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Su1090 Development of the Dysphagia Stress Test: A Novel Tool for Assessment of Esophageal Dysphagia
AGA Abstracts
was to compare clinical presentation, high resolution manometric (HRM) characteristics and bolus transit in patients with EJGOO and achalasia. Methods: Consecutive patients between 1/2012 and 6/2015 identified with achalasia type II and EGJOO per Chicago Classification v 3.0 were included. Achalasia patients with prior treatment were excluded. HRM was performed with a solid state catheter with 36 circumferential pressure sensors spaced 1-cm apart, with 18 impedance channels is some but not all studies. Esophageal pressure topography plots of 10 single 5 ml liquid swallows were analyzed prospectively with Manoview software (Covidien, Duluth, GA). Median 4-sec integrated relaxation pressure (IRP) were calculated. Bolus transit was assessed for studies that included impedance measurements. Incomplete bolus transit was defined as incomplete clearance on ‡30% swallows. Demographics, endoscopic findings and presenting symptoms were collected from electronic medical record. Results: 80 EGJOO and 35 achalasia type II patients were included. Demographics and clinical characteristics are shown in Table 1. Dysphagia was less commonly the presenting complaint for EGJOO (p<0.001). EGJOO group was more likely to have GERD symptoms and less likely to report regurgitation compared to Achalasia group (p<0.001). Mechanical obstruction on endoscopy (strictures/ rings/ hiatal hernia) was common in EGJOO, and as expected, rarely seen in achalasia (Table2). Median IRP was significantly lower for EGJOO compared to Achalasia (20 vs. 27mmHg, p=0.001) Impedance data was available in 35/80 EGJOO patients and 26/35 with achalasia. Incomplete bolus transit was significantly more frequent in Achalasia compared to EGJOO (88%vs.30%, p<0.0001). Conclusion: Clinical presentation in EGJOO patients is different from achalasia: EGJOO patients have more reflux symptoms and less dysphagia and regurgitation. Mechanical outflow obstruction is seen in EJGOO but no Achalasia. Compared to achalasia, EGJOO patients have a lower median IRP and better bolus clearance by impedance. Given these unique differences, we are currently studying comparison of treatments used for each group and outcome of these treatments in EGJOO and achalasia in a large cohort of patients. Clinical Characteristics of Study Sample
were all highly related to each other. Logistically, bread is the simplest food to utilize in a clinical setting. Mean DST Difficulty and Pain Scores by Bolus Challenge
a Difficulty Score. b Pain score.
Su1091 Medication Use Is Associated With Abnormal Esophageal Manometry and Function Deepti A. Jacob, Sarah Pradhan, Lynn Wilsack, Michelle Buresi, Michael Curley, Milli Gupta, Abdel A. Shaheen, Christopher N. Andrews Background: Surprisingly little is known about the effects of common medication on esophageal motor physiology in a real-world setting. Many manometries show nonspecific abnormalities, and it is difficult to know if the abnormalities represent a primary dysmotility versus medication side effects. Aims: We hypothesized that medications known to affect intestinal or colonic motility could also have measurable effects on esophageal pressure and/or function. Methods: All patients who underwent high-resolution esophageal manometry (HRM) with impedance over a 22-month period were analyzed by Chicago Classification. Patients with achalasia, connective tissue disorder, eosinophilic esophagitis or structural lesions on endoscopy were excluded. Detailed medication history on the day of the HRM was taken. Medication types associated with motility effects were grouped into classes (anticholinergics, PPI, narcotics, tricyclics (TCA), selective serotonin reuptake inhibitor (SSRI), serotonin/norepinephrine reuptake inhibitor (SNRI), anticonvulsants, antispasmodics, calcium channel blockers (CCB)) and tested along with age and gender in multiple stepwise linear regression analyses to assess for association with HRM endpoints. Nonlinear dependent variables were log transformed where appropriate. Results: 519 patients (mean age 51 ± 0.6 yrs, 65% female) were included in the analysis, with 36, 27, and 14% reporting dysphagia, reflux, or chest pain as their primary