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Neurogastroenterology and Motility May 2022Upper esophageal sphincter (UES) function has been extensively studied in the context of swallowing and antegrade bolus transit, but relatively little attention has been...
Upper esophageal sphincter (UES) function has been extensively studied in the context of swallowing and antegrade bolus transit, but relatively little attention has been paid to its retrograde function to facilitate belching. Indeed, prior to 2019, there were only three case reports in the world literature of individuals with a physiologically demonstrated inability to belch due to failure of the UES to relax after gas venting from the stomach and ensuing low-pressure esophageal distention. In this minireview, that disorder is termed retrograde UES dysfunction (R-UESD). The associated symptom complex includes some combination of chest pain, gurgling noises in the chest, bloating, nausea, hiccups, and flatulence. The obscurity of R-UESD has recently been challenged by two large series published in the ENT literature of circumstantially demonstrated R-UESD that was resolved by botulinum toxin (BT) injection to the cricopharyngeus. The field has now further advanced with the publication in this issue of the Journal by Oude Nijhuis et al. of 8 cases of R-UESD demonstrated by high-resolution impedance manometry (HRIM) with a provocative challenge of carbonated water. These individuals were also treated with BT and at 3-month follow-up had both an encouraging symptomatic response and HRIM demonstrated resolution of R-UESD.
Topics: Deglutition; Eructation; Esophageal Sphincter, Upper; Flatulence; Humans; Manometry; Stomach
PubMed: 35122356
DOI: 10.1111/nmo.14328 -
Journal of Clinical Sleep Medicine :... Apr 2022The objective of this meta-analysis was to analyze agreement in apnea-hypopnea index (AHI) determination between peripheral arterial tonometry (PAT) and polysomnography... (Meta-Analysis)
Meta-Analysis
STUDY OBJECTIVES
The objective of this meta-analysis was to analyze agreement in apnea-hypopnea index (AHI) determination between peripheral arterial tonometry (PAT) and polysomnography (PSG) studies.
METHODS
Mean AHI bias and standard deviation extracted from Bland-Altman plots reported in studies were pooled in a meta-analysis, which was then used to calculate percentage errors of limit agreement in AHI determination by PAT using PSG AHI as the reference. Individual participant data (where reported in studies) were used to compute Cohen's kappa to assess agreement between PSG and PAT on sleep apnea severity and for computing the sensitivity and specificity of PAT at different AHI thresholds using PSG AHI as the reference.
RESULTS
From 17 studies and 1,318 participants (all underwent simultaneous PSG and use of the WatchPAT device), a pooled mean AHI bias of 0.30 (standard error [SE], 0.74) and a WatchPAT AHI percentage error of 230% was calculated. The meta-analysis of Cohen's kappa for agreement between PSG and WatchPAT studies for classifying patients with no sleep apnea, mild, moderate, or severe sleep apnea severity was 0.45 (SE, 0.06), 0.29 (SE, 0.05), 0.25 (SE, 0.07), and 0.64 (SE, 0.05), respectively. At AHI thresholds of 5, 15 and 30 events/h, WatchPAT studies showed pooled sensitivities and specificities of 94.11% and 43.47%, 92.21% and 72.39%, and 74.11% and 87.10%, respectively. Likelihood ratios were not significant at any AHI threshold.
CONCLUSIONS
The results of this meta-analysis suggest clinically significant discordance between WatchPAT and PSG measurements of AHI, significant sleep apnea severity misclassification by PAT studies, and poor diagnostic test performance.
CITATION
Iftikhar IH, Finch CE, Shah AS, Augunstein CA, Ioachimescu OC. A meta-analysis of diagnostic test performance of peripheral arterial tonometry studies. 2022;18(4):1093-1102.
Topics: Diagnostic Tests, Routine; Humans; Manometry; Polysomnography; Sensitivity and Specificity; Sleep Apnea Syndromes; Sleep Apnea, Obstructive
PubMed: 34879903
DOI: 10.5664/jcsm.9808 -
Arquivos de Gastroenterologia 2020Gastroesophageal reflux disease is associated with slower transit of the bolus through the pharynx and upper esophageal sphincter. Functional heartburn has similar...
BACKGROUND
Gastroesophageal reflux disease is associated with slower transit of the bolus through the pharynx and upper esophageal sphincter. Functional heartburn has similar symptoms to gastroesophageal reflux disease, however, the symptoms are not caused by reflux.
OBJECTIVE
The aim of this investigation was to evaluate oral and pharyngeal transit in patients with functional heartburn, with the hypothesis that, similar to patients with gastroesophageal reflux disease, they have changes in pharyngeal and upper esophageal sphincter transit time.
