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The purpose of our study was to evaluate the use of minimally invasive Marshmallow Swallow Study (MSS) as a preoperative screening technique for patients and correlate marshmallow results with High Resolution Manometry (HRM) results and post-operative dysphagia following antireflux surgery.A retrospective electronic chart review of data on 61 adult patients undergoing MSS was completed. Patients were included if they completed the MSS as well as: HRM and/or antireflux surgery.Sixty-one patients completed MSS. Of the 37 patients that completed HRM, 27 had abnormal results. 23 of these 27 patients who had abnormal results also failed MSS. The NPV for a failure on the MSS and abnormal HRM results is 0.767(p-value = 0.360). The PPV for a pass on the MSS and no post-operative dysphagia is 0.833 (p-value = 0.656).MSS is an effective screening tool for ruling out major esophageal motility disorders and can prevent need for invasive HRM.

Esophageal dysmotility is a common finding in patients being evaluated for antireflux surgery, although its implication remains unclear. We aimed to evaluate outcomes of patients with esophageal dysmotility after fundoplication.A retrospective review of a prospective quality-database was performed. All patients who underwent laparoscopic Nissen (NF) or Toupet (TF) fundoplication were included. Esophageal dysmotility was defined using the Chicago Classification v4.0 and conventional metrics, creating three sub-groups: ineffective esophageal motility (IEM), distal/diffuse esophageal spasm (DES), and hypercontractile esophagus (HE). Quality of life (QOL) outcomes were measured by the Reflux Severity Index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), and Dysphagia Scores.Of 487 patients included, 99 (20.3%) had esophageal dysmotility (49 IEM, 40 DES, 10 HE). While a majority in the dysmotility group (81.8%) underwent TF, most patients in the normal group (76.5%) underwent NF (p 0.001). On multivariable analysis controlling for sex, age, BMI, hiatal hernia, and surgery type, the normal group had higher Dysphagia Scores at 3 weeks (2.2 ± 0.9 vs. 1.7 ± 0.8, p 0.001), but not at 6-month, 1-year, 2-year, or 5-year follow-up. There were no differences between normal and dysmotility groups in terms of RSI or GERD-HRQL scores at any time point. Patients with different sub-types of esophageal dysmotility had similar QOL outcomes at all time points.Patients with esophageal dysmotility had similar outcomes compared to those with normal motility after fundoplication, suggesting the tailored approach favoring partial fundoplication for patients with dysmotility as part of an appropriate treatment algorithm.

Esophageal peristalsis consists of initial inhibition (relaxation) followed by excitation (contraction), both of which move sequentially in the aboral direction. Initial inhibition results in receptive relaxation and bolus-induced luminal distension, which allows propulsion by the contraction with minimal resistance to flow. Similar to the contraction wave, luminal distension has unique waveform characteristics in normal subjects; both are modulated by bolus volume, bolus viscosity, and posture, suggesting a possible cause-and-effect relationship between the two. Distension contraction plots in patients with dysphagia with normal bolus clearance [high-amplitude esophageal contractions (HAECs), esophagogastric junction outflow obstruction (EGJOO), and functional dysphagia (FD)] reveal two major findings: 1) unlike normal subjects, there is luminal occlusion distal to bolus during peristalsis in certain patients, i.e., with type 3 achalasia and nonobstructive dysphagia; and 2) bolus travels through a narrow lumen esophagus during peristalsis in patients with HAECs, EGJOO, and FD. Aforementioned findings indicate a relative dynamic obstruction to the bolus flow during peristalsis and reduced distensibility of esophageal wall in the bolus segment of the esophagus. We speculate that a normal or supernormal contraction wave pushing bolus against resistance is the mechanism of dysphagia sensation in significant number of patients. Representations of distension and contraction, combined with objective measures of flow timing and distensibility are complementary to the current scheme of classifying esophageal motility disorders based solely on the characteristics of contraction phase of peristalsis. Better understanding of the distensibility of the bolus-containing segment of the esophagus during peristalsis will lead to the development of novel medical and surgical therapies in the treatment of dysphagia in significant number of patients.

▪ RESUMO Introdução: Este estudo se trata de um relato de caso que tem por objetivo alertar os cirurgiões para uma possível complicação em pós-operatório de cirurgias estéticas longas sob anestesia geral. A Síndrome de Boerhaave é uma doença grave que ameaça a vida do paciente e merece um diagnóstico precoce até 12hs e um tratamento adequado. Relato de caso: A paciente no pós-operatório de cirurgia plástica abdominal e mastopexia apresentou, após anestesia geral, crises de vômito e náuseas. Resultados: Paciente com 58 anos do sexo feminino submetida à dermolipectomia abdominal e mastopexia pela a técnica de pedículo inferior sob raquianestesia, onde após um período de quatro horas do término da cirurgia apresentou vários episódios de vômitos. Após 10 horas do ato cirúrgico apresentou queixa de algia ao deglutir, seguida de algia intensa generalizada, dispneia intensa, sudorese, palidez, PA 90x50mmhg. Com a piora do quadro a paciente foi encaminhada para a unidade de terapia intensiva onde foi entubada. Foram realizados exames laboratoriais, toracocentese e exames radiológicos. Atualmente, a paciente encontra-se com prótese esofágica. Conclusões: Fazendo a correlação com a bibliografia, no caso em tela sugere-se evitar cirurgias prolongadas, principalmente sob anestesia geral onde pode ocorrer a retenção de gás carbônico, que pode levar a crise emética no pós-operatório em pacientes com antecedentes de doença esofagiana e estar atentos aos sintomas, não descartando a possibilidade da ocorrência da Síndrome Boerhaave. ▪ ABSTRACT Introduction: The objective of this case report is to alert surgeons to a possible postoperative complication of long cosmetic surgery under general anesthesia. Boerhaave syndrome is a serious life-threatening disease that requires diagnosis within 12 hours and proper treatment. Case report: A 58-year-old female patient presented with vomiting and nausea after abdominoplasty and mastopexy under general anesthesia. Results: The patient underwent dermolipectomy and mastopexy using the inferior pedicle technique under spinal anesthesia. Four hours after the operation, she presented several episodes of vomiting. Ten hours after the operation, she reported painful swallowing followed by generalized severe pain and presented severe dyspnea, sweating, pallor, and a 90/50 mmHg blood pressure. As the condition worsened, the patient was referred to the intensive care unit where she was intubated and underwent laboratory tests, thoracentesis, and radiological examinations. The patient currently uses an esophageal prosthesis. Conclusions: The literature suggests avoiding prolonged surgery, especially under general anesthesia, because of the risk of carbon dioxide retention, which may lead to postoperative emetic crisis in patients with a history of esophageal disease. It also suggests paying attention to symptoms, not excluding the possibility of Boerhaave syndrome.

Esophagogastric junction (EGJ) outflow obstruction (EGJOO) per Chicago Classification v4.0 (CCv4.0) represents a high-resolution manometry (HRM) diagnosis with uncertain clinical significance. This study aimed to evaluate functional lumen imaging probe (FLIP) panometry among patients with EGJOO on HRM/CCv4.0 to assess clinical/manometric associations and treatment outcomes.An observational cohort study was performed on patients who completed FLIP during endoscopy and had an HRM/CCv4.0 diagnosis of EGJOO, i.e., HRM-EGJOO (inconclusive). Abnormal FLIP panometry motility classifications were applied to identify FLIP-confirmed conclusive EGJOO. Rapid drink challenge on HRM and timed barium esophagram were also assessed. Clinical management plan was determined by treating physicians and assessed through chart review. Clinical outcome was defined using the Eckardt score (ES) during follow-up evaluation: ES3 was considered a good outcome.Of 139 adult patients with manometric EGJOO (inconclusive per CCv4.0), a treatment outcome ES was obtained in 55 after achalasia-type treatment (i.e., pneumatic dilation, peroral endoscopic myotomy, laparoscopic Heller myotomy, or botulinum toxin injection) and 36 patients after other nonachalasia-type treatment. Among patients with conclusive EGJOO by HRM-FLIP complementary impression, 77% (33/43) had a good outcome after achalasia-type treatment, whereas 0% (0/12) of patients had a good outcome after nonachalasia-type treatment. Of patients with normal EGJ opening on FLIP, one-third of patients treated with achalasia-type treatment had a good outcome, while 9 of the 10 treated conservatively had a good outcome.FLIP panometry provides a useful complement to clarify the clinical significance of an HRM/CCv4.0 EGJOO diagnosis and help direct management decisions.

