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This American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) aims to review the available evidence and provide expert advice regarding advances in per-oral endoscopic myotomy (POEM). This CPU was commissioned and approved by the AGA Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. This review is framed around best practice advice points agreed upon by the authors, based on the current available evidence and expert opinion in this field. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements Patients evaluated for POEM should undergo a comprehensive diagnostic workup, which includes clinical history and review of medications, upper endoscopy, timed barium esophagram, and high-resolution manometry. Endoscopic functional luminal impedance planimetry can be a useful adjunct test, particularly in cases when diagnosis is equivocal. POEM, laparoscopic Heller myotomy, and pneumatic dilation are effective therapies for type I and type II achalasia; the decision between these treatment modalities should be based on shared decision making, taking into account patient and disease characteristics, patient preferences, and local expertise. POEM should be considered the preferred treatment for type III achalasia. Patients with esophagogastric outflow obstruction alone and/or nonachalasia spastic disorders on manometry should undergo a comprehensive evaluation with correlation of symptoms. Evidence for POEM for these manometric findings are limited and should only be considered on a case-by-case basis after other less invasive approaches have been exhausted. A single dose of antibiotics at the time of POEM may be sufficient for antibiotic prophylaxis. POEM can be performed via either an anterior or posterior tunnel orientation, with comparable efficacy, safety, and rate of postprocedure reflux between these 2 approaches. Endoscopist's preferences and patient's surgical history, including prior laparoscopic Heller myotomy and/or POEM, should be considered when determining tunnel orientation. The optimal length of the myotomy in the esophagus and cardia, as it pertains to treatment efficacy and risk for postprocedure reflux, remains to be determined. Adjunct techniques, including real-time intraprocedure functional luminal impedance planimetry, may be considered to tailor or confirm the adequacy of the myotomy. The clinical impact of routine esophagram or endoscopy immediately post-POEM remains unclear. Testing can be considered based on local practice preferences, and in cases in which intraprocedural events or postprocedural findings warrant further evaluation. Same-day discharge after POEM can be considered in select patients who meet discharge criteria. Patients with advanced age, significant comorbidities, poor social support, and/or access to specialized care should be considered for hospital admission, irrespective of symptoms. Pharmacologic acid suppression should be strongly considered in the immediate post-POEM setting, given the increased risk of postprocedure reflux and esophagitis. All patients should undergo monitoring for gastroesophageal reflux disease after POEM. Patients with persistent esophagitis and/or reflux-like symptoms despite proton pump inhibitor use, should undergo additional testing to evaluate for other etiologies besides pathologic acid exposure and management to optimize and achieve reflux control. Long-term postprocedure surveillance is encouraged to monitor for progression of disease and complications of gastroesophageal reflux disease. POEM may be superior to pneumatic dilation for patients with failed initial POEM or laparoscopic Heller myotomy; however, the decision among treatment modalities should be based on shared decision making between the patient and physician, taking into account risk of postprocedural reflux, need for repeat interventions, patient preferences, and local expertise. [ABSTRACT FROM AUTHOR]

Purpose of Review: Obesity and related comorbidities are on the rise, with trends showing that nearly half of the United States population will be obese by 2030. This review focuses on the pathophysiology of esophageal disorders in patients with obesity as well as treatment considerations for obesity in patients with esophageal disorders. Recent Findings: Gastroesophageal reflux disease (GERD) is prevalent in approximately 20% of patients with obesity and is associated with multiple underlying anatomic risk factors. In addition, systemic and paracrine proinflammatory effects mediated by visceral adipose tissue also contribute to the development of GERD-related complications such as erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. Esophageal dysmotility is also common in obesity, although with varying clinical impact as the majority of patients are asymptomatic. Although data regarding laparoscopic sleeve gastrectomy and GERD is conflicting, Roux-en-Y gastric bypass is considered the preferred surgical approach for obesity in patients with GERD. Recent data signal that newer anti-obesity medications like glucagon-like peptide 1 (GLP-1) agonists may lead to increased GERD and related complications; however, data on this subject is limited. Summary: Esophageal dysfunction is prevalent in patients with obesity and should be carefully evaluated prior to considering treatment for obesity such as bariatric surgery or antiobesity medications. [ABSTRACT FROM AUTHOR]

Background: High‐resolution esophageal manometry (HREM) is the gold standard test for esophageal motility disorders. Nasopharyngeal airway‐assisted insertion of the HREM catheter is a suggested salvage technique for failure from the inability to pass the catheter through the upper esophageal sphincter (UES). It has not been demonstrated that the nasopharyngeal airway improves procedural success rate. Methods: Patients undergoing HREM between March 2019 and March 2023 were evaluated. Chart review was conducted for patient factors and procedural success rates before and after use of nasopharyngeal airway. Patients from March 2019 to May 2021 did not have nasopharyngeal airway available and were compared to patients from May 2021 to March 2023 who had the nasopharyngeal airway available. Key Results: In total, 523 HREM studies were conducted; 234 occurred prior to nasopharyngeal airway availability, and 289 occurred with nasopharyngeal airway availability. There was no difference in HREM catheter UES intubation rates between periods when a nasopharyngeal airway attempt was considered procedural failure (85% vs. 85%, p = 0.9). Nasopharyngeal airway use after UES intubation failure lead to improved UES intubation rates (94% vs. 85%, p < 0.01). Thirty‐six patients that failed HREM catheter UES intubation had the procedure reattempted with a nasopharyngeal airway, 30 (83%) of which were successful. The nasopharyngeal airway assisted catheter UES intubation for failures attributed to nasal pain and hypersensitivity, gagging, coughing, and pharyngeal coiling. Conclusions & Inferences: Utilization of the nasopharyngeal airway increased rates of UES intubation. When HREM catheter placement through the UES fails, placement of a nasopharyngeal airway can be trialed to overcome patient procedural intolerance. [ABSTRACT FROM AUTHOR]

