Introduction

Peristaltic reserve is the normal augmentation of peristaltic contraction amplitude at the end of a series of multiple-rapid swallows (MRS). Normal peristaltic reserve in patients with ineffective esophageal motility (IEM) has been reported to a predictor of good outcome after fundoplication. Conversely, absent peristaltic reserve following MRS is associated with poor esophageal clearance.

Aims & Methods

Aim: Evaluate esophageal acid exposure and mean nocturnal baseline impedance (MNBI) in patients with IEM and patients with normal motility with and without peristaltic reserve.
Methods: Patients undergoing high-resolution esophageal manometry (HRM) and 24-h impedance-pH monitoring (24h-Imp-pH) were classified as having IEM or normal esophageal manometry according to Chicago 4.0 criteria. Peristaltic reserve was declared present (PR+) if distal contraction integral (DCI) following a series of 4x5ml rapid swallows >25% greater than the average DCI following 10 single 5ml swallows. We compared esophageal acid exposure (% time pH<4), number of reflux episodes and MNBI in patients with IEM/normal motility with (PR+) and without (PR-) peristaltic reserve.

Results

Between February 2020 and December 2022 we identified 220 patients (132;60% females, avg (±SD) age 54 (±15) years with IEM (49;22%) and normal motility (171;78%). Esophageal acid exposure, number of reflux episodes and MNBI are summarized below:

Conclusion

Absent peristaltic reserve combined with ineffective esophageal motility is associated with higher esophageal acid exposure and lower mean nocturnal baseline impedance suggesting that patients with IEM and absent peristaltic reserve have a more severe form of GERD compared to patients with normal motility with normal peristaltic reserve.

Disclosure

RT - speakers bureau and educational programs of Laborie Inc.

Introduction

Patients with typical Gastroesophageal reflux disease (GERD) symptoms frequently report Dysphagia. During HRM study patients with GERD show in an increased rate ineffective or absent esophageal motility and Low Esophageal Sphincter (LES) pressure though no data exist about disturbances of Distal latency (DL).

Aims & Methods

As typically patients with spastic disorders of the esophagus present with dysphagia and show decreased DL we aimed to investigate if there is a correlation between GERD, dysphagia and DL disturbances. We included 2629 patients with typical long-lasting symptoms, submitted to High Resolution Manometry and 24 hrs pH-Impedance study (pH-IM), off-PPI. Patients with a positive endoscopic GERD diagnosis undergoing pre-operativel HRM/pH-impedance, with a previous definite GERD diagnosis studied “on” PPI, using of opioids, history of esophageal surgery or diagnosed with major motility disorders except absent peristalsis (Chicago IV classification) were excluded. GERD diagnosis was made by using Lyon consensus criteria for pH-IM; Acid Exposure time (AET)> 6%.

Results

GERD was diagnosed in 845 (32.1%) pts while indefinite AET for GERD (4-6%) was found in 300 (11.4%). Any grade of dysphagia was reported by 934 (35.5%) pts. Patients with dysphagia had decrease DL (6.2±1.7 vs 6.5±2.7 in patients not reporting dysphagia, p=0.008) Patients with GERD showed decreased DL in comparison to patients without (6.1±1.8 vs 6.6±2.7, p<0.001). GERD diagnosis was not correlated to report of dysphagia (300/845 35.5% vs 536/1484, 36.1% in pts without GERD, p=0.788) and no difference in mean DL was observed in patients with GERD and or without dysphagia (6.2±1.8 vs 6.1±1.9, p=0.772). GERD was also correlated to Esophagogastric Junction (EGJ) type 2 or 3 anatomy (358/845, 42.4% vs 361/1484, 24.3%, p<0.001), diagnosis of ineffective esophageal motility/absent peristalsis (375/845, 44.7% vs 530/1484, 35.7%, p<0.001) and LES hypotension (449/845, 53.1% vs 665/1484, 44.8%, p<0.001). The correlation of DL to GERD was maintained in the multivariate logistic regression analysis (p=0.002, OR: 0.907, 95% C.I 0.853-0.964) fact also observed for type 2/3 EGJ (p<0.001, OR:2.255) and diagnosis of ineffective motility/absent peristalsis (p=0.001, OR: 1.468).

