Introduction
Esophageal dysphagia and retrosternal chest pain are considered the typical manifestations of major esophageal motility disorders (mEMD). High Resolution Manometry (HRM) is the gold standard for the diagnosis of mEMD. However, in real clinical practice patients are referred for HRM due to several non-typical esophageal symptoms and the rate of EMD among those patients is largely unknown.
Aims & Methods
Aim of our study was to search for mEMDs prevalence among patients with typical symptoms and compare them with patients referred for non-typical symptoms.
We retrospectively collected epidemiological, endoscopic (available in 263/302), barium swallow (available in 176/302) and manometric data from consecutive patients referred for HRM in our center from 1/2020 to 12/2023. Atypical symptoms for which patient were referred for HRM included; heartburn, regurgitation, globus, oropharengeal dysphagia and epigastric pain. Patients with a previous diagnosis of mEMDs/scleroderma/EoE, referred for pre-surgical evaluation for Gastroesophageal Reflux Disease (GERD) or submitted to gastro-esophageal surgery were excluded. Endoscopic data suggestive of an mEMD were considered esophageal dilation, solids/liquids/saliva in the lumen and difficulty to pass the scope through the Lower Esophageal Sphincter (LES), while delay in barium transit from Esophagus to the stomach, esophageal dilation and bird-like LES appearance as barium swallow were considered findings compatible to mEMD.
Results
We included 302 patients (M/F: 147/155, mean age: 56±17 years). Typical symptoms were reported by 234 (77.2%) patients, while only atypical in 68 (22.8%). Main referral symptom was; esophageal dysphagia: 176 (58.3%), chest pain: 42 (13.7%), heartburn: 27 (8.9%), regurgitation: 25 (8.3%), globus/oropharengeal dysphagia/epigastric pain: 32 (10.8%). Diagnosis of mEMDs in HRM was set in 175/302 (57.9%) and was statistically more common when typical symptoms existed (163/233, 69.9% vs 12/78, 15.4%, p<0.001). HRM diagnosis among patients with mEMDs are given in table 1. Among patients with a diagnosis of mEMD in HRM, endoscopic data compatible to mEMDs were statistically more common among patients with typical symptoms, though barium swallow data were not (103/149, 69.1% vs. 4/10, 40%, p=0.037 and 110/116, 94.8% vs. 9/9, 100%, p=0.633 respectively). HRM diagnosis of mEMD among patients with compatible either barium swallow or endoscopic findings was found in a statistically increased rate among patients with typical symptoms (134/145, 92.4% vs. 10/19, 52.6%, p<0.001). We should point that among 43 patients with non-typical symptoms and normal endoscopy and barium swallow study only 1 (2.3%) had a mEMD diagnosis by HRM.
| HRM diagnosis | Total cohort (n=175) | Typical symptoms (dysphagia-chest pain) (n=163) | Non-typical symptoms (n=12) |
Achalasia
Type I
Type II
Type III | 143 (81.7%)
6/143 (4.2%)
134/143 (93.7%)
3/143 (2.1%) | 135(82.8%)
5/135 (3.7%)
127/135 (94.8%)
3/135 (2.2%) | 8 (66.7%)
1/8 (12.5%)
7/8 (87.5%)
0 |
| Esophago-Gastric Junction Outflow Obstruction | 21 (11.4%) | 18 (11.0%) | 2 (16.6%) |
| Diffuse Esophageal Spasm (DES) | 3 (1.7%) | 3 (1.8%) | 0 |
| Hypercontractile Esophagus | 1 (0.6%) | 1 (0.6%) | 0 |
| Absent peristalsis | 8 (4.6%) | 6 (3.7%) | 2 (16.6%) |
Conclusion
More than half of patients referred for HRM will be diagnosed with mEMD, rate significantly increased when typical symptoms, as dysphagia or chest pain, are reported. Achalasia, more specifically type II, is in general the most commonly diagnosed mEMD. Absence of compatible endoscopic or barium swallow findings make mEMDs diagnosis, in the absence of typical symptoms, almost impossible.