Esophageal dysmotility is identified as a contraindication to lung transplantation at some centers due to increased risks of acute rejection, pulmonary infection, and chronic lung allograft dysfunction. Phosphodiesterase-type 5 inhibitors (PDE5i) are a cornerstone pharmacotherapy for pulmonary arterial hypertension (PAH) and are known to exert off-target effects that may impact lung transplant candidacy, including impaired esophageal contractility and decreased lower esophageal sphincter tone. We report 2 patients with PAH who were initially declined listing for lung transplantation due to iatrogenic esophageal dysmotility induced by PDE5is. Upon discontinuation of PDE5i therapy, these patients experienced significant improvement in esophageal motility within 14 days and met the criteria for transplant listing at their centers. Recognizing and mitigating the off-target effects of PDE5i medications is critical for maximizing access to transplant for patients with PAH.

Esophagogastric junction outflow obstruction (EGJOO) is a rapidly evolving diagnosis that can represent early or variant achalasia. Since the publication of the Chicago Classification version 4.0, the criteria for this diagnosis have been more stringent. Currently, the criteria include an elevated median integrated relaxation pressure (IRP) in both the supine and upright positions, elevated intrabolus pressure in at least 20% of supine swallows, dysphagia and/or chest pain, as well as an abnormal timed barium esophagram and/or impedance planimetry testing. Additionally, other secondary causes may result in an elevated IRP and must be excluded. The management of conclusive EGJOO is targeted therapy to the lower esophageal sphincter (LES), although treatment is not straightforward. Overall, adjuvant testing and data should be scrutinized for appropriateness of LES disruption. The spectrum of treatment options includes simple monitoring as well as more invasive therapies such as endoscopic dilation and myotomy. This article explores the newest criteria and management options for clinically relevant EGJOO. [ABSTRACT FROM AUTHOR]

Objective: to evaluate the possibilities of dynamic scintigraphy for the diagnosis of esophageal dysmotility (ED) and gastroesophageal reflux (GER) in patients with systemic sclerosis (SS).Material and methods. The study group included 77 patients with established SS of different disease duration (from several months to 30 years) who underwent Technephyt 99mTc dynamic esophageal scintigraphy using two-stage protocol. During the first stage, the esophageal transport function was evaluated; during the second stage, the presence and severity of GER were assessed. Scans were analyzed using visual assessment, quantitative estimation of time/activity curves, and a proposed three-point scale for evaluating ED and GER severity. The control group consisted of 19 practically healthy individuals who underwent a routine examination to exclude digestive system and gastrointestinal tract diseases, the algorithm of which included dynamic scintigraphy.Results. ED was found in 74 of 77 patients (96%). According to three-point scale, severe ED (3 points) was registrated in 41 (55%) patients, moderate ED (2 points) in 15 (21%), and mild ED in 18 (24%). GER was diagnosed in 35 of 77 cases (45%): mild GER in 13 (37%), moderate GER (2 points) in 22 (63%), and none of the patients was found to have severe GER (3 points). A significant relationship between the presence of GER and the severity of ED was not obtained, but a direct correlation was established between ED and GER severity.Conclusion. Most SS patients demonstrated ED of varying severity associated with mild and moderate GER in nearly 45% of the cases. The study results confirm the practical significance of dynamic scintigraphy for assessing the esophageal transport function and GER in SS patients.

Excess and deficiency of thyroid hormones can have a variety of gastrointestinal manifestations ranging from heartburn, dysphagia, vomiting, diarrhea to constipation. We present a case of chronic thyrotoxic myopathy presenting as generalized weakness with bulbar involvement. He made a complete recovery with antithyroid therapy.