This review aims to provide an overview of the current role of per oral endoscopic myotomy (POEM) in the management of primary esophageal motility disorders and treatment of Zenker's diverticulum.POEM has been shown to be an effective treatment for achalasia. Recent research has suggested that the length of myotomy may be tailored to the disease phenotype and that short myotomy may be equally effective compared to long myotomy. The role of intra-operative EndoFLIP has shown promise as a tool to assess of the adequacy of myotomy. Further research is needed to determine the role of POEM in other esophageal motility disorders and for treatment of Zenker's diverticulum. Per oral endoscopic myotomy has been shown to be an effective and durable treatment option for achalasia with additional potential roles for the treatment of other esophageal motility disorders and Zenker's diverticulum.

Studies with limited sample sizes have investigated association of chronic opioid use with motility disorders of esophagogastric junction and esophageal body peristalsis. Our aims were to use a large cohort of patients to assess (1) the impact of opioid exposure on clinical and manometric characteristics, and (2) the association of opioid exposure with higher long-term symptom burden.Patients recruited from a tertiary medical center who underwent high-resolution manometry (HRM) between 2007 and 2018 were included. Demographics, opiate exposure, clinical symptoms, and HRM parameters were compared. Patient-Reported Outcomes Measurement Information System-Gastrointestinal swallowing domain (PROMIS-GI swallowing domain) and Eckardt score were administered via phone interviews in patients with hypercontractile esophagus (HE) or distal esophageal spasm (DES) to determine long-term symptom burden between opioid and nonopioid users.Our cohort included 4075 patients (869 with opiate exposure with median morphine milligram equivalent [interquartile range] of 30 [10-45]). Patients in the opioid group were significantly more likely to have dysphagia (65% vs 51%, P.01) and diagnosis of DES (11% vs 5%, P.01) and HE (9% vs 3%, P.01). Partial opioid agonists were not associated with motility abnormalities. Patients on opioids had significantly higher symptom burden on median (interquartile range) follow-up of 8.9 years (5.8-10.4) post manometric diagnosis with median PROMIS-GI swallowing domain score of 21.5 (17-25) compared with the nonopioid group at 15 (9.8-21, P = .03).Nearly 2 of 3 patients with opioid exposure undergoing HRM have dysphagia and more than 25% of them with dysphagia as the primary symptom have a diagnosis of either DES or HE. Opioid users with spastic disorders have higher symptom burden long-term compared with nonopioid users.

No recommendation regarding antibiotic prophylaxis and preparation modalities are available for patients with esophageal motor disorders who benefit from Per-Oral Endoscopic Myotomy (POEM). The aim of our study was to evaluate their impact on the POEM's safety.This study was a comparative and multicentric retrospective analysis of a database prospectively collected. Patients over 18 years old with esophageal motor disorders confirmed by prior manometry, who underwent POEM were included. The primary endpoint was the occurrence of adverse events, as classified by Cotton, based on whether or not antibiotic prophylaxis was administered.A total of 226 patients (median age 52.9 ± 19.12 years [18-105], 116 women [51.3%]) were included. The indication for POEM was mainly type 2 achalasia (The antibiotic prophylaxis during POEM does not prevent adverse events, had no impact on their severity and the efficacy of the procedure. A liquid diet before the procedure should be systematically proposed.

Chicago classification version 4.0 (CCv4.0) introduced stringent diagnostic criteria for oesophagogastric junction outflow obstruction (EGJOO), in order to increase the clinical relevance of the diagnosis, although this has not yet been demonstrated.To determine the prevalence of EGJOO using CCv4.0 criteria in patients with CCv3.0-based EGJOO, and to assess if provocative manoeuvres can predict a conclusive CCv4.0 diagnosis of EGJOO.Clinical presentation, high resolution manometry (HRM) with rapid drink challenge (RDC), and timed barium oesophagogram (TBE) data were extracted for patients diagnosed with EGJOO as per CCv3.0 between 2018 and 2020. Patients were then re-classified according to CCv4.0 criteria, using clinically relevant symptoms (dysphagia and/or chest pain), and abnormal barium emptying at 5 min on TBE. Receiver operating characteristic (ROC) analyses identified HRM predictors of EGJOO.Of 2010 HRM studies, 144 (7.2%) fulfilled CCv3.0 criteria for EGJOO (median age 61 years, 56.9% female). Upon applying CCv4.0 criteria, EGJOO prevalence decreased to 1.2%. On ROC analysis, integrated relaxation pressure during RDC (RDC-IRP) was a significant predictor of a conclusive EGJOO diagnosis by CCv4.0 criteria (area under the curve: 96.1%). The optimal RDC-IRP threshold of 16.7 mm Hg had 87% sensitivity, 97.1% specificity, 95.7% negative predictive value and 91.3% positive predictive value for a conclusive EGJOO diagnosis; lower thresholds (10 mmHg, 12 mmHg) had better sensitivity but lower specificity.CCv4.0 criteria reduced the prevalence of EGJOO by 80%, thereby refining the diagnosis and identifying clinically relevant outflow obstruction. Elevated RDC-IRP can predict conclusive EGJOO per CCv4.0.

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: 687 adult patients that 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 (i.e. achalasia subtypes I, II, or III; or EGJ outflow obstruction with abnormal timed barium esophagram) or normal EGJ outflow. RESULTS: All 35 controls had EGJ-DI >3.0mm(2)/mmHg and maximum EGJ diameter >16mm. 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 (REO: EGJ-DI

There is limited data on long-term outcomes of per-oral endoscopic myotomy (POEM). In this study, we aim to evaluate the efficacy of POEM in patients who completed a minimum follow-up of 5 years.Data of patients who underwent POEM and completed ≥ 5-year follow-up were analyzed, retrospectively. Primary outcome of study was clinical success (Eckardt ≤ 3) at ≥ 5 years after POEM. Secondary outcomes included predictors of dysphagia and symptomatic gastroesophageal reflux disease (GERD) on long-term follow-up.Three hundred nineteen patients (males 182, mean age 40.5 ± 14.2 years) completed a median of 73-(60-89) month follow-up. Esophageal motility disorders included idiopathic achalasia (type I 26.6%, type II 60.8%, type III 5.6%) and Jackhammer esophagus or distal esophageal spasm (2.8%). POEM was technically successful in 307 (96.2%) patients. Long-term success was 92.6% (overall), 92.1% (type I), 94.7% (type II), 87.5% (type III), and 75% (Jackhammer esophagus/distal esophageal spasm). Symptomatic GERD and reflux esophagitis were detected in 28.9% and 35.3% patients, respectively. On multivariate analysis, young age and female gender were independent risk factors for recurrent dysphagia (p = 0.037) and symptomatic GERD after POEM (p = 0.025), respectively. Lower post-POEM lower esophageal sphincter pressure was an independent predictor for reflux esophagitis (p = 0.016).POEM is an effective and durable treatment for achalasia and non-achalasia spastic motility disorders. Young patients and females may be at higher risk for recurrent dysphagia and symptomatic GERD, respectively.

Objective Esophageal diverticulum is rare, and the concomitance of esophageal motility disorders (EMDs) and the efficacy of novel endoscopic treatment have not been investigated in Japan. Methods An examination including high-resolution manometry (HRM) was performed for patients with both EMDs and epiphrenic diverticulum. EMD-related epiphrenic diverticulum and Zenker's diverticulum were treated using salvage peroral endoscopic myotomy (s-POEM) and endoscopic diverticulotomy, respectively. Results Six cases of epiphrenic diverticulum were diagnosed in this study. Among 125 patients with achalasia and spastic disorders, concomitant epiphrenic diverticulum was observed in 4 (3.2%). Of these, three showed a normal lower esophageal sphincter pressure on HRM, although gastroscopy and esophagography revealed typical findings of an impaired lower esophageal sphincter relaxation. These four patients were successfully treated with s-POEM, and the Eckardt score improved from 6.3 to 0.25 at 32.5 (range: 13-56) months of follow-up, with equivalent treatment efficacy to that observed for achalasia and spastic disorders without epiphrenic diverticulum. In contrast, the two remaining cases of epiphrenic diverticulum had normal esophageal motility. Six cases of Zenker's diverticulum were diagnosed, and endoscopic diverticulotomy was successfully performed in all. The dysphagia score decreased from 2.8 to 0.17 at 14.8 (range: 2-36) months of follow-up. Overall, 12 endoscopic treatments were performed for esophageal diverticulum; no adverse events were observed. Conclusion In epiphrenic diverticulum patients, concomitant EMDs are not rare and should be carefully diagnosed. A normal lower esophageal sphincter pressure on HRM does not always mean a normal lower esophageal sphincter relaxation. S-POEM and endoscopic diverticulotomy are effective minimally invasive treatment options for EMD-related epiphrenic diverticulum and Zenker's diverticulum.