Conclusion

Patients reporting typical reflux symptoms and dysphagia show decreased DL even when a diagnosis of diffuse Esophageal Spasm is not met. Patients with GERD diagnosis by pH-impedance and typical reflux symptoms show decreased DL in comparison to patients without GERD. Though lower DL observed among patients with GERD was not correlated to dysphagia.

Introduction

Eosinophilic esophagitis (EoE) and gastroesophageal reflux disease (GERD) may coexist. The role of GERD in histologically PPI (proton pump inhibitors)-refractory (PPI-R) EoE has been poorly investigated.

Aims & Methods

We characterized ambulatory reflux monitoring findings and heartburn outcomes in PPI-R EoE patients undergoing 96-h wireless pH monitoring (WPM) or 24-h pH-impedance (MII-pH). In this international study conducted in two EoE referral centres, we enrolled consecutive patients with EoE who did not achieve histological remission with PPIs (≥15 eosinophils/high-power field) and subsequently underwent off-PPIs reflux monitoring. Demographics, symptoms, medical history, endoscopy findings at index endoscopy, and heartburn resolution following a 12-week course of PPI were retrospectively reviewed. Acid exposure time (AET), number of refluxes, and symptoms index and association probability (SI/SAP) were calculated for MII-pH and WPM. Mean nocturnal baseline impedance and post-reflux swallowed induced peristaltic wave index were also calculated for MII-pH. Validated diagnostic thresholds for reflux monitoring and Rome IV criteria were used to formulate each diagnosis. Data are described as median and interquartile range (Q1-Q3) or as counts and percent. Kruskal-Wallis Rank Sum Test was used for continuous data, and Pearson’s Chi-Square test and Fisher’s exact test for counts. Significance threshold was p<0.05.

Results

Among 73 included patients, 54.8% (n=40) had MII-pH, and 45.2% (n=33) had WPM. The prevalence of conclusive GERD was 34.2% (25/73). Among those with normal AET (65.7%, 48/73), 20.8% had positive SI/SAP, while 79.2% had negative SI/SAP. Conclusive GERD was more frequent on WPM (48.5% vs 22.5%, p=0.02), while absence of GERD was more frequent on MII-pH (77.5% vs 51.5%, p=0.02). There was no difference in the prevalence of SI/SAP positivity between MII-pH and WPM. Heartburn was reported in 76.0% of GERD patients and in 66.6% of those without GERD (p=0.41). Patients with GERD and those without GERD received similar doses of PPIs. Among the 28 patients who were assessed for heartburn resolution, those with normal AET combined with SI/SAP positivity had similar response to PPIs compared to those with GERD (60.0% vs 61.1%; p>0.99).

Conclusion

1. Among PPI-R EoE, only one third has GERD, suggesting that an abnormal AET has a limited role in PPI refractoriness. 2. Heartburn response to PPIs does not predict conclusive GERD in patients with EoE. 3. Although per Rome IV criteria EoE should be ruled out to diagnose reflux hypersensitivity, a proportion of EoE patients with a normal AET has positive symptom-reflux correlation suggesting a possible overlap. In this setting, PPIs provided heartburn resolution in most patients regardless of histologically active EoE.

Introduction

Esophageal mucosal admittance (MA) is a promising diagnostic method for gastroesophageal reflux disease (GERD), however, only some studies were done and mainly in Japan.

Aims & Methods

We conducted a study to describe the esophageal MA in patients with reflux symptoms and determine its diagnostic accuracy. We recruited 92 patients with ambulatory pH-impedance monitoring, upper gastrointestinal endoscopy, and MA measured by the tissue conductance meter. MA was measured during endoscopy at 5cm (distal esophagus) and 15cm above the Z line (middle esophagus), repeated at least five times at each position, and median MA was obtained. Afterwards, two biopsies were taken 5cm above the Z line for histopathological evaluation using the Esohisto criteria. Patients were classified as GERD or non-GERD according to the 2018 Lyon consensus.

