Esophageal Hypervigilance and Visceral Anxiety Are Contributors to Symptom Severity Among Patients Evaluated With High-Resolution Esophageal Manometry

Abstract

OBJECTIVES: Symptoms are inconsistently associated with esophageal motor findings on high-resolution manometry (HRM). We aimed to evaluate predictors of dysphagia severity, including esophageal hypervigilance and visceral anxiety, among patients evaluated with HRM. METHODS: Adult patients undergoing HRM at 4 academic medical centers (United States and France) were prospectively evaluated. HRM was completed and analyzed per the Chicago Classification v3.0. Validated symptom scores, including the Brief Esophageal Dysphagia Questionnaire and Esophageal Hypervigilance and Anxiety Scale, were completed at the time of HRM. RESULTS: Two hundred thirty-six patients, aged 18–85 (mean 53) years, 65% female, were included. Approximately 59 (25%) patients had a major motor disorder on HRM: 19 achalasia, 24 esophagogastric junction outflow obstruction, 12 absent contractility, and 4 jackhammer. Approximately 177 (75%) patients did not have a major motor disorder: 71 ineffective esophageal motility and 106 normal motility. Having a major motor disorder was a significant predictor of dysphagia severity (R2adj = 0.049, P < 0.001), but the Esophageal Hypervigilance and Anxiety Scale score carried a predictive relationship of Brief Esophageal Dysphagia Questionnaire that was 2-fold higher than having a major motor disorder: R2adj = 0.118 (P < 0.001). This finding remained when evaluated by the major motor disorder group. HRM metrics were nonsignificant. DISCUSSION: In a prospective, international multicenter study, we found that esophageal hypervigilance and visceral anxiety were the strongest predictors of dysphagia severity among patients evaluated with HRM. Thus, an assessment of esophageal hypervigilance and visceral anxiety is important to incorporate when evaluating symptom severity in clinical practice and research studies.

Multiple rapid swallows and rapid drink challenge in patients with esophagogastric junction outflow obstruction on high‐resolution manometry

“…Finally, greater BEDQ scores remained associated with RAD‐EGJOO, even among the study cohort composed primarily of patients evaluated with an indication of dysphagia. Thus, although abnormal symptoms scores are not unique between esophageal motility disorders, 28 their complementary role in the clinical evaluation is supported by this study.…”

“…Figure used with permission from the Esophageal Center at Northwestern greater BEDQ scores remained associated with RAD-EGJOO,even among the study cohort composed primarily of patients evaluated with an indication of dysphagia. Thus, although abnormal symptoms scores are not unique between esophageal motility disorders,28 their complementary role in the clinical evaluation is supported by this study.While the current study assessed a large cohort of patients that were comprehensively evaluated with HRM including provocative maneuvers, esophagram, and validated symptom scores, this study does carry limitations. As is similar in most of esophageal motor disorders, a perfect "gold standard" to assess for specific esophageal motility disorders is lacking.…”

Supragastric belching in Japan: lower prevalence and relevance for management of gastroesophageal reflux disease compared to United Kingdom

“…Hypervigilance is a part of cognitive and affective process which causes patients to pay much more attention to symptoms, and interacts with hypersensitivity mutually [31]. Recent study shows esophageal hypervigilance can predict dysphagia severity better than objective Adjusted for age, BMI (log scale), study indication, total AET (log scale), total reflux episodes (log scale), acid reflux episodes (log scale), proximal extent (log scale), gastric pH \ 4 holding time and reflux symptom association motility-related parameters [32]. Further studies are required to compare the prevalence of esophageal hypervigilance among race/ethnics.…”

“…Hypervigilance is a part of cognitive and affective process which causes patients to pay much more attention to symptoms, and interacts with hypersensitivity mutually [ 31 ]. Recent study shows esophageal hypervigilance can predict dysphagia severity better than objective motility-related parameters [ 32 ]. Further studies are required to compare the prevalence of esophageal hypervigilance among race/ethnics.…”

Reply

“…level of hypervigilance, a specific psychological approach would be recommended. 3 It therefore is recommended that the diagnostic algorithm in patients with proton pump inhibitor-refractory gastroesophageal reflux disease should include a comprehensive assessment of psychological factors such as anxiety, depression, and levels of hypervigilance. 4 Finally, it is important to acknowledge that both our study on behavioral disorders in reflux hypersensitivity and the co-existence of other functional gastrointestinal disorders in these patients 1,5 Reply.…”