Background and Aim This study aimed to analyze the mechanical properties of the esophagus in eosinophilic esophagitis (EoE) using the functional luminal imaging probe (EndoFLIP®, Crospon Medical Devices, Galway, Ireland). Methods 35 EoE patients (24M, 23-67y) and 15 controls (6M, 21–68y) were included. Subjects were evaluated during endoscopy with the EndoFLIP® probe comprised of a compliant cylindrical bag (maximal diameter 25mm) with 16 impedance planimetry segments. Stepwise bag distensions from 2 to 40mL were conducted and the associated intra-bag pressure and intra-luminal geometry were analyzed. Results The EndoFLIP® clearly displayed the tubular esophageal geometry and detected esophageal narrowing and localized strictures. Stepwise distension progressively opened the esophageal lumen until a distension plateau was reached such that the narrowest cross-sectional area (CSA) of the esophagus maximized despite further increases in intra-bag pressure. The esophageal distensibility (CSA vs. pressure) was reduced in EoE patients (p=0.02) with the distension plateau of EoE patients substantially lower than that of controls (median CSA 267 vs. 438 mm2, p<0.01). Neither mucosal eosinophil count, age, gender, nor current PPI treatment predicted this limiting caliber of the esophagus (p≥0.20). Conclusion Esophageal distensibility, defined by the change in the narrowest measurable CSA within the distal esophagus vs. intra-luminal pressure, was significantly reduced in EoE patients compared to controls. Measuring esophageal distensibility may be an important adjunct to the management of EoE as it is capable of providing an objective means to measure the outcome of medical or dilation therapy.

Backgrounds & Aims This study aimed to refine the criteria for esophageal hypercontractility in high resolution esophageal pressure topography (EPT) and examine the clinical context in which it occurs. Subjects & Methods 72 control subjects were used to define the threshold for hypercontractility as a distal contractile integral (DCI) greater than observed in normals. 2,000 consecutive EPT studies were reviewed to find patients exceeding this threshold. Concomitant EPT and clinical variables were explored. Results The greatest DCI value observed in any swallow among the control subjects was 7,732 mmHg-s-cm; the threshold for hypercontractility was established as a swallow with DCI >8,000 mmHg-s-cm. 44 patients were identified with a median maximal DCI of 11,077 mmHg-s-cm, all with normal contractile propagation and normal distal contractile latency, thereby excluding achalasia and distal esophageal spasm. Hypercontractility was associated with multipeaked contractions in 82% of instances leading to the name Jackhammer Esophagus . Dysphagia was the dominant symptom although subsets of patients had hypercontractility in the context of EGJ outflow obstruction, reflux disease, or as an apparent primary motility disorder. Conclusion We describe an extreme phenotype of hypercontractility characterized in EPT by the occurrence of at least a single contraction with DCI > 8,000 mmHg-s-cm, a value not encountered in control subjects. This phenomenon, branded Jackhammer Esophagus was usually accompanied by dysphagia and occurred both in association with other esophageal pathology (EGJ outflow obstruction, reflux disease) or as an isolated motility disturbance. Further studies are required to define the pathophysiology and treatment of this disorder.

BACKGROUND The manometric diagnosis of distal esophageal spasm (DES) uses “simultaneous contractions” as a defining criterion, ignoring the concept of short latency distal contractions as an important feature. Our aim was to apply standardized metrics of contraction velocity and latency to high-resolution esophageal pressure topography (EPT) studies to refine the diagnosis of DES. METHODS Two thousand consecutive EPT studies were analyzed for contractile front velocity (CFV) and distal latency to identify patients potentially having DES. Normal limits for CFV and distal latency were established from 75 control subjects. Clinical data of patients with reduced distal latency and/or rapid CFV were reviewed. RESULTS Of 1070 evaluable patients, 91 (8.5%) had a high CFV and/or low distal latency. Patients with only rapid contractions (n = 186 [17.4%] using conventional manometry criteria; n = 85 [7.9%] using EPT criteria) were heterogeneous in diagnosis and symptoms, with the majority ultimately categorized as weak peristalsis or normal. In contrast, 96% of patients with premature contraction had dysphagia, and all (n = 24; 2.2% overall) were ultimately managed as spastic achalasia or DES. CONCLUSIONS The current DES diagnostic paradigm focused on “simultaneous contractions” identifies a large heterogeneous set of patients, most of whom do not have a clinical syndrome suggestive of esophageal spasm. Incorporating distal latency into the diagnostic algorithm of EPT studies improves upon this by isolating disorders of homogeneous pathophysiology: DES with short latency and spastic achalasia. We hypothesize that prioritizing measurement of distal latency will refine the management of these disorders, recognizing that outcomes trials are necessary.

Background-This study aimed to correlate oesophageal bolus transit with features of oesophageal pressure topography (OPT) plots and establish OPT metrics for accurately measuring peristaltic velocity.

Backgrounds & Aims Clinical esophageal manometry can be technically challenging. We investigated the prevalence and causes of technically imperfect, high-resolution esophageal pressure topography (EPT) studies at a tertiary referral hospital. Methods We reviewed 2,000 consecutive clinical EPT studies that had been performed with consistent technique and protocol. A study was considered technically imperfect if there was a problem with pressure signal acquisition, if the catheter did not pass through the esophagogastric junction (EGJ), or if there were less than 7 evaluable swallows (without double-swallowing, etc). Data from the technically imperfect studies were interpreted blindly to determine a diagnosis; this diagnosis was compared with that based on chart review. Results We identified 414 technically imperfect studies (21% of the series). These were attributed to fewer than 7 evaluable swallows (58%), inability to traverse the EGJ (29%), sensor or thermal compensation malfunction (7%), and miscellaneous artifacts (6%). The most frequent causes of failure to traverse the EGJ were a large hiatal hernia (50%) and achalasia (24%). The condition most frequently associated with an incomplete swallow protocol was achalasia (33%). Despite the limitations, the diagnosis of achalasia was correctly achieved by blinded interpretation in 77% of cases and non-blinded interpretation in 94% of cases. Conclusion Technically imperfect EPT studies are common in a tertiary care center; large hiatal hernia and achalasia were the most frequent causes. However, despite the technical limitations, the data could still be interpreted, especially in the context of associated endoscopic and radiographic data.

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