Association of Bolus Transit Time on Barium Esophagram With Esophageal Peristalsis on High-resolution Manometry and Nonobstructive Dysphagia

Abstract The threshold criteria for diagnosing ineffective esophageal motility (IEM) has changed over the years and is based on the proportion of failed and weak peristalses. Bolus transit time (BTT) on barium esophagogram (BE) can intuitively be the ‘gold standard' for assessing the effectiveness of esophageal peristalsis. The aim of this study was to associate upright and prone BTT with esophageal peristalsis and dysphagia in patients with normal lower esophageal sphincter (LES) parameters. Methods Patients with normal LES on high-resolution manometry (HRM) who also had a standard-protocol BE from 2017 to 2020 were included. Patients with previous foregut surgery, hiatal hernia, jackhammer esophagus, distal esophageal spasm, fragmented peristalsis, and those with < or > 10 single swallows on HRM were excluded. Based on the number of normal swallows (DCI >450 mmHg.s.cm), the patients were divided into 11 groups (10 normal to 0 normal). Upright and prone BTT were measured on BE. Fractional polynomial and logistic regression analysis were used to study association (along with rate of change) between BTT, dysphagia, and peristalsis. Results In total, 146 patients met the inclusion criteria. Prone BTT increased in tandem with a decrease in the number of normal peristalses (p < 0.001), but no difference was noted in upright BTT (p = 0.317). Two deflection points were noted on the association between peristalsis and prone BTT at 50%, 40 seconds and 30%, 80 seconds on the y and x-axes, respectively, after which declining peristaltic function was independent of prone BTT. Patients with prone BTT >40 seconds had nearly 6-fold higher odds of having zero normal peristalses (p = 0.002). Increasing prone BTT was associated with increasing dysphagia (p < 0.05). Conclusion Prone, but not upright BTT, correlates with the proportion of normal esophageal peristalses and dysphagia. The phenotype of abnormal swallows (failed, weak) appears to have minimal impact on BTT. The current perspective of manometric classification may need to be adjusted to use the proportion of normal peristalses as a criterion.

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373 ESOPHAGEAL BODY PERISTALSIS IN PATIENTS WITH NORMAL LOWER ESOPHAGEAL SPHINCTER: ARE VIDEO ESOPHAGOGRAM AND HIGH-RESOLUTION MANOMETRY IN AGREEMENT?

Diseases of the Esophagus ◽

10.1093/dote/doaa087.90 ◽

2020 ◽

Vol 33 (Supplement_1) ◽

Author(s):

D Razia ◽

L Giulini ◽

R Bremner ◽

S Mittal

Keyword(s):

High Resolution ◽

Lower Esophageal Sphincter ◽

Prone Position ◽

Transit Time ◽

Bolus Transit ◽

High Resolution Manometry ◽

Esophageal Body ◽

Esophageal Clearance ◽

Esophageal Spasm ◽

Esophageal Sphincter

Abstract Peristaltic disorders of the esophageal body have been categorized according to how they appear on high-resolution manometry. Abnormalities in peristalsis may lead to abnormal esophageal clearance and dysphagia. The aim of our retrospective analysis was to study bolus transit patterns on barium esophagogram in patients with various grades of esophageal body peristalsis as diagnosed by high-resolution manometry. Methods After Institutional Review Board approval, we queried an esophageal center database to identify patients with normal lower esophageal sphincter parameters. Patients with jackhammer esophagus, esophageal spasm, previous foregut surgery, hiatal hernia, and fragmented peristalsis were excluded. Remaining patients were divided into 11 groups based on their percentages of normal swallows out of 10 swallows (0%–100% swallows normal, DCI > 450 mmHg.s.cm). All previously obtained video esophagograms were re-evaluated in blinded fashion. Bolus transit time through the esophagus was measured in upright and prone positions, using live time stamps at the entry and exit of the bolus. ANOVA and χ2 were used. Results In total, 146 patients were included in the analysis. 73 (50%) were men. Mean age and body mass index were 58.4 ± 14.7 years and 22.8 ± 10.4 kg/m2, respectively. Bolus transit time in prone-position swallows increased in tandem with increases in number of abnormal swallows (11.3 ± 3.7, 22 ± 15.5, 29.5 ± 24.3, 42.7 ± 39.5, 42.4 ± 46.9, 64 ± 70.8, 59.4 ± 34.6, 58.8 ± 37.9, 110 ± 66.6, 83.2 ± 49.6 and 105.6 ± 72.5 seconds, p < 0.0001) but no difference was noted in upright-position bolus transit time (p = 0.317). There was a dropoff in level of significance at Group 5 (60% swallows normal) compared to Group 11 (absent contractility), after which there were no inter-group differences (Fig. 1). Conclusion Bolus transit time in prone-position swallows progressively increases as percentage of normal swallows decreases. Further work associated with symptoms to define a cutoff between normal and ineffective peristalsis would be useful.

