Ineffective esophageal motility is associated with acute rejection after lung transplantation independent of gastroesophageal reflux

BACKGROUND Gastroesophageal reflux is associated with poorer outcomes after lung transplant,likely through recurrent aspiration and allograft injury.Although prior studies have demonstrated a relationship between impedance-pH results and transplant outcomes,the role of esophageal manometry in the assessment of lung transplant patients remains debated,and the impact of esophageal dysmotility on transplant outcomes is unclear.Of particular interest is ineffective esophageal motility(IEM)and its associated impact on esophageal clearance.AIM To assess the relationship between pre-transplant IEM diagnosis and acute rejection after lung transplantation.METHODS This was a retrospective cohort study of lung transplant recipients at a tertiary care center between 2007 and 2018.Patients with pre-transplant anti-reflux surgery were excluded.Manometric and reflux diagnoses were recorded from pre-transplant esophageal function testing.Time-to-event analysis using Cox proportional hazards model was applied to evaluate outcome of first episode of acute cellular rejection,defined histologically per International Society of Heart and Lung Transplantation guidelines.Subjects not meeting this endpoint were censored at time of post-transplant anti-reflux surgery,last clinic visit,or death.Fisher’s exact test for binary variables and student’s t-test for continuous variables were performed to assess for differences between groups.RESULTS Of 184 subjects(54%men,mean age:58,follow-up:443 person-years)met criteria for inclusion.Interstitial pulmonary fibrosis represented the predominant pulmonary diagnosis(41%).During the follow-up period,60 subjects(33.5%)developed acute rejection.The all-cause mortality was 16.3%.Time-to-event univariate analyses demonstrated significant association between IEM and acute rejection[hazard ratio(HR):1.984,95%CI:1.03-3.30,P=0.04],confirmed on Kaplan-Meier curve.On multivariable analysis,IEM remained independently associated with acute rejection,even after controlling for potential confounders such as the presence of acid and nonacid reflux(HR:2.20,95%CI:1.18-4.11,P=0.01).Nonacid reflux was also independently associated with acute rejection on both univariate(HR:2.16,95%CI:1.26-3.72,P=0.005)and multivariable analyses(HR:2.10,95%CI:1.21-3.64,P=0.009),adjusting for the presence of IEM.CONCLUSION Pre-transplant IEM was associated with acute rejection after transplantation,even after controlling for acid and nonacid reflux.Esophageal motility testing may be considered in lung transplant to predict outcomes.

Exercise-provoked esophageal motility disorder in patients with recurrent chest pain

AIM:To investigate the relationship between exerciseprovoked esophageal motility disorders and the prognosis for patients with chest pain.METHODS:The study involved 63 subjects with recurrent angina-like chest pain non-responsive to empirical therapy with proton pump inhibitor(PPI).In all,a coronary artery angiography,panendoscopy,24-h esophageal pH-metry and manometry,as well as a treadmill stress test with simultaneous esophageal pH-metry and manometry monitoring,were performed.Thirtyfive subjects had no significant coronary artery lesions,and 28 had more than 50% coronary artery narrowing.In patients with hypertensive esophageal motility disorders,a calcium antagonist was recommended.The average follow-up period was 977 ± 249 d.RESULTS:The prevalence of esophageal disorders,such as gastroesophageal reflux or diffuse esophageal spasm,was similar in patients both with and without significant coronary artery narrowing.Exercise prompted esophageal motility disorders,such as a decrease in the percentage of peristaltic and effective contractions and their amplitude,as well as an increase in the percentage of simultaneous and non-effective contractions.In 14(22%) patients the percentage of simultaneous contractions during the treadmill stress test exceeded the value of 55%.Using Kaplan-Meier analysis and the proportional hazard Cox regression model,it was shown that the administration of a calcium channel antagonist in patients with such an esophageal motility disorder significantly decreased the risk of hospitalization as a result of a suspicion of acute coronary syndrome after the 2.7-year follow-up period.CONCLUSION:In patients with chest pain non-responsive to PPIs,a diagnosis of exercise-provoked esophageal spasm may have the effect of lowering the risk of the next hospitalization.

