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

Upper esophageal sphincter (UES) is a muscular structure located at the transition from the pharynx to the esophagus, with the cricopharyngeal muscle as the most important component. One of its main functions is to prevent esophago-pharyngeal reflux; however, it also plays a key role during swallowing, belching, and vomiting. Data on UES involvement on pathogenesis and clinical manifestations of esophagogastric junction outflow obstruction (EGJOO) are lacking.

Aims & Methods

Aim of this study the UES manometric parameters analysis and study of their impact on pathogenesis and clinical presentation of patients affected by Esophagogastric Junction Outflow Obstruction (EGJOO) according to the Chicago Classification v4.0 criteria. Manometric tracings, epidemiological and clinical data of patients with a diagnosis of EGJOO in our departments between 07/2021- 03/2025 were analyzed. Clinical presentation was evaluated by performing Dysphagia Symptom Questionnaire (DSQ) and Eckardt score. Manometric parameters of UES function (mean basal pressure, mean residual pressure, resting time and recovery time) as well as the other manometric parameters were analyzed and correlated through multifactor statistical analysis (MFA) with clinical and epidemiological data.

Results

Data from 94 patients (73F/21M, mean age 66 years) were analyzed. 40.4% presented dysphagia, 46,8% GERD related symptoms and 12.8% Non-Cardiac Chest Pain (NCCP) as main clinical presentation at the time of HRM examination. Mean basal pressure of the lower esophageal sphincter (LES) was 50.85 mmHg (R19.5-78.8), mean integrated relaxation pressure (IRP) was 19.15 mmHg (R 15.2-40.4), mean Distal Contractile Integral (DCI) 5.031 (mmHg -cm-s) (R 3.487-7.345), mean Distal Latency 6.4 (R 4-10.2), mean UES basal pressure 53.3 mmHg (R27.8-220), mean UES residual pressure 8.75 mmHg (R 0.2 -70.9), mean UES resting time 181 ms (R48-476), mean recovery time 465 (R46-880). 34 patients (36.2%) had abnormal UES manometric parameters. Multifactorial statistical analysis revealed a statistically significant correlation of the pathological UES residual pressure with abnormal LES basal pressure (p = 0.040), dysphagia as main clinical symptom (p=0.030), LES length (p=0.013) and dysphagia symptom severity evaluated by DSQ: p=0.017 and Eckardt: p=0.041.

Conclusion

UES motility has not been extensively studied on HRM in patients affected by EGJOO. Our study revealed that a significant number of EGJOO patients presented abnormal UES function. UES motility abnormalities in these patients are correlated with abnormal LES function, symptoms severity and particularly characterize patients with predominant dysphagia.

References

1. Singh S, Hamdy S. The upper oesophageal sphincter. Neurogastroenterol Motil. 2005 Jun;17 Suppl 1:3-12. doi: 10.1111/j.1365-2982.2005.00662.x. Erratum in: Neurogastroenterol Motil. 2005 Oct;17(5):773.
2. Omari, T.I., Maclean, J.C.F., Cock, C., McCulloch, T.M., Nativ-Zeltzer, N., O'Rourke, A.K., Szczesniak, M.M., Wu, P.I., Allen, J., Aoyagi, Y., Bayona, H.H.G., Carrión, S., Ciucci, M.R., Davidson, K., Dhar, S.I., Hamdy, S., Howell, R., Jones, C., Knigge, M.A., Moonen, A., Postma, G.N., Puntil-Sheltman, J., Rameau, A., Regan, J., Schar, M. and Rommel, N. (2025), Defining Pharyngeal and Upper Esophageal Sphincter Disorders on High-Resolution Manometry-Impedance: The Leuven Consensus. Neurogastroenterology & Motility e70042

Introduction

Aging is associated with physiological changes in esophageal function, influencing motility and increasing susceptibility to dysphagia.

