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

Gastroesophageal Reflux Disease (GERD) is a common condition diagnosed by endoscopy and/or pH monitoring. However, only high-resolution manometry (HRM) provides detailed assessment of the pathophysiology underlying reflux mechanisms and GERD symptoms. While it is widely accepted that esophago-gastric junction (EGJ) type 3 is a strong predictor of GERD, EGJ type 2 is less clearly implicated in GERD pathogenesis¹. This study aimed to investigate the clinical and physiological characteristics of patients with EGJ type 2 and to identify HRM variables that predict GERD in this category of patients.

Aims & Methods

535 patients with suspected GERD who underwent HRM and reflux monitoring were retrospectively analyzed. Patients were divided into three groups based on EGJ morphology (type 1, 2, or 3). Clinical data, HRM parameters, and reflux study results were compared among groups. The Milan Score², a novel metric that integrates ineffective esophageal motility (IEM), EGJ-contractile integral (EGJ-CI), EGJ morphology and straight leg raise (SLR) response, was applied to the EGJ type 2 group to identify patients at higher risk of developing GERD. Pathologic GERD was defined as AET >6% on pH-impedance monitoring and/or stricture, Barrett’s esophagus or Los Angeles grade B, C or D, or at endoscopy. As previously demonstrated, a Milan Score of 137 (risk rate 50%) or higher was considered pathologic. Receiver operating characteristic (ROC) analysis was performed to determine Milan score prediction of GERD within patients with EGJ type 2 morphology.

Results

Patients with EGJ type 3 had the highest rate of GERD diagnosis, followed by EGJ type 2 and type 1 (p <0.001). HRM showed differences in EGJ-CI, proportion of patients with IEM and positive SLR response among groups (p <0.001). Reflux monitoring revealed a stepwise increase in AET from type 1 to 3 (5.1±7.3 vs. 8.3±11.1 vs. 12.2±11.3, p <0.001). A pathologic Milan Score identified two subgroups of patients within the EGJ type 2 group: patients with a score below 137 resembled type 1, while those with a score of 137 or higher resembled type 3 in terms of pH monitoring characteristics (Table). On ROC analysis the area under the curve was 0.858, and the optimal threshold to identify pathologic GERD in this group was 137 points (sensitivity 77.3%, specificity 87.7%).

Conclusion

Our data suggests that EGJ type 2 encompasses a wide spectrum of disease severity. The Milan Score with a cut-off of 137 may help to identify patients with EGJ type 2 who are more likely to demonstrate pathologic GERD on reflux monitoring.

References

1. Tolone S, de Cassan C, de Bortoli N, et al. Esophagogastric junction morphology is associated with a positive impedance-pH monitoring in patients with GERD. Neurogastroenterol Motil. 2015 Aug;27(8):1175-82.
2. Siboni S, Sozzi M, Kristo I et al. The Milan score: A novel manometric tool for a more efficient diagnosis of gastro-esophageal reflux disease. United European Gastroenterol J. 2024 Mar 27. doi: 10.1002/ueg2.12565. Epub ahead of print. PMID: 38536701.

Introduction

Gastroparesis (GP) is defined as symptomatic delayed gastric emptying. The most frequent etiologies are diabetes mellitus, after esophageal or gastric surgery and about a third of patients have idiopathic GP. The gastric emptying study by using a scintigraphy scintigraphy (GES) is considered as a principal diagnostic method. Endoscopic pyloromyotomy (G-POEM) is a method improving symptoms in about 60-70% of patients with GP. Its effect on gastric emptying remains controversial.

Aims & Methods

We performed a retrospective single-center analysis to assess the clinical efficicacy of G-POEM based on GES parameters. Between 2016 – 2024, a total of 72 patients with GP (confirmed by scintigraphy) underwent G-POEM and were later invited for clinical as well as scintigraphic assessment after 3, 12 and 36 months. Of these patients, 4 were excluded for missing data, incomplete follow-up data or non-standard testing meal. GES was always performed using the standardized 4 hours protocol with the standard testing meal mixed with 99Tc-DTPA. For this study, all GES were reanalyzed and the following parameters were established : residual activity after 2 hours, residual activity after 4 hours, biological halftimes of ingested activity and proximal-to-distal count ratio for time 0 (PDCR0).