Background Jackhammer esophagus (JE) is a hypercontractile esophageal motility disorder diagnosed using high-resolution manometry (HRM). We sought to determine the clinical presentation and therapeutic data of patients with JE in Japan. Methods The study included patients with JE, diagnosed through HRM performed for suspicious esophageal motility disorders. Demographics, esophagogastroduodenoscopy, radiology, and therapy data were collected from patient charts. Results Among the 4,412 HRM tests performed, 89 patients (61.6 ± 13.4 years; 64 males, 25 females) were diagnosed with JE (2.0%). Dysphagia was the most frequent symptom (80%), followed by chest pain (40%) and heartburn (25%). Esophagogastroduodenoscopy showed abnormal findings in 32% of patients: corkscrew/rosary beads appearance in 26%, narrowing in 11%. Eosinophilic infiltration (> 15 eosinophils/high power field) was diagnosed in 21%. Esophagography showed abnormal findings in 9% of the patients. For the initial therapy, 47 patients received medical treatment followed by peroral endoscopic myotomy (21 patients) and laparoscopic myotomy (two patients). Thirteen patients did not receive any treatment and 10 of those (77%) reported spontaneous resolution of symptoms. Patients who required invasive treatment experienced severe disability in their quality of life and greater maximal distal contractile integral than those who did not. Conclusions HRM showed that the prevalence of JE was very low (2%). Esophagogastroduodenoscopy revealed some characteristic features of JE in patients. Some patients showed improvement of symptoms without invasive treatments. Follow-up with/without medical treatment should be considered before performing invasive treatment in patients whose distal contractile integral is relatively low and the quality of life is not impaired.

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.

Achalasia is a common esophageal motility disorder characterized by inappropriate relaxation of the lower esophageal sphincter and a loss of normal peristalsis in the esophageal body. The newly suggested Chicago Classification ver. 4.0 recommends conclusive diagnoses of types 1, 2, and 3. A conclusive diagnosis of type 3 achalasia requires no appreciable peristalsis compared to the previously used ver. 3.0. In the case of inconclusive diagnosis of achalasia, additional tests, including timed barium esophagogram (TBE) or functional lumen imaging probe (FLIP), are strongly recommended in ver. 4.0. Esophagogastric junction outflow obstruction (EGJOO) in Chicago Classification ver. 3.0 was defined as an elevated median integrated relaxation pressure (IRP) without evidence of achalasia. On the other hand, the diagnosis of EGJOO in Chicago Classification ver. 4.0 requires elevated IRP in both positions, elevated intrabolus pressure, positive clinical symptoms, and additional positive test by TBE or FLIP. The newly suggested Chicago Classification Classification ver. 4.0 will be helpful in an accurate diagnosis of esophageal motility disorders, including achalasia and EGJOO.

This review introduces the updated Chicago Classification ver. 4.0 for esophageal motility disorders using metrics from high-resolution manometry (HRM). The Chicago Classification ver. 4.0 was developed by 52 diverse international experts using validated methodologies over 2 years. Key updates in Chicago Classification ver. 4.0 include: 1) a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, 2) a refined definition of esophagogastric junction outflow obstruction, and 3) emphasis on supportive testing with barium esophagogram with tablet and/or functional lumen imaging probe.

Esophageal motility disorders (EMD) can have significant effects on quality of life. Patient-reported outcomes (PROs) provide valuable insight into the patient's perspective on their treatment and are becoming increasingly used in randomized controlled trials (RCTs). Thus, our investigation aims to evaluate the completeness of reporting of PROs in RCTs pertaining to EMDs. We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials for published RCTs focused on EMDs. Included RCTs were published between 2006 and 2020, reported a primary outcome related to an EMDs, and listed at least one PRO measure as a primary or secondary outcome. Investigators screened and extracted data in a masked, duplicate fashion. Data extraction was carried out using both the CONSORT-PRO adaptation and Cochrane Collaboration Risk of Bias 2.0 tool. We assessed overall mean percent completion of the CONSORT-PRO adaptation and a bivariate regression analysis was used to assess relationships between trial characteristics and completeness of reporting. The overall mean percent completion of the CONSORT-PRO checklist adaptation was 43.86% (SD = 17.03). RCTs with a primary PRO had a mean completeness of 47.73% (SD = 17.32) and RCTs with a secondary PRO was 35.36% (SD = 13.52). RCTs with a conflict of interest statement were 18.15% (SE = 6.5) more complete (t = 2.79, P = .009) than trials lacking a statement. No additional significant associations between trial characteristics and completeness of reporting were found. PRO reporting completeness in RCTs focused on EMDs was inadequate. We urge EMD researchers to prioritize complete PRO reporting to foster patient-centered research for future RCTs on EMDs.

Background/aims No screening test for esophageal motility disorder (EMD) has been established, the objective of this study is to examine the potential usefulness of our newly developed "Onigiri esophagography" combined with an obstruction level (OL) classification system in screening for EMD. Methods A total of 102 patients with suspected EMDs who underwent both high-resolution manometry (HRM) and Onigiri esophagography between April 2017 and January 2019 were examined. The EMD diagnosis was performed based on the Chicago classification version 3.0 by HRM. Onigiri esophagography was performed using a liquid medium (barium sulfate) followed by a solid medium, which consisted of an Onigiri (a Japanese rice ball) with barium powder. The extent of medium obstruction was assessed by the OL classification, which was defined in a stepwise fashion from OL0 (no obstruction) to OL4 (severe obstruction). Results Thirty-two percent of the patients with OL0 (32.3%), OL1 (50.0%), OL2 (88.0%), OL3 (100.0%), and OL4 (100.0%) were diagnosed EMDs by HRM. The area under the curve, as determined by a receiver operating characteristic analysis, for the OL classification was 0.86. Using the cutoff value of OL1, the sensitivity and specificity were 87.3% and 61.3%, respectively, while using a cutoff value of OL2, the sensitivity and specificity were 73.2% and 90.3%, respectively. Conclusion In conclusion, Onigiri esophagography combined with the OL classification system can be used as a screening test for EMDs with a cutoff value of OL1.

Esophageal motility disorders are sometimes misdiagnosed on endoscopic examination. We aimed to identify the proportion of patients with esophageal motility disorders missed during endoscopy and their clinical characteristics.Patients diagnosed with either disorder with esophagogastric junction outflow obstruction or major disorders of peristalsis using high-resolution manometry in our hospital from April 2015 to March 2021 were included in this study. Missed esophageal motility disorders were defined as patients with any endoscopic misdiagnosis such as normal esophagus or esophagitis within 1 year before the manometric diagnosis. We determined the proportion of missed esophageal motility disorders and identified independent predictors of missed esophageal motility disorders using multivariate analysis.A total of 41/273 esophageal motility disorders (15.0%; 95% confidence interval 11.3-19.7%) were missed during endoscopy within 1 year before manometric diagnosis. In the stepwise logistic regression analysis, the following variables were selected as independent variables for patients with missed esophageal motility disorders during endoscopy: non-dilated esophagus (odds ratio = 4.87, 95% confidence interval: 1.81-13.12, p = 0.002), the presence of epiphrenic diverticulum (odds ratio = 8.95, 95% confidence interval: 1.88-42.65, p = 0.006), the use of transnasal endoscopy (odds ratio = 4.71, 95% confidence interval: 1.59-13.92, p = 0.005), and the combined use of esophagram (odds ratio = 0.023, 95% confidence interval: 0.0025-0.20, p = 0.0008).Based on retrospective analysis, 15% of esophageal motility disorders were missed during endoscopy. Understanding the clinical characteristics of missed esophageal motility disorders could help improve endoscopic diagnoses.

PURPOSE OF REVIEW: Chicago Classification has standardized clinical approach to primary esophageal motility disorders. With new clinical data and advancing treatments, Chicago Classification has undergone multiple revisions to reflect updated findings and enhance diagnostic accuracy. This review will describe the recently published Chicago Classification version 4.0 (CCv4.0), which aimed to enhance diagnostic characterization and limit overdiagnosis of inconclusive esophageal motility diagnoses. RECENT FINDINGS: Key revisions outlined in CCv4.0 include (1) a modified standardized HRM study protocol performed in supine and upright positions, (2) recommended ancillary testing and manometric provocation for inconclusive manometric diagnoses (3) the required presence of obstructive symptoms for conclusive diagnoses of esophagogastric junction outflow obstruction, distal esophageal spasm and hypercontractile esophagus, and (4) requirement of confirmatory testing for esophagogastric junction outflow obstruction. SUMMARY: These key modifications aim to improve diagnostic accuracy and consistency of clinically relevant esophageal motility disorders, and subsequently clinical outcomes.

