Can FLIP guide therapy in idiopathic esophagogastric junction outflow obstruction?

Background Esophagogastric junction outflow obstruction (EGJOO) has a variable disease course. Currently, barium swallow (BaS) and manometric parameters are used to characterize clinically significant EGJOO. The esophagogastric junction distensibility index (EGJ-DI) measured via functional lumen imaging probe (FLIP) can provide complementary information. Our aim was to assess symptom response in patients with EGJOO and an abnormal EGJ-DI after botulinum toxin (BT) treatment. Methods A prospective cohort study of adults with idiopathic EGJOO was performed from September 2019 to March 2021. Patients with dysphagia underwent upper endoscopy with FLIP. If the EGJ-DI was abnormally low, BT was injected. Data examined included demographics, medical history, endoscopic and FLIP findings, BaS, manometry, and Eckardt score (ES). ES improvement was assessed via paired samples t-test. Pearson’s chi-square tests were used to assess for associations. Results Of the 20 patients, 75% had an abnormal EGJ-DI and underwent BT injections. Mean ES for patients with abnormal EGJ-DIs significantly improved from baseline to 1, 3, and 6 month follow-up (P-values: 0.01, 0.05, and 0.02, respectively). There was a significant association between an abnormal EGJ-DI with delayed bolus transit and presence of rapid drink challenge panesophageal pressurization on manometry: P = 0.03 and P = 0.03. Conclusion This prospective study revealed that an abnormal EGJ-DI can guide BT as assessed via symptomatic response. Additionally, abnormal EGJ-DI measurements were significantly associated with other parameters used previously to determine clinically relevant EGJOO. Larger follow-up studies are warranted to further elucidate guidance for therapy in EGJOO.

Bolus transit of upper esophageal sphincter on high-resolution impedance manometry study correlate with the laryngopharyngeal reflux symptoms

Laryngopharyngeal reflux symptom is a troublesome upper esophageal problem, and reflux symptom index (RSI) is commonly applied for the assessment of clinical severity. We investigated the relationship between the upper esophageal sphincter impedance integral (UESII) and RSI scores in this study. Totally 158 subjects with high-resolution esophageal impedance manometry (HRIM) with RSI questionnaire assessment were recruited. There are 57 (36.08%), 74 (46.84%), 21 (13.29%), and 6 (3.79%) patients were categorized as normal, ineffective esophageal motility disorder, absent contractility, and achalasia by HRIM examination, respectively. Subjects with RSI > 13 were noted to have lower UESII than others with RSI ≦ 13 (7363.14 ± 1085.58 vs. 11,833.75 ± 918.77 Ω s cm; P < 0.005). The ROC analysis yielded a UESII cutoff of < 2900 Ω s cm for the best prediction of subjects with RSI > 13 (P = 0.002). Both female gender and UESII cutoff of < 2900 Ω s cm were significant predictors of RSI > 13 in logistic regression analysis (OR = 3.84 and 2.83; P = 0.001 and 0.01; respectively). Lower UESII on HRIM study, indicating poor bolus transit of UES during saline swallows, is significantly associated with prominent laryngopharyngeal reflux symptoms scored by RSI score.

807 ASSOCIATION OF BOLUS TRANSIT TIME ON BARIUM ESOPHAGOGRAM WITH ESOPHAGEAL PERISTALSIS

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 &lt; or &gt; 10 single swallows on HRM were excluded. Based on the number of normal swallows (DCI &gt;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 &lt; 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 &gt;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 &lt; 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.

