Introduction

Oropharyngeal dysphagia (OD) is a very prevalent geriatric syndrome that causes serious nutritional and respiratory complications and mortality. Main pathophysiological elements of OD include delayed biomechanics as well as impaired sensitivity with alterations of the pharyngeal sensory/afferent pathway. However, the involvement of the motor/efferent pathway is unknown.

Aims & Methods

To characterize the biomechanics and neurophysiology of the swallow response in older patients with OD.
Observational study in 12 older patients with OD (>65 years) without neurological disorders, 12 young healthy volunteers (HV) and 9 older HV (OHV). Swallowing biomechanics and neurophysiology were measured by videofluoroscopy (VFS) including the Penetration-Aspiration scale (PAS) and time to laryngeal vestibule closure (LVC), pharyngeal sensory (pSEP) and motor evoked-potentials (pMEP) to intrapharyngeal electrical and transcranial magnetic stimulation (TMS), respectively.

Results

Study participants (OD, HV and OHV) presented a mean age of 75.6±6.8, 29.9±6.2 and 74.9±5.5 years, respectively (p<0.0001), and a mean Barthel score of 82.5±29.0, 100.0±0.0 and 99.4±1.7 (p=0.022). 83.3% of OD patients had unsafe swallows (PAS=4.25±2.1 vs. 1.18±0.4 HV vs. 1.40±0.5 OHV; p<0.0001) with delayed LVC time (362.5±73.4ms OD vs. 185 5±57.3ms HV vs. 143.2±46.9ms OHV; p<0.0001 OD vs. HV and OHV). Neurophysiologically we found OD patients had: a) higher pharyngeal sensory threshold (12.2±7.5mV OD vs. 5.9±2.2mV HV vs. 6.2±3.3mV OHV; p=0.009) and delayed pSEP P1 and N2 latencies (p<0.05 vs HV); and b) higher pharyngeal motor thresholds to TMS in both hemispheres (right: 93.4±5.4 OD vs 82.0±11.0 HV vs 85.3±10.3 OHV, p=0.04; left: 92±8.1 OD vs 77.8±10.7 HV vs 86.3±10.4 OHV, p=0.02) and delayed MEPs latencies (tenar: 22.0±1.7ms OD vs 16.3±1.3ms HV vs 22.3±2.0ms OHV, p<0.0001 HV vs OD and OHV; right pharyngeal: 8.5±1.3 OD vs 6.6±1.6 HV vs 9.6±1.3 OHV, p=0.01; left pharyngeal: 7.8±1.0 OD vs. 6.3±1.4 HV vs 8.3±112 OHV, p=0.02).

Conclusion

Older OD patients present impaired swallowing biomechanics, pharyngeal hypoesthesia with disrupted conduction of pharyngeal sensory inputs, and reduced excitability of the pharyngeal motor cortex with delayed responses. These findings reveal a new element in the pathophysiology of aging-associated OD and open the door to new and specific neurorehabilitation treatments for these patients by acting simultaneously at both sensory and motor pathways.

References

Cabib C, Nascimento W, Rofes L, Arreola V, Tomsen N, Mundet L, Muriana D, Palomeras E, Michou E, Clavé P, Ortega O. Neurophysiological and Biomechanical Evaluation of the Mechanisms Which Impair Safety of Swallow in Chronic Post-stroke Patients. Transl Stroke Res. 2020 Feb;11(1):16-28.
Rofes L, Ortega O, Vilardell N, Mundet L, Clavé P. Spatiotemporal characteristics of the pharyngeal event-related potential in healthy subjects and older patients with oropharyngeal dysfunction. Neurogastroenterol Motil. 2017 Feb;29(2).

Introduction

Introduction: High-resolution impedance manometry (HRIM) is now an important tool in the study of upper esophageal sphincter (UES) function and pharynx propulsion in patients with oropharyngeal dysphagia. Our aim was to study the effect of volume, viscosity and sensory TRP stimulants using HRIM in healthy adults.

Aims & Methods

Methods: We present a cross-sectional, controlled, quasi-experimental study in 14 healthy volunteers (median age 33 years) studied by high-resolution solid-state probe manometry of 30 unidirectional pressure channels and 6 circumferential channels at the UES with 16 impedance channels. Duplicate boluses of 5, 10 and 20 mL of 4 viscosities (50, 250, 800 and 2,000 mPa·s) and a duplicate bolus of 5 mL of TRP stimulants with the same 4 viscosities were administered. UES relaxation (UES-IRP), UES opening (UES Max Admittance), flow resistance (hypopharyngeal pressure at nadir impedance (PNadImp) and pharyngeal propulsive forces (peak pharyngeal pressure (PeakP) and pharyngeal contraction integral (PhCI) were assessed. The analysis was performed using SwallowGateway® software.

