Introduction

Commonly known as the “law of the intestine,” gastrointestinal peristalsis consists of contraction in combination with preceding distention. Disturbance of this sequential peristalsis results in impaired transportation of food which would be associated with dysphagia. Recently, using Distension contraction plot (DCP), Mittal K revealed that impaired esophageal distention is indeed responsible for patients with functional dysphagia (FD) who are suffering from dysphagia despite being normal high-resolution manometry (HRM). In contrast, we have developed Onigiri (Japanese rice ball) esophagography (OE) which enables us to screen esophageal motility disorders by the value of obstruction level (OL 0-4; OL0, no obstruction and OL4; the most severe obstruction). In OE of normal subjects, the swallowed onigiri is transported to the stomach forming an American football shape. We found that some patients with FD present OL1-2 out of an American football shape. The objective of this study was to determine whether OE is useful for evaluate esophageal distention.

Aims & Methods

From June 2021 to April 2023, both HRM with DCP and OE were performed on 60 patients of dysphagia. 11 FD (male/female;2/9, median age;63 y.o.) who had a normal HRM but OL1-2 in OE (OL 1/2; 4/7), and 15 volunteer normal subjects (male/female; 9/6, median age; 27 y.o.) with normal HRM and OL0 were also enrolled. AUC Distension (AUCD) and Peak distension (PD) were assessed for distention capacity. In DCP, the esophageal body is divided into 4 segments (seg 1 to 4). In this study, we evaluated the seg 3 and 4, corresponding to the esophageal smooth muscle region.

Results

In seg 4, AUCD of 11 FD (OL1-2) (8176±1536mm²) was significantly lower than that of normal (11067±2703mm²), (p = 0.0022), and PD of 11 FD (OL1-2) (161±17mm²) was significantly lower than that of normal (184±19mm², p=0.005). Furthermore, focusing on FD with OL2, AUCD of the 7 FD (OL2) (6599±487mm²) was significantly lower than that of normal (8019±2145mm²) in seg 3 (p=0.047).

Conclusion

Impaired esophageal distention is responsible for the patients with FD who has normal HRM. OE is useful for screening impaired esophageal distention.

References

Introduction

Esophageal Achalasia (EA) is a rare esophageal motility disorder, characterized by impaired peristalsis and incomplete relaxation of the Lower Esophageal Sphincter (LES) in response to swallowing​​​​​. Key symptoms of the disease include dysphagia, food regurgitation, and retrosternal pain, significantly impacting the quality of life (QoL) and often leading patients to restrict their food intake. Consequently, EA patients often adopt self-managed dietary practices that may result in nutritional imbalances and deficiencies, given the lack of specific dietary guidelines.

Aims & Methods

This retrospective study aimed to describe and evaluate the dietary patterns, eating habits, and nutritional status of achalasic patients. Additionally, the secondary aim was to explore potential associations between food rheology and symptomatology. Patients with a manometric diagnosis of EA were recruited from our outpatient gastrointestinal pathophysiology center. Disease severity was assessed with Eckardt Symptoms Score (ESS), symptoms were evaluated with Modular Questionnaire Roma IV and QoL with the MD Anderson Dysphagia Inventory (MDADI). The MDADI outcomes were stratified into severe, moderate, mild and not perceived disability. Patients also filled out a food diary for 15 days, recording ingested food for each meal and symptoms onset. Estimated caloric intake and macronutrient composition were compared to those recommended by the Italian Society of Human Nutrition (SINU).

Results

Forty-three achalasic patients were included (M 24, F 19, mean age 56.7 +- 15.8 yrs). The median BMI was 23.7 (18.8-32.2), 34 patients (79%) had an active disease (ESS ≥ 3). Most patients reported mild to moderate disability (respectively 42% and 35%), while 21% reported severe disability and 2% perceived no disability. Disease activity, measured by ESS, strongly correlated with perceived disability (r= 0.59; p <0.0001), while no significant correlation was found between ESS and BMI. The diary analysis showed a mean caloric intake of 1572±373 kcal versus the estimated needs of 2293,71±374 kcal based on anthropometric parameters and physical activity, resulting in a mean caloric deficit of 720 ± 416 kcal (p<0.0001). Macronutrient analysis also reported an unbalanced distribution: carbohydrates 43.3%±7.3 vs recommended 55-59%, protein 18.2%±4.5 vs 15-18%, total fat 37.6%±7.7 vs 26–27% and fibre 14g±5.2 vs 25-30g. Solid food caused significantly more symptoms than semiliquid and liquid ones: dysphagia (35.5% vs 3.5% vs 5.7%, p<0.0001), chest pain (10% vs 12.1% vs 0.2%, p<0.0001), regurgitation (8.9% vs 1.4% vs 1.9%, p=0.001), cough (5% vs 0.2% vs 0.6%, p=0.0002). Bread, pasta, and pizza (50-60%), fresh fruit (44%), lean meat (39.5%), crackers, snacks, and vegetables (30-35%) were the most commonly reported triggers of dysphagia. Additionally, 60% of patients reported worsened symptoms with cold foods, while 53% reported improvement with hot foods.

