Fragmented esophageal smooth muscle contraction segments on high resolution manometry: a marker of esophageal hypomotility

Porter, Ryan; Kumar, Nitin; Drapekin, Jesse; Gyawali, C. Prakash

doi:10.1111/j.1365-2982.2012.01930.x

Cited by 34 publications

(28 citation statements)

References 24 publications

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“…We were unable to recruit normal controls on no medications, with no comorbidities and no symptoms in older age groups, which were our standards for the normal cohort. In other comparisons in the past, younger GERD patients had esophageal hypomotility patterns similar to older GERD patients, and both were significantly different from these normal controls (11). Hence, we believe our normal cohort is relevant for the current comparisons.…”

Section: Discussionmentioning

confidence: 76%

Multiple Rapid Swallow Responses During Esophageal High-Resolution Manometry Reflect Esophageal Body Peristaltic Reserve

Shaker

Stoikes

Drapekin

et al. 2013

American Journal of Gastroenterology

221

274

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OBJECTIVES Dysphagia may develop following antireflux surgery as a consequence of poor esophageal peristaltic reserve. We hypothesized that suboptimal contraction response following multiple rapid swallows (MRS) could be associated with chronic transit symptoms following antireflux surgery. METHODS Wet swallow and MRS responses on esophageal high-resolution manometry (HRM) were characterized collectively in the esophageal body (distal contractile integral (DCI)), and individually in each smooth muscle contraction segment (S2 and S3 amplitudes) in 63 patients undergoing antireflux surgery and in 18 healthy controls. Dysphagia was assessed using symptom questionnaires. The MRS/wet swallow ratios were calculated for S2 and S3 peak amplitudes and DCI. MRS responses were compared in patients with and without late postoperative dysphagia following antireflux surgery. RESULTS Augmentation of smooth muscle contraction (MRS/wet swallow ratios > 1.0) as measured collectively by DCI was seen in only 11.1% with late postoperative dysphagia, compared with 63.6% in those with no dysphagia and 78.1% in controls (P≤0.02 for each comparison). Similar results were seen with S3 but not S2 peak amplitude ratios. Receiver operating characteristics identified a DCI MRS/wet swallow ratio threshold of 0.85 in segregating patients with late postoperative dysphagia from those with no postoperative dysphagia with a sensitivity of 0.67 and specificity of 0.64. CONCLUSIONS Lack of augmentation of smooth muscle contraction following MRS is associated with late postoperative dysphagia following antireflux surgery, suggesting that MRS responses could assess esophageal smooth muscle peristaltic reserve. Further research is warranted to determine if antireflux surgery needs to be tailored to the MRS response.

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Section: Discussionmentioning

confidence: 76%

Multiple Rapid Swallow Responses During Esophageal High-Resolution Manometry Reflect Esophageal Body Peristaltic Reserve

Shaker

Stoikes

Drapekin

et al. 2013

American Journal of Gastroenterology

221

274

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“…While some resolved their IEM following ARS, others developed IEM and yet others had persistent IEM. Prior work suggests that the S2 segment is most frequently weak or absent in GERD-associated dysmotility, 6 and this can contribute to delayed onset of smooth muscle contraction, the so called ‘proximal latency’ of smooth muscle contraction in the esophagus. 5 Smooth muscle contraction, including second segment contraction may augment following provocative testing with MRS or solid bolus challenge 23,24 – the likelihood of late postoperative dysphagia is significantly higher in individuals that do not augment smooth muscle contraction and do not have ‘peristaltic reserve’ on provocative testing.…”

Section: Discussionmentioning

confidence: 99%

Ineffective esophageal motility phenotypes following fundoplication in gastroesophageal reflux disease