Background: Studies have demonstrated that non-acid reflux (NAR) is associated with esophageal squamous cell carcinoma (ESCC). Esophageal dysmotility is associated with NAR but few studies have focused on the esophageal motility of ESCC patients. We explored the relationship between ESCC, NAR and esophageal dysmotility with the aid of multichannel intraluminal impedance and pH (MII-pH) and high-resolution manometry (HRM). Methods: From Jan 2021 to Oct 2022, 20 patients with superficial ESCC were enrolled as the ESCC group, while 20 age and gender matched individuals without gastroesophageal reflux disease (GERD) symptoms and 20 age and gender matched patients with GERD symptoms were recruited as the control groups. Patients received 24 h MII-pH and HRM procedure before endoscopic submucosal dissection (ESD), and the data were then collected to identify the type of reflux and esophageal dysmotility. Results: Prevalence of esophageal dysmotility was significantly different among the three groups, 75.0% in the ESCC group, 35.0% in the non-GERD group and 70.0% in the GERD group (P = 0.029). NAR episodes at 15 cm above the lower esophageal sphincter (LES) in the ESCC group were significantly higher than that in the non-GERD group (6.5 (3.5–9.3) vs 1.0 (0.8–4.0), P = 0.001) and were similar with that in the GERD group (6.5 (3.5–9.3) vs 5.5 (3.0–10.5), P > 0.05). NAR episodes at 5 cm above LES was significantly higher in the ESCC group than that in the non-GERD group (38.0 (27.0–60.0) vs 18.0 (11.8–25.8), P = 0.001) and was significantly higher than that in the GERD group (38.0 (27.0–60.0) vs 20.0 (9.8–30.5)), P = 0.010). Prevalence of pathologic non-acid reflux was significantly different among the three groups, 30.0% in the ESCC group, 0.0% in the non-GERD group and 10.0% in the GERD group (P < 0.001). Conclusion: Our study found NAR and esophageal dysfunction frequently occur in ESCC patients. NAR and esophageal dysmotility may be associated with ESCC. Clinical trial registration number: ChiCTR2200061456. [ABSTRACT FROM AUTHOR]

Chronic occult aspiration is the chronic aspiration of small volumes of oral and gastric contents into the lung. This is also termed as chronic microaspiration. It can lead to symptoms of gastroesophageal reflux disease and later lung involvement. This process is less familiar than the acute aspiration syndromes. Here, we present the case of an elderly male patient having diffuse esophageal spasm manifesting as recurrent chest pain and interstitial lung disease.

Systemic sclerosis (SSc) is often associated with dysphagia and esophageal dysmotility; however, only a few clinical studies on this topic have been conducted. Patients with SSc who underwent swallowing examinations and esophagography at our institution between 2010 and 2022 were included. A retrospective evaluation of the patients' backgrounds, autoantibody positivity, swallowing function, and esophageal motility was performed using medical charts. The association between dysphagia and esophageal dysmotility in patients with SSc and respective risk factors was investigated. Data were collected from 50 patients. Anti-topoisomerase I antibodies (ATA) and anti-centromere antibodies (ACA) were detected in 21 (42%) and 11 (22%) patients, respectively. Dysphagia was present in 13 patients (26%), and esophageal dysmotility in 34 patients (68%). ATA-positive patients had a higher risk for dysphagia (p = 0.027); ACA-positive patients had a significantly lower risk (p = 0.046). Older age and laryngeal sensory deficits were identified as risk factors for dysphagia; however, no risk factors for esophageal dysmotility were identified. No correlation was found between dysphagia and esophageal dysmotility. Esophageal dysmotility is more common in patients with SSc than in those with dysphagia. Autoantibodies can be predictors of dysphagia, and dysphagia must be carefully considered in ATA-positive and elderly patients with SSc. [ABSTRACT FROM AUTHOR]

Esophageal disorders are prevalent among patients with chronic lung diseases, including idiopathic pulmonary fibrosis (IPF). Gastroesophageal reflux disease (GERD) has been associated with IPF prevalence, severity, and respiratory decline. The pathophysiologic relationship between GERD and IPF is likely bidirectional, with aspiration of refluxate leading to lung inflammation and fibrosis, while the restrictive pulmonary physiology may contribute to altered transdiaphragmatic pressure gradient and increased reflux. Esophageal symptoms are frequently absent and do not predict esophageal dysfunction or pathologic reflux in patients with IPF, and objective diagnostic tools including upper endoscopy, ambulatory reflux monitoring, and high-resolution manometry are often needed. Impedance-based testing that identifies both weakly/non-acidic and acid reflux may provide important additional diagnostic value beyond pH-based acid testing alone. Novel metrics and maneuvers, including advanced impedance measures on impedance-pH study and provocative testing on HRM, may hold promise to future diagnostic advancements. The main treatment options include medical therapy with acid suppressants and anti-reflux surgery, although their potential benefits in pulmonary outcomes of IPF require further validations. Future directions of research include identifying phenotypes of IPF patients who may benefit from esophageal testing and treatment, determining the optimal testing strategy and protocol, and prospectively assessing the value of different esophageal therapies to improve outcomes while minimizing risks. This review will discuss the pathophysiology, evaluation, and management of esophageal diseases, particularly GERD, in patients with IPF, as informed by the most recent publications in the field, in hopes of identifying targets for future study and research. [ABSTRACT FROM AUTHOR]