Functional and motility gastrointestinal disorders are the most common complaints to the pediatric gastroenterologist. Disorders affecting the small intestine carry a significant morbidity and mortality due to the severe limitation of therapeutic interventions available and the complications associated with such interventions. Congenital colorectal disorders are rare but also carry significant morbidity and poor quality of life plus the social stigma associated with its complications. In this review, we summarize the clinical presentation, diagnostic evaluations, and the therapeutic interventions available for the most common and severe gastrointestinal functional and motility disorders of the small bowel, colon, and anorectum.

Esophageal dysmotility in esophageal atresia (EA) relates to abnormal development of esophageal innervation and musculature and to the esophageal repair. Few studies have investigated the preexisting dysmotility in EA, present prior to surgery. This systematic review aims to summarize the literature on neuronal studies in EA, to understand the causative factors for esophageal dysmotility. We performed a systematic review (PubMed, EMBASE, EBM, CINAHL databases; January 1947-February 2021) in accordance with PRISMA (PROSPERO number CRD42020171014). Fourteen studies were identified (eleven human, 187 EA patients; three animal, 64 EA rat specimens). Neural factors affecting esophageal dysmotility in human and animal studies included proteins, enzymes, growth factors, and genes, which play a role in the nervous system or neuroendocrine system, some of which have functions as neuromodulators or neurotransmitters. This systematic review has identified neural factors that affect esophageal dysmotility and contributes toward our understanding of the underlying dysmotility in patients with EA. The studies identified are important and essential for successful translation of basic science knowledge to impact clinical practice and understanding. Level of evidence: III.

Eosinophil infiltration in esophageal muscularis propria is common in achalasia (AC). This study aims to evaluate the effect of eosinophil infiltration in muscularis propria of the esophagus on esophageal motility in mice. A mouse model with eosinophil infiltration in the esophageal muscle layer was established by long term Ovalbumin (OVA) exposure. The histopathology features of esophageal muscularis propria as well as parameters of esophageal motility, such as lower esophageal sphincter pressure (LESP) and esophageal emptying, were compared between model and control group. In addition, the histopathology and motility of esophagus at each time point in the model group were compared. The esophageal motor function severely deteriorated in the model group, mimicking the abnormal esophageal motility of AC, with more eosinophils and fewer SOX-10-IR cells in esophageal muscularis propria in the model group, compared with control. With the prolongation of OVA treatment, esophageal motility disorder was aggravated, accompanied by increased eosinophils in the the muscle layer of esophagus and decreased SOX-10-IR cells in the model group. In addition, the eosinophil count was negatively correlated with SOX-10-IR cells. Long-term exposure to OVA assisted by alum may induce eosinophil infiltration in esophageal muscularis propria, reduced SOX-10-IR cells and abnormal esophageal motility, which simulates the functional and histopathological features of some AC patients. This suggests that eosinophil infiltration in esophageal muscularis propria may play a role in the pathogenesis of a subgroup of AC.

High-resolution manometry permitted the creation of the Chicago classification, that is the categorization for esophageal motility disorders most currently used. Despite its wide acceptance, there are few pitfalls for the correct interpretation of the tests. This technique review illustrates some difficult cases that may lead to misinterpretation of the results. Difficult cases are analyzed, such as the distinction of: (1) esophagogastric junction morphology and lower esophageal sphincter excursion, (2) intrabolus pressure pattern or common cavity, (3) hypercontractile esophagus (jackhammer) and achalasia type III, (4) absent contractility and severe ineffective esophageal motility or achalasia type I, and (5) simultaneous distal esophageal spasm and ineffective esophageal motility.

BACKGROUND & AIMS: Functional luminal imaging probe (FLIP) Panometry can evaluate esophageal motility in response to sustained esophageal distension at the time of sedated endoscopy. This study aimed to describe a classification of esophageal motility using FLIP Panometry and evaluate it against high-resolution manometry (HRM) and Chicago Classification v4.0 (CCv4.0). METHODS: 539 adult patients that completed FLIP and HRM with a conclusive CCv4.0 diagnosis were included in the primary analysis. 35 asymptomatic volunteers (“controls”) and 148 patients with an inconclusive CCv4.0 diagnosis or systemic sclerosis were also described. Esophagogastric junction (EGJ) opening and the contractile response to distension (i.e. secondary peristalsis) were evaluated with 16-cm FLIP performed during sedated endoscopy and analyzed using a customize software program. HRM was classified according to CCv4.0. RESULTS: In the primary analysis, 156 patients (29%) had normal motility on FLIP Panometry, defined by normal EGJ opening (NEO) and a normal or borderline contractile response; 95% of these patients had normal motility or ineffective esophageal motility on HRM. 202 patients (37%) had obstruction with weak contractile response, defined as reduced EGJ opening and absent contractile response or impaired/disordered contractile response, on FLIP Panometry; 92% of these patients had a disorder of EGJ outflow per CCv4.0. CONCLUSIONS: Classifying esophageal motility in response to sustained distension with FLIP Panometry parallels the swallow-associated motility evaluation provided with HRM and CCv4.0. Thus, FLIP Panometry provides a well-tolerated method that can complement, or in some cases be an alternative to HRM, for evaluating esophageal motility disorders.

Background: Gastro-esophageal reflux disease (GERD) has a prevalence of 10-20% in the Western countries while its prevalence amongst the Pakistani population is between 22 to 24%. Esophageal manometry is currently the gold standard for diagnosing esophageal motility disorders. Aims and Objectives: To determine the frequency of esophageal motility disorder in patients with GERD. Materials and Methods: This cross-sectional study was conducted at the department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan. Patients diagnosed with GERD (defined as having typical reflux symptoms with more than 2 episodes per were) were included in this study. These patients were subjected to upper GI endoscopy followed by esophageal manometry. Esophageal motility disorders were then classificated by using the Chicago classification 3.0. Results: A total of 76 patients were included in our study, out of which 41 (53.9%) were females. A mean age of 46.1 years ± 12 years and a mean body mass index (BMI) of 23.7kg/m2 was noted. The most common comorbid condition seen in our patients was diabetes mellitus, which was seen in 13 patients (17%). A normal EGD was noted in 48 patients (63%). Liquid perfusion esophageal manometer catheter was mainly used in our study that is in 70 patients (92.1%). Weak esophageal peristalsis was the most common esophageal motor abnormality seen in 16 patients (21.1%). Conclusion: A significant proportion of patients with GERD have the presence of a motility disorders, the early identification and treatment of which can lead to improvement GERD symptoms.

Background/Aims High-resolution manometry with the Chicago classification scheme has been introduced in clinical practice as a gold standard for esophageal motility test. This study aims to evaluate the diagnostic yield of high-resolution manometry in Thai patients. Methods All available high-resolution esophageal manometry (HREM) studies performed during the study period were retrospectively reviewed and interpreted according to the Chicago classification version 3.0. The main esophageal symptoms and coexisting factors were correlated with the HREM findings. Results Of the 201 patients, nearly half (49.8%) were documented to have dysphagia. The second most common condition was refractory reflux symptoms (17.4%). More than 70.0% of dysphagia patients showed abnormal esophageal motility, contrary to globus patients who mostly had normal test findings (65.4%). Dysphagia still was the most often correlated condition with major esophageal motility disorders (88.7%), particularly the elderly patients who have coexisting weight loss. Endoscopic and/or surgical procedures were revealed for the highest rate among patients with dysphagia but no one in the globus group needed this intervention. The sensitivity and specificity of dysphagia for major esophageal motility disorders were 70.0% and 67.0%. A much lower sensitivity and higher specificity were found in other non-dysphagia symptoms, especially nausea/vomiting or belching (3.0% or 89.0%). The highest positive likelihood ratio (2.10) to detect major abnormalities was also observed in dysphagia. Conclusion Esophageal manometry provided the highest yield in dysphagia; it was not a strongly beneficial test in patients presenting with non-dysphagia to identify clinically relevant esophageal motor disorders.