Results

Mean value of GCSI before G-POEM was 3.1 and decreased to 1.6, 1.0 and 0.7 after 3, 12 and 36 months. Median value of GES after 2 hours was 60.2% before G-POEM and 38%, 32.6% and 24.2% after 3, 12 and 36 months. Median value of GES after 4 hours was 21.9% before G-POEM and 7.8%, 6.5% and 3.9% after 3, 12 and 36 months. Correlation index was weakly positive for GCSI and GES after 4 hours only for the first follow-up visit and negative for all remaining visits.
The residual activity after 2 hours and residual activity after 4 hours decreased after G-POEM during all follow-up visits (p<0,001). Mean decrease of residual activity after 4 hours was 12.89%, 15.13% and 6.7% after 3, 12 and 36 months.
Biological halftime also decreased after the procedure with statistically significant results with the mean halftime before G-POEM being 150 min and 86 min, 78.4 min and 65.8 min after 3, 12 and 36 months.
There was a difference between the diabetic and non-diabetic groups, with higher residual activity after 2 hours [median 29.6% before G-POEM, 9.0% after 3 months (p<0.001) and 11.0% after 12 months (p=0.005)] and 4 hours [median 64.8% before G-POEM, 39.4% after 3 months (p<0.001) and 37.7% after 12 months (p=0.012)] respectively in patients with diabetes.
The predictive value of PDCR0 for treatment success after G-POEM was only calculated for the first follow-up visit but was not statistically proved (p=0,712).

Conclusion

In our group of patients there is a weak correlation between the decrease of GCSI and GES early after G-POEM. The decrease in GES parameters tends to be lower in patients with diabetes compared to non-diabetic patients. Based on our data, predicting clinical success of G-POEM using PDCR0 cannot be recommended.

Introduction

According to guidelines, in order to strictly diagnose esophageal motility disorders, besides achalasia, high resolution manometry (HRM) findings should be documented in both the upright and the supine position. A common finding among patients with Gastro-Esophageal Reflux Disease GERD submitted to manometry is ineffective esophageal motility (IEM). The clinical impact of such a diagnosis in this setting is ambiguous though it may denote future disturbance of peristaltic reserve even if until now only inadequate response to multiple rapid swallows (MRS) has been correlated to post anti-reflux surgery dysphagia.

Aims & Methods

We aimed to evaluate differences in esophageal contractility in different positions in patients with definite GERD.We included consecutive patients with definite GERD according to Acid Exposure Time (>6%) submitted simultaneously to 24 hours pH impedance off PPI study and HRM in both the upright and supine position. Patients with previous esophago-gastric surgeries as also patients diagnosed with motility disorders besides IEM/absent contractility according to Chicago 4 guidelines were excluded.

Results

In total 49 patients (M/F:26 (53.1%)/23 (46.9%), mean age:51±14) were included. The main referral reason was typical reflux symptoms in 37/49 (75.5%) patients while 8/49 (16.3%) reported dysphagia. Mean Distal Contractile Integral (DCI) was significantly reduced in the upright position (1629.2±1175.6 mm²/s/mmHg) vs supine position (2762.4±2710.4 mm²/s/mmHg), p=0.010. The rate of total ineffective swallows in the upright position was significantly increased in the upright position (29.0%) vs the supine (12.3%), p=0.010 as was also the rate of weak contraction (10.3% vs 3.1%, p=0.033 ) and marginally not of absent contractions (17.0% vs 8.3%, p=0.078). The rate of diagnosis of IEM/absent contractility was doubled in the upright position (8/49, 16.3%) vs in the supine position (4/49, 8.2%) (k-value:0.473, p=0.001). Inadequate post MRS contraction was observed in 9/49 (18.4%) and more specifically among 3/4 (75%) patients with IEM/absent contractility diagnosis in the supine position (k:-0.436, p=0.002) vs 4/8 (50%) in the upright position (k:-0.361, p=0.011). Dysphagia was not correlated to diagnosis of IEM/absent contractility neither in the supine (p=0.675) nor the upright position (p=0.586).

