Tu1184 High Resolution Manometry With Multiple Water Swallows: A Complementary Role in the Detection of Esophageal Pathology

AGA Abstracts

GERD symptoms before seeking medical attention, and so the manometric changes of new onset RE have not been evaluated prospectively in humans. To elucidate those changes, we induced acute RE by discontinuing PPI therapy in patients who had severe RE that was healed by PPIs, and we studied changes in esophageal motility using high resolution esophageal manometry. Methods: Patients with a prior endoscopy showing LA grade C RE were treated with BID PPIs for at least one month before a baseline endoscopy to document healing, after which PPIs were stopped. High resolution esophageal manometry, multichannel intraluminal impedance(MII)/pH monitoring, endoscopy, and GERD-HRQL symptom scoring were performed at baseline (on PPI) and 2 weeks after stopping PPIs. Esophageal mucosal baseline impedance was calculated at study start and 2 weeks after stopping PPIs, by measuring the impedance at the beginning of the MII/pH study, 5 cm above the LES. Results: 14 patients enrolled; 3 were excluded when baseline endoscopy showed LA B RE, 1 was withdrawn for an unrelated adverse event, and 10 completed the study (9 men, 1 woman, mean age 56.5, range 29-69 years). Comparing baseline values to those 2 weeks after stopping PPIs for the 10 patients, the mean esophageal acid exposure (total % time pH<4) increased from 6.0%±11.4% SD to 27.2%±23.0% (p=.005) and mean GERD-HRQL scores increased from 7.7±9.5 to 12.5±9.2 (p=.02). Esophageal mucosal baseline impedance decreased from 2519±340V at week 0 to 1509±194V (p=.009) 2 weeks after stopping PPIs. 8 of the 10 patients developed moderate-to-severe endoscopic RE by 2 weeks (4 LA grade B, 4 LA grade C). In those 8 patients, the mean distal contractile integral (DCI) decreased from 1184.9±932.8 mmHg.s.cm to 798.9±666.6 mmHg.s.cm (p=.025), the mean LES pressure decreased from 15.9±8.2 mmHg to 12.6±9.0 mmHg (p=.16), and the integrated relaxation pressure (IRP) decreased from 4.8±4.7 mmHg to 0.4±5.4 (p=.01) mmHg. Conclusions: Discontinuing PPIs for 2 weeks in patients who had LA C RE healed by PPI therapy is a valid model of acute RE. These patients can develop severe RE associated with a significant increase in esophageal acid exposure and a significant decrease in esophageal impedance values within those 2 weeks. Our finding that acute RE causes a significant decrease in DCI demonstrates that moderate-to-severe GERD is a cause of hypocontractile esophageal motility alterations.

Tu1183 The Clinical Roles of Multiple Rapid Swallow in Patients Showing Ineffective Esophageal Motility and Swallow on Esophageal High Resolution Manometry Inseub Shin, Yang Won Min, Poong-Lyul Rhee Background/Aims: Multiple rapid swallow (MRS) during esophageal manometry is a simple provocative maneuver, which could predict esophageal peristaltic reserve. We sought to investigate the role of MRS in patients showing ineffective esophageal motility (IEM) and normal swallow on the esophageal high-resolution manometry (HRM). Methods: Between November 2013 and September 2014, 33 patients showing IEM on esophageal HRM and 88 normal swallow were included in this study. We calculated average swallow contraction by means of comparing distal contractile integral (DCI) and compared post-MRS contraction with average swallow contraction during esophageal HRM as ratio. We divided patients into two groups by defining that ratio above 1 as normal MRS response and ratio of 1 or less as impaired MRS response. The differences between groups were tested in terms of proportions of gastroesophageal reflux disease (GERD), pathologic acid exposure (PAE) and pathologic bolus exposure (PBE) and total AE and BE times (%). PAE and PBE was defined as an intraesophageal pH of <4 for more than 4.2% and refluxate in contact with distal impedance electrodes for more than 1.4% of the recording time, respectively. Results: In the IEM patients, 15 (45.5%) had impaired MRS response. Impaired MRS group was older than normal MRS response group (58.1 ± 9.4 vs 46.6 ± 17.2, P = 0.027). However, gender, body mass index, presence of hypertension and diabetes, and chief complaints did not differ between the two groups. The proportion of GERD, PAE and PBE did not show statistically significant differences between the two groups (abnormal MRS group vs normal MRS group, 46.7% vs 38.9%, P = 0.653; 15.4% vs 7.7%, P = 1.000; 53.9% vs 46.2%, P = 0.700). Total AE and BE time (%) did not differ between abnormal MRS and normal MRS groups (1.9% vs 1.3%, P=0.57 and 3.2% vs 1.5%, P=0.26). In the normal swallow group, 42 patients (47.7%) had impaired MRS response. Results were similar to that in the IEM group. There were no statistically significant differences between normal MRS response group and impaired MRS response group in terms of the proportion of GERD, PAE, PBE, AE time, and BE time. Conclusions: Impaired MRS response is frequently observed even in the normal swallow. Old IEM patients seem to have less esophageal motor preserve. However, clinical roles of MRS in patients showing IEM and normal swallow on the esophageal HRM is yet limited. Further large scaled study is warranted to confirm out results in the future.

