168). Distal BI was not significantly correlated with heartburn, but degree of dysphagia (z3, r = -0.328; z4, r = -0.361; z5, r = -0.316; z6, r = -0.273; p<0.05). Other symptoms such as acid regurgitation, chest pain, hoarseness, and cough were not related with distal BI. Conclusions Symptoms of heartburn is inversely correlated with PSPW index, but not for dysphagia. However,
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heartburn is not correlated with BI, but dysphagia is inversely correlated with distal BI. These findings suggest that delayed chemical clearance of esophagus may induce heartburn, but not related with dysphagia and lack of esophageal mocosa integrity may related with dysphagia.
Sa1342 Comparison Between Chicago III and Chicago II Classification in Diagnosing Esophageal Motility Disorder Ahmed Alsaegh, Andrew Ming Liang Ong, Yu Tien Wang Abstract OBJECTIVE: The Chicago Classification for esophageal motility disorders was recently updated. The clinical implication of this revision is unknown. The purpose of this study was to assess the potential clinical impact of changes in High Resolution Manometry (HRM) diagnoses based on this new classification. PATIENT AND METHODS: High Resolution Manometry (HRM) results of all patients performed at Singapore General Hospital between January 2012 and December 2014 were reviewed using both ChicagoII and Chicago III diagnostic criterion. The results were compared to patients' symptom and clinical outcomes. RESULTS: 148 HRM were performed and all were analysed. The Diagnoses rate of esophageal motility disorder with Chicago III was 54%(80/148), and 62.1%(92/148) with Chicago II. Overall 117 (79%) patients met same diagnoses in both classifications. Compared to Chicago II, Chicago III detected 3 additional achalasia (18.2% Vs 20.3%), 4 fewer EGJ outflow obstruction (19.6% Vs 16.9%), 5 fewer Major motility disorder(8.8% Vs 5.4%), and 6 fewer minor motility disorder(23% Vs 11.5%). All of the three newly diagnosed achalasia were symptomatic and had previous esophageal dilation, and all four patients diagnosed with outflow obstructions by Chicago II which were reclassified as normal in Chicago III had no symptoms, endoscopic or radiological evidence of distal esophageal obstruction. CONCLUSIONS: There is a good concordance between Chicago II and Chicago III classification in diagnosing esophageal motility disorder. However, ChicagoIII may increase sensitivity to detect symptomatic achalasia while reducing "false positive" diagnosis of Functional EGJ obstruction in asymptomatic patients with no evidence of obstruction.
Dynamic changes of esophageal length along with EGJ pressure alterations before and after CCK administration in achalasia patients (N=19). Esophageal length was measured during expiration to the middle of lower esophageal sphincter (LES), and during inspiration to the peak of crural diaphragmatic (CD) contractile pinch presented as mean and standard error of mean. * p<0.05 and # p<0.001 compared to baseline.
Sa1344 Esophageal Outflow Resistance in Chronic Opiate Use Responds to Amyl Nitrite Similar to Idiopathic Achalasia Arash Babaei, Reza Shaker, Amar Dodda, Aniko Szabo, Benson T. Massey Background: The Chicago classification of esophageal motility includes patients with esophageal outflow resistance (EOR), who don't meet the diagnostic criteria for achalasia. While the etiology of EOR in many cases remains unknown, chronic opioid intake has been associated with elevated integrated relaxation pressure (IRP) and shorter distal latency (DL), in extreme cases having the appearance of achalasia. It is uncertain whether patients with chronic opioid use have only impaired deglutitive LES relaxation or could have other factors contributing to EOR, such as changes in crural diaphragm contraction. The nitric oxide donor amyl nitrate (AN) profoundly inhibits smooth muscle tone, making it possible to distinguish EOR due to impaired lower esophageal sphincter (LES) relaxation from other etiologies. This is seen in achalasia, where we have also observed a striking rebound LES contraction after recovery from the AN induced inhibition. The LES response of patients on chronic opioids to AN is unknown. Aim: To characterize changes in EGJ pressure following AN inhalation in EOR patients on chronic opioid medications and compare these to similar findings in achalasia patients. Method: We identified all patients in our laboratory receiving AN during their esophageal high-resolution manometry to evaluate EOR. Patients fulfilling EOR criteria, on chronic opioids and without operative intervention were identified. Findings were compared to an established group of achalasia patients (N=22) and normal peristalsis patients (N=10). The former group has additional EGJ relaxation with AN beyond that observed with supine wet swallows (AN-induced relaxation gain). The latter group does not show additional AN-induced relaxation. Results: Ten EOR patients (5F, 58 + 11 years) were identified who were on chronic scheduled opioid medications. Total daily morphine equivalent dose of these patients was 140 + 130 mg. Opioid induced EOR patients were sensitive to AN (Figure 1) and showed a relaxation gain of 10 + 6 mmHg beyond nadir EGJ pressures during supine wet swallows (Figure 2). This was significantly higher than controls and similar to achalasia patients. Likewise, rebound EGJ pressures following end of AN effect were higher than controls in chronic opioid patients but of less magnitude than seen in achalasia. Conclusions: EOR in chronic opioid use appears to result from impaired deglutitive LES relaxation, as this corrects with AN administration. While these patients seem to have less vigorous relaxation/rebound responses to AN than those with idiopathic achalasia, there is considerable overlap. Thus, AN challenge cannot reliably distinguish idiopathic achalasia from chronic opiate EOR.