BACKGROUND Functional luminal imaging probe (FLIP) measures pressure-geometry relationships of digestive luminal space. When used in esophageal disorders, it provides several luminal parameters that help better understand the pathophysiology. Data about the potential utility of FLIP in pediatrics are scarce and there is no standardized use in children. We aim to describe the use of FLIP in our center, its safety, feasibility, and clinical impact in esophageal disorders in children. METHODS Consecutive FLIP recordings performed at the CHU-Sainte-Justine, Montreal, Canada between February 2018 and January 2021 were extracted. A chart review was conducted for demographics and medical history. Symptomatology after the procedure was evaluated with validated dysphagia scores. 19 patients were included (11 girls, median age 16 years, range 3.2-19.6) with achalasia (n = 5), post Heller's myotomy dysphagia (n = 3); esophagogastric junction outflow obstruction (EGJOO) (n = 3); congenital esophageal stenosis (n = 2); post esophageal atresia repair stricture (n = 3), post-fundoplication dysphagia (n = 3). There was no significant correlation between integrated relaxation pressure measured with high resolution manometry and distensibility index (DI). The use of FLIP made it possible to differentiate between dysphagia related to an esophageal obstruction (DI ≤ 2.8 mm2/mmHg) and dysphagia without major motility disorder (DI > 2.8 mm2/mmHg) that guided the indication for dilation. FLIP led to a change in management in 47% of the patients. Forty-seven percent of the patients were symptom free at the time of the evaluation.Conclusions & Inferences: FLIP provides key esophageal luminal values and therefore can play an important role in pediatric esophageal disorders management.

Background Esophageal atresia (EA) is a life-threatening congenital condition, affecting one in 2600 newborns. Morbidity remains high, with many patients experiencing complications, including anastomotic leak/stricture, and gastro-esophageal reflux disease (GERD). Increased understanding of esophageal motility patterns may help explain the etiology of these complications. Aims We aimed to review knowledge regarding esophageal motility and related complications in children with EA, evaluate patients' symptomatology and relate this to esophageal motility. Methods We performed a systematic review (PROSPERO: CRD42018092277), according to the PRISMA protocol. Two investigators independently conducted search strategies (OvidMEDLINE, PubMed, Cochrane Review, BMJ BestPractice), identifying complications in patients following EA repair. Rates of esophageal dysmotility, GERD, dysphagia, anastomotic leak, anastomotic stricture, recurrent fistula formation, and esophagitis were sought. Results A total of 65 publications met selection criteria (n = 4882). Rates of morbidity were high: esophageal dysmotility (78%), GERD (43%), dysphagia (44%), anastomotic leak (19%), anastomotic stricture (26%), recurrent fistula formation (7%), and esophagitis (47%). No correlation appeared to exist with severity of symptoms. Conclusions This systematic review identified high rates of complications in children with EA, with esophageal dysmotility present in the majority of patients. Increasing survival, with resultant longer timeframes to develop morbidities, makes standardized follow-up regimens crucial. Type of study Prognosis study. Level of evidence Level 3.

Manometry, particularly high-resolution manometry is the preferred diagnostic tool used to evaluate esophageal motor function. This investigation is strongly indicated in the setting of dysphagia, but is also useful in gastroesophageal reflux disease (GERD), especially in case of failure of conventional treatment to exclude alternative diagnoses and prior to anti-reflux surgery. Moreover, ineffective esophagogastric junction barrier function and esophageal motor dysfunction are pathophysiological mechanisms in GERD and can be identified by manometry. The recent international guidelines have positioned high-resolution manometry as an important part of functional diagnostic work up in GERD in order to identify the GERD phenotype to guide specific treatment. The proposed manometric identification and measurement is based on the Chicago classification version 4.0 adding with new established metrics for GERD evaluation. ispartof: JOURNAL OF NEUROGASTROENTEROLOGY AND MOTILITY vol:28 issue:4 pages:531-539 ispartof: location:Korea (South) status: published

Background: Patients with absent contractility (AC) often suffer from either reflux or dysphagia. It remains unclear what factors determine which phenotype patients present with. We sought to evaluate if high-resolution manometry metrics, especially integrated relaxation pressure (IRP), could explain this. Methods: Cases of AC from three medical centers were reviewed for demographic, clinical, and manometric data. Cases with an IRP between 10–15 mmHg or subsequent diagnosis of achalasia were excluded. Results: 69 subjects were included (mean age 56.1; 71% female). A total of 41 (59.4%) were reflux-predominant. The reflux-predominant group was younger (51.1 vs. 63.5, p = 0.002) and had lower median LES basal pressures (7.5 vs. 12.5 mmHg, p = 0.014) and IRP values (1.5 vs. 5.6 mmHg, p < 0.001) compared to the dysphagia group. When divided into tertiles, the trend in symptoms between LES basal pressure tertiles was not significant. However, the trend for IRP was significant (p < 0.001). For example, in the lowest IRP tertile, 91.3% of subjects were reflux-predominant compared to only 26.1% in the highest tertile, while the dysphagia-predominant group increased from 8.7% to 73.9%. In a regression model controlling for age and using IRP tertile 1 as the reference, having an IRP in tertile 2 increased the likelihood of having dysphagia-predominant disease by 7, while being in tertile 3 increased the likelihood by 22. Conclusions: IRP helps distinguish between the reflux-predominant and dysphagia-predominant phenotypes of AC. This may have therapeutic clinical consequences as procedures such as fundoplication to tighten the LES may benefit patients with reflux and a low IRP, while procedures like peroral endoscopic myotomy (POEM) to disrupt the LES may benefit patients with dysphagia and a relatively high IRP.

Esophageal motility is regulated both by coordinated stimulation and inhibition of the circular and longitudinal muscle layers of the esophagus. Although there are many diseases known to have an effect on esophageal motility, the effect of subepithelial lesions (SELs) of the esophagus on esophageal motility, which is often detected incidentally, remains still unclear. The aim of this study is to reveal the effect of SELs of the esophagus on esophageal motility evaluating it by high-resolution manometry (HRM).A total of 32 patients with SELs in the esophagus and 12 healthy individuals were included. All patients and controls included in the study underwent HRM using a Unisensor UniTip High Resolution catheter (Laborie, Amsterdam, Netherlands) and endosonographic examination.The mean age was 52.60±15.56 years (range: 23-79) and the average body mass index (BMI) was 26.63±4.71 kg/m2. Gender, height, weight, and BMI measurements, smoking status, alcohol use, and DM status did not statistically differ significantly between the groups (p0.05). Of 32 patients with SELs, 65.6% (n=21) had lesions originating in the muscularis propria, while 34.4% had lesions originating in the submucosa. The rate of abnormal motility both in the supine and in upright positions of patients with SELs was found to be significantly higher than in the control group (p=0.001, p0.01, respectively). In patients with SELs, the incidence of infective motility was higher than the normal group (p=0.001, p0.01, respectively). As the size of the lesion increases (2 cm), the probability of abnormal HRM results increased.SELs of the esophagus have pathological effects on esophageal motility, mainly ineffective esophageal motility disorder.

Summary Objective The goal of this study was to determine the prevalence of esophageal disorders among voice patients with intractable laryngopharyngeal reflux (LPR) who have undergone 24 pH impedance and esophageal manometry. Methods A retrospective chart review was performed of patients with LPR-associated dysphonia in the absence of subjective dysphagia who presented between January 1, 2007 and June 30, 2019 and underwent 24 pH impedance and esophageal manometry studies after inadequate response to lifestyle modifications, high dose of Proton Pump Inhibitor (PPIs), H2 blockers, alkaline water, and Gaviscon (GlaxoSmithKline, Warren, NJ, USA). The comorbidities, medications, Strobovideolaryngoscopy findings, 24 pH impedance, and esophageal manometry results were analyzed. Results The study included 109 patients ages 19 to 80 years old, with a mean age of 51.5 (SD 16.8). About 24.8% of the 109 subjects were found to have peristaltic wave abnormalities indicating esophageal dysmotility (11% with esophageal stasis). Lower esophageal sphincter pressures were normotensive in 56.9% of patients, hypertensive in 24.8%, and hypotensive in 18.4% of patients. In addition, the upper esophageal sphincter pressures were normotensive in 57.8% of patients, hypertensive in 36.7%, and hypotensive in 2.8% of patients. About 12.6% had both lower esophageal sphincter and upper esophageal sphincter dysfunction (hypertensive or hypotensive). The average total reflux events in patients exhibiting dysmotility on manometry 101.81, which was significantly higher compared with the mean total of 61.28 in the group of patients without dysmotility (P= 0.0396). In addition, there was a significantly higher prevalence of total events that were weakly acidic in the group with dysmotility compared with the group without (all patients performed the study on reflux medications, mean of total weakly acidic events 70.2 in dysmotility group vs 44.2 in normal motility group, P= 0.0427).Finally, the average number of total supine reflux events and the total acidic supine events were both significantly higher in the dysmotility group compared with the group without motility problems (P = 0.0199 and P = 0.0213, respectively). Conclusion Esophageal dysmotility may be a significant cofactor in voice patients with refractory LPR on appropriate reflux medications and lifestyle modifications. Further research is advised.