Results

The mean age was 43.2 years, and 42 patients were males. The most common symptoms were regurgitation (75.0%), belching (65.2%), and heartburn (46.7%). Twenty-three (32.3%) were diagnosed with GERD using the Lyon consensus, and 24 (26.1%) had esophagitis on histopathology. The median MA at the distal and middle esophagus was moderately correlated. The median MA at both positions was higher in the GERD group but only statistically significant in the middle esophagus. MA was not associated with pH-impedance parameters and esophagitis on histopathology. The diagnostic model developed using the logistic regression did not have good accuracy.

Conclusion

MA was not different between GERD and non-GERD patients. The diagnostic model integrating MA did not have high accuracy in diagnosing GERD.

Introduction

Supragastric belching disorder (SBD) is characterized by unconscious air swallowing and its immediate expulsion from the esophagus. Diagnosis is usually made by history and physical examination though supplementary evaluations can be considered. High-resolution esophageal manometry combined with stationary impedance (HRIM) allows confirmation of SBD diagnosis in patients with esophageal symptoms. Better understanding of this condition is needed to increase recognition and guide treatment.
With the aim of characterizing the population diagnosed with SBD using HRIM and its association with other esophageal motility disorders (EMDs) or gastroesophageal reflux disease (GERD), we conducted a descriptive study.

Aims & Methods

We identified patients with SBD diagnosis who underwent HRIM using MMS-Unisensor® solid-state probe with 36 channels coupled with 16 channels of impedance in a tertiary hospital from January 2020 to December 2024. HRIM studies were interpreted according to Chicago classification v3.0 and v4.0. Demographic and clinical characteristics were collected. Data from pH-metry and/or pH-Impedance (pH-IMM) tests were also gathered to assess presence of pathological acid gastroesophageal reflux (GER).

Results

39 patients were included (64% women) with a mean age of 52.7 years. Demographic and clinical characteristics are summarized in Table 1. Some patients developed SBD after esophagogastric surgery (10.4%). One-third of patients had some EMD: ineffective esophageal motility (27%) and esophageal absent contractility (5.4%). 12.9% of patients associated rumination disorder (RD). 25% patients had pathological acid GER in pH-metry and/or pH-IMM. A significant association was observed between the presence of pathological acid GER and symptoms of regurgitation (p=0.02) and vomiting (p=0.05), and between pathological acid GER and EMD finding in HRIM (p=0.05). 94.1% patients had consumed proton pump inhibitors (PPIs) in the previous 6 months, but only 50% showed symptomatic improvement with PPIs therapy. Symptoms improved in 91% of follow-up patients with diaphragmatic breathing exercises and patient education about the pathophysiology of the disorder to motivate active patient participation in their treatment. On average, patients experienced a diagnostic delay of 38.2 months (IQR: 24–54).

Table 1. Demographic and clinical variables from the SGB patients sample

Conclusion

SBD is more common in middle-aged women as other functional gastrointestinal disorders. Association of SBD with RD is notable. Both SBD and RD could be misdiagnosed as PPI-refractory GERD. It is important to study the presence of GERD in order to optimize PPI treatment: in our study, only one quarter of the patients exhibited esophageal acid burden. Most patients improved with non-pharmacological treatment. SBD may be effectively treated with diaphragmatic breathing exercises and training patients for awareness of belching episodes. Diagnostic delay may be due to lack of awareness and limited access to diagnostic tests. Promoting knowledge about pathophysiology, symptoms and complementary tests would reduce diagnostic time and would improve the management of this rare disorder.

References

1. Sergeev I, Velosa M, Mardare R, Yazaki E, Sifrim D. The influence of supragastric belching severity on esophageal acid exposure and motility. Neurogastroenterol Motil. 2023 Apr;35(4):e14520.

2. Davidson K, Sibley H, O'Rourke AK. Supragastric belching and rumination syndrome: diagnosis and management. Curr Opin Otolaryngol Head Neck Surg. 2023;31(6):343-349.
3. Sawada A, Fujiwara Y. Belching disorders and rumination syndrome: A literature review. Digestion. 2024;105(1):18–25.

Disclosure

The authors report no conflicts of interest related to this work.