Purpose of review
We provide an overview of the clinical application of novel pharyngeal high-resolution impedance manometry (HRIM) with pressure flow analysis (PFA) in our hands with example cases.
...Recent findings
In our Centre, we base our interpretation of HRIM recordings upon a
qualitative
assessment of pressure-impedance waveforms during individual swallows, as well as a
quantitative
assessment of averaged PFA swallow function variables. We provide a description of two global swallowing efficacy measures, the swallow risk index (SRI), reflecting global swallowing dysfunction (higher SRI = greater aspiration risk) and the post-swallow impedance ratio (PSIR) detecting significant post-swallow bolus residue. We describe a further eight swallow function variables specific to the hypopharynx and upper esophageal sphincter (UES), assessing hypo-pharyngeal distension pressure, contractility, bolus presence and flow timing, and UES basal tone, relaxation, opening and contractility.
Summary
Pharyngeal HRIM has now come of age, being applicable for routine clinical practice to assess the biomechanics of oropharyngeal swallowing dysfunction. In the future, it may guide treatment strategies and allow more objective longitudinal follow-up on clinical outcomes.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Objective To quantify the effects of 2 swallowing maneuvers used in dysphagia rehabilitation-the Mendelsohn maneuver and effortful swallowing-on pharyngoesophageal function with novel, objective ...pressure-flow analysis. Study Design Evaluation of intervention effects in a healthy control cohort. Setting A pharyngoesophageal motility research laboratory in a tertiary education facility. Subjects Twelve young healthy subjects (9 women, 28.6 ± 7.9 years) from the general public, without swallowing impairment, volunteered to participate in this study. Methods Surface electromyography from the floor-of-mouth musculature and high-resolution impedance manometry-based pressure flow analysis were used to assess floor-of-mouth activation and pharyngoesophageal motility, respectively. Subjects each performed 10 noneffortful control swallows, Mendelsohn maneuver swallows, and effortful swallows, with a 5-mL viscous bolus. Repeated measures analyses of variance was used to compare outcome measures across conditions. Results Effortful and Mendelsohn swallows generated greater floor-of-mouth contraction ( P = .001) and pharyngeal pressure ( P < .0001) when compared with control swallows. There were no changes at the level of the upper esophageal sphincter, except for a faster opening to maximal diameter during maneuver swallows ( P = .01). The proximal esophageal contractile integral was reduced during Mendelsohn swallows ( P = .001). Conclusion Effortful and Mendelsohn maneuver swallows significantly alter the pharyngoesophageal pressure profile. Faster opening of the upper esophageal sphincter may facilitate bolus transfer during maneuver swallows; however, reduced proximal esophageal contractility during Mendelsohn maneuver swallows may impair bolus flow and aggravate dysphagic symptoms.
Full text
Available for:
FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
We undertook a systematic review of swallowing biomechanics, as assessed using pharyngeal and esophageal manometry in healthy or dysphagic older individuals aged over 60 years of age, comparing ...findings to studies of younger participants. PRISMA-P methodology was used to identify, select, and evaluate eligible studies. Across studies, older participants had lower upper esophageal sphincter (UES) resting pressures and evidence of decreased UES relaxation when compared to younger groups. Intrabolus pressures (IBP) above the UES were increased, demonstrating flow resistance at the UES. Pharyngeal contractility was increased and prolonged in some studies, which may be considered as an attempt to compensate for UES flow resistance. Esophageal studies show evidence of reduced contractile amplitudes in the distal esophagus, and an increased frequency of failed peristaltic events, in concert with reduced lower esophageal sphincter relaxation, in the oldest subjects. Major motility disorders occurred in similar proportions in older and young patients in most clinical studies, but some studies show increases in achalasia or spastic motility in older dysphagia and noncardiac chest pain patients. Overall, study qualities were moderate with a low likelihood of bias. There were few clinical studies specifically focused on swallowing outcomes in older patient groups and more such studies are needed.
Background
Early detection and removal of precursor lesions reduce colorectal cancer morbidity and mortality. Sessile serrated adenomas/polyps (SSP) are a recognized precursor of cancer, but there ...are limited studies on whether current screening techniques detect this pathology.
Aims
To investigate the sensitivity of fecal immunochemical tests (FIT) and epigenetic biomarkers in blood for detection of SSP.
Methods
A prospective study offered FIT and a blood test (Colvera for methylated
BCAT1
and
IKZF1
) to adults referred for colonoscopy. Sensitivity of FIT and the blood test were determined for four types of pathology: low-risk conventional adenoma, high-risk adenoma, SSP, and absence of neoplasia. Comparisons were made for FIT positivity at 10 and 20 μg hemoglobin (Hb)/g feces.