Results

Results: Bolus volume increase at different viscosities caused a) increase in UES integrated relaxation pressure (UES-IRP p < 0.05), b) increase in UES opening (UES Max Admittance p < 0.05), c) increase in flow resistance (PNadImp) at 800 and 2,000 mPa·s (p < 0.005) and d) increase in pharyngeal propulsion at 2,000 mPa·s (PhCI (p < 0.05) with no significant increase with other viscosities or at the PeakP level in all of them.
Viscosity increase at different volumes showed (a) Increase in UES integrated relaxation pressure (UES-IRP p = 0.004) majority at higher volume boluses (10 and 20 mL), (b) increase in UES opening (UES Max Admittance p < 0.05 at 5 and 10 mL), c) no changes in bolus resistance (PNadImp (20 ml) p > 0.05) and d) no changes in pharyngeal forces (PeakP p > 0.05 and PhCI p > 0.05).
TRP stimulants increased the UES-IRP (p < 0.011) and UES Adm (p < 0.001) and had no effect on pharyngeal contraction forces or bolus flow resistance.

Conclusion

Conclusions: In healthy adults without dysphagia, increasing volume has a significant effect on UES with an improvement on opening with less relaxation, increased flow resistance and increased pharyngeal propulsive forces. In contrast, increasing bolus viscosity and adding TRP stimulants impairs relaxation with improvement on the aperture of the UES with no effect on pharyngeal propulsive forces and flow resistance.

Disclosure

Nothing to disclose

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

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 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

Endoscopy abnormalities of eosinophilic esophagitis (EoE) are currently graded based on the EoE endoscopic reference score (EREFS) ranging 0 to 9. Research has shown that esophageal biopsies are often omitted in Europe in patients reporting dysphagia when the upper endoscopy (EGD) shows no abnormalities [1]. However, a proportion of patients with eosinophilic esophagitis (EoE) may have normal endoscopy (i.e., EREFS=0), making the diagnosis more difficult and increasing the risk of diagnostic delay.

Aims & Methods

We investigated predictors of a diagnosis of EoE when the EGD is unremarkable (i.e., EREFS=0). Consecutive adult patients (≥18 years) with dysphagia who had EREFS=0 at an EGD with six esophageal biopsies were prospectively enrolled. All patients underwent EGD while off any eosinophil-depleting treatment. EoE with EREFS=0 was diagnosed based on the presence of at least 15 eosinophils/high-power field in at least one of six esophageal biopsies. When all six esophageal biopsies showed <15 eosinophils/high-power field, patients were diagnosed with non-EoE dysphagia (NED). Demographics, diagnostic delay (i.e., interval time between symptoms onset and diagnosis), esophageal symptoms, and atopic comorbidities (i.e., allergic rhinitis, asthma, eczema) were collected for all patients. Pearson's Chi-squared test and Fisher's exact test were used for comparisons. Odds ratios (ORs) were calculated to quantify associations between disease states. Significance threshold was set at p<0.05.

Results

Of 133 included patients, 51 (38%) had NED, while 82 (62%) had EoE with EREFS=0. Patients with EoE were more commonly males (67% vs 35%; p<0.001) and younger (37 vs 46 years; p=0.005) compared to patients with NED. Patients with EoE were diagnosed with a significantly longer diagnostic delay than NED (28 vs 4 months; p<0.001). Heartburn, regurgitation, chest pain and dyspepsia had similar prevalence in the two groups. In contrast, patients with EoE had a significantly higher prevalence of atopic comorbidities compared to NED (83% vs 39%; p<0.001).
The presence of rhinitis, diagnostic delay longer than 12 months, any atopic comorbidity, age younger than 37 years, and male sex were associated with an increased risk of EoE with OR of 47.0, 11.6, 7.4, 3.8, and 3.7, respectively (p<0.01 for all).

Conclusion

EoE remains a possible diagnosis in patients reporting dysphagia even when endoscopy is normal. The presence of rhinitis and longer diagnostic delay, the presence of any atopic comorbidity, and younger age are associated with a diagnosis of EoE and are helpful to raise the suspicion of EoE and prompt endoscopists to collect esophageal biopsies.

References

[1] Tourlamain, G., Garcia-Puig, R., Gutiérrez-Junquera, C., Papadopoulou, A., Roma, E., Kalach, N., Oudshoorn, J., Sokollik, C., Karolewska-Bochenek, K., Oliva, S., Strisciuglio, C., Bauraind, O., Auth, M. K., Thomson, M., Otte, S., Rok, O., Dias, J. A., Tzivinikos, C., Urbonas, V., Kostovski, A., … ESPGHAN EGID Working group (2020). Differences in Management of Eosinophilic Esophagitis in Europe: An Assessment of Current Practice. Journal of pediatric gastroenterology and nutrition, 71(1), 83–90. https://doi.org/10.1097/MPG.0000000000002672