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The Korean Journal of Gastroenterology... May 2024Patients with chronic constipation (CC) usually complain of mild to severe symptoms, including hard or lumpy stools, straining, a sense of incomplete evacuation after a... (Review)
Review
Patients with chronic constipation (CC) usually complain of mild to severe symptoms, including hard or lumpy stools, straining, a sense of incomplete evacuation after a bowel movement, a feeling of anorectal blockage, the need for digital maneuver to assist defecation, or reduced stool frequency. In clinical practice, healthcare providers need to check for 'alarm features' indicative of a colonic malignancy, such as bloody stools, anemia, unexplained weight loss, or new-onset symptoms after 50 years of age. In the Seoul Consensus on the diagnosis and treatment of chronic constipation, the Bristol stool form scale, colonoscopy, and digital rectal examination are useful for objectively evaluating the symptoms and making a differential diagnosis of the secondary cause of constipation. If patients with CC improve to lifestyle modification or first-line therapies, the effort to determine the subtypes of CC is usually not considered. On the other hand, if conventional therapeutic strategies fail, diagnostic testing needs to be considered to distinguish between the different subtypes of functional constipation (normal-transit constipation, slow transit constipation, or defecatory disorder) because these subtypes of constipation have different therapeutic implications and a correct diagnosis is critical. In the Seoul consensus, physiological testing is recommended for patients with functional constipation who have failed to respond to treatment with available laxatives (for a minimum of 12 weeks and recommended a therapeutic regimen) or who are strongly suspected of having a defecatory disorder. The Seoul consensus contains statements of physiological testing, including balloon expulsion test, anorectal manometry, defecography, and colon transit time.
Topics: Constipation; Humans; Chronic Disease; Manometry; Colonoscopy; Digital Rectal Examination; Defecography; Gastrointestinal Transit
PubMed: 38783618
DOI: 10.4166/kjg.2024.039 -
Neurogastroenterology and Motility Mar 2018Upper gastrointestinal symptoms in children are common and motility disorders are considered in the differential diagnosis. High resolution esophageal manometry (HRM)... (Review)
Review
BACKGROUND
Upper gastrointestinal symptoms in children are common and motility disorders are considered in the differential diagnosis. High resolution esophageal manometry (HRM) has revolutionized the study of esophageal physiology, and the addition of impedance has provided new insights into esophageal function. Antroduodenal motility has provided insight into gastric and small bowel function.
PURPOSE
This review highlights some of the recent advances in pediatric esophageal and antroduodenal motility testing including indications, preparation, performance, and interpretation of the tests. This update is the second part of a two part series on manometry studies in children (first part was on anorectal and colonic manometry [Neurogastroenterol Motil. 2016;29:e12944]), and has been endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the American Neurogastroenterology and Motility Society (ANMS).
Topics: Consensus; Duodenal Diseases; Esophageal Motility Disorders; Gastrointestinal Motility; Humans; Manometry
PubMed: 29178261
DOI: 10.1111/nmo.13239 -
World Journal of Gastroenterology Oct 2016Achalasia is the most common primary motility disorder of the esophagus and presents as dysphagia to solids and liquids. It is characterized by impaired deglutitive... (Review)
Review
Achalasia is the most common primary motility disorder of the esophagus and presents as dysphagia to solids and liquids. It is characterized by impaired deglutitive relaxation of the lower esophageal sphincter. High-resolution manometry allows for definitive diagnosis and classification of achalasia, with type II being the most responsive to therapy. Since no cure for achalasia exists, early diagnosis and treatment of the disease is critical to prevent end-stage disease. The central tenant of diagnosis is to first rule out mechanical obstruction due to stricture or malignancy, which is often accomplished by endoscopic and fluoroscopic examination. Therapeutic options include pneumatic dilation (PD), surgical myotomy, and endoscopic injection of botulinum toxin injection. Heller myotomy and PD are more efficacious than pharmacologic therapies and should be considered first-line treatment options. Per oral endoscopic myotomy (POEM) is a minimally-invasive endoscopic therapy that might be as effective as surgical myotomy when performed by a trained and experienced endoscopist, although long-term data are lacking. Overall, therapy should be individualized to each patient's clinical situation and based upon his or her risk tolerance, operative candidacy, and life expectancy. In instances of therapeutic failure or symptom recurrence re-treatment is possible and can include PD or POEM of the wall opposite the site of prior myotomy. Patients undergoing therapy for achalasia require counseling, as the goal of therapy is to improve swallowing and prevent late manifestations of the disease rather than to restore normal swallowing, which is unfortunately impossible.
