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Tu1993 High-Resolution Impedance Manometry: Effect of Peristaltic Integrity on Esophageal Pressurization
Tu1995
High-Resolution Impedance Manometry: Effect of Peristaltic Integrity on Esophageal Pressurization Maartje Singendonk, Charles Cock, Marc A. Benninga, Taher Omari, Stamatiki Kritas
Supine Versus Sitting: a Comparison of High Resolution Manometry in Patients With Achalasia Congwei Liu, Xiaoxiao Wang, Zhongyuan Li, Lihua Peng, Jie Ai, Yue Fu, Yunsheng Yang
Background: In the Chicago Classification (CC) peristaltic integrity is determined by the size of the largest break in the isobaric contour. However, bolus clearance might be affected by the occurrence of non-continuous breaks. The aim of the study was to assess the effect of peristaltic integrity on bolus clearance by using pressure-flow analysis. Methods: 22 solidstate high-resolution impedance manometry (HRIM) tracings of 10 liquid swallows of healthy asymptomatic adults (6M; mean age 36.1 SD 11.7 years) were retrospectively analysed using MMS analysis software (version 9.1). Measures of peristaltic integrity (largest break and total break size in cm of the 20mmHg isobar) were derived. Pressure-flow analysis was performed using purpose designed MATLAB-based software (AIMplot, T. Omari) which derived peak pressure (PeakP), intra-bolus pressure (IBP), bolus flow relative to peak pressure (PNadImp) and its timing to peak pressure (TNadImp-PeakP). In addition the pressure-flow index (PFI), a composite measure of bolus pressurisation relative to flow and the impedance ratio (IR) a measure of the extent of bolus clearance failure were calculated. Results: Out of 220 swallows, 214 were suitable for analysis. A strong correlation between total break size and the largest break in the isobaric contour was found (r=0.846,p=0.000). There was a trend towards larger break size and higher IR, with a stronger correlation for the largest break (table 1). Both largest break and total break size correlated with lower PeakP, lower PNadImp, lower IBP and longer TNadImp-PeakP. However, no correlation was found between larger break size and PFI. Conclusion: Largest break and total break size seem to characterize peristaltic integrity equally. Larger break size is associated with lower peristaltic pressurization and impaired bolus movement. There seems to be little quantifiable difference between the largest break and total breaksize in relation to bolus pressurization. Esophageal break size and AIM-derived pressure-flow metrics
Background: High resolution manometry (HRM) is a key test to establish the diagnosis of achalasia, which is based on the Chicago Classification. We found that patient had a better tolerance to finish this test in the sitting position, while the Chicago Classification was established based on the data of supine position. Our aims were to make a comparison of the HRM outcomes of the two positions, and to discuss the effect of applying the sitting position. Methods: We reviewed 65 patients with the diagnosis of achalasia (the Chicago Classification 2012, type I: 11 patients, type II: 54 patients). Each patient finished the HRM test with 10 supine and 10 sitting swallows of 5 mL liquid. We used 4.2mm solid-state HRM catheters to perform the test and The ManoViewTM ESO Analysis Program version 3 for analysis. Results: Integrated relaxation pressure (IRP, 27.15 vs. 21.07mmHg, p<0.001) and LES basal pressure (LESBP, 33.76 vs. 27.37 mmHg, p<0.001) of sitting position decreased significantly, compared with the supine position. The times of panesophageal pressurization also decreased in sitting position (median: 8 vs. 3, p<0.001). 25(38.5%) patients had different diagnoses between the two positions (κ=0.155 in consistency analysis, p=0.059, table 1). Conclusions: In patients of type I and type II achalasia, IRP, LESBP and the times of panesophageal pressurization decreased in during sitting position, these changes led to different diagnoses between the two positions. More work should be done to establish criteria based on sitting position. The decreasing of times of panesophageal pressurization maybe related to gravity. Liquid becomes easier to enter the stomach after the shifting of the position, and less liquid provides less intraluminal pressure in the esophagus. These phenomena indicate a similar motility situation of the two subtypes of achalasia. Table 1 Diagnoses of supine and sitting positions.
