Reproducibility patterns of multiple rapid swallows during high resolution esophageal manometry provide insights into esophageal pathophysiology

Abstract

Background Multiple rapid swallows (MRS) during esophageal high resolution manometry (HRM) assess esophageal neuromuscular integrity by evaluating post deglutitive inhibition and rebound contraction, but most reports performed only a single MRS sequence. We assessed patterns of MRS reproducibility during clinical HRM in comparison to a normal cohort. Methods Consecutive clinical HRM studies were included if two separate MRS sequences (4–6 rapid swallows ≤4 sec apart) were successfully performed. Chicago Classification diagnoses were identified; contraction wave abnormalities were additionally recorded. MRS induced inhibition (contraction ≤3 cm during inhibition phase) and rebound contraction was assessed, and findings compared to 18 controls (28.0 ±0.7 year, 50.0% female). Reproducibility consisted of similar inhibition and contraction responses with both sequences; discordance was segregated into inhibition and contraction phases. Results MRS was successfully performed in 89.3% patients and all controls; 225 subjects (56.2 ±0.9 year, 62.7% female) met study inclusion criteria. MRS was reproducible in 76.9% patients and 94.4% controls (inhibition phase: 88.0% vs. 94.4%, contraction phase 86.7% vs. 100% respectively, p=ns). A gradient of reproducibility was noted, highest in well-developed motor disorders (achalasia spectrum, hypermotility disorders and aperistalsis, 91.7–100%, p=ns compared to controls); and lower in lesser motor disorders (contraction wave abnormalities, esophageal body hypomotility) or normal studies (62.2–70.8%, p<0.0001 compared to well-developed motor disorders). Inhibition phase was most discordant in contraction wave abnormalities, while contraction phase was most discordant when studies were designated normal. Conclusions MRS is highly reproducible, especially in well-developed motor disorders, and complements the standard wet swallow manometry protocol.

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

“…HRM studies were performed after an overnight fast using a 36-channel solid-state catheter system with high fidelity circumferential sensors at 1 cm intervals (Medtronic, Duluth, GA), as previously described 7, 8 . After calibration, the catheter was passed through an anesthetized nasal canal, and taped to the nose after adequate positioning.…”

Exaggerated smooth muscle contraction segments on esophageal high‐resolution manometry: prevalence and clinical relevance

“…Multiple rapid swallows sequences were analyzed to assess postdeglutitive inhibition and the subsequent contraction response using the DCI metric, using methodology described elsewhere . Normal responses, characterized by profound inhibition during MRS followed by augmented contraction, were recorded.…”

“…Normal responses, characterized by profound inhibition during MRS followed by augmented contraction, were recorded. Aberrant responses, such as when contraction took place during the phase of profound inhibition or when the following contraction phase was either suboptimal or exaggerated, were also noted; esophageal body contraction metrics were quantified using DCI …”

Advances in Management of Esophageal Motility Disorders

“…This can be by demonstrating compartmentalized pressurization above the EGJ during test swallows or it can be the demonstration of esophageal pressurization during multiple rapid swallows or rapid drink challenge, two provocative tests of the integrity of deglutitive inhibition. With multiple rapid swallows, five 2-ml swallows are taken less than 4 seconds apart [17,18] and with the rapid drink challenge 200 ml of water is swallowed within 30 seconds [19, 20]. By providing a prolonged inhibitory stimulus, multiple rapid swallows are helpful in demonstrating the integrity of deglutitive inhibition in the distal esophagus, LES relaxation, and peristaltic reserve after the termination of the sequence [21].…”