Topics: Barium; Botulinum Toxins; Deglutition Disorders; Dilatation; Endoscopy; Esophageal Achalasia; Esophageal Sphincter, Lower; Esophagoscopy; Humans; Manometry; Recurrence
PubMed: 27818585
DOI: 10.3748/wjg.v22.i39.8670 -
Dysphagia Apr 2023High-resolution esophageal manometry (HRM) utilizes sufficient pressure sensors such that intraluminal pressure is monitored as a continuum along luminal length, similar... (Review)
Review
High-resolution esophageal manometry (HRM) utilizes sufficient pressure sensors such that intraluminal pressure is monitored as a continuum along luminal length, similar to time viewed as a continuum on polygraph tracings in 'conventional' manometry. When HRM is coupled with pressure topography plotting, and pressure amplitude is transformed into spectral colors with isobaric areas indicated by same-colored regions, "Clouse plots" are generated. HRM has several advantages compared to the technology that it replaced: (1) the contractility of the entire esophagus can be viewed simultaneously in a uniform standardized format, (2) standardized objective metrics of peristaltic and sphincter function can be systematically applied for interpretation, and (3) topographic patterns of contractility are more easily recognized with greater reproducibility. Leveraging these advantages led to the current standard for the interpretation of clinical esophageal HRM studies, the Chicago Classification (CC), now in its fourth iteration. Compared to conventional manometry, HRM has vastly improved the sensitivity for detecting achalasia, largely due to the objectivity and accuracy of identification of impaired esophagogastric junction (EGJ) relaxation. Additionally, it has led to the subcategorization of achalasia into three clinically relevant subtypes, differentiated by the contractile function of the esophageal body, and identified an additional disorder of EGJ outflow obstruction wherein esophageal peristalsis is preserved. Headway has also been made in understanding hypocontractile and hypercontractile conditions. In summary, HRM and the CC process have revolutionized our understanding of esophageal motility and motility disorders. Moving forward, there will always be remaining challenges, but we now have the tools to meet them.
Topics: Humans; Esophageal Achalasia; Reproducibility of Results; Esophageal Motility Disorders; Manometry
PubMed: 34739589
DOI: 10.1007/s00455-021-10372-7 -
Neurogastroenterology and Motility Jan 2021Since publication of Chicago Classification version 3.0 in 2015, the clinical and research applications of high-resolution manometry (HRM) have expanded. In order to... (Review)
Review
Since publication of Chicago Classification version 3.0 in 2015, the clinical and research applications of high-resolution manometry (HRM) have expanded. In order to update the Chicago Classification, an International HRM Working Group consisting of 52 diverse experts worked for two years and utilized formally validated methodologies. Compared with the prior iteration, there are four key modifications in Chicago Classification version 4.0 (CCv4.0). First, further manometric and non-manometric evaluation is required to arrive at a conclusive, actionable diagnosis of esophagogastric junction (EGJ) outflow obstruction (EGJOO). Second, EGJOO, distal esophageal spasm, and hypercontractile esophagus are three manometric patterns that must be accompanied by obstructive esophageal symptoms of dysphagia and/or non-cardiac chest pain to be considered clinically relevant. Third, the standardized manometric protocol should ideally include supine and upright positions as well as additional manometric maneuvers such as the multiple rapid swallows and rapid drink challenge. Solid test swallows, postprandial testing, and pharmacologic provocation can also be considered for particular conditions. Finally, the definition of ineffective esophageal motility is more stringent and now encompasses fragmented peristalsis. Hence, CCv4.0 no longer distinguishes between major versus minor motility disorders but simply separates disorders of EGJ outflow from disorders of peristalsis.
Topics: Esophageal Motility Disorders; Esophagogastric Junction; Humans; Manometry; Peristalsis
PubMed: 33340190
DOI: 10.1111/nmo.14053 -
Clinical and Translational... May 2023While high-resolution manometry (HRM) is widely accepted as a safe procedure, no study has assessed the safety profile of HRM in clinical practice. This study aimed to...
INTRODUCTION
While high-resolution manometry (HRM) is widely accepted as a safe procedure, no study has assessed the safety profile of HRM in clinical practice. This study aimed to determine the safety and tolerability of HRM and to investigate potential determinants of intolerability.
METHODS
We obtained HRM procedure reports, demographics, and clinical data (2005-2022) at a tertiary center using electronic chart review. Our primary outcome was HRM tolerability. Multivariable regression was performed to identify associations between the outcome and covariates including age, sex, race, and comorbidities.