Correlation of acid reflux and esophageal motility in patients with gastroesophageal reflux disease

Objective:To explore the relationship between acid reflux and esophageal motility in patients with gastroesophageal reflux disease.Methods:From January 2018 to December 2019,80 patients with typical gastroesophageal reflux symptoms such as reflux and heartburn were randomly selected from the Department of Gastroenterology,First Affiliated Hospital of guangxi university of chinese medicine.The patients were divided into pathological group,sensitive group and physiological group based on the percentage of acid exposure time and reflux-symptom correlation.The GerdQ score,quality of life score,esophageal acid test and esophageal manometry related parameters of the three groups of patients were compared.Results:Compared with the sensitive group and the physiological group,the GerdQ score,DeMeester score,orthostatic acid reflux time,orthostatic acid reflux time,longest acid reflux time and acid reflux times in the pathological group were significantly higher.Sf-36 score,lower esophageal sphincter pressure and effective rate of deglutition were all significantly reduced,with statistically significant differences(P<0.05).Compared with the physiological group,the GerdQ score of the sensitive group was higher.The sf-36 score was low,and the differences were statistically significant(P<0.05).The acid indexes in the sensitive group were higher than those in the physiological group,but the differences were not statistically significant(P>0.05).Compared with the physiological group,the distal contraction integral and the amplitude of the lower esophageal sphincter 3cm above the pathological group and the sensitive group decreased significantly(P<0.05).There were no statistically significant differences in the length of the lower esophageal sphincter,the length of the lower esophageal sphincter in the abdominal segment,the amplitude of the upper esophageal sphincter at 7cm and 11cm and the peristaltic wave velocity of the esophageal body in the three groups(P>0.05).Conclusion:the decrease of lower esophageal sphincter pressure is the key factor leading to pathological acid reflux,and acid reflux is closely related to distal contraction integral and peristaltic amplitude of 3cm on lower esophageal sphincter in patients with gastroesophageal reflux disease.

Water-jet vs traditional triangular tip knife in peroral endoscopic myotomy for esophageal dysmotility:A systemic review and metaanalysis

BACKGROUND Peroral endoscopic myotomy is an increasingly used less invasive modality to treat esophageal dysmotility.Recently,triangular tip knife with integrated water jet function has been introduced to mitigate multiple instrument exchanges.AIM To compare traditional triangular tip knife and water jet knife in terms of procedural success,duration,instrument exchanges,coagulation forceps use,and adverse events.METHODS We conducted a systemic review and meta-analysis with two authors independently in electronic databases(PubMed,Embase,and Cochrane Library)from inception through May 2021.In addition,we conducted a relevant search by Reference Citation Analysis(RCA)(https://www.referencecitationanalysis.com).A fixed-effects model was used to calculate weighted mean,odds ratio(OR),and confidence intervals(CI).RESULTS We included 7 studies involving 558 patients.Triangular knife and water jet knife were similar in odds of procedural success with ratio of 4.78(95%CI=0.22-102.47)and odds of clinical success with ratio of 0.93(95%CI=0.29-2.97),respectively.Water jet knife had fewer instrument exchanges compared to triangular knife(2.21,95%CI=1.98-2.45 vs 11.9,95%CI=11.15-12.70)and usage of coagulation forceps(1.75,95%CI=1.52-1.97 vs 2.63,95%CI=2.37-2.89).Adverse events were higher in triangular knife group(OR:2.30,95%CI=1.35-3.95).CONCLUSION Peroral endoscopic myotomy using water jet knife is comparable in terms of pro cedural success to triangular tip knife.Water jet knife also required shorter procedural duration,less instrument exchanges,coagulation devices,and overall adverse events.

Comparison of clinical features and high-resolution esophageal motility characteristics between esophagogastric junction outflow obstruction and type Ⅱ achalasia patients

Objective To compare the clinical features and high-resolution esophageal motility-impedance characteristics among esophagogastric junction outflow obstruction(Eoo)patients,typeⅡachalasia(Ach)patients and healthy controls(Con),in order to explore the values of esophageal high-resolution manometry(HRM)in diagnosis and treatment of Eoo patients.Methods Patients

Effect of Yunqi Decoction (匀气汤 ) on Esophageal Mucosal Morphology and Esophapeal Motility in Reflux Esophagitis Patients

Objective: To observe the effects of Yunqi decoction (匀气汤, YQD) on both esophageal mucosal morphology and esophageal motility in patients with reflux esophagitis (RE). Methods: According to syndrome differentiation of traditional Chinese medicine (TCM), 42 RE patients were divided into three groups fdisharmony of Liver and Stomach (group D), Deficiency-Cold of Spleen and Stomach (Group DC), Heat Syndrome caused by stagnation of Liver Qi (Group H). No. Ⅰ, Ⅱ, Ⅲ of YQD were taken respectively for 4 weeks.Before and after treatment scores of typical symptoms were collected, gastroscopy was performed and esophagealmotility were measured. Results: (1 ) The symptom remission rate was 81. 1 %, there were significant differences between the group DC with group D and group H (P< 0. 01 ). (2) The esophageal mucosal healing ratewas 61. 9 %, the effective rate was 90. 5 %, and the ineffective rate was 9. 5 %. There were not significant differences of effective rate among the three groups (P > 0. 05). (3) The changes of esophageal motility: Loweresophageal sphincter pressure (LESP) and average peristaltic pressure (APP) of group D were obviously higherthan before treatment (P < 0. 05), LESP, gastro--esophageal barrier pressure (GEBP) and peristaltic conductspeed (PCS) of group DC were remarkably higher (P < 0. 05). GEBP of group H was improved (P < 0. 05 ).Conclusions: YQD has a good therapeutic effect. It's not only resolving reflux esophageal symptoms, healingesophageal mucosa, but also improving esophageal motile function.