Sa1343 Crural Diaphragmatic Separation From Lower Esophageal Sphincter (LES) by Pharmacologic Esophageal Shortening In Achalasia Patients Uncovers Inspiratory LES Relaxation Arash Babaei, Reza Shaker, Benson T. Massey Background: Mechanical stretching of the lower esophageal sphincter in animal models results in lower esophageal sphincter (LES) relaxation. A similar stretch might occur during diaphragmatic descent during inspiration, because the LES is attached to diaphragmatic hiatus via the phrenoesophageal ligament. However, inspiratory crural diaphragm (CD) contraction would normally obscure any associated LES relaxation during luminal esophagogastric junction (EGJ) pressure recording. We have observed in achalasia patients that cholecystokinin octapeptide (CCK) causes a striking esophageal shortening, resulting in a transient separation of LES and CD. This separation allows inspiratory changes in LES pressure to be observed independent of the effects of crural contraction. Aim: To investigate respiratory phasic pressure changes of LES before and after pharmacologic induced esophageal shortening in achalasia patients. Method: We identified 19 achalasia patients without a hiatal hernia (12 Chicago type II/7 type III) who received CCK (40 ng/kg intravenously) during their esophageal manometry. Esophageal length was measured using two methods; 1- Distance from the highest pressure point of upper esophageal sphincter (UES) high pressure zone during expiration to the middle of end-expiratory esophagogastric junction high pressure zone (corresponding to LES), and 2- Distance from the UES to the peak inspiratory EGJ pressure (corresponding to CD). Esophageal length and corresponding EGJ respiratory pressure oscillations were recorded before and after pharmacologic challenge. Results: At baseline, achalasia patients without hiatal hernia demonstrated inspiratory augmentation in EGJ pressure, due to the superimposed effects of CD contractions on LES. During CCK induced esophageal shortening all patients showed visible separation of LES and CD pinch (Figure 1). Moreover CCK resulted in reversal of inspiratory EGJ pressure augmentation pattern and there was a clear rhythmic attenuation in LES pressure that was 64% of baseline and 12% of CCK-induced LES contraction (Figure 2). This phenomenon was seen in both type II and III achalasia patients. Conclusions: In achalasia patients, CCK induced esophageal shortening produces a transient separation of the LES from the CD allowing assessment of changes in LES pressure independent from effects of diaphragmatic contraction. This model uncovers phasic inspiratory falls in LES pressure during respiratory excursions of the crural diaphragm, which would tend to stretch the LES. The fact that this inhibition occurs in patients who have compromised nitrergic LES relaxation may suggest that other mediators may contribute to this effect in humans.
Representative topographic pressure plot before (left) and after amyl nitrite (right) administration in a chronic opioid patient. As shown at baseline wet swallow (WS) is associated with elevated residual EGJ pressue and intrabolus pressure along with premature esophageal contraction. AN results in complete abolition of residual esophagogastric junction pressure. Lower esophageal sphincter displays a rebound contractile response during recovery period similar to achalasia patients. This patient noted onset of dysphagia following opioid treatment (total daily morphine equivalent dose of 400 mg) for her metastatic breast cancer.
