Normative values in esophageal high‐resolution manometry Herregods, T. V. K.; Roman, S.; Kahrilas, P. J. ...
Neurogastroenterology and motility,
February 2015, 2015-Feb, 2015-02-00, 20150201, Letnik:
27, Številka:
2
Journal Article
Recenzirano
Background
Esophageal high‐resolution manometry (HRM) has rapidly gained much popularity worldwide. The Chicago Classification for esophageal motility disorders is based on a set of normative values ...for key metrics that was obtained using one of the commercially available HRM systems. Thus, it is of great importance to evaluate whether these normative values can be used for other HRM systems as well.
Purpose
In this review, we describe the presently available HRM systems, the currently known normative thresholds and the factors that influence them, and assess the use of these thresholds. Numerous factors including the type of HRM system, demographic factors, catheter diameter, body position during testing, consistency of bolus swallows, and esophageal length have an influence on the normative data. It would thus be ideal to have different sets of normal values for each of these factors, yet at the moment the amount of normative data is limited. We suggest broadening the normal range for parameters, as this would allow abnormal values to be of more significance. In addition, we suggest conducting studies to assess the physiological relevance of abnormal values and stress that for each system different normative thresholds may apply.
In this review, the currently known normative thresholds for high‐resolution manometry, and the factors influencing them, are illustrated. In addition, the use of these thresholds is assessed.
Background
Ano‐rectal manometry (ARM) is the most commonly performed investigation for assessment of anorectal dysfunction. Its use is supported by expert consensus documents and international ...guidelines. Variation in technology, data acquisition, and analysis affect results and clinical interpretation. This study examined variation in ARM between institutions to establish the status of current practice.
Methods
A 50‐item web‐based questionnaire assessing analysis and interpretation of ARM was distributed by the International Anorectal Physiology Working Group via societies representing practitioners that perform ARM. Study methodology and performance characteristics between institutions were compared.
Key Results
One hundred and seven complete responses were included from 30 countries. Seventy‐nine (74%) institutions performed at least two studies per week. Forty‐nine centers (47%) applied conventional ARM (≤8 pressure sensors) and 57 (53%) high‐resolution ARM (HR‐ARM). Specialist centers were most likely to use HR‐ARM compared to regional hospitals and office‐based practice (63% vs 37%). Most conventional ARM systems used water‐perfused technology (34/49); solid‐state hardware was more frequently used in centers performing HR‐ARM (44/57). All centers evaluated rest and squeeze. There was marked variation in the methods used to report results of maneuvers. No two centers had identical protocols for patient preparation, setup, study, and data interpretation, and no center fully complied with published guidelines.
Conclusions & Inferences
There is significant discrepancy in methods for data acquisition, analysis, and interpretation of ARM. This is likely to impact clinical interpretation, transfer of data between institutions, and research collaboration. There is a need for expert international co‐operation to standardize ARM.
This survey shows that there is significant discrepancy in methods for data acquisition, analysis, and interpretation of ARM. This is likely to impact clinical interpretation, transfer of data between institutions, and research collaboration. There is a need for expert international co‐operation to standardize ARM.
Background
The Chicago Classification (CC) of esophageal motility disorders, utilizing an algorithmic scheme to analyze clinical high‐resolution manometry (HRM) studies, has gained acceptance ...worldwide.
Methods
This 2014 update, CC v3.0, developed by the International HRM Working Group, incorporated the extensive clinical experience and interval publications since the prior (2011) version.
Key Results
Chicago Classification v3.0 utilizes a hierarchical approach, sequentially prioritizing: (i) disorders of esophagogastric junction (EGJ) outflow (achalasia subtypes I‐III and EGJ outflow obstruction), (ii) major disorders of peristalsis (absent contractility, distal esophageal spasm, hypercontractile esophagus), and (iii) minor disorders of peristalsis characterized by impaired bolus transit. EGJ morphology, characterized by the degree of overlap between the lower esophageal sphincter and the crural diaphragm and baseline EGJ contractility are also part of CC v3.0. Compared to the previous CC version, the key metrics of interpretation, the integrated relaxation pressure (IRP), the distal contractile integral (DCI), and the distal latency (DL) remain unchanged, albeit with much more emphasis on DCI for defining both hypo‐ and hypercontractility. New in CC v3.0 are: (i) the evaluation of the EGJ at rest defined in terms of morphology and contractility, (ii) ‘fragmented’ contractions (large breaks in the 20‐mmHg isobaric contour), (iii) ineffective esophageal motility (IEM), and (iv) several minor adjustments in nomenclature and defining criteria. Absent in CC v3.0 are contractile front velocity and small breaks in the 20‐mmHg isobaric contour as defining characteristics.