Results
One thousand eight hundred and eighty-two subjects completed FIT and underwent colonoscopy. One thousand four hundred and three were also tested for methylated
BCAT1/IKZF1
. The sensitivity of FIT (20 μg Hb/g feces) for SSP was 16.3%. This was lower than the sensitivity for high-risk adenomas (28.7%,
p
< 0.05), but no different to that for low-risk adenomas (13.1%) or no neoplasia (8.4%). A positive FIT result for SSP was not associated with demographics, morphology, concurrent pathology or intake of medications that increase bleeding risk. FIT sensitivity for SSP did not significantly increase through lowering the positivity threshold to 10 μg Hb/g feces (20.4%,
p
> 0.05). Sensitivity of the blood test for SSP was 8.8%, and 26.5% when combined with FIT.
Conclusions
Both FIT and blood-based markers of DNA hypermethylation have low sensitivity for detection of SSP. Further development of sensitive screening tests is warranted.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
UES opening occurs following cricopharyngeus deactivation and submental muscle contraction causing hyolaryngeal elevation and UES distraction. During impedance manometry, the inverse of impedance ...(admittance) can be used to measure bolus presence and infer UES opening. We hypothesized that the temporal relationship between UES relaxation, opening and hyolaryngeal elevation would change with increasing bolus volume. Simultaneous intramuscular cricopharyngeal (CP) electromyography (EMG), surface submental EMG (SM-EMG), and high-resolution impedance manometry were recorded in eight (aged 27 ± 7 years, 5 M) healthy volunteers, while swallowing 0.9 % saline boluses of 2, 5, 10, and 20 ml. Data were exported and analyzed via Matlab. Statistical analysis comprised repeated measures one-way ANOVA and Pearson correlation. A
P
value of <0.05 was considered significant. Duration of CP deactivation increased at 20 ml volume (
P
< 0.001). UES relaxation and opening increased with increasing bolus volume (
P
< 0.001); however, overall duration of SM activation did not change. As UES opening occurs progressively earlier with increasing volumes, peak SM-EMG activity occurs relatively later (
P
< 0.001) and shifts from occurring before to following peak UES distention. During healthy swallowing, there is sensory modulation of cricopharyngeal and submental muscle activity. Intrabolus pressures, transmitted from the tongue base and pharynx, play a progressively more important role in sphincter opening with increasing volume. The findings may explain why some healthy elderly and patients with oropharyngeal dysphagia have difficulty swallowing larger while tolerating smaller bolus volumes.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background. Iron deficiency (ID) is a common micronutrient deficiency and the leading cause of anemia worldwide. ID can be caused by chronic occult blood loss from colorectal neoplasia including ...colorectal cancer (CRC) and advanced precancerous colorectal lesions. Current guidelines recommend colonoscopy in both men and postmenopausal women presenting with ID anemia (IDA). However, there is controversy on the investigation of patients presenting with a lower risk of CRC including younger women with ID and those with nonanemic ID (NAID). There is a need for a triaging tool to identify which ID patients may benefit from colonoscopy. The fecal immunochemical test (FIT) is sensitive for CRC screening in an asymptomatic population, but its role in ID patients is unclear. The aim of this study is to conduct a systematic review to determine the diagnostic accuracy of FIT for detecting CRC and advanced precancerous neoplasia in individuals presenting with ID with or without anemia. Methods and Analysis. This protocol conforms with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols and Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. A comprehensive search of the MEDLINE, Embase, and Web of Science databases will be undertaken for studies published after 2010 which involve patients with ID, who completed a FIT in the 6 months prior to colonoscopy, with FIT sensitivity and specificity calculated against the reference standard colonoscopy. The search will be limited to studies conducted after 2010 to reduce variability in colonoscopy quality. Risk of bias assessment will be conducted using the Quality Assessment of Diagnostic Accuracy Studies version 2. FIT sensitivity and specificity will be the primary measure of diagnostic accuracy, and data will be analysed using a random effects meta-analysis. Discussion. This review and meta-analysis will be the first to systematically explore the value of the FIT as a triaging tool for patients with ID. This trial is registered with CRD42022367162.
Full text
Available for:
FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Objectives: Pharyngeal high-resolution impedance manometry (HRIM) studies can be analysed by automated impedance manometry (AIM)-analysis to objectively asses swallowing. The aim of this study was to ...evaluate the reliability of a recently developed online AIM analysis portal.
Methods: A database of 24 pharyngeal HRIM and videofluoroscopy studies (n = 18 oropharyngeal dysphagia patients and n = 6 controls; mean age 66, range 58-71 years) was established. Five observers of varying expertise analysed the database twice using AIMplot-online. Two experienced observers also performed the analysis using original AIMplot. Intra- and inter-rater reliability was determined by the intra-class correlation coefficient (ICC). Results from AIMplot and AIMplot-online and their relation to penetration aspiration scale (PAS) scores were compared.
Results: The expert analysis confirmed that both analysis platforms differentiated patients from controls and, amongst patients, significant swallowing dysfunction. Intra- and inter-rater reliability were substantial to excellent; however, expertise and the inclusion of highly aberrant cases influenced the reliability of some measures.