Introduction High-resolution manometry (HRM) is generally considered the primary method to evaluate esophageal motility; functional luminal imaging probe (FLIP) panometry represents a novel method to do so and is completed during sedated endoscopy. This study aimed to compare HRM and FLIP panometry in predicting esophageal retention on timed barium esophagram (TBE). Methods A total of 329 adult patients who completed FLIP, HRM, and TBE for primary esophageal motility evaluation were included. An abnormal TBE was defined by a 1-minute column height >5 cm or impaction of a 12.5-mm barium tablet. The integrated relaxation pressure (IRP) on HRM was assessed in the supine and upright patient positions. Esophagogastric junction (EGJ) opening was evaluated with 16-cm FLIP performed during sedated endoscopy through EGJ-distensibility index and maximum EGJ diameter. Results Receiver operating characteristic curves to identify an abnormal TBE demonstrated AUC (95% confidence interval) of 0.79 (0.75-0.84) for supine IRP, 0.79 (0.76-0.86) for upright IRP, 0.84 (0.79-0.88) for EGJ-distensibility index, and 0.88 (0.85-0.92) for maximum EGJ diameter. Logistic regression to predict abnormal TBE showed odds ratios (95% confidence interval) of 1.8 (0.84-3.7) for consistent IRP elevation and 39.7 (16.4-96.2) for reduced EGJ opening on FLIP panometry. Of 40 patients with HRM-FLIP panometry discordance, HRM-IRP was consistent with TBE in 23% while FLIP panometry was consistent with TBE in 78%. Discussion FLIP panometry provided superior detection of esophageal retention over IRP on HRM. However, application of a complementary evaluation involving FLIP panometry, HRM, and TBE may be necessary to accurately diagnose esophageal motility disorders.

Background: Studies have found possible physiologic changes to esophageal motility with aging currently not taken into account in routine high-resolution manometry (HRM) interpretation. We aimed to quantify the relationship between these physiologic changes and aging to improve HRM interpretation. Methods: We conducted a retrospective analysis of patients who underwent HRM at a tertiary hospital center between 2015 and 2019. Inclusion criteria were patients aged >= 18 years with normal HRM. Exclusion criteria were abnormal HRM, abnormal upper digestive endoscopy or imagery. Outcomes were median integrated relaxation pressure (IRP), lower esophageal sphincter (LES) pressure, distal contractal integral (DCI), distal latency (DL), and peristaltic break (PB) according to the v4.0 Chicago classification criteria. Effect of age was examined through univariate and multivariate linear regression analysis. Results: We identified 1,917 patients with HRM and included 722 patients with normal exams (median age 56 years (interquartile range (IQR) 46 - 66), 63.8% female). Indications for HRM included dysphagia (39.6%), gastroesophageal reflux disease (29.5%), and chest pain (11.5%). There was statistically significant relationship between age and IRP (r = 0.20, P < 0.0001) as well as DCI (r = 0.12, P = 0.001) and DL (r = -0.09, P = 0.02). No statistically significant relationship was found between age and LES pressure or PB. Conclusion: We found that IRP, DCI, and to a lesser extent, DL, are significantly correlated with the normal aging process in symptomatic patients. These findings should be taken into consideration when interpreting esophageal HRM. J Clin Med Res. 2021;13(8):413-419 doi: https://doi.org/10.14740/jocmr4576

Systemic sclerosis is a connective tissue disease that presents with significant gastrointestinal involvement, commonly in the esophagus. Dysphagia is a common clinical manifestation of systemic sclerosis and is strongly related to esophageal dysmotility. However, there are multiple other contributing factors in each step in the physiology of swallowing that may contribute to development of severe dysphagia. The oral phase of swallowing may be disrupted by poor mastication due to microstomia and poor dentition, as well as by xerostomia. In the pharyngeal phase of swallowing, pharyngeal muscle weakness due to concurrent myositis or cricopharyngeal muscle tightening due to acid reflux can cause disturbance. The esophageal phase of swallowing is most commonly disturbed by decreased peristalsis and esophageal dysmotility. However, it can also be affected by obstruction from chronic reflux changes, pill-induced esophagitis, or Candida esophagitis. Other contributing factors to dysphagia include difficulties in food preparation and gastroparesis. Understanding the anatomy and physiology of swallowing and evaluating systemic sclerosis patients presenting with dysphagia for disturbances in each step can allow for development of better treatment plans to improve dysphagia and overall quality of life.

Background/Aims Esophageal high-resolution manometry (HRM) enables the comprehensive evaluation of the esophageal motor function. However, protocols are not uniform and clinical practices vary widely among institutions. This study aims to understand the current HRM practice in Korea. Methods The survey was sent via email through the Korean Society of Neurogastroenterology and Motility. The questions covered descriptive information, preparation, techniques, analysis, and reporting of esophageal HRM. Results The survey was completed in 32 (74.4%) out of 43 centers, including 24 tertiary and 8 secondary referral centers. Of the 32 centers, 25 (78.1%) performed HRM in a sitting position, while 7 centers (21.9%) reported performing HRM in a supine position. All the centers utilized single wet swallows as a standard, but the volume, frequency, and interval between swallows varied widely. Sixteen centers (50.0%) applied adjunctive tests, including multiple rapid swallows (n = 16) and rapid drink challenges (n = 9). Parameters assessed and documented in the report were similar. In addition to the assessment of the esophagogastric junction and esophageal body, 27 centers (84.8%) and 18 centers (56.3%) included measurements for the upper esophageal sphincter and the pharynx, respectively, in the HRM protocol. Conclusions We found a variation in the available HRM practice among centers, even though they broadly agreed in the data analysis. Efforts are needed to develop a standardized protocol for HRM measurement. (J Neurogastroenterol Motil 2021;27:347-353)

Introduction and aims: Post-fundoplication dysphagia is resolved with no therapeutic intervention in the majority of cases but it can persist in 5.3% of children that undergo the procedure. Among the differential diagnoses, esophagogastric junction outflow obstruction (EGJOO) is a disorder that should be suspected if there is a persistence of dysphagia. The aim of our study was to describe the clinical characteristics, treatment, and follow-up in a case series of patients diagnosed with post-fundoplication EGJOO. Materials and methods: The clinical records of patients diagnosed with EGJOO at a tertiary care hospital within the time frame of September 2015 to September 2019 were reviewed, with respect to manometry, etiology, treatment, and clinical course of the disease. Results: Of the 213 high-resolution esophageal manometries performed, 4 patients met the criteria for post-fundoplication EGJOO. The primary symptom was dysphagia, presenting 15 days after the procedure. Esophageal dilations were carried out on all the patients but with no improvement. Symptoms related to the condition resolved spontaneously in three of the four patients. Conclusion: The management of children with post-fundoplication EGJOO continues to be a challenge. Even though more than half of the cases resolve with no intervention, optimum management of the motility disorder is still limited, given the scant experience with the condition in the pediatric population. Resumen: Introducción y Objetivos: La disfagia postfunduplicatura en la mayoría de los casos se resuelve sin intervención terapéutica, sin embargo, en algunas ocasiones esta puede persistir en 5.3% de los niños sometidos a este procedimiento. Dentro de los diagnósticos diferenciales, la obstrucción al tracto de salida de la unión esofagogástrica (OTSUEG) es un trastorno que se debe sospechar ante la persistencia de la disfagia. El objetivo de este estudio es describir las características clínicas, tratamiento y seguimiento de una serie de pacientes con diagnóstico de OTSUEG postfunduplicatura. Material y métodos: Se llevo a cabo la revisión de los expedientes clínicos con diagnóstico de OTSUEG en un hospital de tercer nivel durante el periodo de septiembre 2015 a septiembre 2019. En todos ellos se revisó la manometría, sintomatología, etiología, tratamiento y el curso clínico de la enfermedad. Resultados: Del total de 213 manometrías esofágicas de alta resolución realizadas, 4 pacientes cumplían con los criterios de OTSUEG postfunduplicatura. El síntoma principal fue la disfagia, presentándose 15 días posteriores al procedimiento. En todos los pacientes se realizaron dilataciones esofágicas, con pobre respuesta al tratamiento tras procedimiento. Los síntomas relacionados con la condición se resolvieron en 3/4 de los pacientes de manera espontánea. Conclusión: El manejo de niños con OTSUEG postfunduplicatura continúa siendo un desafío, ya que, si bien mas de la mitad de ellos resuelven sin intervención alguna, aun existen limitaciones para definir un manejo óptimo de este trastorno de la motilidad dada la poca experiencia que existe en la población pediátrica.