High-resolution manometry (HRM) with the Chicago Classification (CC) is the standard paradigm to define esophageal motility disorders. Functional lumen imaging probe (FLIP) panometry utilizes impedance planimetry to characterize esophageal compliance and secondary peristalsis. The aim of this study was to explore the clinical impact of FLIP panometry in addition to HRM. A retrospective chart review was performed on FLIP panometry cases utilizing the 322N catheter. Cases with prior foregut surgeries or botulinum injection within 6 months of FLIP panometry were excluded. EGJ-diameter and distensibility index (DI) and secondary contraction patterns at increasing balloon volumes were recorded. An EGJ-DI of ≥2.8 mm2/mm Hg at 60 mL was considered as a normal EGJ distensibility. CC diagnosis, Eckhardt score, Brief Esophageal Dysphagia Questionnaire, and clinical outcomes were obtained for each FLIP case. A total of 186 cases were included. Absent contractility and achalasia types 1 and 2 showed predominantly absent secondary contraction patterns, while type 3 had a variety of secondary contractile patterns on FLIP panometry. Among 77 cases with EGJ outflow obstruction (EGJOO), 60% had a low EGJ-DI. Among those with no motility disorder or ineffective esophageal motility on HRM, 27% had a low DI and 47% had sustained contractions on FLIP, raising concern for an esophageal dysmotility process along the achalasia and/or spastic spectrum. FLIP panometry often confirmed findings on HRM in achalasia and absent contractility. FLIP panometry is useful in characterizing EGJOO cases. Spastic features on FLIP panometry may raise concern for a motility disorder on the spastic spectrum not captured by HRM. Further studies are needed on FLIP panometry to determine how to proceed with discrepancy with HRM and explore diagnoses beyond the CC. [ABSTRACT FROM AUTHOR]

Background: There is conflicting evidence about the association between eosinophilic esophagitis (EoE) and esophageal motility disorders. The aim of this study was to evaluate esophageal manometry findings in EoE. Methods: We conducted a systematic review using PubMed, EMBASE, and Web of Science. All articles from 1990 to 2021 with EoE patients who underwent esophageal manometry were eligible. We also included pertinent abstracts from national conferences from 2015 to 2020. The primary outcomes were the prevalence of specific Chicago 3 Classification (CCv3) diagnoses in EoE, as well as broader categories of non‐relaxing lower esophageal sphincter, and major and minor peristaltic disorders. When multiple studies reported a specific outcome, we performed random effects meta‐analysis to obtain pooled prevalence of each outcome. To reduce heterogeneity, we restricted meta‐analysis to high‐resolution manometry (HRM) studies only. Key Results: Of 763 publications identified, 27 original studies met criteria for inclusion, encompassing 706 EoE patients; 14 studies (425 patients) had HRM and underwent meta‐analysis. The pooled prevalence of any motility abnormality was 53% (95% CI: 43%–63%), largely comprised of minor motility disorders such as ineffective esophageal motility and fragmented peristalsis. Major motility disorders, classified by CCv3, were less common in EoE, with pooled prevalence of 2% (0%–7%), 10% (5%–16%), and 1% (0%–3%), for achalasia, esophagogastric‐junction outflow obstruction, and hypercontractile disorders, respectively. Conclusion and Inferences: Non‐specific motility disorders were common in patients with EoE, but major motility disorders were rare. Further studies are needed to determine the relationship between eosinophilic infiltration and the clinical relevance of abnormal esophageal motility findings in this population. [ABSTRACT FROM AUTHOR]

Background: Esophageal dysmotility has been attributed to opioid use. The goal was to assess the differences in pre- and post-treatment timed-barium esophagram (TBE) barium heights at 1 and 5 minutes and symptomatic response to treatment in esophagogastric junction outflow obstruction (EGJOO) patients according to opioid use status. Methods: We performed a retrospective cohort study. Consecutive patients with EGJOO were eligible for inclusion. Data were collected on demographics, pre and post-treatment 1 and 5 minutes TBE barium heights and symptom outcomes. Groups were compared according to opioid use. Results: Thirty-one EGJOO patients met the inclusion criteria. All patients were treated with pneumatic dilation. Of the 31 patients, 11 (35%) had opioid exposure and 20 (65%) did not. The median follow-up post-treatment was two months (range 1–47 months). There was no statistically significant difference in post-treatment outcomes for opioid exposed vs. unexposed groups. The median per cent decrease in the TBE barium height at 1 minute was 100% for the opioid exposed vs. 71% for the unexposed group (p = 0.92). The median per cent decrease in the TBE barium height at 5 minutes was zero % for the opioid exposed and unexposed groups (p = 0.67). The incidence of symptomatic improvement was 82% (9/11) for the opioid exposed group vs 95% (19/20) for the unexposed group (p = 0.28). Conclusions: Patients with EGJOO seem to respond to treatment similarly regardless of being on opioids. [ABSTRACT FROM AUTHOR]

Aim of the study. To investigate the esophageal dysmotility, changes in the esophageal mucosa and the immune response depending on the type of refluxate in gastroesophageal reflux disease (GERD) patients.Material and methods. 68 patients with GERD were recruited: 28 (14 men; mean age, 45.74 ± 2.23 years) nonerosive reflux disease (NERD), 22 (15 men; mean age, 45.0 ± 3.24 years) erosive reflux disease (EE), 18 (13 men; mean age, 47.22 ± 2.95) Barrett’s Esophagus (BE). GERD patients underwent esophageal high-resolution manometry (HRM) with a 22-channel water-perfused catheter and Solar GI system (Medical Measurements Systems, Enschede, the Netherlands), 24-hour impedance and pH monitoring using the Ohmega Ambulatory Impedance pH Recorder (Medical Measurements Systems). We analyzed receptor characteristics of monocyte-derived macrophages in all groups of patients.Results. On HRM examination, we showed that DCI (distal contractile integral) in NERD patients was higher than in EE (p = 0.088) and BE (p = 0.076), also LES RP (lower esophageal sphincter resting pressure) in NERD patients was higher than in EE (p = 0.039) and BE (p = 0.012). The analysis of reflux characteristics showed that the total reflux time with pH < 4 for BE patients was longer than that for NERD and EE patients. An analysis of receptor characteristics of monocyte-derived macrophages showed the prevalence of CD25 and CD80 expression in all groups of patients.Conclusion. An analysis of the phenotype of macrophages derived from blood monocytes of GERD patients revealed a prevalence of М1 macrophages that was typical for the Th1 type of immune response. The degree of esophageal dysmotility was correlated with GERD severity and type.