Conclusion: In conclusion, swallow function variables can be reliably derived using online software-based analysis and are altered in relation to increasing levels of swallowing dysfunction. By making the AIM analysis widely available via the Internet, the diagnostic potential of pharyngeal HRIM recordings can be fully and independently assessed.
Background and Aim
Surveillance colonoscopy for colorectal cancer (CRC) is generally not recommended beyond 75 years of age. The study determined incidence and predictors of advanced adenoma and CRC ...in older individuals undergoing surveillance colonoscopy.
Methods
This was a retrospective cohort study of asymptomatic older participants (≥75 years), enrolled in a South Australian CRC surveillance program who underwent colonoscopy (2015–2020). Clinical records were extracted for demographics, personal or family history of CRC, comorbidities, polypharmacy, and colonoscopy findings. The associations between clinical variables and advanced adenoma or CRC at surveillance were assessed with multivariable Poisson regression analysis.
Results
Totally 698 surveillance colonoscopies were analyzed from 574 participants aged 75–91 years (55.6% male). The incidence of CRC was 1.6% (11/698), while 37.9% (260/698) of procedures had advanced adenoma detected. Previous CRC (incidence rate ratio IRR 5.9, 95% CI 1.5–22.5), age ≥85 years (IRR 5.8, 95% CI 1.6–20.1) and active smoking (IRR 4.9, 95% CI 1.0–24.4) were independently associated with CRC diagnosis, while advanced adenoma at immediately preceding colonoscopy (IRR 1.6, 95% CI 1.3–2.0) and polypharmacy (IRR 1.2, 95% CI 1.0–1.5) were associated with advanced adenoma at surveillance colonoscopy in asymptomatic older participants (≥75 years).
Conclusion
Advanced neoplasia was found in more than one third of the surveillance procedures completed in this cohort. Continuation of surveillance beyond age 75 yeasrs may be considered in participants who have previous CRC or are active smokers (provided they are fit to undergo colonoscopy). In other cases, such as past advanced adenoma only, the need for ongoing surveillance should be considered alongside participant preference and health status.
Full text
Available for:
FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
The swallowing muscles that influence upper esophageal sphincter (UES) opening are centrally controlled and modulated by sensory information. Activation and deactivation of neural inputs to these ...muscles, including the intrinsic cricopharyngeus (CP) and extrinsic submental (SM) muscles, results in their mechanical activation or deactivation, which changes the diameter of the lumen, alters the intraluminal pressure, and ultimately reduces or promotes flow of content. By measuring the changes in diameter, using intraluminal impedance, and the concurrent changes in intraluminal pressure, it is possible to determine when the muscles are passively or actively relaxing or contracting. From these "mechanical states" of the muscle, the neural inputs driving the specific motor behaviors of the UES can be inferred. In this study we compared predictions of UES mechanical states directly with the activity measured by electromyography (EMG). In eight subjects, pharyngeal pressure and impedance were recorded in parallel with CP- and SM-EMG activity. UES pressure and impedance swallow profiles correlated with the CP-EMG and SM-EMG recordings, respectively. Eight UES muscle states were determined by using the gradient of pressure and impedance with respect to time. Guided by the level and gradient change of EMG activity, mechanical states successfully predicted the activity of the CP muscle and SM muscle independently. Mechanical state predictions revealed patterns consistent with the known neural inputs activating the different muscles during swallowing. Derivation of "activation state" maps may allow better physiological and pathophysiological interpretations of UES function.
Current guidelines recommend topical steroids as first-line treatment for patients with eosinophilic esophagitis (EoE). However, the evidence for this approach has been inconsistent in earlier ...reports. This meta-analysis aimed to clarify the efficacy of topical steroid treatment in active EoE using updated evidence.
CENTRAL, MEDLINE and EMBASE databases were searched for randomized controlled trials (RCTs) published up to May 2014 that compared topical steroids with control treatments for active EoE. Study bias was assessed using the Cochrane Collaboration Tool, and outcomes were pooled using random effects models. The primary outcome was the mean change in eosinophil counts. Secondary outcomes were symptom responses and adverse events.
In total, seven RCTs (226 patients) were included. Topical steroids were associated with a significant reduction in esophageal mucosal eosinophil counts compared with control therapy although substantial heterogeneity between studies was observed (weighted mean difference (WMD) -27.2, 95% confidence interval (CI) -45.3 to -9.1, I(2)=56.2%). Subgroup analysis indicated the reduction in eosinophil counts was only present in studies where a proton pump inhibitor (PPI) trial was used to exclude other diagnoses (WMD -46.3, 95% CI -61.3 to -31.4, I(2)=0.0%). Subdivision of studies on the use of a PPI trial also accounted for the majority of heterogeneity among RCTs. No clear trends in symptom resolution were observed. Eleven out of 127 patients who received topical steroids developed asymptomatic esophageal candidiasis.
These data provide updated high-quality evidence that support current guidelines for first-line EoE treatment with topical steroids after an initial PPI trial to exclude non-EoE pathologies (PROSPERO ID: CRD42014008828).
PDF