METHODS
Oral and pharyngeal transit was evaluated by videofluoroscopy in eight women with functional heartburn, five with mild dysphagia for solid foods, and 12 female controls. Controls and patients swallowed in duplicate 5 mL and 10 mL of liquid and paste boluses.
RESULTS
No difference in the oral or pharyngeal transit time was found between patients and controls. No aspiration of bolus into the airways was detected in any individual. Pharyngeal residues were detected in the same proportion of swallows, in patients (12.5%) and controls (15.0%), after swallows of 10 mL paste bolus.
CONCLUSION
Oral, pharyngeal and upper esophageal sphincter transit time are similar in patients with functional heartburn to healthy controls.
Topics: Deglutition; Deglutition Disorders; Female; Gastroesophageal Reflux; Heartburn; Humans; Manometry; Pharynx
PubMed: 32609156
DOI: 10.1590/S0004-2803.202000000-28 -
Neurogastroenterology and Motility Oct 2021Magnetic sphincter augmentation (MSA) is an innovative antireflux procedure that can improve lower esophageal sphincter (LES) competency and reduce symptoms of...
BACKGROUND
Magnetic sphincter augmentation (MSA) is an innovative antireflux procedure that can improve lower esophageal sphincter (LES) competency and reduce symptoms of gastroesophageal reflux disease (GERD). Some patients report postoperative dysphagia. To date, no studies have described reference high-resolution manometry (HRM) values after MSA implantation.
METHODS
High-resolution manometry was performed in patients free of dysphagia after MSA with or without concurrent crura repair. Reference values for all parameters of the Chicago Classification were defined as those between the 5th and 95th percentiles. The contribution of concurrent crura repair to LES competency and to reference values was also analyzed.
KEY RESULTS
Eighty-four patients met the study inclusion criteria. The upper limit of normality for integrated relaxation pressure (IRP) and intrabolus pressure (IBP) was 20.2 mmHg and 30.3 mmHg, respectively. Both variables were higher after MSA compared to normative Chicago Classification v3.0 values. The Distal Contractile Integral upper limit was in the range of normality. Patients undergoing crura repair had a significantly higher IRP (p = 0.0378) and lower GERDQ-A scores (p = 0.0374) and Reflux Symptom Index (p = 0.0030) compared to those who underwent MSA device implantation alone.
CONCLUSION & INFERENCES
This study provides HRM reference values for patients undergoing successful MSA implantation. Crural repair appears to be a key component of LES augmentation and is associated with improved clinical outcomes.
Topics: Deglutition Disorders; Esophageal Sphincter, Lower; Gastroesophageal Reflux; Humans; Magnetic Phenomena; Manometry; Reference Values
PubMed: 33772949
DOI: 10.1111/nmo.14139 -
Critical Care (London, England) Jan 2015The value of gastric intramucosal pH (pHi) can be calculated from the tonometrically measured partial pressure of carbon dioxide ([Formula: see text]) in the stomach and... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
The value of gastric intramucosal pH (pHi) can be calculated from the tonometrically measured partial pressure of carbon dioxide ([Formula: see text]) in the stomach and the arterial bicarbonate content. Low pHi and increase of the difference between gastric mucosal and arterial [Formula: see text] ([Formula: see text] gap) reflect splanchnic hypoperfusion and are good indicators of poor prognosis. Some randomized controlled trials (RCTs) were performed based on the theory that normalizing the low pHi or [Formula: see text] gap could improve the outcomes of critical care patients. However, the conclusions of these RCTs were divergent. Therefore, we performed a systematic review and meta-analysis to assess the effects of this goal directed therapy on patient outcome in Intensive Care Units (ICUs).
METHODS
We searched PubMed, EMBASE, the Cochrane Library and ClinicalTrials.gov for randomized controlled trials comparing gastric tonometry guided therapy with control groups. Baseline characteristics of each included RCT were extracted and displayed in a table. We calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs) for dichotomous outcomes. Another measure of effect (risk difference, RD) was used to reassess the effects of gastric tonometry on total mortality. We performed sensitivity analysis for total mortality. Continuous outcomes were presented as standardised mean differences (SMDs) together with 95% CIs.
RESULTS
The gastric tonometry guided therapy significantly reduced total mortality (OR, 0.732; 95% CI, 0.536 to 0.999, P = 0.049; I(2) = 0%; RD, -0.056; 95% CI, -0.109 to -0.003, P = 0.038; I(2) = 0%) when compared with control groups. However, after excluding the patients with normal pHi on admission, the beneficial effects of this therapy did not exist (OR, 0.736; 95% CI 0.506 to 1.071, P = 0.109; I(2) = 0%). ICU length of stay, hospital length of stay and days intubated were not significantly improved by this therapy.
