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(a) Hypotensive peristalsis with small break (between 2 and 5 cm). (b) Hypotensive peristalsis with a large break (>5 cm). (c) Failed peristalsis
Source publication
Esophageal hypomotility (EH) is characterized by abnormal esophageal peristalsis, either from a reduction or absence of contractions, whereas spastic motor disorders (SMD) are characterized by an increase in the vigor and/or propagation velocity of esophageal body contractions. Their pathophysiology is not clearly known. The reduced excitation of t...
Context in source publication
Context 1
... diagnosis of IEM is established by the presence of contractions in >30 % of wet swallows with any of the following characteristics: (1) peristaltic contractions with an amplitude of <30 mmHg, (2) simultaneous contractions <30 mmHg, (3) failed peristalsis (the peristaltic contraction does not cross the entire length of the distal esophageal body) (Fig. 2), or (4) absent peristalsis [1]. The contraction amplitude criterion of <30 mmHg was established based on its correlation with disor- ders in esophageal transit observed in videofluoroscopy [77,83]. Subsequently, using combined esophageal impedance and con- ventional manometry, Blonski et al. [84] demonstrated that the presence of >50 % ...
Citations
... JE is a rare disorder, seen largely in expert centers, diagnosed in less than 1-2% of HRMs with waning POEM enthusiasm based on the perceived lower POEM efficacy seen even in the limited studies mentioned above. Most authorities would agree that for JE, a trial of pharmacologic therapies should precede the consideration of surgical therapy [23,24]. Much more important from a public health perspective is EGJOO since it is a more frequent HRM diagnosis (~ 5% of HRMs) and since the favorable preliminary data mentioned above may prompt inappropriate "reflexive" POEM therapy. ...
Purpose of review
Our goal in this focused review is to discuss areas of POEM where significant knowledge gaps exist. We identified two such important areas: (1) The role of POEM in non-achalasia motility disorders, particularly EGJOO, the most prevalent and problematic one. (2) Post-POEM GERD, including its prevalence, particularly in comparison to Heller, objective assessment, and techniques to prevent or treat it.
Recent findings
Regarding non-achalasia motility disorders, limited retrospective multicenter studies suggest that, compared to achalasia, POEM has lower efficacy for Jackhammer esophagus (JE) but equivalent efficacy for DES and EGJOO. However, higher-quality single-center studies found that, even with careful selection of EGJOO patients that meet criteria for true achalasia-like LES obstruction, POEM outcomes are inferior to those of POEM for achalasia. Regarding post-POEM GERD, higher-quality studies report more favorable prevalence rates than lower quality studies, particularly when GERD is measured objectively by pH studies, which show similar or only modestly higher acid exposure after POEM compared to Heller. Reflux esophagitis rates may be overestimated after POEM due to ischemic ulcers at the poorly vascularized mucosa overlying the tunnel scar. Furthermore, intriguing preliminary data suggest that post-POEM GERD may improve on long-term follow-up, unlike GERD after Heller. PPIs are highly effective and remain the cornerstone of management. However, preliminary data on GERD therapy using anti-reflux procedures such as TIF and the novel POEF procedure and on GERD prevention using POEM technique modifications such as the novel “anti-reflux” POEM are intriguing.
Summary
POEM appears less effective in JE and EGJOO compared to achalasia. More research is needed on how to optimally select patients with non-achalasia motility disorders that may benefit from POEM. GERD after POEM, when properly assessed with objective testing, may not be much different than after Heller in the long run. Promising initial data on POEM technique modifications to decrease GERD and adjunctive anti-reflux procedures such as TIF and POEF merit further investigation.
... Although the optimal treatment for JHE has not yet been established, cases of spontaneous remission have been reported (11). A calcium-channel blocker or nitrous acid agent is administered to relax the smooth muscles, and balloon dilatation and a muscle layer incision are performed (12). There are also cases in which a lengthy incision of the muscle layer from the middle to lower esophagus is required. ...
... Within at least one month after the onset of GERD symptoms, a choking sensation on food ingestion, dysphagia, and chest pain appeared, and JHE was diagnosed based on HRM findings. Furthermore, in cases 1 and 2, in which EoE was diagnosed with JHE as the causal factor, longitudinal furrows and vitiligo (characteristic endoscopic findings of EoE) and luminal compression exhibiting esophageal dysmotility were seen (12). Although case 3 was attributed to EGD, luminal compression was not seen, and an esophageal biopsy revealed no invasion of eosinophils, which is a definitive diagnostic criterion of EoE. ...