Abstract Background Intrabolus pressure (IBP) recorded by high-resolution manometry (HRM) portrays the compartmentalized force on a bolus during esophageal peristalsis. HRM may be a reliable screening tool for esophageal dysmotility in patients with elevated average maximum IBP (AM-IBP). Timed barium esophagram (TBE) is a validated measure of esophageal emptying disorders, such as esophagogastric junction outflow obstruction and achalasia. This study aimed to determine if an elevated AM-IBP correlates with esophageal dysmotility on HRM and/or delayed esophageal emptying on TBE. Methods A retrospective analysis of all HRM (unweighted sample n = 155) performed at a tertiary referral center from 09/2015–03/2017 yielded a case group (n = 114) with abnormal AM-IBP and a control group (n = 41) with a normal AM-IBP (pressure

ABSTRACT: History of present illness: A 32-year-old male smoker with a BMI of 38.1 kg/m2, history of esophageal stricture, gastroesophageal reflux disease (GERD), and years of intermittent dry cough presented with three weeks of exacerbated, persistent cough worse in the morning and after eating. He denied fever, constitutional symptoms, dysphagia, or vomiting. He presented to the emergency department following an abnormal outpatient chest X-ray. Bilateral expiratory wheezing was noted on exam. Significant findings: The chest X-ray demonstrated a markedly widened mediastinum (red brackets), raising concern for thoracic aortic aneurysm/aortic dissection, which prompted labs and contrast-enhanced computed tomography (CT) of the chest. The CT revealed a dilated proximal esophagus that narrowed distally (yellow tracing and red arrow), with particulate material, mass-effect on the trachea (purple outline), and bilateral patchy opacities suggesting aspiration. Barium esophagram showed a drastically dilated esophagus filled with contrast (yellow arrow), terminating into the classic “bird’s beak sign” (red arrow) at the lower esophageal sphincter (LES). Esophageal manometry later confirmed achalasia, proving that widened mediastina can have unexpected etiologies. Discussion: Achalasia is a rare (prevalence ~0.3-9.5/100,000, increasing with age) digestive disorder characterized by denervation to the distal esophagus, promoting regional aperistalsis and tonic contraction of the LES.1-3 Achalasia most commonly presents as acute, simultaneous dysphagia to both solids and liquids, but can present as heartburn, regurgitation, or even unexplained cough.1-3 A dilated esophagus with narrowing at the LES (“Bird’s Beak Sign”) and delayed esophageal emptying on barium esophagram are pathognomonic for achalasia (sensitivity 90%, specificity 95%),4 as is distal aperistalsis with increased resting LES tone on high-resolution manometry (sensitivity 98%, specificity 96%).5 Pharmacologic LES relaxation may be trialed, but surgical myotomy is usually necessary.1,2,3,6 Our patient underwent laparoscopic Heller myotomy resulting in a dilated, aperistaltic esophagus with no evidence of obstruction and is being followed for continued GERD and dysphagia. Topics: Achalasia, widened mediastinum, acute dysphagia, barium esophagram, lower esophageal sphincter, esophageal dysmotility, aspiration, gastroenterology.

Objective. Esophageal dysmotility is a common and neglected complication of systemic sclerosis (SSc) associated with poor prognosis, while the assessment remains a challenge. We aimed to develop a diagnostic model for esophageal dysmotility in SSc patients that provides individualized risk estimates. Methods. Seventy-five SSc patients who underwent high-resolution manometry (HRM) were included in the study. Esophageal widest diameter (WED) was measured on a chest CT scan. Esophageal parameters between patients with and without esophageal dysmotility were compared. Multivariate logistic regression analysis and Least Absolute Shrinkage and Selection Operator (LASSO) regression were used to fit the model. The diagnostic model was evaluated by discrimination and calibration. Internal validation was estimated using the enhanced bootstrap method with 1000 repetitions. Results. Sixty-one systemic sclerosis patients (81.3%) were diagnosed with esophageal dysmotility according to the Chicago Classification v 3.0. The diagnostic model for evaluating the probability of esophageal dysmotility integrated clinical and imaging features, including disease duration, ILD, and WED. The model displayed good discrimination with an area under the curve (AUC) of 0.923 (95% CI: 0.837–1.000), a Brier score of 0.083, and good calibration. A high AUC value of 0.911 could still be achieved in the internal validation. Conclusion. The diagnostic model, which combines the disease duration, ILD, and imaging feature (WED), is an effective and noninvasive method for predicting esophageal dysmotility in SSc patients. [ABSTRACT FROM AUTHOR]