Conclusion

This study underscores the significant impact of EA on QoL, influenced by disease activity. Achalasic patients tend to modify their diets to minimize symptoms, favoring easily swallowable soft and fatty foods while reducing intake of solid foods rich in carbohydrates and fiber. Thus, comprehensive nutritional assessment is strongly recommended for EA patients to mitigate dietary imbalances and manage possible deficiencies promptly.

Clinical Case Summary

We report the case of a 50-year-old woman with a history of arterial hypertension who consulted for progressive dysphagia to solids since seven months, tolerating only liquids in the last week. In addition, retrosternal knotting sensation, regurgitations, weight loss and a painful whitish plaque on the oral mucosa. Hospital admission was decided to complete study and to ensure the nutritional status.
Gastroscopy was performed, observing a punctiform stenosis of the esophageal lumen at 18 cm of the dental arch, which did not allow the passage of the endoscope. We observed erythematous mucosa and fibrinous exudate covering almost all of it (Figure 1), biopsies were taken.
Barium esophagogram showed two strictures, a short one at the proximal esophagus level and a second one of approximately 7 cm in distal third (Figure 2). Biopsies were negative for microbiology, histological study showed Civatte bodies, compatible with erosive lichen planus.
Endoscopic dilatation of stenoses was considered but this entailed a high risk of complications. Finally, it was decided jointly with Dermatology and Systemic Diseases Department to start systemic corticosteroids and oral acitretin. In the following days, patient showed clinical improvement with adecuate tolerance to a liquid-shredded diet. Nowadays, the patient takes methotrexate and oral acitretin, improving findings in gastroscopy and tolerance to diet.
Lichen planus is a common cutaneous-mucosal disease, where symptomatic esophageal involvement is exceptional. The diagnosis is established by histological study, highlighting the degeneration of the keratinocytes of the basal layer of the epithelium "Civatte bodies". Therapeutic options are varied, the first line being the use of systemic corticosteroids, with patients presenting a rapid response but high percentage of relapses. In addition, immunosuppressants can be used, although all of them have low long-term response rate. JAK-kinase inhibitors are being studied.

References

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) guideline-Uptodate 2021.
Malagelada JR, Bazzoli F, Boeckxstaens G, et al. Directrices globales de la organización mundial de gastroenterología: disfagia: actualización de las pautas globales y cascadas de septiembre de 2014. J Clin Gastroenterol 2015; 49:370.
Le Cleach L, Chosidow O. Práctica clínica. Liquen plano. N Engl J Med 2012; 366:723.

Introduction

Dysphagia is a very common symptom and entities such as Eosinophilc Esophagitis (EoE) or an esophageal motility disorder can be its basis. A controversy among guidelines when approaching a patient with dysphagia exists, as it is mandated to obtain esophageal sampling when EoE is sought but is not a prerequisite for motility disorders diagnosis. Therefore, the necessity of esophageal sampling is based on endoscopists’ assessment.

Aims & Methods

Aim of our study was to search for factors driving clinicians to obtain esophageal biopsies among patients with dysphagia. Secondary aim was to search for the incidence of EoE and factors correlated with EoE diagnosis among patients with dysphagia.
We included consecutive patients presented with dysphagia during a 6-year period (1/2018-12/2023). We excluded patients with a history of; esophageal stenosis, esophageal motility disorders, metastatic disease, EoE, esophageal/gastric cancer, carcinoma that could impair esophageal motility, bone/food impaction, caustic agent ingestion, esophagogastric surgeries as also severely immune-compromised patients (HIV, recently transplanted). Furthermore, 58 patients were excluded as they showed endoscopic evidence of another disease that could explain patients’ symptoms. Epidemiological, endoscopy and histological data were collected and analyzed.

Results

We included 63 patients (M/F: 29 (46.0%)/34 (54.0%), mean age 64±19 yrs). A history of dysphagia > 6 months was reported by 51 (80.9%), while <6 by 11 (19.1%). During the endoscopy; 7 (11.1%) had findings supportive of EoE, and 56 (89.9 %) had normal endoscopy. Biopsies were obtained by 30/63 (47.6%). Significant higher rates of biopsy sampling were seen among patients <65 years old and with endoscopic EoE signs, while dysphagia duration and sex did not affect sampling. In the multivariate analysis only age, but not endoscopic findings compatible to EoE, drove clinician decision to obtain biopsies. (Table) We were able to retrieve the histology report of 29/30 patients. EoE was diagnosed in 4/29 (13.8%). All patients with EoE were male (4/14, 28.6% vs female 0/15, 0% p=0.042). Existence of compatible endoscopic signs (3/6, 50% vs normal endoscopy 1/23, 4.3% p=0.020) was correlated with EoE diagnosis but age (<65 years old 4/22, 18.7% vs <65 year old 0/7, 0% p=0.307) and longstanding dysphagia (4/25, 16% vs female 0/4, 0% p=0.533) were not.