Aims & Methods

This study investigates esophageal peristaltic reserve across different age groups by employing multiple rapid swallow (MRS) during high-resolution manometry (HRM). A retrospective analysis was conducted on 331 patients presenting with dysphagia who underwent HRM between 2021 and 2023. Participants were stratified into four age groups: early adulthood (≤34 years, 12.1%), early middle-age (35–49 years, 12.7%), late middle-age (50–64 years, 45.3%), and late adulthood (≥65 years, 29.9%). Peristaltic reserve was assessed using MRS to evaluate esophageal contractile function.

Results

Among the 311 patients included, 195 (58.9%) were male, with a median age of 57 years (IQR 45–66). The prevalence of normal esophageal motility was highest in early adulthood (67.5%) and early middle-age (78.6%) but declined significantly in late middle-age (48.7%; p=0.014) and late adulthood (44.4%; p<0.001). Late adulthood was also characterized by lower median upper esophageal sphincter (UES) pressure (101 mmHg) and reduced UES length (3 cm; p<0.05). Additionally, esophagogastric junction (EGJ) type II and III morphology was more frequently observed in late adulthood (52.5%; p<0.05). In patients with normal motility (n=177), MRS motor wave transmission was lower in late adulthood (75%, p<0.05) compared to early adulthood (96.3%), early middle age (88.1%) and late middle age (93.2%), and the prevalence of incomplete MRS inhibition was higher in late adulthood (79.5%, p<0.05) compared to early adulthood (11.1%), early middle age (21.2%) and late middle age (46.6%). The DCI-MRS and DCI wet ratio were significantly lower in late adulthood (0.51, IQR 0.13 – 0.88; p<0.01).

Conclusion

Peristaltic reserve declines with advancing age, which may contribute to dysphagia. MRS proves to be a useful diagnostic tool for detecting subtle motility impairments related to aging.

Introduction

Ineffective esophageal motility (IEM) is a rare motility disorder characterized by weak or failed peristalsis at high-resolution manometry (HRM). There is an established association between IEM and gastroesophageal reflux-disease (GERD) symptoms. However, it is unclear why some patients present with dysphagia. In this study we aimed to investigated whether dysphagia in IEM is associated with specific HRM or pH-impedance monitoring (MII-pH) findings.

Aims & Methods

Adults (≥18 y) who underwent HRM for upper gastrointestinal symptoms who were diagnosed with IEM according to Chicago v4.0 between January 2021 and November 2024 were included. Patients’ gender, age, symptoms (dysphagia, chest pain, heartburn, regurgitation, belching), response to proton pump inhibitor (PPI) treatment and HRM data were recorded. All patients underwent MII-pH. Wilcoxon rank sum test, Pearson's chi-squared test and Fisher's exact test were used for comparisons. Significance was set at p<0.05.

Results

In the study period, 54 patients were diagnosed with IEM. Of them, 33 (61%) did not report dysphagia (IEM-GERD), while 21 (39%) had dysphagia (IEM-DYSPHAGIA). Of note, patients with or without dysphagia had a comparable prevalence of heartburn, chest pain, regurgitation, and erosive esophagitis. In addition, IEM-GERD and IEM-DYSPHAGIA were comparable in age and response to PPI treatment. IEM-GERD and IEM-DYSPHAGIA did not show significant differences in EGJ type, EGJ contractile integral (EGJ-CI), integrated relaxation pressure (IRP), percentage of ineffective or failed swallows, or the rapid drinking challenge (RDC) findings (p>0.05 for all), demonstrating an overall similar pathophysiology of peristalsis and EGJ opening. In terms of MII-pH, there was no statistical difference in GERD-related parameters between IEM-GERD and IEM-DYSPHAGIA, who showed comparable values of acid exposure time (AET), mean nocturnal baseline impedance (MNBI), symptoms association indexes (SI), and post-reflux swallow-induced peristatlic wave index (PSPW-I) (p>0.05 for all).