CONCLUSIONS
In critical care patients, gastric tonometry guided therapy can reduce total mortality. Patients with normal pHi on admission contributed to the ultimate result of this outcome; it may indicate that these patients may be more sensitive to this therapy.
Topics: Critical Care; Humans; Intensive Care Units; Manometry; Stomach Diseases
PubMed: 25622724
DOI: 10.1186/s13054-015-0739-6 -
Surgical Endoscopy Mar 2023The end-stage achalasia is a difficult condition to treat, for the esophageal diameter and conformation of the gullet, that may progress to a sigmoid shape. The aim of...
BACKGROUND
The end-stage achalasia is a difficult condition to treat, for the esophageal diameter and conformation of the gullet, that may progress to a sigmoid shape. The aim of this study was to examine the outcome of Laparoscopic Heller-Dor in patients with end-stage achalasia, comparing them with patients who had mega-esophagus without a sigmoid shape.
METHODS
From 1992 to 2020, patients with a diagnosis of sigmoid esophagus, or radiological stage IV achalasia (the SE group), and patients with a straight esophagus larger than 6 cm in diameter, or radiological stage III achalasia (the NSE group), were all treated with LHD. The two groups were compared in terms of patients' symptoms, based on the Eckardt score, and on barium swallow, endoscopy and manometry performed before and after the treatment. The failure of the treatment was defined as an Eckardt score > 3, or the need for further treatment.
RESULTS
The study involved 164 patients: 73 in the SE group and 91 in the NSE group. No intra- or postoperative mortality was recorded. The median follow-up was 51 months (IQR 25-107). The outcome was satisfactory in 71.2% of patients in the SE group, and in 89% of those in the NSE group (p = 0.005).
CONCLUSIONS
SE is certainly the worst condition of the disease and the final outcome of LHD, in term of symptom control, is inferior compared to NSE. Despite this, almost 3/4 of the SE patients experienced a significant relieve in symptoms after LHD, which may therefore still be the first surgical option to offer to these patients, before considering esophagectomy.
Topics: Humans; Esophageal Achalasia; Treatment Outcome; Manometry; Fundoplication; Laparoscopy
PubMed: 36217057
DOI: 10.1007/s00464-022-09696-8 -
Neurogastroenterology and Motility Mar 2023The functional lumen imaging probe (FLIP) evaluates esophagogastric junction (EGJ) opening and esophageal contractility. Both post hoc and real-time analyses are...
BACKGROUND
The functional lumen imaging probe (FLIP) evaluates esophagogastric junction (EGJ) opening and esophageal contractility. Both post hoc and real-time analyses are possible, but reproducibility and reliability of analysis remain undefined. This study assesses inter- and intra-rater agreement of normative FLIP measurements among novice and experienced users.
METHODS
Eight motility experts from different institutions independently evaluated de-identified video recordings from 27 asymptomatic healthy subjects using FLIP. Interpretation methods simulating a post-procedure and a live procedure setting were tested. Novice FLIP users (n = 3) received training prior to post-procedure interpretation. Experienced FLIP users (n = 5) interpreted using both methods. Users recorded maximum EGJ and distal esophageal body diameter, distensive pressure, and EGJ distensibility index (EGJ-DI), at balloon fill volumes of 50-, 60-, and 70 ml, as well as repetitive antegrade contractions (RACs). Inter- and intra-rater agreements of diameters, distensive pressure and EGJ-DI were assessed by intra-class correlation coefficient (ICC) and Pearson's correlation coefficient (PCC). Percentage agreement evaluated inter- and intra-rater reliability for RACs.
KEY RESULTS
Novice and experienced users acquired normative FLIP metrics. Good-to-excellent inter- and intra-rater reliability were achieved for all variables at 60 ml balloon fill volumes. Median parameters at 60 ml balloon fill volume were as follows: EGJ-DI 5.5 mm /mmHg, maximum EGJ diameter 18.6 mm, distensive pressure at maximum EGJ diameter 48.1 mmHg, and distal esophageal body diameter 19.5 mm.
CONCLUSIONS AND INFERENCES
Normative FLIP parameters can be reliably extracted from FLIP videos using both real-time and post hoc analyses, with high reliability between experienced and novice users.
Topics: Humans; Esophageal Achalasia; Reproducibility of Results; Healthy Volunteers; Esophagogastric Junction; Manometry
PubMed: 36480408
DOI: 10.1111/nmo.14505 -
Clinical Gastroenterology and... Mar 2017Reported global incidence and prevalence values for achalasia vary widely, from 0.03 to 1.63 per 100,000 persons per year and from 1.8 to 12.6 per 100,000 persons per...