Tu1182 High Resolution Esophageal Manometry in Italian Healthy Volunteers: A Comparison With North-American and North-European Values Tommaso Giuliani, Luca Maria Saadeh, Renato Salvador, Edoardo V. Savarino, Francesca Galeazzi, Loredana Nicoletti, Stefano Merigliano, Mario Costantini

Tu1184

Introduction: Esophageal High-Resolution Manometry (HRM) has become the reference technology for the assessment of esophageal motor disorders, and prompted the development of the new Chicago Classification, now widely used. However, this is based on normal parameters derived from the original set of 75 volunteers studied at the Northwestern Chicago University. The aim of our study was to provide a new set of normal parameters calculated on a group of Italian volunteers and to compare them to the published NorthAmerican (Chicago, IL & Rochester, NY) and North-European (Amsterdam) data sets. Methods: Thirty-five healthy volunteers underwent Esophageal HRM with a solid-state catheter, with 36 transducers 1-cm apart. Ten wet swallows in the supine position were analyzed using the ManoView software. Data were expressed as median and 5th-95th percentiles, and the statistical analysis was performed using the Student t test with Bonferroni's correction. Results: The normal range of the different parameters were: EGJ length 3.9 cm (2.6-6.2); EGJ resting pressure: 28.6 mmHg (17-52.6); EGJ 4-s IRP: 10.4 mmHg (3.5-17); Intrabolus pressure 11 mmHg (6.8-18.9); DCI 1641 mmHg*s*cm (514-2965); CFV 3.6 cm s-1 (2.3-5.7); Distal Latency 6.7 s (4.9-8.5). Most of these figures were similar to previously described parameters. However, the parameters reflecting the contractility strength of the gullet, namely DCI, were lower than the corresponding American values (p<0.05), albeit similar to the European ones (p=n.s.). Conclusions: In conclusion, our study provided an additional data set for "normal" parameters for solid-state esophageal HRM, and demonstrated that differences among volunteers of different countries do exist, thus suggesting caution in the global usage of one particular data set of normality.