Pearson's correlation. Significance at *P<0.05, **P<0.01, ***P<0.001
κ=0.155, p=0.059
Tu1994
Tu1996
Increased Frequency of Transient Lower Esophageal Sphincter (LES) Relaxation in Cascade Stomach Akiyo Kawada, Hiroko Hosaka, Shiko Kuribayashi, Shingo Ishihara, Yasuyuki Shimoyama, Osamu Kawamura, Motoyasu Kusano, Masanobu Yamada
Visual Assessment of High Resolution Esophageal Manometry Composite Swallows: Comparison to Conventional Computer Analysis of Individual Swallows. Zubair A. Malik, Henry P. Parkman
Background and Aim: Cascade stomach (CS) is a characteristic morphologic type of the stomach. We previously reported that persons with CS had a high incidence of reflux symptoms as well as dyspepsia (Neurogastro Motil, 2012). It is well known that transient LES relaxation (tLESR) is a major mechanism of gastroesophageal reflux, and that delayed gastric emptying is responsible for tLESR. We hypothesized that persons with CS could have frequent tLESR due to modified gastric empting. Methods: Nine subjects with CS and 8 control non-CS subjects were enrolled. CS was chiefly diagnosed by barium studies and also from endoscopic findings. CS was defined by detection of an air-fluid level in the fundus on an upright barium X-ray film, or by finding separation of the fundus and corpus by a ridge or angle on upper GI endoscopy after air inflation of the stomach. The control subjects were all volunteers with normal barium X-ray studies. Gastroesophageal manometry was performed with a high resolution manometry system (ManoScan, USA) for 2 hours in the sitting position after intake of a standard liquid test meal (250 ml of Ensure H:375 kcal with 31.5 % fat) and gastric emptying was simultaneously measured by a continuous 13C breath ID system (Exalenz Bioscience Ltci. Israel). tLESR was defined as characteristic spontaneous relaxation associated with common cavity (Romans S. Aliment Pharmacol Ther. 2011). The number of tLESR events was counted in the early period (E; 0-60 min.), late period (L; 60-120 min.), and total period (T; 2 hours). The parameters of gastric emptying, including the half empting time (T1/2), lag time (T lag), and gastric empting coefficient (GEC), were calculated over 2 hours. All data were expressed as the median with interquartile range. Results: A total of 166 tLESR events were detected, and there was not significant differences of BMI between CS and control groups; 23.8 (20.9-24.9) vs 20.8(20.5-22.1). In the CS group, the incidence of tLESR in L (4.0 /h, 3.0-7.5) was significantly (p<0.05, MannWhitney U test) higher than (2.5/h, 2.0-3.5) in the controls. In the CS group, the incidence of tLESR in E (6.0/h, 4.0-9.9) and in T (10.0/2h, 7.8-16.0) was also higher than in the controls (4.5/h, 3.5-6.0 and 7.0/2h, 6.5-9.5), but there were no significant differences. In the CS and control groups, the parameters of gastric emptying were as follows: T 1/2 was 112.6 (101.6-130.2) min vs. 118.5 (111.4-149.4) min, T lag was 67.9 (64.0-77.5) min vs. 77.8 (72.0-82.9) min, and GEC was 3.61 (3.31-3.99) vs. 3.52 (3.23-3.97). There were no significant differences between the two groups. Conclusions: In the CS group, the incidence of tLESR was significantly higher than in the control group. This frequent tLESR was not caused by delayed gastric emptying, but could be induced by distention of the gastric fundus due to morphological changes in CS.
