Introduction

Delayed gastric emptying (GE) is a necessary condition for the diagnosis of gastroparesis (1). Motor alterations leading to delayed GE remain poorly identified and are not assessed in routine care. High-resolution antroduodenal manometry (HR-ADM) allows precise characterization of antral, pyloric, and duodenal motility (2). However, HR-ADM has not been assessed in delayed GE.

Aims & Methods

We aimed to identify motility alterations related to delayed GE. Consecutive patients referred for HR-ADM for dyspeptic symptoms performed a concurrent GE breath test with 13C-octanoic acid. HR-ADM involved 36 sensors 1 cm apart placed across the pylorus, with a commercially available probe. Interdigestive and postprandial periods were identified. Antral, pyloric, and duodenal motor profiles were analyzed recording the frequency, amplitude, and propagative nature of contractions. The contractile integral was also measured for each period. Plots of patients with normal and delayed GE, based on the result of the breath test, were compared.

Results

Sixty patients underwent both HR-ADM and GE tests. Twenty-five and 35 patients had delayed and normal GE, respectively. Antral and duodenal motor profiles were not different between the two groups during the interdigestive period, whether during phase II or phase III of the migrating motor complex. The basal pyloric pressure was not different between patients with or without delayed GE. During the postprandial period, a lower frequency of antral contractions was associated with delayed GE (2.22 vs 1.39 contractions/min; p=0.002), but no difference in the amplitude of antral contractions was observed. No difference in duodenal contractions was observed. Finally, the pyloric region was identified in all the patients, and pylorospasms, defined as 3 min of repeated isolated pyloric contractions, were more frequent in patients with delayed GE (32.0% vs 5.7%; p=0.02) during the postprandial period. Manometric alterations in the postprandial period were observed in 72% of the patients with delayed GE, with a low frequency of antral contractions, defined as less than 1 contraction/min, in 56% of the patients.

Conclusion

Using HR-ADM, patients with delayed GE displayed different postprandial antro-pyloric motility as compared with patients with normal GE. HR-ADM could, therefore, be useful in the future to better select patients for treatments targeting the pylorus.

References

1. Camilleri M, Sanders KM. Gastroparesis. Gastroenterology 162: 68-87.e1, 2022. doi: 10.1053/j.gastro.2021.10.028.
2. Desipio J, Friedenberg FK, Korimilli A, Richter JE, Parkman HP, Fisher RS. High-resolution solid-state manometry of the antropyloroduodenal region. Neurogastroenterol Motil 19: 188–195, 2007. doi: 10.1111/j.1365-2982.2006.00866.x.

Introduction

Idiopathic gastroparesis (IG) remains a challenging condition, with few effective therapeutic options available. Despite recent European and international consensuses, some management modalities are still different in the French practice (1).

Aims & Methods

We aimed to develop French recommendations on the diagnosis and management of IG in adults and paediatric patients, highlighting the similarities and differences with recent consensuses. A Delphi process was conducted among a panel of 16 French neurogastroenterology experts, including gastroenterologists and paediatricians. A first list of statements was drafted with a literature summary. After revisions and clarifications, 3 voting rounds were conducted and consensus statements were identified (defined as ≥ 80% agreement).

Results

Consensus was reached for 39 out of 46 statements. Definition and diagnostic modalities were similar to recent guidelines. IG was defined as symptoms associated with delayed gastric emptying (GE), in the absence of a mechanical obstruction. The panel agreed that nausea and vomiting are cardinal symptoms, with postprandial distress symptoms frequently overlapping. Variable presentations according to age were highlighted in paediatric patients.
Delayed GE can be confirmed by either scintigraphy or a GE breath test, using a solid meal, and a 4-hour measurement. Food retention at endoscopy was not considered a diagnostic criterion. Pyloric EndoFlip was not considered a diagnostic or pretherapeutic tool. A blood test and screening for Helicobacter pylori were supported before diagnosing IG.
Regarding the management, like in recent guidelines, the panel supported a first-line therapy using dietary advice and dopamine antagonists (metoclopramide or domperidone). The panel supported the efficacy of intravenous erythromycin, but not oral erythromycin. Agreement on the efficacy of other drugs, including prucalopride, antiemetics, or neuromodulators, was not reached. The use of nutritional support was recommended if deemed necessary for refractory vomiting and malnutrition, with enteral post-pyloric nutrition recommended as the first option.
The consensus supported different strategies for the management of refractory gastroparesis. Stopping opioids, or drugs inducing delayed GE, and the treatment of associated constipation were recommended before considering more invasive procedures. The efficacy of pyloric toxin injection was not agreed upon. Gastric endoscopic pyloromyotomy and gastric electrical stimulation were considered effective therapies for refractory IG. Finally, surgical procedures were not supported.