Conclusion

We showed that dysphagia in IEM is not explained by impaired EGJ outflow or worse peristalsis. IEM with and without dysphagia have a similar proportion of GERD symptoms, comparable MII-pH findings, and respond similarly to PPI treatment. Our findings suggest that dysphagia in IEM could be a symptomatic manifestation of GERD.
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Introduction

Outcome after treatment of achalasia is usually assessed by the Eckardt score (ES). The timed barium esophagogram (TBE) is used to objectively assess esophageal clearance after treatment. High-resolution manometry with impedancemetry (HRiM) provides information on esophageal clearance of liquids in addition to motility parameters. The aim of this study was to compare esophageal clearance determined by HRiM and TBE in patients with achalasia treated by POEM.

Aims & Methods

Consecutive patients treated with POEM had pre and post-POEM assessment with ES, TBE, and HRiM. Treatment failure was defined by an ES > 3 at 3 months post-POEM. Incomplete esophageal clearance (IEC) was defined by the presence of an esophageal stasis > 2 cm at 5 minutes in HRiM and/or TBE. All of the data available pre and post-POEM at 3 months was pooled for analysis. The correlation between ES, TBE and HRiM was evaluated by Spearman's method.

Results

Fifty patients with a median age of 65 years (23-84) were included in this study (85% with type 2 achalasia). The clinical response rate at 3 months was 94%. TBEM/HRiM results were available in (29/33) pre-POEM patients and (43/46) post-POEM patients at 3 months. Overall, an IEC was found in 91% on TBE and in 50.8% on HRiM. The correlation between the ES and IEC in HRiM and TBE were respectively 0.66 and 0.31. The correlation between esophageal clearance values between TBE and HRIM was low (r=0.375). At 3 months after POEM, IEC was present in 90.7% and 21.7% for TBE and HRiM, respectively (p<0.001). In univariate and multivariate analysis, only IEC in HRiM was significantly associated with ES > 3 (RR = 17.0 (p < 0.001)). The HRiM AUC was 0.872 vs. 0.707 for the TBE (p<0.001). The diagnostic performance of HRiM to predict an ES > 3 was Se: 85%; Sp: 77%; PPV: 74%; NPV: 87% vs. Se: 95%; Sp: 11%; PPV: 42%; NPV: 83% for the TBE. Data at one year will be available for the presentation.

Conclusion

In achalasia, the evaluation of esophageal clearance by HRiM is better correlated with ES than TBE and may be a relevant criterion for pre and post-therapeutic evaluation. Additional studies are underway to validate the relevance of this parameter more specifically in the evaluation of treatments for esophageal achalasia.

References

1. Lin Z, Nicodème F, Lin CY, Mogni B, Friesen L, Kahrilas PJ, et al. Parameters for quantifying bolus retention with high-resolution impedance manometry. Neurogastroenterol Motil. 2014 Jul;26(7):929–36.
2. Conchillo JM, Selimah M, Bredenoord AJ, Samsom M, Smout AJPM. Assessment of oesophageal emptying in achalasia patients by intraluminal impedance monitoring. Neurogastroenterol Motil. 2006 Nov;18(11):971–7.
3. Cho YK, Lipowska AM, Nicodème F, Teitelbaum EN, Johnston ER, Gawron A, et al. Assessing Bolus Retention in Achalasia using High Resolution Manometry with Impedance: A Comparator Study with Timed Barium Esophagram. 2015;15.
4. de Oliveira JM, Birgisson S, Doinoff C, Einstein D, Herts B, Davros W, et al. Timed barium swallow: a simple technique for evaluating esophageal emptying in patients with achalasia. Am J Roentgenol. 1997 Aug;169(2):473–9.
5. Kostic S, Andersson M, Hellström M, Lönroth H, Lundell L. Timed barium esophagogram in the assessment of patients with achalasia: Reproducibility and observer variation. Dis Esophagus. 2005 Jun 1;18(2):96–103.

Introduction

An intact esophagogastric junction (EGJ) barrier consists of the lower esophageal sphincter (LES) in the same anatomical plane as the crural diaphragm (CD). When there is separation between the planes of the LES and the CD, the morphology of the EGJ is disrupted, and a hiatus hernia is identified on high resolution manometry (HRM). The integrated relaxation pressure (IRP) is typically measured as the nadir residual pressure across the EGJ during swallow induced LES relaxation.