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Neuronal Control of Esophageal Peristalsis and Its Role in Esophageal Disease

Current Gastroenterology Reports ◽

10.1007/s11894-019-0728-z ◽

2019 ◽

Vol 21 (11) ◽

Cited By ~ 4

Author(s):

K. Nikaki ◽

A. Sawada ◽

A. Ustaoglu ◽

D. Sifrim

Keyword(s):

High Resolution ◽

Smooth Muscles ◽

Circular Muscle ◽

Esophageal Disease ◽

Esophageal Peristalsis ◽

High Resolution Manometry ◽

Neuronal Control ◽

Neuronal Mechanisms ◽

Main Factors ◽

Contraction And Relaxation

Abstract Purpose of Review Esophageal peristalsis is a highly sophisticated function that involves the coordinated contraction and relaxation of striated and smooth muscles in a cephalocaudal fashion, under the control of central and peripheral neuronal mechanisms and a number of neurotransmitters. Esophageal peristalsis is determined by the balance of the intrinsic excitatory cholinergic, inhibitory nitrergic and post-inhibitory rebound excitatory output to the esophageal musculature. Recent Findings Dissociation of the longitudinal and circular muscle contractions characterizes different major esophageal disorders and leads to esophageal symptoms. Provocative testing during esophageal high-resolution manometry is commonly employed to assess esophageal body peristaltic reserve and underpin clinical diagnosis. Summary Herein, we summarize the main factors that determine esophageal peristalsis and examine their role in major and minor esophageal motility disorders and eosinophilic esophagitis.

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Assessing Bolus Retention in Achalasia Using High-Resolution Manometry With Impedance: A Comparator Study With Timed Barium Esophagram

The American Journal of Gastroenterology ◽

10.1038/ajg.2014.61 ◽

2014 ◽

Vol 109 (6) ◽

pp. 829-835 ◽

Cited By ~ 41

Author(s):

Yu K Cho ◽

Anna M Lipowska ◽

Frédéric Nicodème ◽

Ezra N Teitelbaum ◽

Eric S Hungness ◽

...

Keyword(s):

High Resolution ◽

High Resolution Manometry ◽

Barium Esophagram

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372 ESOPHAGEAL BODY PERISTALSIS CORRELATES FOR DYSPHAGIA AND REGURGITATION: AN ASSESSMENT BASED ON BARIUM ESOPHAGRAM

Diseases of the Esophagus ◽

10.1093/dote/doaa087.89 ◽

2020 ◽

Vol 33 (Supplement_1) ◽

Author(s):

L Giulini ◽

D Razia ◽

S Mittal

Keyword(s):

Clinical Symptoms ◽

Objective Assessment ◽

Esophageal Peristalsis ◽

High Resolution Manometry ◽

Number Of Patients ◽

Barium Esophagram ◽

Group A ◽

The Mean ◽

Definition Of ◽

Group B

Abstract Because it offers real-time assessment, barium esophagram should be the modality of choice when studying esophageal peristalsis. However, no standard reporting method is available for BE results. Presently, peristaltic disorders are defined according to high-resolution manometry (HRM), but HRM findings do not correlate with clinical symptoms. The aim of this study was to stratify esophageal peristaltic function via standardized evaluation of BE, and to define the association between esophageal peristalsis and dysphagia and regurgitation. Methods After IRB approval, a prospectively maintained database was reviewed for patients who underwent both HRM and BE from 08/01/2016 to 12/31/2019. Patients with conditions associated with outflow impairment were excluded. BEs were re-examined in blinded fashion and assigned subjective scores (0, 1, or 2) for dilation grade (DG) and contractility grade (CG). Patients were categorized according to the sum of the DG and CG: Group A = 0, Group B = 1–2, and Group C = 3–4. Mean distal contractile integral (DCI), number of failed contractions on HRM, and number of patients with dysphagia/regurgitation in each group were analyzed and compared. Results In all, 124 patients were included. The mean DCI (mmHg*cm*s) was 2539.1 ± 1357.8 in Group A, 884.4 ± 916.9 in Group B, and 77.4 ± 192.3 in Group C (p < 0.001). The mean number of failed contractions were 0.7 ± 1.3, 3.4 ± 3.4, and 8.6 ± 3.2, respectively (p < 0.001). Table 1 shows the distribution of patients with dysphagia or regurgitation across groups. The proportion of patients with dysphagia in Group C was higher than in Groups A or B (OR 3.75, p = 0.02; and OR 2.58, p = 0.07, respectively). Similarly, Group C was significantly more often associated with regurgitation than in Groups A or B (OR 4.69, p = 0.009; and OR 4.42, p = 0.005). Conclusion The combined DG and CG allowed us to identify the patients with a grade of peristaltic disfunction that was significantly more associated with dysphagia or regurgitation (Group C). However, in order to achieve a clearer definition of the different peristaltic disfunction levels according to their propensity to cause dysphagia or regurgitation, a more objective assessment of both DG and CG should be provided; therefore, further studies are required.