RESULTS
A total of 5,107 patients (60.3% female) were included. Of them, 5,050 patients (98.9%) tolerated HRM well and 57 patients (1.1%) did not. Age had a statistically significant effect on tolerance: those younger than 18 years had more than a 5-fold increase in not tolerating HRM compared with those aged 18-79 years (5.77% vs 0.99%; odds ratio [OR] = 5.44, 95% confidence interval [CI] 1.60-18.45; P = 0.007), and those aged 80 years or older were also more likely to terminate HRM (2.43% vs 0.99%; OR = 2.56, 95% CI 1.13-5.76; P = 0.024). While prior foregut surgery had a significant effect on tolerance (OR = 8.06, 95% CI 2.29-28.39; P = 0.001), other factors of race, sex, body mass index, and psychological or cognitive disorders had no significant impact. No serious complications were identified.
DISCUSSION
HRM is safe and well-tolerated with approximately 1 in every 100 patients being unable to tolerate HRM. Intolerance was more commonly seen in children and seniors due to minor symptoms of discomfort without serious complications. These data points are crucial to counsel patients in whom HRM is being considered.
Topics: Humans; Adult; Child; Female; Male; Esophagus; Manometry; Body Mass Index; Cognition Disorders
PubMed: 36854056
DOI: 10.14309/ctg.0000000000000571 -
The Korean Journal of Gastroenterology... Feb 2022The Chicago Classification is being revised continuously for the accurate diagnosis of esophageal peristaltic disorders in which the etiology is unclear, and the disease... (Review)
Review
The Chicago Classification is being revised continuously for the accurate diagnosis of esophageal peristaltic disorders in which the etiology is unclear, and the disease behavior is heterogeneous. The ver. 4.0 was recently updated. A representative change in the diagnosis of esophageal peristaltic disorders of the ver. 4.0 showed that the distinction between major and minor disorders was eliminated and was divided into the following four diagnoses: absent contractility, distal esophageal spasm (DES), hypercontractile esophagus (HE), and ineffective esophageal motility. Compared to the ver. 3.0, it recommended a more detailed protocol of high-resolution esophageal manometry and methods of interpreting manometric. In addition, it emphasized the clinically relevant symptoms in diagnosing DES and HE, and presented provocative tests (e.g., multiple rapid swallow and rapid drinking challenge), as well as additional testing, including impedance, timed barium esophagogram and functional lumen imaging probe, which may provide more standardized and rigorous criteria for peristaltic patterns and to minimize the ambiguity in diagnosis. Although it will take time and effort to apply this revised Chicago Classification in clinical practice, it may help diagnose and manage patients with esophageal peristalsis disorder in the future.
Topics: Esophageal Achalasia; Esophageal Motility Disorders; Humans; Manometry; Peristalsis
PubMed: 35232921
DOI: 10.4166/kjg.2022.016 -
Current Opinion in Gastroenterology Jul 2017Esophageal high-resolution manometry (HRM) is the current state-of-the-art diagnostic tool to evaluate esophageal motility patterns and, as such, is widely adopted in... (Review)
Review
PURPOSE OF REVIEW
Esophageal high-resolution manometry (HRM) is the current state-of-the-art diagnostic tool to evaluate esophageal motility patterns and, as such, is widely adopted in clinical practice. This article will review the interpretation of esophageal HRM in clinical practice.
RECENT FINDINGS
HRM uses a high-resolution catheter to transmit intraluminal pressure data that are subsequently converted into dynamic esophageal pressure topography (EPT) plots. Metric data from EPT plots are synthesized to yield an esophageal motility diagnosis according to the Chicago Classification, a formal analytic scheme for esophageal motility disorders, which is currently in version 3.0. The standard HRM protocol consists of a baseline phase and a series of 10 wet swallows in the supine or reclined position. In addition, data from swallows in the seated position and provocative HRM maneuvers provide useful information about motility properties. Combined high-resolution impedance technology is also clinically available and enables concurrent assessment of bolus transit and postprandial responses. Finally, there is ongoing interest to optimize the training and competency assessment for interpretation of HRM in clinical practice.
SUMMARY
Esophageal HRM is a valuable and sophisticated clinical tool to evaluate esophageal motility patterns. Emerging clinical applications of esophageal HRM include combined impedance technology, provocative maneuvers, and postprandial evaluation.