complaint, respectively. Manometry showed frequent failed peristalsis in 40%, weak peristalsis with defects (small & large) in 21%, EGJ outlet obstruction in 7%, and was normal in 26%. Regular narcotic use, SNRI, female gender and increasing age were found to be significant predictors of higher LES mean basal pressure, whereas PPI use was associated with lower LES mean basal pressure (table; all presented predictors are significant at p<0.05). Anticonvulsants and tricyclics were associated with higher LES mean residual pressure. SNRI and age were associated with higher, and CCB with lower mean DCI. Anticholinergic and SSRI use were associated with more failed swallows, and anticholinergic with higher incomplete bolus transit. The proportion of narcotic use in patients with normal manometry vs abnormal manometry was not significantly different. Patients with elevated basal LES pressure were more likely to be on SNRI (16% vs 6% of patients with normal basal LES, OR 2.8 (1.4-5.6), p=0.002). Conclusions: Common medications are significantly associated with changes in HRM variables and esophageal function. SNRI in particular have not been previously associated with significant effects on the esophagus in clinical practice to our knowledge. Clinicians should take patient medications into consideration when assessing manometry. Variables affecting HRM endpoints
Upper Endoscopic Findings
Su1090 Development of the Dysphagia Stress Test: A Novel Tool for Assessment of Esophageal Dysphagia Tiffany Taft, Emily Kern, Jenna Craft, Kristen Starkey, Laurie Keefer, Ikuo Hirano, Nirmala Gonsalves, Bethany Doerfler, Peter Kahrilas, John Pandolfino Introduction: Esophageal dysphagia is a common symptom identified in clinical practice and is associated with several chronic conditions including gastroesophageal reflux disease (GERD), eosinophilic esophagitis (EoE), and achalasia (ACH). We previously reported on the Dysphagia Stress Test (DST) as a novel means of rapid assessment of esophageal dysphagia allowing for direct observation and rating of swallowing via five bolus challenges. We aim to further refine the DST by evaluating each challenge to determine the minimum number needed to accurately gauge swallowing ability. Methods: Patients of an outpatient gastroenterology practice for routine follow-up visits were recruited; those diagnosed with GERD, EoE, ACH, or dysphagia NOS (DYS) served as the experimental groups and patients diagnosed with other chronic GI conditions served as a patient control (PC) group. Healthy controls (HC) were recruited from the community. Participants underwent five separate bolus challenges: water, 5 cc applesauce, teaspoon rice, 2x2x1 cm piece of bread, barium tablet with water sips. After 15-30 seconds, patients marked on a 0-10 visual analog scale their difficulty and pain for each item. A trained study technician rated the number of swallows needed, if the patient required water, or if the patient was unable to complete a challenge. Difficulty and pain scores for each item are summed separately and combined for a total DST score. Higher scores indicate better swallowing ability. A correlation cutoff score was set for 0.70 to identify items with multicollinearity. Results: 132 patients participated. Mean(SD) age is 44.7(17.9), 61% female, 67% Caucasian. 17% are HC, 27% PC, 11% GERD, 14% ACH, 14% EOE, 14% DYS. For Total DST score, PC and HC demonstrated the highest scores without significant differences between groups (M=253.5 vs 250.8, p=.70). GERD patients also did not differ significantly from PC or HC (M=243.6, p = .32) while ACH, EOE, and DYS scored significantly lower. Total difficulty and pain scores were highly correlated (all r > 0.82) (Table). Water did not show multicollinearity with any challenge items (barium r=0.16 to applesauce r=0.40). Applesauce was highly correlated with rice (r=0.70) and bread (r=0.70, both p < .01); rice and bread demonstrated the greatest relationship (r=0.77, p<.01). No multicollinearity existed for barium (rice r=0.40 to applesauce r=0.44). The same trends exist for pain scores by challenge and remained after HC and PC were excluded from analyses for both difficulty and pain. Conclusions: The results of this study suggest that the number of bolus challenges on the DST may be reduced from 5 to 3. Water and barium tablet did not show multicollinearity and should be retained. However, applesauce, rice, and bread