AGA Abstracts

High Resolution Manometry With Multiple Water Swallows: A Complementary Role in the Detection of Esophageal Pathology Daphne Ang, Emily Tucker, Jeff Wright, Kevin R. Knowles, Tiing Leong Ang, Rami Sweis, Mark R. Fox Background/Aim:The Chicago Classification (CC) based on ten 5mLs water swallows (WS) identifies clinically relevant esophageal motility disorders by high resolution manometry (HRM). Adjunctive testing by multiple rapid swallows (MRS) or multiple water swallows (MWS) challenge swallowing function and may increase diagnostic sensitivity. MRS involves taking 5-10mLs water in 4-6 rapid swallows; MWS involves the "real life challenge" of drinking a larger volume (200ml) of water by rapid swallows. There is a lack of published data available on MWS as an adjunctive test of esophageal function. We reports results of MWS from a large cohort of patients referred for esophageal HRM. Methods:Prospective cohort study of patients undergoing HRM between January 2010-December 2013 for evaluation of dysphagia or reflux symptoms. Patients underwent HRM with standard 5mLs WS followed by MWS (200mLs water). Integrated relaxation pressure (IRP) during MWS and post-MWS contractile response (measured by distal contractile integral [DCI]) were compared with IRP and DCI during WS. Abnormal response to MWS was defined by (i) absent EGJ relaxation with pan-esophageal pressurization (PEP); (ii) incomplete inhibition of contractility during MWS sequence and/or (iii) no augmentation of contraction after MWS. Data are expressed as median (95% confidence interval) and pairwise differences analyzed with Wilcoxon Signed rank test. Patients were categorized according to the CC. Patients who had normal HRM findings and asymptomatic healthy volunteers (HV) served as controls. Informed consent and ethics approval was obtained for analysis of clinical database. Results:Patients (N=178; 76[42.7%]M; mean age 54.3 ± 16.6 years) were evaluated for dysphagia (N=134;60[44.8%]M; mean age 54.6 ± 17.7 years) or reflux symptoms (N=44; 16[36.4%]M; mean age 53.4 ± 12.3 years). Controls (N=67; 29[43.3%]M; mean age 42.3 ± 14.5 years) included 44 patients (N=20[45.5%] M; mean age 46.4 ± 14.8 years) with normal HRM findings and 23 HV (N=9[39.1%]M; mean age 34.4 ± 10.4years). MWS reduced IRP and post-contraction DCI compared to WS in controls(Table 1). This pattern was present in all patient groups except achalasia patients who had similar or increased IRP (p<0.05; Table 1). Failure to suppress contractions during MWS was often seen in achalasia III, spasm and hypertensive motility disorders but rarely (<5%) in other groups (p<0.001; Table 2), although secondary spasm was occasionally seen in EGJ obstruction. LES contraction post MWS was more common in controls than patients (p<0.001; Table 2). Conclusions: MWS serves an adjunctive role in evaluating patients. Failure to suppress IRP during MWS in achalasic patients; failure to suppress contractility during MWS in hypertensive motility disorders and preservation of an effective post contraction in controls were distinguishing features of MWS.

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EGJ outflow obstruction (17%), and hypercontractile motility patterns (13%). Dysphagia to liquids was the best individual symptomatic predictor of a manometric abnormality. EGD and esophagram findings did not reliably predict abnormalities found on high-resolution esophageal manometry.

AGA Abstracts

Table 1

SWS single water swallows; MWS multiple water swallows;IRP integrated relaxation pressure; DCI distal contractile integral. *p<0.05, **p<0.01, +p<0.001 compared to SWS Table 2