Conclusion

Upright position in HRM is correlated to a decreased mean DCI and an increased rate of ineffective esophageal contractions leading to an increased rate of diagnosis of IEM/absent contractility. Such a diagnosis in the upright position is correlated in a lesser extent to inadequate post-MRS swallow and not correlated to symptom of dysphagia. Until new data arise such an overdiagnosis among patients with GERD may be misleading and therefore the procedure in such patient may be better to be undertaken only in the supine position.

Introduction

Gastro-esophageal reflux disease (GERD) is a multifactorial disease that manifests in patients with different degrees of anti-reflux barrier impairment. GERD significantly impacts quality of life despite the fact that symptom burden may not always correlate with disease severity. Precise pathophysiologic evaluation can identify patients with actionable GERD who may benefit from anti-reflux surgery or escalation of medical therapy. The Milan Score, a novel high-resolution manometry (HRM) metric, numerically quantifies the degree of anti-reflux barrier disruption¹. While the Milan Score has been proven to predict pathologic GERD, its ability to distinguish non-severe from severe GERD and to identify patients with a higher grade of anti-reflux barrier disruption requires further study.

Aims & Methods

A database of prospectively collected data from a cohort of patients undergoing HRM and pH-study for persistent GERD symptoms was queried. Using Lyon 2.0 consensus, pathologic GERD was defined as AET >6%, grade B-C-D esophagitis or Barrett’s esophagus on endoscopy. Severe reflux was defined as AET >12%, DeMeester score >50, grade C-D esophagitis or Barrett’s esophagus². Demographic, HRM and pH data were extracted, classified and compared between groups with varying GERD severity (no GERD, non-severe GERD, severe GERD). The Milan Score integrates the main manometric parameters related with the pathophysiology of GERD (ineffective esophageal motility, esophago-gastric junction (EGJ) contractile integral, EGJ morphology and straight leg raise maneuver response). In order to simplify the use of the Milan Score, risk rates have been classified into six categories, from extremely unlikely to extremely likely. A cumulative odds ordinal logistic regression was run to determine the independent effect of HRM variables on reflux severity. The ability of the Milan Score to predict severe reflux was assessed, as well as its association with the pH-study criteria proposed by Lyon 2.0 as adjunctive evidence for pathologic GERD (>80 reflux episodes, mean nocturnal baseline impedance (MNBI) <1500 W or positive reflux-symptom association).

Results

Among 603 patients enrolled (median age 49.9 years, median body mass index (BMI) 25.3 Kg/m², 50.5% males), 124 (20.6%) had non-severe and 142 (23.5%) had severe GERD. Non-severe and severe GERD patients had similar demographic and clinical characteristics, but were significantly different from the no-GERD group (Table). On univariate analysis, presence and size of hiatal hernia, Milan Score and Milan Score categories were significantly different among the groups (p <0.001). On ordinal logistic regression, hiatal hernia size and Milan Score category were found to be independent predictors of GERD severity (OR 1.28, 95% CI, 1.04-1.57, p=0.018 and OR 2.92, 95% CI, 2.47-4.45, p=<0.001 respectively). A significantly higher Milan Score (p <0.001) was found in patients with >80 reflux episodes, MNBI <1500 W, positive reflux-symptom association and any criteria of severe GERD.

Conclusion

Hiatal hernia size and Milan Score assessed at HRM are independent factors associated with severe GERD. The Milan Score is significantly higher in patients with pathologic adjunctive pH-impedance metrics and in patients with severe GERD.

References

1. Siboni S, Sozzi M, Kristo I et al. The Milan score: A novel manometric tool for a more efficient diagnosis of gastro-esophageal reflux disease. United European Gastroenterol J. 2024 Mar 27. doi: 10.1002/ueg2.12565. Epub ahead of print. PMID: 38536701.
2. Horvath KD, Jobe BA, Herron DM et al. Laparoscopic Toupet fundoplication is an inadequate procedure for patients with severe reflux disease. J Gastrointest Surg. 1999 Nov-Dec;3(6):583-91. doi: 10.1016/s1091-255x(99)80079-1. PMID: 10554364.