Representative topographic pressure plots before and after cholecystokinin octapeptide (CCK) administration in a type III achalasia patient. Esophagogastric Junction (EGJ) electronic sleeve (eSleeve), esophageal and gastric tracings have been superimposed on the color plot in orange, green and red color respectively. CCK results in a biphasic LES response (relaxation then contraction) in this patient. Please note reversal of inspiratory EGJ pressure augmentation at baseline, to inspiratory EGJ pressure attenuation during recovery period.
AGA Abstracts
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Table 1. The number of cases for each EGJ morphology type and GEFV grade
Table 2. The prevalence of gastroesophageal reflux disease
Fig 1. Changes in EGJ distensibility after PD.
* p<0.01 against the low risk group
Sa1340 Causative Effect of Gastroesophageal Reflux on Supragastric Belching (SGB): Reactive and Proactive SGB Jay Patel, Joseph A. Roscamp, Ismail Miah, Terence Wong, Jafar Jafari Background: An SGB is characterised by rapid antegrade and retrograde flow of air in the esophagus that does not reach the stomach*. Whilst proactive SGB is a behavioural phenomenon, reactive SGB occurs in response to a particular stimulus. Currently treatment for SGB is behavioural therapy however this may not be the most appropriate treatment for patients with reactive SGB. Aims: We aimed to ascertain prevalence of proactive versus reactive SGB in response to a certain pathological stimulus i.e. GER. Methods: Database of the Esophageal Physiology Laboratory at Guy's Hospital London were retrospectively searched (November 2014 - present) for patients diagnosed with SGB (>13 SGBs within 24hrs). The 24-hour pH-impedance studies were analysed to differentiate proactive SGB from reactive (proactive SGB being an SGB without preceding reflux event (or preceding event lasting < 1 second), and reactive SGB being an SGB with preceding reflux event (> 1 second)). A patient was then labelled as having predominantly reactive SGB (PR-SGB) if >60% of their SGB was reactive and having predominantly proactive SGB (PP-SGB) if >60% of their SGB was proactive. Reflux Diseases Questionnaire (RDQ) score was obtained for all patients. P value <0.05 was considered significant. Results: 28 patients identified for this study (14 males (M), 14 females (F), mean age 51 [27-75]). 82% of patients had PP-SGB events, 11% PR-SGB and 7% had the same number of proactive and reactive SGB. The most common symptoms in patients with PR-SGB were: heartburn 66.6%, belching 66.6% and throat burning sensation 66.6% and, in patients with PP- SGB: belching 68%, heartburn 39% and regurgitation 21%. In total, in all 28 patients, proactive SGBs accounted for 1124 and reactive 216 of SGB events (19.22% of all SGBs being reactive). The 3 patients with PRSGB had an average RDQ of 3.53, whilst the average RDQ for the patients with PP- SGB was significantly lower 2.36 (p = 0.00004). There was 1 patient with 100% proactive SGB and no patient with purely reactive SGB. The median presentation of reactive SGB was 15.38%. Conclusion: Treating GERD may resolve SGB in a small group of patients and ameliorate potential psychological stress caused by a behavioural therapy referral. Whether the remaining SGB events are purely behavioural or in reaction to other types of stimuli other than GER requires further investigation. Having a high RDQ score may help in identifying patients with PR-SGB. References: * Bredenoord, A. J. et al. (2004) Aerophagia, gastric, and supragastric belching: a study using intraluminal electrical impedance monitoring. Gut. [Online] 53 (11), 1561-1565.
Fig 2. ROC of the EGJ distensibility at predicting clinical response after PD.