Introduction: Esophagus dysmotility is a crucial risk factor of gastroesophageal reflux disease (GERD), which is one of the most common diseases in digestive medicine globally. This review emphasiz...

BACKGROUND: Obesity is an independent risk factor for esophageal symptoms, gastroesophageal reflux disease (GERD), and motor abnormalities. When contemplating bariatric surgery, patients with obesity type III undergo esophagogastroduodenoscopy (EGD) and also esophageal manometry (EMN), and prolonged pHmetry (PHM) as part of their pre-operative evaluation. OBJECTIVE: Description of endoscopy, manometry and pHmetry findings in patients with obesity type III preparing for bariatric surgery, and correlation of these findings with the presence of typical GERD symptoms. METHODS: Retrospective study in which clinical symptoms of GERD were assessed, focusing on the presence of heartburn and regurgitation. All patients underwent EMN, PHM and most of them EGD. RESULTS: 114 patients (93 females-81%), average age 36 years old, average BMI of 45.3, were studied. Typical GERD symptoms were referred by 43 (38%) patients while 71 (62%) were asymptomatic. Eighty two patients (72% of total) underwent EGD and 36 (42%) evidenced esophageal abnormalities. Among the abnormal findings, hiatal hernia was seen in 36%, erosive esophagitis (EE) in 36%, and HH+EE in 28%. An abnormal EMN was recorded in 51/114 patients (45%). The main abnormality was a hypotensive lower esophageal sphincter (LES) in 32%, followed by ineffective esophageal motility in 25%, nutcracker esophagus in 19%, IEM + hypotensive LES in 10%, intra-thoracic LES (6%), hypertensive LES (4%), aperistalsis (2%) and achalasia (2%). Among the 43 symptomatic patients, 23 (53%) had abnormal EMN and 31/71 asymptomatic cases (44%) also presented this finding (P=0.30). PHM showed abnormal reflux in 60/114 patients (53%), with a predominance of bi-positional reflux (42%), followed by supine reflux (33%) and upright reflux (25%). Abnormal PHM was found in 26/43 symptomatic cases (60%) and also among 34/71 asymptomatic cases (48%) (P=0.19). CONCLUSION: Manometric abnormalities were common in obesity type III patients, the most frequent being hypotensive LES, followed by IEM. Most patients were asymptomatic. There was no correlation between the finding of motor abnormalities and the presence of symptoms. More than half the patients had abnormal reflux at PHM. We found no significant correlation between abnormal reflux and the presence of symptoms. RESUMO CONTEXTO: A obesidade é fator de risco independente para sintomas esofagianos, doença do refluxo gastroesofágico (DRGE) e alterações motoras. Pacientes com obesidade tipo III, candidatos à cirurgia bariátrica foram submetidos a endoscopia digestiva alta (EDA) e também realizaram esofagomanometria (EMN) e pHmetria prolongada (PHM) como parte da avaliação pré-operatória. OBJETIVO: Em um grupo de pacientes com obesidade tipo III em pré-operatório de cirurgia bariátrica, descrever os achados endoscópicos, manométricos e pHmétricos, correlacionando-os com a presença de sintomas típicos de DRGE. MÉTODOS: Estudo retrospectivo, de pacientes com obesidade tipo III, candidatos a cirurgia bariátrica. A avaliação clínica focalizou a presença de sintomas típicos de DRGE (pirose/regurgitação); todos foram submetidos a EMN, PHM e a maior parte à EDA, realizada previamente. RESULTADOS: Foram incluídos 114 pacientes, 93 (81%) do sexo feminino, média de idade de 36 anos e IMC médio de 45,3. Sintomas típicos de refluxo foram referidos por 43 (38%) pacientes e 71 (62%) eram assintomáticos. EDA foi realizada por 82 (72%) pacientes, havendo anormalidades esofagianas em 36 (42%). Entre os anormais, havia hérnia hiatal (HH) em 36%, esofagite erosiva (EE) em 36% e HH + EE em 28%. A EMN foi anormal em 51/114 (45%). Entre os anormais, predominou o esfíncter esofagiano inferior (EEI) hipotenso em 32%, seguido por motilidade esofagiana ineficaz (MEI) em 25%, esôfago em quebra-nozes (19%), EEI hipotenso + MEI (10%), EEI intra-torácico (6%), EEI hipertenso (4%), aperistalse (2%) e acalasia (2%). Dentre os 43 sintomáticos, 23 (53%) apresentavam EMN anormal, sendo que em 31 dos 71 (44%) assintomáticos a EMN também era anormal (P=0,30). A PHM revelou refluxo anormal em 60 (53%) pacientes. Predominou o refluxo anormal biposicional (42%) seguido do refluxo supino (33%) e refluxo ereto (25%). Dentre os 43 pacientes sintomáticos, 26 (60%) apresentavam PHM anormal, sendo que em 34 dos 71 assintomáticos a PHM também era anormal (48%) - P=0,19. CONCLUSÃO: Alterações manométricas foram comuns em obesidade tipo III, sendo as mais frequentes o EEI hipotenso, seguida de motilidade ineficaz. A maioria dos pacientes era assintomática. Mais da metade dos pacientes apresentou refluxo anormal à PHM. Não houve diferença significativa entre o achado de refluxo anormal e a presença de sintomas. Não houve relação entre o achado de alterações motoras e a presença de sintomas.

The Chicago Classification (CC) used to define esophageal motility disorders in high-resolution manometry (HRM) has evolved over time. Our aim was to compare the frequency of motility disorders diagnosed with the last two versions (CCv3.0 and CCv4.0) and to evaluate symptoms severity according to the diagnoses.From June to December 2020, patients who underwent esophageal HRM with swallows in supine and sitting positions were included. HRM studies were retrospectively analyzed using CCv3.0 and CCv4.0. Symptoms severity and quality of life were assessed with validated standardized questionnaires.Among the 130 patients included (73 women, mean age 52 years), motility disorder diagnoses remained unchanged in 102 patients (78%) with both CC. The 3 patients with esophago-gastric junction outflow obstruction (EGJOO) with CCv3.0 were EGJOO, ineffective esophageal motility (IEM) and normal with CCv4.0. Twenty-four out of 63 IEM diagnosed with the CCv3.0 (38%) turned into normal motility with the CCv4.0. Whatever the CC used, brief esophageal dysphagia questionnaire score was significantly higher in patients with EGJ relaxation disorders compared to those with IEM (25 (0-34) vs 0 (0-19), p = 0.01). Gastro-Esophageal Reflux disease questionnaire (GERD-Q) score was higher in patients with IEM with both CC compared to those who turned to normal with CCv4.0.While motility disorders diagnoses remained mainly unchanged with both CC, IEM was less frequent with CCv4.0 compared to CCv3.0. The higher GERD-Q score in IEM patients with CCv4.0 suggests that CCv4.0 might identify IEM more likely associated with GERD.

Background and Aims: High-resolution esophageal manometry (HREM) is the gold standard procedure used for the diagnosis of esophageal motility disorders (EMD). Artificial intelligence (AI) might provide an efficient solution for the automatic diagnosis of EMD by improving the subjective interpretation of HREM images. The aim of our study was to develop an AI-based system, using neural networks, for the automatic diagnosis of HREM images, based on one wet swallow raw image. Methods: In the first phase of the study, the manometry recordings of our patients were retrospectively analyzed by three experienced gastroenterologists, to verify and confirm the correct diagnosis. In the second phase of the study raw images were used to train an artificial neural network. We selected only those tracings with ten test swallows that were available for analysis, including a total of 1570 images. We had 10 diagnosis categories, as follows: normal, type I achalasia, type II achalasia, type III achalasia, esophago-gastric junction outflow obstruction, jackhammer oesophagus, absent contractility, distal esophageal spasm, ineffective esophageal motility, and fragmented peristalsis, based on Chicago classification v3.0 for EMDs. Results: The raw images were cropped, binarized, and automatically divided in 3 parts: training, testing, validation. We used Inception V3 CNN model, pre-trained on ImageNet. We developed a custom classification layer, that allowed the CNN to classify each wet swallow image from the HREM system into one of the diagnosis categories mentioned above. Our algorithm was highly accurate, with an overall precision of more than 93%. Conclusion: Our neural network approach using HREM images resulted in a high accuracy automatic diagnosis of EMDs.