Conclusion

Clinician obtain esophageal biopsies in less than 50% of patients with dysphagia. Endoscopic findings supportive of EoE and most importantly age seem to drive their decision. The rate of EoE among patients with dysphagia and esophageal sampling is not negligible and is more commonly observed in young males with longstanding dysphagia and compatible endoscopic findings.

Introduction

Esophageal dysphagia is a common complaint in daily clinical practice. After excluding structural and motility disorders, it may be related to functional disorders, which are challenging to diagnose and manage, leading to high health care utilization and both patient and physician dissatisfaction.

Aims & Methods

This is a prospective multicentric 6-months follow-up study to characterize dysphagic patients with normal esophageal motility, in terms of epidemiology and clinical aspects, focusing on patient-reported outcome measures, and evaluate their evolution at 6-months.

Results

From 2021-2024, 91 patients were recruited, 78.0% female, with a median age of 65 years [22-88]. Of these, 27.5% (n = 25) suffered from rheumatologic or endocrinologic disorders, and 56.0% were previously exposed to medical therapies.
Dysphagic symptoms had a median duration of 3 years [1-31], with a median Eckardt of 3 [0-9], PROMIS GI Disrupted Swallowing (PDS) of 60.4 [40.3-84.1], EuroQol-5D TTO of 0.592 [-0.055-1] and VAS of 70 [0-100].
Compared to non-dysphagic participants (n=123), these patients had significantly worse Eckardt, EuroQol-5D and PDS scores (p-values <0.001).
Compared to esophageal motility disorders (Chicago V4.0), the Eckardt and PDS scores in this group were significantly lower when compared to EGJ outflow disorders (p-value <0.001 and 0.003), without differences regarding EuroQol-5D.
Regarding gastroesophageal reflux, 24 (26.4%) patients had a positive GERD-Q questionnaire and 3 had an objective GERD diagnosis. Even though, compared to motility disorders, this score was significantly lower in this group when compared to EGJ outflow disorders (p-value 0.001).
Medical treatments (PPI, amitriptyline) were optimized in 6 patients (6.6%), without any differences in Eckardt or EuroQol-5D scores at 6-months. However, at 6-months, the PDS improved in untreated patients (p-value <0.001).

Conclusion

Non-obstructive dysphagia with normal esophageal motility has a negative impact on quality of life. However, symptoms tend to have a favorable course independently of treatment, therefore mandating a holistic management.

Introduction

Functional lumen imaging probe (FLIP) is an adjunctive test indicated in the evaluation of the esophagogastric junction and esophageal motility, especially in those with an inconclusive diagnosis during esophageal high-resolution manometry (HRM) such as esophagogastric junction outflow obstruction (EGJOO) or absent contractility per Chicago Classification v4.0 (CCv4.0), and in patients that are unable to perform a HRM.

Aims & Methods

Our study aimed to evaluate the efficacy of the FLIP procedure in establishing diagnosis in a cohort of patients who underwent assessment due to dysphagia, who were either diagnosed with EGJOO or absent contractility according to CCv4.0, or were unable to perform HRM.
Our study population consisted of patients who were evaluated by FLIP due to dysphagia between March 2023 and April 2024. All patients had completed an upper gastrointestinal endoscopy and HRM per CCv.4.0. Additionally, most patients underwent further evaluation with a timed barium esophagram (TBE).

Results

We included 58 patients (52% female, median age 62.5 years) in the study cohort. Most patients (67.24%) referred to the FLIP procedure had a prior failed attempt to perform a HRM or had an inadequate test. 46.5 % of all patients had an abnormal FLIP procedure. Of those, 15 patients had EGJOO with absent contractile response compatible with achalasia (55.5 %) and another 5 patients had a confirmed diagnosis of EGJOO on FLIP (18.5 %). Of those patients who had a FLIP procedure performed due to abnormal esophageal manometry findings per CCv4.0 (n=19), 8 patients were diagnosed with EGJOO (42.1%), 5 had absent contractility (26.3 %), 4 had a hypercontractile esophagus (21 %) and 2 had ineffective esophageal motility (10.5 %). 60 % of the patients diagnosed with EGJOO by FLIP were offered an achalasia-targeted treatment (pneumatic dilation (6), POEM (4), Heller myotomy (1) and Botox injection (1)), while the rest were treated conservatively. Additionally, TBE was performed in 55% of patients with an abnormal FLIP procedure and the result was pathological in about half of them. Furthermore, in 70% of patients the diagnosis of EGJOO during FLIP was correlated to a delayed esophageal clearance on TBE.