BACKGROUND & AIMS
Reported global incidence and prevalence values for achalasia vary widely, from 0.03 to 1.63 per 100,000 persons per year and from 1.8 to 12.6 per 100,000 persons per year, respectively. This study aimed to reconcile these low values with findings from a major referral center, in central Chicago (which began using high-resolution manometry in 2004 and used it in all clinical studies since 2005), and has determined the incidence and prevalence of achalasia to be much greater.
METHODS
We collected data from the Northwestern Medicine Enterprise Data Warehouse database (tertiary care setting) of adults residing in Chicago with an encounter diagnosis of achalasia from 2004 through 2014. Patient files were reviewed to confirm diagnosis and residential address. US Census Bureau population data were used as the population denominator. We assumed that we encountered every incident case in the city to calculate incidence and prevalence estimates. Data were analyzed for the city at large and for the 13 zip codes surrounding the Northwestern Memorial Hospital (NMH), the NMH neighborhood.
RESULTS
We identified 379 cases (50.9% female) that met the full inclusion criteria; of these, 246 were incident cases. Among these, 132 patients resided in the NMH neighborhood, 89 of which were incident cases. Estimated yearly incidences were stable over the study period, ranging from 0.77 to 1.35 per 100,000 citywide (average, 1.07 per 100,000) and from 1.41 to 4.60 per 100,000 in the NMH neighborhood (average, 2.92 per 100,000). The corresponding prevalence values increased progressively, from 4.68 to 14.42 per 100,000 citywide and from 15.64 to 32.58 per 100,000 in the NMH neighborhood.
CONCLUSIONS
The incidence and prevalence of achalasia in central Chicago diagnosed using state-of-the-art technology and diagnostic criteria are at least 2- to 3-fold greater than previous estimates. Additional studies are needed to determine the generalizability of these data to other regions.
Topics: Adult; Aged; Aged, 80 and over; Chicago; Esophageal Achalasia; Female; Humans; Incidence; Male; Manometry; Middle Aged; Prevalence; Retrospective Studies; Young Adult
PubMed: 27581064
DOI: 10.1016/j.cgh.2016.08.030 -
Clinical Gastroenterology and... Jun 2022This study aimed to assess the accuracy of functional luminal imaging probe (FLIP) panometry to detect esophagogastric junction (EGJ) obstruction assigned by...
BACKGROUND & AIMS
This study aimed to assess the accuracy of functional luminal imaging probe (FLIP) panometry to detect esophagogastric junction (EGJ) obstruction assigned by high-resolution manometry (HRM) and the Chicago Classification version 4.0 (CCv4.0).
METHODS
Six hundred eighty-seven adult patients who completed FLIP and HRM for primary esophageal motility evaluation and 35 asymptomatic volunteers (controls) were included. EGJ opening was evaluated with 16-cm FLIP during sedated endoscopy via EGJ-distensibility index (DI) and maximum EGJ diameter. HRM was classified according to CCv4.0 and focused on studies with a conclusive disorder of EGJ outflow (ie, achalasia subtypes I, II, or III; or EGJ outflow obstruction with abnormal timed barium esophagogram) or normal EGJ outflow.
RESULTS
All 35 controls had EGJ-DI >3.0 mm/mmHg and maximum EGJ diameter >16 mm. Per HRM and CCv4.0, 245 patients had a conclusive disorder of EGJ outflow, and 314 patients had normal EGJ outflow. Among the 241 patients with reduced EGJ opening (EGJ-DI <2.0 mm/mmHg and maximum EGJ diameter <12 mm) on FLIP panometry, 86% had a conclusive disorder of EGJ outflow per CCv4.0. Among the 203 patients with normal EGJ opening (EGJ-DI ≥2.0 mm/mmHg and maximum EGJ diameter ≥16 mm) on FLIP panometry, 99% had normal EGJ outflow per CCv4.0.
CONCLUSIONS
FLIP panometry accurately identified clinically relevant conclusive EGJ obstruction as defined by CCv4.0 in patients evaluated for esophageal motor disorders. Thus, FLIP panometry is a valuable tool for both independent and complementary evaluation of esophageal motility.
Topics: Adult; Endoscopy, Gastrointestinal; Esophageal Achalasia; Esophageal Motility Disorders; Esophagogastric Junction; Humans; Manometry
PubMed: 34216821
DOI: 10.1016/j.cgh.2021.06.040 -
Neurogastroenterology and Motility Sep 2019Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral... (Review)
Review
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.
Topics: California; Congresses as Topic; Esophageal Motility Disorders; Forecasting; Humans; Manometry
PubMed: 30974032
DOI: 10.1111/nmo.13584