Introduction: High resolution esophageal manometry (HREM) is commonly used to evaluate esophageal motility. HREM uses 10 or more swallows to evaluate the function of the esophagus and lower esophageal sphincter. When completed, a composite picture averaging the swallows from the study is often created for result reporting. How visual assessment of this composite compares to analysis based on individual swallows is not known. The aim of this study is to examine the accuracy of diagnosis of esophageal motility disorders using the composite picture compared with the full study analysis of individual swallows. Methods: Eighty two patients who underwent HREM for any clinical indication were evaluated. Patients who had previous surgery to their LES or esophagus were excluded. All patients completed a full HREM that was analyzed using individual swallow analysis using the Chicago Classification by a trained individual. After completion of the analysis, a de-identified composite picture of the study was presented to a second expert gastroenterologist, and a diagnosis was made based solely on the composite image without knowledge of the individual swallow analysis or symptoms. The accuracy of the composite analysis was compared to the individual swallow analysis. Results: Forty three (52.4%) patients were diagnosed correctly based on the composite. The diagnoses included normal, achalasia type 2, scleroderma-like esophagus, and EGJ outflow obstruction. Another 25 patients (30.4%) were diagnosed partially correct. In 12 of these patients a hiatal hernia (HH) was missed, 5 of which were sliding. Another 4 patients had a difference in the size of the breaks (large or small breaks in the esophageal contraction). Six patients had a difference in assessment of LES pressure as low, normal, high. However, 14 patients (17.1%) had an incorrect diagnosis based on the composite picture. Four were incorrect based on LES pressure assessment, and another 3 based on the esophageal contractile strength. One was thought to have small breaks that didn't, and the other two had frequent failed peristalsis that was described as weak peristalsis on the composite. Of patients with achalasia and scleroderma by individual swallow analysis, the composite analysis correctly identified these patients. Conclusions: Visual composite swallow assessment accurately predicts HREM findings in the majority (52%) of patients, while minor abnormalities were missed in another 30.4%, including small or sliding HH. It accurately identifies major motility disorders such as achalasia and scleroderma-like esophagus. However, it is not accurate in correctly assessing the pressure of the LES or esophageal contraction amplitude particularly borderline pressure amplitudes, or intermittent contractile abnormalities such as breaks or failed swallows.
S-893
AGA Abstracts
AGA Abstracts
Tu1993
High-Resolution Impedance Manometry: Effect of Peristaltic Integrity on Esophageal Pressurization Maartje Singendonk, Charles Cock, Marc A. Benninga, Taher Omari, Stamatiki Kritas
Supine Versus Sitting: a Comparison of High Resolution Manometry in Patients With Achalasia Congwei Liu, Xiaoxiao Wang, Zhongyuan Li, Lihua Peng, Jie Ai, Yue Fu, Yunsheng Yang
Background: In the Chicago Classification (CC) peristaltic integrity is determined by the size of the largest break in the isobaric contour. However, bolus clearance might be affected by the occurrence of non-continuous breaks. The aim of the study was to assess the effect of peristaltic integrity on bolus clearance by using pressure-flow analysis. Methods: 22 solidstate high-resolution impedance manometry (HRIM) tracings of 10 liquid swallows of healthy asymptomatic adults (6M; mean age 36.1 SD 11.7 years) were retrospectively analysed using MMS analysis software (version 9.1). Measures of peristaltic integrity (largest break and total break size in cm of the 20mmHg isobar) were derived. Pressure-flow analysis was performed using purpose designed MATLAB-based software (AIMplot, T. Omari) which derived peak pressure (PeakP), intra-bolus pressure (IBP), bolus flow relative to peak pressure (PNadImp) and its timing to peak pressure (TNadImp-PeakP). In addition the pressure-flow index (PFI), a composite measure of bolus pressurisation relative to flow and the impedance ratio (IR) a measure of the extent of bolus clearance failure were calculated. Results: Out of 220 swallows, 214 were suitable for analysis. A strong correlation between total