Oropharyngeal and esophageal dysmotility can cause serious clinical complications such as aspiration pneumonia, cachexia, and sarcopenia, with a resulting increase in mortality and disability. The current standard of care for the treatment of SSc-associated swallowing dysfunction is mainly supportive, although severe cases are usually refractory to conventional management. Recent studies have shown that the abnormal production of functional autoantibodies such as anti-cholinergic muscarinic receptor III antibodies may participate in the pathogenesis of SSc-associated gastrointestinal dysmotility and may provide a novel target for therapeutic intervention. We describe two patients with severe and rapid onset of SSc-associated severe swallowing dysfunction and esophageal dysmotility who had failed standard of care therapy, requiring complete enteral and parenteral nutrition. Both patients were positive for the presence of circulating antimuscarinic III receptor antibodies. They were treated with IVIG at a dose of 2 g/Kg/month divided in two consecutive days, for six months. Following IVIG therapy, both patients markedly improved their symptoms as shown by a reduction in their UCLA2.0 score, and achieved an improvement of esophageal motility documented radiologically. Both patients resumed oral feeding and had their feeding tubes removed within the treatment period. None of the patients developed severe adverse events attributable to IVIG, except for low-grade fever during IVIG infusion in one of the cases. These results provide support for the role of functional autoantibodies in the development of SSc-associated gastrointestinal dysfunction. [ABSTRACT FROM AUTHOR]

Background: Symptoms of reflux after sleeve gastrectomy (SG) are common and may be refractory to medical treatment., Objectives: To assess outcomes of conversion of SG to Roux-en-Y gastric bypass (RYGB) with concomitant repair of hiatal hernias on symptoms of reflux., Setting: Tertiary community hospital., Methods: We reviewed data from all consecutive patients (2018-2021) who underwent conversion from SG to RYGB for refractory reflux symptoms. Concomitant hiatal hernias were diagnosed endoscopically or radiographically. Improvement in reflux symptoms, nausea, vomiting, dysphagia, or abdominal pain and postoperative proton pump inhibitor (PPI) use were compared with McNemar statistical test. Data are reported as mean ± standard deviation., Results: In total, 64 patients (92% female; 48 ± 10 years) underwent conversion from SG to RYGB and repair of concomitant hiatal hernias 4 ± 3 years after the index SG. A hiatal hernia was detected preoperatively in 57 of 64 patients (89%) by either upper gastrointestinal contrast studies, computed tomography scan, or esophagogastroduodenoscopy. At 29 ± 14 months postconversion to RYGB, percent total body weight loss was 14 ± 9% and percent excess weight loss was 37 ± 29%, and body mass index decreased from 37 ± 7 to 32 ± 6 kg/m 2 . Symptoms of reflux and use of PPI improved during the early follow-up period (median: 14 months; P < .001) and was sustained at late follow-up (median: 32 months; P < .01). Improvement of nausea and dysphagia reached statistical significance at late follow-up (median: 32 months; P < .01). Vomiting and abdominal pain decreased with time but did not reach statistical significance. Postoperative complications were deep surgical-site infection (n = 3), pulmonary embolism (n = 1), bleeding (n = 5), reoperation (n = 3), and 30-day readmission (n = 6)., Conclusions: Conversion of SG to RYGB and repair of concomitant hiatal hernia improves reflux symptoms, nausea, and dysphagia, reduces PPI use, and confers additional weight loss., Competing Interests: Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Connective tissue disorders (CTDs) are associated with esophageal dysmotility and gastroesophageal reflux disease, which may diminish survival after lung transplantation (LTx). We studied LTx outcomes in patients with a CTD stratified by esophageal motility. We identified patients who underwent bilateral LTx from 2012 to 2017. Patients with a CTD were classified by pre-LTx diagnosis: absent esophageal motility (AEM), ineffective esophageal motility (IEM), or preserved esophageal motility (PEM). The primary endpoint was 3-year survival. Sub-analysis compared survival between the AEM group and a propensity-matched (lung allocation score), non-CTD control group. Kaplan-Meier method and log-rank test were used. In total, 495 patients underwent LTx; 33 (6.7%) had a CTD. Median (IQR) age was 62 years (55.5-67.0); 24 (72.7%) were women. Survival trended lower for recipients with a CTD than without a CTD at 1-year (84.8% vs 91.8%; p = 0.2) and 3-years (66.7% vs 73.5%; p = 0.5). Within the CTD cohort, 1- and 3-year survival was significantly higher in the PEM (100%, 87.5%) and IEM (100%, 85.7%) groups than in the AEM group (50%, 20%; p < 0.001). The AEM group had significantly lower survival at 1-year (50% vs 92.5%) and 3-years (20% vs 65%) than a lung allocation score-matched cohort of patients without a CTD. LTx recipients with a CTD and AEM had significantly lower survival than those with PEM or IEM as well as significantly lower survival than that of a propensity-matched cohort of patients without a CTD. Patients with a CTD and AEM should be considered for LTx with extreme caution and counseled appropriately. [ABSTRACT FROM AUTHOR]

Introduction. Laparoscopic sleeve gastrectomy (LSG) is a popular weight loss surgery technique, but the impact on esophageal physiology and esophagogastric junction is still debatable. The aim of our study was to evaluate the manometric changes of the lower esophageal sphincter (LES) after LSG in order to indicate LES manometry pre- procedure.

