Relevance of ineffective oesophageal motility during oesophageal acid clearance

Abstract

Background: Oesophageal clearance of acid reflux consists of an initial volume clearance followed by neutralisation of the acidified mucosa by swallowed saliva (chemical clearance). Ineffective oesophageal motility (IOM), a frequent finding in patients with gastro-oesophageal reflux disease (GORD), has been claimed to underlie prolonged acid clearance by affecting oesophageal emptying and saliva transport. Intraluminal impedance allows non-radiological monitoring of movement of oesophageal liquids. Aims: To evaluate the relevance of IOM during oesophageal volume and chemical clearance using combined pH impedance measurements. Subjects: Impedance was validated with fluoroscopy to study volume clearance in three healthy subjects. Acid clearance tests were performed in 10 healthy subjects in the upright and supine positions, before and after oesophageal peristaltic disruption with sildenafil 50 mg. Methods: After instillation of an acid bolus, simultaneous manometry, pH, and impedance were used to study oesophageal motility, chemical clearance, and volume clearance, respectively. Results: Impedance allowed assessment of volume clearance accurately, showing a strong correlation with fluoroscopy (r 2 =0.89). Sildenafil provoked a graded impairment in oesophageal motility in healthy subjects without affecting saliva secretion. In the upright position, volume clearance was slightly prolonged only with severe IOM (>80% abnormal peristaltic sequences). In the supine position, severe IOM significantly prolonged chemical and volume clearance. Moderate IOM (30-80% abnormal peristalsis) had no effect. With normal peristalsis and moderate IOM, clearance times were similar in the upright and supine positions. Severe IOM however had a greater impact on clearance in the supine than in the upright position. Conclusion: Ineffective oesophageal motility has little effect on oesophageal clearance during upright acid reflux. With supine reflux, only severe IOM is associated with prolonged oesophageal clearance.

Different patterns of oesophageal acid exposure distinguish complicated reflux disease from either erosive reflux oesophagitis or non‐erosive reflux disease

“…These findings confirm that peristaltic dysfunction contributes to increased oesophageal exposure to refluxed acid material, 31 particularly in the supine position when it is associated with impaired oesophageal clearance. 34 Moreover, our results confirm that the presence of hiatal hernia contributes much more than the basal lower oesophageal sphincter tone to the presence and severity of endoscopically detectable mucosal lesions in GERD, [35][36][37] and this is in keeping with its relevance in the management of complicated and atypical GERD. 26 The severity of heartburn was similar between the three groups of patients in our series, confirming that NERD should not be considered as a mild form of GERD, 3 and that the severity of reflux symptoms is similar when patients with erosive reflux oesophagitis and with complicated reflux disease are compared.…”

The effect of sildenafil on segmental oesophageal motility and gastro‐oesophageal reflux

“…But, along with the publication by Simren et al 18 in which only severe ineffective oesophageal motility induced by sildenafil is associated with prolonged oesophageal clearance, at least we can conclude that gastro-oesophageal reflux may not be a major side effect of sildenafil. In summary, we investigated the effect of sildenafil on segmental oesophageal motility and gastro-oesophageal reflux using combined MII-EM and MII-pH devices.…”

High-resolution Impedance Manometry Criteria in the Sitting Position Indicative of Incomplete Bolus Clearance

“…Several studies showed strong correlation between impedance measurements and videofluoroscopy in assessing bolus transit in healthy adults. 14,21 Only one small study validated esophageal impedance method for bolus transit patterns in comparison with barium videoesophagram in 16 dysphagia patients, and still showed impedance monitoring as a valid transit test in dyspeptic patients with severe barium stasis. 22 However, studies using concurrent manometric and videofluoroscopic recording in symptomatic patients showed an excellent correlation between the findings from 2 tests.…”

“…Bolus entry was defined as ≥ 50% decrease in impedance with respect to baseline. [12][13][14] Bolus clearance was defined as sustained (＞ 5 seconds) ≥ 50% increase in impedance from the original baseline impedance. 15 Complete bolus clearance was defined as bolus entry followed by bolus clearance at all impedance recording sites, and incomplete bolus clearance was defined as bolus entry followed by failure of bolus clearance at any of the impedance recording sites.…”

“…In the isobaric 30-mmHg contour, the median (interquartile range) length of the break of incomplete bolus clearance was 13.5 (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) cm and that of complete clearance was 3 (1-6) cm (P ＜ 0.001).…”