Ineffective esophageal motility and bolus clearance. A study with combined high‐resolution manometry and impedance in asymptomatic controls and patients

Abstract

Background The definition and relevance of ineffective esophageal motility (IEM) remains debated. Our aim was to determine motility patterns and symptoms associated with IEM defined as impaired bolus clearance. Methods To define altered bolus clearance, normal range of swallows with complete bolus transit (CBT) on high‐resolution impedance manometry (HRIM) was determined in 44 asymptomatic controls. The results were then applied to a cohort of 81 patients with esophageal symptoms to determine the motility patterns which best predicted altered bolus clearance. Subsequently, in a cohort of 281 consecutive patients the identified motility patterns were compared with patients’ customary symptoms. Key Results In asymptomatic controls, the normal range of swallows with CBT was 50%‐100%. In patients, altered bolus transit (<50% CBT) was only associated with 30% or more failed contractions (P < .001). Neither weak peristalsis nor absence of contraction reserve (CR) was associated with altered bolus clearance. The patterns which best predicted altered bolus clearance were failed contractions ≥30% (specificity 88.2% and sensitivity of 84.6%), and ≥70% ineffective (failed + weak) contractions (sensitivity 84.6% and specificity 80.9%). No motility pattern was correlated to symptom scores. Conclusions and Inferences Based on bolus clearance assessed by HRIM, ≥30% failed contractions and ≥70% ineffective contractions have the best sensitivity and specificity to predict altered bolus clearance. Weak contractions and absence of CR are not relevant with respect to bolus clearance.

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

“…Fragmented peristalsis is now removed as a disorder and incorporated into the overall diagnosis of IEM (Very Low GRADE, Strong Recommendation). 60,61 Disorders of peristalsis are considered when a disorder of EGJ outflow has been ruled out. There is potential for overlapping features of abnormal peristalsis to exist.…”

“…Consistent with prior iterations of Chicago Classification, absent contractility, DES, hypercontractile esophagus, and IEM are considered disorders of peristalsis. Fragmented peristalsis is now removed as a disorder and incorporated into the overall diagnosis of IEM (Very Low GRADE, Strong Recommendation) 60,61 . Disorders of peristalsis are considered when a disorder of EGJ outflow has been ruled out.…”

“…• A conclusive diagnosis of IEM requires more than 70% ineffective swallows or at least 50% failed peristalsis (Very Low GRADE, Strong Recommendation). 60,[69][70][71] As detailed in Diagnostic Thresholds and in…”

Impact of ineffective esophageal motility on secondary peristalsis: Studies with high‐resolution manometry

“…With the advent of high‐resolution manometry (HRM) and esophageal pressure topography (EPT), these criteria were translated as distal contractile integral (DCI) < 450 mm Hg.cm.s to define ineffective swallows, and ≥50% ineffective swallows are required for an IEM diagnosis according to the Chicago Classification 3.0 6 . Studies have found that IEM can impair esophageal clearance and might be an important contributing pathophysiologic factor in GERD 3,4,7–9 …”

“…6 Studies have found that IEM can impair esophageal clearance and might be an important contributing pathophysiologic factor in GERD. 3,4,[7][8][9] Secondary peristalsis contributes to maintenance of an empty esophagus by clearing refluxed gastric contents or residual food bolus after a failed primary peristalsis or after a reflux event. 10 This plays an important role in the return of esophageal pH to baseline following a reflux event, in order to prevent prolonged acid exposure in the esophagus.…”