Conclusions & Inferences
Chicago Classification v3.0 is an updated analysis scheme for clinical esophageal HRM recordings developed by the International HRM Working Group.
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The Chicago Classification (CC) of esophageal motility disorders, utilizing an algorithmic scheme to analyze clinical high‐resolution manometry (HRM) studies, has gained acceptance worldwide. This 2014 update, CC v3.0, developed by the International HRM Working Group, incorporated the extensive clinical experience and interval publications since the prior (2011) version.
Background
Criteria for transient lower esophageal sphincter relaxations (TLESRs) are well‐defined for Dentsleeve manometry. As high‐resolution manometry (HRM) is now the gold standard to assess ...esophageal motility, our aim was to propose a consensus definition of TLESRs using HRM.
Methods
Postprandial esophageal HRM combined with impedance was performed in 10 patients with gastroesophageal reflux disease. Transient lower esophageal sphincter relaxations identification was performed by 17 experts using a Delphi process. Four investigators then characterized TLESR candidates that achieved 100% agreement (TLESR events) and those that achieved less than 25% agreement (non‐events) after the third round. Logistic regression and decision tree analysis were used to define optimal diagnostic criteria.
Key Results
All diagnostic criteria were more frequently encountered in the 57 TLESR events than in the 52 non‐events. Crural diaphragm (CD) inhibition and LES relaxation duration >10 seconds had the highest predictive value to identify TLESR. Based on decision tree analysis, reflux on impedance, esophageal shortening, common cavity, upper esophageal sphincter relaxation without swallow and secondary peristalsis were alternate diagnostic criteria.
Conclusion & Inferences
Using HRM, TLESR might be defined as LES relaxation occurring in absence of swallowing, lasting more than 10 seconds and associated with CD inhibition.
A consensus definition of transient lower espohageal sphincter relaxation (TLESR) using high resolution manometry is proposed. TLESR is defined as LES relaxation occurring in absence of swallowing, lasting more than 10 seconds and associated with crural definition inhibition. Reflux on impedance, esophageal shortening, common cavity, upper esophageal sphincter relaxation without swallow and secondary peristalsis are alternate diagnostic criteria.
Background
High‐resolution anorectal manometry (HRAM) is a relatively new method for collection and interpretation of data relevant to sphincteric function, and for the first time allows a global ...appreciation of the anorectum as a functional unit. Historically, traditional anal manometry has been plagued by lack of standardization and healthy volunteer data of variable quality. The aims of this study were: (i) to obtain normative data sets for traditional measures of anorectal function using HRAM in healthy subjects and; (ii) to qualitatively describe novel physiological phenomena, which may be of future relevance when this method is applied to patients.
Methods
115 healthy subjects (96 female) underwent HRAM using a 10 channel, 12F solid‐state catheter. Measurements were performed during rest, squeeze, cough, and simulated defecation (push). Data were displayed as color contour plots and analysed using a commercially available manometric system (Solar GI HRM v9.1, Medical Measurement Systems). Associations between age, gender and parity were subsequently explored.
Key Results
HRAM color contour plots provided clear delineation of the high‐pressure zone within the anal canal and showed recruitment during maneuvers that altered intra‐anal pressures. Automated analysis produced quantitative data, which have been presented on the basis of gender and parity due to the effect of these covariates on some sphincter functions. In line with traditional manometry, some age and gender differences were seen. Males had a greater functional anal canal length and anal pressures during the cough maneuver. Parity in females was associated with reduced squeeze increments.
Conclusions & Inferences
The study provides a large healthy volunteer dataset and parameters of traditional measures of anorectal function. A number of novel phenomena are appreciated, the significance of which will require further analysis and comparisons with patient populations.
Two images of the same push in the same individual. Inspection of image (A) shows an increase in both anal and rectal pressures during push (which could led to the mistaken interpretation of dyssynergia) however, when the same event is displayed relative to rectal pressure (B), this more clearly reveals an appropriate change in the recto‐anal gradient.
