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Gastroenterology May 2022Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the... (Review)
Review
Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.
Topics: Endoscopy, Gastrointestinal; Esophageal Achalasia; Esophageal Motility Disorders; Humans; Manometry; Quality of Life
PubMed: 35227779
DOI: 10.1053/j.gastro.2021.12.289 -
Neurogastroenterology and Motility Apr 2021The Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). A key... (Review)
Review
The Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). A key feature of CCv.4.0 is the more rigorous and expansive protocol that incorporates single wet swallows acquired in different positions (supine, upright) and provocative testing, including multiple rapid swallows and rapid drink challenge. Additionally, solid bolus swallows, solid test meal, and/or pharmacologic provocation can be used to identify clinically relevant motility disorders and other conditions (eg, rumination) that occur during and after meals. The acquisition and analysis for performing these tests and the evidence supporting their inclusion in the Chicago Classification protocol is detailed in this technical review. Provocative tests are designed to increase the diagnostic sensitivity and specificity of HRM studies for disorders of esophageal motility. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification, decrease the proportion of HRM studies that deliver inconclusive diagnoses and increase the number of patients with a clinically relevant diagnosis that can direct effective therapy. Another aim in establishing a standard manometry protocol for motility laboratories around the world is to facilitate procedural consistency, improve diagnostic reliability, and promote collaborative research.
Topics: Deglutition; Esophageal Motility Disorders; Esophagus; Humans; Manometry; Patient Positioning
PubMed: 33729668
DOI: 10.1111/nmo.14120 -
Current Gastroenterology Reports Sep 2020Objective measurement of anorectal sensorimotor function is a requisite component in the clinical evaluation of patients with intractable symptoms of anorectal... (Review)
Review
PURPOSE OF REVIEW
Objective measurement of anorectal sensorimotor function is a requisite component in the clinical evaluation of patients with intractable symptoms of anorectal dysfunction. Regrettably, the utility of the most established and widely employed investigations for such measurement (anorectal manometry (ARM), rectal sensory testing and the balloon expulsion test) has been limited by wide variations in clinical practice.
RECENT FINDINGS
This article summarizes the recently published International Anorectal Physiology Working Group (IAPWG) consensus and London Classification of anorectal disorders, together with relevant allied literature, to provide guidance on the indications for, equipment, protocol, measurement definitions and results interpretation for ARM, rectal sensory testing and the balloon expulsion test. The London Classification is a standardized method and nomenclature for description of alterations in anorectal motor and sensory function using office-based investigations, adoption of which should bring much needed harmonization of practice.
Topics: Anal Canal; Anus Diseases; Humans; Manometry; Rectal Diseases; Terminology as Topic
PubMed: 32935278
DOI: 10.1007/s11894-020-00793-z -
Dysphagia Apr 2023The pathogenesis of gastroesophageal reflux disease (GERD) is multifactorial. The severity of abnormal reflux burden corresponds to the dysfunction of the antireflux... (Review)
Review
The pathogenesis of gastroesophageal reflux disease (GERD) is multifactorial. The severity of abnormal reflux burden corresponds to the dysfunction of the antireflux barrier and inability to clear refluxate. The crural diaphragm is one of the main components of the esophagogastric junction and plays an important role in preventing gastroesophageal reflux. The diaphragm, as a skeletal muscle, is partially under voluntary control and its dysfunction can be improved via breathing exercises. Thus, diaphragmatic breathing training (DBT) has the potential to alleviate symptoms in selected patients with GERD. High-resolution esophageal manometry (HRM) is a useful method for the assessment of antireflux barrier function and can therefore elucidate the mechanisms responsible for gastroesophageal reflux. We hypothesize that HRM can help define patient phenotypes that may benefit most from DBT, and that HRM can even help in the management of respiratory physiotherapy in patients with GERD. This systematic review aimed to evaluate the current data supporting physiotherapeutic practices in the treatment of GERD and to illustrate how HRM may guide treatment strategies focused on respiratory physiotherapy.
Topics: Humans; Gastroesophageal Reflux; Esophagogastric Junction; Manometry; Breathing Exercises
PubMed: 35842548
DOI: 10.1007/s00455-022-10494-6 -
Neurogastroenterology and Motility Feb 2015The Chicago Classification (CC) of esophageal motility disorders, utilizing an algorithmic scheme to analyze clinical high-resolution manometry (HRM) studies, has gained...
