Background
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.
Methods
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.
Key Results
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.
Conclusions and Inferences
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.
Applying the Chicago Classification v4.0 changed the diagnosis in 22% of patients but dysphagia score was still higher in patients with esophago‐gastric junction relaxation disorders compared to those with ineffective esophageal motility (IEM). The new definition of IEM might be more likely associated with gastro‐esophageal reflux disease.
•Fundoplication is a valid option in patients with proven persistent acid reflux on PPI.•Vonoprazan might improve acid suppression compared to PPI.•Minimally invasive procedures require further ...evaluation in refractory GERD.•Diaphragmatic breathing might decrease esophageal symptoms and excessive belching.
Pharmacologic therapy, surgery, minimally invasive therapies, and alternative therapies are different options available for the management of refractory GERD. The choice may depend on the cause of refractoriness. Increased gastric acid suppression therapy might be useful in the rare patients with persistent elevated esophageal acid exposure on proton pump inhibitors (PPI). Potassium-competitive acid blockers (P-CAB) might induce a more important acid inhibition than PPI. Baclofen might act as a reflux inhibitor and demonstrates a significant efficacy in rumination syndrome. The role of topical antacid–alginate in refractory GERD might be limited. Surgery might be a valid option in case of persistent pathological acid esophageal exposure despite PPI. Further evaluation of minimally invasive procedures is necessary. Finally diet, diaphragmatic breathing and transcutaneous electrical acustimulation might be of interest in patients with esophageal hypersensivity or functional symptoms.
Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and ...aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.
Background
Glucose breath test (GBT) is used for the diagnosis of small intestine bacterial overgrowth. A restrictive diet without fibers and/or fermentable food is recommended on the day before the ...test. The aim of our retrospective study was to evaluate the impact of two different restrictive diets on the results of GBT.
Methods
A change of the pretest restrictive diet was applied in our lab on September 1, 2020. The recommended diet was a fiber‐free diet before this date, and a fiber‐free diet plus restriction of all fermentable food afterward. We thus compared the results of GBT performed before (group A) and after (group B) this pretest diet modification. Demographics, reasons to perform GBT, digestive symptoms, and hydrogen and methane baseline values and variations after glucose ingestion were compared between the two groups.
Key Results
269 patients underwent GBT in group A, and 316 patients in group B. The two groups were comparable in terms of demographics. Methane and hydrogen baseline values were significantly higher in group A (respectively 14 18 vs. 8 14 ppm, p < 0.01 and 11 14 vs. 6 8 ppm, p < 0.01). The percentage of positive tests was higher in group A for methane (43% vs. 28%, p < 0.05), and for hydrogen (18% vs. 12%, p = 0.03).
Conclusion & Inferences
This retrospective study suggests the importance of the restrictive diet prior to GBT. A strict limitation of fibers and fermentable food decreased hydrogen and methane baseline values, and the prevalence of positive GBT. Thus a strict restrictive diet should be recommended on the day before the test, in order to limit the impact of food on hydrogen and methane breath levels, and possibly improve the diagnosis quality of GBT.
A strict diet without all kinds of fermentable food on the day before the test decreases significantly the baseline values of breath hydrogen and methane, compared to a diet without dietary fibers. Glucose breath tests results are less frequently positive with a strict diet on the day before the test.
Introduction and Purpose
Sleeve gastrectomy (SG) is gaining ground in the field of bariatric surgery. Data are scarce on its impact on esophagogastric physiology. Our aim was to evaluate the impact ...of SG on esophagogastric motility with high-resolution impedance manometry (HRIM) and to assess the usefulness of HRIM in patients with upper gastrointestinal (GI) symptoms after SG.
Methods
A retrospective analysis of 53 cases of HRIM performed after SG was conducted. Upper GI symptoms at the time of HRIM were scored. HRIM was analyzed according to the Chicago classification v3.0. A special attention was devoted to the occurrence of increased intragastric pressure (IIGP) after water swallows and reflux episodes as detected with impedance. A measurement of sleeve volume and diameter was performed with CT scan in a subgroup of patients.
Results
IIGP occurred very frequently in patients after SG (77 %) and was not associated with any upper GI symptoms, specific esophageal manometric profile, or impedance reflux. Impedance reflux episodes were also frequently observed after SG (52 %): they were significantly associated with gastroesophageal reflux (GER) symptoms and ineffective esophageal motility. The sleeve volume and diameters were also significantly smaller in patients with impedance reflux episodes (
p
< 0.01).
Conclusion
SG significantly modified esophagogastric motility. IIGP is frequent, not correlated to symptoms, and should be regarded as a HRIM marker of SG. Impedance reflux episodes were also frequent, associated with GER symptoms and esophageal dysmotility. HRIM may thus have a clinical impact on the management of patients with upper GI symptoms after SG.