153 THE CLINICAL SIGNIFICANCE OF INCOMPLETE BOLUS CLEARANCE IN PATIENTS WITH DYSPHAGIA

The primary function of the esophagus is to facilitate bolus transport to the stomach. High-resolution manometry assesses the functions of esophageal motility, but not the clearance of bolus transit through the esophagus. The development of combined multichannel intraluminal impedance and manometry (MII-EM) has enabled simultaneous measurement of bolus transport and manometry. This study investigated the effects of bolus transit on esophageal motility disorders and its effect on the quality of life of patients with dysphagia. Methods A total of 810 wet swallows were reviewed and analyzed in 81 patients with dysphagia who underwent MII-EM. Incomplete bolus clearance (IBC) was defined based on impedance measurement. IBC was classified into four types (A: normal, B: incomplete clearance in the upper esophagus, C: incomplete clearance in the lower esophagus, D: incomplete clearance of the whole esophagus), and was also evaluated according to the appearance rate of complete bolus transit. Then, the clinical significance of IBC was determined by our previously validated dysphagia symptom score and the SF8 quality of life instrument (physical component summary and mental component summary). Results There were 16 cases of esophageal achalasia (Ach), 9 of esophagogastric junction outflow obstruction (EGJOO), 8 of distal esophageal spasm (DES), 7 of Jackhammer esophagus (JE), 2 of absent contractility (AC), 10 of ineffective esophageal motility (IEM) and 29 normal cases. The figure shows the breakdown of IBC for each disorder. Complete bolus transit was found in 27.8% in EGJOO, 52.5% in DES, 14.2% in JE, 4.0% in IEM, and 83.3% in normal; no CBT was found in Ach and AC. Patients with IBC had significantly higher dysphagia symptom scores (p &lt; 0.05) and lower mental component summaries (p &lt; 0.05) than those without. Conclusion Patients with dysphagia with esophageal dysmotility were classified into two groups: those with and without IBC. Assessment of bolus transport is an important clinical marker for patients with dysphagia, because those with IBC had a significantly higher dysphagia symptom scores and impaired quality of life.

Functional Changes of the Upper Esophageal Sphincter in Gastroesophageal Reflux

Introduction The upper esophageal sphincter (UES) is a muscular structure located at the transition from the pharynx to the esophagus, with the cricopharyngeal muscle as the most important component. During gastroesophageal reflux, the pressure in the UES elevates, which is apparently a protective mechanism to prevent esophagopharyngeal reflux and airway aspiration. In gastroesophageal reflux disease (GERD), there may be functional changes in the UES. Objective The objective of the present review was to determine UES functional changes in GERD. Data Synthesis In healthy individuals, gastroesophageal reflux causes an increase in the UES pressure. This response of the sphincter is at least partially impaired in patients with GERD. In the disease, the UES has a reduced length and decreased resting pressure. However, other publications found that in chronic gastroesophageal reflux the basal sphincter pressure increase, differences which may be consequent to the measurement method or to disease severity. The UES opening during swallowing has a smaller diameter, and the bolus transit time through the sphincter is longer. Conclusion The UES of patients with GERD does not open as expected and the bolus flow through the sphincter is longer. This behavior may be associated with dysphagia, a frequent complaint in patients with GERD.

Which Physiological Swallowing Parameters Change with Healthy Aging?

Research suggests there are age-related changes in swallowing that do not constitute impairment (“presbyphagia”). The goal of this study was to explore the influence of age on quantitative measures of healthy swallowing by controlling for the effects of sex and sip volume in order to determine the specific characteristics of presbyphagia. Videofluoroscopy recordings of thin liquid swallows from 76 healthy adults (38 male), aged 21-82 were analysed. Blinded duplicate ratings of swallowing safety, efficiency, kinematics, and timing were made using the ASPEKT method. Hierarchical regression models were used to determine the effects of age, sex, and sip-volume on swallowing. There were no age-related changes in sip volume, number of swallows per bolus, frequency or severity of penetration-aspiration, duration of the hyoid-burst (HYB)-to-upper-esophageal-sphincter (UES) opening interval, time-to-laryngeal-vestibule-closure (LVC), peak hyoid position, hyoid speed, or pharyngeal residue. Significant changes seen with increasing age included: longer swallow reaction time, UES opening duration and LVC duration; larger pharyngeal area at rest and maximum constriction; and wider UES diameter. Male participants had larger sip volume and pharyngeal area at rest. Larger sip volumes were associated with multiple swallows per bolus and shorter hyoid-burst-to-UES opening intervals. These results help to define presbyphagic changes in swallowing that can be expected in healthy older adults up to 80 years of age, and distinguish them from changes that represent impairment. Certain parameters showed changes that were opposite in direction to changes that are usually considered to reflect impairment: longer UES opening, longer LVC duration and wider UES opening. These changes may reflect possible compensations for slower bolus transit. Further research is needed to determine the points along the age continuum where observed age-related changes in swallowing begin to emerge.