Conclusion

This consensus shows that the diagnostic modalities for IG are similar in France as compared to international guidelines, but highlights differences in the management of refractory gastroparesis, supporting endoscopic pyloromyotomy or the implantation of gastric electrical stimulation.

References

1. Schol J, Wauters L, Dickman R, Drug V, Mulak A, Serra J, et al. United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on gastroparesis. United European Gastroenterol J. 2021 Apr;9(3):287–306.
2. Schol J, Huang IH, Carbone F, Fernandez LMB, Gourcerol G, Ho V, et al. Rome Foundation and international neurogastroenterology and motility societies’ consensus on idiopathic gastroparesis. Lancet Gastroenterol Hepatol. 2025 Jan;10(1):68–81.

Disclosure

HS received lecture fees from Enterra Medical, and Viatris.

Introduction

Dyspeptic patients frequently report nausea and vomiting. However, Rome IV criteria distinguish functional dyspepsia (FD) and chronic nausea and vomiting syndrome (CNVS) as separate disorders.

Aims & Methods

We aimed to assess and compare the characteristics and symptoms of patients with FD alone, with CNVS alone and those fulfilling both FD+CNVS criteria in a population of investigated dyspepsia. The retrospective study included 3,471 consecutive patients with investigated dyspepsia. Functional dyspepsia and CNVS were diagnosed according to Rome IV criteria. The severity of eight digestive symptoms during the 15 days preceding their appointment was assessed prospectively using a 5-point Likert scale. Quality of life (QoL) was quantified by the GastroIntestinal Quality of Life Index (GIQLI). Anxiety and depression were evaluated using the Hospital Anxiety and Depression scale (HADS). Sleep was assessed by the Pittsburgh Sleep Quality Index (PSQI).

Results

Among the 2,317 patients kept for analysis, 651 had FD alone, 144 CNVS alone and 393 FD+CNVS overlap. 73.2% of patients with CNVS fulfilled the criteria for FD, whereas 37.6% of FD patients met the criteria for CNVS. Patients with FD+CNVS overlap had worse quality of life, higher depression levels, and worse sleep quality than both diagnoses alone (p < 0.05). All symptoms were at least as prevalent in patients with FD+CNVS overlap as in patients with FD alone, except early satiation.

Conclusion

Nausea and vomiting are frequently reported by patients investigated for dyspepsia. Nearly three-quarters of patients with CNVS fulfil the criteria for FD, whereas more than one-third of FD patients meet the criteria for CNVS. Patients exhibiting FD+CNVS overlap have more severe disease than those with FD or CNVS alone.

Introduction

Achalasia is a primary motility disorder, which presented by dysphagia. The most effective treatment of the disease is surgical (peroral myotomy or laparoscopic myotomy). However, there are few studies which assess the changes in esophageal motility after surgery.

Aims & Methods

The aim of our study was evaluating the changes in esophageal manometry in patients with achalasia after peroral endoscopic myotomy (POEM).
Subjects and methods: 43 patients with achalasia were consequently observed before and 1 year after POEM. Females predominated (28 subjects). All patients examined endoscopically, then high resolution manometry (HRM) was performed by Solar™ GI (MMS/Laborie, Netherland). Achalasia was defined as described in Chicago Classification 4.0. Eight patients had I type of achalasia, 24 – II type and 11 – III type.