break size and the largest break in the isobaric contour was found (r=0.846,p=0.000). There was a trend towards larger break size and higher IR, with a stronger correlation for the largest break (table 1). Both largest break and total break size correlated with lower PeakP, lower PNadImp, lower IBP and longer TNadImp-PeakP. However, no correlation was found between larger break size and PFI. Conclusion: Largest break and total break size seem to characterize peristaltic integrity equally. Larger break size is associated with lower peristaltic pressurization and impaired bolus movement. There seems to be little quantifiable difference between the largest break and total breaksize in relation to bolus pressurization. Esophageal break size and AIM-derived pressure-flow metrics
Background: High resolution manometry (HRM) is a key test to establish the diagnosis of achalasia, which is based on the Chicago Classification. We found that patient had a better tolerance to finish this test in the sitting position, while the Chicago Classification was established based on the data of supine position. Our aims were to make a comparison of the HRM outcomes of the two positions, and to discuss the effect of applying the sitting position. Methods: We reviewed 65 patients with the diagnosis of achalasia (the Chicago Classification 2012, type I: 11 patients, type II: 54 patients). Each patient finished the HRM test with 10 supine and 10 sitting swallows of 5 mL liquid. We used 4.2mm solid-state HRM catheters to perform the test and The ManoViewTM ESO Analysis Program version 3 for analysis. Results: Integrated relaxation pressure (IRP, 27.15 vs. 21.07mmHg, p<0.001) and LES basal pressure (LESBP, 33.76 vs. 27.37 mmHg, p<0.001) of sitting position decreased significantly, compared with the supine position. The times of panesophageal pressurization also decreased in sitting position (median: 8 vs. 3, p<0.001). 25(38.5%) patients had different diagnoses between the two positions (κ=0.155 in consistency analysis, p=0.059, table 1). Conclusions: In patients of type I and type II achalasia, IRP, LESBP and the times of panesophageal pressurization decreased in during sitting position, these changes led to different diagnoses between the two positions. More work should be done to establish criteria based on sitting position. The decreasing of times of panesophageal pressurization maybe related to gravity. Liquid becomes easier to enter the stomach after the shifting of the position, and less liquid provides less intraluminal pressure in the esophagus. These phenomena indicate a similar motility situation of the two subtypes of achalasia. Table 1 Diagnoses of supine and sitting positions.
Pearson's correlation. Significance at *P<0.05, **P<0.01, ***P<0.001
κ=0.155, p=0.059
Tu1994
Tu1996
Increased Frequency of Transient Lower Esophageal Sphincter (LES) Relaxation in Cascade Stomach Akiyo Kawada, Hiroko Hosaka, Shiko Kuribayashi, Shingo Ishihara, Yasuyuki Shimoyama, Osamu Kawamura, Motoyasu Kusano, Masanobu Yamada
Visual Assessment of High Resolution Esophageal Manometry Composite Swallows: Comparison to Conventional Computer Analysis of Individual Swallows. Zubair A. Malik, Henry P. Parkman
Background and Aim: Cascade stomach (CS) is a characteristic morphologic type of the stomach. We previously reported that persons with CS had a high incidence of reflux symptoms as well as dyspepsia (Neurogastro Motil, 2012). It is well known that transient LES relaxation (tLESR) is a major mechanism of gastroesophageal reflux, and that delayed gastric emptying is responsible for tLESR. We hypothesized that persons with CS could have frequent tLESR due to modified gastric empting. Methods: Nine subjects with CS and 8 control non-CS subjects were enrolled. CS was chiefly diagnosed by barium studies and also from endoscopic findings. CS was defined by detection of an air-fluid level in the fundus on an upright barium X-ray film, or by finding separation of the fundus and corpus by a ridge or angle on upper GI endoscopy after air inflation of the stomach. The control subjects were all volunteers with normal barium X-ray studies. Gastroesophageal manometry was performed with a high resolution manometry system (ManoScan, USA) for 2 hours in the sitting position after intake of a standard liquid test meal (250 ml of Ensure H:375 kcal with 31.5 % fat) and gastric emptying was simultaneously measured by a continuous 13C breath ID system (Exalenz Bioscience