Dysphagia,reflux and related sequelae due to altered physiology in scleroderma

Systemic sclerosis is a connective tissue disease that presents with significant gastrointestinal involvement,commonly in the esophagus.Dysphagia is a common clinical manifestation of systemic sclerosis and is strongly related to esophageal dysmotility.However,there are multiple other contributing factors in each step in the physiology of swallowing that may contribute to development of severe dysphagia.The oral phase of swallowing may be disrupted by poor mastication due to microstomia and poor dentition,as well as by xerostomia.In the pharyngeal phase of swallowing,pharyngeal muscle weakness due to concurrent myositis or cricopharyngeal muscle tightening due to acid reflux can cause disturbance.The esophageal phase of swallowing is most commonly disturbed by decreased peristalsis and esophageal dysmotility.However,it can also be affected by obstruction from chronic reflux changes,pill-induced esophagitis,or Candida esophagitis.Other contributing factors to dysphagia include difficulties in food preparation and gastroparesis.Understanding the anatomy and physiology of swallowing and evaluating systemic sclerosis patients presenting with dysphagia for disturbances in each step can allow for development of better treatment plans to improve dysphagia and overall quality of life.

Changes in the esophagogastric junction outflow obstruction manometric feature based on the Chicago Classification updates

BACKGROUND The critical diagnostic criteria for esophagogastric junction outflow obstruction(EGJOO)were published in the latest Chicago Classification version 4.0(CCv4.0).In addition to the previous criterion[elevated integrated relaxation pressure(IRP)in supine position],manometric diagnosis of EGJOO requires meeting the criteria of elevated median-IRP during upright wet swallows and elevated intrabolus pressure.However,with the diagnostic criteria modification,the change in manometric features of EGJOO remained unclear.AIM To evaluate the esophageal motility characteristics of patients with EGJOO and select valuable parameters for confirming the diagnosis of EGJOO.METHODS We performed a retrospective analysis of 370 patients who underwent highresolution manometry with 5 mL water swallows×10 in supine,×5 in upright position and the rapid drink challenge(RDC)with 200 mL water from November 2016 to November 2021 at Peking University First Hospital.Fifty-one patients with elevated integrated supine IRP and evidence of peristalsis were enrolled,with 24 patients meeting the updated manometric EGJOO diagnosis(CCv4.0)as the EGJOO group and 27 patients not meeting the updated EGJOO criteria as the isolated supine IRP elevated group(either normal median IRP in upright position or less than 20%of supine swallows with elevated IBP).Forty-six patients with normal manometric features were collected as the normal high-resolution manometry(HRM)group.Upper esophageal sphincter(UES),esophageal body,and lower esophageal sphincter(LES)parameters were compared between groups.RESULTS Compared with the normal HRM group,patients with EGJOO(CCv4.0)had significantly lower proximal esophageal contractile integral(PECI)and proximal esophageal length(PEL),with elevated IRP on RDC(P<0.05 for each comparison),while isolated supine IRP elevated patients had no such feature.Patients with EGJOO also had more significant abnormalities in the esophagogastric junction than isolated supine IRP elevated patients,including higher LES resting pressure(LESP),intrabolus pressure,median supine IRP,median upright IRP,and IRP on RDC(P<0.05 for each comparison).Patients with dysphagia had significantly lower PECI and PEL than patients without dysphagia among the fifty-one with elevated supine IRP.Further multivariate analysis revealed that PEL,LESP,and IRP on RDC are factors associated with EGJOO.The receiver-operating characteristic analysis showed UES nadir pressure,PEL,PECI,LESP,and IRP on RDC are parameters supportive for confirming the diagnosis of EGJOO.CONCLUSION Based on CCv4.0,patients with EGJOO have more severe esophagogastric junction dysfunction and are implicated in the proximal esophagus.Additionally,several parameters are supportive for confirming the diagnosis of EGJOO.