Topics: Esophageal Motility Disorders; Esophagus; Humans; Image Interpretation, Computer-Assisted; Manometry; Observer Variation; Peristalsis; Practice Guidelines as Topic; Reproducibility of Results
PubMed: 28426462
DOI: 10.1097/MOG.0000000000000369 -
Clinical and Translational... Dec 2019Defecation is a complex process that can be easily disturbed. Defecatory disorders may be diagnosed using specialized investigation, including anorectal manometry (ARM)... (Clinical Trial)
Clinical Trial
INTRODUCTION
Defecation is a complex process that can be easily disturbed. Defecatory disorders may be diagnosed using specialized investigation, including anorectal manometry (ARM) and the balloon expulsion test (BET). Recently, we developed a simulated stool named Fecobionics that integrates several tests and assesses pressures, orientation, and bending during evacuation. The aim was to evaluate the feasibility and performance of Fecobionics for assessing defecatory physiology in normal subjects.
METHODS
Physiological expulsion parameters were assessed in an interventional study design. The 10-cm-long Fecobionics probe contained pressure sensors at the front and rear and inside a bag and 2 motion processor units. The bag was distended in the rectum of 20 presumed normal subjects (15 female/5 male) until urge to defecate. ARM-BET was also performed. Three subjects used +2 minutes to evacuate BET, and 1 subject had a high fecal incontinence score. Therefore, the normal group consisted of 16 subjects (13 female/3 male aged 25-78 years).
RESULTS
All subjects reported that Fecobionics evacuation was similar to normal defecation. Fecobionics expulsion pressure signatures demonstrated 5 phases, reflecting rectal pressure, anal relaxation, and anal passage. Preload-afterload loop diagrams demonstrated clockwise contraction cycles. The expulsion duration for BET and Fecobionics was 16 ± 2 and 23 ± 5 seconds (P > 0.2), respectively. The duration of the Fecobionics and BET expulsions was associated (P < 0.001). The change in bending of Fecobionics during defecation was 40 ± 3°.
DISCUSSION
Fecobionics obtained reliable data under physiological conditions. Agreement was found for comparable variables between ARM-BET and Fecobionics but not for other variables. The study suggests that Fecobionics is safe and effective in evaluation of key defecatory parameters.
Topics: Adult; Aged; Constipation; Defecation; Feasibility Studies; Fecal Incontinence; Female; Healthy Volunteers; Humans; Male; Manometry; Middle Aged; Rectum; Reproducibility of Results
PubMed: 31800543
DOI: 10.14309/ctg.0000000000000108 -
Arquivos Brasileiros de Cirurgia... 2017High resolution manometry is the current technology used to the study of esophageal motility and is replacing conventional manometry in important centers for esophageal... (Review)
Review
INTRODUCTION:
High resolution manometry is the current technology used to the study of esophageal motility and is replacing conventional manometry in important centers for esophageal motility with parameters used on esophageal motility, following the Chicago Classification. This classification unifies high resolution manometry interpretation and classifies esophageal disorders.
OBJECTIVE:
This review shows, in a pictorial presentation, the new parameters established by the Chicago Classification, version 3.0, aimed to allow an easy comprehension and interpretation of high resolution manometry.
METHODS:
Esophageal manometries performed by the authors were reviewed to select illustrative tracings representing Chicago Classification parameters.
RESULTS:
The parameters are: Esophagogastric Morphology, that classifies this junction according to its physiology and anatomy; Integrated Relaxation Pressure, that measures the lower esophageal sphincter relaxation; Distal Contractile Integral, that evaluates the contraction vigor of each wave; and, Distal Latency, that measures the peristalsis velocity from the beginning of the swallow to the epiphrenic ampulla.
CONCLUSION:
Clinical applications of these new concepts is still under evaluation.
OBJETIVO:
Mostrar, de forma pictórica, os novos parâmetros compilados na versão 3.0 da Classificação de Chicago, buscando facilitar a compreensão e interpretação da manometria de alta resolução.
MÉTODOS:
Foram revistas as manometrias da casuística dos autores e selecionados os traçados representativos dos parâmetros da Classificação de Chicago.
RESULTADOS:
Entre os parâmetros apresentados foram considerados a Morfologia da Transição Gastroesofágica, que classifica o segmento de acordo com sua fisiologia e anatomia; a Integral da Pressão de Relaxamento, que mede o relaxamento do esfíncter esofagiano inferior; a Integral Contrátil Distal, que avalia o vigor contrátil da onda peristáltica; e, a Latência Distal, que mede o tempo da peristalse, desde o início da deglutição até a ampola epifrênica.
CONCLUSÃO:
A aplicabilidade clínica desses novos conceitos ainda está sendo estudada.
Topics: Esophageal Motility Disorders; Humans; Manometry
PubMed: 28489175
DOI: 10.1590/0102-6720201700010019