Conclusion

FLIP is a useful tool in the assessment of dysphagia in patients who have an inconclusive diagnosis per CCv4.0, either EGJOO or absent contractility, as well as in patients who are unable to perform a HRM.

Disclosure

NO CONFLICT OF INTEREST

Introduction

Functional Dyspepsia (FD), a common disorder of gut-brain interaction [1], is associated with alterations in gastric accommodation, gastric emptying, gastric sensitivity, gastroduodenal permeability, and the gut microbiome. Resilience, the ability to maintain function under personal or physical stress, may play a role in the development of FD, although no studies have evaluated this theory. We hypothesize that FD patients have lower resilience than the general population, which may lead to a new therapeutic target.

Aims & Methods

This prospective questionnaire study compared patients with FD (Rome IV criteria) with internal medicine clinic patients without dyspepsia at a tertiary referral center. Participants completed the FD symptom severity score [2], Brief Resilience Scale (BRS) [3], Connor-Davidson Resilience Scale (CDRS) [4], hospital anxiety and depression scale (HADS) [5], early childhood adverse life event questionnaire [6], and perceived stress score [7]. Questionnaires were distributed to clinic patients meeting inclusion/exclusion criteria.

Results

38 FD (mean age 43 years old, 87% female) and 31 control (mean age 57 years old, 39% female) patients completed the survey. FD patients exhibited lower resilience on the CDRS (96.83 vs. 90.26, P<0.04, CI -12.93 to -0.21) but not on the BRS (3.018 vs. 3.022, P<0.96, CI -0.15 to 0.13). FD patients and controls scored no different on the HADS anxiety index (17.05 vs. 18.38, P<0.064, CI -2.74 to 0.08) and depression scores (P<0.14, CI -0.21 to 1.5). The FD group reported "high" perceived psychological stress while the control group reported a “moderate” level (P<0.004, CI 2.002 to 9.827). In childhood, FD patients had significantly more adverse childhood events (29.3% vs. 15%, P<0.004, CI 0.05 to 0.25). FD patients were more likely to have been exposed to a household member suffering from a psychiatric illness compared to control patients (47% vs. 20%, P<0.049, CI 0.001 to 0.5). FD patients were also more likely to report psychological abuse in childhood (53% vs. 17%, P<0.03, CI 0.034 to 0.67). No other significant differences were found in types of early childhood trauma including physical abuse, familial substance abuse, witnessed maternal violence, or criminal behavior by a household member.

Conclusion

This novel, prospective questionnaire pilot study shows that FD patients have lower resilience compared to the general outpatient population on the CDRS. The long-term symptoms of FD may further decrease resilience. While anxiety and psychological stress are not strongly associated with FD, the significant exposure to childhood household members with a psychiatric diagnosis and significantly higher prevalence of self reported psychological abuse may explain the higher prevalence of antidepressant use in this population, especially considering the significantly higher level of self perceived psychological stress [8]. Otherwise, early childhood trauma appears similar between FD patients and patients without FD and is thus not likely to influence resilience markers. Understanding the contribution of resilience to development of FD may lead to therapies enhancing resilience, improving symptoms, and patient well-being.

References

1. El-Serag HB, Talley NJ. Systemic review: The prevalence and clinical course of functional dyspepsia. Aliment Pharmacol Ther. 2004;19:643-654.
2. Taylor F, Higgins S, Carson RT, et al. Development of a symptom-focused patient-reported outcome measure for functional dyspepsia: the functional dyspepsia symptom diary (FDSD). Am J Gastroenterol. 2018 Jan,113(1):39-48.
3. Smith BW, Dalen J, Wiggins K, et al. The brief resilience scale: assessing the ability to bounce back. Int J Behav Med. 2008;15(3):194-200
4. Connor KM & Davidson JR. 2003. Development of a new resilience scale: The Connor-Davidson Resilience Scale (CD-RISC). Depress. Anxiety, 18; 76-82
5. Zigmond AS & Snaith RP. 1983. The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67: 361-370
6. Felitti VJ, Andra RF, Nordenburg D, et al. Relationship of childhood abuse and household dysfunction to many of the causes of death in adults. The adverse childhood experiences (ACE) study. Am J Prev Med. 1998 May;14(4):245-58
7. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983 Dec;24(4):385-96.
8. Esterita T, Dewi S, Suryatenggara FG, Glenardi G, et al. Association of Functional Dyspepsia with Depression and Anxiety: A Systematic Review. J Gastrointestin Liver Dis. 2021 Jun 18;30(2):259-266.