Results

The median Eckardt score was 7 on the start and 2 – after POEM in 35 patients (group A). However, 8 patients were dissatisfied with the surgery (4 pts with II type achalasia and 4 – III type). They continued to suffer from dysphagia and/or noncardiac chest pain (group B).
According to HRM the mean resting pressure of LES in group A reduced 2 folds from 39,1±2,7 mmHg to 18,9±1,4 mmHg. Also we revealed the dramatic decrease in integrated residual pressure (IRP) from 22,8±0,7 mmHg to 9,8±0,6 mmHg and DCI: from 1865,5±286,9 to 128,2±53,8. In a group B the mean resting pressure of LES reduced from 48,8±2,4 mmHg to 33,6±2,4 mmHg. The integrated residual pressure (IRP) decreased from 22,8±0,7 mmHg to 15,01±0,6 mmHg and DCI: from 2999,6±417,6 to 1038,1±107,7.
Even though, we didn’t observed the peristaltic waves in two groups before and after POEM as a normal manometric criteria: the consistent contraction of upper part of esophagus and then lower part of esophagus. Besides, HRM evaluated persisting spastic contraction in the middle and lower part of esophagus in patients with type III achalasia from group B. Two patients from group B with type II had good results in esophageal manometry.

Conclusion

The reduction of resting pressure, integrated resting pressure and distal contractile interval in several times can be accepted as criteria of POEM effectiveness. Besides, in patients with III type of achalasia we must assess the absence of spastic contraction as additional criteria of POEM satisfaction.

Introduction

Oesophageal high-resolution manometry (HRM) is the test of choice for the study of oesophageal motility disorders. The Chicago 4.0 classification facilitates analysis and interpretation of these studies. However, the influence of patient position and analysis methodology of some parameters is not well defined. In addition, it has not been precisely defined where to place the gastric pressure sensor to determine the integrated relaxation pressure (IRP).

Aims & Methods

The aim was to evaluate if postural changes and analysis methodology applied affect the results of oesophageal high-resolution manometry.
Oesophageal HRM with Chicago 4.0 extended protocol (10 swallows in supine and 10 swallows in up-right position) performed in our Neurogastroenterology and Motility Unit between December 2021 and October 2022 were included. The distal contraction integral (DCI) was determined automatically and manually. The IRP was evaluated positioning the gastric pressure sensor in the lowest gastric area pressure zone (GS-LP) and 2 cm below the lower oesophageal sphincter (GS-2cm).

Results

A total of 96 patients were included, 65% women (mean age 57 years). Mains indications of oesophageal HRM were GERD symptoms (52%) and dysphagia (41%). DCI values were significantly higher in the supine position (2607 and 2014 mmHg/cm/sec with automatic and manual analysis respectively, p<0,0001) compared to the up-right position (1558 and 1371 mmHg/cm/sec with automatic and manual analysis respectively, p<0,0001). These represent changes in the diagnosis of 11% of the studies regarding methodology and 17% regarding posture. A higher proportion of ineffective peristalsis was observed with manual analysis in the up-right position. Additionally, IRP values were significantly higher in both positions using GS-LP (15.5 and 11.1 mmHg) rather than GS-2cm (11.9 and 7.9 mmHg). This represents an increase in the proportion of oesophageal outflow obstruction using GS-LP in both positions.

Conclusion

The position and analysis methodology applied affects the distal contractile integral values. The location of the gastric reference sensor affects the integrated relaxation pressure value. Manometric diagnosis can change depending on the selected posture and analysis methodology applied. Consensus on posture and analysis methodology for oesophageal high-resolution manometry is needed to reduce differences between laboratories.

Disclosure

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Introduction

Evidence is scarce regarding the impact of overweight and obesity on the interpretation of high-resolution esophageal manometry (HREM) parameters. We aimed to investigate whether the presence of overweight and/or obesity influences the HREM parameters.