We experienced marked efficacy with steroid treatment of three patients with jackhammer esophagus (JHE). An esophageal biopsy revealed eosinophilic esophagitis (EoE) in two patients. One of the patients without EoE had eosinophilia and an increased serum immunoglobulin E level, and endoscopic ultrasonography revealed thickening of the esophageal muscularis propria. Esophageal manometry was used to diagnose all cases of JHE. Treatment consisted of steroid administration, which improved the symptoms and resolved the esophageal muscularis propria thickening in all patients. The esophageal manometry findings also normalized following treatment. Allergic diseases, including EoE, were assumed to have caused JHE.
... Furthermore, we observed the known relationship between hypomotility esophageal disorders and erosive esophagitis. In fact, an estimated 21-49% of patients with ineffective esophageal motility have a concomitant diagnosis of gastroesophageal reflux disease (GERD) [13]. Chronic acid exposure is hypothesized to lead to irreversible changes in esophageal motor function [13], resulting in lower LES pressures and decreased esophageal peristaltic wave amplitudes, longer durations of contractions and slower velocity of propagation [14]. ...
... In fact, an estimated 21-49% of patients with ineffective esophageal motility have a concomitant diagnosis of gastroesophageal reflux disease (GERD) [13]. Chronic acid exposure is hypothesized to lead to irreversible changes in esophageal motor function [13], resulting in lower LES pressures and decreased esophageal peristaltic wave amplitudes, longer durations of contractions and slower velocity of propagation [14]. These associations have led to more frequent presence of erosive esophagitis in hypomotility esophageal disorders, as evident in our study. ...
Background
High-resolution esophageal manometry (HREM) is the diagnostic test of choice for evaluation of non-obstructive dysphagia. Studies regarding the predictors of esophageal dysmotility are limited. Therefore, our aim was to study the prevalence of and factors associated with esophageal motility disorders in patients with non-obstructive dysphagia.
Methods
We performed a retrospective review of all patients with non-obstructive dysphagia who underwent HREM in a tertiary center between 1 January 2014 and 31 December 2015. After obtaining IRB approval (16–051), clinical records were scrutinized for demographic data, symptoms, medication use, upper endoscopic findings and esophageal pH findings. HREM plots were classified per Chicago Classification version 3.0. Primary outcome was prevalence of esophageal motility disorders; secondary outcomes assessed predictive factors.
Results
In total, 155 patients with non-obstructive dysphagia (55 ± 16 years old, 72% female) were identified. HREM diagnosis was normal in 49% followed by ineffective esophageal motility in 20%, absent contractility in 7.1%, achalasia type II in 5.8%, outflow obstruction in 5.2%, jackhammer esophagus in 4.5%, distal esophageal spasm in 3.9%, fragment peristalsis in 1.9%, achalasia type I in 1.9%, and achalasia type III in 0.6%. Men were five times more likely to have achalasia than women [odds ratio (OR) 5.3, 95% confidence interval (CI): 2.0–14.2; P = 0.001]. Patients with erosive esophagitis (OR 2.9, 95% CI: 1.1–7.7; P = 0.027) or using calcium channel blockers (OR 3.0, 95% CI: 1.2–7.4; P = 0.015) were three times more likely to have hypomotility disorders.
Conclusion
From this study, we concluded that HREM diagnosis per Chicago Classification version 3.0 was normal in 49% of patients with non-obstructive dysphagia. Male gender, erosive esophagitis and use of calcium channel blockers were predictive of esophageal motility disorders.
... The revised Chicago classification recently defined jackhammer esophagus as a hypercontractile esophagus, with at least one contraction with a distal contractile integral (DCI) of at least 8000 mmHg·s·cm [1]. Many treatments of jackhammer esophagus have been tried, including oral nitrates, balloon dilation, and surgical myotomy [2]. Recently POEM has been demonstrated as a safe and effective therapeutic modality for the treatment of spastic esophageal disorders [3], and particularly for jackhammer esophagus [4]. ...
... In patients with DES who also have concomitant GERD, the first line of treatment should be proton pump inhibitor. 41,42 Calcium channel blockers, such as nifedipine and diltiazem may be of benefit for reducing chest pain and dysphagia in patients with DES who have no GERD. 41 The study of antidepressants including tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) in patients with non-cardiac chest pain showed an advantage for these patients. ...
Esophageal manometry is an important tool for evaluating esophageal function. It can be used for assessing the esophageal peristaltic pattern and also peristaltic intensity. Additionally, lower esophageal sphincter (LES) function can be studied simultaneously. This information allows clinicians to thoroughly investigate patients presenting with esophageal and/or respiratory symptoms without identifable structural cause. At present, high resolution manometry (HRM) is preferred over conventional manometry as it informs the result in pressure topography. These data correlate more precisely with the clinical presentation of patients with esophageal dysmotility. Consequently, the HRM working group has proposed the criteria known as Chicago classifcation to categorize and specify the esophageal motility abnormality based on the results from HRM. This article describes esophageal motility disorders according to the current diagnostic criteria and also how to manage them in brief.
