Evaluating esophageal motility beyond primary peristalsis: Assessing esophagogastric junction opening mechanics and secondary peristalsis in patients with normal manometry

Abstract

Background Functional luminal imaging probe (FLIP) Panometry assesses the esophageal response to distention and may complement the assessment of primary peristalsis on high‐resolution manometry (HRM). We aimed to investigate whether FLIP Panometry provides complementary information in patients with normal esophageal motility on HRM. Methods Adult patients that completed FLIP and had an HRM classification of normal motility were retrospectively identified for inclusion. 16‐cm FLIP studies performed during endoscopy were evaluated to assess EGJ distensibility, secondary peristalsis, and identify an abnormal response to distention involving sustained LES contraction (sLESC). Clinical characteristics and esophagram were assessed when available. Key Results Of 164 patients included (mean(SD) age 48(16) years, 75% female), 111 (68%) had normal Panometry with EGJ‐distensibility index (DI) ≥2.0 mm2/mmHg, maximum EGJ diameter ≥16mm and antegrade contractions. Abnormal EGJ distensibility was observed in 44/164 (27%), and 38/164 (23%) had an abnormal contractile response to distension. sLESC was observed in 11/164 (7%). Among 68 patients that completed esophagram, abnormal EGJ distensibility was more frequently observed with an abnormal esophagram than normal EGJ opening: 14/23 (61%) vs 10/45 (22%); P=0.003. Epiphrenic diverticula were present in 3/164 patients: 2/3 had sLESC. Conclusions & Inferences Symptomatic patients with normal esophageal motility on HRM predominantly have normal FLIP Panometry; however, abnormal FLIP findings can be observed. While abnormal Panometry findings appear clinically relevant via an association with abnormal bolus retention, complementary tests, such as provocative maneuvers with HRM and timed barium esophagram, are useful to determine clinical context.

Functional Luminal Imaging Probe (FLIP) as an Adjunctive Modality in Evaluation of Esophageal Dysmotility

“…This was demonstrated in a study focused on symptomatic patients with normal motility on HRM (ie, normal primary peristalsis and normal deglutitive EGJ pressures) that described FLIP Panometry findings in this cohort. 21 Overall, 73% of patients (120/164) with normal HRM had normal EGJ opening and 77% patients (126/164) had antegrade contractions on FLIP (NCR or BCR). 21 Thus, abnormal secondary peristalsis in this cohort of symptomatic patients with normal primary peristalsis was observed at similar rates as the aforementioned studies that compared secondary and primary peristalsis on manometry.…”

“…21 Overall, 73% of patients (120/164) with normal HRM had normal EGJ opening and 77% patients (126/164) had antegrade contractions on FLIP (NCR or BCR). 21 Thus, abnormal secondary peristalsis in this cohort of symptomatic patients with normal primary peristalsis was observed at similar rates as the aforementioned studies that compared secondary and primary peristalsis on manometry. 34,35 Of interest however, was that when the subset of this cohort that completed TBE was examined (n = 64), abnormal retention on TBE was associated with abnormal EGJ opening, suggesting the potential for the clinical significance of abnormal EGJ opening in the setting of normal deglutitive EGJ pressures.…”

“…FLIP Panometry measures distensibility and parameters of EGJ opening, distensibility of the esophageal wall, as well as evaluating the contractile response to distension, that is, secondary peristalsis. 17,[21][22][23] Secondary peristalsis functions to clear the esophagus of retained or refluxed esophageal contents and maintain an empty esophagus. 21,22,[24][25][26] On the other hand, primary peristalsis (which is typically evaluated by HRM) is the principle form of esophageal motility triggered by swallowing that facilitates bolus transit to the stomach.…”

“…17,[21][22][23] Secondary peristalsis functions to clear the esophagus of retained or refluxed esophageal contents and maintain an empty esophagus. 21,22,[24][25][26] On the other hand, primary peristalsis (which is typically evaluated by HRM) is the principle form of esophageal motility triggered by swallowing that facilitates bolus transit to the stomach. 11 Similar to primary peristalsis, abnormal secondary peristalsis can lead to dysphagia and pathologic acid reflux.…”

“…Additionally, when dynamic changes in EGJ opening dimensions are occurring, such as in response to antegrade contractions, the EGJ-DI is calculated at moments of greatest EGJ opening (ie, greatest EGJ-diameters). 17,21,29 Normal values of the EGJ-DI (at 60 ml with 16-cm FLIP) and the "maximum EGJ diameter" (ie, the greatest EGJ-midline diameter achieved during the 60 or 70 ml fill volume, with the 16-cm FLIP) were shown to be a median (5th-95th percentiles) EGJ-DI of 5.8 (3.2-8.4) mm 2 /mmHg and a maximum EGJ diameter of 20.4 (16.7-21.9) mm. 30 Further, clinical interpretation of EGJ opening function can be facilitated by jointly applying both the EGJ-DI and the maximum EGJ diameter (Figure 3).…”