High‐resolution impedance manometry parameters in the evaluation of esophageal function of non‐obstructive dysphagia patients

Abstract

Background High‐resolution impedance manometry (HRIM) allows evaluation of esophageal bolus retention, flow, and pressurization. We explored novel HRIM measures and assessed their temporal relationship to dysphagia symptoms for boluses of different volume and consistency in non‐obstructive dysphagia (NOD) patients. Methods Thirty‐three NOD patients (n = 19 minor or no disorder of peristalsis (“Normal”) and n = 14 esophagogastric junction outflow obstruction (“EGJOO”)) were evaluated with HRIM. Patients were administered 5 and 10 mL liquid, semisolid, and 2 and 4 cm solid boluses and indicated bolus perception during individual swallows using a 5‐point Likert scale. HRIM was analyzed to assess Chicago Classification and pressure flow metrics, esophageal impedance integral (EII) ratio, and bolus flow time (BFT). Key Results Overall, bolus perception increased with increasing bolus consistency (P < 0.001), but did not differ significantly between EGJOO and Normal patients. EGJOO patients had higher IRP4, higher levels of bolus residual (ie, EII ratio and IR), and restricted esophageal emptying. The results for linking semisolid bolus perception to semisolid‐derived measures revealed more biomechanically plausible and consistent patterns when compared to those derived for liquid boluses. In Normal patients, perception of boluses of heavier viscosity was related to higher bolus flow resistance during transport, whilst in EGJOO, perception was related to restriction of esophageal emptying. Conclusion & Inferences These novel pressure‐impedance measures may aid in the evaluation of NOD patients by revealing abnormal motor patterns, which may explain symptom generation. Future studies are needed to evaluate which of these measures are worthy of calculation and to establish protocol settings that allow for their meaningful interpretation.

Esophageal motility disorders on high‐resolution manometry: Chicago classification version 4.0©

“…• A manometric diagnosis of EGJOO is defined as an elevated median IRP in the primary and secondary position and ≥20% swallows with elevated intrabolus pressure in the supine position, with evidence of peristalsis (Low GRADE, Conditional Recommendation). 11,18,46,50,51,[53][54][55] •…”

“… A manometric diagnosis of EGJOO is always considered clinically inconclusive (Strong Recommendation). A manometric diagnosis of EGJOO is defined as an elevated median IRP in the primary and secondary position and ≥20% swallows with elevated intrabolus pressure in the supine position, with evidence of peristalsis (Low GRADE, Conditional Recommendation) 11,18,46,50,51,53–55 A clinically relevant conclusive diagnosis of EGJOO requires a manometric diagnosis of EGJOO and clinically relevant symptoms with at least one of the following supportive investigations supporting obstruction (TBE, preferably in conjunction with a barium tablet swallow, and/or FLIP) (Moderate GRADE, Conditional Recommendation) 11–13,18,37 …”

Jackhammer esophagus: Clinical presentation, manometric diagnosis, and therapeutic results—Results from a multicenter French cohort

“…However, these results confirm that symptoms are not driven solely by the vigor or frequency of abnormal esophageal contractions; the other peripheral or central factors that participate in symptom perception in these patients need to be determined. High‐resolution impedance manometry that allows evaluation of esophageal bolus retention, flow, and pressurization might be useful to better understand the mechanism of dysphagia in patients with JE, as it has been recently reported in patients with achalasia and in patients with non‐obstructive dysphagia related to esophagogastric junction outflow obstruction 24,25 …”

Chicago classification version 4.0© technical review: Update on standard high‐resolution manometry protocol for the assessment of esophageal motility

“…High‐resolution impedance manometry is recommended, though not required by CCv4.0, to assess not only pharyngeal function, but also intra‐bolus pressure and bolus clearance through the EGJ. This combined technology is the subject of separate articles 11‐13 …”