Mello

Shriver

et al. 2015

Neurogastroenterology Motil

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Background Ineffective esophageal motility (IEM) is associated with reflux disease, but its natural history is unclear. We evaluated patients undergoing repeat esophageal high resolution manometry (HRM) for symptomatic presentations after antireflux surgery (ARS) to understand the progression of IEM. Methods Patients with repeat HRM after ARS were included. Ineffective esophageal motility was diagnosed if ≥5 sequences had distal contractile integral (DCI) <450 mmHg cm s. Augmentation of DCI following multiple rapid swallows (MRS) was assessed. The esophagogastric junction (EGJ) was interrogated using the EGJ contractile integral (EGJ-CI). Esophageal motor function was compared between patients with and without IEM. Key Results Sixty-eight patients (53.9 ± 1.8 years, 66.2% female) had pre- and post-ARS HRM studies 2.1 ± 0.19 years apart. Esophagogastric junction-CI augmented by a mean of 26.3% following ARS. Four IEM phenotypes were identified: 14.7% had persistent IEM, 8.8% resolved IEM after ARS, 19.1% developed new IEM, and 57.4% had no IEM at any point. Patients with IEM had a lower DCI pre- and post-ARS, lower pre-ARS EGJ CI, and lower pre-ARS-integrated relaxation pressure (p ≤ 0.02 for all comparisons); presenting symptoms and other EGJ metrics were similar (p ≥ 0.08 for all comparisons). The IEM phenotypes could be predicted by MRS DCI response patterns (p = 0.008 across groups); patients with persistent IEM had the least DCI augmentation (p = 0.007 compared to no IEM), while those who resolved IEM had DCI augmentation comparable to no IEM (p = 0.08). Conclusions & Inferences Distinct phenotypes of IEM exist among symptomatic reflux patients following ARS. Provocative testing with MRS may help identify these phenotypes pre-ARS.

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“…We demonstrate that high burden of dysphagia assessed by MDQ suggests patterns such as esophageal outflow obstruction and hypermotility. High reflux symptom burden specifically assessed by the GERDQ portends a higher likelihood of having a hypomotility pattern on HRM, which are known to be associated with GERD 18 . We report that subjects with dominant specific symptoms particularly dysphagia or reflux tend to have the most profound CC diagnoses, particularly when GSS is >70, and dysphagia is rated at least moderate or occurring daily.…”

Section: Discussionmentioning

confidence: 99%

Impact of symptom burden and health‐related quality of life (HRQOL) on esophageal motor diagnoses

Reddy

Patel

Gyawali

2016

Neurogastroenterology Motil

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High resolution manometry (HRM) categorizes esophageal motor processes into specific Chicago Classification (CC) diagnoses, but the clinical impact of these motor diagnoses on symptom burden remain unclear. Methods 211 subjects (56.8±1.0 yrs, 66.8% F) completed symptom questionnaires [GERDQ, Mayo dysphagia questionnaire (MDQ), visceral sensitivity index (VSI), short-form 36 (SF-36), dominant symptom index (DSI), and global symptom severity (GSS) on a 100-mm visual analog scale] prior to HRM. Subjects were stratified according to CC v3.0 and by dominant presenting symptom; contraction wave abnormalities (CWA) were evaluated within ‘normal’ CC. Symptom burden, impact of diagnoses, and HRQOL were compared within and between cohorts. Results Major motor disorders had highest global symptom burden (p=0.02), ‘normal’ had lowest (p<0.01). Dysphagia (MDQ) was highest with esophageal outflow obstruction (p=0.02), but reflux symptoms (GERDQ) were similar in CC cohorts (p=ns). Absent contractility aligned best with minor motor disorders. Consequently, pathophysiologic categorization into outflow obstruction, hypermotility, and hypomotility resulted in a gradient of decreasing dysphagia and increasing reflux burden (p<0.05 across groups); GSS (p=0.05) was highest with hypomotility and lowest with ‘normal’ (p=0.002). Within the ‘normal’ cohort, 33.3% had CWA; this subgroup had symptom burden similar to hypermotility. Upon stratification by symptoms, symptom burden (GSS, MDQ, HRQOL) was most profound with dysphagia. Conclusions CC v3.0 diagnoses identify subjects with highest symptom burden, but pathophysiologic categorization may allow better stratification by symptom type and burden. CWA are clinically relevant and different from true normal motor function. Transit symptoms have highest yield for a motor diagnosis.

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Fragmented esophageal smooth muscle contraction segments on high resolution manometry: a marker of esophageal hypomotility

Abstract: Evaluation of smooth muscle contraction segments adds value to HRM analysis. Specifically, fragmented smooth muscle contraction segments may be a marker of esophageal hypomotility.

Cited by 34 publications

References 24 publications

Multiple Rapid Swallow Responses During Esophageal High-Resolution Manometry Reflect Esophageal Body Peristaltic Reserve

Multiple Rapid Swallow Responses During Esophageal High-Resolution Manometry Reflect Esophageal Body Peristaltic Reserve

Ineffective esophageal motility phenotypes following fundoplication in gastroesophageal reflux disease

Impact of symptom burden and health‐related quality of life (HRQOL) on esophageal motor diagnoses

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