Sa1339 Assessment of Esophago-Gastric Junction Morphology and Barrier Function by Combined High Resolution Manometry and Endoscopy for Evaluating a Risk of Gastroesophageal Reflux Disease Shiko Kuribayashi, Hiroko Hosaka, Akiyo Kawada, Junichi Akiyama, Yasumori Fukai, Takeshi Kobayashi, Tetsuo Nakayama, Taku Tomizawa, Hidetoshi Yasuoka, Tatsuya Ohyama, Masafumi Mizuide, Norio Horiguchi, Yuichi Yamazaki, Yasuyuki Shimoyama, Ken Sato, Satoru Kakizaki, Osamu Kawamura, Masanobu Yamada, Motoyasu Kusano Background: Esophago-gastric junction (EGJ) morphology, as assessed by high resolution manometry (HRM) to distinguish the lower esophageal sphincter from the crural diaphragm, has been shown to be an important factor of EGJ barrier function in gastroesophageal reflux (GER). The gastroesophageal flap valve (GEFV), as evaluated by esophagogastroduodenoscopy (EGD), has also been reported to be related to the presence of hiatal hernia and the occurrence of GER. EGJ morphology type II or III and GEFV grade III or IV are considered as risk factors for GER. The aim of the study was to clarify the association between EGJ morphology and GEFV, and to assess the efficacy of evaluating this association to determine the risk of gastroesophageal reflux disease (GERD). Material and Methods: A total 307 consecutive cases in which esophageal HRM was performed at Gunma University Hospital were assessed retrospectively. Patients with achalasia, patients who did not undergo EGD at our hospital, and patients whose EGJ morphology could not be assessed were excluded. EGJ morphology was evaluated during HRM in the supine position. GEFV was evaluated by retroflex view of endoscopic images from the stomach. Patients with esophagitis or who were taking anti-acids (proton pump inhibitor or histamine receptor 2 antagonist) were considered as having GERD. Results: A total 215 patients were evaluated. The number of patients with each EGJ morphology type and GEFV grade are shown in Table 1. The prevalence of EGJ morphology type II or III was 34/215 (16%), while the prevalence of GEFV grade III or IV was 94/215 (44%). There was a significant difference in the prevalence of a risk of GER between EGJ morphology and GEFV (p<0.01). The prevalence of GERD in patients with EGJ morphology type II or III and GEFV grade III or IV (high risk group) was significantly higher than those with EGJ morphology type I and GEFV grade I or II (low risk group) (88% vs. 39%, respectively, p<0.01, Table 2). In addition, the prevalence of GERD in patients with EGJ morphology type I and GEFV grade III or IV (only GEFV risk group) was also significantly higher than the low risk group (74% vs. 39%, respectively, p<0.01). The prevalence of GERD in patients with EGJ morphology type II or III and GEFV grade I or II (only EGJ morphology risk group) was higher than the low risk group, but the difference did not reach statistical significance, likely due to the small sample size (67% vs. 39%, respectively, p>0.05). Conclusions: The nature of EGJ morphology can be assessed by HRM, and barrier function against air insufflation into the stomach can be assessed by EGD. Although many factors such as transient lower esophageal relaxation and esophageal motility are related to the pathophysiology of GERD, the combination assessment of EGJ morphology and GEFV may be useful for evaluating the risk of GERD.
Sa1341 Post-Reflux Swallow-Induced Peristaltic Wave Index, Esophageal Intraluminal Baseline Impedance and GERD Symptoms Joon Seong Lee, Young Kyu Cho, Tae Hee Lee, Su Jin Hong, Jae Pil Han, Jun-Hyung Cho, Seong Ran Jeon, Hyun Gun Kim, Jin-Oh Kim Background/Aims Post-reflux swallow-induced peristaltic wave (PSPW) index and esophageal intraluminal baseline impedance (BI) are known as novel impedance parameters evaluating esophageal chemical clearance and mucosal integrity. These are improving diagnosis of GERD. However, their relationships with reflux symptoms are not known. We aimed to evaluate the correlation of between PSPW index, baseline impedance and GERD symptoms. Methods We performed a retrospective review of impedance-pH tracings from patients with suspected GERD. Reflux symptoms including heartburn and dysphagia were also reviewed from checklist with ordinal scales of severity (0-4) and frequency (0-4) in each symptom before impedance-pH monitoring. Degree of each symptoms were calculated from add of severity and frequency scales. PSPW index was defined as the number of refluxes followed within 30 s by a swallow-induced peristaltic wave divided by the number of total refluxes. BI was measured in six lesions of esophagus from proximal (z1) to distal (z6). We used bivariate (Pearson) correlation to analysis relationship between PSPW index, BI and degree of each symptoms. Results One-hundred-forty-three patients were analyzed for impedancepH monitoring. PSPW index resulted significantly lower in patients who has heartburn and correlated with degree of heartburn (r = -0.186; p<0.05). On the contrary, PSPW index was not significantly correlated with degree of dysphagia (r = -0.091; p=0.168). Distal BI was not significantly correlated with heartburn, but degree of dysphagia (z3, r = -0.328; z4, r = -0.361; z5, r = -0.316; z6, r = -0.273; p<0.05). Other symptoms such as acid regurgitation, chest pain, hoarseness, and cough were not related with distal BI. Conclusions Symptoms of heartburn is inversely correlated with PSPW index, but not for dysphagia. However,
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heartburn is not correlated with BI, but dysphagia is inversely correlated with distal BI. These findings suggest that delayed chemical clearance of esophagus may induce heartburn, but not related with dysphagia and lack of esophageal mocosa integrity may related with dysphagia.