Aims & Methods

Retrospective cohort study including adult patients undergoing HREM (Manoscan® 36-sensor probe) between 2019-2022, regardless of the indication, with measurement of height and weight at the time of HREM. A HREM diagnosis was obtained according to the Chicago 4.0 classification and the following HREM parameters were collected: esophageal length, length and type of esophagogastric junction (EGJ), presence and extent of hiatal hernia, minimum basal, mean and residual lower esophageal sphincter pressures, basal and residual upper esophageal sphincter pressures, percentage of failed, weak, ineffective, with pressurization, premature, fragmented, intact, hypercontractile swallows and mean and after multiple rapid swallows distal contractile integral. Body mass index (BMI) was calculated, and patients were categorized as underweight (<18.5), normal weight (18.5-24.9), overweight (25-29.9) and obesity (≥30). The relationship between BMI and its categories with the HREM parameters was evaluated.

Results

A total of 249 patients were included, mostly women (59.8%) with a mean age of 56 ± 14 years. The median BMI was 26 (IQR 5) kg/m2 and 115 (46.2%) patients were overweight, 91 (45.7%) normal weight and 43 (17.3%) obese. A normal HREM (51.8%), followed by ineffective esophageal motility (21.7%) and EGJ outflow obstruction (8.8%) were the most frequent HREM diagnoses. There were no statistically significant differences between the presence of overweight and/or obesity and the HREM parameters evaluated, regardless of the HREM diagnosis.

Conclusion

Overweight and obesity do not seem to influence HREM parameters, so its interpretation should not be influenced by these factors.

Introduction

Based on the Chicago classification, HREM diagnosis is classically based on metrics obtained with wet swallows carried out in the supine position. However, both patients and physicians often feel that this is not a physiological position to conduct the test as it may not translate to the real world experience. With the patient in the upright/sitting position, the test would more closely simulate real-life behaviour and may be safer for elderly patients at risk of aspiration.

Aims & Methods

In an Asian tertiary centre, a total of 104 patients had undergone high resolution esophageal manometry (HREM) with retrospective data analysis comparing both conventional supine position with the upright position. The latter is generally favoured by all patients as this represents the physiological posture during meals.

Results

Using 2-tailed paired sample T-test, comparison across all cases showed a consistently lower median Integrated Relaxation Pressure (IRP) [6.0 mmHg vs to 8.7 mmHg; p <0.01] and lower mean Distal Contractile Integral (DCI) [1463 mmHg/cm/sec vs 1864 mmHg/cm/sec; p =0.014] in the upright posture compared to supine position although the mean Distal Latency (DL) difference was not significant [6.21secs vs 6.27 secs; p =0.491]. During upright and supine position comparison respectively, subgroup analysis on subjects with normal HREM diagnosis showed even lower median IRP [4.9 mmHg vs 7.5 mmHg; p <0.01] and lower mean DCI results [1436 mmHg/cm/sec vs 1695 mmHg/cm/sec; p <0.01] with mean DL in this subgroup showing no significant statistical difference [6.29 secs vs 6.38secs; p=0.545]. The final HREM diagnosis in upright position is concordant with the conventional supine position up to 81.7% and showed an even higher concordance in terms of management similarity up to 98.1%. Only 2 cases (2/104) showed a significant discordance between supine and upright HREM diagnosis [normal HREM vs esophagogastric juntion –outflow obstruction(EGJ-OO) and hypercontractile esophagus vs normal HREM]. Minor diagnostic discordance [normal HREM vs ineffective esophageal motility (IEM)] was noted in 17/104 cases which had no major clinical impact on patients and may be overcome by adopting a lower cut-off for mean DCI for upright group.

Conclusion

In patients who are unable to perform HREM in supine position, adopting the upright position shows a high clinical concordance and may be considered a more physiological approach in the HREM protocol.

References

Riva CG, Siboni S, Ferrari D, Sozzi M, Capuzzo M, Asti E, Ogliari C, Bonavina L. Effect of Body Position on High-resolution Esophageal Manometry Variables and Final Manometric Diagnosis. J Neurogastroenterol Motil. 2020 Jul 30;26(3):335-343. doi: 10.5056/jnm20010. PMID: 32606256; PMCID: PMC7329148.