Upper esophageal sphincter abnormalities on high-resolution esophageal manometry and treatment response of type Ⅱ achalasia

BACKGROUND Little is known about the clinical significance of upper esophageal sphincter(UES)motility disorders and their association with the treatment response of typeⅡachalasia.None of the three versions of the Chicago Classification of Esophageal Motility Disorders has defined UES abnormality metrics or their function.UES abnormalities exist in some patients and indicate a clinically significant problem in patients with achalasia.AIM To demonstrate the manometric differentiation on high-resolution esophageal manometry between subjects with abnormal UES and normal UES,and the association between UES type and the treatment response of typeⅡachalasia.METHODS In total,498 consecutive patients referred for high-resolution esophageal manometry were analyzed retrospectively.The patients were divided into two groups,those with normal and abnormal UES function.UES parameters were analyzed after determining lower esophageal sphincter(LES)function.Patients with typeⅡachalasia underwent pneumatic dilation for treatment.Using mixed model analyses,correlations between abnormal UES and treatment response were calculated among subjects with typeⅡachalasia.RESULTS Of the 498 consecutive patients,246(49.40%)were found to have UES abnormalities.Impaired relaxation alone was the most common UES abnormality(52.85%,n=130).The incidence rate of typeⅡachalasia was significantly higher in subjects with abnormal UES than those with normal UES(9.77%vs 2.58%,P=0.01).After pneumatic dilation,LES resting pressure,LES integrated relaxation pressure,and UES residual pressure were significantly decreased(41.91±9.20 vs 26.18±13.08,38.94±10.28 vs 16.71±5.65,and 11.18±7.93 vs 5.35±4.77,respectively,P<0.05).According to the Eckardt score,subjects with typeⅡachalasia and abnormal UES presented a significantly poorer treatment response than those with normal UES(83.33%vs 0.00%,P<0.05).CONCLUSION Impaired relaxation alone is the most common UES abnormality.The incidence of typeⅡachalasia is associated with abnormal UES.TypeⅡachalasia with abnormal UES has a poorer treatment response,which is a potentially prognostic indicator of treatment for this disease.

Factors influencing lower esophageal sphincter relaxation after deglutition

AIM:To study the relationship between upper esophageal sphincter (UES) relaxation,peristaltic pressure and lower esophageal sphincter (LES) relaxation following deglutition in non-dysphagic subjects.METHODS:Ten non-dysphagic adult subjects had a high-resolution manometry probe passed transnasally and positioned to cover the UES,the esophageal body and the LES.Ten water swallows in each subject were analyzed for time lag between UES relaxation and LES relaxation,LES pressure at time of UES relaxation,duration of LES relaxation,the distance between the transition level (TL) and the LES,time in seconds that the peristaltic wave was before (negative value) or after the TL when the LES became relaxed,and the maximal peristaltic pressure in the body of the esophagus.RESULTS:Relaxation of the LES occurred on average 3.5 s after the bolus had passed the UES and in most cases when the peristaltic wave front had reached the TL.The LES remained relaxed until the peristaltic wave faded away above the LES.CONCLUSION:LES relaxation seemed to be caused by the peristaltic wave pushing the bolus from behind against the LES gate.

Botulinum Toxin A in the Treatment of Oropharyngeal or Esophageal Dysphagia

Objectives: In this retrospective analysis, we explored the effect of botulinum toxin A (BTA) injection to treat oropharyngeal dysphagia or esophageal dysfunction caused by diseases of the upper (UES) and lower (LES) esophageal sphincter. Methods: In total, 48 patients (17 patients with UES disorders, and 31 patients with LES dysfunction;mean age 64 years) were treated between 1996 and 2007 in our hospital. Comorbid diseases as well as maintenance medication were documented to evaluate the overall health status of our patients. The mean duration of symptoms, the number of pre-treatments and the specification of dysphagia were considered. Results: One month after injection, the response rates were 73.3% (UES group) and 76.6% (LES group). Most patients in the UES group received 30-40 units BTA (Botox?) whereas most patients in the LES group were treated with 100 units BTA. In cases of re-injection, 50% of patients in the UES group experienced an escalation of dosage (up to 75 units), whereas the other 50% received the same dosage. The dosages in the LES group were mostly kept constant. Conclusion: Comparing the two groups with esophageal dysfunction of fundamentally different etiologies (UES/LES), a discrepancy in the level of symptom relief, onset and a longer cessation of clinical benefit were observed in the LES group. In this analysis, we were able to show that injection of BTA is an effective and safe treatment for disorders of the UES and LES.

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.