BACKGROUND
The Chicago Classification (CC) of esophageal motility disorders, utilizing an algorithmic scheme to analyze clinical high-resolution manometry (HRM) studies, has gained acceptance worldwide.
METHODS
This 2014 update, CC v3.0, developed by the International HRM Working Group, incorporated the extensive clinical experience and interval publications since the prior (2011) version.
KEY RESULTS
Chicago Classification v3.0 utilizes a hierarchical approach, sequentially prioritizing: (i) disorders of esophagogastric junction (EGJ) outflow (achalasia subtypes I-III and EGJ outflow obstruction), (ii) major disorders of peristalsis (absent contractility, distal esophageal spasm, hypercontractile esophagus), and (iii) minor disorders of peristalsis characterized by impaired bolus transit. EGJ morphology, characterized by the degree of overlap between the lower esophageal sphincter and the crural diaphragm and baseline EGJ contractility are also part of CC v3.0. Compared to the previous CC version, the key metrics of interpretation, the integrated relaxation pressure (IRP), the distal contractile integral (DCI), and the distal latency (DL) remain unchanged, albeit with much more emphasis on DCI for defining both hypo- and hypercontractility. New in CC v3.0 are: (i) the evaluation of the EGJ at rest defined in terms of morphology and contractility, (ii) 'fragmented' contractions (large breaks in the 20-mmHg isobaric contour), (iii) ineffective esophageal motility (IEM), and (iv) several minor adjustments in nomenclature and defining criteria. Absent in CC v3.0 are contractile front velocity and small breaks in the 20-mmHg isobaric contour as defining characteristics.
CONCLUSIONS & INFERENCES
Chicago Classification v3.0 is an updated analysis scheme for clinical esophageal HRM recordings developed by the International HRM Working Group.
Topics: Esophageal Achalasia; Esophageal Motility Disorders; Humans; Image Interpretation, Computer-Assisted; Manometry
PubMed: 25469569
DOI: 10.1111/nmo.12477 -
Respiratory Care Jun 2020The estimation of pleural pressure with esophageal manometry has been used for decades, and it has been a fertile area of physiology research in healthy subject as well... (Review)
Review
The estimation of pleural pressure with esophageal manometry has been used for decades, and it has been a fertile area of physiology research in healthy subject as well as during mechanical ventilation in patients with lung injury. However, its scarce adoption in clinical practice takes its roots from the (false) ideas that it requires expertise with years of training, that the values obtained are not reliable due to technical challenges or discrepant methods of calculation, and that measurement of esophageal pressure has not proved to benefit patient outcomes. Despites these criticisms, esophageal manometry could contribute to better monitoring, optimization, and personalization of mechanical ventilation from the acute initial phase to the weaning period. This review aims to provide a comprehensive but comprehensible guide addressing the technical aspects of esophageal catheter use, its application in different clinical situations and conditions, and an update on the state of the art with recent studies on this topic and on remaining questions and ways for improvement.
Topics: Catheters; Esophagus; Humans; Manometry; Monitoring, Physiologic; Respiration, Artificial; Respiratory Mechanics
PubMed: 32457170
DOI: 10.4187/respcare.07425 -
British Journal of Hospital Medicine... Jan 2023Achalasia, characterised by the absence of peristalsis and failure of relaxation of the lower oesophageal sphincter, is an uncommon degenerative condition that results... (Review)
Review
Achalasia, characterised by the absence of peristalsis and failure of relaxation of the lower oesophageal sphincter, is an uncommon degenerative condition that results in dysphagia. If left untreated it can lead to aspiration, oesophageal perforation, oesophagitis and malnutrition. It has a range of immune, allergic, viral and genetic aetiological causes. Successful diagnosis relies on the use of oesophagogastroduodenoscopy, barium swallow and oesophageal manometry to characterise the severity of the disease and to rule out underlying malignancy. Although no treatment can reverse the degenerative process, therapeutic strategies including lifestyle modification, medication, endoscopic and operative intervention can help to reduce symptoms. This article reviews the latest methods used to investigate and manage achalasia.