Dysphagia among patients after total laryngectomy: diagnostic and therapeutic procedures

Dysphagia concerns 10–89% patients after total laryngectomy; to a greater extent, it concerns patients receiving complementary radiotherapy. The disease mechanism is associated with anatomical changes after surgery (scope of surgery) or complications of adjuvant therapy (xerostomia, neuropathy, swelling of tissue, etc.). The above changes lead to: decreased mobility of the lateral walls of the pharynx and tongue retraction, the occurrence of lingual pumping, decreased swallowing reflex, weakening of the upper esophageal sphincter opening, contraction of the cricopharyngeal muscle, tissue fibrosis, formation of pharyngeal pseudodiverticulum, etc. As a result: regurgitation of food through the nose and oral cavity, food sticking in middle and lower pharynx, prolongation of bolus transit time. Upon the formation of tracheoesophageal fistula, there may be aspiration of gastric contents. The above changes considerably reduce patients’ quality of life after surgery. The diagnostic protocol includes: medical interview (questionnaires can be helpful such as: EAT 10, SSQ, MDADI, DHI), clinical swallowing assessment and instrumental examinations: primarily videofluoroscopy but also endoscopic evaluation of swallowing. In selected cases, multifrequency manometry is necessary. The treatment options include: surgical methods (e.g. balloon dilatation of the upper esophageal sphincter, cricopharyngeal myotomy, pharyngeal plexus neurectomy, removal of the pharyngeal pseudodiverticulum), conservative methods (e.g. botulinum toxin injection of the upper esophageal sphincter, speech therapy, nutritional treatment) and supportive methods such as consultation with a psychologis physiotherapist, clinical dietitian. The selection of a specific treatment method should be preceded by a diagnostic process in which the mechanism of functional disorders related to voice formation and swallowing will be established.

Quantification of pulmonary perfusion in idiopathic pulmonary fibrosis with first pass dynamic contrast-enhanced perfusion MRI

IntroductionIdiopathic pulmonary fibrosis (IPF) is a fatal disease of lung scarring. Many patients later develop raised pulmonary vascular pressures, sometimes disproportionate to the interstitial disease. Previous therapeutic approaches that have targeted pulmonary vascular changes have not demonstrated clinical efficacy, and quantitative assessment of regional pulmonary vascular involvement using perfusion imaging may provide a biomarker for further therapeutic insights.MethodsWe studied 23 participants with IPF, using dynamic contrast-enhanced MRI (DCE-MRI) and pulmonary function tests, including forced vital capacity (FVC), transfer factor (TLCO) and coefficient (KCO) of the lungs for carbon monoxide. DCE-MRI parametric maps were generated including the full width at half maximum (FWHM) of the bolus transit time through the lungs. Key metrics used were mean (FWHMmean) and heterogeneity (FWHMIQR). Nineteen participants returned at 6 months for repeat assessment.ResultsSpearman correlation coefficients were identified between TLCO and FWHMIQR (r=−0.46; p=0.026), KCO and FWHMmean (r=−0.42; p=0.047) and KCO and FWHMIQR (r=−0.51; p=0.013) at baseline. No statistically significant correlations were seen between FVC and DCE-MRI metrics. Follow-up at 6 months demonstrated statistically significant decline in FVC (p=0.040) and KCO (p=0.014), with an increase in FWHMmean (p=0.040), but no significant changes in TLCO (p=0.090) nor FWHMIQR (p=0.821).ConclusionsDCE-MRI first pass perfusion demonstrates correlations with existing physiological gas exchange metrics, suggesting that capillary perfusion deficit (as well as impaired interstitial diffusion) may contribute to gas exchange limitation in IPF. FWHMmean showed a significant increase over a 6-month period and has potential as a quantitative biomarker of pulmonary vascular disease progression in IPF.