Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium

Abstract

Background Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450 mm Hg cm s) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high‐resolution manometry (HRM). Ineffective esophageal motility is not consistently related to disease states or symptoms and may be seen in asymptomatic healthy individuals. Purpose A 1‐day symposium of esophageal experts reviewed existing literature on IEM, and this review represents the conclusions from the symposium. Severe IEM (>70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.

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

“…The presence of 70% or more ineffective contractions should also be considered in the definition, as recently suggested by a group of experts 11 . Indeed, in the present study, this pattern could predict impaired bolus clearance with a high sensitivity and a better specificity than the cut‐off of more than 50% currently used in the Chicago classification 7 .…”

“…In the current version of the Chicago classification, no distinction is made between failed and weak contraction to reach the threshold of more than 50% of ineffective contractions 7 . Recently, it has been proposed to consider severe IEM as defined by 70% or more ineffective contractions 11 as it has been shown to be associated with more severe gastro‐esophageal reflux 12 . The aim of the present study was to determine motility patterns which best predict IEM, defined as impaired bolus clearance, using high‐resolution esophageal motility combined with multichannel esophageal impedance recording, in a control group of healthy non‐symptomatic subjects, and a cohort of consecutive patients referred for esophageal manometry.…”

“…Some authors recently proposed to consider “severe” IEM when 70% or more ineffective contractions were observed, 11 because this pattern is associated with abnormal esophageal acid burden 12 . Finally, the absence of a contraction reserve (CR) after multiple rapid swallows (MRS) has been associated with IBT, 3 more severe acid reflux 13 and occurrence of late post‐fundoplication dysphagia 14 and therefore may be an additional criterium included in the definition of IEM 11 …”

Alteraciones motoras menores del esófago según manometría de alta resolución: ¿qué significan?

“…Se la ha descrito en relación con múltiples trastornos (Tabla 2). Desde un punto de vista fisiopatológico es un trastorno muy heterogéneo y se han descrito alteraciones neuropáticas aferentes y eferentes, así como alteraciones miopáticas y fibrosis [16][17][18] . La preponderancia de cada uno de estos mecanismos parece depender sobre todo de la causa de la MEI.…”

Neuronal Control of Esophageal Peristalsis and Its Role in Esophageal Disease

“…The pathophysiology of IEM is multifactorial, and any factors affecting peristalsis, bolus transit, and clearance may be involved. In physiologic terms, IEM is the end result of defects in either (a) the initial stretching of the esophageal muscle that fires off a mechanosensitive pathway for the initiation of peristalsis, (b) the intrinsic esophageal contractility, or (c) the "afterload" resistance that the contraction should overcome [105].…”