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Topographical plots of esophageal distension and contraction: effects of posture on esophageal peristalsis and bolus transport

AJP Gastrointestinal and Liver Physiology ◽

10.1152/ajpgi.00397.2018 ◽

2019 ◽

Vol 316 (4) ◽

pp. G519-G526 ◽

Cited By ~ 4

Author(s):

Ali Zifan ◽

Hyun Joo Song ◽

Young-Hoon Youn ◽

Xinhuan Qiu ◽

Melissa Ledgerwood-Lee ◽

...

Keyword(s):

High Resolution ◽

Healthy Subjects ◽

Temporal Relationship ◽

Entire Length ◽

Esophageal Peristalsis ◽

Descending Inhibition ◽

Position Change ◽

Trendelenburg Position ◽

High Resolution Manometry ◽

Esophageal Contraction

Each swallow induces a wave of inhibition followed by contraction in the esophagus. Unlike contraction, which can easily be measured in humans using high-resolution manometry (HRM), inhibition is difficult to measure. Luminal distension is a surrogate of the esophageal inhibition. The aim of this study was to determine the effect of posture on the temporal and quantitative relationship between distension and contraction along the entire length of the esophagus in normal healthy subjects by using concurrent HRM, HRM impedance (HRMZ), and intraluminal ultrasound (US). Studies were conducted in 15 normal healthy subjects in the supine and Trendelenburg positions. Both manual and automated methods were used to extract quantitative pressure and impedance-derived features from the HRMZ recordings. Topographical plots of distension and contraction were visualized along the entire length of the esophagus. Distension was also measured from the US images during 10-ml swallows at 5 cm above the lower esophageal sphincter. Each swallow was associated with luminal distension followed by contraction, both of which traversed the esophagus in a sequential/peristaltic fashion. Luminal distension (US) and esophageal contraction amplitude were greater in the Trendelenburg compared with the supine position. Length of esophageal breaks (in the transition zone) were reduced in the Trendelenburg position. Change in posture altered the temporal relationship between distension and contraction, and bolus traveled closer to the esophageal contraction in the Trendelenburg position. Topographical contraction-distension plots derived from HRMZ recordings is a novel way to visualize esophageal peristalsis. Future studies should investigate if abnormalities of esophageal distension are the cause of functional dysphagia. NEW & NOTEWORTHY Ascending contraction and descending inhibition are two important components of peristalsis. High-resolution manometry only measures the contraction phase of peristalsis. We measured esophageal distension from intraluminal impedance recordings and developed novel contraction-distension topographical plots to prove that similar to contraction, distension also travels in a peristaltic fashion. Change in posture from the supine to the Trendelenburg position also increased the amplitude of esophageal distension and contraction and altered the temporal relationship between distension and contraction.

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Quantifying esophageal peristalsis with high-resolution manometry: a study of 75 asymptomatic volunteers

AJP Gastrointestinal and Liver Physiology ◽

10.1152/ajpgi.00510.2005 ◽

2006 ◽

Vol 290 (5) ◽

pp. G988-G997 ◽

Cited By ~ 147

Author(s):

Sudip K. Ghosh ◽

John E. Pandolfino ◽

Qing Zhang ◽

Andrew Jarosz ◽

Nimeesh Shah ◽

...

Keyword(s):

High Resolution ◽

Transition Zone ◽

Contractile Activity ◽

Normative Values ◽

Esophageal Peristalsis ◽

Data Set ◽

High Resolution Manometry ◽

Asymptomatic Volunteers ◽

Temporal And Spatial Characteristics ◽

Novel Concept

The vastly enhanced spatial resolution of high-resolution manometry (HRM) makes it possible to simultaneous monitor contractile activity over the entire length of the esophagus. The aim of this investigation was to define the essential features of esophageal peristalsis in novel HRM paradigms and establish their normative values. Ten 5-ml water swallows were recorded in each of 75 asymptomatic controls with a solid-state manometric assembly incorporating 36 circumferential sensors spaced at 1-cm intervals positioned to record from the hypopharynx to the stomach. The data set was then subjected to intensive computational analysis to distill out the essential characteristics of normal peristalsis. Esophageal peristalsis was conceptualized in terms of a proximal contraction, a distal contraction, and a transition zone separating the two. Each contractile segment was quantified in length and then normalized among subjects to summarize focal fluctuation of contractile amplitude and propagation velocity. Furthermore, the temporal and spatial characteristics of the transition zone separating the proximal and distal contraction were quantified. For each paradigm, graphics were developed, establishing median values along with the 5th to 95th percentile range of observed variation. In addition, the synchronization between peristalsis and esophagogastric junction relaxation was analyzed using a novel concept of the outflow permissive pressure gradient. We performed a detailed analysis of esophageal peristalsis aimed at quantifying its essential features and, in so doing, devised new paradigms for the quantification of peristaltic function that will hopefully optimize the utility of HRM in clinical and investigative studies.

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