Objectives/Hypothesis
Empiric proton pump inhibitor (PPI) trials for laryngopharyngeal reflux (LPR) are common. A majority of the patients respond to acid suppression. This work intends to evaluate ...once‐daily, 40 mg omeprazole and once‐nightly, 300 mg ranitidine (QD/QHS) dosing as an alternative regimen, and use this study's cohort to evaluate empiric regimens prescribed for LPR as compared to up‐front testing with pH impedance multichannel intraluminal impedance (MII) with dual pH probes and high‐resolution manometry (HRM) for potential cost minimization.
Study Design
Retrospective cohort review and cost minimization study.
Methods
A chart review identified patients diagnosed with LPR. All subjects were treated sequentially and outcomes recorded. Initial QD/QHS dosing increased after 3 months to BID if no improvement and ultimately prescribed MII and HRM if they failed BID dosing. Decision tree diagrams were constructed to determine costs of two empiric regimens and up‐front MII and HRM.
Results
Ninety‐seven subjects met the criteria. Responders and nonresponders to empiric therapy were identified. Seventy‐two subjects (74%) responded. Forty‐eight (67% of responders and 49% of all) improved with QD/QHS dosing. Forty‐nine (51%) subjects escalated to BID dosing. Twenty‐four subjects (33% of responders and 25% of all) improved on BID therapy. Twenty‐five subjects (26%) did not respond to acid suppression. Average weighted cost was $1,897.00 per patient for up‐front testing, $3,033.00 for initial BID, and $3,366.00 for initial QD/QHS.
Conclusions
An alternate QD/QHS regimen improved the majority who presented with presumed LPR. Cost estimates demonstrate that the QD/QHS regimen was more expensive than the initial BID high‐dose PPI for 6 months. Overall per‐patient cost appears less with up‐front MII and HRM.
Level of Evidence
4. Laryngoscope, 127:S1–S13, 2017
Background
A substantial pressure drift in high‐resolution manometry (HRM) has been reported; however, fundamental questions remain regarding the origin and management of this drift. The aim of this ...study was to provide critical in‐depth analyses of ManoScan™ HRM drift in vitro and in vivo.
Methods
A total of sixteen 15‐min studies and twelve 5‐h studies were performed in a water bath at 37 °C at 4.0 cm depth (2.9 mmHg) with ESO and ESO Z catheters. Six 5‐h in vitro studies were performed similarly at a depth of 9.0 cm (6.6 mmHg). Eight 15‐min studies and nine 8‐h in vivo studies were performed with healthy participants. Two correction methods – thermal compensation (TC) and interpolated thermal compensation (ITC) – were tested.
Key Results
Overall pressure drift varied both between studies (p < 0.01) and within sensors (p < 0.01). Drift resulted from thermal shock, an initial pressure change at intubation, and baseline drift, a linear drift over time (R2 > 0.96). Contrary to previous reports, there was no correlation between drift and average (r = −0.02) or maximum pressure exposure (r = −0.05). Following data correction, ITC had the lowest median error but persisted with a maximum error of 2.5 mmHg (IQR = 3.0).
Conclusions & Inferences
The substantial drift in the ManoScan™ HRM system is highly variable and not corrected via the standard operating instructions. ITC has superior performance but requires communication with the manufacturer to enable this option. This has a substantial impact on clinical diagnosis, utility of existing normative data, and future research of HRM.
The aim of this study was to provide critical in‐depth analyses of ManoScan™ high‐resolution manometry pressure drift in vitro and in vivo. Results indicate that the substantial drift in the ManoScan™ HRM system is highly variable and not corrected via the standard operating instructions.
Background
In constipated individuals, high-resolution anorectal manometry (HRM) may suggest the presence of a defecatory disorder. Despite known physiological differences between men and women, our ...understanding of functional anorectal pathophysiology is based upon predominantly female cohorts. Results are generalized to men.
Aims
To evaluate whether recto-anal pressure patterns in constipated men are similar to those in constipated women.
Methods
The electronic health records at Mayo Clinic, Rochester were used to identify constipated adult patients, without organic anorectal disease, who had undergone HRM and balloon expulsion testing (BET) in 2018, 2019, and 2020. Comparative analyses were performed.