Aims & Methods

Our aim was to determine if measurement of the IRP across the LES, both LES and CD, and across the CD alone yields different values, and whether differences, if any, have clinical implications. All patients undergoing HRM during a 3-year period at a tertiary facility were eligible for inclusion; incomplete studies were excluded. Demographics and esophageal function testing results were extracted from patient records. EGJ morphological subtypes consisted of type 1 when LES and CD were superimposed; type 2 when LES-CD separation was <3 cm, and type 3 when separation was ≥3 cm. Standard analysis consisted of IRP measured across the entire EGJ in type 1 and 2 EGJ, and across LES in type 3 EGJ. IRP was calculated across LES and CD, separately as well as together in type 2 and type 3 EGJ. An IRP threshold of <15 mmHg defined normal EGJ relaxation. Categorical variables were compared using chi square, and continuous values using Mann Whitney U. Absolute IRP values, and proportions with outflow obstruction were compared between EGJ morphological subtypes, and between LES IRP and CD IRP when a hernia was identified.

Results

Data from 467 patients (median age 54.0 years, 68.7% female, median body mass index 30.5 kg/m²) were analyzed, of which 61.2% had type 1 EGJ, 28.7% had type 2 and 10.1% had type 3 (Table). Using standard methodology, the median IRP was similar in the three morphological subtypes. However, when a hernia was present, IRP across the EGJ was significantly higher than that across either LES or CD (p<0.001), and LES IRP was significantly different from CD IRP (p<0.001). In type 2 EGJ, median IRP across LES was lower across the LES compared to CD (p<0.001). The CD was not traversed in 23 of 47 type 3 EGJ; in the remainder, LES IRP was similar to CD IRP (p=0.784). Of 11 patients with IRP>15 mmHg within types 2 and 3 EGJ, only 3 patients had persistent IRP elevation when LES and CD were separately assessed. Median AET increased as separation between LES and CD increased; patients with elevated IRP had normal AET (0.9, IQR 0.2-6.2). After differential IRP measurement, abnormal IRP was most frequent with type 1 EGJ, and IRP elevation across CD alone was rarely encountered.

Conclusion

In the presence of a hiatus hernia, the IRP across LES and CD together is higher than IRP recorded separately across LES and CD. We speculate that this is because the IRP measurement tool might be picking up pressurization within the hiatus hernia when IRP is measured across both LES and CD. Differential assessment of IRP across LES and CD can reduce over-diagnosis of outflow obstruction.

Introduction

Esophageal motility disorders are common in the clinical practice, with impact in patient’s quality of life. High-resolution esophageal manometry (HREM) is the gold standard for evaluation of patients with functional esophageal disorders. The Chicago Classification offers a standardized approach HREM, reducing bias and enabling a precise diagnosis of these disorders. Despite these, HREM remains a complex exam, both in data analysis and in accessibility. This proof-of-concept study aims to develop and validate an artificial intelligence model for identification of motility disorders in HREM according to the Chicago Classification.

Aims & Methods

618 HREM exams from two different devices and three centers from Spain and the United States of America were used for model development. Several machine learning models were trained and evaluated for detection of motility disorders. The exams were classified according to the Chicago Classification 4.0, based on a consensus reached by two independent HREM experts. The training and testing dataset were divided in a 80%/20% patient split design based on label frequency. Models’ performance was evaluated through their accuracy and area under the receiver-operating characteristic curve (AUC-ROC).

Results

The GradientBoostingClassifier model outperformed the remaining machine learning models with an accuracy of 94.2% and an AUCROC of 0.921 for identifying disorders of esophagogastric junction outflow. The xGBClassifier model detected disorders of peristalsis with an accuracy of 80.9% and an AUC-ROC of 0.871.

Conclusion

In this pilot study with integration of exams from different devices and demographic contexts, several machine learning models accurately identified disorders of the esophagogastric junction outflow and peristalsis in HREM according to Chicago Classification.
The integration of AI into the study of esophageal motility disorders through HREM-driven diagnosis is expected to revolutionize the way these conditions are managed, optimizing both exam accuracy and accessibility, transforming patient management.