Tu1186 The Role of Integrated Relaxation Pressure Assessed by Using High Resolution Manometry in Achalasia Patients Renato Salvador, Edoardo V. Savarino, Elisa Pesenti, Lorenzo Spadotto, Tommaso Giuliani, Francesca Galeazzi, Loredana Nicoletti, Giovanni Zaninotto, Romeo Bardini, Stefano Merigliano, Mario Costantini Background: The Integrated Relaxation Pressure (IRP) is a new manometric parameter used to assess the esophageal-gastric junction (EGJ) relaxation by high resolution manometry (HRM). According to the Chicago Classification v2.0 (CC) the diagnosis of achalasia is established on the basis of an IRP>15mmHg and absence of normal esophageal peristalsis in the esophageal body. The aim of this study was to investigate the correlation of IRP values with the diagnosis of achalasia, the demographics and clinical findings in a group of consecutive well-defined achalasia patients. Patients and Methods: We prospectively collected data of patients who underwent HRM because of suspected primary achalasia between 2009 and 2014. Esophageal symptoms were collected and scored using a detailed questionnaire for dysphagia, regurgitation, and chest pain. Barium swallow was used to assess esophageal diameter and shape. Endoscopy was always performed to rule out malignancies. Manometric diagnoses were performed by using the CC. All the patients with a confirmed diagnosis of achalasia were surgically treated and failure was defined as a postoperative symptom score >10th percentile of the preoperative score (i.e. > 10). Results: We enrolled 139 consecutive primary achalasia patients (M:F=72:67). According to the CC, patients were classified as: 58 (42.3%) with type I, 63 (46%) with type II and 16 (11.7%) with type III. At univariate analysis IRP was correlated with the gender, the basal and resting lower esophageal sphincter (LES) pressure, and the dysphagia score (Figure). All the patients had absence of normal peristalsis, but 11(10.9%) had an IRP<15 mmHg. All these patients had a barium swallow showing a radiological grade I disease and their HRM pattern were: type I:type II:type III=4:4:3. At a median follow-up of 24 months, none of these patients presented a failure. Conclusions: An increased IRP directly correlated with LES function and dysphagia score emphasizing its major role in provoking dysphagia rather than chest pain and/or regurgitation in achalasia patients. Moreover, the occurrence of more than 10% of the patients with an IRP<15mmHg despite a clinical/radiological/endoscopic diagnosis of achalasia requires particularly caution when we observe absence of normal peristalsis and a normal IRP during HRM testing.

EGJ esophagogastric junction; MWS multiple water swallows; LES lower esophageal sphincter Tu1185 Community-Based Characterization of Esophageal Motility Disorders Using High-Resolution Manometry (HRM) in Symptomatic Adults Eric Leslie, Drew Michael S. Donnell, Kathy Geissler, Ilche T. Nonevski Background: Esophageal symptoms are common in the general population, and include dysphagia, heartburn and chest pain. High-resolution manometry (HRM) is often utilized to characterize motility disorders as contributors to these symptoms. Studies using HRM have been largely performed at specialized tertiary medical centers, and thus could be influenced by referral bias. To date, there are no studies evaluating the type and frequency of motility abnormalities in patients presenting in a community setting. Methods: A retrospective review of 100 consecutive HRM studies for adult patients was performed at a single, community-based medical center in Rockford, IL from January 2012 through December 2013. The Chicago Classification was applied to characterize motility findings. EGD and esophagram studies performed within 2 months of HRM were reviewed. Results: In this community-based study, 59% of patients who underwent HRM met major manometric criteria for esophageal abnormalities. Achalasia (I,II,III) was the most common major manometric abnormality (n=17), followed by esophagogastric junction (EGJ) outflow obstruction (n=10), and hypercontractile esophagus, including jackhammer (n=7) and nutcracker (n= 1). Weak peristalsis with large defects (n=3) and small defects (n=8) accounted for the most common minor criteria. Patients who underwent HRM most commonly presented with dysphagia (54%), followed by heartburn (25%) and chest pain (16%). Manometric abnormalities were present in 42/58 (72%) presenting with dysphagia, 14/26 (54%) with heartburn, and 7/17 (41%) with chest pain. Dysphagia to liquids, when noted by clinicians, was associated with manometric abnormalities 72% of the time. In those patients with manometric abnormalities, findings of abnormal esophagram (radiologist observed tertiary contractions, presbyesophagus, spasm, or dysmotility) were seen in 28/35 (80%) patients (SEN 80%; SPEC 36%; ACC 67%). Abnormal EGD findings (gastroenterologist observed dysmotility and/or spasm, significant retained food, tight LES, or suspected achalasia) were seen in 33/ 54 (61%) patients (SEN 61%; SPEC 65%; ACC 63%). In those HRM(abnormal) patients that received both EGD and esophagram, the presence of concurrent abnormalities in these tests occurred in only 17/35 (49%) patients (SEN 49%; SPEC 71%; ACC 55%). Conclusions: To our knowledge, this is the first community-based study to characterize esophageal symptoms using high-resolution esophageal manometry. Manometric abnormalities were common, seen in nearly 60% of patients, and included achalasia (28% of all abnormalities),

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AGA Abstracts