Ltci. Israel). tLESR was defined as characteristic spontaneous relaxation associated with common cavity (Romans S. Aliment Pharmacol Ther. 2011). The number of tLESR events was counted in the early period (E; 0-60 min.), late period (L; 60-120 min.), and total period (T; 2 hours). The parameters of gastric emptying, including the half empting time (T1/2), lag time (T lag), and gastric empting coefficient (GEC), were calculated over 2 hours. All data were expressed as the median with interquartile range. Results: A total of 166 tLESR events were detected, and there was not significant differences of BMI between CS and control groups; 23.8 (20.9-24.9) vs 20.8(20.5-22.1). In the CS group, the incidence of tLESR in L (4.0 /h, 3.0-7.5) was significantly (p<0.05, MannWhitney U test) higher than (2.5/h, 2.0-3.5) in the controls. In the CS group, the incidence of tLESR in E (6.0/h, 4.0-9.9) and in T (10.0/2h, 7.8-16.0) was also higher than in the controls (4.5/h, 3.5-6.0 and 7.0/2h, 6.5-9.5), but there were no significant differences. In the CS and control groups, the parameters of gastric emptying were as follows: T 1/2 was 112.6 (101.6-130.2) min vs. 118.5 (111.4-149.4) min, T lag was 67.9 (64.0-77.5) min vs. 77.8 (72.0-82.9) min, and GEC was 3.61 (3.31-3.99) vs. 3.52 (3.23-3.97). There were no significant differences between the two groups. Conclusions: In the CS group, the incidence of tLESR was significantly higher than in the control group. This frequent tLESR was not caused by delayed gastric emptying, but could be induced by distention of the gastric fundus due to morphological changes in CS.
Introduction: High resolution esophageal manometry (HREM) is commonly used to evaluate esophageal motility. HREM uses 10 or more swallows to evaluate the function of the esophagus and lower esophageal sphincter. When completed, a composite picture averaging the swallows from the study is often created for result reporting. How visual assessment of this composite compares to analysis based on individual swallows is not known. The aim of this study is to examine the accuracy of diagnosis of esophageal motility disorders using the composite picture compared with the full study analysis of individual swallows. Methods: Eighty two patients who underwent HREM for any clinical indication were evaluated. Patients who had previous surgery to their LES or esophagus were excluded. All patients completed a full HREM that was analyzed using individual swallow analysis using the Chicago Classification by a trained individual. After completion of the analysis, a de-identified composite picture of the study was presented to a second expert gastroenterologist, and a diagnosis was made based solely on the composite image without knowledge of the individual swallow analysis or symptoms. The accuracy of the composite analysis was compared to the individual swallow analysis. Results: Forty three (52.4%) patients were diagnosed correctly based on the composite. The diagnoses included normal, achalasia type 2, scleroderma-like esophagus, and EGJ outflow obstruction. Another 25 patients (30.4%) were diagnosed partially correct. In 12 of these patients a hiatal hernia (HH) was missed, 5 of which were sliding. Another 4 patients had a difference in the size of the breaks (large or small breaks in the esophageal contraction). Six patients had a difference in assessment of LES pressure as low, normal, high. However, 14 patients (17.1%) had an incorrect diagnosis based on the composite picture. Four were incorrect based on LES pressure assessment, and another 3 based on the esophageal contractile strength. One was thought to have small breaks that didn't, and the other two had frequent failed peristalsis that was described as weak peristalsis on the composite. Of patients with achalasia and scleroderma by individual swallow analysis, the composite analysis correctly identified these patients. Conclusions: Visual composite swallow assessment accurately predicts HREM findings in the majority (52%) of patients, while minor abnormalities were missed in another 30.4%, including small or sliding HH. It accurately identifies major motility disorders such as achalasia and scleroderma-like esophagus. However, it is not accurate in correctly assessing the pressure of the LES or esophageal contraction amplitude particularly borderline pressure amplitudes, or intermittent contractile abnormalities such as breaks or failed swallows.
S-893
AGA Abstracts
AGA Abstracts
Tu1993