... The results of the present study have illustrated the potential of HRM technology to facilitate the diagnosis and improve our understanding of functional esophageal disorders in dogs, particularly those that cannot be routinely diagnosed via esophagoscopy or videofluoroscopy. High-resolution manometry should be further evaluated to assess pharyngeal and UES function in dogs with cricopharyngeal dysphagia, 36,37 esophageal dysmotility, 38 ...
OBJECTIVE To validate the use of high-resolution manometry (HRM) in awake, healthy dogs and compare the effects of bolus type (liquid vs solid) and drug treatment (saline [0.9% NaCl] solution [SS] vs cisapride) on esophageal pressure profiles.
ANIMALS 8 healthy dogs.
PROCEDURES In a crossover study, each dog received SS (10 mL) IV, and HRM was performed during oral administration of 10 boluses (5 mL each) of water or 10 boluses (5 g each) of canned food. Cisapride (1 mg/kg in 60 mL of SS) was subsequently administered IV to 7 dogs; HRM and bolus administration procedures were repeated. Two to 4 weeks later, HRM was repeated following administration of SS and water and food boluses in 4 dogs. Pressure profile data were obtained for all swallows, and 11 outcome variables were statistically analyzed.
RESULTS After SS administration, predicted means for the esophageal contractile integral were 850.4 cm/mm Hg/s for food boluses and 660.3 cm/mm Hg/s for water boluses. Predicted means for esophageal contraction front velocity were 6.2 cm/s for water boluses and 5.6 cm/s for food boluses after SS administration. Predicted means for residual LES pressure were significantly higher following cisapride administration.
CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that HRM was feasible and repeatable in awake healthy dogs of various breeds and sizes. Stronger esophageal contractions and faster esophageal contraction velocity occurred during solid bolus and liquid bolus swallows, respectively. Lower esophageal sphincter pressure increased significantly following cisapride administration. Esophageal contractions and bolus transit latency should be further evaluated by HRM in clinically dysphagic dogs.
... Jackhammer esophagus is rare, occurring in approximately 4 % of cases referred to a tertiary esophageal center [4]. The treatment of Jackham-mer esophagus has included oral nitrates, balloon dilation, and surgical myotomy [5]. Surgical myotomy has not been widely performed due to the usual requirement for a long myotomy to achieve clinical success, which generally necessitates a combined abdominal and thoracic approach if a complete myotomy of the LES is to be performed [6 -8]. ...
Background and study aims: With the success of peroral endoscopic myotomy (POEM) in treatment of achalasia, its successful application to other spastic esophageal motility disorders such as Jackhammer esophagus has been noted. The question of whether the lower esophageal sphincter (LES) should be included in the myotomy for Jackhammer esophagus is a topic of current debate. Here, we report our experience and results with four patients with Jackhammer esophagus treated with POEM. The clinical and manometric results are presented and their potential implications are discussed.
Patients and methods: Between January 2014 and July 2015, four patients underwent POEM for treatment of Jackhammer esophagus at our center. Manometry was performed prior to and after POEM. All patients met the Chicago classification criteria for Jackhammer esophagus and received a barium esophagram and endoscopic examination before having POEM.
Results: All patients had uneventful procedures without any intraoperative or post-procedure complications. Patients in which the LES was included during POEM had resolution or significant improvement in symptoms. One patient in whom the LES was preserved had resolution of chest pain but developed significant dysphagia and regurgitation. Subsequently this individual received a repeat POEM which included the LES, resulting in symptom resolution.
Conclusions: POEM is a suitable treatment for patients with Jackhammer esophagus. Until there are larger-scale randomized studies, we speculate that based on our clinical experience and physiologic and manometric observations, obligatory inclusion of the LES is justified to reduce the risk of symptom development from iatrogenic ineffective esophageal motility or subsequent progression to achalasia.
... However, vement of long-lasting esophageal dysphagia and symptomatic gastroesophageal reflux in adults. Dysphagia is often a poorly defined symptom and can lead to misinterpretation of investigative and therapeutic results [12] . Long-lasting oropharyngeal dysphagia is mostly of neurologic origin [13] , whereas esophageal dysphagia presents either a stenotic character, which causes a blocking feeling with a certain ingested bolus size [14] , or an intermittent nonstenotic character, which is common in patients with hiatal hernia [15] . ...
To examine whether muscle training with an oral IQoro(R) screen (IQS) improves esophageal dysphagia and reflux symptoms.