Background: Intrabolus pressure (IBP) recorded by high-resolution manometry (HRM) portrays the compartmentalized force on a bolus during esophageal peristalsis. HRM may be a reliable screening tool for esophageal dysmotility in patients with elevated average maximum IBP (AM-IBP). Timed barium esophagram (TBE) is a validated measure of esophageal emptying disorders, such as esophagogastric junction outflow obstruction and achalasia. This study aimed to determine if an elevated AM-IBP correlates with esophageal dysmotility on HRM and/or delayed esophageal emptying on TBE.Methods: A retrospective analysis of all HRM (unweighted sample n = 155) performed at a tertiary referral center from 09/2015-03/2017 yielded a case group (n = 114) with abnormal AM-IBP and a control group (n = 41) with a normal AM-IBP (pressure < 17 mmHg) as consistent with Chicago Classification 3. All patients received a standardized TBE, with abnormalities classified as greater than 1 cm of retained residual liquid barium in the esophagus at 1 and 5 min or as tablet retention after 5 min.Results: AM-IBP was significantly related to liquid barium retention (p = 0.003) and tablet arrest on timed barium esophagram (p = 0.011). A logistic regression model correctly predicted tablet arrest in 63% of cases. Tablet arrest on AM-IBP correlated with an optimal prediction point at 20.1 mmHg on HRM. Patients with elevated AM-IBP were more likely to have underlying esophageal dysmotility (95.6% vs. 70.7% respectively; p < 0.001), particularly esophagogastric junction outflow obstruction disorders. Elevated AM-IBP was associated with incomplete liquid bolus transit on impedance analysis (p = 0.002).Conclusions: Our findings demonstrate that an elevated AM-IBP is associated with abnormal TBE findings of esophageal tablet retention and/or bolus stasis. An abnormal AM-IBP (greater than 20.1 mm Hg) was associated with a higher probability of retaining liquid bolus or barium tablet arrest on TBE and esophageal dysmotility on HRM. This finding supports the recent incorporation of IBP in Chicago Classification v4.0. [ABSTRACT FROM AUTHOR]

Weak or absent peristalsis of the esophageal musculature is a common finding in ambulatory patients suffering from dysphagia and frequently associated with gastroesophageal reflux. There is currently no pharmacologic intervention that reliably improves esophageal contractility in patients suffering from various esophageal motility disorders. Our objective was to evaluate the acute effects of pyridostigmine on high-resolution manometry parameters in patients suffering from dysphagia with evidence of esophageal dysmotility. Pyridostigmine is an acetylcholinesterase inhibitor which increases effective concentrations of acetylcholine at the neuromuscular junction of both striated and smooth muscle cells. We conducted a prospective crossover study of five patients with dysphagia and proven esophageal dysmotility. Three patients had baseline ineffective esophageal motility and two had achalasia. Patients underwent pharyngeal and esophageal manometry before and after pyridostigmine administration. The median distal contractile integral (DCI), a marker of esophageal contractile vigor, was significantly higher post pyridostigmine administration 3001 (1950.3–3703.2) mmHg × s × cm compared to pre-pyridostigmine DCI of 1229.9 (956.2–2100) mmHg × s × cm; P < 0.001. Pre-pyridostigmine 18/25 (72%) of the patient's swallows was peristaltic compared to 25/25 (100%) post-pyridostigmine; P < 0.005. No other pharyngeal or esophageal high-resolution manometry parameter differed significantly after pyridostigmine administration. The results of this pilot study demonstrate that pyridostigmine acutely improves esophageal contractile vigor in patients suffering from dysphagia with esophageal dysmotility. Further investigation with larger sample size, longer follow-up, side effect profile, and patient-reported outcome measures is still needed to determine the clinical usefulness of pyridostigmine in specific disorders of esophageal motility. [ABSTRACT FROM AUTHOR]

Eosinophilic esophagitis (EoE) is an immune mediated chronic inflammatory disease resulting from antigen exposure and is characterized by mucosal inflammation with eosinophils. Diagnosis is based on the histological finding of at least 15 eosinophils per high power field in esophageal biopsy specimens from upper gastrointestinal endoscopies. These endoscopies are usually performed in the setting of esophageal dysfunction, however, EoE can occasionally be incidentally diagnosed during endoscopies performed for other indications like coeliac disease. The eosinophilia is in the absence of other causes of esophageal eosinophilia (e.g., parasitic infection, esophageal leiomyomatosis or Crohn's disease). Presentation can be wide ranging and often varies according to age. Infants and younger children can present with choking/gagging, feed refusal, failure to thrive, irritability and vomiting. Older children and adults commonly present with dysphagia, chest pain or food bolus obstruction. EoE was first described in the 1970s, but was only recognized as a distinct disease entity in the 1990s. It has been rising in incidence and prevalence, with reported prevalence ranging between 1 in 2,500 and 1 in 10,000. Although the diagnosis of EoE is dependent on clear histopathologic diagnostic criteria, there is a disconnect between the degree of esophageal eosinophilia and symptom severity especially that of reported dysphagia. Multiple anatomical changes can be seen in the spectrum of presentations of EoE which explain dysphagia, including isolated strictures, diffuse trachealisation, fixed rings, including Schatzki, as well as tissue remodeling and fibrotic changes. However, a majority of EoE patients do not have any of these findings and will still often report ongoing dysphagia. Some will report ongoing dysphagia despite histological remission. This suggests an underlying esophageal dysmotilty which cannot be assessed with endoscopy or correlated with histological changes seen in biopsies. This review will describe the types of motor disturbances seen and their prevalence, the pathophysiological basis of dysmotility seen in EoE, how best to investigate esophageal dysfunction in EoE and the role of manometry in the management of EoE.