AGA Abstracts
S-466
was to compare clinical presentation, high resolution manometric (HRM) characteristics and bolus transit in patients with EJGOO and achalasia. Methods: Consecutive patients between 1/2012 and 6/2015 identified with achalasia type II and EGJOO per Chicago Classification v 3.0 were included. Achalasia patients with prior treatment were excluded. HRM was performed with a solid state catheter with 36 circumferential pressure sensors spaced 1-cm apart, with 18 impedance channels is some but not all studies. Esophageal pressure topography plots of 10 single 5 ml liquid swallows were analyzed prospectively with Manoview software (Covidien, Duluth, GA). Median 4-sec integrated relaxation pressure (IRP) were calculated. Bolus transit was assessed for studies that included impedance measurements. Incomplete bolus transit was defined as incomplete clearance on ‡30% swallows. Demographics, endoscopic findings and presenting symptoms were collected from electronic medical record. Results: 80 EGJOO and 35 achalasia type II patients were included. Demographics and clinical characteristics are shown in Table 1. Dysphagia was less commonly the presenting complaint for EGJOO (p<0.001). EGJOO group was more likely to have GERD symptoms and less likely to report regurgitation compared to Achalasia group (p<0.001). Mechanical obstruction on endoscopy (strictures/ rings/ hiatal hernia) was common in EGJOO, and as expected, rarely seen in achalasia (Table2). Median IRP was significantly lower for EGJOO compared to Achalasia (20 vs. 27mmHg, p=0.001) Impedance data was available in 35/80 EGJOO patients and 26/35 with achalasia. Incomplete bolus transit was significantly more frequent in Achalasia compared to EGJOO (88%vs.30%, p<0.0001). Conclusion: Clinical presentation in EGJOO patients is different from achalasia: EGJOO patients have more reflux symptoms and less dysphagia and regurgitation. Mechanical outflow obstruction is seen in EJGOO but no Achalasia. Compared to achalasia, EGJOO patients have a lower median IRP and better bolus clearance by impedance. Given these unique differences, we are currently studying comparison of treatments used for each group and outcome of these treatments in EGJOO and achalasia in a large cohort of patients. Clinical Characteristics of Study Sample
were all highly related to each other. Logistically, bread is the simplest food to utilize in a clinical setting. Mean DST Difficulty and Pain Scores by Bolus Challenge
a Difficulty Score. b Pain score.
Su1091 Medication Use Is Associated With Abnormal Esophageal Manometry and Function Deepti A. Jacob, Sarah Pradhan, Lynn Wilsack, Michelle Buresi, Michael Curley, Milli Gupta, Abdel A. Shaheen, Christopher N. Andrews Background: Surprisingly little is known about the effects of common medication on esophageal motor physiology in a real-world setting. Many manometries show nonspecific abnormalities, and it is difficult to know if the abnormalities represent a primary dysmotility versus medication side effects. Aims: We hypothesized that medications known to affect intestinal or colonic motility could also have measurable effects on esophageal pressure and/or function. Methods: All patients who underwent high-resolution esophageal manometry (HRM) with impedance over a 22-month period were analyzed by Chicago Classification. Patients with achalasia, connective tissue disorder, eosinophilic esophagitis or structural lesions on endoscopy were excluded. Detailed medication history on the day of the HRM was taken. Medication types associated with motility effects were grouped into classes (anticholinergics, PPI, narcotics, tricyclics (TCA), selective serotonin reuptake inhibitor (SSRI), serotonin/norepinephrine reuptake inhibitor (SNRI), anticonvulsants, antispasmodics, calcium channel blockers (CCB)) and tested along with age and gender in multiple stepwise linear regression analyses to assess for association with HRM endpoints. Nonlinear dependent variables were log transformed where appropriate. Results: 519 patients (mean age 51 ± 0.6 yrs, 65% female) were included in the analysis, with 36, 27, and 14% reporting dysphagia, reflux, or chest pain as their primary complaint, respectively. Manometry showed frequent failed peristalsis in 40%, weak peristalsis