Sa1342 Comparison Between Chicago III and Chicago II Classification in Diagnosing Esophageal Motility Disorder Ahmed Alsaegh, Andrew Ming Liang Ong, Yu Tien Wang Abstract OBJECTIVE: The Chicago Classification for esophageal motility disorders was recently updated. The clinical implication of this revision is unknown. The purpose of this study was to assess the potential clinical impact of changes in High Resolution Manometry (HRM) diagnoses based on this new classification. PATIENT AND METHODS: High Resolution Manometry (HRM) results of all patients performed at Singapore General Hospital between January 2012 and December 2014 were reviewed using both ChicagoII and Chicago III diagnostic criterion. The results were compared to patients' symptom and clinical outcomes. RESULTS: 148 HRM were performed and all were analysed. The Diagnoses rate of esophageal motility disorder with Chicago III was 54%(80/148), and 62.1%(92/148) with Chicago II. Overall 117 (79%) patients met same diagnoses in both classifications. Compared to Chicago II, Chicago III detected 3 additional achalasia (18.2% Vs 20.3%), 4 fewer EGJ outflow obstruction (19.6% Vs 16.9%), 5 fewer Major motility disorder(8.8% Vs 5.4%), and 6 fewer minor motility disorder(23% Vs 11.5%). All of the three newly diagnosed achalasia were symptomatic and had previous esophageal dilation, and all four patients diagnosed with outflow obstructions by Chicago II which were reclassified as normal in Chicago III had no symptoms, endoscopic or radiological evidence of distal esophageal obstruction. CONCLUSIONS: There is a good concordance between Chicago II and Chicago III classification in diagnosing esophageal motility disorder. However, ChicagoIII may increase sensitivity to detect symptomatic achalasia while reducing "false positive" diagnosis of Functional EGJ obstruction in asymptomatic patients with no evidence of obstruction.
Dynamic changes of esophageal length along with EGJ pressure alterations before and after CCK administration in achalasia patients (N=19). Esophageal length was measured during expiration to the middle of lower esophageal sphincter (LES), and during inspiration to the peak of crural diaphragmatic (CD) contractile pinch presented as mean and standard error of mean. * p<0.05 and # p<0.001 compared to baseline.
Sa1344 Esophageal Outflow Resistance in Chronic Opiate Use Responds to Amyl Nitrite Similar to Idiopathic Achalasia Arash Babaei, Reza Shaker, Amar Dodda, Aniko Szabo, Benson T. Massey Background: The Chicago classification of esophageal motility includes patients with esophageal outflow resistance (EOR), who don't meet the diagnostic criteria for achalasia. While the etiology of EOR in many cases remains unknown, chronic opioid intake has been associated with elevated integrated relaxation pressure (IRP) and shorter distal latency (DL), in extreme cases having the appearance of achalasia. It is uncertain whether patients with chronic opioid use have only impaired deglutitive LES relaxation or could have other factors contributing to EOR, such as changes in crural diaphragm contraction. The nitric oxide donor amyl nitrate (AN) profoundly inhibits smooth muscle tone, making it possible to distinguish EOR due to impaired lower esophageal sphincter (LES) relaxation from other etiologies. This is seen in achalasia, where we have also observed a striking rebound LES contraction after recovery from the AN induced inhibition. The LES response of patients on chronic opioids to AN is unknown. Aim: To characterize changes in EGJ pressure following AN inhalation in EOR patients on chronic opioid medications and compare these to similar findings in achalasia patients. Method: We identified all patients in our laboratory receiving AN during their esophageal high-resolution manometry to evaluate EOR. Patients fulfilling EOR criteria, on chronic opioids and without operative intervention were identified. Findings were compared to an established group of achalasia patients (N=22) and normal peristalsis patients (N=10). The former group has additional EGJ relaxation with AN beyond that observed with supine wet swallows (AN-induced relaxation gain). The latter group does not show additional AN-induced relaxation. Results: Ten EOR patients (5F, 58 + 11 years) were identified who were on chronic scheduled opioid medications. Total daily morphine equivalent dose of these patients was 140 + 130 mg. Opioid induced EOR patients were sensitive to AN (Figure 1) and showed a relaxation gain of 10 + 6 mmHg beyond nadir EGJ pressures during supine wet swallows (Figure 2). This was significantly higher than controls and similar to achalasia patients. Likewise, rebound EGJ pressures following end of AN effect were higher than controls in chronic opioid patients but of less magnitude than seen in achalasia. Conclusions: EOR in chronic opioid use appears to result from impaired deglutitive LES relaxation, as this corrects with AN administration. While these patients seem to have less vigorous relaxation/rebound responses to AN than those with idiopathic achalasia, there is considerable overlap. Thus, AN challenge cannot reliably distinguish idiopathic achalasia from chronic opiate EOR.