Results
Among 3,298 constipated adult patients (2,633 women, 665 men), anal and rectal pressures were higher in men. Women more likely to have HRM findings suggestive of a defecatory disorder (39% versus 20%,
P
< 0.001). Women were more likely to exhibit a type 4 pattern (27% versus 14%,
P
< 0.001), and less likely to exhibit a type 1 pattern (14% versus 38%,
P
< 0.001), of dyssynergia. Men were more likely to have an abnormal balloon expulsion test (BET, 34% versus 29%,
P
= 0.006). Nominal logistic regression demonstrates that male sex, age over 50 years, reduced recto-anal gradient during simulated evacuation, and types 2 and 4 dyssynergia are associated with an abnormal BET.
Conclusions
In this large retrospective study, constipated men and women exhibited different patterns of dyssynergia both in the presence and absence of an abnormal BET. These findings were independent of sex-specific baseline physiological differences.
Background/Aims
Esophageal manometry is the gold standard for esophageal motility evaluation. High-resolution esophageal manometry with impedance (HRIM) allows concurrent assessment of bolus transit ...and manometry. Inconsistencies between concomitant impedance and manometry data pose a clinical dilemma and has not yet been addressed. We aim to assess interpretation trends of HRIM data among gastroenterologists worldwide.
Methods
A cross-sectional study using an anonymous survey was conducted among gastroenterologists worldwide. Statistical analysis was performed to compare responses between providers.
Results
We received responses from 107 gastroenterologists (26 countries). Most were adult providers (69, 64.5%), and most (77, 72.0%) had > 5 years of experience. Impedance was found to be helpful by 83 (77.6%) participants, but over 30% reported inconsistencies between impedance and manometry data. With incomplete bolus clearance and normal manometry 41 (38.7%) recommended observation, 41 (38.7%) recommended 24-hours pH-impedance, and 16 (15.1%) recommended prokinetics. With abnormal manometry and complete bolus clearance, 60 (57.1%) recommended observation while 18 (17.1%) recommended 24-hours pH impedance and 15 (14.3%) recommended prokinetics. A significant difference was found between providers from different continents in treating cases with discrepancy between impedance and manometry findings (P < 0.001). No significant differences were seen in responses between adult versus pediatric providers and between providers with different years of experience.
Conclusions
There is no consensus on interpreting HRIM data. Providers’ approaches to studies with inconsistencies between manometry and impedance data vary. There is an unmet need for guidelines on interpreting impedance data in HRIM studies.
(J Neurogastroenterol Motil 2024;30:46-53)
Background
Multiple water swallow is increasingly used as a complementary challenge test in patients undergoing high‐resolution manometry (HRM). Our aim was to establish the range of normal pressure ...responses during the rapid drink challenge test in a large population of healthy subjects.
Methods
Pressure responses to a rapid drink challenge test (100 or 200 mL of water) were prospectively analyzed in 105 healthy subjects studied in nine different hospitals from different countries. Esophageal motility was assessed in all subjects by solid‐state HRM. In 18 subjects, bolus transit was analyzed using concomitant intraluminal impedance monitoring.
Key Results
A virtually complete inhibition of pressure activity was observed during multiple swallow: Esophageal body pressure was above 20 mm Hg during 1 (0‐8) % and above 30 mm Hg during 1 (0‐5) % of the swallow period, and the pressure gradient across the esophagogastric junction was low (−1 (−7 to 4) mm Hg). At the end of multiple swallow, a postswallow contraction was evidenced in only 50% of subjects, whereas the remaining 50% had non‐transmitted contractions. Bolus clearance was completed after 7 (1‐30) s after the last swallow, as evidenced by multichannel intraluminal impedance.
Conclusions & Inferences
The range of normal pressure responses to a rapid drink challenge test in health has been established in a large multicenter study. Main responses are a virtually complete inhibition of esophageal pressures with a low‐pressure gradient across esophagogastric junction. This data would allow the correct differentiation between normal and disease when using this test.
The range of normal pressure responses during a rapid drink challenge test has been established in a multicenter study using high‐resolution manometry. During multiple swallow, there is a complete inhibition of pressure activity in the esophageal body and a low‐pressure gradient across the esophagogastric junction. Complete bolus clearance occurs soon after multiple water swallow stops despite no evident postswallow peristaltic activity is common.
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