with defects (small & large) in 21%, EGJ outlet obstruction in 7%, and was normal in 26%. Regular narcotic use, SNRI, female gender and increasing age were found to be significant predictors of higher LES mean basal pressure, whereas PPI use was associated with lower LES mean basal pressure (table; all presented predictors are significant at p<0.05). Anticonvulsants and tricyclics were associated with higher LES mean residual pressure. SNRI and age were associated with higher, and CCB with lower mean DCI. Anticholinergic and SSRI use were associated with more failed swallows, and anticholinergic with higher incomplete bolus transit. The proportion of narcotic use in patients with normal manometry vs abnormal manometry was not significantly different. Patients with elevated basal LES pressure were more likely to be on SNRI (16% vs 6% of patients with normal basal LES, OR 2.8 (1.4-5.6), p=0.002). Conclusions: Common medications are significantly associated with changes in HRM variables and esophageal function. SNRI in particular have not been previously associated with significant effects on the esophagus in clinical practice to our knowledge. Clinicians should take patient medications into consideration when assessing manometry. Variables affecting HRM endpoints
Upper Endoscopic Findings
Su1090 Development of the Dysphagia Stress Test: A Novel Tool for Assessment of Esophageal Dysphagia Tiffany Taft, Emily Kern, Jenna Craft, Kristen Starkey, Laurie Keefer, Ikuo Hirano, Nirmala Gonsalves, Bethany Doerfler, Peter Kahrilas, John Pandolfino Introduction: Esophageal dysphagia is a common symptom identified in clinical practice and is associated with several chronic conditions including gastroesophageal reflux disease (GERD), eosinophilic esophagitis (EoE), and achalasia (ACH). We previously reported on the Dysphagia Stress Test (DST) as a novel means of rapid assessment of esophageal dysphagia allowing for direct observation and rating of swallowing via five bolus challenges. We aim to further refine the DST by evaluating each challenge to determine the minimum number needed to accurately gauge swallowing ability. Methods: Patients of an outpatient gastroenterology practice for routine follow-up visits were recruited; those diagnosed with GERD, EoE, ACH, or dysphagia NOS (DYS) served as the experimental groups and patients diagnosed with other chronic GI conditions served as a patient control (PC) group. Healthy controls (HC) were recruited from the community. Participants underwent five separate bolus challenges: water, 5 cc applesauce, teaspoon rice, 2x2x1 cm piece of bread, barium tablet with water sips. After 15-30 seconds, patients marked on a 0-10 visual analog scale their difficulty and pain for each item. A trained study technician rated the number of swallows needed, if the patient required water, or if the patient was unable to complete a challenge. Difficulty and pain scores for each item are summed separately and combined for a total DST score. Higher scores indicate better swallowing ability. A correlation cutoff score was set for 0.70 to identify items with multicollinearity. Results: 132 patients participated. Mean(SD) age is 44.7(17.9), 61% female, 67% Caucasian. 17% are HC, 27% PC, 11% GERD, 14% ACH, 14% EOE, 14% DYS. For Total DST score, PC and HC demonstrated the highest scores without significant differences between groups (M=253.5 vs 250.8, p=.70). GERD patients also did not differ significantly from PC or HC (M=243.6, p = .32) while ACH, EOE, and DYS scored significantly lower. Total difficulty and pain scores were highly correlated (all r > 0.82) (Table). Water did not show multicollinearity with any challenge items (barium r=0.16 to applesauce r=0.40). Applesauce was highly correlated with rice (r=0.70) and bread (r=0.70, both p < .01); rice and bread demonstrated the greatest relationship (r=0.77, p<.01). No multicollinearity existed for barium (rice r=0.40 to applesauce r=0.44). The same trends exist for pain scores by challenge and remained after HC and PC were excluded from analyses for both difficulty and pain. Conclusions: The results of this study suggest that the number of bolus challenges on the DST may be reduced from 5 to 3. Water and barium tablet did not show multicollinearity and should be retained. However, applesauce, rice, and bread
AGA Abstracts
S-466