Topics: Humans; Esophageal Achalasia; Esophageal Sphincter, Lower; Deglutition Disorders; Manometry; Esophagoscopy
PubMed: 36708337
DOI: 10.12968/hmed.2022.0437 -
Sleep Medicine Reviews Feb 2022PAT Technology is a plethysmographic based measurement method which facilitates the accurate recording of the pulsatile volume changes of the arteries of peripheral... (Review)
Review
PAT Technology is a plethysmographic based measurement method which facilitates the accurate recording of the pulsatile volume changes of the arteries of peripheral vascular beds at the distal end of the fingers over sustained periods of time. It represents a departure from previously available plethysmographic methods, in so far as it applies a uniform pressure field which completely envelopes the measured part of a digit, including its distal-most tip. Applying near diastolic blood pressure levels of pressure within the PAT probe optimizes the dynamic range of the signal, prevents confounding veno-arteriolar reflex vasoconstriction at the measurement site, reduces respiratory and movement artifacts and thus facilitates accurate long term measurement. The vascular bed of the distal phalanx of the finger is a major site of sympathetic nervous system mediated vasoconstrictor activity, and the PAT response to sympathetic changes provides a platform for accurate and robust measurement in a number of sleep and sleep related clinical areas, foremost as a patient friendly and extensively validated home sleep testing device.
Topics: Arteries; Fingers; Humans; Manometry; Polysomnography; Technology
PubMed: 34920273
DOI: 10.1016/j.smrv.2021.101566 -
Neurogastroenterology and Motility Jan 2020This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of...
The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function.
BACKGROUND
This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high-resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed.
METHODS
Twenty-nine working group members (clinicians/academics in the field of gastroenterology, coloproctology, and gastrointestinal physiology) were invited to six face-to-face and three remote meetings to derive consensus between 2014 and 2018.
KEY RECOMMENDATIONS
The IAPWG protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia.
CONCLUSIONS AND INFERENCES
This framework introduces the IAPWG protocol and the London classification for disorders of anorectal function based on objective physiological measurement. The use of a common language to describe results of diagnostic tests, standard operating procedures, and a consensus classification system is designed to bring much-needed standardization to these techniques.
Topics: Anal Canal; Gastroenterology; Humans; Intestinal Diseases; Manometry
PubMed: 31407463
DOI: 10.1111/nmo.13679 -
Digestion 2024Functional endoscopy signifies a significant advancement in gastrointestinal examination, integrating motor function assessments alongside routine endoscopy findings.... (Review)
Review
BACKGROUND
Functional endoscopy signifies a significant advancement in gastrointestinal examination, integrating motor function assessments alongside routine endoscopy findings. Traditional gastrointestinal endoscopy primarily focuses on the detection of early-stage cancer by identifying morphological changes within the gastrointestinal tract. These alterations include modifications in lumen structure, color tone, and surface patterns, which can be diagnosed using endoscopic images that assess these morphological changes. In contrast, functional endoscopy aims to dynamically evaluate the peristaltic movements of the digestive tract and the presence or movement of reflux of digestive fluids during the endoscopic procedure. It also seeks to identify morphological changes such as hiatal hernias, as observed in conventional endoscopy. Consequently, relying solely on endoscopic images proves inadequate for diagnosis, necessitating continuous observation of these dynamic movements.
SUMMARY
The endoscopic pressure study integrated system (EPSIS) serves as an exemplar of functional endoscopy. It incorporates a stress test to assess the functionality of the lower esophageal sphincter (LES) through intragastric insufflation. A crucial element of EPSIS evaluation is the identification of the scope holding sign (SHS), which signifies LES contraction. EPSIS also encompasses the observation of esophageal peristaltic waves and the auditory detection of burping, providing a comprehensive diagnostic approach while observing the sphincter from a retroflex view on the stomach side. By integrating these dynamic findings, functional endoscopy offers an efficient method for diagnosing functional gastrointestinal diseases, such as gastroesophageal reflux disease (GERD).
KEY MESSAGES
Functional endoscopy combines motor function assessments with traditional endoscopy, enhancing the diagnostic capabilities of gastrointestinal examinations. Traditional endoscopy focuses on identifying morphological changes, while functional endoscopy evaluates dynamic movements, reflux, and sphincter functionality. EPSIS exemplifies functional endoscopy, featuring a stress test and the SHS for LES contraction assessment. EPSIS provides a comprehensive approach to diagnose GERD by integrating dynamic observations.
Topics: Humans; Gastroesophageal Reflux; Endoscopy, Gastrointestinal; Esophageal Sphincter, Lower; Hernia, Hiatal; Manometry
PubMed: 38008079
DOI: 10.1159/000534831