Sa1343 Crural Diaphragmatic Separation From Lower Esophageal Sphincter (LES) by Pharmacologic Esophageal Shortening In Achalasia Patients Uncovers Inspiratory LES Relaxation Arash Babaei, Reza Shaker, Benson T. Massey Background: Mechanical stretching of the lower esophageal sphincter in animal models results in lower esophageal sphincter (LES) relaxation. A similar stretch might occur during diaphragmatic descent during inspiration, because the LES is attached to diaphragmatic hiatus via the phrenoesophageal ligament. However, inspiratory crural diaphragm (CD) contraction would normally obscure any associated LES relaxation during luminal esophagogastric junction (EGJ) pressure recording. We have observed in achalasia patients that cholecystokinin octapeptide (CCK) causes a striking esophageal shortening, resulting in a transient separation of LES and CD. This separation allows inspiratory changes in LES pressure to be observed independent of the effects of crural contraction. Aim: To investigate respiratory phasic pressure changes of LES before and after pharmacologic induced esophageal shortening in achalasia patients. Method: We identified 19 achalasia patients without a hiatal hernia (12 Chicago type II/7 type III) who received CCK (40 ng/kg intravenously) during their esophageal manometry. Esophageal length was measured using two methods; 1- Distance from the highest pressure point of upper esophageal sphincter (UES) high pressure zone during expiration to the middle of end-expiratory esophagogastric junction high pressure zone (corresponding to LES), and 2- Distance from the UES to the peak inspiratory EGJ pressure (corresponding to CD). Esophageal length and corresponding EGJ respiratory pressure oscillations were recorded before and after pharmacologic challenge. Results: At baseline, achalasia patients without hiatal hernia demonstrated inspiratory augmentation in EGJ pressure, due to the superimposed effects of CD contractions on LES. During CCK induced esophageal shortening all patients showed visible separation of LES and CD pinch (Figure 1). Moreover CCK resulted in reversal of inspiratory EGJ pressure augmentation pattern and there was a clear rhythmic attenuation in LES pressure that was 64% of baseline and 12% of CCK-induced LES contraction (Figure 2). This phenomenon was seen in both type II and III achalasia patients. Conclusions: In achalasia patients, CCK induced esophageal shortening produces a transient separation of the LES from the CD allowing assessment of changes in LES pressure independent from effects of diaphragmatic contraction. This model uncovers phasic inspiratory falls in LES pressure during respiratory excursions of the crural diaphragm, which would tend to stretch the LES. The fact that this inhibition occurs in patients who have compromised nitrergic LES relaxation may suggest that other mediators may contribute to this effect in humans.
Representative topographic pressure plot before (left) and after amyl nitrite (right) administration in a chronic opioid patient. As shown at baseline wet swallow (WS) is associated with elevated residual EGJ pressue and intrabolus pressure along with premature esophageal contraction. AN results in complete abolition of residual esophagogastric junction pressure. Lower esophageal sphincter displays a rebound contractile response during recovery period similar to achalasia patients. This patient noted onset of dysphagia following opioid treatment (total daily morphine equivalent dose of 400 mg) for her metastatic breast cancer.
Representative topographic pressure plots before and after cholecystokinin octapeptide (CCK) administration in a type III achalasia patient. Esophagogastric Junction (EGJ) electronic sleeve (eSleeve), esophageal and gastric tracings have been superimposed on the color plot in orange, green and red color respectively. CCK results in a biphasic LES response (relaxation then contraction) in this patient. Please note reversal of inspiratory EGJ pressure augmentation at baseline, to inspiratory EGJ pressure attenuation during recovery period.
AGA Abstracts
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