Background
High‐resolution manometry (HRM) is a key method to evaluate esophageal motility disorders. Current evaluation is usually performed with single water swallows (SWS) that may not challenge ...esophageal function or reproduce symptoms. Solid food swallows (SFS) could increase the diagnostic yield for clinically relevant disorders.
Methods
Patients with dysphagia referred for esophageal HRM during a 2‐year period in a single center were reviewed retrospectively and included if SFS was performed during HRM. Chicago classification v3.0 was used to define esophageal motility disorders.
Key Results
One hundred and four patients with dysphagia were included (59% women, mean age 57 years). Ineffective esophageal motility was the most frequent motility disorder. Compared to SWS, the diagnosis changed after SFS in 33 patients (31.7%) including a change from normal or minor diagnosis toward major motility disorders in 14 (13.4%). Fifteen subjects (14.4%) shifted from a minor disorder on SWS to normal after SFS. SFS changed the diagnosis in 53.8% of patients with previous surgery versus 29.5% of those without (p = 0.023). Pressurization during rapid drink challenge was more frequent when SFS changed the diagnosis to major motility disorders (69.2% vs. 37.3%, p = 0.033). Twenty‐nine percent of patients reported symptoms during SFS, mostly those with diagnostic change to major disorders after SFS (71.4% of patients with changes to major disorders vs. 22.2% of patients without, p < 0.0001).
Conclusion & Inferences
Solid food swallows is a simple way to improve the diagnostic yield of HRM in patients with dysphagia and should be added to manometry protocol in daily clinical practice.
Solid food swallow (SFS) evidenced a hypercontractile esophagus together with dysphagia and pain, that were not present during single water swallow (normal SWS). SFS is a simple way to improve the diagnostic yield of HRM in patients with dysphagia that can be added to the manometry protocol in daily clinical practice.
Combined pH and impedance monitoring can detect all types of reflux episodes within the esophageal lumen and the pharynx. We performed a multicenter study to establish normal values of pharyngeal and ...esophageal pH-impedance monitoring in individuals on and off therapy and to determine the interobserver reproducibility of this technique.
We collected ambulatory 24-hour pH-impedance recordings from 46 healthy subjects by using a bifurcated probe that allowed for detection of reflux events in the distal and proximal esophagus and pharynx. Data were collected when subjects had not received any medicine (off therapy) and after receiving 40 mg esomeprazole twice daily for 14 days (on therapy). The interobserver agreement for the detection of reflux events was determined in 20 subjects off and on therapy. Results were expressed as median (interquartile range).
Off therapy, subjects had a median of 32 reflux events (17-45) in the distal esophagus and 3 (1-6) in the proximal esophagus; they had none in the pharynx. On therapy, subjects had a median number of 21 reflux events (6-37) in the distal esophagus and 2 (0-5) in the proximal esophagus; again, there were none in the pharynx. Interobserver agreement was good for esophageal reflux events but poor for pharyngeal events.
We determined normal values of pharyngeal and gastroesophageal reflux events by 24-hour pH-impedance monitoring of subjects receiving or not receiving esomeprazole therapy. Analyses of esophageal events were reproducible, but analyses of pharyngeal events were not; this limitation should be taken into account in further studies.
Combined esophageal pH-impedance monitoring allows detection of nearly all gastroesophageal reflux episodes, acid as well as nonacid. However, the role of nonacid reflux in the pathogenesis of ...symptoms is poorly known. The aim of this study was to evaluate the diagnostic yield of this technique in patients with suspected reflux symptoms while on or off PPI therapy.
The recordings of 150 patients recruited at seven academic centers with symptoms possibly related to gastroesophageal reflux were analyzed. Reflux events were detected visually using impedance (Sandhill, CO) and then characterized by pHmetry as acid or nonacid reflux. The temporal relationship between symptoms and reflux episodes was analyzed: a symptom association probability (SAP) > or =95% was considered indicative of a positive association.
One hundred fifty patients were included, 102 women (mean age 52 +/- 14 yr, range 16-84). Among the 79 patients off PPI, five did not report any symptom during the recording period. A positive SAP was found in 41 of the 74 symptomatic patients (55.4%), including acid reflux in 23 (31.1%), nonacid reflux in three (4.1%), and acid and nonacid in 15 (20.3%). In the group of patients on PPI (N = 71, 46 women, mean age 51 +/- 15 yr), 11 were asymptomatic during the study, SAP was positive in 22 of the 60 symptomatic patients (36.7%), including acid reflux in three (5.0%), nonacid reflux in 10 (16.7%), and acid and nonacid in nine (15.0%). The symptoms most frequently associated with nonacid reflux were regurgitation and cough.
Adding impedance to pH monitoring improves the diagnostic yield and allows better symptom analysis than pHmetry alone, mainly in patients on PPI therapy. The impact of this improved diagnostic value on gastroesophageal reflux disease management remains to be investigated by outcome studies.
PDF