A total of 43 adult patients (21 women and 22 men) were consecutively referred to a swallowing center for the treatment and investigation of long-lasting nonstenotic esophageal dysphagia. Hiatal hernia was confirmed by radiologic examination in 21 patients before enrollment in the study (group A; median age 52 years, range: 19-85 years). No hiatal hernia was detected by radiologic examination in the remaining 22 patients (group B; median age 57 years, range: 22-85 years). Before and after training with an oral IQS for 6-8 mo, the patients were evaluated using a symptom questionnaire (esophageal dysphagia and acid chest symptoms; score 0-3), visual analogue scale (ability to swallow food: score 0-100), lip force test (≥ 15 N), velopharyngeal closure test (≥ 10 s), orofacial motor tests, and an oral sensory test. Another twelve patients (median age 53 years, range: 22-68 years) with hiatal hernia were evaluated using oral IQS traction maneuvers with pressure recordings of the upper esophageal sphincter and hiatus canal as assessed by high-resolution manometry.
Esophageal dysphagia was present in all 43 patients at entry, and 98% of patients showed improvement after IQS training [mean score (range): 2.5 (1-3) vs 0.9 (0-2), P < 0.001]. Symptoms of reflux were reported before training in 86% of the patients who showed improvement at follow-up [1.7 (0-3) vs 0.5 (0-2), P < 0.001). The visual analogue scale scores were classified as pathologic in all 43 patients, and 100% showed improvement after IQS training [71 (30-100) vs 22 (0-50), P < 0.001]. No significant difference in symptom frequency was found between groups A and B before or after IQS training. The lip force test [31 N (12-80 N) vs 54 N (27-116), P < 0.001] and velopharyngeal closure test values [28 s (5-74 s) vs 34 s (13-80 s), P < 0.001] were significantly higher after IQS training. The oral IQS traction results showed an increase in mean pressure in the diaphragmatic hiatus region from 0 mmHg at rest (range: 0-0 mmHG) to 65 mmHg (range: 20-100 mmHg).
Oral IQS training can relieve/improve esophageal dysphagia and reflux symptoms in adults, likely due to improved hiatal competence.
... [15][16][17][18][19] No consensus with regards to the formal indications for POEM exists, but with current safety and efficacy data and an experienced operator, it can be considered as a first-line treatment for all achalasia, reserving oesophagectomy for terminal disease. Spastic oesophageal motility disorders such as Jackhammer o esophagus, diffuse oesophageal spasm (DES), hypertensive lower oesophageal sphincter (HTLES) and Nutcracker oesophagus can also be treated with POEM; 17,[20][21][22][23][24][25] how ever, these motility disorders are less common than acha lasia and so less evidence exists for the efficacy of POEM as a treatment. With respect to contraindications for POEM, no universally established criteria are available at this time. ...
Peroral endoscopic myotomy (POEM) was first performed in Japan in 2008 for uncomplicated achalasia. With excellent results, it was adopted by highly skilled endoscopists around the world and the indications for POEM were expanded to include advanced sigmoid achalasia, failed surgical myotomy, patients with previous endoscopic treatments and even other spastic oesophageal motility disorders. With increased uptake and performance of POEM, variations in technique and improved management of adverse events have been developed. Now, 6 years since the first case and with >3,000 procedures performed worldwide, long-term data has shown the efficacy of POEM to be long-lasting. A growing body of literature also exists pertaining to the learning curve, application of novel technologies, extended indications and physiologic changes with POEM. Ultimately, this once experimental procedure is evolving towards becoming the preferred treatment for achalasia and other spastic oesophageal motility disorders.
... If PPIs are not effective, smooth muscle relaxants (nitrates, calcium channel blockers, 5-phosphodiesterase inhibitors) and pain modulators may be given to alleviate both pain and dysphagia, although the data do not show a clear benefit. [25][26][27] The administration of low-dose antidepressants (such as trazodone) was assessed in patients with abnormal esophageal contractility in a double-blind, placebo-controlled trial 28 in which the authors observed symptomatic but not manometric improvement. Antidepressants are not recommended to treat patients with DES, despite some studies having demonstrated a possible benefit in patients with hypercontractile (or hypersensitive) esophagus. ...
Background
Gastroesophageal reflux disease and its complication, Barrett’s esophagus, are two modern Western epidemics, and they are managed by a combination of medical and surgical approaches. Two new radiofrequency-based endoscopic methods, Stretta and HALO, have been introduced recently, and they are aiming at altering the compliance of the gastroesophageal junction and ablating the Barrett’s metaplastic mucosa, respectively.
Methods
We reviewed PubMed for all studies pertaining to Stretta and HALO technologies and collected data on techniques, clinical efficacy, safety, tolerability, and durability of effect.
Results
Although limitations exist, the safety, efficacy, tolerability, and durability of endoscopic radiofrequency energy application are robust and poised to facilitate the nonsurgical management of gastroesophageal reflux disease (GERD) and Barrett’s esophagus.
Conclusions
Over the past decade, Stretta and HALO have become valuable options in the current algorithms of management of refractory GERD and Barrett’s esophagus. Ongoing vigilance on the long-term benefits of radiofrequency and its effect on esophageal structure and function will allow even wider and more successful applications.