Dysphagia, or difficulty swallowing, can result from esophageal motility disorders and is often linked to hypocalcemia. Calcium is essential for the proper function of pharyngeal and esophageal muscles, and low calcium levels can impair swallowing. Additionally, certain diuretics may worsen this by increasing calcium and magnesium loss, complicating the management of hypocalcemia. In this case, an 82-year-old male presented with a sudden onset of dysphagia, which had worsened over one week. He was intolerant to both solids and liquids and had a complex medical history, including non-erosive gastritis and previous benign adenoma surgery. Magnetic resonance imaging (MRI) of the brain ruled out acute stroke. On admission, he had severe hypocalcemia (serum calcium level of 1.19 mmol/L) and hypomagnesemia (serum magnesium level of 0.17 mmol/L). A mildly elevated parathyroid hormone (PTH) level of 7.5 pmol/L suggested a compensatory response. Despite intravenous (IV) calcium administration, his calcium levels showed only slight improvement. Hypomagnesemia contributed to resistance to calcium therapy, necessitating IV magnesium. His use of furosemide at a dose of 40 mg per day, a diuretic that increases renal calcium excretion, likely exacerbated both conditions. After two days of IV calcium and magnesium, his serum calcium normalized to 1.96 mmol/L, and magnesium improved to 0.84 mmol/L. Post-treatment, he showed marked improvement in dysphagia, regaining the ability to swallow both solids and liquids. The endoscopic examination of the upper gastrointestinal (GI) tract shows normal findings. The gastroesophageal junction and esophagus have healthy mucosa with no visible abnormalities such as lesions, strictures, or inflammation. The stomach appears normal, with smooth, intact mucosa and well-formed gastric folds. Some food debris is present but does not indicate any pathology. The resolution of symptoms with electrolyte correction confirmed that hypocalcemia was the primary cause of his dysphagia, which was challenging to manage due to hypomagnesemia. This case emphasizes the importance of considering electrolyte imbalances, particularly hypocalcemia, as potential reversible causes of severe dysphagia. The patient's improvement in swallowing function with calcium correction supports the hypothesis that these electrolyte disturbances significantly contributed to his symptoms. This case highlights the crucial role of calcium in esophageal motility and emphasizes the need to evaluate and correct electrolyte imbalances in acute dysphagia. This case also highlights the role of magnesium in overcoming resistance to calcium supplementation in cases of severe hypocalcemia. Further research could improve the understanding and management of similar cases., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Akhtar et al.)

Dysphagia is a common manifestation of endocrine and metabolic diseases. Swallowing is a complex neuromuscular process, with an interplay of sensory and motor function, that has voluntary and involuntary control. Disruptions in any of these processes can cause significant dysphagia. Endocrine disorders and metabolic derangements are systemic conditions that affect multiple organ systems. They contribute to the development of neuropathies, myopathies, and motility disorders that lead to swallowing difficulty. Malnutrition and critical illness can lead to deconditioning and atrophy which can cause dysphagia, which in turn can lead to further malnutrition and deconditioning., Competing Interests: Disclosure The authors have no relevant disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose of Review: To explore the role of upper gastrointestinal disease in the clinical course of lung transplant patients – including its pathophysiology, diagnostic testing, and treatment options. Recent Findings: Gastroesophageal reflux disease (GERD) and foregut motility disorders are more prevalent among end-stage lung disease patients and are associated with poorer outcomes in lung transplant recipients. A proposed mechanism is the exposure of the lung allograft to aspirated contents, resulting in inflammation and rejection. Diagnostic tools to assess for these disorders include multichannel intraluminal impedance and pH (MII-pH) testing, high resolution esophageal manometry (HREM), and gastric emptying scintigraphy. The main treatment options are medical management with acid suppressants and/or prokinetic agents and anti-reflux surgery. In particular, data support the use of early anti-reflux surgery to improve outcomes. Summary: Newer diagnostic tools such as MII-pH testing and HREM allow for the identification of both acid and non-acid reflux and esophageal motility disorders, respectively. Recent studies have demonstrated that early anti-reflux surgery within six months post-transplant better protects against allograft injury and pulmonary function decline when compared to late surgery. However, further prospective research is needed to evaluate the short and long-term outcomes of these diagnostic approaches and interventions. [ABSTRACT FROM AUTHOR]

Objective: 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). Methods: 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. Results: 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). Conclusion: 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. [ABSTRACT FROM AUTHOR]