The goal of this paper is to provide a Machine Learning-based solution that can be utilized to automate the Chicago Classification algorithm, the state-of-the-art scheme for esophageal motility disease identification. First, the photos were preprocessed by locating the area of interest—the precise instant of swallowing. After resizing and rescaling the photos, they were utilized as input for the Deep Learning models. The InceptionV3 Deep Learning model was used to identify the precise class of the IRP. We used the DenseNet201 CNN architecture to classify the images into 5 different classes of swallowing disorders. Finally, we combined the results of the two trained ML models to automate the Chicago Classification algorithm. With this solution we obtained a top-1 accuracy and f1-score of 86% with no human intervention, automating the whole flow, from image preprocessing until Chicago classification and diagnosis.

Esophagogastric junction outflow obstruction (EGJOO) comprises a heterogeneous group of conditions that demonstrate impaired deglutitive relaxation of the esophagogastric junction (EGJ) with intact esophageal peristalsis on high-resolution manometry. Functional luminal imaging probe (FLIP) panometry is a powerful tool that can help to clarify the etiology of this manometric diagnosis. The aim of this review is to summarize the use of FLIP for the evaluation and management of EGJOO.FLIP panometry provides measures of esophageal compliance at the EGJ and information on esophageal body contractile responses to balloon distention that have important implications for the management of patients with EGJOO. After excluding anatomic causes of impaired EGJ distensibility, FLIP panometry is useful in differentiating true lower esophageal sphincter dysfunction from manometric artifact. FLIP panometry has been shown to be useful in determining the need for invasive treatment in patients with EGJOO, and in intraoperative tailoring of myotomy procedures.FLIP panometry is easy to perform during endoscopy and provides useful information for characterizing the EGJOO population. FLIP panometry can be used to guide treatment and improve outcomes in the management of patients with EGJOO.

Background Hypercontractile esophagus is a rare hypercontractile esophageal motility disorder. The etiology of hypercontractile esophagus is unknown but an association between acid reflux and hypercontractile esophagus has been suggested. We present the first report on the use of potassium-competitive acid blockers in the treatment of hypercontractile esophagus. Case presentation A 43-year-old man presented with dysphagia, chest pain and regurgitation for a period of 1 year. Initial workup showed a twisted lumen with abnormal contractions in the distal esophagus during upper gastrointestinal endoscopy and abnormal acid exposure under 24-h esophageal pH monitoring. The use of standard-dose proton pump inhibitors didn’t relieve his symptoms. Subsequent high-resolution esophageal manometry made a diagnosis of hypercontractile esophagus. Treatment with vonoprazan resulted in symptomatic resolution and abnormal contractions were no longer detected on follow-up high-resolution manometry. Conclusions Potassium-competitive acid blockers like vonoprazan offer an alternative therapeutic method for patients with hypercontractile esophagus who are refractory to proton pump inhibitor therapy. The use of potassium-competitive acid blockers in hypercontractile esophagus warrants further research and may provide evidence for an acid-related etiology of hypercontractile esophagus.

Infectious esophagitis is the third most common cause of esophagitis after gastroesophageal reflux disease and eosinophilic esophagitis (EoE) and should always be considered in the differential of patients with dysphagia and odynophagia. The most common organisms causing disease are candida, Herpes simplex virus (HSV) and cytomegalovirus (CMV). It is well recognized that an impaired local or systemic immune system is a risk factor for disease; however, esophageal dysmotility and disruptions in esophageal homeostasis and the esophageal milieu are likely to represent additional risk factors in disease pathogenesis.

The interaction between the respiratory and gastrointestinal systems, and the role of the latter in the development of respiratory pathology, has been examined with a focus on gastro-oesophageal reflux disease (GORD). However, little data exists examining the link between oesophageal motility and respiratory disease.In this study, we examined patterns in oesophageal motility using high-resolution oesophageal manometry (HROM) in patients with refractory respiratory symptoms.Data were collected retrospectively for all patients that were investigated using HROM at a single centre for refractory respiratory symptoms between January 1st, 2011-December 1st, 2021. Patients were selected for investigation based on airway reflux symptoms, measured by the Hull Airways Reflux Questionnaire (HARQ).441 patients were investigated with HROM (64% female, mean age = 56.5 [SD = 13.9]). The commonest diagnoses of these patients were Chronic Cough (77%, n = 339), Asthma (10%, n = 44), and Interstitial Lung Disease (7%, n = 29). The prevalence of oesophageal dysmotility was 66% in our cohort. Those with oesophageal dysmotility had significantly higher HARQ scores than those with normal motility (40.6 vs 35.3, p 0.001) and there was a significant inverse correlation between HARQ scores and distal contractile integral (DCI), a measure of oesophageal contractility.Two-thirds of patients with refractory respiratory symptoms were found to have oesophageal dysmotility on HROM. These findings suggest motility disorders of the oesophagus may contribute to the development and progression of respiratory disease. This study highlights the need for further prospective study of the relationship between oesophageal dysmotility and respiratory disease.

Esophageal distal baseline impedance (DBI) is an indicator of mucosal integrity; lower values suggest increased permeability. Aims were to characterize the (1) effect of DBI category (900 Ω, 900-2000 Ω, and 2000 Ω) on sensory-motor characteristics of mid-esophageal provocation-induced motility reflexes, and (2) clinical outcomes among high-risk human infants evaluated for gastroesophageal reflux disease. Symptomatic infants (N = 49, 41 ± 3 weeks postmenstrual age) underwent pH-impedance testing to characterize acid reflux index (ARI) and DBI, and pharyngo-esophageal manometry to examine upper esophageal sphincter (UES), peristaltic, and lower esophageal sphincter (LES) functions. Sensory-motor response characteristics included response threshold (ml), occurrence (%), latency (s), duration (s), and magnitude (mmHg) upon mid-esophageal stimulations (0.1-2.0 ml of air, water, and apple juice). Motility and clinical outcomes were compared among DBI groups. In infants with DBI900 Ω and 900-2000 Ω (vs.2000 Ω): (a) Long-term feeding milestones did not differ (p 0.05); (b) complete peristaltic propagation decreased in 900-2000 Ω (p 0.05), polymorphic waveforms increased in900 Ω and 900-2000 Ω (p 0.05); (c) media effects were noted with liquids (vs. air) wherein UES and esophageal contractility were prolonged in900 Ω and 900-2000 Ω (p 0.05), and esophageal sensitivity heightened for900 Ω with water and for 900-2000 Ω with air (both p 0.05). ARI was not correlated with DBI in infants with chronic lung disease (r = 0.05, p = 0.82). We conclude that pharyngo-esophageal motility sensory-motor characteristics in infants are modified by DBI category. These preliminary findings pave-the-way for further physiological testing in convalescing high-risk infants to ascertain potential mechanisms of airway-digestive reflex interactions and symptom generation, which may lead to targeted therapies.

Our aim was to evaluate the relationship between esophageal dysmotility and lung disease by correlating the results of Echocardiogram and Pulmonary Function Test (PFT) with Esophageal Transit Study (ETT). Charts of Systemic Sclerosis (SSc) patients fulfilling 2013 ACR/EULAR classification criteria seen in Rheumatology clinics were reviewed and their demographics, ETT result, PFT, and echocardiogram data were collected at baseline, years 1, 3, 5, and 10. Patients were divided based on their ETT status and were compared with respect to each variable using a two-sided two-sample t test for continuous variables and a Fisher’s exact test for categorical variables. 130 patients were identified with either limited cutaneous SSc (109) or diffuse cutaneous SSc (21) with a mean age of 52.65 years. The mean DLCO was statistically worse in abnormal ETT patients [p value = 0.0004] as were the progression rates per year for DLCO at − 2.25 (p value = 0.019). Progression rate of FVC per year was statistically significant in the abnormal ETT group, although the mean value was not. The number of patients with abnormal PASP was not statistically different between the two groups (p values 0.104, 0.178, 0.653 at baseline, years 3 and 5, respectively). The presence of esophageal dysmotility was associated with increased pulmonary involvement in the form of abnormal DLCO with worsening progression rates per year. There was no statistically significant difference in PASP and FVC between the two groups; however, the progression rate for FVC was worse in adjusted models.